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ED physicians group ousted, sues — power struggle with CEO blamed
Here are tips that can ensure a good working relationship
Haywood Emergency Physicians, which had managed the ED at Haywood Regional Medical Center in Clyde, NC, since 1991, was ousted by a unanimous vote of the hospital's board in late December 2006 and replaced by the corporate physicians staffing firm Phoenix Physicians following a heated contract dispute. The termination occurred a full 18 months before the Haywood contract was slated to expire.
"I think the main issue was really a story about command and control [by the hospital CEO]," says Mark Jaben, MD, who had been the associate ED director at Haywood Regional for 15 years. Most of the particulars cited in negotiations and/or the local press "were smoke screens," he asserts.
The hospital board "felt Phoenix would be more cooperative in hospital initiatives aimed at improving wait time, moving patients through different departments more smoothly, and working with a new digital medical records system," according to the Smoky Mountain News.1
ED managers who are part of groups such as Haywood Emergency Physicians are all too familiar with the potential tenuousness of their relationship with hospital administration, but experts assert that such a termination should never come as a surprise and usually can be avoided if the ED managers take certain steps.
"Medicine is an art, a science, and a business," says Gregory L. Henry, MD, FACEP, risk management consultant at Emergency Physicians Medical Group, Ann Arbor, MI. "The day you forget that is the day you are no longer a great doctor."
The day you and your group have to pull a contract out of a drawer "is the day you've lost," Henry continues. "The day the contract has to be enforced, you're screwed."
Winning a lawsuit is no way to endear oneself to a hospital, he says. "Let's say the hospital loses a million dollars; these guys are still out," says Henry.
If you find yourself being defensive, you have waited too long, adds Josh Rubin, MD, FACEP, president of the Western Region for Emergency Medicine Physicians, a privately held physician-owned group, based in Roseville, CA. "You should always be proactive," he says.
An issue of control
While the board had cited several reasons for the dismissal, including failure to fully implement new triage and testing protocols and failure to implement a new information technology system rapidly and efficiently, the real issue was power, Jaben says.
"The CEO felt he needed to have a level of control — that he should be able to choose ED staff and fire them at will," he explains. "We resisted; we had had a stable group and had never asked the hospital for help with recruiting."
Jaben says the group had no problem with the board having input, "but they were asking for thumbs-up, thumbs-down power and to dismiss any doc on 14 days notice with no warning."
However, argues Henry, this is not a realistic stance from a business point of view. "You are in a business; you provide a service," says Henry. "Some of these guys do not realize who their 'daddy' is; where their bread is buttered." In the case of the right to hire and fire, if he were the ED manager, "I'd say, 'That's very interesting; I'd love to have you involved. Here's how I think it could work,'" he says.
Jaben argues that medicine is different from any business in America. "Traditionally, to really provide good care takes a balance between administration and the medical staff — neither should have the upper hand on the other," he says.
But, counters Rubin, someone does have the upper hand. "We live in the hospital's house — it's not our house, it's theirs," adds Rubin. "We have to be perceived as being cooperative, although we should not be passive."
An ounce of prevention
If the ED manager takes the appropriate steps on a daily basis, this kind of crisis can be avoided, Rubin maintains.
"Your most natural allies are fellow members of the medical staff," he says. "If they are pleased with the service you provide, they will support you." These allies include the chief of staff and the medical executive committee, he says.
Have routine meetings with senior administration, and have a seat on the executive committee, Rubin advises. Your physicians should serve on various medical staff committees, he adds. In addition, Rubin says, "If you have a functional partnership with the nurse manager, these kinds of outcomes are less likely to occur." If you have established these relationships, he argues, if a conflict ever arises, "they will support you, and the hospital will listen."
There are almost always warning signs, says Rubin. "If you do not see them, it's because you did not spend enough time working with the nurse manager, the medical staff, and the hospital administrator," he says. "You should almost never be surprised; you should know what problems exist."
Henry agrees. "If you do not know the CEO's kids' names and birthdays, if you do not know his secretary personally and stop in and say hello, you deserve what you get," he says. "After all, you are by law the retained agent in service of the hospital when they have a contract with you."
Every day he is in the hospital, says Henry, he does "administration rounds." "I show up in the office, I talk to the secretary and ask if there's anything going on that I need to know about," he explains. "Then, when I get asked about it 10 minutes later by the administrator, I can say 'I know, and I'm on it.'"
You should meet regularly with the administrator and ask what you can do to do make things better, adds Henry. "If I walk into a fine restaurant and do not like how the food tastes, nobody from the kitchen is going to come out and say, 'Eat it, it's good,'" he notes. "They say, 'What else can we give you?'"
Jaben admits that he and his group could have done a better job of building relationships. "You have to maintain relationships with your board as individuals — not just the CEO, but the board members," he says. In fact, he suggests, it might not be a bad idea for your group to have a "relationship director." "That's not what we chose to do, but it's more important now than it's ever been," he concedes.
Don't make it personal
One problem ED managers must avoid is taking these issues personally, Henry advises. "The rules of human interaction never change," asserts Henry, adding that the two most valuable days of his career were the days he took a class in negotiation techniques.
"Humans are only tuned in to one radio station: WIFM [What's In It For Me?]," he notes. "You need to understand how disagreements take place, how to get to yes, and discovering what the real agendas are," Henry says.
Henry and others provide mediation services for situations like these, and he says ED managers who spot a problem with management "need to call me or someone like me early on to give them a look from the outside." What is needed in such situations, he says, is someone to come in and say, "What's really going on here?"
Henry insists it's an integral part of the ED manager's job responsibilities to have a positive working relationship with management. "If you're not making people happy," he says, "You are not a great doctor."
For more information on maintaining good relationships with hospital administration, contact: