march 2016 expertise in the role of physician advisor or...

March 2016

Expertise in the Role of Physician Advisor or Medical Director, Part One

Expertise in the Role of Physician Advisor or Medical Director, Part One 2

Contents

1. INTRODUCTION

2. DEFINING SCOPE

3. THE BASE RATE AND HOW TO USE IT

4. PHYSICIAN ATTRIBUTES THAT IMPACT EXPERTISE

5. PERSONALITY CHARACTERISTICS THAT IMPACT EXPERTISE

6. ORGANIZATIONAL FACTORS THAT IMPACT EXPERTISE

7. CASE STUDY

8. CONCLUSION


1. Introduction Physician Advisors and Medical Directors are a crucial part of the hospital eco-system. These roles directly support the growth of hospitals, which in turn leads to the hiring of more Physician Advisors and Medical Directors. Ask anyone that works in a hospital leadership role and they will have seen the difference in contribution between experts and non-experts in these roles. For the remainder of this paper, when we use the term “Physician Advisor,” it should also be assumed to refer to those Medical Directors who have similar responsibilities in the major practice areas of Utilization Management, Care Management, and Clinical Documentation Improvement. The research team at IndusMente saw that there is currently no standardized approach to assess the development of Physician Advisor expertise. We have developed a methodology for estimating the time requirements for achieving expertise in the major practice areas, and to assess the potential impact of training and other factors on this time requirement. The core of this methodology is what we call the Base Rate. The Base Rate is essentially the average number of hours required for a Physician Advisor to achieve expertise in a given practice area. This rate is influenced by different factors, some of which are related to the skills of the Physician Advisor directly while others have to do with intrinsic characteristics of the hospital or health system. We also look at case studies using this model. To develop the Base Rate and expertise methodology IndusMente sought the consensus of our Physician Advisor team, relevant research in related industries, and an empirical survey of practicing Physician Advisors and Medical Directors. The methodology that we have developed is a simplification of the many factors that go into the development of expertise and may not reflect individual performance accurately. However, we believe the model we have built will be applicable at the practice level. Modern studies that compare simple algorithms based on experience and intuition to more complex mathematical formulas have generally showed that the simple algorithms win. This philosophy is prominent in our methodology. Simplicity has the advantages of being more generally applicable to different cases and less prone to the error found in more complicated models. There is an important assumption to our method. We assume that the Physician Advisor will actively seek to develop expertise, through the deliberate practice of lessons and by consciously reflecting on their strengths and weaknesses. If an active effort is not made to develop expertise and learn from mistakes, it is impossible to become an expert. One more thing - there’s no way to quantify outliers. Some people are experts almost from day one, while others spend years and never reach that level.


2. Defining Scope The role of the Physician Advisor is evolving and complex. It is important to define the scope of what is being measured in this paper. We start by answering two questions: 1. What is the definition of expertise for a given function of the Physician Advisor? 2. How many hours on the job does a Physician Advisor need to spend to develop expertise in

the given area? In the hospital setting expertise is the basis of credibility of a Physician Advisor in a specific area resulting from their study, training, and experience. Functionally speaking, expertise is the possession of accessible and usable knowledge acquired when people continually try to confront new situations in terms of what they know. It is generally developed over hundreds and thousands of hours of learning and experience. Experts are set apart from non-experts in their ability to demonstrate and apply knowledge in problem solving through large-scale pattern recognition as well as applying understanding of advanced cause and effect relationships. Experts also have developed nearly automatic recall of much of the specifics of their field, allowing them to focus their energy on higher-level functions. [1] There are three practice areas that generally fall into the Physician Advisor profile, while Medical Directors often will be involved with at least one of these areas. As each area has its own unique requirements and processes, each needs to be considered individually for expertise. Utilization Management: An expert in Utilization Management (UM) has expertise in the areas of medical necessity, regulatory compliance, running a UM committee, appeals, and communicating with physicians. Care Management: An expert in Care Management has expertise in the areas of medical necessity, clinical case management, patient disposition, running a care management huddle, hospital resources, and communicating with physicians. Clinical Documentation: An expert in Clinical Documentation has expertise in proper documentation practices, coordinating a CDI team, coding practices in your hospital, and communicating with physicians. Now that expertise and the different practice areas have been defined, let’s look at the model and methodology.

