Models of Medical Staff Redesign page 2
Internal Strategy to Support Programs and Performance
By Andrew L. Epstein, MD
This paper is based upon Dr. Epstein's presentation at the ACHE 2008 Congress on Healthcare Leadership, "Redefining the Healthcare Landscape". See the original slides here.
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Page 2: Traditional organizational models and their limitations
Getting there requires understanding where we are now, and how we got here.
Twenty-five years ago, the fundamental relationship between physician and hospital was a customer-supplier relationship. The hospital’s task was to manage a critical community resource; the physicians cared for individual patients more or less as members of independent guilds. The equation was relatively simple, and the traditional medical staff structure, in which the hospital provided a workshop for independent physicians who policed themselves by granting and revoking privileges, worked fairly well.
Things are different now. Today, physicians have all kinds of relationships with their hospitals:
• Trustee
• Joint venture partner
• Customer
• Vendor
• Contractor
• Employee
And increasingly, it is the two together that are responsible for managing a whole range of resources and meeting a range of goals, including:
• Mission
• Quality
• Safety
• Service to the community
• Maintaining and building market share
• Business performance
As an example of just one arena where this plays out, the Centers for Medicare and Medicaid Services (CMS) announced in August, 2007, that they would no longer pay for errors it considers preventable.
Among the list of “preventable errors”:
• Wrong site surgery
• Post-operative wound infection
• Infection from indwelling urinary catheter
• Infection from indwelling intravenous line
• Misinterpretation of medical orders
• Diagnostic errors
• Failure to take action on abnormal tests
• Misinterpretation of test results
There is no way for doctors or hospitals to address concerns like those on this list independently of one another. The response must be system-wide, and requires the commitment of all the organization’s constituencies.
In the past, when healthcare organizations talked about aligning with their physicians, the emphasis was on aligning financial incentives. But that’s insufficient to meet this kind of challenge. The mental model of “alignment” must be expanded beyond financial relationship models to strategic and operational relationship models. Hospitals do not just need their doctors to go along with new initiatives. To make the kinds of systemic changes that are needed, and to make them effectively, doctors must be involved in every facet of their planning and execution.
And for that level of participation, new models of organization are required.
The voluntary medical staff
Let’s begin with the traditional model that has been the most common structure for hospital-physician interaction: The voluntary medical staff.
Below is a map of a typical healthcare organization, whose medical staff model is the traditional one. There is no real connection between hospital management and the individual physicians, and many “barriers” to communication and systemic action.
Voluntary Medical Staff features:
• Medical staff physicians are independent of the hospital
• The leaders of the medical staff organization are elected, rotating, and uncompensated, and serve for a limited term
• Leaders and staff physicians share a “peer” relationship
• No accountability
• Department chiefs may or may not constitute the Medical Executive Committee/oversight body
Some organizations have established an “enhanced” voluntary medical staff model that incorporates elected or appointed leaders who are paid a stipend for their work, but where most of the other factors that inhibit accountability and involvement still pertain.
Go on to Page 3: Contemporary organizational models and their benefits
Go back to Page 1: The importance of internal strategy