Xem mẫu
40 Pursuing Excellence in Healthcare
24. Epstein, A. L., and Bard, M. A. 2008. Selecting physician leaders for clinical service lines: Critical success factors. Academic Medicine 83 (3): 226–234.
25. Larson, E., and Gobeli, D. 1987. Matrix management: Contradictions and insights. California Management Review 29:126–138.
26. Crist, T. B., LaRusso, N. F., Meyers, F. J., Clayton, C. P., and Ibrahim, T. 2003. Centers, institutes, and the future of clinical departments: Part II. American Journal of Medicine 115 (9): 745–747.
27. Longshore, G. F. 1998. Service-line management/bottom-line management. Journal of Health Care Finance 24 (4): 72–79.
Chapter 3
Leadership in the Academic Medical Center
I recommend that the organization of the Hospital shall be on the Military or Railroad plan, i.e., that it shall have one head, and only one, who shall receive his directions from, and be responsible directly to the Board of Trustees, and that all orders and instructions which the Board may make relative to the discipline and internal manage-ment of the Hospital shall be issued through him. This Oficer should be a competent medical man, and a man of executive ability.
John Shaw Billings Planner of The Johns Hopkins Hospital, 1875 [1]
Introduction
Although the AMC at the turn of the century might have been amenable to a leadership structure similar to that of the military or the railroad, as described by Dr. Billings, the complexity found in today’s AMC makes it unlikely that lead-ership strategies can be defined in such a straightforward model. Unfortunately, few objective assessments have been made of the value of different leadership structures in the AMC. This is in marked contrast to the wealth of data avail-able on leadership strategies in the world of business. For example, Amazon.com lists over 53,000 titles related to “business” leadership, but only 33 titles related
41
42 Pursuing Excellence in Healthcare
to leadership in academic medical centers—half of which are not specifically related to the search term.
As AMCs face increasing economic challenges and begin to integrate their various entities, the development of an effective leadership structure becomes increasingly important. Indeed, integration and restructuring cannot effectively be undertaken without a significant change in the leadership structure. In this chapter, we will look at recent data confirming that the current leadership struc-ture needs to be revised, discuss the organizational impediments to effective leadership that are found at many AMCs, describe a model that can improve the role of leaders in today’s AMCs, and present recommendations on how to transition from our current structure to a new leadership paradigm. This new leadership structure strengthens the ability of the AMC to focus on the core mission of providing outstanding patient care.
AMC Leaders Face Formidable Challenges
Although business scholars have not carefully studied the leadership structures of the AMC, substantive information supports the notion that current leadership structures are not effective. For example, the average tenure of a dean of a U.S. medical school—the individual generally presumed to be the senior academic oficial at an AMC—is less than 4 years, which is 1 year less than the median tenure of CEOs of Fortune 500 companies [2]. Arthur Rubenstein, dean of the University of Pennsylvania School of Medicine and executive vice president for the health system, attributed the relatively short tenure of medical school deans to “a combination of dean burnout because of the intensity and time requirements of the job as well as the challenges associated with maintaining the favor of a broad range of constituents—including faculty, students, donors and the university leadership—in a challenging environment and with limited resources” [2]. Claire Pomeroy, vice chancellor for human health services at the University of California, Davis, and dean of the university’s School of Medicine similarly noted [2]:
Being a dean is challenging. First, you have to balance these really diverse missions—academics, research and a complex clinical deliv-ery system—which takes a wide spectrum of skills. We’re all more expert in one of those areas than in others, and it’s very hard to find the person who is comfortable talking with the HMO providers as meeting one-on-one with first-year medical students. There’s a lot of culture clash that goes on and it’s really hard to satisfy all those constituencies for a long period of time. Secondly, one of the main
Leadership in the Academic Medical Center 43
jobs of being dean is getting people the resources they need in those diverse missions, and recently they have been inadequate resources. You’re constantly battling to get the resources that your organization needs to be successful and you don’t meet everybody’s needs.
