Leading beyond the bottom line, Part 4. The questions it has raised.

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.

Leading beyond the bottom line.

Do physician executives approach managing and leading health care organizations like a CEO of a Fortune 100 company? Or does their training as physicians first give them a unique perspective, leading them to view organizational issues differently? The authors suggest that to be a physician executive is to be the practitioner, teacher, coach, and mentor for a new philosophy of leadership and management called Leading Beyond the Bottom Line. While the financial health of an organization is critical to its survival and its ability to fulfill its purpose, the trap is to focus on maximizing the bottom line. This new philosophy leads an organization to attend in equal measure to the (1) welfare of its patients, (2) its financial health, (3) the well-being of its employees, and (4) the building of its community. "The Optimal Organization" is one in which these four objectives are seen not only as related, but interconnected, and the goal is to maximize all of them. The legitimate role of the physician executive is to manage in search of Pareto Optimum, or the maximum benefit for all four organizational objectives. Clearly, this is a tougher job than maximizing profits or just optimizing profits and patient care.

Leading beyond the bottom line: organizational assets for the new economy. 2.

Organizations are created to aggregate resources to accomplish some purpose, be it to provide health care, raise a family, or build cars. These resources are assets. A manager has a fiduciary responsibility, by practice, and, in many cases, by law, to make the best use of those assets. Traditionally, we've evaluated the use of assets through financial statements. The troublesome aspect of these financial statements is that they were designed to measure only those things that can be counted simply--financial and physical assets. But our world has moved from an industrial, manufacturing age to an information, service economy and we are learning that intangible assets are as powerful--potentially more powerful--in creating value as are tangible assets. Recognizing the intangible asset value of employees, customers, and the community is the challenge in this new service economy. Effective health care leaders need to leverage and manage all of an organization's assets.

So, what's the problem?

Medical care presents complex problems to physician executives--thoughtful problem definition is a crucial management task. Without understanding the context, cultures, bottom line implications, and personal relevance, problem definition is incomplete and problem resolution may be inadequate or inappropriate. If our choices are complex, some of the difficulty may lie in our understanding of the problem. Until we have properly defined the problem, we can't act to resolve it. We need to step back, reframe the issue, ask if it feels right, and understand the whole story, not just the situation at hand. The tests of an organized story are coherence, direction, meaning, and implication. These should be perceptible both as individual attributes and as a whole. The purpose of such a story is not the resolution of the problem, but a coherent understanding of the direction to be taken. When the diagnostic work-up is complete, the next step can begin.

Trusting in the future: the distinct advantage of nonprofit HMOs.

Managed care's success in improving the health status of communities can be directly attributed to the not-for-profits. Three of the major organizations-Harvard Community Health Plan, Kaiser Permanente, and Group Health Cooperative of Puget Sound-in this category have participated in the critical public policy debates of the past 30 years, have conducted and funded data-based research, and have trained numerous U.S. primary care physicians for practice. An emphasis on health, rather than profits, has led tham to favour community rating. Not-for-profits have created an environment that encourages good relationships between patients and professional caregivers. They have discovered that delivering superior care is the most effective way to control costs, and they have done this while fostering partnerships with organized labor. It is critical for the not-for-profits to communicate their obvious advantages to the general public in order to ensure their survival.

Can the patient be the focus of managed care?

If the question were simply put: "What is it that succeeds or fails to meet patients' needs in managed care?" Dr. John M Ludden would have a short answer. "It depends. Success depends on whether you are talking about individuals or about populations of patients. And it depends on whether you are talking about meeting patients' needs or their desires. It depends on whether you're talking about well patients or sick patients, young patients or older patients, new patients or established patients, rich patients or poor patients. And it depends on your ability to balance each of these qualities." This article explores how to translate high-quality care for a population to high-quality care for individuals.

In pursuit of physician/organization linkage.

A friend of mine once said that medical staff/administrative relationships are the Bermuda Triangle of health care management. The Bermuda Triangle, as I recall it, is an area of the Atlantic Ocean into which ships and planes disappear without a trace, for no apparent reason. Sometimes, especially late at night on reruns of "Twilight Zone," these planes reappear years later, crew intact and youthful. Sometimes, salt and sharks get the ships, planes, and voyagers. In a like manner, problems in medical staff/administrative relations draw consultants into a vortex. Sometimes, the consultants and their reports float to the surface a long afterward. Sometimes, they are digested by the organization and become a part of its mythology. Sometimes, they vanish forever. This is the story of three consultations. All were intended to make recommendations concerning the structural relationship of management to the physicians and their groups in our HMO: How to link the physician organization to the corporate structure. Like any narrative, this story is constructed to provide a context for reflection and is not intended to question the value of the contribution of specific individuals or companies.

The "teaching HMO": a new academic partner.

Health care reform is a potential threat to the academic missions of medical schools and academic health centers. But managed care, the source of much of their concern, may also represent a way for medical schools to improve their future academic outcomes. Harvard Medical School and the Harvard Community Health Plan, a large health maintenance organization (HMO) in greater Boston, recently formed the first medical school department to be based in a freestanding HMO. This arrangement is an example of a model that replicates, in a managed care organization, the long-standing and highly successful teaching hospital academic structure in academic medical centers. The authors describe this model in detail, show how the Harvard collaboration works, and explain the benefits each institution saw in creating a joint entity, the rationale for making that new entity an academic department, and the implications for other academic health centers. They conclude that the Harvard experience shows that alliances between medical schools and large HMOs can create vibrant practice settings for teaching and research in academic areas (such as prevention and primary care medicine) that have been relatively neglected in recent times, and that the "teaching HMO" may have the potential to transform academic medicine in the next century just as the teaching hospital transformed it in this century.

Surgical management of a ruptured peroneus longus tendon with a fractured multipartite os peroneum.

Injury of the peroneus longus tendon with concurrent fracture of the os peroneum is a seldom reported injury. This injury is probably underdiagnosed or misdiagnosed. The mechanism of this injury often involves sudden inversion, and therefore may often be misdiagnosed as a lateral ankle sprain or tendonitis. From the author's research review, this is the first reported case involving a fractured multipartite os peroneum with rupture of the peroneus longus tendon. The injury was diagnosed preoperatively by magnetic resonance imaging (MRI) as well as radiographs.

Quality planning for mental health.

This article describes quality improvement theory and its application in planning a major clinical initiative. The experience of the Harvard Community Health Plan in redesigning its mental health program is used to describe how theory can be translated into practice. A formal process is involved which relies heavily on the use of data in designing the program as well as evaluating its success.

Teaching psychiatry in the health maintenance organization.

Psychiatric residents training in a health maintenance organization (HMO) rapidly encounter the conflict between high demand for services and limited supply of time. In one HMO setting, the Harvard Community Health Plan, supervisors assist trainees in managing their practices to recognize their avoidances and conflicts and to respond therapeutically in keeping with the setting.

Psychological aspects of medical care: a training seminar for primary care providers.

A seminar devoted to the psychological aspects of medical care has formed the major portion of the psychiatric training of primary care internal medicine residents at the Kenmore Center of the Harvard Community Health Plan since 1973. The group includes a psychiatrist, a psychiatric nurse, staff physicians, residents, and nurse practitioners. The atmosphere is open and supportive, and discussion focuses on particular situations causing discomfort to members. Content issues include professional identity, relationships with co-workers, and difficulties in handling patients. The group teaches the value of communication and sharing and improves skills in caring for patients.