3. The Base Rate and How to Use It The Base Rate is the key input for the expertise model. The Base Rate is empirical data collected by the consensus of our expert team of Physician Advisors as well as the results of industry surveys. We polled Physician Advisors on how much time on the job it would take to develop expertise in each area, based on the practice area definitions above. The resulting Base Rates by practice area are:


Base Rate Hours to Expertise

Utilization Management 2,600

Care Management 2,700

Clinical Documentation 2,200

The Base Rate will be modified according to various factors that are important to developing expertise. For example, you would expect that a more experienced physician entering one of these practice areas would have an easier time developing expertise than a physician with less experience. Similarly, Hospitalists have an easier time developing expertise in these areas than other specialties. Some factors are external to the Physician Advisor. If the leadership structure of the hospital is unclear, or if the medical staff is not engaged, developing expertise will be more difficult. The rest of this paper looks at the different factors that influence the development of expertise and quantifies their impact to the Base Rate. Each factor will have an associated multiplier. The Base Rate is multiplied by these factors, which can either increase or decrease the time that a Physician Advisor requires to develop expertise in a practice area. The LOWER the multiplier, the MORE QUICKLY the Physician Advisor is expected to develop expertise. Applying a 0.9 multiple for example:

Base Rate x 0.9 (Base Rate Multiplier) = hours to develop expertise (Adjusted Base Rate) For example, let’s look at the impact of physician experience in developing expertise in Care Management. We can all agree that someone with more than ten years of relevant clinical experience will have an easier time developing expertise in this practice area and will need less on the job training than someone with two years of clinical experience. The Base Rate Multiplier for relevant experience in the example above is 0.9. This means that the more experienced physician will develop expertise in Care Management in 90% of the predicted time required. Put another way, rather than needing 2,700 hours to develop expertise, they would only require 2,430 hours. Now let’s tackle the many factors that go into developing expertise.

4. Physician Attributes That Impact Expertise

Experience in Related Areas This factor does not refer to experience in the actual duties as a Physician Advisor, but to experience acquired through clinical practice or leadership activities related to the practice area. For example a Hospitalist already deals with issues of medical necessity and patient disposition on a regular basis. This Hospitalist may not have any idea how to do a care management huddle or some of the other duties, but experience as a Hospitalist will still help with the transition into a Physician Advisor role. The following table shows some specialties and if their experience applies to the Physician Advisor practice area, as well as the Base Rate multiplier:


Specialty <3 Years Experience

3-6 Years Experience

>6 Years Experience

Hospitalist 0.95 0.90 0.80

Primary Care Physician 0.98 0.95 0.90

Medical Subspecialist 0.98 0.95 0.90

Emergency Medicine 1.00 1.00 1.00

Surgery or Surgical Subspecialty 1.00 1.00 1.00

Note: This assumes that the physician has a significant amount of recent experience rounding in the hospital and not at an exclusively outpatient based practice. This does NOT mean that physicians with training in Emergency Medicine or Surgery will not become excellent Physician Advisors - in fact, EM is one of the most overrepresented specialties in the field for various reasons. However, they do have a higher learning curve in most cases because the excellent job they are doing in taking care of patients may not touch on some of the areas that are important in developing expertise in these practice areas. What if your clinical experience is primarily in Pediatrics, and you want to work as a physician advisor in an adult hospital? The good news is that it is still quite possible to do so despite a somewhat steeper learning curve. We consider this and similar scenarios as special cases that will be covered in future articles. Now, let’s interpret the table. For a Primary Care Physician with five years of experience, who is going to be the Director of Care Management, the multiplier is 0.95. This is because experience as a Primary Care Physician applies to the Care Management practice area and between 3 and 6 years of experience provides a Base Rate Multiplier of 0.95 (Table 1). Generally, Hospitalists have an advantage in leveraging their experience into expertise as Physician Advisors. No other specialty touches as many hospital functional areas as frequently or interacts with as many service lines and ancillary support staff.

A Word on Clinical Expertise Clinical expertise is the most difficult factor to quantify, yet remains important. Why? Because physicians who are excellent clinicians will have an easier time reviewing cases, identifying key factors in medical necessity, and anticipating the natural course of a disease process. Once again, experience does not necessarily equal expertise. Physicians with extensive experience (ten years or more) who have actively improved their skills and bolstered areas of weakness certainly are more likely to be clinical experts. However, some physicians achieve


expertise clinically sooner than others. Because it is so difficult to determine clinical expertise, we elected not to incorporate it into the methodology within this paper.

