Canadian health care leaders’ perceptions of physician–hospital relations

Part 2 of a report on the Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators

Atefeh Samadi-niya, MD, DHA

 

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This second article on the Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators (CANSIRPH) focuses on health care leaders’ responses to the CANSIRPH questionnaire. Health care leaders at senior levels of management perceive physician–hospital relations to be more collaborative compared with leaders at mid-levels of management. Non-physician leaders also perceive these relations to be more collaborative than physician leaders.  Such differences could be the foundation of future planning to increase the satisfaction level of health care leaders toward the quality of physician–hospital relations, improve the quality of patient care, and manage budgets more efficiently.

 

An overview of physician–hospital relations from 1800 to 2014 in many OECD countries reveals skepticism, optimism, pessimism, and some harsh realism concerning the nature of relations between physicians and hospital administrators and its effects on the quality of patient care, health care costs, decision-making processes, and patients’ satisfaction.1-6 In the 1980s and 90s, the financial instability of health care systems led to increased interest in physician–hospital relations.7 Recently, researchers have suggested moving from skepticism to engagement as a solution to this problem.8-12 Lively interprofessional relations between physicians and hospital administrators have many benefits,13,14 and their importance was the topic of an earlier article.15 These discussions have shown that a gap exists in Canada’s literature concerning the quality of physician–hospital relations, although these relations are crucial to the quality of patient care.4,5,15,16 Top

 

The Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators (CANSIRPH) is a quantitative multivariate correlational research study. The term interprofessional relations encompasses physician–hospital relations, physician–health care relations, physician–executive relations, physician–administrator relations, doctor–manager relations, and, recently, physician engagement in leadership. Thus, the term interprofessional relationships between physicians and hospital administrators (IRPH) in this article is used to emphasize the need for relations between physicians and hospital administrators to be interprofessional and interrelated rather than interdisciplinary and separate.17-19 The acronym CANSIRPH (pronounced can surf) implies that the information gained from this research will help physician leaders and hospital administrators or managers successfully surf the waves of changing health care demands in Canada and beyond. According to the leaders who participated in CANSIRPH, interprofessionality is critical and crucial for physicians and managers as the key to the success of the Canadian health care system.1 Top

 

Purpose of CANSIRPH

The main purpose of CANSIRPH was to determine the perceptions of health care leaders about the quality of IRPH across Canada. A second aim was to discover the factors that influence the professional opinions of health care leaders about IRPH in Canadian hospitals. The third goal was to determine whether and to what degree those factors are correlated with leaders’ level of satisfaction with IRPH. Several open-ended questions were also included in the questionnaire to explore suggestions of health care leaders related to various aspects of IRPH; however, this article focuses on the main purpose of the study: to understand how Canadian health care leaders perceive IRPH in their organizations.  Top

 

CANSIRPH design

CANSIRPH was similar to studies designed by Shortell,20 Rundall et al.,5 and Davies et al.21 in the United States and United Kingdom. A detailed description of methods and statistical analysis is available elsewhere.1

 

The main business of health care leaders is to provide quality care to patients; thus, some decisions they make might be different from those made by leaders in other industries. Four frameworks that are currently accepted as pertaining to physicians and hospital administrators shaped the design of CANSIRPH: LEADS in a Caring Environment Leadership Framework22; CanMEDS23; Interprofessional Care Framework19; Participative Leadership.24

 

These frameworks guide leadership expectations for health care managers/physician leaders (LEADs), practice/leadership expectations for physicians (CanMEDs), and the expectation that health care leaders will work interprofessionally and collaboratively (Interprofessional Care and Participative Leadership).  Top

 

Study population

According to the Canadian Healthcare Association, 6000–7000 physicians and non-physicians work as senior and mid-level managers at hospitals across Canada. The study population consisted of Canadian physicians and hospital administrators whose email address appears in Scott’s directories25,26 (2800 mid-to-senior-level health care leaders in 566 hospitals across Canada). In addition, the Canadian College of Health Leaders and the Canadian Society of Physician Executives sent their members a link to the questionnaire with an invitation to participate and to pass the link along to their colleagues. After accounting for duplication and bounced-back messages, in all about 4000 physician leaders and hospital administrators received an email message that included an introductory letter and links to an online consent form and the CANSIRPH questionnaire.

 

Results

Demographics of questionnaire respondents

To generalize the study results to the total population of health care leaders at mid- to senior levels at acute care hospitals across Canada, a sample of at least 209 respondents was needed; the actual number of respondents was 215. Top

 

Half of the CANSIRPH respondents were physician leaders (107) and half were hospital administrators (108). About half were in senior leadership roles (113); the remainder were in mid-level management (102). Physician leaders were from a range of specialties including surgical specialties. There were respondents from all the personal, professional, geographic, organizational, and generational categories included in the CANSIRPH demographic questions.

