Letter of Authorization

September 06, 2008

Dear Readers

I am the student of Health Management MBA program at Institute of

Business Management (IoBM), where as course requirement of Managing

Physician, I am authorized by Col (rtd) Tariq uz Zafar to submit this Term

report on "_________________"

The content of this report reflects the practical life scenario and I have tried

my level best to justify the valuable information gathered

Sincerely

Shahid RazaMHM

Letter of Transmittal

September 06, 2008

Col (rtd) Tariq uz Zafar Course FacilitatorInstitute of Business ManagementKarachi

Dear Madam:

The Term Paper is on “_____________” which you authorized me to

submit.

This informative report unveils the major areas of concerns faced in the

working and daily life environment.

Review the report and if there is need for further clarification or elaboration,

contact me at information below.

Sincerely

Shahid RazaMHM 2007-3-20-7289Cell: 0333-2705509shahidnraza@yahoo.com

Letter of Acknowledgement

September 06, 2008

Dear Reader

I praise Allah All Mighty for giving me the courage and strength to complete

the task of writing the report on “________________”. This report would be

incomplete without the impeccable support and guidance received from Sir

Col (rtd) Tariq uz Zafar, our course facilitator of Managing Physician at the

IoBM.

Sincerely

Shahid RazaMHM

Health care is a system in this technical sense. So are health care procedures, such as a surgical operation or the process of caring for a diabetic patient. Viewed through this lens, the model for improvement does not just ask about local, "elemental" aims; it asks about shared systemic aims. It seeks the measurement of systemic progress, not just the performance of parts; and the changes it refers to are changes in system designs and interdependencies, not just changes in the components of care.

In health care, the tendency has been to seek improvement by trying to perfect the elements of care-to make doctors better at doctoring, to make nurses better at nursing, to give equipment more functions, or to replace one drug with a better one. All of this "subject matter" or "discipline-specific" improvement helps, but modern systems theory suggests that greater leverage often lies in changing the patterns of interaction and in redesigning the overall flow of work. A hospital frustrated with delays in moving admitted patients from the emergency department to the acute care floor can make little progress by changing either emergency department or acute care processes alone. Success depends on changing the interactions between the two units; for example, moving steps in the process from one department to the other, simplifying handoff procedures and developing shared measurements of delay.

If improving health care were easy, we might be seeing more of it. Instead, most physicians nowadays seem to feel that just plain holding on is difficult enough. In fact, searching for one word to describe the state of mind of the physician today, we might choose beleaguered. Threats appear from all sides-from payers, would-be managers of care, the growth of technology, and even. The rhetoric is one of siege and battle, and the dynamic seems to be a clash of values from which only one winner can emerge.

But scientific and health services research suggest otherwise. Science suggests that health care could, indeed, perform a great deal better than it does today and that a shared aim of improving health outcomes for patients at a cost that society can afford is sensible and within reach. However, achievement of these improvements will require of physicians not hand wringing and resistance to change but concerted, positive, capable leadership.

The Role of the Healthcare Leader, Past, Present, Future

Respected health care futurist Leland Kaiser, PhD, tells the tale of a Sufi Master who rides backward on a donkey. When the Sufi is asked about his unorthodox equestrian style, he replies that by riding backwards, he is unafraid of the future-because by the time he "got there" he had already seen it.

That may be the case for the health care leaders of 2001 and beyond. The role of the executive will have less to do with shaping health care delivery than shaping people to do the job.

It was, perhaps, the image of executives backing into the future that prompted the memory of a dust-covered book in my library: The Functions of the Executive, by Chester Barnard. Barnard, former president of New Jersey Bell Telephone Company, published the original edition in 1938.

Barnard postulates that executives perform three functions in an organization. They are:

1. Provide the system of communication

2. Promote essential and cooperative efforts

3. Formulate and define purpose

System of CommunicationSo what do health care leaders need to communicate? The list is legion, but

certainly includes quality standards. Expectations for mutual respect, organizational goals, individual goals, and so on.

