Professional Documents
Culture Documents
There are two important cultural distinctions to be made. The first involves the
cultural differences between managers and physicians. The second involves the
differences between corporate management and the individual entrepreneur. Each
is highlighted below.
Table 1.2 summarizes some of the primary cultural distinctions between managers
and physicians. These differences have their roots in both the self-selecion of
individuals into different careers and the different training and socialization
experiences associated with professional education itself (Kurtz,1987). For health
care executives, the underlying basis of knowledge is primarily the social and
management sciences (economics, sociology, quantitative methods, finance,
marketing, organization behavior, etc). while for physicians the primary basis is
the biomedical sciences. The patient focus of executives is typically broad,
encompassing all patients in the organization today as well as the larger
community from which future patients may be derived. In contrast, the physicians
focus is much narrower; the concern is with individual patients and their
immediate needs. In regard to exposure to other health professionals and patients
while in training, helath care executives typically receive relatively little exposure,
while physicians receive a great deal. In contrast, physicians receive almost no
exposure in training to the larger business/economic world of health care. The
time frame of action for the health care executive is typically longer than for
physicians. The executives’ strategic responsibility to position the organization
vis-a-vis the environment requires a long-run focus and orientation (while still
attending to daily operations); physicians are much more short-run-oriented-in
part, due to the need to solve immediate clinical problems facing their parents.
The two groups also have different views of “evidences”. While both managerial
decision making and clinical decision making are fraught with ambiguity and
uncertainty, the training and background of the health care executive leads to a
greater acceptance of “soft” qualitative data loosely linked cause-and-effect
relationship upon which to base decisions, while the training and
Tabel 1.2 Cultural Differences between Health Care Executives and Physicians
Attribute Health Care Executives Physicians
Basis of knowledge Primarily social and Primarily biomedical
management sciences sciences
Exposure to relevant Relatively little exposure Great deal of exposure to
other while in training to physicians, nurses, nurses, other health care
other health care professionals, and,
professionals, or patients patients; little exposure to
broader business/economic
world of health care
Patient focus Broad: all patients in the Narrow : one’s individual
orhanization and the patients
larger community
Time frame of action Middle to long run; Generally short run; meet
emphasis on positioning immediate needs of
the organization for the patients
future
Rules of evidence Understand the need to “soft” qualitative
act on “soft qualitative information viewed with
information; loose- skepticism; prefer “hard”
linked cause-effect fact; tightly linked cause-
relationships that may effect relationships that are
not be well undestood well understood
View of resources Always limited; Resources essentially
challenge lies in unlimited or at least should
allocating scarce be unlimited; resources be
resources efficiently and available to maximize the
effectively quality of care
Professional identity Less cohesive; less well More cohesive; highly
developed developed
A recent study of 152 CEOs revealed that the lack of physicians commitment was
the most frequent reason given for the failure of hospital projects, and ineffective
administrator physician relationships were also cited as a leading factor (second
only to reimbursement constraints) contributing to industrywide hospital failures
(Boyle 1998). Physicians are beginning to experience similar consequences. the
stakes are indeed high. What is required is a redefinition of the hospital physician
relationship along multiple lines-clinical, economic, ethcal, legal, and
organizational. This will require a new form of social contract based on mutual
involvement and shared authority and influence. Some models of newly emerging
relationships are discussed further in the next chapter.
ECONOMICS-BASED PERSPETIVES
Buyer-Seller Relatioship
In the economics-based perspective, physicians are viewed as purchasers or
“demanders” (Harris 1977) of hospital services, while hospitals are viewed as the
sellers or “suppliers”. Thus, physicians constitute the “demand organization”
particularly as reflected through the medical staff organization, while nursing and
the various hospital ancillary support functions constitute the “supply
organization.” Under this perspective, the hospital’s primary mission is to meet
the needs of the buyers (i.e., the demanding physiciaans). To help assure that this
occurs, the buyers organize themselves into a cooperative represented by the
medical staff organization structure (Pauly and Redisch 1973). This model is most
consistent with the physician-controlled era of the 1930-1974 period noted in
Chapter 1. The Changes that have occurred in the succeeding years, however,
have posed a distinct threat to this concept of the relationship since they have
significantly changed the hospitals financial ability to meet physician demands on
the one hand and, on the other hand, have given rise to multiple groups of new
buyers (employers, consumer groups, and managed care purchasers) to whom
attention must be paid.