 

Less than half of the participants were women (40%). Of the women leaders who responded to CANSIRPH, 66% were at the senior level of management, whereas male leaders were mostly at the mid-level of management (60%). No significant difference was reported for the opinion of leaders toward IRPH based only on their gender. As expected, most participants were 40–70 years old; half were 50–60 years old and only 5% were under 40 years old. Top

 

About 40% of the participants were senior-level hospital administrators, 10% were mid-level administrators (managers), 10% were senior-level physician leaders, and 40% were mid-level physician leaders. These differences imply that senior hospital administrators and mid-level physician leaders may be those most interested in physician–hospital relations.

 

The participants represented all types of acute care hospitals and health care centres across Canada, although most were at teaching and community hospitals; about 50% of the hospitals were teaching hospitals and 30% were community hospitals. The participants worked in mixed, private, and religious hospitals. About 54% of participants were from large urban areas, 30% from small urban areas, 8% from rural towns, and 4% from suburban areas. Remote and isolated hospitals were also represented. Top

 

Analysis of the data

The following is a brief summary of the results (Table 1). Please see Samadi-niya (2013)1 for a full analysis and details.

 

Table 1. Summary of research questions regarding health care leaders’ perceptions of interprofessional relations between physicians and hospital administrators (IRPH)1

How do physician leaders and hospital administrators across Canada perceive IRPH?

More physician leaders and hospital administrators across Canada perceive IRPH as excellent or very good than those who considered them to be below average or poor.

How do physician leaders across Canada perceive IRPH?

Significantly more physician leaders perceived IRPH to be below average or poor compared with those who thought them excellent or very good.

How do hospital administrators across Canada perceive IRPH?

Significantly more hospital administrators perceived IRPH as excellent or very good than those who considered them to be below average or poor.

How do the opinions of physician leaders differ from those of hospital administrators about IRPH?

Physician leaders are less optimistic than hospital administrators about IRPH across Canadian hospitals.

How do the opinions of mid-level management differ from the senior-level management about IRPH?

Mid-level managers are less optimistic than senior-level managers about IRPH across Canadian hospitals.

How do the opinions of mid-level physician leaders, mid-level hospital administrators, senior-level physician leaders, and senior-level hospital administrators differ about IRPH?

There are meaningful differences in the opinions of leaders toward quality of IRPH. Opinions toward IRPH across Canada, from most optimistic to least optimistic: senior administrators, mid-level administrators, senior-level physician administrators,mid-level physician leaders (Figure 1).

 

Table 2 shows the overall level of satisfaction of nine categories of leaders whose results were included in more advanced statistical analyses.1 Overall, a higher proportion of all participants considered IRPH to be excellent or very good compared with those who believed them to be below average or poor. This was also the case for hospital administrators. The reverse was true for physician leaders; indeed, more considered IRPH to be non-collaborative as compared to those who felt the relationship to be excellent or above average. Top

 

More senior-level leaders believed IRPH to be collaborative than their colleagues in mid-level management and the perception of non-physician leaders about the quality of IRPH was more optimistic than that of physician leaders.

 

Looking at all four groups — mid- and senior-level physician leaders and non-physician leaders — the data show that the group most optimistic about IRPH was senior-level hospital administrators followed by mid-level administrators and senior-level physician leaders. Mid-level physician leaders were least satisfied with the quality of IRPH (Table 2 and Figure 1).

Discussion

Canada and other members of the OECD have witnessed a rise in the scientific–bureaucratic model of health care delivery, in which evidence-based medicine or evidence-based decision-making have replaced the traditional practice of medicine. In the scientific–bureaucratic model of health care delivery, the processes used by management may interfere with physicians’ motivation and personal judgement.27 Physicians must follow management dictates in caring for patients, despite the fact that they view themselves as independent, trustworthy, and knowledgeable professionals.

 

Administrators usually believe that medical and other staff members are highly satisfied with hospitals.1,21 Although hospital administrators are aware of the importance of the role physicians play in allocation of their hospital resources,4 they may sometimes forget to include physicians in the decision-making process and create a more collaborative environment in which physicians feel sufficiently considered in decisions that affect their workplace.28 Physicians usually want more input regarding “strategic decision-making and hospital operation.”29 The literature reveals discontent among physicians, which could be due, in part, to lack of satisfaction with physician–administrator relations.30 Top

 

 

 

 

 

Managers’ interference with the professional autonomy of physicians and a lack of trust in the decision-making of managers has been causing professional unhappiness among both physicians and managers.31 Reviewing historical events that led to the current situation helps us understand the challenges that physicians and administrators perceive in the 21st century health care system.7,32 Hospitals faced with deficits often hire a new president or CEO to balance their budget, but they may not realize that IRPH are crucial to hospital performance.33 Hospitals with better and more organized physician–hospital relations have less or no budget deficit.34 Pairing medicine and management is necessary, not only for high-quality patient care, but also for managing the budget of the health care system, including hospitals.

