Physician Executive Promotes Process for Managing Change: Building consensus for group plan is key to successful transitions - Leadership

IN THIS ARTICLE...

Thrust into a leadership position after years in solo practice demanded quick thinking for one physician executive. Faced with a need for change, he developed his own process far turning an individual's idea into a plan af actian far an entire group. Learn the steps he took to build consensus and ease resistance to change.

QUESTIONS ABOUT THE nature of effective leadership abound.

* What are the characteristics and attributes of an effective leader?

* Are there natural born leaders or can one learn to be an effective leader?

* Is there a process or formula to facilitate effective leadership?

* How should a novice physician leader proceed?

Four years ago, I was suddenly thrust into a personal leadership crisis.

After many years in solo practice, I became medical director and interim CEO of a 40-physician, 300-employee, newly formed multispecialty medical group.

I pondered the questions above, searched for answers and formulated a personal process for leadership. My answers are certainly not unique and won't work well in all situations or for all leaders in every type of organization.

However, the process helped me find solutions to various situations. It may serve as a successful approach for other novice physician leaders, as well.

Figuring out the plan

My process, outlined in Figure 1, drew on limited personal experience, advice from trusted colleagues and literary inspiration. Specifically, the process crystallized in my mind while I was reading The Peloponnesian War by Thucydides. (1)

It seemed that Perecles perfectly embodied my idea of an effective leader in exhorting his fellow citizens of Athens at a particularly low point in the war.

Leadership often entails initiating change. A successful leader must have a thorough knowledge of the formal mission and vision of the organization, the internal politics, personal missions and agendas of members of the organization.

Successful change can only occur if it is anchored in group mission and vision. And change will not occur unless individuals can be given reasons to overcome resistance to change.

Leaders must also know and understand:

* The external environment and market forces

* Their own personal mission and vision

* Intuitive and analytical reasoning skills

Out of this fertile soil, the seed for a specific plan is born either proactively as a part of a strategic plan or reactively as the potential solution to a specific problem. In other words, the idea might be self-generated or generated by another individual or group.

At this point in the process, the idea is what I call a "my plan," meaning it belongs to only one person or a few individuals.

"My plan" vs "our plan"

The next step is to transform the "my plan" into an "our plan" -- a plan owned by many. It must not be viewed as dogma, but as a starting point for further discussion and deliberation. It certainly should not be presented as "my plan."

This demands proper communication facilitated by an effective leader. The leader's forum is based on trust and respect that depends in large measure on the clinical involvement, credibility and personal integrity of the leader.

Has the leader built this trust through appropriate actions in similar situations in the past and is he or she perceived as a clinical peer? Also, is there a general culture of trust and cooperation within the organization in working toward common goals or are individuals within the organization advancing their own agendas ahead of the common good?

The leader must understand the perspectives of others after the "my plan" is presented for consideration. This helps ensure that the "my plan" will be transformed into the "our plan" and that "our plan" will almost certainly be superior to the "my plan."

This requires both group and individual meetings until consensus is reached.

Stephen Covey describes this type of communication in The 7 Habits of Highly Effective People. (2) He calls it "communicating first to understand then to be understood" where an agent who enjoys the respect of a second party (ethos) can communicate empathetically with the second person (pathos).

Communication

Covey asserts that all too often leaders attempt to skip meaningful communication and proceed directly to the logical conclusion. I think this tendency is especially true for physicians.

Lack of meaningful communication limits the possibility of success and often tarnishes personal and organizational relationships. Positive energy and effective communication create health and well-being.

Achieving consensus or a working majority is a major milestone. Once this is accomplished, implementing the "our plan" is much easier. Once the plan is executed, results should be measured and assessed and another cycle of planning can begin, as in classic continuous quality improvement.

I find this process useful in many types of situations from changing shareholder compensation formulas and setting standards for provider productivity to establishing an internal hospitalist program for our family practice department.

It also works for encouraging individual providers to change their attitude, behavior or performance.

