ADMINISTRATION Clinical Service Lines

Clinical Service Lines

A training ground for the emerging physician leader

DANIEL K. ZISMER. PH.D.

The demand for trained and experienced physician leaders is increasing at an accelerating rate domestically and internationally, and opportunities for physician leaders are no longer isolated to the C-Suite of health care organizations, or larger medical groups. Likewise, these job openings are no longer reserved for the physicians who may have matured into the twilight years of their career, or physicians who must abandon clinical care in favor of full-time medical administration.

Experience with the Health Care Administration Program, University of Minnesota identified growing interest from younger, practicing physicians in developing competencies in a parallel career; healthcare management. By the third year of the newly launched Executive MHA program, it was clear that physicians at mid-career and less, whether domestic or international, came to the program with unapologetic enthusiasm for their desire, as one young physician put it “to develop a different part of my brain”. Another, a young interventional radiologist, by his mid thirties, had already decided that he “did not want to go through the rest of his career wearing a lead apron”, and a third interviewed for admission to the program had stated that “I want to provide myself options as my medical career unfolds”.

As physicians consider a career in organizational leadership there are typically two questions that loom large. Both are addressed here. The first is “will I need to eventually give up the practice of medicine to succeed?”, the second “is there a reasonable, more measured way to get started on the path?” The answer to the first is easy. No! There are a number of leaders who effectively navigate roles as clinicians and as leaders in health systems and medical practices, while some do decide to hang up their stethoscopes in favor of an alternative way to contribute to patient care, and healthcare delivery more broadly.

The second question presents the centerpiece of this article: “is there a manageable way to get started on the path of becoming a physician leader?” The answer to this question is represented by a fast expanding opportunity for physicians who wish to get their feet wet with a meaningful role in leadership without jumping into the deep end of the pool. That opportunity is serving as the physician member of a “leadership dyad” in charge of a clinical service line within a health system or medical clinic.

In a chapter written for Mechanick and Kushner’s 2020 book titled “Creating a Lifestyle Medicine Center” (Zismer, D.K.) a clinical service line is described as “a grouping of defined clinical services and programs dedicated to an identified constellation of related diagnoses, and clinical conditions, designed and dedicated to produce superior course of care, over time, based upon evidence-based, best practices for defined clinical populations”. Clinical service lines are often, but not exclusively, dedicated to the management of chronic diseases and conditions. The clinical service line “leadership dyad” pairs a practicing physician leader with a trained administrative services partner to oversee the design, leadership and management of the clinical service line. The physician partner in the dyad has a defined, part-time job. The position is typically responsible for providing the clinical guidance to how, and how well, the clinical service line functions and performs its obligations to patients served, including how providers work as teams to enhance clinical outcomes, and how clinical and staff resources are applied to create optimal outcomes. To be clear, the leadership dyad is not two people doing the same job. The physician and administrative dyad partners bring unique skill sets and competencies to the leadership of the service line.

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But are clinical service lines a real and sustainable strategy worthy of redirection of a physician’ career path? In a survey of 47 health systems conducted by Wegmiller and Zismer, 85% of systems in the sample stated they had already launched, or expected to launch one or more clinical services as principal components of an overall organizational strategic plan. Most health systems in Minnesota have long since decided to compete based upon what are easily identified as clinical service lines including; “heart and vascular centers”, “sports medicine”, “mother and baby hospitals”, “pain management centers”, “behavioral health programs”, “lifestyle and wellness centers” and “diabetes management programs” to name a few.

So if starting on the path of physician leadership can begin as member of clinical service line dyad, what does the emerging physician, with little

David Schultz, MD Chief Executive Officer Nura Pain Clinics Peter Schultz, MD, MPH Medical Director Nura Pain Clinics

R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers

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According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

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3Clinical Service Lines from page 20