 

The role of physician leaders has become difficult as they attempt to cut services and shorten lengths of stay for patients who need adequate resources for their medical care.35 Researchers have acknowledged the difficult role of physician leaders, whose colleagues may view them as betrayers and collaborators with hospital administrators.36 Periods of silence among physicians are alarming rather than reassuring, because indifference is a potent action.36  More important, physician leaders may not receive payment for their managerial activities or their involvement in hospital administration. Top

 

Deciding on goals, measuring progress toward them, and sharing information regarding the results with other health care disciplines are key factors in a shared quality agenda.37 As the biggest players in quality of care, physicians often receive the credit,  control most of the costs in health care, and do not share any financial risks with hospitals.38 Success in quality of care is equal to success in IRPH.16,39-41 Thus, the success of a quality system depends on physicians’ active and continuous involvement.42

 

At the Healthcare Financial Management Association Executive Roundtable in October 2010, executives and industry experts shared their ideas and specified that the only group of professionals who could define quality, control costs, and reduce redundancy is physicians.43 Their findings indicated that physicians prefer simple straightforward reports, and they want to see the raw data on which reports are based. In addition, involving physicians in the process from the beginning and providing updates increases the likelihood of their acceptance of an initiative. Top

 

Remaining indifferent or not deciding to improve IRPH is an action. Indifference can negatively affect patient care.16,44 A survey of members of the American College of Physician Executives found that lack of trust is one of the main issues affecting the development of collaborative IRPH.45 Physicians involved in hospital management and leadership roles need special skill sets and managerial knowledge.46,47 Engagement of clinical directors in hospital management is an opportunity to engage physicians in the decisions that affect their daily work. Use of CANSIRPH results could enable hospital administrators and physicians to establish national guidelines to improve IRPH and, as a result, increase the quality of patient care and patient safety in all Canadian provinces. Top

 

Some stereotypical images held by physician and hospital administrators affect IRPH.48 Both groups consider the other to be more powerful and to have different goals.48 Health care leaders ought to refute incorrect stereotypes and replace them with appropriate views of the other group.49,50 After all, in a governance plan for Canada’s health care system, collaboration among medical staff, senior leadership teams, and board members seemed necessary.39 Many hospitals and health care centres claim that using teams made up of a physician leader and a non-physician leader has helped their organizations.1,51-55

 

Conclusion

Participants in CANSIRPH emphasized that IRPH are the key to the success of Canada’s health care system. Improving IRPH means quality improvement or, in fact, “quality investment.” IRPH and quality improvement mean patient satisfaction, patient care improvement, error reduction, employee and physician satisfaction, better interprofessional relations (not only with managers but also with other health care professionals), budget management, debt reduction for hospitals, and a sense of institutional pride. Top

References

1.Samadi-niya A. Interprofessional relationships between physicians and hospital administrators across Canada: a quantitative multivariate correlational study. DHA dissertation (PMI: 3583264). Phoenix AZ: University of Phoenix; 2013. Available:  http://pqdtopen.proquest.com/doc/1552485304.html?FMT=ABS

2.Curtis RS. Successful collaboration between hospitals and physicians. PhD thesis. Charleston SC: Medical University of South Carolina, College of Health Professions; 1999.

3.Lemieux-Charles L. Hospital–physician integration: the influence of individual and organization factors. PhD thesis. Toronto: University of Toronto; 1989.

4.Hospital Physician Issues Working Group. Hospital–physician relationships: where do we go from here? Toronto: Ontario Hospital Association; 2004. Available:  http://www.oha.com/CurrentIssues/keyinitiatives/eHealth/Documents/Hospital%20Physician%20Relationships%20-%202004.pdf

5.Rundall TG, Davis HT, Hodges CL, Diamond M. Doctor-manager relationships in the United States and the United Kingdom. J Healthc Manag 2004;49(4):251-68.

6.Welle-Powell D. Physician-owned specialty hospitals: friend, foe-or (system) failure? Healthc Financ Manage 2009;63(1):26-7.

7.Hariri S, Prestipino A, Rubash HE. The hospital–physician relationship: past, present, and future. Clin Orthop Relat Res 2007;457:78-86.

8.Kane N, Madden S, Saunders C. From skepticism to engagement. Healthc Financ Manage, 2010;64(12):68-74.

