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    Marieann Thornburg, MBA, FACMPE

    The ideal administrative structure for medical school departments and clinical practices has been discussed often in the past decade. There has been talk of creating one all-encompassing basic science department. Some schools have considered combining clinical departments into various pods such as primary care, surgical specialties and medical specialties. Some organizations have moved their faculty practices under hospital leadership, which introduces additional complexities such as service lines. The combination of research and clinical practice requires physicians to work across specialties. As a result, the industry has created centers and institutes. Despite the noble goal of simplification, the opposite has happened. In fact, administrative roles have proliferated, and the span of control (employee-to-management ratio) has gone down. While there are more titles, more bosses, more layers and more structures in many institutions, nothing really seems to work any better.  

    As money remains tight for the foreseeable future, both the cost and performance of administrative  infrastructure must be addressed. Since medical schools and their health system partners have been unable to define the ideal organizational structure over the past decade or more, a new approach is needed. Consider reversing the usual process of creating an organization chart and then fitting people into boxes. Instead, by exercising the discipline needed to first define the ideal administrative skill set needed, organizations may find themselves defining the ideal organizational structure. Said another way, if organizations have the right people performing at their optimum level (assuming organizations are willing to create such a culture), perhaps structure isn’t as important as historically thought.

    As work environments become continually more challenging and complex, a new administrative skill set must evolve. No longer is the rote management of people and processes enough to keep organizations competitive or assure fiscal viability. If change is to occur, a 21st century skill set must look quite different from the past and comprise seven critical competencies for future administrative leaders — characteristics that truly matter and will continue to matter far into the future.

    Partner effectively. Traditionally, administrators and leaders protect their turf, even at the expense of others within their organizations. Internal competition has been acceptable even when it has been unhealthy. Energy has gone into protecting a microcosm instead of contributing to the greater good. Some organizations have created an environment where there are winners and losers rather than a culture of “when we all win together, the patient wins.” Future administrators must collaborate at levels previously unheard of, with hospitals, payers, communities, referring physicians and especially nursing professionals (the care navigators of the future). Silos must break down: research versus clinical, departments versus service lines, inpatient versus outpatient, physicians versus staff, etc. Strong partnerships must be formed at all levels within and outside each organization. Administrators of the future must learn how to partner and collaborate. Astute organizations should start now, teaching those skills and evaluating administrators' ability to partner as part of their performance review.

    Recruit and retain a productive and engaged physician workforce. Physician satisfaction matters. A physician shortage is anticipated in the upcoming years, and even now physicians are opting for careers outside academic medicine. For the past decade, medical schools and health systems have focused on physician productivity and compensation. While these factors are important, other factors are equally important. Academic organizations often have higher benefit costs (some organizations have benefit costs in excess of 45%, purchasing benefits that are either too many years off or that don’t matter to many) in lieu of salaries, when the fact is that younger physicians care more about salaries, especially with increasing medical school debts. Current models are outdated. Academics is also slow to get rid of the “dead weight” — physicians who are enabled to spend their time thinking, contributing little to nothing in terms of revenue at the expense of their hardworking colleagues. Most of our academic clients do not conduct any relevant physician satisfaction surveys and have no idea why physicians stay or leave. Likewise, exit interviews rarely are conducted, meaning that organizations miss out on valuable feedback. Little annoyances become big frustrations in the workplace. Often these things are easy to fix if the problems receive proper attention and intervention. Administrators of the future must learn how to create a positive workplace for physicians and staff — a place where people want to come daily, where they feel productive and satisfied with their performance, and where their focus is on doing what they love to do rather than just surviving the chaos of the workplace. (Hopefully that includes taking care of patients. If not, you’ve got the wrong people.)

    Get the patient through the system. Access and throughput is the lifeblood of a financially stable healthcare enterprise. There is a reason that retail health and virtual visits are thriving. Patients (at least the ones who have the resources to pay) want access to care when they want it — when it’s convenient for them. That care has become plentiful in many communities. Academics for the most part aren’t participating in many of the 21st century patient access tools: call centers that run around the clock, patients scheduling their own appointments online, urgent care and/or extended hours, primary care virtual visits, etc. Instead, academia continues to put up all kinds of obstacles — reviewing patient records before granting appointments; scrutinizing every referral for appropriateness; screening out, delaying or even bumping appointments — anything but seeing the patient (which would actually take less time than enacting the barriers described above). Keeping patients out also costs far more than actually seeing them, between staff time, unused schedule slots, dissatisfied referring physicians, delays in care and ultimately patients who just go elsewhere. Another flaw in our thinking is how many academic practices utilize advanced practice providers (APPs) and registered nurses (RNs) who serve at the convenience of the physicians rather than improve patient throughput, outcomes and education. Underutilization of APPs and RNs is costly, yet there seems to be little commitment to using these highly trained professionals at the full level of their licensure. Patient satisfaction surveys usually ask about access and wait times. These typically yield the lowest scores but often get neutralized by less meaningful items, which raise overall scores and result in access being ignored. How would healthcare organizations look if, for the next quarter, patient satisfaction questions only addressed access and throughput issues? Administrators of the future will prioritize patient access. After all, it is the only dependable means of creating revenue.

