The Ship Has Sailed

The biggest problems facing healthcare? Lack of ownership and effective leadership.

Many of the problems facing the healthcare system come down to two fundamental issues: lack of ownership and absence of effective leadership. As a mid-career physician, I've been around long enough to have witnessed the gradual decline of both. We have more entities wanting to insert themselves in the patient journey than we've ever had in my 15 years in practice. Payors, hospitals/health systems, conveners, navigators, Big Retailers, startups, CMS, etc. All want to exert influence without taking ownership. Instead, frontline healthcare workers are expected to bear the burden.

The irony is that these same frontline workers have slowly abdicated ownership or have had it taken from them. Loss of autonomy, distraction by pointless admin tasks, inefficient/overly burdensome EHRs, and the stress of being required to do more with less have created box checking silos. Nurses used to rely on experience and intuition to take care of patients. Now they're tethered to "computers-on-wheels." Over-protocolization and an endless stream of mandates from on high have stripped critical thinking skills -- and ownership. Similarly, physicians have become increasingly siloed, sending electronic referrals and secure messages while assuming the next person down the line figure will figure it out. K. Thanks. Bye.

Lack of effective leadership contributes to lack of ownership. The paradox is that, as layers of administration have grown, the disconnect between leadership and ownership has widened. Sit in on any meeting (trust me, there are plenty), and you quickly realize there is fundamental misunderstanding about what's happening on the frontlines. Ineffective leaders assume that, if everything is copasetic in their immediate sphere, everything must be functioning as expected. (Another unfortunate consequence of having bloated leadership structure). Like many fields, healthcare is stuck on antiquated views of leadership. Being wrong and loud is favored over being introspective. Hubris leads to doubling down on poor or out-of-touch decisions. Egos prevent learning, iterating, and maturing (and drive away or drown out voices of innovation and change).

Fixing these issues is difficult because they have become fundamentally ingrained into our healthcare system. Too often, taking ownership requires time and resources we no longer have. The system is not well positioned to reward this difficult work -- a promise VBC hints at but hasn't solved. In terms of leadership, we need those who can efficiently turn thought into action, aren't afraid to challenge the status quo, and have a deep connection to what's happening in the trenches. It’s no longer good enough for the C-suite to be far removed from the daily happenings of the operative suite.

Being in clinical practice and serving in leadership positions has given me firsthand experience with these issues. I'm increasingly convinced that fixing the problems is going to require stepping outside of what currently exists. With so many layers to go through, there are too many opportunities to impede progress. Healthcare inertia means that even the smallest gains eventually regress back to the status quo. Forward thinking clinicians are fed up and tuned out (or worse, just plain “out”).

There are pockets in healthcare where effective leadership supports process ownership resulting in high quality care the way it should be. Visit a busy, efficient outpatient center or ASC (often physician-owned and led), and you’ll experience well-orchestrated care the way it was meant to be. Alternative primary care models have also placed emphasis on owning the patient journey and flat, collaborative leadership structures (their business model sustainability uncertainty notwithstanding). These arrangements also highlight another side of ownership in healthcare that’s too often overlooked — fostering a sense of ownership in those doing the work. No one being treated as a cog in the machinery with little autonomy feels a sense of ownership. Converse to the above examples, spend some time in traditional healthcare settings. The sense of frustration and desperation is palpable. So is the lack of ownership and effective leadership.