9.Dickson G. Anchoring physician engagement in vision and values: principles and framework. Regina: Regina Qu’Appelle Health Region and Canadian Policy Network; 2012. Available: http://www.rqhealth.ca/inside/publications/physician/pdf_files/anchoring.pdf

10.Kaissi A. A roadmap for trust: enhancing physician engagement. Regina: Regina Qu’Applle Health Region and Canadian Policy Network; 2012. Available: http://www.rqhealth.ca/inside/publications/physician/pdf_files/roadmap.pdf

11.Metrics@Work Inc., Grimes K, Swettenham J. Compass for transportation: barriers and facilitators to physician engagement. Regina: Regina Qu’Appelle Health Region and Canadian Policy Network; 2012. Available:  http://www.rqhealth.ca/inside/publications/physician/pdf_files/compass.pdf

12.Denis JL, Baker GR, Black C, Langley A, et al. Exploring the Dynamics of physician engagement and leadership for health system improvement: prospects for Canadian healthcare systems. Regina: Saskatchewan Ministry of Health; 2013. Available: http://www.cfhi-fcass.ca/sf-docs/default-source/reports/exploring-dynamics-physician-engagement-Denis-E.pdf?sfvrsn=0

13.Larson L. Keeping the relationship alive. Trustee 2006;59(7):22-4,6.

14.Larson L. Physician autonomy vs. accountability: making quality standards and medical style mesh. Trustee 2007;60(7):14-6,21.

15.Samadi-niya, A. Part 1: The importance of physician–hospital relations in Canadian healthcare system. Can J Physician Leadership 2014;Fall:18-23. Available: http://www.cspexecs.com/assets/cspejournalfall.pdf

16.Edwards N. Doctors and managers: poor relationships may be damaging patients — what can be done? Qual Saf Health Care 2003;12(suppl. 1):i21-4.

17.D’Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care 2005;19(Suppl. 1):8-20.

18.Hanna A. Interprofessional care [policy paper]. Toronto: Ontario Medical Association; 2007. Available: https://www.oma.org/Resources/Documents/2007IPCPaper.pdf

19.Interprofessional Care Steering Committee. Interprofessional care: a blueprint for action in Ontario. Toronto: Ministry of Health and Long-Term Care; 2007. Available: http://www.healthforceontario.ca/UserFiles/file/PolicymakersResearchers/ipc-blueprint-july-2007-en.pdf

20.Shortell SM. Effective hospital–physician relationships. Chicago: Health Administration Press; 1990.

21.Davies HT, Hodges CL, Rundall TG, Kaiser HJ. Consensus and contention: doctors’ and managers’ perceptions of the doctor–manager relationship. Brit J Healthc Manag 2003;9(6):170-6.

22.LEADS framework: overview. Ottawa: Canadian Health Leadership Network; 2014. Available: http://www.chlnet.ca/tools-resources/leads-framework

23.The CanMEDS program overview. Ottawa: Royal College of Physicians and Surgeons of Canada; 2010.

24.Yukl G. Leadership in organizations (7th ed). Upper Saddle River, N.J.: Pearson Education; 2010.

25.Canadian healthcare personnel directory. Toronto: Scott’s Directories; 2011.

26.Canadian medical directory online. Toronto: Scott’s Directories; 2011.

27.Green S. Professional/bureaucratic conflict: the case of the medical profession in the National Health Service. Sociol Rev 1975;23(1):121-41.

28.Neogy I, Kirkpatrick I. Medicine and management: lessons across Europe. Leeds, UK: Centre for Innovation and Health Management, University of Leeds; 2009.

29.Bavin S, Wolosin R. Follow the money. Marketing Health Serv 2008;28(2):13.

30.Goldsmith J. Hospitals and physicians: not a pretty picture. Health Aff 2007;26(1):w72-5.

31.Farrar S, Collins-Williams D, Kingston J. Improving linkages between family physicians and hospitals. Healthc Q 2006;9(3):56-9.

32.Reif R, Ferry TP. Insights on subsidiary physician corporations by two hospital CEOs. Physician Exec 2008;34(4):43.

33.Branz K. Hospital–physician relations. Healthc Exec 2009;24(4):4.

34.Lemieux-Charles L, Leatt P. Hospital–physician integration: case studies of community hospitals. Health Serv Manage Res 1992;5(2):82-98.

35.Kaissi A. Manager–physician relationships: an organizational theory perspective. Health Care Manag (Frederick) 2005;24(2):165-76.

36.Kissoon N, Matheson D. Politics of health care are pulling doctors down. Physician Exec 2006;32(6):40-3.

37.Heenan M, Higgins D. Engaging physician leaders in performance measurement and quality. Healthc Q 2009;12(2):66-9.

38.Lewis S. Spare the policy, spoil the profession [essay]. Toronto: Longswoods; Dec. 2008.

39.Baker RG, Denis JL, Pomey MP, MacIntosh-Murray A. Designing effective governance for quality and safety in Canadian healthcare. Healthc Q 2010;13(1):38-45.

40.Liebhaber A, Draper DA, Cohen GR. Hospital strategies to engage physicians in quality improvement. Issue Brief Cent Stud Health Syst Change 2009;Oct(127):1-4.

41.Weiner B, Shortell S, Alexander J. Promoting clinical involvement in the hospital quality improvement efforts; the effects of top management, board, and physician leadership. Health Serv Res 1997;32(4):491-510.

42.Kunkel S, Rosenqvist U, Westerling R. The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden. BMC Health Serv Res 2007;7:104.

