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2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future. Mastering Physician-Hospital Collaboration. Kenneth H. Cohn, M.D., MBA, FACS Cambridge Management Group. May 18, 2006. 11:30-12:00pm.

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mastering physician hospital collaboration

2nd Annual Ellison Pierce Symposium

Positioning Your ORs For The Future

Mastering Physician-Hospital Collaboration

Kenneth H. Cohn, M.D., MBA, FACS

Cambridge Management Group

May 18, 2006


in your opinion which of the following factors is has the most impact on healthcare
In your opinion, which of the following factors is has the MOST impact on healthcare?


  • Nursing shortage
  • Consumer expectations
  • Aging/Demographics
  • Regulations
  • Cost & Reimbursement pressures
  • Outpatient migration


regarding their approach to their jobs how different are hospital administrators from physicians
Regarding their approach to their jobs, how different are hospital administrators from physicians?


  • Completely different
  • Very different
  • Somewhat different
  • Not different

0 / 10

  • Context for collaboration
  • Appreciative inquiry
  • Structured dialogue
trends in physician compensation and practice costs 1996 2002
Trends in Physician Compensation and Practice Costs 1996-2002*
  • Compensation
    • Down 1.2% for primary care
    • Up 8.1% for specialists
  • Expenses
    • Malpractice insurance up 19.3%
    • Support staff up 52.3%
    • Medical supplies up 70.1%
  • Inflation
    • CPI up 14.6%

On average, physicians’ reimbursement did not keep up with practice expenses and inflation.

* Holm CE. Allies or Adversaries: Revitalizing the Medical Staff Organization. 2004. Health Admin Press, 90.


Some Cultural Differences


Paid for seeing patients

Focus on patient survival/ practice

Rapid-fire decisions based on personal judgment and experience

Hour-day-week time horizon

Responsive to needs of patients, families, and colleagues


Largely salaried

Focus on organizational survival

Deliberative decisions based on consensus

Month-year time horizon

Responsive to needs of patients, families, physicians, employees, community organizations, and Board

Gill S. Can doctors and administrators work together? Physician Exec 1987;13(5):11-16.

understanding complexity a path to more realistic expectations
Understanding Complexity: A Path to More Realistic Expectations
  • Complicated problems
    • Require coordination, expertise, and knowledge sharing
    • For example, preparing for JCAHO site visit
  • Complexproblems
    • Relationships are key
    • Experience is no guarantee of future success, but people remain generally optimistic (cf child-rearing)
    • For example, patient flow, risk management, clinical priority setting
  • Glouberman S, Zimmerman B. 2004. Complicated and Complex Systems:
  • What Would Successful Reform of Medicare Look Like?
improving predictability
Improving Predictability
  • Advantage of improved communication: predictability
    • Physicians: better use of time and energy
    • Management: improved competitive position, survival
      • Through their collective decision-making, physicians influence hospital costs, revenue, quality and safety
    • Creating an environment that celebrates learning can lead to competitive advantage
  • Effective dialogue is in both parties’ enlightened self-interest
conflict resolution framework
Conflict Resolution Framework
  • Physicians are used to hierarchical, command-and-control settings, but most organizations are matrices, where people have influence but lack control
    • Our only control is our choice of response
  • Teams go through stages of forming, storming, norming, and performing
    • Teams cannot perform well without storming
  • Conflict, if well managed, leads from creative abrasion to innovation
    • Avoid “Always, never, why, but, just, I disagree, cost”
    • Send “I” rather than “you” messages to deescalate conflict
tips for successful confrontations
Tips for Successful Confrontations
  • Start from a position of safety:
    • Maintain respect
    • Use contrasting to reassure what is not going to happen
    • Establish mutual purpose
    • End with a question
    • “I am concerned about a problem that is affecting all of us.
    • One of our veteran OR nurses quit because she felt that the stress in the room was affecting her health.
    • This is not a witch-hunt. I value your service to the hospital, just as I value hers. I would like to understand better if there is anything that I can do to limit the stress that builds up here. I welcome your suggestions.
    • Is there a time next week that might be convenient for us to discuss the situation?”
successful confrontations ii
Successful Confrontations, II
  • Motivate by exploring natural consequences
    • Make the invisible visible
      • Introduce hidden victims
      • Hold up a mirror
    • Link to shared values
    • Focus on long-term benefits of changing behavior rather than relying on perks or power for persuasion
  • Make a plan that specifies who, what task, and when
    • No “we” in accountability