Comfort with Technology Comfort with technology is important in the modern healthcare setting. Familiarity with Electronic Health Records, health care apps, video conferencing, databases and platforms will make developing expertise easier. Alternately, a lack of basic technology skills will prolong the path. We have divided this factor into four levels of proficiency. Most physicians fall into the “Proficient” category. Technology Expert – Base Rate Multiplier 0.95: - Fully comfortable using multiple Electronic Health Records (EHR) - Comfortable using medical applications - Comfort with medical messaging applications and instant messaging - Understand the interface between medical triage platforms, EHR, and data collection

software, and can credibly discuss it in a meaningful way - Working knowledge of how data mining software operates - Working knowledge of how CDI software and Coding software operates - Awareness of all of the software used within the hospital, including that by physicians, nurses,

emergency department, care management, utilization management, and clinical documentation

Proficient - Base Rate Multiplier 1.0: - Fully comfortable using the Electronic Health Record at hospital. - Comfort with Smartphones - Comfort with conducting advanced Internet searches Novice - Base Rate Multiplier 1.1: - Comfort using e-mail and basic Internet searches - Typing skills Non-Proficient - Base Rate Multiplier 1.4: - Unable to type effectively

5. Personality Characteristics that Impact Expertise Given some self-reflection and the honest feedback of colleagues or friends, a physician can identify whether or not they possess the personality characteristics that we discuss in this section. A Physician Advisor will be faced with many stressful situations. It’s a given that at times they will be out of their comfort zone. How a physician reacts is what impacts the ability to objectively learn from the situation. Developing expertise is highly dependent on the capacity to analyze performance in a given situation and apply meaningful lessons.


Which personality traits are most helpful? The consensus of our team identified two important traits.

Excellent Listener Excellence as a listener is an active process. It means giving someone the space to say what is on their mind and asking specific questions to help clear up misunderstandings. Here are the characteristics of an excellent listener: - Others feel comfortable bringing any and all problems to the listener - Never giving the impression that they are too busy when listening - Actively listening to both what is being said and not being said - Asking follow up questions to help clarify the underlying issue - Is perceived as a fair broker by all sides If a Physician Advisor has all of the characteristics of an excellent listener the Base Rate Multiplier is 0.95.

Ability to Effectively Manage Stress Stress is in plentiful supply as a Physician Advisor. It’s easy to feel caught in the middle between physicians who are trying to care for patients and health care organizations that want to usher in change. Tense interactions with peers are almost inevitable. There is also the stress that comes with time pressure and deadlines. How effectively does a physician deal with this? A great attitude and humility are an excellent start, but even the most happy-go-lucky folks will have bad days in a stressful environment. Is the stress carried over to the next task? Dwelling on mistakes or negative interactions will hinder the ability to reflect and learn from those mistakes. Learning from mistakes is a key element to developing expertise. Having the right frame of mind is necessary to objectively assess the situation and learn from it. The following characteristics are possessed by those that are effective at managing stress: - Active coping mechanisms: Having a process or activity that actively diffuses the tension when

under stress - Introspection: When someone points out a mistake the physician looks first at themselves.

Even if the message is delivered in an emotional way they assess if there is something valid to the criticism that can be worked on

- Short memory: After the criticism has been assessed and stress diffused, the physician moves on without dwelling on the issue

These characteristics of effective stress managers result in a Base Rate Multiplier of 0.95.

Leadership Skills There are many different aspects of leadership, and there are many styles of leader. Yet there is a specific set of leadership skills that are more important to functioning in the role of Physician Advisor in the modern health care setting.


Here we are most concerned with skills rather than traits. Traits include important qualities such as communication, approachability, innovativeness and decisiveness. While having these and many other traits are beneficial, leadership skills often involve the application of multiple traits in real world settings with physicians and administration. For example, the ability to find consensus is a critical leadership skill to helping develop expertise. This skill in particular is essential to being effective as a Physician Advisor and will hasten the development of expertise.

Proven Ability to Find Consensus For a more extensive discussion of this essential leadership skill, please see our paper, “Find Consensus - Or Dysfunction Will Find You” at www.indusmente.com The proven ability to find consensus results in a Base Rate Multiplier of 0.95.

