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Health-care organizations have recognized the need to prepare physicians for various leadership and management positions within their own institutions. In the past, those who desired further education had to search beyond the boundaries of their practice to fulfill this need. The demands of a dynamic and changing health-care environment have created increased pressure on organizations to develop a larger cadre of physician leaders and managers among their staff and to accomplish this outcome in a cost-effective, efficient manner. This article examines the results from a survey of leading medical institutions on the existence of in-house leadership and management educational programming. It also documents the approaches used by the responding organizations and the content of their course work. Numerous institutions are accepting the challenge for increased physician expertise in leadership and management by developing their own in-house programs. Future directions for Mayo initiatives in succession planning will be obtained from this benchmark survey.
observed that, with critical reforms emerging during the 1990s, healthcare organizations are changing at “lightning speed.” They noted that, although historically, health-care leaders were predominantly from nonclinical backgrounds, today the presence of physicians as leaders of reform is increasingly strong. The need to educate physician-scholars for leadership in the health-care system has also been an identified priority for “stakeholders” in traditional medical education.
attributed this shift toward physician leadership to four developments in health-care delivery during the late 20th century—the increase in institutions that deliver complex health care, a fundamental restructuring of health-care finances, a progressive change from inpatient to ambulatory care, and the introduction of a series of leadership and management practices known collectively as total quality management. Aluise and colleagues
asserted that, because physicians have a central role in planning and allocating medical care services and other health-care resources, they must be prepared to serve as interface professionals between the delivery of medical services and the management of health care. For whatever the reasons identified, health-care institutions must now make the critical decision of who should be trained in health-care leadership and how this training should be provided.
Some institutions respond to the need for physician leadership by providing opportunities for their staff to attend administrative programs that are offered off campus. Many institutions, however, are fulfilling this need by offering their own in-house leadership programs. At least one managed-care organization has established its own “university” for the education of its physician staff.
During the late 1980s, only 32% of responding hospital chief executive officers (CEOs) informed the American Hospital Association (AHA) that they were providing leadership training for elected and appointed medical staff leaders or heads of departments.
indicated an increasing trend toward organized physician leadership programs for elected and appointed medical staff leaders in community hospitals (35.5% in 1991). Unfortunately, only minimal information is available on the nature of these in-house programs, especially in regard to integrated group practices and academic health centers.
MAYO FOUNDATION SURVEY
In 1995, Mayo Foundation in Rochester, Minnesota, undertook a survey of 122 of the leading medical institutions in the nation. The purposes of the survey were to ascertain the existence of physician leadership and management educational programs among these institutions and to benchmark the efforts of Mayo concerning organized physician education. The survey was conducted under the auspices of the Leadership Education Subcommittee, a group of seven physicians and administrators charged by the Mayo Personnel Committee to establish and implement physician leadership education and development programs. At both the institutional and the individual level, there was a “readiness for development”
new ideas and explore unfamiliar issues. The findings of that surveyare subsequently described.
In May 1995, a survey developed by the subcommittee was mailed to CEOs of the 112 best hospitals (as identified in the July 1994 issue of U.S.News and World Report) and the top 10 health maintenance organizations (HMOs) (as identified in the December 1994 issue of Business Insurance).
The survey was accompanied by a cover letter to the CEO that explained the purpose of the survey and was signed by one of the authors (C.E.B.), who is chair of the subcommittee and a member of the Board of Governors. We chose to undertake our own survey rather than use a sponsoring organization such as the AHA. Names and addresses of the CEOs were obtained from the 1994 AHA guide.
Respondents were asked to answer 33 questions relating to demographics, program existence, history, design, and evaluation. They were asked to respond within 3 weeks. Data from these surveys were compiled and are reported herein by major descriptive category.
Program History and Background.—Of the 122 institutions surveyed, 26 responded; thus, the response rate was 21.3%. (Responses were kept anonymous because we believed that this approach would increase the likelihood of response.) This response rate is comparable to that reported by Collins and Porras
(23.5%) in their recent evaluation of visionary companies from service and industry nationwide. In our survey, 15 of the 26 institutions tracked the external programs attended by their physician leaders. The program that was attended the most often was the one offered for division chiefs by the Harvard School of Public Health (53.3%). The program offered by the American College of Physician Executives was also well attended (33.3%).
Eight institutions (31%) provided some type of in-house physician leadership educational programming, whereas 18 (69%) did not. The ensuing discussion focuses only on those eight institutions.
Of the eight respondents with in-house programs, five institutions had had programs for 5 or more years, whereas two had had programs for 2 to 4 years. Most respondents (86%) with in-house programs used focus groups to identify their physicians' educational needs, although some (43%) were also influenced by legal or regulatory mandates and by the recommendations of external consultants. Most of these institutions surveyed a mean of three groups to assess educational needs. Representatives from the physician executive leadership of the institution (department chairs, chiefs, and presidents) were surveyed by 63% of respondents. Board members, administrators, and attending physicians were each surveyed by 50% of respondents.
Program Design and Implementation.—Of the respondents with organized in-house programs, 88% preferred seminars for program delivery. Most of these institutions (88%) directed their leadership programs to their executive tier, although many (63%) also targeted attending physicians and administrators.
