By JEFF GOLDMSITH
As healthcare systems struggle to emerge from the post-COVID financial crisis, the importance of the clinical enterprise to these systems has increased dramatically. Healthcare organizations are becoming larger as failing companies are integrated into growing systems.
Yet clinicians of all stripes, but especially physicians, feel a growing sense of alienation from the expanding care systems in which they work. In many “would-be” health systems, the clinical “enterprise” is a loosely connected collection of independent practices held together by RVU-based compensation plans and a common corporate logo on the door.
A roll-up is not a credible basis for a system, it is just a holding pattern. If you lost your doctors, you don’t have a franchise!
At a time when clinical staff burnout and moral injury threaten the well-being of nurses, how care systems promote nurses’ commitment to their organization has become a key strategic challenge. When you look at the leaders in healthcare—from the Mayo Clinic to Johns Hopkins Medicine—they have one thing in common. Not only are they led by clinicians, but the clinicians there also work together to both maintain high clinical standards and develop and disseminate clinical innovations.
This commitment has direct financial consequences for healthcare systems. In an environment where an increasing percentage of healthcare revenue is “risk revenue,” positive control over healthcare costs is key to the organization’s future. Ultimately, this control rests not on clever compensation schemes, but on the behavior of doctors as they work together to care for their patients.
To be clear, the clinical enterprise does not mean that all clinicians are employees. In some organizations, such as Kaiser Permanente, clinicians are employees of the Permanente Medical Groups, a closed board entity that provides the majority of Kaiser’s clinical care.
However, in many organizations, physicians may be independent physicians or members of affiliated medical groups, but are still actively involved in the management of the clinical enterprise. In academic institutions, not all members of the clinical enterprise are full-time faculty. And not all of them have a doctor after their name, but are nurses and other clinicians with postgraduate degrees.
Rather, the successful clinical company is characterized by:
1) a shared set of values that defines what constitutes a high-quality medical practice. This value system embodies the beliefs and values that shape clinical care and is maintained and reinforced through educational programs, awards and recognition, and high standards of promotion and compensation
2) strict quality and safety standards Rather than being paralyzed by the demands of documenting dozens or hundreds of clinical standards, physicians are given high expectations for collaboration and patient outcomes. These standards evolve and improve as clinical medicine advances.
3) high level of collegiality and mutual trust Fundamentally, high-quality patient care requires collaboration, and that collaboration cannot occur without a high level of trust – both in clinical judgment and behavior. A well-functioning clinical enterprise can be thought of as interlocking circles of trust – between the clinician and the patient (and his family), between the clinician and his circle of advisors, between that circle and the clinical and administrative teams that support his care of the patient, and between all those circles and the management that looks after them. Without trusting collaboration, patients experience their care as a series of missed contacts or dropped batons (where they are the baton). These circles of trust act as shock absorbers for the inevitable surprises and events that arise in the caregiving process.
4) effortless communication and advice In this complex collaboration, clinicians rely on high-function information technology to share information about patients with colleagues and receive feedback from them on next steps. The electronic record is not simply a static electronic version of the old paper chart, but a communication tool to support patient care. One reason that the electronic health record has not reached its potential is that this communication function is often a stepchild to the billing functions of clinical IT. Effective communication is critical to ensure timely and safe management of patient issues and “patient progress” during the care phase – a growing problem as hospital length of stay increases post-pandemic. This increasing length of stay poses a direct financial threat to hospitals, particularly under Medicare’s prospective payment system or under risk contracts with private health insurance companies.
5) inspiring leadership Maintaining high clinical standards and morale is not guaranteed by artificial intelligence, clinical MBAs or clever compensation models. Inspirational leadership is the driving force in a well-functioning clinical organization. Leadership by example – living the values of the organization – is the essential part of this company. Promoting and maintaining collegiality starts at the top.
How do you know you have a well-functioning clinical enterprise? Because clinicians in this company feel and behave like owners. They feel they can effectively address and change factors that impede effective patient care, damage morale, cause moral harm, and waste their time (the most scarce resource in most healthcare organizations).
There is no better diagnosis of a lack of a sense of ownership in an organization than a movement toward unionization among practicing physicians. The movement to unionize physicians is not driven by money, but rather by a sense of powerlessness because physicians cannot rely on management to commit to changing the things that prevent them from being effective caregivers .
One danger of the wave of consolidation currently taking place is that systems will outgrow their nervous system and not reach the clinics, operating rooms, intensive care units and doctor’s offices where all the value is created. Clinical organizations that connect with and motivate their employees will have a prohibitive competitive advantage in the coming era of physician shortages as baby boomers and other caregivers retire.
In an effective clinical organization, physicians and nonphysician colleagues feel empowered to change things that harm their patients or practicing colleagues. It is not mass and scale or wealth that will determine who survives and thrives in this coming healthcare environment, but rather the ability of clinicians in the clinical enterprise to work together effectively to meet our needs. The health and vitality of the clinical enterprise is the most important factor in the success of healthcare companies large and small.
Jeff Goldsmith is an experienced healthcare futurist, President of Health Futures Inc, and regular THCB contributor. This comes from his personal Substack