A recent survey by the Council of Deans of the Association of American Medical Colleges provides additional insights into the challenges facing AMC leaders [3]. A majority of respondents noted that the role of dean was impacted most by the decline in the resources available to medical schools following an era of abundance, the increased competition that AMCs faced in the clinical arena, and a reliance on clinical revenues to support medical education. One dean noted that this change resulted in a shift from “being what I’d call more of an academic deanship to more of what I’d call a marketplace CEO” [3]. The majority of respondents also noted that a major impediment to surviving both as a dean and as a medical school in the new healthcare environment was the failure of the AMC environment to align the dean’s responsibilities with the authority to manage. The respondents noted three factors that could be assessed to evaluate the dean’s potential for leading the institution in a time of change [3]:
1. Does the dean have adequate support from higher management to serve as a change agent?
2. Does the dean have suficient authority over the clinical enterprise?
3. Does the dean have enough internal leverage to pursue the school’s mis-sion effectively?
Institutional stability was also seen as an important component of a success-ful tenure as a dean. Two-thirds of the respondents noted that, to be effective, a dean needed support from above as well as stability in senior leadership in both the university and the hospital. Indeed, four of eleven former deans had resigned their positions due to institutional instability. Additional obstacles to success were a “failure of will on the part of the institution to endorse the dean in ini-tiating change” and university leaders who “distance themselves from the dean, who, in turn, becomes expendable” [3]. As one former dean noted [3]:
There’s got to be a clear understanding between whoever is doing the hiring and the candidate as to what the university or the institution wants accomplished, and ideally, there is an understanding that the resourcesandpoliticalsupportthatwillbenecessarytoachievethose objectives will be forthcoming, if not forever, for three years, for five years, whatever the time frame may be to accomplish the changes.
44 Pursuing Excellence in Healthcare
A major cause of the early departure of deans has been the intense conflicts that arise between the academic and clinical missions at many AMCs. One dean summed it up best when he said [3]:
If I am in charge of both the hospital and the medical school, I don’t have to arbitrate[;] I just say that’s what’s going to happen. I may have people below me, one says we don’t want the students, the other says I want the students, but there’s somebody who has the author-ity to make the final decision.…If you have split administrations, how do a man and wife decide? They argue it out. They fight it out. If you have one person calling the shots, it’s easy.…It is the central governance problem in academic medicine today.
The chairpersons of the clinical departments face challenges no different from those of the dean. In the early parts of the twentieth century, the chairs of clinical departments had God-like status. They spent their time caring for patients, teaching, and pursuing research and, because of the relatively small size of most departments, their administrative roles were limited. As AMCs grew in both size and complexity, the job of the department chair became increas-ingly administrative and far more intricate. Because departmental practice plans remained independent, the chairs of the large departments had considerable autonomy and authority.
In the mid- to late 1990s, the independent department practice plans began to merge together into unified practice plans. Although these practice plans often did not work as integrated entities—that is, revenues were not shared across the traditional departmental barriers—they did have leadership teams. In some cases, the boards of the practice plan consisted of the entire group of clinical chairmen; in others, the practice plan was managed by a committee of chairs.
Regardless of structure, major decisions regarding clinical finances began to be made by the group of departments rather than by the individual chairs. At the same time, the economic and administrative separation of academic hos-pitals from their afiliated medical schools further diminished the role of the department chair. Chairs found themselves with similar levels of responsibility, but substantially less authority and a reporting structure to a large number of administrators—many of whom had different agendas [4]. In some AMCs, a department chair may need to discuss a single business opportunity or recruit-ment with a dean, a practice plan director, a practice plan CEO, a hospital CEO, a hospital COO, a hospital CMO, and a provost in order to achieve the neces-sary buy-in and support. This ineficient and cumbersome leadership structure usually results in nothing getting done.
...
- tailieumienphi.vn
nguon tai.lieu . vn