Under the buyer-seller model, the medical staff organization was a useful
mechanism for minimizing the transaction costs on the part of both hospitals and
physicians. Hospitals faced accreditation and legal responsibilities that required
physician input and oversight in reviewing the quality of patient care . these
needs were met through the credentials committee and various medical audit and
utilization review committees through which physicians voluntarily gave their
time as part of the obligations associated with hospital privileges. Physicians, in
turn, minimized their transaction cots by sharing among themselves the
responsibility for overseeing quality assurances activities. The medical staff also
served as a useful mechanism for organizing referrals in support of the physician’s
private practice (Shorthell 1973; Burns and Wholey 1989).
The physician-hospital relationship, however, is a special type of buyer-seller
relationship because of the seller’s (i.e., the hospital’s) role in overseeing much of
the patient care activity that has been “purchased”. Once the purchase has been
made, the buyer normally takes responsibility to the hospital, enabling physicians
to maintain their autonomy and pursue other income-producing activities in their
offices. The hospital’s role is essentrially that process through the medical staff
organization functions and activities described above, which also helps to reduce
the transaction costs for the hospital. The transaction costs between the hospital
and physician can be further reduced through such mechanisms as employing full-
time or part-time salaried medical directors or executive vice presidents for
medical affairs, and through part-time or full-time salaried chiefs of service. To
the extent that hospital’s interest to align physicians as closely as possible to the
hospital in order to improve the hospital’s position vis-à-vis other purchaser of
care and to further differentiate itself from competitors (Porter 1985,418).
Examples of these effects are discussed further in chapter 12 (Joint Ventures) and
Chapter 17 (Strengthening the relstionship).
Principal-Agent Relationship
An agent is someone who acts on behalf of or in place of another (the principal).
In the doctor-patient relationship, the doctor is the agent acting on behalf of the
patient. But in the hospital-physician relationship, in determination of who is the
principal and who is the agent may vary. If the physician is viewed as the buyer
and the hospital the supplier, then the hospital is the physician’s agent in, for
example, negotiating to obtain discounts on supplies or in purchasing major new
technology. From this perspective, it is easy to understand physicians’ anger when
the hospital does things that appear to be competitive or contrary to physician
desires. The hospital as agent is viewed as not acting in the principal’s best
interest. It is not simply an economic issue but a betrayal of trust
As the patients’s agent, the physician’s goal is to use whatever
resources are needed to restore the patient to health. But as the
agent for the hospital, the goal is to limit the amount of resources
need to restore the patient to helath as expressed through
conservative testing and early hospital discharge (Eisenberg 1986).
While conserving resources and providing quality patient care are
not inherently incompatible, they place increased strain on the
hospital-physician relationship.
ORGANIZATION-BASED PERSPECTIVE
In the organization-based perspective, hospitals and physicians are viewed as two
realtively loosely coupled entities with defferent goals and objectives but with
some interdependent need. This relationship has been variously described as
resulting in a dual herarchy (Smith 1955), a heteronomous organization (Scott
1982), or an incompletely designed organization (Shortell 1983). As expressed by
friedon (1970, 175). “the profession constitutes a continuous breach in the walls
of the organization.” Wheter the economic or legal form of the relationship is
conceived of as buyer-seller or principal agent is immaterial to the fact that
organizational problems are created. These primarily involve coordinating work,
managing conflicting interest, and setting strategic direction. Organization
theorists also offer proposals or models for modelling with the peroblems. These
center on mutual involvement and sharing of power and authority, variously
described as a conjoint model (Scott 1982), shared authority (Shortell 1985), and
professional bureaucracy (Mintzberg 1979; Schneller and Hughes 1988). This
approach requires the willingness of both parties to give up something in the
present to gain a potential desired good in the future. Hospital executives must be
willing to give up or share some of the authority and control that they have gained
in recent years, and physicians must be willing to give up some practice time and
professional autonomy. The reward to be gained in the future is organizational and
professional succesa-to position both the hospital and physician as the preferred
providers of health care in their communities.
HSOSPITAL STRATEGIS
RELATIONSHIP TRACERS
STRUCTURE/PROCESS FACTORS Physician disciplining-denial or restriction of
Medical staff organization and structure privileges
Physician involvement in management and Physician credentialing
governance Impaired physician
Board and management involvement in a Physician recruitment-open vs. closed staff
medical staff issues Hospital-physician ambulatory care
Organization of managed care relationship, competition
parallel organizations, etc Malpractice
Exclusivity in hospital-physician JV
relationships
ORGANIZATION CULTURE
Efforts to contain costs-staff reductions, etc
What is it ?