6. Organizational Factors that Impact Expertise We would like to believe that our careers are fully under our control, yet many experienced Physician Advisors can attest to the importance of a health care organization’s ability to support their role. In many ways this field is still in its’ infancy. Health care systems are still figuring out how these roles fit into their operations, and have not always learned how to effectively support their activities. There is also a broad range of readiness. Some health systems have experienced Physician Advisors and support staff with well-developed department leadership and written protocols. In practice, most organizations are lacking in some areas. Like it or not, the ability to develop as a Physician Advisor depends to a large degree on the health system. Is it clearly understood where a physician goes for backup on a problem and are they equipped to help? Does the health system have an established process for keeping the team up to date on regulatory changes? Does the Physician Advisor have a trusted mentor to actively help develop expertise? The organizational factors we see as the most essential to the development of expertise are discussed below. These factors need to be considered separately for the practice area of the Physician Advisor - whether it’s Utilization Management, Care Management, or Clinical Documentation.

Mentorship and Guidance Let’s start with the most important organizational factor – mentorship. Our research has shown that this is arguably the factor most lacking in the majority of organizations. Mentoring has been identified as an essential element to developing expertise in medicine. Finding a trusted mentor with the inclination and time available nevertheless remains a challenge. Yet it can significantly speed the process of developing expertise, and not having a mentor can lead to many preventable problems for a Physician Advisor. Imagine a situation where a Physician Advisor has just stepped into their role, but there is no mentor at the institution. Many different administrators and managers ask the Physician Advisor

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to sit on committees to assist them and they gladly accept through a desire to excel in their new role. A few months pass and they have not devoted adequate time to working with the Appeals department – and now there are big regulatory changes coming. As the Physician Advisor scrambles to get up to speed, their other time commitments begin to suffer and their credibility takes a hit. A mentor could have helped navigate these processes and made sure that the Physician Advisor was getting involved in the right areas to fulfill their duties and develop expertise. The ideal mentor is an experienced Physician Advisor who has been functioning in the health system long enough to be credible to the medical staff. They also take an active interest in the personal development and success of the mentee. Most importantly there are many issues that come up regularly that a new Physician Advisor may not be equipped to handle. It could be conflict resolution, where to find information, or the best way to implement an initiative without ruffling feathers, active mentorship provides a tremendous advantage in the development of expertise. There is simply no factor that is more important than mentorship. The table below shows the Base Rate Multiplier for access to a trusted and experienced mentor, considering the amount of mentoring time per year.

Trusted and Experienced Mentor Available

Amount of Time Working with Mentor Per Year

Base Rate Multiplier

Yes More than 12 hours 0.60

Yes 8 to 12 hours 0.70



Yes Less than 2 hours 1.00

No No mentor 1.40

Adequate Time Allocation The amount of time that a Physician Advisor allocates to their role will play a big part in how quickly expertise is developed, and should be considered when negotiating time commitments. We generally advocate that these roles maintain clinical duties. However, being spread too thin can put one in “damage control” mode. Scrambling to fulfill the minimum expectations of the role will significantly hinder the ability to develop expertise. How much time that a Physician Advisor should have depends on many factors. These factors include administrative expectations, the size of the institution and associated case load, how many different departments they are responsible for, clinical workload, and how well-developed the various departments are to name just a few. Consider that a busy day in Care Management at a large hospital could easily involve reviewing up to two hundred cases and having a dozen conversations with physicians. Below is a table to assess how much has been allocated. An Ideal time allocation allows for performance of clinical and administrative duties with time left over for independent research


and fact-finding to help develop expertise. At the other end of the scale a Very Inadequate time allocation is a stressed working state, barely keeping up with responsibilities and in constant damage control mode. Identifying the adequacy of time allocation is a judgment call.