But we often see physician organizations disintegrating because executives communicated poorly about:

o The financial impact of a building program

o The potential impact of changing the MIS vendor on accounts receivable during a transition

o Why the current compensation plan is crippling the organization

o Why high-producing procedural specialists change from "revenue centers" to "expense centers" in capitates, managed care environments

In short, the executives communicated poorly.

Promote Essential Efforts

The word choice is critical. The executive "promotes." Too often, executives despair of "promoting" and simply "do." They fail to develop others and severely limit their own ability to manage because they are entangled by the jobs of others.

This illustration is from real life. And unfortunately, it's typical of physician-run groups. It's a situation where each board member, elected with a promise to lower overhead, feels empowered to micromanage all aspects of the operation.

"Essential" suggests that there are some efforts that may not be essential. Effective executives know the difference.

Formulate and Define Purpose

The executive's job is to remind the staff why their efforts are critical to the purpose of the organization.

The role of the health care executive is to overcome the one and accomplish the other. That was the case 65 years ago. It's still true today and will be tomorrow. Something to consider as we ride facing south on our northbound donkeys.

The Increasing Demand for Physician Executives

Physician executives are in demand. And, this demand is accelerating. Hospitals and health systems are clamoring for physician executives to lead a variety of efforts

across their organizations. Physicians are being asked by hospitals to assume key roles leading, developing and improving systems and programs that address:

Financial outcomes Quality outcomes Operational outcomes Clinical outcomes

What is driving this increase for physician leadership? Since the Institute of Medicine’s (IOM) Crossing the Quality Chasm (1996), which documented the serious and pervasive nature of the nation’s overall quality of healthcare problem, and the subsequent document, To Err is Human: Building a Safer Health System (1999), knowledgeable and savvy physician executives with advanced training in evidence-based medicine, systems of quality improvement, and in healthcare business and finance have become increasingly in demand. Subsequent recommendations from The Leap Frog Group encouraging public reporting of healthcare quality and outcomes, and the new Centers for Medicare and Medicaid Services (CMS) and the Leap Frog Hospital Rewards Program that provides incentives and rewards for hospitals that are both high in quality and efficient in resource use, are adding to the demand.

In May 2005, CMS reported that financial incentives to reward hospitals for quality care work have resulted in better care and fewer complications. Hospitals in the top 20 percent of each clinical category expect to receive Medicare incentive payments. In fact, as the project continues, Medicare will reward high performers with bonuses totaling $7 million per year. Poorly performing hospitals may also face financial penalties in the third year. These programs require sophisticated leadership. Pay-for-performance metrics can’t be obtained without knowledgeable physician leaders leading the endeavors.

In addition to quality, safety, and pay-for-performance initiatives, other healthcare developments are spurring the demand for physicians in leadership roles. These include the rise of new specialty hospitals or acute care tertiary/quaternary hospitals for specialized programs in heart care, cancer care, rehabilitation, neurosciences, orthopedics, etc. In addition, health systems, realizing the need to “be ahead of the pack” and inundated by horizon scanning reports forecasting significant new technologies, services and programs, are launching innovative “research and development” think tank operations for their systems. These “R and D” operations will identify, analyze and evaluate these new technologies for possible adoption and investment. Some of these same advances in technology as well as in biomedicine and genomics are also creating the need for physician medical ethics leaders.

At a time when physician leaders are in higher demand, previous recruitment processes for identifying and selecting physician executives has become ineffective. Finding and choosing the right physician for these leadership positions has been difficult for hospitals and hospital executives. Previously, physicians were promoted to leadership positions such as Medical Director or Vice President of Medical Affairs because they were “popular” physicians within their respective medical staff. Although many of these physicians possessed some leadership skills, they did not possess business, financial, or

hospital operations experience nor the associated educational preparation and training. They were not “healthcare or business administrators.”

