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Effective working relationships between hospitals and physicians: This is Part 3 of our 3 Part Series on T Effective working

his is the third article of the series the Ontario Hospital Association (OHA) has published on the topic of hospital-physician relationships. The first article in this series, “Key Themes from the Literature” highlighted seven considerations to successfully foster and maintain positive relationships between hospitals and physicians. The second, “A Practical Approach to Enhancing the Relationship” provided strategies and guidance on developing and nurturing an effective hospital-physician relationship. Over the past year, the OHA has been consulting with hospitals across the province to better understand the current landscape in Ontario as it relates to hospital-physician relationships, both from a quantitative and qualitative perspective.

Results of online survey

In April 2015, the OHA conducted an online survey to evaluate the current state of physician relationships within Ontario hospitals and the strategies that hospitals and physicians were using to strengthen their relationship. The survey was sent to hospital Board Chairs, Chief Executive Officers (CEOs), Chiefs of Staff, Vice-Presidents of Medical Affairs, Department Chiefs and Medical Staff Association (MSA) Presidents to gain an understanding of the organizational structures and processes being used to foster effective hospital-physician relationships. Forty-eight per cent of Ontario hospitals responded to the survey (69 hospitals, 98 responses), and represented a variety of hospital types. Responses at each of these hospitals were provided by a variety of leaders. The chart below illustrates the common job titles of respondents to the survey. Respondents were divided into three groups, based on the individual respondents’ role within the hospital: (1) Corporate Leadership (e.g., Board, CEO, n = 27); (2) Senior Leadership (e.g., Chief of Staff, Vice President – Medical, n = 28); and (3) Clinical Leadership (e.g., staff physician, Chief Operating Officer, Chief Quality Officer, n = 43). Analysis of responses by respondent group illuminated a number of statistically significant differences in average responses between groups.

Corporate Leadership and Senior Leadership

Corporate Leadership and Senior Leadership groups responded differently when asked if their hospital promotes trust. Where Corporate Leadership had an average response of 3.97, Senior Leadership had an average response of 3.71; the difference was found to be statistically significant. Corporate Leadership and Clinical Leadership groups differed in their average re-


sponses to the statements on six of ten cultural aspects: 1) Hospital recognizes and values input of physicians; 2) Hospital welcomes innovative ideas and supports fresh approaches; 3) Hospital promotes trust, favours openness and transparency; 4) Hospital provides education and leadership training for physicians; 5) Hospital provides timely and accurate data to physicians to enable appropriate decisions; and, 6) Hospital use rewards and recognition strategies to acknowledge efforts by physicians. The differences in responses suggest that these groups may not be aligned in their views on cultural aspects that support positive hospital-physician working relationships. Further work may be required to explore these areas to ensure that the goals and priorities of “on the ground” leadership, often provided by physician leaders, are in alignment with the overall vision for the hospital.

Senior Leadership and Clinical Leadership

Senior Leadership and Clinical Leadership were the more closely aligned groups upon comparison. These groups only provided statistically significant yet different responses on one structural aspect: “Physicians actively involved at the board level”. The average response of Senior Leadership on this item was 3.5, where the Clinical Leadership response was lower, at 3.46. This difference suggests that physicians may not perceive their involvement as sufficient at the board level, or that physician involvement at the board level may not be communicated effectively to clinical staff. The survey also identified a number of common issues that generally impact the relationship with hospital management: financial resources; culture; leadership structure and processes; and information management. Resources (i.e. physician time and funding) were also highlighted as a major challenge by physician leaders during

the interviews, as was the need to develop strong physician leaders through leadership training.

Results of Informational Interviews

The majority of CEOs and physician leaders (e.g., Chief of Staff, Vice PresidentMedical) interviewed describe the relationship between their hospital and physician leaders as ‘good’ to ‘very good/excellent’ (15 of 17 CEOs interviewed and 9 of 11 physician leaders interviewed). Many indicated that there has been steady incremental growth in engagement and collaboration. Respect, trust and open communication were often noted as key ingredients for a positive relationship. The remaining CEOs and physician leaders, however, indicated that the current relationship is a ‘work in progress’ or ‘strained’, largely attributed to lack of engagement, poor communication, and lack of trust, which they are working to overcome through more open and transparent communication, and structured engagement of physician leaders. Interviewees were asked to identify the top three enablers of an effective relationship between hospital and physician leaders. The most commonly noted enablers were: • Physician Engagement: To engage physicians at all levels and as early as possible in the change process, give them formal roles so they are part of the change process, build trust, have meaningful engagement, transparency and respect; • Leadership Development: Provide leadership development, recognizing that strong physician leadership goes a long way to enabling the work of the hospital, provide physicians with the skills and supports for team-based problem solving, and recruit the right individuals; • Inter-professional Team Approach: Provide an inter-professional team approach to patient care and leadership (also called shared leadership), programmatic management, dyad teams and clinical leadership teams; • Shared Decision-Making: Ensure physi-

relationships between hospitals and physicians

cians h have meaningful f l involvement l and d influence on process, outcomes and accountability, that they feel listened to and encouraged to suggest innovative ideas; and • Engaged Hospital Leaders: Promote attendance and involvement of the CEO and hospital leadership at all levels of physician groups, have an open door policy and hospital leadership that is very responsive. The most common barriers to developing effective hospital-physician relationships were identified by hospital and physician leaders as: • Physician availability and time; multiple work-life demands; • Physician payment/income models/status as independent contractors; • Tensions between the OMA and the Ministry of Health and Long-term Care (MOHLTC); • Generational barriers/ “old school” attitudes/slow leadership turnover; and, • Challenges with recruiting and retaining physicians who are strong leaders. Some leaders shared that they are actively working to improve what can be a somewhat tenuous relationship. These conversations have reinforced that there is no “one-size fits all” approach to hospitalphysician relationships, although embracing the common enablers highlighted in the literature, survey and interviews appears to be a shared approach among hospitals with positive relationships. Another common observation during interviews was the ongoing work required to maintain and foster effective hospital-physician relationships. Leaders shared that these relationships require constant attention to improve and strengthen the connection between hospitals and their physicians. As the demands on the health care system continue to grow, it will become increasingly important for hospitals and physicians to navigate through the changes as partners with shared goals and expectations in order to deliver high-quality, effective and efficient patient care. Continued on page 17

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