Patterson K, Grenny J, McMillan R, Switzler A. 2005. Crucial Confrontations. New York: McGraw Hill.

principles of active listening
Principles of Active Listening
  • Concentrate on the speaker, maintaining comfortable eye contact
  • Listen with multiple senses
  • Open one’s stance to convey receptivity
  • Suspend judgment, to maintain objectivity
  • Empathize, trying to put oneself in the speaker’s frame of reference
    • Use summary questions, such as, “Do I understand you to say….,”

Caro J. The Power of Effective Listening, Shawnee Mission: National Seminars Publications; 1989

fundamental collaborative skills
Fundamental Collaborative Skills
  • Inquiry
  • Appreciative Inquiry
  • Structured Dialogue
  • Inquiry is an open process designed to foster the exchange of ideas
  • Decision making is not an event, but a process
  • Tests of strength among competing positions suppress innovation
  • Inquiry encourages critical thinking and constructive conflict
  • Effective leaders:
    • pay careful attention to the way that issues are framed
    • convey openness to new ideas
    • make clear that initial opinions are provisional and subject to change

Garvin DA, Roberto MA. What you don’t know about making decisions. HBR Sept 2001, 110-116.

appreciative inquiry
Appreciative Inquiry
  • Focuses on learning from success instead of uncovering deficits, problems, and individual or collective weaknesses
  • Based on assumptions that:
    • people within organizations respond to positive knowledge
    • both the shared vision of the future and the process for creating the shared vision create the energy to drive lasting change
    • the power of affirmation and envisioning goals increases the likelihood of transforming those goals into reality
differences between problem solving and appreciative inquiry

Identify problem

Perform root-cause analysis

Brainstorm solutions

Pick best solution

Develop action plan


Organizations are problems

to be solved

Appreciative Inquiry

Appreciate what is going well

Imagine what might be

Determine what should be

Design what will be


Organizations are a solution/

mystery to be embraced

Differences Between Problem-Solving and Appreciative Inquiry

Cooperrider et al. Appreciative Inquiry Handbook. Lakeshore Publishers, Bedford Heights, 2003.

adverse consequences of deficit thinking
Adverse Consequences of Deficit Thinking
  • Defensiveness re: blame
  • Fragmentation and turf battles
  • Yesterday thinking, mired in the past
  • Voices without shared vision
  • Negativism and fatigue pervade culture
  • Slow response time
ai story telling
AI: Story-telling
  • Obtaining anecdotes and stories, approaching the data in a fresh way
  • Writing the stories in the first person in the quoted language of the person who told them
  • Sharing them with the rest of the organization generates shared imagery and more energy to improve than pointing out problems and attributing blame

Johnson G, Leavitt W. Transforming organizations through an appreciative inquiry. Public Personnel Management. 2001;30(1):129-135.

the power of story telling
The Power of Story-telling


  • Decrease the inhibiting effects of hierarchy upon an organization
  • Flesh out metaphors, which summarize important messages and make them vivid
  • Provide vignettes that are remembered much more readily than facts

Cox K. Stories as case knowledge. Med Educ 2001;35:852-6

ways to build on physician responses
Ways to Build on Physician Responses
  • Be proactive
    • Rounding, passing on compliments from patients and staff*
  • Reward positives
    • Look for what can agree with vs oppose
  • Show that you value physicians’ time
    • Take a task off their plates, remove an obstacle, modify an inefficient process, close the loop

* Studer Q. Hardwiring Excellence. 2003. Fire Starter Publishing, Gulf Breeze, FL.