The Healthy HospitalThe term “healthy hospital” to reflect the closer integration and interdependence

of physician and non-physician leadership roles across all functional areas of a healthcare organization. Achieving the outcomes being demanded and required by payers, governmental agencies and consumers for safer, more efficient, and more profitable healthcare organizations is dependent upon effective physician leadership. Physicians are assuming leadership roles in each of these organizational areas.

Financial Outcomes

Physicians have a unique understanding of healthcare; they understand healthcare delivery, what is being created for the patient, and patient care – perhaps more than anyone else. In addition, numerous graduate programs in business, health administration, public health, and medical management are giving physicians the administrative expertise required for true leadership and executive roles. With their understanding of healthcare plus the additional education, physicians are better prepared to impact, lead, and improve financial outcomes and success for health care organizations.

As hospitals strive to adopt new technologies that decrease medical errors, improve access to information for their physicians, or provide new advances in patient care, acceptance by medical staff is not always automatic. Physicians are being asked to lead this sometimes difficult cultural shift to adoption of new technology. Physician leaders are playing key roles in prioritizing capital needs, identifying new innovative technology for adoption, and leading system-wide implementations for electronic medical records, computerized physician order entry systems (CPOE), digital radiography (PACS) systems, etc.

Service line development opportunities are also being led by physician executives, sometimes in partnership or co-leadership roles with non-physician executives. These partnership roles are becoming increasingly used in heart institutes,

cancer hospitals, and neuroscience centers. Physicians know the business; they bring credibility to the marketplace for consumers and to referring physician networks. They serve as the instigator and champion for change to new and better practice standards and they now bring business expertise gained through MBA, MHA, MPH, or MMM programs.

Operational OutcomesPhysician leaders are key members of operational teams dealing with staffing,

strategic planning, capital equipment selection and allocation, and program development. Physician leaders can differentiate what is required from what is desired by physicians or staff in many circumstances. Efficient patient flow and throughput is an incredibly important area both to patients and physicians so that appointment delays are decreased, access to care is improved, and scheduling is predictable. These are all things with inputs controlled greatly by physicians that require physician leadership in order to facilitate continual improvements in efficiency and productivity.

Clinical and Service Outcomes Traditionally, physicians have led peer review processes, risk management

initiatives, and medical staff functions involving medical staff by-laws, rules, and regulations. Today, physician leaders are also the new drivers of quality and cost for hospitals. Physician executives are providing leadership in the establishment of programs for disease management and other evidence-based medicine initiatives that are resulting in improved clinical and service outcomes and incentive-based reimbursement to their organizations.

Current Physician Leadership RolesPhysicians are in or being recruited to leadership positions across the spectrum of

healthcare organizations and for numerous roles. Many of these positions are full-time while others allow for continuation of some level of clinical practice. Whether as the CEO, COO, Chief Medical Officer, Vice President of Medical Affairs, or in newer roles such as Senior Vice President of Research and Development, Chief Medical Ethics Officer, or Chief Quality Officer, physician leadership roles are increasing to meet the needs of the evolving healthcare environment.

Recruiting and Selecting Effective Physician LeadersThe identification, recruitment, and selection process for effective physician

leaders should not be unlike that for any other healthcare executive. This may appear simplistic but without specification of key criteria required and a vigorous search and interview process, organizations run the risk of selecting a physician who is “burned out,” in “pre-retirement mode,” a “popular” physician, and/or one without a proven track record of expertise. Completing a position description with specific responsibilities, expectations, accountabilities, and scope of authority is critical. Organizations need to identify the required academic training, certification, specialization, and employment history desired. Do you want a physician with an MBA, MHA, MPH, or MMM? Most organizations do. Specification of areas of expertise must be identified. Will the physician lead pay-for-performance, quality, or patient safety initiatives? If so, what is their formal training and experience? What has been their scope of responsibilities? Is experience at a national level required? Are you looking for proven operational expertise?

