Authoritarian, command-and-control, orders followed to a T—that’s what most of us assume about military leadership. Movies and media tell us it’s true, especially when it comes to high intensity environments. If we don’t have total control, how will we be safe from attack or catastrophe! It’s strange, then, to discover that a person trained in such an environment was able to cure dissatisfaction and minimize physician burnout by relinquishing control.
Way back in 2005, before physician burnout had really entered the spotlight (according to this NEJM survey, a concern for 83 percent of the clinicians and leaders they surveyed), Todd Grages, a former nuclear biological and chemical officer who served in Operation Desert Storm, was hired to lead the Methodist Physician’s Clinic in Omaha, Nebraska, a multi-specialty medical group with 20 or so practices spread throughout eastern Nebraska and western Iowa. The organization was struggling. Patient satisfaction was falling. Weak performance was having significant financial impact on the health system’s ability to thrive. Physician satisfaction had fallen to the 44th percentile, compared to national benchmarks, and talented doctors were leaving the medical group.
What would Todd do first? Where would he start an effort to transform the organization? By sitting down with each and every physician and listening! He spent 2 to 3 months meeting with every single one of the 125 physicians across all of the practices.
What are we doing right, he wanted to know, and what are we doing wrong.
Depending on your role, this simple act might conjure a scene from The Hunt for Red October: “Red October has turned directly into the torpedo’s path, sir!” says a radar tech, describing Sean Connery’s risky move to evade a catastrophic hit. To which James Earl Jones replies … “Mother of God.” A dim view of physicians’ motives and contributions dominates policy and regulation discussions. It’s been that way for years. It can trickle down. Leaders who are influenced by that view don’t take important steps to engage or empower physicians or work with them in partnership.
Todd assumed he would get a laundry list of complaints, varying by specialty and location, that he would have to prioritize and tackle. Instead, physicians talked about 3 causes of dissatisfaction. First, there was far too much administration. Second, everybody was getting a better deal than the people who were taking care of patients. Third, and top on the list: “Everyone makes decisions about my practice except me!”
In many healthcare organizations this is still the status quo. According to Todd, statistics show that only 30% of practicing physicians and only 20% of primary care physicians participate in decisions about their practice. Does that have a positive impact on provider satisfaction and performance? Todd thought not.
He believed if he could engage the practicing physicians, all other change would become easier.
Todd began by restructuring his administration and management staff, eliminating the CMO, COO, and several other positions. The changes saved Methodist more than $1.6 million. He encouraged physicians by site and specialty to have monthly meetings to discuss concerns about their practices. He encouraged them to run their practices as if they owned them. What he was pushing for was a dramatic change in culture, and that takes time.
Although Todd was seeing dramatic improvement in some areas, provider satisfaction improved slowly, moving into the 56th percentile nationally over 4 years (using the AMGA Provider Satisfaction Survey). But in year 5 the culture shift finally jumped the gap and provider satisfaction rose to the 87th percentile. Two years later they broke into the 95th percentile and have stayed in that ballpark ever since. Todd did it by reversing an argument I made in the last blog: that not all doctors are the amazing leaders we assume they should be, nor do they necessarily want to be.
He asked, How can we help doctors be the leaders they want to be? How can we give them leadership over those things they most want to control?
He didn’t identify the true leaders as much as he identified how people could truly lead. Doctors most want to lead in determining how care is delivered within their practice. Physician burnout seems to be growing, in part, with the percentage of doctors who are employed rather than in private practice. The former became the majority for the first time in 2017, according to the AMA. Creating practices, physician-owned or not, that focus on autonomy is an important part of addressing the crisis, because physicians feel that decisions are taken out of their hands and replaced with tasks that are frustrating and demoralizing.
“It wasn’t even close to perfect when we started,” Todd said of the years long process of rebuilding autonomy at Methodist, “but having practicing physicians succeed and fail on their own merits laid the foundation of our culture, which has driven our provider satisfaction to some of the highest scores nationally. More important, it developed our physicians as leaders. Learning from good decisions and bad decisions provided the experience to make better decisions in the future.”
Todd Grages spent years building a truly physician-led organization. He empowered physicians to feel, think, and act like owners or partners in their practices, even though those practices are owned and operated by a large healthcare system. Today, physicians work with their partners to take responsibility for the best performance of their practices and the optimal care of their patients. Here is how Methodist operates:
- Physician Executive Committee: In each specialty, the physicians elect one of their peers to serve on this committee. The committee provides guidance for the entire medical group, with broad strategic ideas for how things should be done, what changes should be implemented, and so on.