Time Allocation Base Rate Multiplier

Ideal 0.80

Adequate 1.00

Inadequate 1.20

Very Inadequate 1.40

Leadership Structure Having a clear leadership structure in place not only helps a Physician Advisor to be more effective but also is helpful in developing expertise. Barriers are invariably encountered when attempting to implement organizational goals. Additionally, these roles will be tasked with the final decision on issues ranging from medical necessity to implementing physician education. For example, a Medical Director is huddling with their Care Management team and has discovered that a patient is medically ready for discharge. They call the attending and she agrees from her standpoint that the patient is ready pending a consultation. After asking the care manager to follow up, it is later learned that this was not done and the patient was not discharged. Does the care manager have a manager who will ensure the issue does not recur? What if there are deeper problems in the department that require a more thoughtful and sustained analysis that might result in the care managers changing their workflow or staggering coverage? A clear and effective leadership structure allows you to observe the solution and be part of it. Seeing solutions develop contributes to the development of real world expertise. Watching the process allows you to learn how to be more effective in studying the barriers and suggest fixes. If there is no clear leadership structure, that process may not happen and you will be robbed of an important opportunity to develop.

Clear Leadership Structure in Place

Leadership Structure is Effective

Base Rate Multiplier

Yes Yes 0.95

Yes No 1.00

No N/A 1.10


Administrative Support Barriers will sometimes come up that are “above your pay grade.” In our experience there are no cases where the Physician Advisor has the ultimate say. Physician Advisors are facilitators. Sometimes that just isn’t enough to overcome a barrier. When that happens you will sometimes need help from someone who has greater authority to resolve the situation. Achieving resolution is a teaching moment. It allows you to learn different methods for solving problems from experienced administrators and also to learn the broader principle of when it is a good idea to get someone involved. As time progresses you will achieve a greater capacity to resolve more problems on your own, which is the essence of expertise. Remember to apply this principle to each individual area you are looking at. It’s possible that you may have someone you can go to in the area of Utilization Management, but not in Care Management. For example, maybe a physician habitually changes the Level of Care order without consulting the UM department, and this results in loss of revenue or an inappropriate Level of Care order on multiple occasions. You reach out repeatedly and the physician does not feel inclined to answer pages or change their behavior. If a high-level administrator is willing to back you up and has the authority to change the behavior, that is an example of a well-functioning leadership structure in UM. They are willing and able to provide meaningful backup.

Level of Administrative Support Multiplier

Yes, willing to support 0.95

Yes, not willing to support 1.00

No administrative presence 1.10

Program Structure More mature and well-developed programs contain tangible working elements that can fit you seamlessly into the workflow. Having a functioning program structure means you spend more time analyzing and developing solutions rather than building things from scratch or trying to define responsibilities and accountability. There are two elements to having a mature program structure. The first element involves the structure of the physician advisor role, while the second is the structure of the individual department, whether it’s Utilization Management, Care Management, or Clinical Documentation.

Physician Advisor Role Physician Advisors often deal with a lot of uncertainty in their job description. This is partly a consequence of the rapidly changing healthcare landscape, and partly due to how new the field is. Many programs are not sure how to leverage their Physician Advisor to help them. In departments that have a well-developed role for the Physician Advisor, the expectations are clear. There is a clear escalation process in place that is understood by all parties involved. If you are the Physician Advisor for Clinical Documentation, the department could leverage your


position to help answer queries and provide targeted physician education. Programs where the Physician Advisor role is less clear may ask them to get involved too early or too late, or may not bring important issues to their attention. If the Physician Advisor role in the program is clearly defined, the multiplier for developing expertise is 0.95. If the role is not clearly defined, the multiplier for developing expertise is 1.1.

Department Structure Most departments have a clear structure in place but this may not always be the case. An excellent example is the Utilization Management committee in a UM program. The UM Committee is an important tool. It allows face time with physicians, administrators and the rest of the UM team. This committee is an important place to learn how new regulations are implemented and how the different committee members emphasize different areas that they consider important. If we continue to use Utilization Management as an example, a well-developed program structure includes the UM Nurses, a Director of UM, a Manager of UM, and a functioning UM Committee. When these elements are not in place the Physician Advisor will not have the opportunity to analyze the process and learn from it. Indeed, the process may not work properly to begin with. In instances where there is a well-developed program structure with clearly defined responsibilities, the multiplier for expertise is 0.9. If the program structure is new or underdeveloped, the multiplier is 1.2.

