Physician groups are notoriously deficient in planning for future growth and in using accepted business procedures to make quality decisions. Neurosurgery groups fare no better than their other surgical colleagues. Businesses with revenues equal to those of small- to mid-sized neurosurgical groups expect to invest time and money at an annual retreat to plan. Yet, mention the word “retreat” or “plan” to an action-oriented group of neurological surgeons and there is likely to be a range of responses from an enthusiastic “We’ve needed to do this for a long time!” to eye rolling among the skeptics who argue, “Why give up free time? Everything is just fine.” Still others will complain, “We did that before and nothing happened.”
All of these attitudes merely demonstrate why “retreating” is as important to physicians as it is to business people. The Chinese have a saying, “If you don’t know where you are going, then any road will take you there.” Medical groups need to periodically, if not annually, revisit their assumptions about budgets, personnel issues (both professional and administrative), recruiting options, relationships with hospitals, competition in the market and perhaps, most importantly, governance of their group.
Working Out Problems
Here are some specific reasons for holding a strategy and planning retreat.
- Leadership changes. Consider, for instance, when a senior “founding father” who has successfully led the group announces plans to retire within the next few years. With a leadership vacuum clearly in sight, developing a transition plan should be a priority. After all, it takes time to groom successors. For some, a wise option is to retain the senior doctor as group managing partner, allowing him or her to discontinue clinical duties and call and to receive compensation for managing the business. This allows the younger doctors to practice full time, undistracted by business. Waiting until the senior respected leader unexpectedly retires due to a health problem is a risk to many groups. The challenge of recruiting other neurosurgeons and qualified nurses and the perception that long-time managers are no longer able to “take the practice to the next level” are other reasons to invest in planning time.
- Group tensions. Group practices formed out of fear of managed care plans or hospital politics may begin to feel their relationships fraying. Because the groups’ clinical and business styles were inherently different, they never truly meshed. With reduced threats from plans and hospitals, some groups may be questioning the value of their combined group. Others, at the very least, are troubled by the dysfunctionality. Necessary changes in the compensation plan and the employment buy-in and buy-outs are other hot issues that simmer and boil over when not discussed and resolved in a comprehensive business-like fashion. Partners whose sole measure of “satisfaction” is based on take-home pay and vacation time, with little consideration for patient satisfaction, actual measurement of clinical outcomes, and meaningful investment in practice infrastructure, contribute a negativity that threatens the ongoing success of the group.
- Differing world views. There are bound to be big problems if some group members believe that moving aggressively into clinical activities, such as neurovascular centers in cooperation with radiology, is a must, while others object just as strenuously. If some members believe that a spine group is a must, while their partners consider this a potential political faux pas despite the impressive revenue projections, the chance for conflict increases. Instituting recognized dispute resolution methodologies is essential to good governance.
Pushing differences and dissenters into the background has never worked for other organizations; it’s unlikely ttto succeed for medical groups. Often such disagreements arise out of a persistent lack of ongoing, meaningful dialogue with one another. In part, schisms among group members grow because not all physician members are equally aware of the various socioeconomic choices and positions open to their group. Absent ongoing education and dialogue, making big decisions is painful. Decisions will be delayed and opportunities missed because options are never debated openly, nor are outside experts brought in to present differing points of view, thus preventing everyone from ever getting to the “same page.” Retreats can provide the right forum to develop a common understanding of big issues and choices.
Revisiting the physician attitudes mentioned above and the differences among factions could be perilous. For example, the visionary doctors who see the value of planning are likely to grow restive about partners who think in the short term, preferring the adrenaline rush of crisis management. If not yet partners, the visionaries may decide to explore opportunities with other, more proactive groups. The eye-rolling skeptics-who object to all business processes-clearly need education to appreciate, if not participate more, in the group’s business. Physician partners solely interested in clinical practice can create a vacuum by abdicating involvement in the business side of the practice. Such individuals, if not already partners, might best maintain their employee status. Interestingly, some groups have different classes of stockowners-giving some more voting rights to account for assuming key roles in group governance.
Lastly, there are organizational benefits to heeding the complaints of group members who recall and resent the lack of follow-through from previous retreats. Their perception of having made an expensive mistake and not wishing to repeat it is a call for leaders to lead. Paralysis by procrastination and over-analysis are costly to doctors and represent a lost opportunity.
Do It Right
Thorough planning can result in a successful retreat, advancing the group’s interests and ensuring ongoing enthusiastic responses and participation. Groups can get better results from strategy planning sessions by following these guidelines:
- Use an outside facilitator. No one can do their own therapy and much of group dynamics is a lot like therapy. Plus, group members often lack the neutrality to keep their hot buttons from coloring their perspective. Someone knowledgeable about physician culture and group process can help from the beginning to organize a successful experience. Additionally, a facilitator familiar with neuroscience issues and who has worked with many groups brings new options and insightful information to the group’s deliberations.
- Focus on specific issues and outcomes. One group focused their retreat on referral building and practice growth. Specific topics pertained to the hospital contracts, relationships with primary care doctors and new ways of tracking business. Ownership of implementation was assigned along with deadlines.
- Do the homework. Taking off on a Saturday and then beginning to collect opinions on a flip chart is not going to make for a satisfying retreat. Begin at least six weeks ahead of time by asking members to complete questionnaires that solicit opinions on the key issues. Use that information to develop an action agenda. The advantage of collecting opinions before the event also means that everyone’s voice is heard. Typically, the opinions are collated into one document with no names on any idea. Using this methodology, one can see how strongly views are held and how common some perceptions are. This gives the group the advantage of celebrating their unanimity on some points, confident that there is a base for dealing with more contentious issueess. Using the dictated and collated opinion polls, even the most introverted doctor’s thoughts are captured. Anonymity provides a mechanism for expressing criticism that is often difficult to verbalize. Good facilitators edit out personal attacks, vitriolic comments or unnecessary verbiage to keep things positive.
- Hold the retreat in the right environment. For some groups this means booking at the local country club with nice meeting rooms, comfortable chairs and good food. Other groups will use the boardroom of a local hotel. Some groups cover their call, and head away from home base to a nice location with recreation. There’s no single right option, but comfort counts.
- Set up the rules for engagement. How the retreat will be conducted needs clarification. Is speaking on cell phones to be permitted? Or will no phones be allowed and telephone breaks scheduled? One group paid their physician assistant to monitor all calls and in rare cases to interrupt. What happens if people straggle in whenever they want delaying start times? Several groups publish rules and violators are fined. The point is that strategic planning retreats cannot be run like the typical monthly or group business meeting. The group is making a substantial, collective time commitment and should expect a strong return on their investment.
To move their practices forward, many neurosurgeons will benefit by “retreating” with their partners and articulating a cohesive plan for future growth.
Karen Zupko is the president of medical management consulting group, KarenZupko & Associates. KZA works with neurosurgical practices and participates in the AANS Coding and Reimbursement Workshops.