    Get the money in the door. In the recent past, accounts receivable (A/R) management has improved in most organizations. Billing platforms have stabilized, automation has improved, A/R days and other metrics have improved. Electronic records, in most case, have improved documentation, and in some cases revenue has increased. Cash yield improvement sometimes allows organizations to procrastinate when it comes to tackling the more difficult factors, often those related to behavior. Too many organizations are painfully hesitant to tackle no-show rates (patient behavior), physician cancellations and missing documentation (physician behavior). Old issues remain, such as denials for noncredentialed providers and missed filing dates for delayed charge entry and/or documentation, resulting in avoidable losses. Many organizations still do not audit payers for underpayments and inappropriate rejections. Many of the metrics healthcare organizations use to gauge revenue cycle performance have not changed in the past decade. In many instances, the things organizations diligently measure often do not result in actionable information, either because they are reported at a global level or simply do not look at metrics that focus on improved cash per unit of service (total RVU). Truly informative dashboards must be developed to replace the antiquated reports used in many organizations. A new and significant challenge in today’s organizations involves managing high-deductible plans in a reasonable way. The industry has spawned a new category of bad debt, not as a result of self-pay or underinsured patients. Most billing systems are not accounting for this phenomenon, and managers cannot manage what is not being measured. Patients often do not understand their plan designs and are not prepared to pay what might be full charges. Physician offices are still unable to tell the patient what the cost of care will be in advance of the provision of care. Administrators of the future must develop a much greater understanding of customers and cash. Patients are charged flat rates for virtual visits and retail health visits (prices that are not only published on websites but also advertised on TV). Physician office practices must begin incorporating such a simple approach when dealing with paying customers. After all, cash at time of service eliminates all billing costs and all bad debt.

    Deliver great outcomes. Regardless of how far academic medicine ends up on the population health continuum, payers are starting to measure quality, as are patients. While the internet is full of misinformation, reliable sites do exist and patients are better informed. Great outcomes require more than great physicians. Care must be coordinated, safely and timely instead of fragmented and unorganized. Communication must exist among the entire care team, which requires respect for nurses, case workers, APPs and all levels of staff. Our hospitals and physician practices must have safe environments with technology, tools and equipment that assist staff in avoiding errors rather than contributing to mishaps. Residents and fellows must be adequately trained and supervised (their care must contribute to the quality of care to patients, not negatively affect it). New staff require adequate orientation, training and oversight. Administrators of the future will recognize that great outcomes are recognizable, measurable, reportable and cost-effective.

    Use sophisticated technology. The healthcare industry appears to have survived EHR implementation and is anxious to take a break from escalating IT expenses and implementation dramas. But technology is a part of our lives, and our understanding and use of it will need to grow. Technology has improved patient care — better genomics, better diagnostics, better devices and drugs, etc. It also must improve patient access and throughput. For better or worse, other industries rely much less on entry-level staff and more on technology. The job of the receptionist (as difficult as it is to hire, train and pay adequately) may become obsolete; every part of this job can and should be automated. Administrators of the future must be tech savvy and use automation to drive better processes and better care.

    Understand what success means and focus leadership on this goal. Administrative jobs have become miserable. Every day seems to bring a new crisis: an impossible budget, bad behavior to deal with, absent staff, systems that are down, facilities in need of repair — the list is endless. Fixing the impossible has to fit into a calendar filled with meetings and constant emails. Many organizations have noble mission and vision statements, but it is rare to find an administrator who has any time to even think about mission and vision, let alone do something about them. This is a formula for failure. What if we took a time out and looked at the bigger picture? What is our mission and vision? How do we know if we are moving in that direction? Do all those leading the organization share the same definition of success? Most organizations would be shocked to find how little time and energy are left for leaders to actually do the big job of leading. What if we didn’t schedule any meetings before noon and didn’t open email until 10 a.m.? What would happen if our administrators and leaders used the first hours of the day to work — to do those things that move our organizations toward their mission and vision? Administrators of the future cannot afford to expend their effort, expertise, creativity and their passion putting out the same fires every day when they have so much more to offer our organizations.

    Yesterday’s leaders strive for control and sacrifice performance. Leaders of the future must master the seven critical competencies listed above. In fact, these seven competencies should become mandates — the strategic plan for every organization seeking a sound future.

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