It All Starts with Governance & Leadership

Thursday, March 21, 2019 | Joel Sauer

For any service line – or company for that matter – to run efficiently and profitably, it must master governance and leadership.  These make up the bedrock foundation of any successful organization and healthcare is no exception.  In fact, I recently had the privilege of presenting to a hospital Board of Directors on the development of a robust co-management program with its cardiovascular physicians.  One of the cardiologists, Dr. Frank Gredler, who was also in attendance stated the importance of governance succinctly: “Without this, nothing else matters” (Figure 1).


His point was simple.  All the great ideas in the world would languish without an infrastructure to synthesize, implement and monitor performance.  If Thomas Edison had merely thought of the lightbulb, but never actually executed it, his name might very well be as obscure as mine.  In a system as complex as healthcare and in particular cardiovascular medicine, execution requires structure and input from the diverse and intricate areas of the service line. 

Let’s start by looking at the definitions of these two very different roles in your organization. 

Leadership is about setting a vision and then both motivating and structuring the team to achieve its goals.  It is about putting the right people in the right positions so they can thrive personally and for the service line.  Leadership can certainly take many forms, but one is to act personally in a way that promotes the vision that has been established.  If I am in a leadership position and my behaviors are contrary to our organizational vision, I’m effectively telling the team the vision isn’t real; it’s simply window dressing to make us all feel better.  We lead by example, both good and bad. 

As former Speaker of the House, John Boehner, once said, “A leader without followers is just a man taking a walk”.  Leadership must have the ability to motivate the team to follow its vision.  Other attributes include honesty and integrity (saying what you mean and doing what you say you’ll do), the ability to articulate the vision (strong communication) and why it matters (passion), consistently holding team members accountable to their roles in the organization, recognizing when a course correction needs to occur, and sticking with organizational core values even when the going gets tough (integrity). 

For these reasons, it is important that we think long and hard about the people we put in leadership positions.  Does our CVSL executive team have the attributes described above?

Governance, on the other hand, is about implementing and regulating the vision.  It is about creating a structure that garners input from a wide variety of positions across our complicated service line and synthesizing those data efficiently so effective front-line decisions can be made.  Governance must be close to the work being performed and, in cardiovascular worlds, may take a form similar to the subspecialty areas of the physicians with committees of content experts within that clinical area (see Figure 2).

Figure 2


A best practice is to put a dyad team (a physician paired with an administrator role) over each of these clinical domains, not necessarily as the decision makers, but to organize the working structure and ensure that it operates effectively.  This can entail establishing agendas, distributing project work, publishing minutes, and tracking and reporting progress.  

Governance is about creating and enforcing policies and procedures – or removing barriers and eliminating redundant rules when they’ve become obsolete or too obtrusive without commensurate value.  It is also about setting up the structure on how decisions will be made and how, when necessary, dealing with dissent (Figure 3).

Figure 3

Span the Continuum

In my role as a consultant I fly a lot with airplanes constantly part of my life.  So, I’m going to use an airline metaphor to make a point.  Let’s say Delta had a governance structure that only managed the airplanes themselves.  They made sure that each flight had a pilot, co-pilot and requisite flight attendants, that the plane had gas and was properly maintained, but that was it.  If Delta ignored how passengers check in, how they get assigned seats and what happens to their luggage, will it matter how well-oiled its airplane process is?  In short, how do we think this will turn out?  Spoiler alert – badly!

However, in today’s cardiovascular world where more than 80 percent of the physicians are employed by a hospital or health system, we regularly see this disconnect.  It may not be as blunt as my example above, but it is often highly ineffective.  Specifically, the activities of the hospital are governed independently from those of the ambulatory practice.  Often these two worlds are separate legal and billing entities, and thus a solid leadership separation has been created.  While they may ultimately and eventually come together at the C-suite, this is often much too late to avoid bad outcomes. 

Here’s an example.  Let’s imagine that Acme Hospital is trying to reduce heart failure readmissions – something happening regularly around the country right now.  At the exact same moment, the Acme Cardiology Practice is having to reduce office staffing as part of a system wide cost reduction effort – also common in 2019. 

If these two worlds aren’t connected, the office may logically reduce certain support staff positions in order to achieve the system level edict. However, the impact of these reductions is to make access into the practice difficult and, therefore, pushes out appointments for post-discharge patients.  The result is our heart failure patient recently discharged gets a follow-up visit well beyond the optimal five-day window and the result: they bounce back into the hospital as a readmission. 

Clearly this result is not good for organization, but more importantly isn’t good for the patient.  While it may seem farfetched, I see these kinds of disconnects all too regularly. 

Broad Physician Engagement

Cardiovascular medicine is extremely complicated and very subspecialized, with the latter becoming deeper nearly every year.  Within the last five years we’ve seen the advent of physicians focusing exclusively on structural heart and heart failure.  Prior years saw similar concentrations around electrophysiology and advanced imaging.  At the same time, we’re seeing an explosion of new technologies and procedures within each of these clinical domains, further complicating the management of our cardiovascular worlds.

With all of this complexity, we need a broad level of both physician participation and engagement to help improve the cardiovascular product.  Several years ago, the former editor of the New England Journal of Medicine, Arnold Relman, MD, once noted that, “. . . physicians influence and often control 100 percent of the [healthcare] expenditures”.   Given this, doesn’t it make sense to have our physicians involved in the governance of the organization?  The answer is obviously a resounding yes. 

To do this work effectively, physicians must be given access to the tools and data that will allow for good decision making.  Continuing my airline metaphor, we wouldn’t want pilots flying without their instruments or just some elements of cockpit data.  Likewise, we don’t want our physicians in governance and leadership positions getting only a partial look at the cardiovascular service line.  The results in both scenarios will be disastrous.  Thus, data transparency, including financial information, is a must. 

Similarly, if our economic model either doesn’t reward governance participation or provides no time for participation, we should expect there to be little to no physician engagement – or at best just glancing at participation at a very superficial level.  Going back to the attributes of successful leaders, what we reward – and by contrast what we don’t reward – speaks volumes in terms of our values and true priorities. 


Let’s face it, as healthcare providers there are a lot of outside forces organizing around our traditional industry poised to try and eat our lunch (Figure 4).  These organizations are no slouches and have a history of innovation and disruption.  With this kind of pressure, we better make sure our house is in order and we can adapt quickly.  This all starts with effective governance and leadership.

Figure 4


Take time to review your current structure.  Is it providing you with an adequate vision?  Are the leaders able to articulate this vision and motivate the team to passionately pursue its achievement? Are we properly aligning the cardiovascular resources to be successful in 2019 and beyond?  Do we have physicians broadly involved and engaged in governance?  Are they provided the tools and resources to be successful?

If the answer to one or all of these questions is no, it may be well worth the investment of time to look at a restructuring of our governance and leadership.  As Dr. Gredler aptly pointed out, without this, nothing else matters!

Illustrations: Lee Sauer

About the Author
Joel Sauer

Joel Sauer, MBA, is Executive Vice President of MedAxiom Consulting. Joel consults around the country in the area of value-oriented physician/hospital partnerships preparing health organizations for the value economy. His work includes vision and strategy setting, creating and implementing effective governance and leadership structures, co-management development, joint venture and other innovative partnerships, and provider compensation plan design. Beyond the above, Joel has a wealth of experience in service line development, clinical strategy development, provider workforce planning; including care team creation and physician slow-down policies, MACRA and bundled payment planning, and operational assessments.

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