• Identifications of practice style markers that may serve as useful sources of clinical service line operating productivity performance or no real leadership or management experience have to offer? The answer metrics; e.g., types of provider work relative value units, types of hides in plain sight; it is what they already know, or know how to know, as diagnostics applied, care model team configurations, interactions an experienced clinician. The value of the dyad, with related patient care providers, and use of pharmaceuticals. and the clinical service team, is best described by • Expected rates of hospitalizations and the old bromide, “two heads are better than one”. re-hospitalizations. With dyad leadership, the physician member of the team brings the clinical experience and • Identifications of the provider behaviors understandings. This includes, but is not limited to, knowledge of the following: The leadership dyad is not two people doing the same job. that are counterproductive to the mission, goals and objectives of the clinical service line, including how to identify them in • Expected clinical outcomes. related service line performance metrics. • Evidence-based standards of practice • The construction of useful, applied service brought about by an integrated and line performance scorecards. coordinated team care. • Ongoing analyses of how the incentives • How to understand variation of practice created by provider compensation plans style and the effects on clinical outcomes and related resource use align (and misalign) with service line variation. mission, goals and objectives. • How various combinations of clinical program inputs (diagnostic and therapeutic services) can enhance or sub-optimize clinical Pursuit of these goals provides for more than a sufficient part-time job efficacy, efficiency, and total cost of care performance. for any physician member of a clinical service line leadership dyad. The physician leader in the dyad carries at least half of the responsibility for • How specific patient characteristics, and traits, may interact with encouraging high-functioning team care. Virtually every clinical service care protocols to affect program adherence, clinical outcomes and line promises patients an integrated and coordinated experience. Those that value derived from established care models. succeed deliver on that promise.

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Developing Advanced Skills

The leader interested in “moving up the leadership chain of command” in health systems, and in larger medical group practices, will need to develop advanced skills and competencies. Here the expectations of the physician leader expands, and more formal, graduate-level healthcare administration or “B-School” education and training may be required. But beware the trap, and trust this bit of advice. The trap is physicians who pursue graduate degree training in an attempt to compete with the seasoned, non-physician executive. Physicians can fall prey to the belief that “if I earn an MBA, I’ll know everything that every other MBA knows”. Translate that thinking to medicine. Does the new medschool grad know everything a physician with 20 years of experience knows? The answer is obvious. Physician leaders don’t need to compete with the non-physician executives. Remember, physician leaders have a special knowledge and experience foundation that can’t be replicated by non-physicians; it’s the knowledge of the practice of medicine! The other MBAs or MHAs in the room can’t bring that. Never try to play another person’s game. Too many physician leaders fail as leaders, or quit as leaders, because they tried to compete with the wrong “competitors”. Many-a-physician in the C-Suite has told me “I don’t even understand the language the non-physician executives are speaking. The best response is always, “turn the tables”. Step-up with what you know and what is always relevant; the effective “manufacturing” and delivery of the right patient care, at the right time. Your job is to bring the medical care and relevant patient care aspects of the service line business plan to the table. The successful physician leader learns to integrate the language of clinical care and the practice of medicine with service line business planning, management and performance evaluation. Clinical service

line strategies often fail because the practicalities of clinical practice were • Clinician and staff behavior effects on the patient experience. missing during the developmental stages of business planning and service • Understandings of how the clinical processes implicate other line implementation. clinical care requirements of patient served; i.e., the integration of

For the physician clinical service line leader who has designs on being the clinical care beyond the identified service line. next CEO of the health system or medical group, • Organizational psychology and the effects on formal, graduate “business school” training may be culture and performance. required. If pursued, be mindful of the curriculum design provided. The curricular offerings need • The discipline of innovation and business practice. to complement the role of a physician leader. A portfolio of syllabi representing general business Physician leaders don’t need to compete with the non-physician • Change management. Completing the Circle courses can be useful, but may not be specifically executives. Now let’s return to the beginning. Almost relevant to the needs of a physician with leadership everything an emerging physician leader needs experience under their belt. When examining the to know about the “business of medicine” resides curriculum of a graduate level degree program, with the design, leadership and management of look for the opportunities to acquire skills and a single clinical service line. Every large health competencies in the areas of: system and complex medical group practice is composed of a combination • Organizational culture and its effects on clinical process and patient of clinical service lines. Even the complexity of the clinical enterprise that experience performance. is Mayo can be distilled to an aggregation and integration of multiple • How the right clinical processes will bear upon service line staffing clinical service lines. There practicing physicians who are the next composition, business operations and financial performance. generation of health system and medical group physician leaders have a • Analyses of clinician practice style variation and the potential effects practical path and training ground to test the waters of leadership in a way on service line productivity and operational and financial performance. that doesn’t put their clinical career at risk. • Continuous quality improvement. • Continuous process improvement. Clinical Service Lines to page 324

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