- Site or Specialty Physician Executive Committee: Todd encourages each specialty and site to have their own executive committee that meets as needed with administration to optimize practice performance. In small sites or specialties this encompasses the entire group of physicians. These meetings are led by the physicians, not administrators.
- Physician Quality Committee: The Physician Executive Committee plus 24 additional doctors from the medical group’s primary care sites and specialties work to set quality strategy, monitor performance, and communicate activities and best practices back to their partners.
- Physician partners: Physicians at each site or by specialty meet monthly to decide how practice changes will be implemented. They talk about things that are not going well and new challenges they need to address, and then they make decisions on how they feel they can best improve them. Physicians run the meetings and administrators attend. The manager for the practice reports to both the physicians and administration, and works with the physicians to implement changes.
- Operations support: The clinic administration consists of nonclinical administrators with a president, 2 vice presidents, 8 directors, and a number of managers or supervisors working in the practices. The Methodist system provides operations support for the practices: HR, payroll, IT, billing and claims, contracting, and so on. They keep all other administration to the bare minimum. They still don’t have a chief medical officer.
- Transparency: Metrics used to track performance, such as chronic disease management, are transparent by site and by physician. This transparency has increased overall performance and raised the bar.
What Todd emphasized again and again as we talked is that the physicians decide what happens in their practices, as a group. Each physician participates in those discussions as much or as little as they like. They make and implement decisions locally. If, for instance, a physician wants to hire another nurse or medical assistant, they make the decision with their partners, not based on approval from administration. As long as the practice is hitting the metrics it needs to hit, nobody interferes.
It works amazingly well.
For those readers who hold that dim view of physicians as arrogant prima donnas, this approach might sound dreadful. But when you walk around one of the clinics, you feel and see the effect on the culture—happy, engaged teams providing great care and patient experiences.
Physicians care about the care teams. They want them to succeed, to feel satisfied, and to feel taken care of. Years ago, the staff received bonuses for hitting a certain number of appointments per quarter (reducing no-shows, scheduling appropriately, etc.). Doctors would come in on their off days, if necessary, to guarantee the practice hit the number.
Physicians care about how they’re performing on key outcomes. When they transitioned to the patient-centered medical home model in 2012, they were able to better track and report how well they were managing their patients with chronic conditions. Initially, the news wasn’t great. They had never had access to the data in that way, and they had assumed they were doing a much better job. It took only 12 months to see massive gains in quality, as their blood sugar control metrics improved by 75 percent!
In fact, on most chronic disease management metrics, 100 percent of the sites are performing well above the HEDIS 5-star rating.
Physicians care about how the organization overall is advancing. You might think those elected to the committees are those who’ve been there the longest, with the most power. But it’s common for physicians to elect peers who are just a couple years in practice. Everybody values the diverse perspectives. They want to grow and improve.
Across the board, the data is amazing:
- The AMGA has recognized Methodist as a Best Practice in provider satisfaction since 2012. Their scores in primary care are almost off the charts, scoring more than twice the AMGA average provider satisfaction. This is especially important given recent MGMA data that shows the rising problem of primary care physician shortages.
- Physician productivity averaged at the 72nd percentile in 2017. Time spent at work is 16 percentage points higher than the national average. Yet somehow, physician burnout is not a serious problem in the organization.
- In the last 6 years, more than 100 providers have moved their practices from other health systems to Methodist.
- Their patient panel keeps growing and increased by 6.7 percent in the first quarter of 2018
- They continue to innovate how they provide care for chronic conditions. They have embraced health coaches, rigorous management efforts, specialized primary care practices, and more.
Here’s a final and truly amazing statistic:
They accomplish all of this with administrative costs that fall in the 10th percentile.
It’s amazing how few people you need to make decisions when you empower the right people, the practicing physicians.
A year ago or so, another group in the area lost it’s contract with a major insurer. Methodist absorbed 40,000 new patients! Their competition probably thought the chaos would bring the insurer back to the negotiating table. Lots of people also thought that once the contract was resolved and reinstated, many of those patients would return to their previous doctors. It didn’t happen. Methodist retained all but a fraction. “If absorbing 40,000 new patients had been a strategy pushed down on the practices by administration, it never would have worked,” Todd told me. “It was a cultural thing. The physicians and practice staff made it happen because they wanted to prove they could.”
If you’re a doctor reading this, you can submit your application, but don’t hold your breath. Their turnover is miniscule.