Physician Leadership and Ambulatory Care: Small and Rural Hospitals

Experience has shown that the greatest deficiency in developing and implementing an integrated ambulatory system of care is leadership—both administrative and physician leadership. Most physicians and administrative leaders, even in larger systems, do not have experience working in this type of setting. Without a dynamic leader, there is almost always a default back to the familiar. This makes it difficult to visualize the integration possibilities.

Additionally, the economic reward for leadership is generally bottom-line driven, with a modicum of recognition for improved customer service and quality performance being part of this incentive. This would also indicate that hospital boards do not understand the concept of care integration or there would be a willingness to change the model of incentive expectations. To be successful in this strategy, leadership must understand and embrace this change concept. Leaders at all levels—including leaders of larger systems that own small or rural hospitals—need appropriate training regarding the dynamics of this type of change.

Leadership training should be multi-dimensional; the layers of education should be at the board, administrative, and physician leadership levels and knowledge should be gleaned from others who have been successful in the strategy being considered. Leadership training should move outside the nucleus of the core business. If the organization is hospital-centric, then movement toward education in the physician practice world should be considered. Similarly, if the organization is physician-centric, movement toward understanding the hospital world should be pursued.

Leadership Errors

When creating a small/rural hospital integrated system of care, it can be a mistake to move too fast. This has been the case particularly in small/rural hospitals that are owned by larger systems. The CEOs of these smaller hospitals are trying to build a resume so they can move within their own or possibly another organization. This quick build can be destructive to the local market as well as the relationship with the medical staff, whether employed or not employed.

Building a small/rural hospital integrated ambulatory care system should be a slow, methodical process. Many of the physicians in these communities might have worked with each other, but they are not clinically aligned in thought or processes. It takes time to build these relationships; building a governance group for physicians can be a challenge when trying to bring disparate groups together.

Additionally, some of the physician groups may have their own strong market identity that can overshadow a local hospital. Dealing with market identity is critical to success. The consumer, no matter the approach taken, will almost always relate to the historical names of organizations versus a newly contrived name that is established in hopes of creating a new identity. For medical groups, name recognition might be built on a historic location or the names of the founders of the clinic. Knowing your consumer market will help drive the approach of changing market identities of any organization.

Focus group assessment of the market is a valid approach to managing changes in the brand identity of organizations. It’s important to be sensitive to these issues. The best leaders for small/rural hospitals are those who have a longer-standing relationship in the market. There is insufficient time to build strong strategies when the leadership is looking for a quick resume build before they move on.

Physician Medical Staff Planning – Recruitment

Small/rural hospitals many times are confronted with the need to employ some share of the local physicians. This is particularly true with regard to primary care. Additionally, some specialty physicians must be employed, since new physicians find it difficult to survive economically and are uncomfortable in not being part of a larger group of similar specialists. Being in a similar specialty group provides good call coverage and clinical collegial relationships for the specialists. As well, such services as Ob/Gyn and general surgery are critical in these types of settings.

Observational experience shows a very simplistic method in determining specialty mix to primary care base. Every 10–15 primary care physicians with average patient panels (3,000+) requires one general surgeon. Twenty primary care physicians in the community can usually accommodate one Ob/Gyn. This, of course, will depend on how many family practitioners are providing obstetrical services. Even if this number is high, that does not mean that an integrated service line for women’s care cannot be constructed.

As to the mix of primary care, this should be determined by the demographics of the community. A small/rural hospital located in a bedroom community for a larger metropolitan area would warrant pediatricians in a mix with family practice and internal medicine. On the opposite end of the spectrum might be the need for a higher balance of internal medicine and possibly a geriatrician if the community’s population is aging. Family practitioners can manage the care of elderly patients, but they may be dissatisfied in an aging community if they prefer to manage care for a wide array of age groups. Any of these scenarios will affect the design and implementation of a small/rural integrated medical delivery system.

In recruiting family practitioners, consider the new recruit who is looking for practice locations that provide favorable call rotation as well as facilities with a hospitalist program. In addition, residency programs are training students to work in a Medical Home environment. As time progresses, having a Medical Home model in place will become an attractive recruitment tool for high-quality family practitioners. This structure will also bode well when conducting negotiations in insurance contracting.

The need for additional specialty types should be based on the medical requirements of the community. If a higher incidence of coronary artery disease is present in the community, the need for a non-invasive cardiologist might be warranted. This specialty physician can also be a great adjunct to the primary care physician, as well as family practice, internal medicine, and hospitalists, regarding more complex care.

One of the greatest failures in physician recruitment for the small/rural integrated system is lacking a vision of uniqueness for the physician being recruited. A unique vision should be built on clinical integration. If the system presents itself as any other small/rural hospital setting, there is no competitive advantage to draw the physician. Even the retention of current physicians can be difficult. That is why it is so critical to develop a service line-oriented integrated model of care. Without this strategy, yours is like any other small/rural hospital with an employed medical group.

Excerpted from Integrated Ambulatory Care: Key Growth Strategies for Small and Rural Hospitals by James Hamilton, MBA, FACMPE.