Theoretical and practical knowledge

Innate abilities and knowledge of leadership theory are not enough to ensure effective leadership.

The theory and innate ability must be merged with practical knowledge of effective communication. Leaders must learn to be resilient, persistent and patient when facing resistance and adversity.

Managing change as a physician leader is most often done with a team approach. Gratification and reward are internal. Contrast that to a clinical practice oriented toward individual physicians and external rewards.

In addition, organizational change often occurs much more slowly than changes a physician sees in clinical practice.

And change is neither static nor smoothly continuous. When it is properly managed, it is more like the cogwheeling of Parkinson's disease with sudden advances as the resistance opposing it gives way in small increments when positive energy is applied. There are also moments of shuffling and falling as an organization walks down the path of change.

This process is a starting point for the novice physician leader. It is built on the attributes of knowledge, vision, personal integrity, clinical credibility, and intuitive and analytical reasoning. It is powered by communication, communication, and more communication leading to a successful conclusion.

References:

(1.) Thucydides. History of the Peloponnesian War, Penguin classics. Reprint 1986. Book 2, Section 60 -- 64.

(2.) Covey, Stephen. The 7 Habits of Highly Effective People. Fireside, August, 1990.

(3.) Mark C. Shields, M.D., "Hospital rounding program: An example," Medical Group Management Journal, July/August 1998, p. 10-16.

[Figure 1 Omitted]

RELATED ARTICLE: Case study

Using 'My Plan' and 'Our Plan' to Establish a Hospitalist Program

Several months ago, our 13-provider (8 physicians, 5 extenders) family practice department lost two physicians and a third was moved to our occupational medicine service.

Fortunately, we'd recently recruited two experienced physicians, but they wouldn't be starting work for several more months. Our family practice physicians averaged an aggregate of only five hospitalized patients per day and two admissions per day. So with the increased office demand, I was asked to help start a hospitalist program.

I researched the literature and discovered other groups similar to ours successfully initiated hospitalist programs while preserving quality and patient satisfaction. (3) The findings were consistent with our group's mission statement and could improve provider satisfaction.

In addition, I obtained revenue numbers about our family practice hospitalized patients and estimated incremental revenue and profit related to our family practice physicians working five days per week in the clinic rather than four.

They agreed to this idea in exchange for no hospital duties. This turned out to be a substantial amount of money and met our mission of fiscal responsibility.

Armed with this knowledge, I devised a draft "my plan" that called for internists and pediatricians in the group to admit and care for the family practice patients in the hospital.

They agreed with varying degrees of enthusiasm. The reward was improved group function and a modest increase in personal productivity. It would later result in a salary increase.

Meeting with physicians in the three departments, I obtained some very good feedback. The internists and pediatricians were worried about their increased workload. All were concerned about:

* Continuity of care

* Patient satisfaction

* Loss of family practice hospital skills

* possible loss of hospital privileges

* Potential negative effect on future recruitment, especially in family practice

* Family practice physician burnout in working up to 12 consecutive days

After carefully considering this feedback, we successfully transformed the "my plan" into a new "our plan" with a rotating family practice hospitalist of the week.

This required the hospitalist to admit and care for hospitalized patients in family practice from Saturday to Saturday in the mornings and work in the clinic Monday through Friday afternoons.

They had two days off for each cycle of hospital work--the Wednesday prior and Monday after. In turn, the other two departments agreed to cover family practice patients on weeknights and on weekends after the hospitalist's rounds were complete.

External and internal nurse triage systems at night and on weekends continued with physician backup, and local ER and floor staff were educated on the details of the plan. Many other operational details were addressed, as well.

Significantly, all the original concerns were successfully addressed in the new "our plan" while preserving slightly less revenue and profit. After one cycle of the plan, it seems to be working quite well.

We are tracking:

* Outpatient provider capacity -- demand

* Subjective provider satisfaction

* Revenue and profit

* Patient satisfaction

And we're comparing these to pre-program measurements.

COPYRIGHT 2001 American College of Physician Executives
COPYRIGHT 2002 Gale Group