Summary.    McLeod Health, a health system that serves patients in South Carolina and North Carolina, has worked for a decade in forging a collaborative partnership with 903 physicians. This article shares the process that it used to achieve that alignment. By applying its...

Misalignment between physicians and health systems is among the fundamental issues ailing U.S. health care. One major cause is the tension between the goals of improving clinical quality and controlling financial costs, including aligning physicians’ compensation with value-based payment models. A second is the burden that administrative and documentation tasks such as updating electronic health records has placed on physicians who would rather spend that time with patients. Left unresolved, these issues will slow progress in achieving affordable high-value care.

The problems stemming from lack of alignment — dissatisfied patients, uncoordinated care, inequities in care access, and escalating costs — have long plagued health care but have deepened during the Covid-19 pandemic. As the nation struggled with the crisis, health systems were also challenged by their own unique epidemic: disillusionment and burnout among physicians rose sharply. Hospital leaders must act on these issues because the care we all value is at risk.

Health systems’ performance — and resiliency — depends on having aligned, collaborative relationships with physicians. These kinds of relationships take time to establish, and they must be built on trust, honesty, and transparency. But once those relationships are in place, clinical care improves, and innovative care-delivery models emerge. Gains accrue in quality, productivity, and efficiency, which all contribute to better financial performance.

But achieving alignment is notoriously difficult. That’s because physicians align with health systems as a matter of choice, and that choice must be earned. Bringing them on board requires a person-to-person approach that starts with setting common values for the organization and a shared purpose for the health system — and physicians must have an integral role in setting them. Getting to alignment takes will, intentionality, and grit, as well as tactics, supporting systems, and iteration — with leaders continuously eliminating friction points along the way.

These are just some of the lessons that McLeod Health, a midsize health system that serves patients in South Carolina and North Carolina that has both employed and independent physicians, has learned from its decade of work on physician and health system alignment. Today McLeod’s 903 physicians (416 of them are employees) are engaged in the decision-making processes at all organizational levels, and surveys of them indicate they feel that their work is meaningful and is making a real difference in care delivery. It estimates that its physician turnover rate is significantly lower than industry benchmarks.

Alignment with its physicians was a key reason McLeod was able to navigate the Covid-19 crisis nearly seamlessly. Physicians and hospital leaders held daily calls that assessed information from the field, deliberated upon options, made decisions, disseminated plans, and then deployed solutions. The results: Patients were triaged so scarce resources, including hospital beds, were directed to those with the greatest needs, and the health system rapidly rolled out a mass-vaccination program across the region and delivered monoclonal antibody therapy to its most vulnerable patients.

In this article, we share the process that was used to achieve alignment between McLeod and its physicians. The three of us played a central role in that effort. One of us (Kathleen MacDonald) facilitated the numerous conversations among stakeholders, including physicians, executives, and board members. Another (Michael Rose) chaired a board committee that defined the vision for developing a “best of the best” medical staff organization at McLeod. The third (Robert Colones), as the health system’s CEO, was the executive sponsor of the work. Change on this scale can only be successful with commitment from the top of the organization.

Set the terms for alignment.

Too often the fragmentation of U.S. health care has meant that patients receive care that is poorly coordinated and that feels insufficiently focused on them. Because physicians are the ones who prescribe treatments, they play a vital role in defining the costs and outcomes of the health system. If McLeod’s aim was to improve the quality, safety, and cost of care, we knew these improvements would have to be led by physicians and grounded in values that they and the organization shared.

McLeod’s physicians, executives, and board members laid this foundation by defining and systemically incorporating “pillars of professionalism.” These pillars represent best-in-class principles and characteristics of physicians, a value set that includes embracing evidence, practicing medicine ethically and with empathy, and continually educating themselves and others in service to patients. By design, the pillars connect to McLeod’s mission and to its core values: they set the minimum terms for alignment.

Identify role model physicians to lead the cultural change.

To launch the alignment initiative, McLeod physicians were asked to nominate colleagues who embodied the pillars through demonstrated practice and leadership, and those colleagues were then celebrated at a formal event. These physicians are McLeod’s ideal team players. The medical staff leaders have kept up this annual nomination practice to show McLeod’s collective commitment to the pillars. The process grounds the concepts in people rather than words.

Once the pillars were defined and role models identified, the pillars provided clear expectations of any physician who sought to join McLeod. When interviewing candidates, physician-led recruiting teams pay close attention to whether individuals demonstrate competency and capability in each area. The pillars were also embedded in physicians’ employment contracts, and physician reviews emphasize performance related to the pillars.

With every hire and performance review, the organization took intentional steps to develop ideal physician team players. Many health systems have vastly underestimated the criticality of these steps.

Engage physicians as unique individuals.

Alignment can’t begin until health systems recognize physicians as individuals, each having unique perspectives and aspirations. Physicians engage with health systems in groups and on teams, but if they align, they do so one by one.