43.Hospital–physician alignment: insights and strategies. Healthc Financ Manage 2010; 64(10):1.

44.Thomas J. Hospital–physician alignment: no decision is a decision. Healthc Financ Manage 2009;63(12):76-80.

45.MacNulty A, Reich J. Survey and interview examine relationships between physicians and hospitals. Physician Exec 2008;34(5):48-50.

46.Degeling P, Zhang K, Coyle B, et al. Clinicians and the governance of hospitals: a cross-cultural perspective on relations between profession and management. Soc Sci Med 2006;63(3):757-75.

47.Moore KD, Coddington DC. Multiple paths to integrated health care. Healthc Financ Manage 2009;63(12):46-54.

48.Klopper-kes, AH, Meerdink N, van Harten WH, et al. Stereotypical images between physicians and managers in hospitals. J Health, Organ Manag 2009;23(2):216-24.

49.Boshier ML, Hinton JT. Strengthening support for your physicians. Physician leaders want and need support — but how can executives provide it? Healthc Exec 2006;21(1):52,4.

50.Mealiea L, Baltazar R. A strategic guide for building effective teams. Publ Pers Manage 2005; 34(2):141-61.

51.Samadi-niya A. Suggested methods to improve physician–hospital relationships in Canada. Healthc Manage Forum 2015;28(3):106-13.

52.Fitzgerald L, Dufour Y. Clinical management as boundary management: a comparative analysis of Canadian and U.K. healthcare institutions. J Manage Med 1998;12(4/5);199-214.

53.Zismer D, Proeschel S. Understanding the quality of earnings for integrated health systems. Healthc Financ Manage 2009;63(12):88-94.

54.Zismer DK, Brueggemann J. Examining the ‘‘dyad’’ as a management model in integrated health systems. Physician Exec 2010; 36(1):14-19.

55.Zismer DK, Person PE. Integrative specialty care: pursuing a convergent path with medical staff. Healthc Exec 2006;21(4):16-18,20,22-24.

 

 

Author

Atefeh Samadi-niya, MD, DHA (PhD), CCRP, designed and led CANSIRPH. She is vice-president and cofounder of IRACA Solutions, Inc., which provides consultations in health care, information technology, and physician–hospital relations.

 

Correspondence to:

Atefeh.samadiniya@gmail.com or

416 402-3906

 

Conflicts of interest: No personal or financial conflict of interest declared. Funding for CANSIRPH was provided by the author.

This article has been reviewed by a panel of physician leaders.

Top

 

This second article on the Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators (CANSIRPH) focuses on health care leaders’ responses to the CANSIRPH questionnaire. Health care leaders at senior levels of management perceive physician–hospital relations to be more collaborative compared with leaders at mid-levels of management. Non-physician leaders also perceive these relations to be more collaborative than physician leaders.  Such differences could be the foundation of future planning to increase the satisfaction level of health care leaders toward the quality of physician–hospital relations, improve the quality of patient care, and manage budgets more efficiently.

 

An overview of physician–hospital relations from 1800 to 2014 in many OECD countries reveals skepticism, optimism, pessimism, and some harsh realism concerning the nature of relations between physicians and hospital administrators and its effects on the quality of patient care, health care costs, decision-making processes, and patients’ satisfaction.1-6 In the 1980s and 90s, the financial instability of health care systems led to increased interest in physician–hospital relations.7 Recently, researchers have suggested moving from skepticism to engagement as a solution to this problem.8-12 Lively interprofessional relations between physicians and hospital administrators have many benefits,13,14 and their importance was the topic of an earlier article.15 These discussions have shown that a gap exists in Canada’s literature concerning the quality of physician–hospital relations, although these relations are crucial to the quality of patient care.4,5,15,16 Top

 

The Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators (CANSIRPH) is a quantitative multivariate correlational research study. The term interprofessional relations encompasses physician–hospital relations, physician–health care relations, physician–executive relations, physician–administrator relations, doctor–manager relations, and, recently, physician engagement in leadership. Thus, the term interprofessional relationships between physicians and hospital administrators (IRPH) in this article is used to emphasize the need for relations between physicians and hospital administrators to be interprofessional and interrelated rather than interdisciplinary and separate.17-19 The acronym CANSIRPH (pronounced can surf) implies that the information gained from this research will help physician leaders and hospital administrators or managers successfully surf the waves of changing health care demands in Canada and beyond. According to the leaders who participated in CANSIRPH, interprofessionality is critical and crucial for physicians and managers as the key to the success of the Canadian health care system.1 Top

 

Purpose of CANSIRPH

The main purpose of CANSIRPH was to determine the perceptions of health care leaders about the quality of IRPH across Canada. A second aim was to discover the factors that influence the professional opinions of health care leaders about IRPH in Canadian hospitals. The third goal was to determine whether and to what degree those factors are correlated with leaders’ level of satisfaction with IRPH. Several open-ended questions were also included in the questionnaire to explore suggestions of health care leaders related to various aspects of IRPH; however, this article focuses on the main purpose of the study: to understand how Canadian health care leaders perceive IRPH in their organizations.  Top

