Physician compensation is a challenging issue, especially while we are in a transition from fee-for-service to value-based reimbursement. I would recommend a balanced approach:
1. Base salary set at the 25th percentile of national benchmarks.
2. Portion of base salary at risk if minimum metrics are not met (patient experience scores, quality metrics, etc.)
3. Incentives based upon personal achievements (RVU’s above 75th percentile, patient experience physician communication scores above 75th percentile, complication rate below a certain threshold, etc.)
4. Incentives based upon the group’s performance on quality, patient experience and financial metrics.
I would also make sure to negotiate incentives with the payers that align with the above quality and patient experience metrics.
We also struggle with empowerment and ownership. I would first make sure there are clear hospital-wide goals and then create a goal cascade, allowing each division or unit to create their own specific goals that roll up to the hospital goals. The tactics to achieve those goals should be created by the frontline staff. I would also make sure to celebrate successes, but also teach leaders how to “fail well”. Senior leadership needs to create a safe environment for leaders to acknowledge failure and teach them the skills to transform a failure to an opportunity. One way to create this culture is to hold frequent debriefs. During a debrief you discuss what went well, what didn’t go well, and what you would change next time. Debriefs can be held after meetings, go-lives, clinical events, etc. This helps to install a culture of reflection.
One argument that is well validated is the relationship between volume and quality outcomes. This is seen in many surgical specialties especially pediatric cardiac surgery. Thus there is an argument to be made that when some tertiary and quaternary services are diluted in a region, the region receives mediocre care at best.
As an academic medical center I would recommend leading the conversation in the community around value-based payment and new reimbursement methodologies such as bundled payments. Your value proposition is to improve the health of your community and contain costs. Academic medical centers have traditionally been leaders in creating innovating treatments and interventions. I would recommend expanding the academic focus to include creation of innovative ways to better deliver healthcare in a more community-centric model.
Throughput and patient flow is a common problem for many hospitals. We have a Transfer Center that manages beds. The Transfer Center has situational awareness of all patients needing admission or transfer within the next 24 hours (ED admissions, OR admissions, ICU transfers to the floors, transfers from outside hospitals, etc.) They also can see in real time which beds are clean and which are waiting to be cleaned. The Transfer Center works closely with the in-house nursing supervisor who can help prioritize patient movement. I also agree that incentives for discharges prior to 11:00 am are very helpful, but the incentives need to apply not only to physicians but also front line staff. Some hospitals have also opened “Discharge Lounges” for patients that have been discharged from a bed but are waiting for a ride home. This can help open floor beds earlier and help to decompress the ED. You also can consider opening a short-stay or observation unit for patients expected to stay longer than 8 hours but less than 48. This has helped to drive rapid throughput, especially with the use of standardized clinical protocols and order sets.
We also struggle with our “dyads” however there are several key strategies/tactics that have helped with alignment:
1. You need very tight alignment in the dyad at the top of both the physician and nursing/administrative chain of command. In our case its the hospital CMO and CNO.
2. Set very clear goals and expectations for the dyad and align incentives/compensation to achieving these shared goals. The goals should cascade down from the board. Create a dashboard to measure goals (quality, patient safety, operational metrics, financial, etc.)
3. Focus on coaching rather than solving disagreements or poor accountability. Formal training in Crucial Conversations can help the dyad navigate uncomfortable or difficult conversations.
4. Keep the patient at the center of your decisions.
5. Strong communication – Regular meetings with shared agenda. At least weekly brief check-ins or huddles.
6. Visibility & Managing up – Regular joint leadership rounds. Manage up each other with front line staff and physicians.