Programs were generally offered on weekdays, during the day, or on work time, and they were usually well attended. Most institutions (88%) did not charge for program attendance. Of the eight responding institutions, four always provided continuing medical education credits to physicians for program attendance, whereas four had never provided continuing medical education credits.
Speakers for intramural programs were usually identified through institutional networks, through recommendations of others, and by institutional representatives visiting universities, colleges, conferences, or workshops. Of the seven respondents who answered this question, four indicated that 26 to 49% of their speakers were from their own organization, two had intramural speakers at least 75% of the time, and one had intramural speakers 50 to 74% of the time. For most institutions, the typical 1-day fee for an outside consultant was between $1,000 and $5,000. Overall program costs for 1994 varied by institution and ranged from $25,000 to $250,000.
The topics most likely to be addressed in leadership programs included quality management, issues in health care, leadership principles, strategic planning, management principles, economics of health care, finance and accounting, and government and policy issues Fig. 1. Each one of these topics was addressed in organizational leadership programs by more than 60% of responding institutions. Courses that dealt with communication and interpersonal skills were of less importance.
An equal percentage of institutions (29%) indicated that participants usually attended between 8 and 16,17 and 24, or more than 30 hours of in-house leadership and management educational programs annually. Participants generally attended these programs during working hours. In addition to leadership educational programs, most institutions offered other developmental activities for physicians, such as tuition reimbursement, planned mentoring, or on-site M.B.A. programs.
Program Evaluation.—Of the eight institutions with organized leadership programs, two had no formal mechanisms for obtaining participant feedback. The other six indicated that participants generally rated their programs as good or very good. Organizational perspective on program effectiveness was similar. More than 70% of the institutions believed that their leadership programs were effective in achieving their stated objectives.
The rapidly changing health-care environment and the necessity to prepare physicians for future roles in managed care and in-system governance were some of the factors cited for the development of in-house physician leadership programs. The belief was that organized institutional programming could be tailored to specific knowledge deficiencies in physician staff while providing the key business and management skills needed for them to become collaborative partners in the delivery of cost-effective, quality health care.
Benefits of In-House Programs.—In addition to building general management and leadership skills, organizations that participated in the survey wanted their in-house programs to be vehicles for communicating internal activities, finances, and plans to physician staff. Programs were designed to accomplish manifold objectives, including assisting physicians in the transition from clinician to manager, developing leadership potential in young physicians, and preparing physicians to understand and manage the changes resulting from the evolving health-care environment.
Not surprisingly, participating institutions with organized in-house programs believed that the customization of programs to fulfill organizational needs was one of their greatest strengths. They also identified faculty expertise and a team environment as other important program strengths. Some organizations were able to identify tangible achievements from their programs, citing improved Joint Commission on the Accreditation of Health Care Organizations scores or measurable gains in specific leadership skills. In addition, institutions ascribed the building of collegial relations within their organizations as an important indirect benefit of these programs.
Several suggestions were also volunteered by the respondents. These included securing the involvement of formal and informal physician leadership, developing an advisory board primarily composed of physicians, focusing on customization of the program to fulfill the needs of the organization, maintaining small class size to foster interactive learning, establishing some means to measure learning, and considering the provision of academic credits toward an M.B.A.
Limitations of the Study.—The responses to our survey suggest that several leading medical institutions have organized in-house physician leadership programs and that some are also extending this service to administrators. Because our survey was mailed anonymously with a return envelope, we do not know if the responses actually reflected the position of the CEO, an educational coordinator, or a person in human resources.
In light of our response rate, the margin of error for our sample is ±20%. Thus, it is difficult for us to extrapolate the results of our survey and to apply them to the entire population of medical institutions that provide in-house physician leadership programs. The main purposes of this report are to relate the findings from the survey and to communicate common characteristics among responding institutions.
We could have used a different approach to produce higher response rates. A premailing telephone call may have identified the appropriate person to whom we should have addressed the survey if that person was not the CEO. Eliminating deadlines on responses and using a sponsoring organization such as the AHA might also have resulted in higher response rates.
Our survey should provide insight into the process used by some medical organizations to develop and implement in-house programs for physician leadership. Among organizations, no uniform approach has yet emerged for the development of physician leadership and management skills. Institutions that participated in the study seem to be broadening their base of physician leadership talent by targeting not only physician executives for organized in-house programs but also other attending physicians who might be interested in ongoing leadership opportunities within the organization.
The programs in these institutions are appreciated and valued by participating physicians and often result in the building of a collegial climate within the organization. In addition, in-house programs are primarily designed to tailor leadership and management education; thus, they are consistent with organizational culture and needs. Often, the topics selected are those that help physicians meet the challenges of external environmental forces.
Because of the demands of a highly competitive and rapidly changing health-care environment, the trend toward more in-house leadership programs in medical institutions will continue. Good university-based programming exists for those who seek leadership training. Organizations will continue to identify ways to prepare their physicians to assume various leadership positions while medicine continues its evolutionary path into the business environment.
No longer a solo practice: how physician leaders lead.