 

CANSIRPH design

CANSIRPH was similar to studies designed by Shortell,20 Rundall et al.,5 and Davies et al.21 in the United States and United Kingdom. A detailed description of methods and statistical analysis is available elsewhere.1

 

The main business of health care leaders is to provide quality care to patients; thus, some decisions they make might be different from those made by leaders in other industries. Four frameworks that are currently accepted as pertaining to physicians and hospital administrators shaped the design of CANSIRPH: LEADS in a Caring Environment Leadership Framework22; CanMEDS23; Interprofessional Care Framework19; Participative Leadership.24

 

These frameworks guide leadership expectations for health care managers/physician leaders (LEADs), practice/leadership expectations for physicians (CanMEDs), and the expectation that health care leaders will work interprofessionally and collaboratively (Interprofessional Care and Participative Leadership).  Top

 

Study population

According to the Canadian Healthcare Association, 6000–7000 physicians and non-physicians work as senior and mid-level managers at hospitals across Canada. The study population consisted of Canadian physicians and hospital administrators whose email address appears in Scott’s directories25,26 (2800 mid-to-senior-level health care leaders in 566 hospitals across Canada). In addition, the Canadian College of Health Leaders and the Canadian Society of Physician Executives sent their members a link to the questionnaire with an invitation to participate and to pass the link along to their colleagues. After accounting for duplication and bounced-back messages, in all about 4000 physician leaders and hospital administrators received an email message that included an introductory letter and links to an online consent form and the CANSIRPH questionnaire.

 

Results

Demographics of questionnaire respondents

To generalize the study results to the total population of health care leaders at mid- to senior levels at acute care hospitals across Canada, a sample of at least 209 respondents was needed; the actual number of respondents was 215. Top

 

Half of the CANSIRPH respondents were physician leaders (107) and half were hospital administrators (108). About half were in senior leadership roles (113); the remainder were in mid-level management (102). Physician leaders were from a range of specialties including surgical specialties. There were respondents from all the personal, professional, geographic, organizational, and generational categories included in the CANSIRPH demographic questions.

 

Less than half of the participants were women (40%). Of the women leaders who responded to CANSIRPH, 66% were at the senior level of management, whereas male leaders were mostly at the mid-level of management (60%). No significant difference was reported for the opinion of leaders toward IRPH based only on their gender. As expected, most participants were 40–70 years old; half were 50–60 years old and only 5% were under 40 years old. Top

 

About 40% of the participants were senior-level hospital administrators, 10% were mid-level administrators (managers), 10% were senior-level physician leaders, and 40% were mid-level physician leaders. These differences imply that senior hospital administrators and mid-level physician leaders may be those most interested in physician–hospital relations.

 

The participants represented all types of acute care hospitals and health care centres across Canada, although most were at teaching and community hospitals; about 50% of the hospitals were teaching hospitals and 30% were community hospitals. The participants worked in mixed, private, and religious hospitals. About 54% of participants were from large urban areas, 30% from small urban areas, 8% from rural towns, and 4% from suburban areas. Remote and isolated hospitals were also represented. Top

 

Analysis of the data

The following is a brief summary of the results (Table 1). Please see Samadi-niya (2013)1 for a full analysis and details.

 

Table 1. Summary of research questions regarding health care leaders’ perceptions of interprofessional relations between physicians and hospital administrators (IRPH)1

How do physician leaders and hospital administrators across Canada perceive IRPH?

More physician leaders and hospital administrators across Canada perceive IRPH as excellent or very good than those who considered them to be below average or poor.

How do physician leaders across Canada perceive IRPH?

Significantly more physician leaders perceived IRPH to be below average or poor compared with those who thought them excellent or very good.

How do hospital administrators across Canada perceive IRPH?

Significantly more hospital administrators perceived IRPH as excellent or very good than those who considered them to be below average or poor.

How do the opinions of physician leaders differ from those of hospital administrators about IRPH?

Physician leaders are less optimistic than hospital administrators about IRPH across Canadian hospitals.

How do the opinions of mid-level management differ from the senior-level management about IRPH?

Mid-level managers are less optimistic than senior-level managers about IRPH across Canadian hospitals.

How do the opinions of mid-level physician leaders, mid-level hospital administrators, senior-level physician leaders, and senior-level hospital administrators differ about IRPH?

There are meaningful differences in the opinions of leaders toward quality of IRPH. Opinions toward IRPH across Canada, from most optimistic to least optimistic: senior administrators, mid-level administrators, senior-level physician administrators,mid-level physician leaders (Figure 1).

 

Table 2 shows the overall level of satisfaction of nine categories of leaders whose results were included in more advanced statistical analyses.1 Overall, a higher proportion of all participants considered IRPH to be excellent or very good compared with those who believed them to be below average or poor. This was also the case for hospital administrators. The reverse was true for physician leaders; indeed, more considered IRPH to be non-collaborative as compared to those who felt the relationship to be excellent or above average. Top

 

More senior-level leaders believed IRPH to be collaborative than their colleagues in mid-level management and the perception of non-physician leaders about the quality of IRPH was more optimistic than that of physician leaders.

 

Looking at all four groups — mid- and senior-level physician leaders and non-physician leaders — the data show that the group most optimistic about IRPH was senior-level hospital administrators followed by mid-level administrators and senior-level physician leaders. Mid-level physician leaders were least satisfied with the quality of IRPH (Table 2 and Figure 1).

Discussion

Canada and other members of the OECD have witnessed a rise in the scientific–bureaucratic model of health care delivery, in which evidence-based medicine or evidence-based decision-making have replaced the traditional practice of medicine. In the scientific–bureaucratic model of health care delivery, the processes used by management may interfere with physicians’ motivation and personal judgement.27 Physicians must follow management dictates in caring for patients, despite the fact that they view themselves as independent, trustworthy, and knowledgeable professionals.

 

Administrators usually believe that medical and other staff members are highly satisfied with hospitals.1,21 Although hospital administrators are aware of the importance of the role physicians play in allocation of their hospital resources,4 they may sometimes forget to include physicians in the decision-making process and create a more collaborative environment in which physicians feel sufficiently considered in decisions that affect their workplace.28 Physicians usually want more input regarding “strategic decision-making and hospital operation.”29 The literature reveals discontent among physicians, which could be due, in part, to lack of satisfaction with physician–administrator relations.30 Top

 

 

 

 

 

Managers’ interference with the professional autonomy of physicians and a lack of trust in the decision-making of managers has been causing professional unhappiness among both physicians and managers.31 Reviewing historical events that led to the current situation helps us understand the challenges that physicians and administrators perceive in the 21st century health care system.7,32 Hospitals faced with deficits often hire a new president or CEO to balance their budget, but they may not realize that IRPH are crucial to hospital performance.33 Hospitals with better and more organized physician–hospital relations have less or no budget deficit.34 Pairing medicine and management is necessary, not only for high-quality patient care, but also for managing the budget of the health care system, including hospitals.

 

The role of physician leaders has become difficult as they attempt to cut services and shorten lengths of stay for patients who need adequate resources for their medical care.35 Researchers have acknowledged the difficult role of physician leaders, whose colleagues may view them as betrayers and collaborators with hospital administrators.36 Periods of silence among physicians are alarming rather than reassuring, because indifference is a potent action.36  More important, physician leaders may not receive payment for their managerial activities or their involvement in hospital administration. Top

 

Deciding on goals, measuring progress toward them, and sharing information regarding the results with other health care disciplines are key factors in a shared quality agenda.37 As the biggest players in quality of care, physicians often receive the credit,  control most of the costs in health care, and do not share any financial risks with hospitals.38 Success in quality of care is equal to success in IRPH.16,39-41 Thus, the success of a quality system depends on physicians’ active and continuous involvement.42

 

At the Healthcare Financial Management Association Executive Roundtable in October 2010, executives and industry experts shared their ideas and specified that the only group of professionals who could define quality, control costs, and reduce redundancy is physicians.43 Their findings indicated that physicians prefer simple straightforward reports, and they want to see the raw data on which reports are based. In addition, involving physicians in the process from the beginning and providing updates increases the likelihood of their acceptance of an initiative. Top

 

Remaining indifferent or not deciding to improve IRPH is an action. Indifference can negatively affect patient care.16,44 A survey of members of the American College of Physician Executives found that lack of trust is one of the main issues affecting the development of collaborative IRPH.45 Physicians involved in hospital management and leadership roles need special skill sets and managerial knowledge.46,47 Engagement of clinical directors in hospital management is an opportunity to engage physicians in the decisions that affect their daily work. Use of CANSIRPH results could enable hospital administrators and physicians to establish national guidelines to improve IRPH and, as a result, increase the quality of patient care and patient safety in all Canadian provinces. Top

 

Some stereotypical images held by physician and hospital administrators affect IRPH.48 Both groups consider the other to be more powerful and to have different goals.48 Health care leaders ought to refute incorrect stereotypes and replace them with appropriate views of the other group.49,50 After all, in a governance plan for Canada’s health care system, collaboration among medical staff, senior leadership teams, and board members seemed necessary.39 Many hospitals and health care centres claim that using teams made up of a physician leader and a non-physician leader has helped their organizations.1,51-55

 

Conclusion

Participants in CANSIRPH emphasized that IRPH are the key to the success of Canada’s health care system. Improving IRPH means quality improvement or, in fact, “quality investment.” IRPH and quality improvement mean patient satisfaction, patient care improvement, error reduction, employee and physician satisfaction, better interprofessional relations (not only with managers but also with other health care professionals), budget management, debt reduction for hospitals, and a sense of institutional pride. Top

References

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2.Curtis RS. Successful collaboration between hospitals and physicians. PhD thesis. Charleston SC: Medical University of South Carolina, College of Health Professions; 1999.

