Survey Results are In: Key Attributes of Hospital-Physician Alignment

Thursday, December 7, 2017 | Larry Sobal

When hospital leaders are asked about their major concerns and priorities, relationships with physicians top the list, along with hospital clinical performance and financial viability. This has been true for decades. Since the care decisions made by physicians related to hospital and ambulatory-based care strongly influence hospital/heath system financial and clinical performance, maybe these concerns are really just one: how to best align physicians in addressing issues and solving the many challenges that exist in health care today.

While the goal of attaining successful physician alignment may not have changed over time, the parameters of meeting that goal have. In a more traditional fee-for-service environment, physician alignment often meant that physicians supported hospital admissions and generated referrals and procedures to their aligned hospital rather than to a competitor.

Today, successful physician alignment suggests (and likely requires) something far different: a common mindset among hospital leaders and physicians that care should be thoughtfully provided with a mutual commitment toward value, and making sure patients are receiving high-quality care at a lower cost. Taken further, the Triple Aim encourages the addition of also providing an optimal patient experience and the Quadruple Aim notes that without the added emphasis on an improved physician and caregiver work environment, the Triple Aim is not likely to occur. To accomplish any of these, successful alignment is a necessity.

But, the current reality is that effective hospital-physician alignment has proven to be elusive for many organizations. I decided to dig deeper into the issue and find out why, or at least identify the key attributes of physician alignment. Let me share what I’ve learned.

To obtain information about the key attributes of hospital-physician alignment, I’ve done a number of things.  First, I sought your input on how both physicians and administrative leaders view alignment through a simple 7-question survey. (The survey is still open, by the way, if you want to add your perspective to the results.)

Take this 7-question survey on Hospital-Physician Alignment

In addition, this fall I facilitated various strategic planning sessions, health care advisory councils, MedAxiom Pod meetings, and other gatherings of physicians and administrative leaders where I incorporated exercises that attain answers to the 7 questions, and take the discussion further to correlate what specific tactics can be used to apply the most important attributes to each aspect of the Quadruple Aim. In all, I have somewhere close to 150 contributions to the survey along with takeaways from some interesting, in-depth discussions. The data I am sharing reflects about 60% physician and 40% administrator input, and is a diverse representation of academic, national, regional and single market health systems, employed and independent physicians.

The survey and exercises asked participants to apply 100 “points” to ten possible choices that represent key attributes of hospital-physician alignment. In other words, if someone wanted to apply all 100 of their points to a single attribute (since they felt so strongly about it), they were free to do so. That didn’t happen, but the methodology allowed the leading attributes to emerge.

In alphabetical order, the choices were:

1. An economic hospital-physician vehicle that delivers a win/win through shared risk and reward
2. Candor in communications and conversations
3. Consistency in relationships (i.e. same people working together over time)
4. Courage to face challenges and make tough decisions together
5. Decisiveness and a bias toward action
6. Discipline in choosing priorities and executing on them
7. Focus on the patient above organizational or individual agendas
8. Shared interdependent vision of the future
9. Transparent sharing of information
10. Trust earned through consistent integrity, honesty and follow through on commitments

Now for the results. 

Let’s start with the question of whether hospital-physician alignment is the most important aspect of achieving successful clinical performance. Not surprisingly, the results came back in support of this statement with 50% or more strongly agreeing and 35% or more agreeing. This is 85% or more agreeing, with very small percentages strongly disagreeing. Clearly, the vast majority feel that alignment is critical to hospital clinical performance.

Next, let’s consider the same question related to whether hospital-physician alignment is the most important aspect of successful hospital financial performance. Again not surprisingly, participants strongly agree (57%) or agreed (34%) in similar fashion, with minute percentages strongly disagreeing.

It is important to remember that the survey is asking whether these are “the most important aspects.” Both physicians and administrators feel successful hospital-physician alignment is very valuable.

This analysis gets interesting when we look at the results of the question asking participants to describe whether the hospital-physician alignment in their organization is very strong. Over half of surveyed participants either disagree or strongly disagree, with only around 10% strongly agreeing that it is. 

In other words, although the vast majority feel that successful alignment is the most important aspect of hospital clinical and financial performance, more than 50% say that they don’t have strong alignment today.  That’s unfortunate. But if that’s the case, what attributes of alignment are most important to focus on if you want to change this?

It turns out there are four attributes that are most commonly identified as the key attributes. They are:

• An economic hospital-physician vehicle that delivers a win/win through shared risk and reward
• Focus on the patient above organizational or individual agendas
• Consistency in relationships (i.e. same people working together over time)
• Trust earned through consistent integrity, honesty and follow through on commitments

Next in line are:

• Shared interdependent vision of the future
• Candor in communications and conversations

Based on my experience doing this research and in my consulting engagements, I would make the following conclusions.  

1. With so much at stake (namely clinical and financial performance), you can’t afford not to be focused on improving your alignment.
2. It strikes me that employing physicians, or executing a PSA or co-management arrangement, is often assumed to be a guarantee of alignment. That’s a false and dangerous assumption, and you need to revisit the aspects of those legal relationships to make sure they are effectively supporting alignment and not just serving as a compensation transaction. But that alone won’t get you to optimal alignment.
3. The remaining key attributes of alignment all involve relationships and behaviors. I think that’s why so many physicians and administrators don’t rate their current alignment as optimal. If there is a reliance on the economic model to be a “pseudo alignment” without the focus on these other less tangible elements, it’s pretty clear your alignment will not consist of enough of the critical attributes and will fail to deliver the results you are hoping for.

So, how do you start down the road to improvement? I think the key to successful alignment is to first define which of these attributes is most lacking, and make sure your tactics to address them fit the corporate strategy as well as the needs of the physicians and administrative leaders. This will then define the current state of the relationship and make it easier to measure performance against set goals and objectives. The physicians, for example, may indicate several important objectives (lifestyle issues, maintenance of income, top-quality patient service, use of facilities and patient records or access to the best technology) as how they judge whether there is a focus on the patient or commitment and follow-through. A common mistake is to have prolonged discussions about defining a “structure” as the primary way to fix relational or behavioral issues. Figure out what your relational and behavioral gaps are and then you can hold discussions about ways your governance, which is often a contentious issue, should follow.

Finally, as I blogged about last week, your problems may be more foundational; if so, you might need to focus on making sure you are effective in the four disciplines of being a healthy organization. 

Please let me know your thoughts about the survey results.

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