I am sometimes asked: what does a CEO look for in a CMO? I’ve heard this discussed at the American Association for Physician Leadership (AAPL) meetings and American College of Healthcare Executives (ACHE) meetings, and it was a topic of discussion during the week-long tutorial for the Certified Physician Executive (CPE) qualification. I’ve looked at dozens of job descriptions which also provides insight into identifying the essential abilities the CEO wants in a Chief Medical Officer.
There is no one set of skills or abilities, of course. Each organization and CEO will be looking for a set of skills to meet its unique needs. But there are some common themes.
After the hospitalist movement began, it wasn’t on the radar at our 300-bed hospital for many years. Robert Wachter and Lee Goldman made the case for dedicated hospital-based physicians years earlier. And as DRG payments failed to keep up with inflation, and inpatient care became more complicated and costly, it seemed our medical staff was not becoming any more efficient with inpatient care.
Our CEO and other executives began to read more in their professional journals about hospitalists. Hospitalists had the ability to provide more timely, evidence-based care. Community based internists and family physicians were working in both inpatient and outpatient settings. Therefore, they had limited time to devote to hospital rounds.
And it was clear that a hospitalist service could provide better patient satisfaction, shorter lengths of stay and better documentation. The last issue resulted in better payments from Medicare. Such benefits could produce $1 million or more to our bottom line. And externally reported quality metrics would improve.
In spite of being patient-centered and quality driven, physicians are also resistant to change, especially when the proposed change appears to threaten their autonomy. Our physicians were no different. As a result, the slightest hint of starting a hospitalist program was met with intense resistance.
There were some good arguments against adopting this new approach that might fragment a patient’s care:
- Without the PCP involved, knowledge of the patient’s history and previous response to treatments might be lost.
- With handoffs on admission and discharge, there could be an increase in the risk of medication errors.
- The PCPs did not know the new hospitalists, so how could they recommend referral to them in good faith?
- Patients might be upset because they were expecting to see their own PCP when admitted to the hospital.
This situation is a good example of the type of new service line that the chief medical officer is expected to lead. In our case, the CEO asked that I develop and implement a plan to establish an effective hospitalist program. The process did not proceed quickly or easily.
Here are the steps that we followed to establish a full-time hospitalist service. The long-term goal was to staff with two daytime hospitalists and one “nocturnist,” all of whom rotated day and night shifts. The service we started was not mandated, but would be used by those physicians wishing to focus on their outpatient practices. The implementation team:
- Educated the medical staff using memos, and discussion at department and quarterly medical staff meetings; presented the supporting evidence from the literature; and, demonstrated examples from other hospitals that showed that care was measurably better, and that the potential handoff problems could be prevented with good planning and communication.
- Identified several physicians who wanted (in some cases, demanded) the hospital provide such a service to free them up to focus on outpatient care ( I had already cut back my care, so I was one of the physicians seeking such a service for my patients as I transitioned into full-time administrative medicine).
- Started with a part-time service with two providers who covered the evening admissions from home, coming in as needed, until the volumes justified a full-time service.
- Interviewed several national and regional hospitalist groups in preparation for starting a full-time service with six new internists to cover the hospital as outlined above.
- Selected the best of the new programs and entered into contract negotiations.
- Executed an agreement and began interviewing candidates.
- Went live about six months later, with six newly credentialed, board certified internists.
This process is similar to many that the hospital executive must lead. The process took years to complete. It met a strategic need, and involved staff at all levels of the organization. We worked with the formal medical staff leadership and multiple individual medical staff members. Good communication, project planning skills and patience were required.
As the CMO, I was administratively responsible for the implementation. This meant that I:
- dealt with the concerns of the medical staff by listening to them in every venue conceivable;
- developed the structure of the program, and the timeline for implementation, with input from other senior executives;
- worked with the facilities department to identify office space for the hospitalists;
- made initial inquiries with hospitalist groups and arranged their presentations to our senior staff;
- reviewed the proposed contracts, involved our attorney and negotiated changes that we needed;
- executed the agreement and worked with the new group on implementation;
- interviewed every new candidate (as did other members of our team); and,
- approached members of our medical staff to personally invite them to use the service.
My involvement in this process is an example of what your CEO will expect of you, whether it is starting a new hospitalist program, a wound management service, or a new patient safety initiative.
Reflecting on my own experiences, speaking with hospital CEOs and CMOs, reviewing published accounts and looking at dozens of job descriptions, I believe that there are eight primary abilities the CEO wants in a chief medical officer.
