The New (CMO) Math: Passion + Power = Progress

In his five years on the job, Dr. Ernie Ring taught me why the Chief Medical Officer role is crucial, and how to do it right. Since Ernie is retiring at week’s end, it seems like an opportune time to share what I’ve learned.

A bit of background. UCSF Medical Center didn’t have a Chief Medical Officer until about 8 years ago; indeed, even today many U.S. hospitals lack a senior physician who is compensated by and works for the hospital. It is easy to understand why.

Through several accidents of nature and politics, American hospitals have traditionally operated under two completely distinct organizational structures. The first, of course, is that of the hospital itself, with its governing board, a CEO and assorted senior administrators (the “C-Suite”), and a cast of thousands that includes nurses, pharmacists, social workers, billers and coders, and many more. The flavor is corporate and hierarchical; many members of the staff are unionized and the lines of authority are reasonably clear.

Remarkably, this hierarchy excludes the most important players (at least in terms of the ability to affect quality and cost): the physicians. In most hospitals, the docs are independent practitioners, working for themselves or as part of small corporations (most U.S. physicians practice in groups of four or less), each with an independent bottom line and operating under incentives that are distinct from those of the hospital. The most glaring example of this disconnect can be seen in Medicare’s financial approach to a hospitalization – the hospital is paid a (fixed) DRG payment (providing an incentive to decrease costs and lengths of stay), while the physicians are paid a per diem, with no incentive to furrow their brows over hospital costs and LOS.

Like a divided Congress and Executive branch, this structure is perfectly designed to create organizational gridlock, particularly since the physicians are anything but a unified bloc themselves. (Two of my favorite quips about medical staffs:  What do you call a 99-1 vote of the medical staff?  Answer: A tie; and, What is the world’s biggest oxymoron? Answer: The “organized medical staff.”)

This asinine organizational framework could survive only if the hospital and the physicians were under absolutely no pressure to demonstrate value: namely, to provide the highest quality, safest care at the lowest possible cost. And in fact, that lack of pressure perfectly described the situation until recently. But, as we’ve seen, over the past decade this bit of healthcare exceptionalism (since it is unlike virtually every other part of the market-based economy) has eroded like a polar ice cap, aided by a variety of strategies (regulatory, accreditation, legal, public reporting, differential payments) that have created immense pressure to perform. This New Reality has exposed the fatal flaws in the typical hospital/medical staff relationship: how can a hospital ever achieve excellence when it is governed by two parties that are at best wary but collegial; at worst, overtly venomous.

A new breed of physician-leaders has been asked to step into this massive breach, hired by the hospitals to work with the physicians. These docs (sometimes called Chief Medical Officers; other times Vice Presidents for Medical Affairs) have taken over a variety of functions, including working with the medical staff, improving quality/safety/efficiency, overseeing risk management, preparing for the Joint Commission, negotiating hospital payments to the docs, dealing with disruptive physicians, and more. In short, every contentious and thankless chore that has anything to do with physicians.

When this trend took root about a decade ago, many of the newly-minted CMOs dug foxholes and tried to avoid taking on enemy fire, and who could blame them? Not only was their job incredibly fraught, but few had much management training and experience, and virtually none had access to meaningful performance data or the know-how to analyze it. Instead, most CMOs and VPMAs were chosen because they were well-liked members of the medical staff nearing retirement age, yet not quite ready for a daily tee-time. The choice of these boon companions for Top Dog was logical, since anyone more forceful might have been unacceptable to the medical staff (who essentially had the veto power also known as, “I’ll take my patients elsewhere”). So many first generation CMOs were relatively toothless… and generally ineffective. Everybody was happy.

The only fly in the ointment was that there were real problems that truly needed fixin’. As more of these problems came to light through more vigorous error reporting, root cause analyses, malpractice suits, and transparency, it became clear that everybody – the hospital, the physicians, and, most of all, the patients – had a strong interest in an empowered CMO who could actually set standards, create rules that people followed, and improve culture; in short, make change happen.

