Accountability: Taking Your Influence as Physician Advisor to the Next Level

Alistair Aaronson, MD, MHA, FACP
Member, ACPA

Few Physician Advisors like to confront their physician colleagues when their performance lags, and even fewer like holding them accountable. This can be for a number of reasons: 

1. It is uncomfortable.
2. It is perceived as out of scope for the role and more of a “CMO thing.”
3. There is the notion that it casts you as the “bad guy”, which is not as appealing as being seen as the supporter, the advocate, the ally.
4. It may be perceived as eroding the effective working relationship that you have spent so much time and effort to build. 

However, while this thinking is natural and common, it is also misplaced, and it actually stifles our effectiveness as Physician Advisors, and as leaders. 

In fact, when you set clear boundaries and expectations, and then hold someone accountable when they cross those boundaries or do not meet those expectations, it engenders trust. It promotes respect. And it builds a safe space of bidirectional, honest, and transparent conversation that hallmarks effective communication.

As Medical Director for Care Management and Clinical Documentation Improvement (CDI) for the South Division at Providence, I oversee the Physician Advising program at 17 hospitals in California, which comprises dozens of Physician Advisors, each of whom has a different background, skillset, and approach to accountability when it comes to engaging with physicians who do not respond to CDI queries, hold on to patients beyond the point of any medical necessity, or refuse to communicate with Care Managers or Utilization Management nurses. 

From my personal experience as a Physician Advisor, as well as through my experience working with and leading a team of Physician Advisors, some key patterns have emerged that seem to consistently yield great results when it comes to holding physicians accountable:

1. Be Direct: 

Physician Advisors who succeed at these challenging conversations are direct. They stipulate the expectations, and they then indicate that the physician is not meeting those expectations. No emotion attached to the conversation, just stating facts.

2. Show Data: 

After verbalizing the expectations are not met, it is critical to show data that led to this conclusion. Again, declarative, not judgmental. Facts are facts, and the physician performance is simply not meeting expectations.

3. Toe the line:  

At this point, Physician Advisors must engage in their most challenging test. Do they simply state the facts and then hope for the best? Or do they use that as a springboard for holding the physician accountable for their performance? And if the latter, how do they maintain their relationship while not capitulating to and therefore enabling the behavior they are seeking to change? 

I have found that the most effective Physician Advisors are those who still cast themselves as supporter and advocate while simultaneously saying that things need to change with a sense of detached urgency. They do this deftly by indicating that external pressures or forcing their hand, whether that be hospital policies and bylaws, or CMS regulations, or an insurance company’s policies. The Physician Advisor by telling a physician that they need to change their behavior is therefore seen as simply doing so in order to protect them and ensure they are not subject to reprimand or suspension by the Medical Executive Committee, the recipient of a fraud charge by CMS, or the cause of a costly denial. 

4. Collaboration 

Finally, the Physician Advisors who are most successful at holding their physician colleagues accountable do so by collaborating closely with their CMO, Chief of Staff, as well as other hospital leaders. This is because the teeth in accountability lie within actual policies and processes, which CMS and insurance companies have in spades, but that are not always or even often present in the hospital. 

Physician Advisors who lead from the front do so by working with their CMO, Chief of Staff, and other hospital leaders to develop and implement internal processes for accountability such as incentivizing physicians through contractual terms as well as through celebrations, developing a peer review process vis a vis LOS performance, conducting 1:1 meetings with physicians at a routine cadence to address performance shortfalls, and tie key performance metrics to credentialing through rules and regulations and bylaws to name a few.

Finally, know that as Physician Advisors who take their game to the next level by holding physician colleagues accountable, you have a support system among your Physician Advisor peers through the ACPA to provide guidance, to hear and share in your frustrations, and to create a community of high performing physician leaders who don’t shy away from challenging conversations but rather embrace them as opportunities not only for personal and professional growth, but also as an engine to improve performance at your hospital in all areas of CDI, utilization management, and care management. 

Dr. Alistair Aaronson is Division Medical Director of Care Management and CDI for the South Division of Providence, comprising 17 hospitals in California.