Published in the July 2016 issue of Today’s Hospitalist
AS A CONSULTANT who’s been called in to help fix many troubled programs, John Nelson, MD, has seen plenty of bad hospitalist leaders.
“While an effective leader isn’t the only item you need for optimal group performance, it is a necessary one,” said Dr. Nelson, speaking at a practice management precourse during this year’s Society of Hospital Medicine annual meeting. “There are too few talented leaders to meet demand.”
But that doesn’t mean subpar leaders can’t improve. Dr. Nelson, who has been a hospitalist group leader for decades, most recently at Overlake Medical Center in Bellevue, Wash., shared many of the pitfalls he sees hospitalist leaders landing in, along with his vision of what effective leaders should be doing instead.
Too often, said Dr. Nelson, group leaders either see themselves as being powerless, or they settle for such circumscribed roles that they effectively give their power away.
“You cannot work a seven-on/seven-off schedule and expect group leadership to be on hold when you’re not there.”
He has run into leaders, for instance, who cede active leadership to a practice administrator, or who see their main role as filling out the group’s schedule, which is really a clerical function. Or they believe their key responsibility as leader is to be the sweep doctor who fills open shifts.
But Dr. Nelson said that group leaders shouldn’t work any more extra shifts than everyone else in the group. And one hallmark of weak leadership, he explained, is group leaders who don’t negotiate protected administrative time for themselves.
He cited one rule of thumb—one he credited to Win Whitcomb, MD, his fellow co-founder of the Society of Hospital Medicine—that holds that group leaders should dedicate 5% of their own FTE for administrative time for every hospitalist FTE in their group. Under this rule, someone running a five-person group would have one-quarter of their time protected for administrative duties, while those with 10 physicians would set aside half their time for administration.
But Dr. Nelson pointed out that Society of Hospital Medicine survey data indicate that leaders in groups of four or fewer doctors tend to work 23% FTE of administrative time, while those heading up groups of 30 or more dedicate one-third of their FTE to administration.
Further, just having dedicated time isn’t enough. According to Dr. Nelson, many leaders try to squeeze their administrative time into their clinical practice. They make the mistake of not carving out administrative time when they’re working clinically, and they don’t do administration if they are off shift.
“This is going to very much limit your success,” he said. “You cannot work a seven-on/seven-off schedule and expect group leadership to be on hold when you’re not there.” Instead, leaders should be available for some administrative work on most business days, including sometimes setting aside time on days when they’re working clinically.
Other red flags that indicate a low-functioning leader: little knowledge of group performance; failing to set performance expectations, either during orientation or doctors’ annual performance review; and an inability to hold group members accountable for performance shortfalls.
The first steps toward accountability are tracking and distributing both group and individual performance data. Dr. Nelson said his group opts for unblinded data, with hospitalists aware of each other’s performance. They also fill out an annual survey to rate each of their hospitalist colleagues.
Whether or not your program chooses to unblind data, it’s important to keep performance data front and center. Leaders need to deliver those data in the same format on a predictable schedule. They should also use multiple ways to broadcast results: e-mails, posting performance data in the hospitalist office and discussing performance at meetings.
For issues that leaders want group members to focus on, Dr. Nelson recommended weekly e-mails. That’s what his group does with patient satisfaction data, sending out an e-mail every week that reports the number of satisfaction surveys received that week, the percentage of top-box scores for each of the three physician-related questions, and any comments patients write in about individual physicians.
Effective leaders also need to regularly recognize good performance, giving good performers shout-outs at group meetings or sending doctors a brief note.
Just as importantly, high-functioning leaders need a method to address underperformance. Dr. Nelson said he understands that some people are uncomfortable with conflict and don’t want to tackle performance problems head-on. It’s a discomfort he shares.
“For tough conversations, I often get someone to sit with me, like a chief medical officer,” he noted. “If it’s a really serious talk, I like to have someone from HR with me.”
Settling for a small role
Another indication of subpar leadership, and one that’s found across all specialties, not just in hospital medicine: Physician leaders who see themselves as a “union boss” whose job is to “extract concessions from administration and go beat up the hospital,” Dr. Nelson said.
But such doctors tend to have short stints as leaders because they’re not able to get physicians on the same page as administrators in terms of quality improvement and patient safety initiatives. One possible solution is to have such doctors attend any number of leadership development courses. “That can open one’s eyes to the bigger picture of what success looks like” when leaders promote both the interests of the hospital and of the group, said Dr. Nelson.
Another solution is for “union bosses” to be mentored by other physician leaders—and in general, good leaders spend time with other leaders. Physicians who head up hospitalist groups should be on their hospitals’ medical executive committees, he noted.
They should seek out elected positions like president of the medical staff and actively lead key hospital committees such as quality or process improvement. And they should network with other hospitalist leaders, as well as physicians who head up other clinical departments.
Dr. Nelson also pointed out that some responsibility for hospital leadership rests on the shoulders of rank-and-file hospitalists. One complaint he hears over and over from hospitalist groups is that they’re given no respect and are viewed by the rest of their medical staff as super-residents. But, he added, he invariably sees such groups failing to engage with other doctors in the hospital.
“At lunch, all the hospitalists go to the doctors’ lounge, get their food to go and then eat together in their own office. They’re shooting themselves in the foot,” he said. “You need to seek out relationships.”
Finally, poor leaders are content to take a back seat during recruiting. In fact, said Dr. Nelson, recruiting new physicians and reaching out to doctors who apply for positions with his program are his favorite roles as a group leader.
“I like to call prospective recruits within an hour or two of their contacting our recruiter, even if we don’t have an open position,” Dr. Nelson pointed out. “I don’t rely on recruiters because I feel that’s my job.
The recruiter is there to help me.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
What it takes for good group meetings
IF YOU WANT to gauge how effective leadership is within a group, look no further than group meetings, or the lack thereof. Poorly led groups hold group meetings only PRN, said John Nelson, MD, an experienced hospitalist leader and principal with Nelson Flores Consultants, a national practice management consulting firm. And groups that hold only random meetings have a hard time engaging their physician members.
Instead, group meetings should be regularly scheduled, said Dr. Nelson, speaking at a practice management precourse before the Society of Hospital Medicine’s annual meeting. Moreover, meetings should focus on problem-solving, with agenda items e-mailed out ahead of time to group members.
“You also need a real method of making decisions, which you should write down, and you shouldn’t rely exclusively on consensus,” said Dr. Nelson. Instead, set ground rules for voting.
Can only full-time group members vote, for instance, or should part-timers have some say? What constitutes a quorum, do votes need a simple or super majority to pass, and how should tie votes be resolved? Group members should also receive meeting minutes, with some mechanism (or time set aside at each meeting) to track agenda items through to resolution.
Programs also need to decide how many meetings members must attend. (Phone-in attendance should be fine for doctors off-shift.) Dr. Nelson said he expects members to attend at least 75% of group meetings.
Then there’s this question: Should hospitalists be paid to attend group meetings? Dr. Nelson said he doesn’t believe so.
“Attending meetings is a basic expectation of you doing your job,” he explained. However, he thinks it’s OK for meeting attendance to act as a “light switch” to turn off or on doctors’ access to bonuses.
Say, for instance, potential bonuses in your group could total 20% of your income. Doctors who don’t attend an agreed-upon percentage of group meetings wouldn’t be eligible for those bonus amounts.