3.Lemieux-Charles L. Hospital–physician integration: the influence of individual and organization factors. PhD thesis. Toronto: University of Toronto; 1989.

4.Hospital Physician Issues Working Group. Hospital–physician relationships: where do we go from here? Toronto: Ontario Hospital Association; 2004. Available:  http://www.oha.com/CurrentIssues/keyinitiatives/eHealth/Documents/Hospital%20Physician%20Relationships%20-%202004.pdf

5.Rundall TG, Davis HT, Hodges CL, Diamond M. Doctor-manager relationships in the United States and the United Kingdom. J Healthc Manag 2004;49(4):251-68.

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10.Kaissi A. A roadmap for trust: enhancing physician engagement. Regina: Regina Qu’Applle Health Region and Canadian Policy Network; 2012. Available: http://www.rqhealth.ca/inside/publications/physician/pdf_files/roadmap.pdf

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16.Edwards N. Doctors and managers: poor relationships may be damaging patients — what can be done? Qual Saf Health Care 2003;12(suppl. 1):i21-4.

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18.Hanna A. Interprofessional care [policy paper]. Toronto: Ontario Medical Association; 2007. Available: https://www.oma.org/Resources/Documents/2007IPCPaper.pdf

19.Interprofessional Care Steering Committee. Interprofessional care: a blueprint for action in Ontario. Toronto: Ministry of Health and Long-Term Care; 2007. Available: http://www.healthforceontario.ca/UserFiles/file/PolicymakersResearchers/ipc-blueprint-july-2007-en.pdf

20.Shortell SM. Effective hospital–physician relationships. Chicago: Health Administration Press; 1990.

21.Davies HT, Hodges CL, Rundall TG, Kaiser HJ. Consensus and contention: doctors’ and managers’ perceptions of the doctor–manager relationship. Brit J Healthc Manag 2003;9(6):170-6.

22.LEADS framework: overview. Ottawa: Canadian Health Leadership Network; 2014. Available: http://www.chlnet.ca/tools-resources/leads-framework

23.The CanMEDS program overview. Ottawa: Royal College of Physicians and Surgeons of Canada; 2010.

24.Yukl G. Leadership in organizations (7th ed). Upper Saddle River, N.J.: Pearson Education; 2010.

25.Canadian healthcare personnel directory. Toronto: Scott’s Directories; 2011.

26.Canadian medical directory online. Toronto: Scott’s Directories; 2011.

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29.Bavin S, Wolosin R. Follow the money. Marketing Health Serv 2008;28(2):13.

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33.Branz K. Hospital–physician relations. Healthc Exec 2009;24(4):4.

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36.Kissoon N, Matheson D. Politics of health care are pulling doctors down. Physician Exec 2006;32(6):40-3.

37.Heenan M, Higgins D. Engaging physician leaders in performance measurement and quality. Healthc Q 2009;12(2):66-9.

38.Lewis S. Spare the policy, spoil the profession [essay]. Toronto: Longswoods; Dec. 2008.

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44.Thomas J. Hospital–physician alignment: no decision is a decision. Healthc Financ Manage 2009;63(12):76-80.

45.MacNulty A, Reich J. Survey and interview examine relationships between physicians and hospitals. Physician Exec 2008;34(5):48-50.

46.Degeling P, Zhang K, Coyle B, et al. Clinicians and the governance of hospitals: a cross-cultural perspective on relations between profession and management. Soc Sci Med 2006;63(3):757-75.

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Author

Atefeh Samadi-niya, MD, DHA (PhD), CCRP, designed and led CANSIRPH. She is vice-president and cofounder of IRACA Solutions, Inc., which provides consultations in health care, information technology, and physician–hospital relations.

 

Correspondence to:

Atefeh.samadiniya@gmail.com or

416 402-3906

 

Conflicts of interest: No personal or financial conflict of interest declared. Funding for CANSIRPH was provided by the author.

This article has been reviewed by a panel of physician leaders.

Top

 

Managers’ interference with the professional autonomy of physicians and a lack of trust in the decision-making of managers has been causing professional unhappiness among both physicians and managers.31 Reviewing historical events that led to the current situation helps us understand the challenges that physicians and administrators perceive in the 21st century health care system.7,32 Hospitals faced with deficits often hire a new president or CEO to balance their budget, but they may not realize that IRPH are crucial to hospital performance.33 Hospitals with better and more organized physician–hospital relations have less or no budget deficit.34 Pairing medicine and management is necessary, not only for high-quality patient care, but also for managing the budget of the health care system, including hospitals.