what is structured dialogue
What is Structured Dialogue?
  • A process that helps physicians articulate their collective, patient-centered self interest. For example, structured dialogue can help physicians establish clinical priorities for the next 3-5 years:
  • Led by a panel of high-performing, well-respected clinicians
  • Who review and recommend clinical priorities based on presentations by the major clinical sections
  • Clinical priorities are a physician-led statement of the direction in which the hospital should be heading, not capital-intensive budget items

Clinical Priority Setting Process


Board of Trustees

Medical Advisory Panel

prioritized recommendations

Medical Staffs/

Physician Organizations

set guidelines;

appoint presenters

written documents;

oral presentations



Clinical Presenters and peer

participation in departments,

sections, and services

value proposition
Value Proposition

For those interested in:

  • Developing physician engagement and a sense of ownership among their medical staff
  • Deterring physicians from skimming off profitable services, or at least initiating discussion of opportunities for financial collaboration
  • Decreasing the cost and variability of medical care
value proposition1
Value Proposition

The Structured Dialogue Approach:

  • Addresses major issues, such as revenue,costs,financial collaboration, and clinical outcomes
  • Creates an environment in which physicians are accountable to one another and thus open to facilitating long-term change
  • Helps channel hospital investment into high-priority services based on community needs and clinical strengths
  • Facilitates solutions to service problems that do not require major capital expenditures
  • A three-year clinical operating plan, expressing the vision of practicing physicians for where the hospital should concentrate its resources
  • A list of approximately 100 prioritized recommendations, most of which can be implemented without major capital expenditures, improving quality of care and morale
  • A group of 10-15 clinicians, knowledgeable in all major aspects of the hospital’s business, who become a major source of formal and informal medical staff leadership and trust-building
  • An improved work climate, which strengthens employee morale and facilitates recruitment and retention
report summary
Report Summary
  • Panel members have had a unique opportunity to consult with their colleagues and take stock of current medical practice.
  • It has become abundantly clear that we have lost touch with each other. Forces are being brought to bear which many of us have ignored or dismissed, perhaps because we have felt powerless to influence them.
  • Our professional, ethical charge is to provide our services in the manner which is most beneficial to the welfare of our patients. We are now reminded that the hospital has the same responsibility.
  • Our task is to work together to find solutions which will benefit all three- patient, physician, and hospital- and in so doing, gain strength from one another
vi ten steps hospital executives can take now to engage physicians and improve care
VI.Ten Steps Hospital Executives Can Take NOWTo Engage Physicians and Improve Care
  • Encourage practicing physicians to articulate future clinical priorities
  • Include doctors who are users of radiology, anesthesiology, pathology, and emergency services to draw up contract specifications and monitor performance
  • Establish a hotline for process improvement issues
  • Treat top 20% as accounts, with (at least) quarterly visits
  • Ask “go-to” docs, “What can we take off your plate,” at least semiannually
ten steps continued
Ten Steps, continued
  • Map out steps of policies and procedures to improve effectiveness and refine handoffs
  • Have the CIO and programmers round periodically with physicians
  • Develop hospitalist surgical service to off-load call burdens
  • Celebrate and reward all healthcare professionals who exceed their job descriptions to care for patients
  • Establish a pool with fines from using hot-button words and killer phrases to support a worthwhile service or celebration
asking the right questions
Asking the Right Questions
  • Instead of asking:
    • When are they going to tell us what is going on?
    • Who’s going to solve the problem?
    • When is somebody going to train me?
    • Who dropped the ball?
    • Why is this happening to me?
  • Substitute:
    • How can I help?
    • How can I adapt to the changing healthcare marketplace?
    • What can I do to develop my talents?
    • How can I understand others’ challenges and frustrations?
    • What can I do today to excel at my work?
    • How can I become part of the solution?

Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004

qbq prayer
QBQ Prayer

God grant me the serenity to accept the people I cannot change, the courage to change the one I can, and the wisdom to know… it’s me!”

Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004

conclusions and recommendations
Conclusions and Recommendations
  • Promoting effective communication is in both physicians’ and hospital leaders’ self-interest
  • Obtaining quick wins builds momentum and credibility, which are key to successful collaboration
  • Admitting cluelessness is an underutilized way to bring in fresh approaches and energy
  • Start now rather than waiting for crisis