Leading Beyond the Bottom Line (updated)

It’s a philosophy refreshing and thought-provoking on the larger scale of hospitals and health care delivery systems and on the more parochial level of emergency medicine. Presented in July-August issue of The Physician Executive (pp. 6-11) published by the American College of Physician Executives (ACPE, not to be confused with ACEP), Leading Beyond the Bottom Line was followed by an online cyber forum during August.

Leading Beyond the Bottom Line is a concept that suggests that physicians who act more like managers is a failed approach that vitiates the physician’s unique role in health care. The physician-executive authors of this approach assert that rather than ensure profit, the health care entity must reach a Pareto optimum among financial health, patient care, employee well-being, and community commitment. The Pareto optimum is named for Wilfred Pareto, who first articulated the optimum as a socioeconomic concept of balancing competing and cooperating interests. Balancing these interconnected objectives goes beyond conducting a “stakeholder analysis” or the 360° assessment that Leading Beyond the Bottom Line articulates as a philosophy for guiding action.

Because I’d like to take this month’s column to discuss how the Leading Beyond the Bottom Line concept might apply in emergency medicine, I don’t have sufficient space to detail the thesis. Read the entire series on the ACPE website.

I believe that the philosophy inherent in Leading Beyond the Bottom Line connects to us in emergency medicine very directly. My hope is that it may provide a philosophical basis for recasting our engagement with our hospitals while also leading us out of the dichotomizing rhetoric of the past half-decade within our specialty’s ranks. This month I’ll address only the potential for recasting your interaction with your hospital.

Adopting this philosophy can facilitate the creation of a shared mission for your hospital and emergency physician group, and the process will develop your communication and negotiation skills. Yet, confronting the need for the struggle and then entering into it with people on the “other side” with whom you have “history” may be a daunting challenge.

Begin by engaging hospital representatives. Sharing a copy of this article with almost any hospital administrator is a good way to start. The nursing administrator for the ED may be the most accessible representative of the hospital and a good person with whom to start. However, there’s no need to limit your approach to a single individual, and indeed approaching as many of the hospital managers as you can may generate momentum and at the least will stimulate some interest among your hospital administrators that can facilitate opening the dialogue.

Entering upon an effort to recast your “working” (notice I’ve said nothing about your contractual) relationship with your hospital with nothing new in your approach will doom the effort to certain failure. The Leading Beyond the Bottom Line philosophy as a starting point can only succeed if you sit down and talk together. Your quiet insistence about the importance of meeting coupled with your equanimity when denied can go a long way to bringing even the most contrary hospital manager to the discussion table. Confrontation is not about fighting with your administration; it’s about addressing squarely — face to face — the issues before the respective groups. Rehearsing your approach, words, and facial expressions in the mirror, trite though it may sound, will make it easier for you to stay focused if baited by the “opposition.”

Once engaged in dialogue, the most important task entails moving beyond philosophy to successfully making something real happen through the use of the framework. The arrival of the ambulatory payment classification (APC) method for outpatient prospective payment provides an almost ideal focus. Although implementation began in August, by the time you read this, it’s likely that you will have heard from your administration in one form or another about the negative effect on hospital revenues the implementation of APCs has wrought.

Challenge any demand from a hospital administrator by calmly stating how unproductive such a demand is to the improvement they seek and the dialogue essential to gain the improvement. Point to the copy of the Leading Beyond the Bottom Line article you’ve sent around. Suggest that calm dialogue about the hospital and practice’s concerns will more likely reach a useful resolution for both.

Lastly, point out that pitting the hospital against the practice assumes a “zero-sum game” in which for one to “win” the other must “lose,” and that you’re confident that neither the hospital, the particular administrator nor the practice wants to “lose.” Suggest that finding the Pareto optimum for the practice and the hospital around the larger objectives noted will benefit everyone. Advise the particular administrator that he has nothing to lose and everything to gain by entering into the work with you because of the consequences of effective teamwork: better and more consistent results requiring less continuing attention as working together becomes more the usual way of doing business.

Your ace in the hole is that facility billing with APCs is entirely dependent upon the quality of the documentation. Either physician or nursing documentation must support medical necessity and document the delivery of the services. This is another reason to involve the ED nurse administrator because documentation that isn’t present in the physician note entails more reliance upon nursing notes for proper coding. Yet, a well-written physician note can suffice for the facility’s coding purposes as well as the practice’s.

In this endeavor, the physician group and the nursing staff are natural allies in meeting the needs of the process, and cooperation with nursing provides leverage in bringing the hospital financial administrators — and by extension operating administrators — to the table for direct confrontation on the issue. Are you and your administration together leading beyond the bottom line?