Quality assurance and improvement
How is it used ?
Young physician involvement
Past history and tradition
Physician Leadership
Involvement is a two-way process. Most of the study sites were fortunate in
having strong physician leadership willing and able to accept responsibility. Such
leadership stemmed form many sources. Some of it grew form a history of
involvement and nurturing. This resulted in a sense of responsibility to keep the
leadership strong. As expressed by a west allis physician: “we have had an
unbroken string of good chiefs of staff. No one wants to srew it up.”
In other cases, management worked hard over a period of many years to develop
staff leadership. As expressed by a scripps physician: “ I think the maturation of
physician organizational skills is very important. I think that takes time. For us, I
think in another couple of years we will be there. I don’t think we’re there yet. I
think in another couple of years we will be there. I don’t think it can happen
quickly even when when you have a number of responsible and sophisticated.
Many of the sites engaged in active programs of physician management
development. These included participation in conferences, institues, and semnars;
university-based management courses; extending the terms of office for physician
leaders; creating five nonvoting positions on the medical staff executive
committee to expose young physicians to hospitalwide issues; rehearsing
meetings with the medical staff executive committee; pushing decisions and
encouraging medical staff responsibility for decision making. An expressed by a
West Allis Boar member: “we try to see their (the doctor’s) problems form the
doctors’ (page 66)
ACOMMITMENT TO VALUES
Medical staff, queen of the valley hospital
We have commited to being leaders in shaping our society’s health care. We
believe that we must serve the board health needs of persons: spiritual, physicial,
social, and emotional.
We stand at the heart of the health care services, interacting with patients,
families, professional colleagues, agencies and isntitutiions. As medical staff
members of the Queen of the Valley hospital, we are associated with an institution
which has a strong tradition of values. We are vital partners in the concrete
expression of those values. Therefore, we offer the following statement.
We believe:
Life is scared. We should courageously defend life but should not do so when all
attempts to preserve life are futile.
Sickness and healing are important events that effect all dimensions of a person’s
life. Physicians should address the spiritual, emotional and social dimensions of
illness.
Informed competent patients are their own primary decision makers. Our
decisions about patient care involve the professional expertise and the personal
values of the patient, family and professionals. The conscience of the physicians
should be respected by parents and institutions.
Quality patient care is effected by clear, respectful, communication between
family and health care professionals.
Nurses have a unique relaltionship with doctors, patients, and the patient’s
families. Their presence and expertise is of geat importance in the care of patients.
Human dignity demands that our society insure universal acces to an adequate
level of health care. Physicians should play an active role in this process.
Physicians should serve on medical staff and peer review committees. Physician
should constructively challenge the goals of te institution and examine with
insight their own role and level performance.
Only a community of shared vision can achieve these far reaching goals. We
commit ourselves to be part of a community to work for these goals. We recognize
that resources are limited and require hard choices. We will join making such
choices as fairly and accountably as possible.
Providing feedback is a special aspect oof communication. Such communication
involves both providing information and elicting a response. A number of
suggestions growing out of the experiences of the study and existing literature
(Athos and Gabarro 1978) are relevant :
1. The feedback should be given with attention. The communicator must be
very aware of what is being said to recipient and alert to the recipient’s
verbal and nonverbal responses.
2. The feedback should be directly expressed. Executives and physician
sometimes fall into communication traps due to the inclination to withhold
information or make overly vague statements that are of little value. The
most useful communication is direct, open, and concrete
3. The feedback should be free of evaluative judgments. Situations and
events should be described as you see them but should be done in a way
that does not put the recipient on the defensive. If a judgement is offered,
it should be clear that the issue is one of subjective evaluation. The other
party should be invited to make their own judgment and evaluation of the
situation. In this fashion, engagement in joint problem solving can occur
4. The feedback should be well timed. Feedback should be given when the
receiver is receptive to it and should be sufficientlyn close to the event
being discussed for it to be fresh in their mind. Storing up comments from
the past can lead to a buildup of negative feelings and reduce the
effectiveness of feedback when it is finally given
5. Feedback should be readily actionable. It should center around behavior
that can be changed by the receiver. Feedback concerning matters outside
the control of the receiver is less useful. In addition, it is useful for those
communicating feedback to suggest alternative ways of behaving that may
allow the receiver to think about different ways of tackling the problems
identified.
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