At UCSF, enter one Ernest J. Ring, MD. Ernie is a bearded, brilliant, and slightly gruff elder statesman, one of the true legends in the field of Interventional Radiology. At first blush, he might have seemed to be yet another example of the respected clinician doing his pre-retirement swan song. And, though he had had some management experience (Associate Dean of our Mt. Zion campus, Chief of Radiology at San Francisco General Hospital), Ernie would have been the first to tell you that he knew little about the science of quality and safety when he assumed his CMO mantle.

But anyone who thought that Ernie was going to play out the clock was quickly disabused of that notion. Ernie read everything he could get his hands on in quality and safety. He took advantage of his bully pulpit to get people’s attention on issues like smoking cessation (near and dear to his heart as a former smoker) and handwashing. He was intolerant of “We can’t do this because…”, constantly pushing for action.

That’s all well and good, but in a huge academic medical center, even a passionate CMO will find him or herself on the short end of a lopsided battle. After all, there is but one CMO (perhaps with a lieutenant or two), and – in large places like ours – literally thousands of faculty and residents. To make meaningful change, the CMO has to go toe to toe with a dozen or two very powerful department chairs, who control the salaries, job descriptions, promotions, and space of their faculty and trainees. Ernie is a student of power, and immediately knew what he had to do.

“I need for the chairs to wake up in the morning,” he said on many occasions, “and care as deeply about their quality and safety as their do about their rankings on the NIH grants list and their residency match results.”

The strategies he used to accomplish this transformation were varied – it wasn’t one thing, it was many. Suddenly, department chairs found themselves discussing and defending their department’s quality data in front of their peers, the hospital CEO, the medical school Dean, and the Chancellor. Ernie held yearly quality and safety retreats with prominent speakers. A weekly root cause analysis meeting, which he chaired, ensured that clinical leaders participated in robust, interdisciplinary discussions of errors or near misses on their services, with action plans developed and re-presented to the high level committee a few weeks later. Most importantly, without ever explicitly saying so, Ernie hinted that departmental requests for medical center support – to recruit faculty, build new programs, develop space – would be viewed through the lens of that department’s performance on quality and safety.

Suddenly, department chairs woke up in the morning and did care about their clinical performance as much as they did about their match lists. And things began to improve. God knows, they’re far from perfect (this is really tough stuff), but today UCSF Medical Center is a much better, safer place than it was five years ago.

Several years ago, the University HealthSystem Consortium (UHC), an umbrella organization of more than 100 academic medical centers (AMCs), sent a team of experts to UCSF to visit. The UHC reps were doing a fascinating study. Through a detailed review of performance data (they tap into loads of clinical and financial data from all their client hospitals), they had identified three top performing AMCs and three mediocre ones. The UHC investigators – top experts in healthcare quality and organizational performance – were blinded as to which of the six AMCs were in the excellent vs. mediocre categories. But, after a day or two on each campus, they were able to identify who belonged in each group, without fail. UCSF Medical Center, despite being ranked by US News & World Report as the 7th best hospital in the U.S., was in the mediocre group. And the UHC experts figured it out in an instant. As they noted in the paper’s abstract:

Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration.

Earlier this year, the UHC group staged a return visit to UCSF. Why? They had reviewed the performance of the six original institutions a few years after their initial observations, and what they found shocked them: UCSF had skyrocketed from the middle-of-the-pack to one of the top ten performers (in doing so, leapfrogging over several dozen other AMCs that were each working like hell to improve), an improvement that would translate into at least 150 fewer deaths per year. On their return visit, they found a completely different place, with the faculty and chairs far more engaged, a greater sense of both collaboration and accountability, and a real commitment to doing the hard work to create and sustain clinical excellence.

They asked me what accounted for the difference. My answer was simple: “Ernie Ring.”

You see, one person really can change the world, if he or she has enough skill and courage. Happy and healthy retirement, Ernie.