Leadership StylesOrganizations have sought to understand the differences in leadership styles each

executive team member brings to the table. Physicians, like non-physicians, are a product of their own genetics, culture, family backgrounds, academic training, and preparation. Understanding a few differences may facilitate acceptance and improved team effectiveness. Again, most of the differences are derived or developed because of differences in training and academic preparation. Most non-physician executives are trained in thought leadership and are process driven, team oriented, consensus builders, and facilitative. Physicians, on the other hand, are trained to be decisive, data driven, action oriented, more individual focused and values driven.

The changing healthcare environment is creating a broader involvement and demand for physician leaders. Given proper education and training, as well as a rigorous selection and recruitment process, physician leaders are making significant contributions in our healthcare organizations-ensuring that are organizations are safer, more efficient, and more profitable.

Improvement and Change

It is usually easier to defend the status quo than to change it, and in this difference lay the roots of the dominant professional response to the pressures on health care today. However, evidence is mounting that the excellence of the status quo is a sentimental illusion. Some physicians have begun to confront this issue directly; however, to affect a positive outcome for the emerging structure of our health care system, all physicians will increasingly need to replace hand wringing with active citizenship and use of their considerable power and influence in the improvement of care. Because resistance to change runs deep, physicians fail to acknowledge the degree to which the very pressures that threaten their security are the consequences of their own action or inaction

The financial pressures that endanger our integrity did not arise spontaneously from avaricious private marketers. Even if one accepts (as we do not) that avarice and free markets are driving the system now, the opportunity for them to do so arose because health care, as it is pursued today, causes some serious social problems and fails to address others that it should help to solve. The failures of our system breed attempts to control it, some wise, some unwise. A struggle against managed care, price cutting, rationing, or market competition is a struggle against symptoms, not causes. Physicians who want to preserve the integrity of their profession must use that integrity to solve some of the problems that their profession has created or, through inaction, has permitted to accumulate.

That will require change, and the first change is in our aims. The professional leadership of improvement must begin with a clear acknowledgment of the need for improvement. For example, take the cost of care. There are two camps. One, plausible and pedigreed, argues that rising costs in U.S. health care are driven by social, demographic, and technological factors beyond our control. Those who defend this view argue that we have no choice but to pay the bill or ration care. One option is economically ruinous; the other, politically untenable.

Another camp argues with equal force that it is possible to dramatically reduce the cost of care without causing harm. These experts cite the wide gap between health care costs in the United States and in other nations that have equal or better care. They note the evidence of useless and even harmful excesses in specialty care, procedure rates, medical equipment, hospital bed supply, administrative procedures, and regulatory inspection, and they describe with even more evidence how other industries have found enormous waste deeply embedded in their own time-honored processes.

We are firmly in the second camp. We believe that the prognosis for the health care system is good if physicians will contribute actively to improving the system as a whole. If we are wrong, our agenda at least gives professionals something more pleasant to do than complain. More important, if we are correct in stating that the seeds of fundamental improvement in health care systems lie within the reach of physicians, then physicians can best exert their influence by recognizing the problems to be solved and then doing everything in their power to assure that the solutions they help develop are technically proper, ethically sound, and effective.

Let us assume that you believe that the changes affecting medical practice get their ammunition from real social problems and that you, as a caring physician, want to take action to influence the solutions to those problems. What can you do?

A Model for Improvement

How can you know? Nothing about medical school prepares a physician to take a leadership role with regard to changes in the system of care. Physicians are taught to do their very best within the system and to perfect themselves as individual professionals by advancing their skills and knowledge every day. But being a better physician and making a better system are not the same job. They require analogous, but somewhat different, skills.

To describe the kind of knowledge, much of it foreign to the clinician, that will help physicians participate effectively in the redesign of the health care system. We intend to raise the curiosity of physicians about the new skills they will need to become more active and influential citizens of the health care community in accomplishing improvement. This new knowledge will serve as a conduit for deploying clinical expertise into a debate heretofore informed primarily by economics.

Our list of skills comes from a simple model for improvement that one of us has crafted over the past decade in the company of colleagues.

The model is a response to the question, what are the components of efforts that

continually improve organizational or individual performance? Four elements appear time and time again in the efforts that actually lead to progress

1. Aim

2. Measurement

3. Good ideas for change

4. Testing

The four elements of the model for improvement (aim, measurement, change, and tests of change) are necessary for improvement to occur, but they are not sufficient.

The model for improvement tries to strike a pragmatic balance between the need for action and the desire for action to be timely and scientifically grounded. Use of this model will require physicians, other clinical health care workers, and administrators to change their views about the level of scientific rigor that should accompany changes in systems. Currently, changes in the components of health care systems (such as payment mechanisms, compensation, staffing patterns, referral options, workloads, supply contracts, formularies, and locations of care) are not tested on a small scale, nor are measures of outcomes and costs readily available to assure that changes are improvements. The call to increase the rigor of local tests of change is not a request for the wholesale implementation of research methods. It will usually suffice to collect data over time on a few key outcome and cost measures and to annotate the resulting time series graph with the changes that have been made.

The model for improvement also involves an underlying set of theories about how complex systems improve. Most important among these is general systems theory, which has implications for health care that are profound, although not well understood in our profession (and industry). Following this theory, we define a system as "a set of interdependent elements interacting to achieve a common aim." This view emphasizes the importance of interdependence and interaction. The elements alone do not constitute the system; rather, the elements plus their interactions constitute the system

Skills and KnowledgeTo Help with Improvement

Physicians who want to establish improvement as their goal, whether they are motivated by aspiration or by fear, will be more effective if they study these areas and then use the model for improvement to apply what they learn both to their subject-matter area (for example, emergency medicine, chronic disease, or primary care) and to systems of care.

21st Century Hospital ExecutiveDuring the last 10 years, hospital executives were focused on restructuring and re-

engineering their organizations for greater efficiency. They scrambled to cope with cutbacks in federal funding while attempting to minimize their effects on healthcare quality. Executives demonstrating skills in these areas were in high demand.

Today, the leadership skill set being sought by future-oriented hospital organizations has shifted dramatically. This does not mean that financial acumen and operational expertise are no longer needed or important, though.

The shift in “hot” leadership skills is being fueled by amazingly rapid technological developments as well as by demographic changes. As healthcare executive search consultants, we are seeing this shift begin to drive how senior healthcare executives are recruited and how mid-level managers are being developed at the most future-oriented organizations.

As the leadership paradigm changes, financial acumen and operational expertise continue to be very important. An ability to accomplish more with less continues to matter a great deal. What has changed is that beyond financial acumen, a much wider range of complex skills in leadership, communications and management of rapid technological changes are increasingly essential for managers.

Tomorrow’s most successful healthcare organizations will be those that are now identifying existing managers with the strongest potential to develop these broad leadership skills. The next step is to develop those individuals into effective senior executives. Emerging, critical skills that they will need include:

Leaders will need the highest-level skills in asking the right questions of both external and internal experts to elicit the knowledge needed to evaluate and select technologies that represent the best investments for their organizations. As is true today, technological decision-making processes will need to encompass competitive analysis of nearby healthcare entities’ product lines and planned initiatives. They also will need to consider retention of affiliated physicians, the organization’s mission and a variety of other factors and concerns.

Clinical connectivity: Due to increasing depth of physician involvement in management decision-making, tomorrow’s non-medical senior executives will have to connect well with clinical management. Far beyond understanding clinical issues and how they are impacted by management, he or she will have to include physicians’ perspectives and effectively integrate them into decision-making.