Traditional approaches to creating alignment include holding staff meetings to communicate changes and new policies, but most physicians — who are used to having autonomy and making life-or-death decisions in the field — don’t just line up to follow instructions and read memos. That means organizations must do the painstaking work of understanding what matters to and drives individual physicians, bringing their voices into the conversation. Additionally, health system leaders must solve problems side by side with physicians, finding mutual solutions with them instead of for them. Any time a decision is made — whether clinical, operational, or strategic — physicians must be at the table. McLeod’s CEO has made it clear that true alignment means physicians have the right to say “no” to decisions not in the best interests of their patients.

While all of this is obvious to physicians, it is an epiphany for many health systems. The talents and creativity of physicians can only manifest themselves when the system around them is tuned to amplify what they do rather than dampen it.

Physicians are willing to deal with the on-call shifts, the time away from family, and the stress so long as they have the resources and technology they need to excel day to day and feel able to pursue their professional interests. This second point is especially important and one often overlooked by health system executives.

Imposed production demands and the documentation burden of the electronic health record have wiped out what little discretionary time physicians had left in their schedules. But we know that tapping into physicians’ passion by making room for them to explore, discover, and to act on their priorities is essential for their well-being — and certainly is a way to forestall burnout. Experts have found that reserving just 10% to 15% of physicians’ time for tasks such as doing research or learning new techniques is enough to maintain energetic alignment. McLeod’s leadership has recognized that giving physicians some time back delivers more for the organization, not less.

Let physicians help shape the organization.

Health systems’ leaders often don’t realize that physicians enter medicine not just to improve individual lives directly but also to make a difference on a larger scale by shaping the organization’s direction.

But effecting change in the health system is a skill that requires physicians to partner with many people both internally and externally. It’s a skill that is counterintuitive to how most physicians are trained in school and residency, where they are taught to be self-sufficient and to make decisions individually. In addition, how ideas get implemented at scale can be a puzzle for physicians, most of whom have had little to no training in operations, finance, or program deployment. That means health system leaders have to help physicians learn how to enact change and then support them in doing it.

McLeod launched two programs to get physicians involved in shaping the health system: one to address quick wins that could be implemented immediately, and the second to build long-lasting strategic improvements.

Achieve quick wins to build momentum.

Clinical effectiveness (CE) is the workstream that targets close-to-the-ground areas where teams do their work. McLeod’s CE teams are physician-led, evidence-based, data-driven work groups for care improvement. They include master’s-level registered nurses (RNs), process engineers, and project managers, supported by research and analytics personnel. CE teams are engaged to solve narrow problems for which solutions can be researched, designed, and implemented in 90 days. The teams focus on areas where the opportunity is real and measurable — such as getting heart-attack patients into the catheterization lab in minutes rather than hours or improving the mortality rate for a particular disease.

McLeod sifts for opportunities constantly by searching for gaps between its outcomes and those of its peers or its methods and best practices. A leadership team of physicians, the chief quality officer, and executives create a CE schedule by quarter, and McLeod leaders organize the various initiatives into rounds to help assign personnel and resources. At the conclusion of each round, the findings and recommendations are carried through the medical staff organization and ultimately reviewed as part of the board quality committees. The results are also presented by the CE teams at medical staff meetings and are regularly the first agenda item at system board meetings.

In addition — and importantly — the results are acknowledged and celebrated up and down the organization.  Success stories and attribution for the work are presented at formal health system events and are featured prominently in newsletters and other publications.

This structure has enabled CE teams to deliver new care models while solving clinical challenges and improving care quality — an unprecedented achievement for McLeod care teams. CE teams also help physicians make meaningful improvements to the health system, which both increases their professional satisfaction and benefits patients.

Invest in physician leadership for long-term success.

McLeod also launched a physician-executive leadership academy (PLA). While CE focuses on short-term improvements, the PLA is MBA-level training that readies a physician to be a leader of leaders or of larger teams in more complex work. These individuals join McLeod’s physician leadership pipeline and are key to succession planning.

Nominated physicians participate in a yearlong program taught by McLeod and a faculty of national thought leaders, who include experts from prominent medical institutions and health care-focused consulting firms as well distinguished authors and speakers. Meetings take place monthly with a formal scheduled agenda. The topics covered include health care finance and process improvement, trust building, conflict management, physician resiliency, and emotional intelligence. Participants also team up with executives to complete system-level projects of their choosing such as designing and implementing clinical decision units across emergency services to make better and faster decisions about patient care.

Graduates then move into leadership roles in the health system, including operations leadership or C-suite management positions. Of McLeod’s physicians, both employed and independent, just over 20% have completed the PLA.

The ripple effects of alignment.

McLeod’s shared purpose has helped physicians both see how their work ties into the health system’s larger goals and directly contribute to those goals. They know what to expect from others and what they themselves need to do to meet others’ expectations. The result is a health care system that is aligned around helping physicians serve patients better. We hope that other health systems can learn from McLeod’s experience.