Authoritarian, command-and-control, orders followed to a T — that’s what most of us assume about military leadership. Movies and media tell us that if we don’t have total control, we won’t be safe from attack or catastrophe. But one person trained in that high-intensity environment was able to cure dissatisfaction and minimize physician burnout by relinquishing control.
Back in 2005, before physician burnout entered the spotlight (according to this NEJM survey, a concern for 83% 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, Neb., a multispecialty medical group with about 20 practices spread throughout the Midwest. At the time, the organization was struggling. Patient satisfaction was falling. Physician satisfaction had fallen to the 44th percentile compared to national benchmarks, and talented doctors were leaving the medical group.
So what did Todd do first? He sat down with each and every physician and listened. He spent months meeting with every single one of the 125 physicians across all the practices, finding out what the group was doing right and what they were doing wrong.
A dim view of physicians’ motives and contributions often dominates policy and regulation discussions. 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 to prioritize and tackle. Instead, physicians outlined three specific sources of dissatisfaction:
- There was far too much administration.
- Everybody was getting a better deal than the people who were taking care of patients.
- “Everyone makes decisions about my practice except me!”
In many healthcare organizations this is still the status quo. MGMA DataDive finds that fewer than 30% of practices — both multispecialty and primary care single specialty — have operational decisions made via collaboration between an administrator and physicians.
To Todd, that would not have a positive impact on provider satisfaction and performance. He believed all other changes would be easier if he could engage the practicing physicians.
Todd began by restructuring his administration and management staff and encouraging physicians by site and specialty to have monthly meetings to discuss their concerns and operate with a sense of ownership.
This was a dramatic change in culture — not to mention $1.6 million in savings. Though some areas saw dramatic improvement, provider satisfaction improved slowly, moving into the 56th percentile nationally in four years (per AMGA Provider Satisfaction Survey results). 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.
The secret? Todd realized that not all doctors are the amazing leaders we assume they should be, and then he took it a step further: 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. Creating practices 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 yearslong 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:
- In each specialty, physicians elect one of their peers to serve on a physician executive committee that provides guidance and broad strategic ideas for the entire medical group.
- Each specialty and site are encouraged to have an executive committee that meets as needed with administration to optimize practice performance. These meetings are led by the physicians, not administrators.
- A 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.
- Physicians 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, working with the physicians to implement changes.
- The clinic administration consists of nonclinical administrators with a president, two vice presidents, eight directors and several 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.
- 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.
It works amazingly well.
For those 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.
The engagement of physicians translated into better performance. When 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, the group was able to better track and report on management of chronic conditions. Initially, the news wasn’t great. Access to that kind of data was new, and practice leaders had assumed they were doing a much better job. It took only 12 months to see massive gains in quality, as blood sugar control metrics improved by 75%.
In fact, on most chronic disease management metrics, 100% of the sites are performing well above the HEDIS 5-star rating.
Physicians care about how the organization overall is advancing. You might think committees are assembled based on who’s been there the longest or has 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. Methodist’s 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 even as the patient panel keeps growing — it increased by 6.7% in the first quarter of 2018.
- Methodist continues 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 accomplished 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. Empowering people in healthcare to lead as they can, to feel a sense of true ownership of ideas and innovation, is the best strategy I’ve seen for improving satisfaction, reducing physician burnout and building practices that achieve our grand healthcare goals. Look no further than Methodist Physician’s Clinic to see how it’s done.