Letters to the Editor

Physician Leadership and Health Care Teams

July 21, 2001

Dr Jacobs:

Your Editorial in the Spring 2001 Permanente Journal was excellent. Health Care Teams (HCTs) need not be a complex concept nor a radical departure from the principles of quality care and caring.

A few months ago, I sat in on a discussion about HCTs--and someone said that we have a ways to go yet (and we do)--we currently have Health Care "Groups," not Health Care "Teams." I realized that perhaps we should have paid more attention to mentoring new leaders about team building and personal accountability.

The Hawaii Region approached HCTs with a purposefully flat administrative structure. The intent was to allow staff direct exposure to, and influence on, the HCT development and implementation process. We were purposefully vague with our vision because we did not feel we had a successful model to endorse. Thus, instead of a clear operational vision, we used behavioral principles as a conceptual framework that HCTs could build on, and we encouraged operational variation in search of a best practice.

It's been almost four years now, and I think it is safe to say that we have buy-in from most of our staff. What we have seen is that the best predictor of an HCT's overall success (defined arbitrarily with a mix of patient satisfaction, clinical outcome, and operational measurements) seems to be who the physician leader is. We have found no correlation of an HCT's performance to panel size, appointment utilization or walk-in volume, medical acuity, or the socioeconomic status of the community it serves. No matter how we slice it, it all seems to boil down to accountable physician leadership and their team building skills; individuals who lead because they want to (not because they have to); who take the time to understand, communicate, and give feedback; and who sincerely care about the welfare of their staff.

There is a difference in being "held" accountable versus "being" accountable: the successful MD leaders I've seen are MD leaders who are accountable to their own values. They do not respond to administrative oversight (ie, being held accountable): they respond to their values (ie, being accountable). Success is achieved because we got lucky and their values are aligned with the organization's mission.

To improve what we have for the future, some of the things the Hawaii Region will focus on include:

1. Team dynamics, turning "groups" of professionals into a "team" (easier said than done).
2. Shift our HCT focus from discussions and meetings about operational flow to clinical issues.
   Operational efficiency falls into place easier if one addresses it in the context of a clinical issue. Physicians also relate to a clinical perspective better than they do to an operational one.
3. Continue to refine what process and outcome measurements we feed back to our HCTs.
4. Emphasize the HCT physician's role in the continuing education of nonphysician staff.
5. Improve alignment by getting in place a "Values-Based Leadership" philosophy. Many regions including ours, have defined "Core Values." How to keep those Core Values front of mind and consistently applied to the work environment is what we have been wrestling with.

One of the key leadership values we hope to improve and emphasize is that patient satisfaction is directly related to staff satisfaction: an enabled, satisfied staff is capable of delivering a higher level of care and service. Staff satisfaction is thus as much a strategic differentiator as any operational/business initiative we pursue.

HCTs are basically interdisciplinary medical care integrated under the guidance of the PCP where everyone is utilized to their fullest potential. Leadership, team dynamics, and accountability to core values are, in my opinion, the most important factors for success.

Ben Tamura, MD
Chief of Medicine, Hawaii Permanente Medical Group

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