When Yale New Haven Health System decided to move an acute rehabilitation unit out of its location at Bridgeport (Connecticut) Hospital in 2015 to an off-site location to gain space, what helped ease the staff’s acceptance of the change was alignment between executives and providers, according to Ryan O’Connell, MD, Vice President, Performance and Risk Management at Bridgeport Hospital.
“We knew the idea would be unpopular because everyone liked the unit’s existing site, but the decision was unanimous by medical leadership, and because there was alignment and engagement between non-clinical and clinical leaders, there was trust,” O’Connell says.
NEJM Catalyst’s recent Insights Council report, “Leadership Survey: Why Big Gaps in Organizational Alignment Matter,” reveals that while an overwhelming majority of respondents recognize the necessity of alignment between key stakeholders, such as executives and clinical leaders, the reality in their organizations is much different. For most, the degree of alignment is far from the necessity.
O’Connell defines alignment as “a mutually agreed-on common purpose, vision, and goals among employees.” In the survey, this definition ranks second behind “the organization’s mission, vision, and goals are supported by governance, strategy, and incentives,” which nearly half of respondents consider the best way to define alignment among key stakeholders.
O’Connell stresses that alignment does not mean everyone always agrees with one another. “If the CEO of the hospital always does what any physician group wants, that would be poor leadership. Good leadership is being present, understanding, and investing a tremendous amount of time with medical staff,” he says, adding that is where the bond of trust is formed.
Bridgeport Hospital, which has competition from another hospital in town, is studying why patients choose one hospital over another. What they’ve uncovered is the power of physician alignment with patients (as well as physician reputation). In the Insights Council survey, almost all respondents say alignment between frontline clinicians and patients is necessary, and 83% say it exists in their organization.
But managing alignment between clinicians and patients is often not simple, O’Connell says. Because Connecticut is still firmly entrenched in volume-based payment, patients and providers feel pressured to choose aggressive care. Better alignment of payment incentives would move both stakeholders to a shared decision-making model, he believes.
Colorado Permanente Medical Group (CPMG), a multispecialty physician group that provides medical care to Kaiser Permanente members across the state, is focusing on transparency and alignment on strategy, mission, and goals, according to Monica VanBuskirk, MBA, Portfolio Director of Value at CPMG.
“In any organization, you have to be nimble, and that is much easier when you’re on the same page. It’s hard to be nimble when there is rampant misalignment,” she says. CPMG works closely with Kaiser Foundation Health Plan, but the two are separate organizations that have traditionally kept parallel but discrete strategic plans. With fairly new leadership in place — each organization named a new president in 2016 — the two entities now agree on a single strategic plan, a move VanBuskirk believes bodes well for transparency and alignment. The two presidents have embarked on a tour of Kaiser Permanente sites around the region to explain the plan and gather feedback. “Two years ago, I would have said we were 30% aligned. Now, I feel we have doubled that and continue to get better,” VanBuskirk says.
Only 21% of Insights Council members say their organization’s alignment approach is formally stated, while 24% say it is tacitly understood. VanBuskirk monitors sentiment toward transparency via a visual management touchscreen that shows what is being done to execute on incentives and strategy and how that is being received by key stakeholders. For instance, an internal survey conducted last year at CPMG showed “frontline clinicians are hungry for executive interaction, something we see as an opportunity for our leadership team,” she says.
A clinical leader at a health system in the South (who asked to remain anonymous) says keeping close tabs on alignment is essential for organizational stability in today’s dynamic, changing health care marketplace.
Using short “pulse” surveys on employee engagement, the clinical leader says she can gauge alignment and transparency impressions from the organization’s nearly 5,000 staff members, asking questions such as “Does my manager give me feedback?” and “Does the hospital follow its mission?” The health system also conducts a more comprehensive survey every few years to assess its status as a “model community.”
As more physicians move from affiliated to employed status, the clinical leader says the organization is learning how to set guidelines and incentives for performance. “If you’re in private practice, you might elect to do X many surgeries a week, but as an employee of the hospital, you have to do a minimum amount,” she says. This discrepancy can cause friction. However, as the health system becomes more transparent with its strategy, goals, and mission, she is confident that alignment between physicians and executives will improve.