Improving the doctor-manager relationship. Building a successful partnership between management and clinical leadership: experience from New Zealand.
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ABSTRACT: The most recent reforms, facilitated by the new integrated district health board structure and guidance from the New Zealand Health Strategy, have led to important quality progress in secondary care. This is associated with a 'convergence' of managerial and clinical cultures. The role of the 'centre' emerged only recently, providing support and resources to assist rather than exert leadership for quality. New Zealand appears to be adopting Freidson's preferred model of clinical organisation—a 'new professionalism' that recognises the importance of professional leadership and the organisational context for collective accountability for both health services quality and cost.The New Zealand medical journal 08/2004; 117(1198):U978.
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ABSTRACT: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.Occupational Medicine 02/2005; 55(1):40-7. · 1.45 Impact Factor
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ABSTRACT: This chapter explores the relationship between two components of our healthcare system: physicians, representing all providers of direct care, and hos- pital executives, referring to those with administrative responsibilities, regulatory obligations, and resource control. Currently, there is a wide gulf, or gap, represent- ing an adversarial interaction. Over the past 50 years, there have been dramatic, frankly, revolutionary, changes in the practice of medicine without corresponding or matching adjustments in the healthcare system. As a result, both physicians and healthcare executives are frustrated. The present adversarial tone between health- care executives and physicians adversely impacts healthcare outcomes. We discuss data showing differences between physicians and healthcare executives in education, background, work experience, and culture. However, the two share common core values: altruism, service, and love of a challenge. They also have common concerns about the future. We conclude that the real enemy is not the so-called other—physicians or healthcare executives—but our dysfunctional healthcare system. The common values and concerns shared by physicians and healthcare executives could provide the framework for successful communication leading to a bridge across the gap and a collaborative rather than confrontational relationship. Physicians could teach healthcare executives about clinical priorities, useful new technologies, and scientific methodology, including evidence-based decision making. Healthcare executives could educate physicians about management tools and techniques for planning, implementation, and assessment, especially systems thinking. To- gether as partners, healthcare executives and physicians could address many of the currently insoluble problems in healthcare.
report cards might have helped in earlier recognition
of system failures at, for example, the Bristol Royal
Infirmary and at hospitals in the United States with
Fifthly,we should build educational bridges early in
professional education by encouraging, for example,
combined MD/MBA programmes. Currently, nearly a
third of US medical colleges have a formal integrated
combined degree programme with a school of
business or health administration.3Generally, young
physicians can obtain both degrees in five years before
becoming interns and residents. These graduates will
become the cross cultural agents of the future, able to
narrow the gap between doctors and managers.
Sixthly, we ought to reinforce the work of the US
Accreditation Council for Graduate Medical Educa-
tion, through which an outcomes based accreditation
system has been in place for all US medical colleges
since July 2002 (www.acgme.org). Aspects of this new
outcomes system are exclusively focused on systems
based practice and practice based learning, two key
areas needing close collaboration between doctors and
managers. The accreditation council recognises that
only through the development of effective teams and
clinical decision support systems can we hope to
narrow the “quality chasm.”
Finally, US medical schools must vigorously seek
philanthropic support from all sectors to endow
professorships in fields related to medical manage-
ment, health policy, and organisational behaviour.
Whereas thousands of endowed chairs exist in the
more traditional fields, less than a handful of endowed
chairs exist in fields related to management and health
policy (Thomas Jefferson University Hospital, press
release, September 2001).
The outcome of US health care is undergoing
increasing scrutiny. We need to “mind the gap”
between costs and outcome and try to close this gap
partly through better relations between doctors and
Competing interests: None declared.
1 Institute of Medicine. Crossing the quality chasm: a new system for the 21st
century. Washington, DC: National Academic Press, 2001.
Carpenter C, Proenca E, Nash DB. Clinical decision making. What every
nonclinician should know but was never taught. J Health Adm Ed
Page L. Within your reach. Mod Physician 2002;12:13-5.
Building a successful partnership between management and
clinical leadership: experience from New Zealand
Laurence Malcolm, Lyn Wright, Pauline Barnett, Chris Hendry
Recent New Zealand studies have shown important
progress in addressing a key issue facing all health
systems: the gap between clinical culture and govern-
ance or managerial culture.1 2The key terms in this
progress are partnership,quality,clinical leadership,and
Three factors have been important. Firstly, New
Zealand—with a national per capita income some 20%
below the mean for member countries of the Organis-
ation for Economic Co-operation and Development—
has had to make difficult choices about health
priorities. This has compelled greater collaboration
between clinicians and management. In primary care,
major budget management—of drugs, for example—is
being seen as a new form of clinical autonomy.2 3
Secondly, the Cartwright inquiry of 1988, perhaps
New Zealand’s equivalent of Britain’s Bristol inquiry,
played a key part in sensitising the medical profession
to the need for greater collective professional account-
ability. The inquiry has also been a critical factor in the
promotion of a culture of quality.