In order to elicit effective contributions from physicians, leaders will need to do more than become skilled at understanding clinical perspectives. They will need to engage physicians in business decisions and foster physician understanding of business issues

facing their organizations. Many healthcare CEOs today tell us that effective physician relationship development is among the top three core competencies for rising leaders.

Leadership of diverse management teams: As healthcare organizations succeed in developing more diverse management teams, the most senior executives will need to be effective at leading diverse groups and using each member’s expertise to advance the organization. Beyond racial, cultural and gender diversity, tomorrow’s healthcare management teams also will include members with very different professional and educational backgrounds, forms of expertise, and knowledge bases. The richer the diversity of viewpoints, the more effective the idea generation process will be, with better outcomes the likely result.

21st Century Physician ExecutiveOpportunities for physician executives in hospitals and health systems, drug

companies, HMOs, medical product companies, large group practices and other organizations have expanded during the past decade. The good news for these organizations is that many physicians possess abilities that are critical in executive roles and are more interested than ever in pursuing these opportunities. Aptitudes typical among physicians include critical thinking skills, thoroughness, the ability to solve complex problems, strong motivation to be successful and, in many cases, the ability to work well with other physicians.

Medical training and clinical practice do not, however, encourage development of all characteristics and habits that executives must have to succeed and advance into top-level positions. MBA or MMM degrees provide vitally important knowledge of financial functions and management theory. No degree, however, can make a physician – or anyone else – a successful executive.

Developing As a Leader : Physicians who experience success in leadership roles via hospital medical staff roles or in their practices, especially in larger groups, have likely developed leadership skills. Key skills that these experiences may foster include:

Political savvy.

Financial management and accountability

The ability to hire, manage and motivate the right people

Hospital administration relations

Development of strategic plans and the ability to operationalize them

A healthy, competitive business attitude.

When combined with an advanced degree in business, these traits and skills can catapult a physician into an executive career. Few physician executives find shortcuts on the road to the top, however. A physician with a newly minted business degree typically still spends several years after obtaining the degree gaining the all-important “E” word… Experience.The Teamwork Factor

Expanding leadership skills in a team environment is vital to a physician executive’s ability to advance. In the business world, people work as collaborators when

making decisions and build working relationships that enable them to implement strategies and complete tasks together effectively. Communication-based problem-solving and task management are norms, vs. directing clinical cases on your own. Teamwork is a skill that in some cases, physicians must consciously strive to develop. Part of the teamwork model involves a less hierarchical approach to communication. It is important to respect the opinions of everyone in the process, even though you may think they are wrong.

The complexity of the team environment and multiple matrix relationships is a development opportunity for some physician executives. In most organizations, cross-functional, matrix environments are the norm. That means that you may report and be accountable to two, three or five people, rather than having just one boss. None of these individuals may even work in the state where you are located, let alone the same office. Also, virtual teams may be set up to deal with short-term problems, including representatives of functions as diverse as finance, maintenance, information technology, and human resources. Some team members may be on site, while others are at remote locations. And, the physician executive typically is a member of the team, not the team leader.

Critical Skill Sets for 21st Century Physician Executives

In today’s financially complex healthcare world, overall effectiveness as a communications “bridge” between physicians and non-physicians on the senior management team can reap great career benefits for the physician executive. For example, if a healthcare system is experiencing major shifts in services offered by its affiliated physician groups, with groups trying to leverage new revenue sources by spinning off surgery centers, imaging centers, etc., that compete with the hospital, a physician executive can play a critical role. Although it may not be possible, due to competing priorities, to completely solve these conflicts, effective work with both sides in setting up “win-win” situations for physicians and healthcare systems can make a physician executive a star.

Other skills that help generate success in today’s healthcare world include

o Lead Change by Telling Effective Storieso Bridge the Gaps Between Clinical Outcomes and Business

o Understand Consumerism.

o Develop Key Leadership and Character Traits

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leadership.htm

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21st_century_physician_executive.htm