The Eight Essential Abilities
1. Patient Safety and Quality
This is the most often cited skill set. The CMO should have an excellent knowledge of healthcare quality and safety and be able to lead quality initiatives. The director(s) of quality and patient safety often report to the CMO. Hence, familiarity with these specific issues will be important:
- Sentinel Events, Never Events, Patient Safety Indicators and Root Cause Analysis;
- Measurement of risk adjusted mortality, complications, and readmission rates;
- National and regional quality collaboratives;
- Patient Safety Organizations, the National Quality Forum, the Institute for Healthcare Improvement and the Leapfrog Group;
- Infection control initiatives and reducing hospital acquired infections; and,
- Pharmaceutical safety and the Institute for Safe Medical Practices best practices.
2. Medical Staff Affairs
This includes the areas of medical staff structure and governance, bylaws, and medical staff meetings. The Director of Physician Services/Medical Staff Office often reports to the CMO. Medical Staff restructuring efforts fall under this skill set.
And it is not uncommon to find the Continuing Medical Education enterprise to be housed in this area, so an understanding of CME planning and accreditation may be needed.
3. Clinical Service Line Development
This is one practical way in which the CMO contributes to the strategic initiatives of the organization. The CMO should be able to identify possible new service lines, evaluate them, present them to the senior management team and then accept accountability for successfully operationalizing them.
These new service lines could be as simple as an inpatient wound care program involving one or two wound care nurses and a medical director, to a brand new open heart surgical program or neurosurgical service line. Or, it might be more unit based, like starting an observation unit or an inpatient dementia unit.
4. Resource Utilization and Standardized Care Processes
This requires an understanding of care management, evidence-based protocols and nurse case management. The CMO may be administrator assigned to direct the activities of the Length of Stay Team. Measurement of length of stay is dependant on accurate documentation and coding. Therefore, it is common for the director or manager of clinical documentation and coding to report to the CMO.
As CMO, I brought in outside documentation and coding experts to educate our staff. To do so, I executed agreements with two different consulting firms over 10 years to help us optimize our documentation and coding practices.
5. New Payment Models
The CMO will be valuable as changes in payment models drive changes in care delivery. It takes a sophisticated understanding of new care models, including inpatient and outpatient support systems, and the ability to educate and engage physicians to adopt the new models of care.
There have been many such changes over the years that have required the expertise of the physician executive. These changes have included:
- Moving from fee for service to DRG payments in the 1980s, which required physicians to think about discharging patents earlier rather than when they had reached “maximum hospital benefits” or had returned to “pre-illness level of function.”
- Helping physician colleagues to balance a shrinking length of stay with the need to reduce readmission rates in order to avoid Medicare penalties.
- Engaging care teams in new population health initiatives, such as palliative care, diabetes and other chronic care management programs.
- Creating collaborative relationships in order to implement bundled payments for elective surgical procedures such as total joint, cardiac valve, and spinal fusion or medical conditions such as congestive heart failure and acute pneumonia.
6. Clinical IT and the Electronic Health Record
It is not surprising to find that physicians helping to implement electronic health records stay on to run the clinical informatics efforts as Chief Medical Information Officers. Often, the CMIOs progress to a broader role as CMO in many institutions.
The CMO must again demonstrate the ability to engage physicians and solve safety and quality problems, in this case with evidence-based order sets and IT solutions.
7. Communication Expert
When trying to describe important new technologies or recent quality efforts, the CMO is often chosen to deliver the message. Hence, the CMO must have the ability to take complicated topics involving epidemiology, statistics, population and public health, and quality improvement initiatives and convey them for the board and other lay audiences.
He or she also needs to be able to recruit team members to support initiatives that may not be profitable, but will create better patient care and improved health outcomes.
8. Liaison to Contracted Hospital Based Groups
Many health systems rely on the use of independent medical groups to provide certain speciality services. The most well-known specialties contracted in general medical hospitals are anesthesia, emergency medicine, and radiology. It is also common to use contracted groups for hospital medicine and pathology.
Each hospital must have a liaison who will meet regularly with the group’s leadership and monitor the following issues:
- Patient satisfaction;
- Quality, safety, length of stay;
- Utilization of resources;
- Relationship with nursing, pharmacy and other professional staff;
- Maintaining regulatory compliance and being “survey-ready” at all times;
- Addressing complaints from patients, physicians and other stakeholders;
- Monitoring any financial performance measures; and,
- Soliciting feedback and input from the contracted group
The CMO is in a very good position to apply the other abilities (safety, quality, resource utilization) to the relationship with these independent hospital-based groups. The CMO can monitor performance and ensure that there is a partnership that benefits both parties. As a physician, the CMO can understand the practice challenges and empathize with issues important to physicians, further enhancing the relationship.
In reality, no CMO is an expert in all of these areas. And in specific situations, some very different skills may be needed. For example, with the increasing employment of physicians as I have previously described, knowledge of physician employment, contracting and compensation design can be very helpful.
CMOs need to be adaptable and committed to life-long learning. And by developing in the eight areas described above, they will become a valued member of the senior executive team at any healthcare organization.
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