Thirdly, the commercially driven reforms of the
1990s, perhaps more radical and damaging than the
reforms in Britain, led to a major shake up of the clini-
cal culture. In some secondary care settings a widening
gap between clinical and management cultures led to
open conflict.4 5However, in other settings managers
who were more health oriented collaborated with
clinicians to build the working partnerships that are
now being generally adopted.1
The formation by a new centre left government in
promoted this partnership, perhaps best described as a
“convergenceof cultures.” This
required from the governance or management culture a
shift from a preoccupation with resource management
to health outcomes as the “bottom line” of the
organisation.This commitment is reinforced by the con-
tract between government and district health boards, as
set out in the New Zealand health strategy.6
clinicians of a key role in managing resources and in
Education and debate
Public Health and
School of Medicine
BMJ VOLUME 32622 MARCH 2003 bmj.com
achieving the organisation’s goals. Both cultures need
to move—and are moving—towards a more trusting
relationship that is based on a shared vision and on
shared goals of better outcomes for patients and com-
munities, within limited available resources. This
partnership is a critical factor in quality improvements
reported in New Zealand studies.1 2 7
Clinical leadership is playing a key role in this part-
nership. But clinical leaders, although appointed by
management, remain clinicians. They have not crossed
to the “other side.” They are being helped by the rela-
tively new Clinical Leaders Association of New
Through clinical leadership, the New
Zealand health system may be implementing what the
sociologist Eliot Freidson calls the “third logic,” an
alternative to market or bureaucratic models.8In
contrast to the failings of these models, a new
professionalism may be emerging—but with clinicians
becoming collectively and professionally accountable
for both the quality and cost of their decisions,in a new
and successful form of clinical autonomy.
Competing interests: None declared.
1 Malcolm L, Wright L, Barnett P, Hendry C. Clinical leadership and qual-
ityimprovements indistrict health
www.clanz.org.nz/downloads/ (accessed 3 Mar 2003).
Malcolm L, Wright L, Barnett P, Hendry C. Clinical leadership and qual-
ity in primary care organisations in New Zealand. www.clanz.org.nz/
downloads/ (accessed 3 Mar 2003).
associations: a working model of clinical governance in primary care?
Hornblow A. New Zealand’s health reforms: a clash of cultures. BMJ
Health and Disability Commissioner. Canterbury Health Ltd, Auckland.
Auckland: Health and Disability Commissioner, 1998.
Minister of Health.The New Zealand health strategy.Wellington:Ministry of
Blendon R, Schoen C, DesRoches C, Osborn R, Scoles K, Zapert Z. Ineq-
uities in health care: a five country study. Health Aff (Millwood)
Freidson E. Professionalism:the third logic. Cambridge: Polity Press, 2001.
boards in NewZealand.
Kaiser Permanente: a propensity for partnership
Francis J Crosson
Fifty years ago, the belief that physicians and managers
could effectively share responsibility and accountability
for overall performance of health systems brought the
wrath of the American medical establishment down on
the first generation of Permanente physicians, who
were excluded from their local medical societies. Then,
the hard work of making such a partnership succeed
nearly destroyed Kaiser Permanente in its first decade.
The outcome became the key to the success of Kai-
sational culture that transcends the traditional conflicts
between “medicine” and “management.” That culture
has been nurtured over decades of continuous negotia-
tion by hundreds of committees and leadership councils
that jointly manage the organisation on a daily basis.
Today, the mutual commitment to an exclusive partner-
ship between the physicians and management is deeply
ingrained in the organisation. Many factors may be
credited for this success,but three stand out.
Joint leadership—From the earliest days, leaders of
physicians and management within Kaiser Perma-
nente have acknowledged their mutual dependency.
Having this propensity for partnership explicitly mod-
elled at the highest levels of the organisation has
guided behaviour at all levels, including frontline care
givers and their counterparts in management.
Alignment—Without an explicit mutual alignment of
mission and strategy, the partnership would have
collapsed amid the traditional gaps between medicine
and management. Most of the highly fragmented, dis-
wellas oneof the
aggregated healthcare structures in the United States
suffer from just this condition—conflicting incentives
and goals among physicians, insurers, and hospital
administrators. Physicians focusing solely on patient
care and administrators focusing solely on use of
resources and productivity are destined for collision.
Bringing both sides into a mutually interdependent
relationship, where the success of each side is in the
hands of the other,forces a powerful alignment of inter-
ests that transcends professional or cultural differences.
Management training for physicians—It makes no
sense to send managers to medical school, but there
are good reasons to train physicians in management
or at least those on a leadership track. Collaboration
and cooperation, negotiation and persuasion, and del-
egation and teamwork are just some of the critical
skills in the management of large and complex
organisations that are lacking in the training and
development of physicians.If physicians are to work as
truly effective partners in the management of their
practices they need to take the time to acquire these
skills,either through in house training programmes or
at outside educational institutions. At Kaiser Perma-
nente a range of such programmes ensures that
physician leaders now understand both the bedside
and the boardroom and make competent partners for
similarly well trained managers.
Competing interests: FJC is the executive director of the Perma-
nente Federation, the national umbrella organisation of the
eight Permanente Medical Groups that make up the physician
side of the Kaiser Permanente organisation.
Education and debate
Federation, 1 Kaiser
Francis J Crosson
BMJ VOLUME 32622 MARCH 2003 bmj.com