Medical Staff Engagement In an ideal hospital, the medical staff greets the Physician Advisor with cheers. They always look forward to your phone calls and enthusiastically ask how they can help you. In this mythical place your colleagues volunteer for committees, communicate new hospital policies with each other and are willing partners in implementing important changes. This may be your hospital. If it is, congratulations are in order. Developing expertise will be a much easier task. You will learn from experienced physicians who may have knowledge that can assist your development. Since they always follow your recommendations you have the opportunity to try new initiatives and methods and learn from their implementation. Most hospitals don’t quite reach this level of engagement. On the other end of the spectrum, a medical staff with a low level of engagement will make it much harder to implement recommendations. You’ll find yourself trying to change the same behaviors repeatedly. While this also provides the chance to build certain skills (and character), a medical staff with a lower level of engagement will hinder your ability to become an expert. Using the examples above as a basis, you can assess the level of engagement of the medical staff at your hospital and apply the appropriate multiplier.


Medical Staff Engagement Multiplier

High 0.9

Moderate 1.0

Low 1.2

7. Case Study

Let’s take a real world example of a Physician Advisor and apply the above lessons to their situation to see if the results hold water. We’ll start with a Hospitalist who has been practicing for two years and is considering an offer to be the Physician Advisor of a medium sized community hospital, and has been offered a position at 0.2 Full Time Equivalents (FTEs) to support Utilization Management. The Hospitalist is highly motivated to develop expertise in their new role - a key requirement. They don’t have any outstanding abilities in listening, stress management, or consensus-finding. There is no mentor available for the new role, and there is limited time that the physician can allocate to developing their new position. The administration has an effective leadership structure and is able to and willing to support the Physician Advisor. The role is well defined, the program is well developed, and the medical staff is generally engaged. The table below considers all these elements of the case. There are two areas in particular that will make the Hospitalist’s desire to develop expertise in Utilization Management much more difficult - lack of mentoring, and inadequate time allocation. On the other hand, there is a well-developed UM program and administrative support to assist the Hospitalist in becoming an expert in UM. Considering the attributes and their impact on the base rate, a total multiplier of 1.23 is found. If we multiply the total multiplier times the Base Rate for Utilization Management, it yields: 2600 hours x 1.23 = 3,200 hours. In this case, having a trusted and experienced mentor and a better time allocation would significantly assist the Hospitalist in becoming an expert.


Expertise Base Rate (hours) 2,600

Practice Area Utilization Management

Physician Attributes that Impact ExpertiseBase Rate

Multiplier

Experience in Related Areas

Specialty Hospitalist

Experience Less than 3 years

Clinical Applicability to PA Role Yes

Practice Area Utilization Management 0.95

Comfort with Technology Proficient 1.00

Personality Characteristics That Contribute to Expertise

Listening Skills No 1.00

Ability to Deal with Stress No 1.00

Leadership Skills

Proven Ability to find Consensus No 1.00

Organizational Readiness and Support

Mentorship and Guidance

Hours available per year No mentor 1.40

Adequate Time Allocation

Effective allocation to PA role Inadequate 1.20

Leadership Structure

Effectiveness of in-place structure Yes, effective 0.95

Administrative Support

Presence and willingness to leverage Yes, willing 0.95

Program Structure

Physician Advisor Role

Clearly defined role for PA Yes 0.95

Department Structure

Is program structure well-developed Yes 0.90

Medical Staff Engagement

Level of staff engagement with PA Moderate 1.00

Total Multiplier 1.23

Adjusted Expertise Base Rate (hours) 3,202

Adjusted Rate vs. Base Rate 123%


8. Conclusion We hope this paper helps clarify questions about what defines an “expert” Physician Advisor or Medical Director and what the pathway is to developing that expertise. We believe this covers the majority of situations and allows you to take a long look at what it takes to be successful and contribute to your hospital. This is in keeping with IndusMente’s mission to help Physician Advisors and Medical Directors excel in their role, a role which will continue to develop into one of the most important and dynamic positions in any health system. Remember that the most important underlying assumption is your active engagement in the process. Even in the face of considerable barriers, you will eventually become an expert if you systematically examine your strengths and weaknesses, learn from them, and tirelessly devote yourself to your craft. The Physician Advisor has the potential to dramatically impact the hospital’s performance. If you persevere, and obtain the right training and guidance, be prepared to have a long and fulfilling career that will ultimately make you a better doctor and tremendously benefit many patients. [1] Glaser, Robert. The Nature of Expertise. 1985 [2] Mott, Vivian. The Development of Professional Expertise in the Workplace. 2000

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