My Open Letter to the New Physician Leader

So I've been in my current position for almost seven years now. I've learned a lot during that time, and I always enjoy sharing my lessons with other people, so maybe they won't have to spend as much time learning them as I did. So in the spirit of education, and with love and fellowship for other physician leaders, I share this blog post:

MY OPEN LETTER TO THE NEW PHYSICIAN LEADER 

To the New Physician Leader,

Welcome! You're a board-certified physician who has been honored by being asked to serve some sort of leadership position in healthcare, generally either a committee chair, department chief, or physician executive. Given all of the reform and change going on, we need good physician leadership in healthcare! We need you to bring a physician's voice to the discussion, and your hours spent in the ED, OR, ICU, floors, or clinic, will help keep you honest and patient-focused. Your experience will help answer detailed questions about how to deliver great patient care. Your clinical hours are being cut with the expectation that you will step into this new role, help coordinate with other physicians, help shape the future of healthcare, and make it great.

Unfortunately, there's no great training course for this new role. Some of you got voted into your positions, whether you wanted it or not. Some of you demonstrated your skills at many long committee meetings, and eventually earned a reputation as a physician leader. And some of you obtained MBAs, MPHs, or other advanced degrees which helped to get you started in your new role.

But I'm writing to share with you some of the lessons that I've learned in my seven years as an eternally questioning physician leader, in the hope that you will use them in any way you see fit - Hopefully, to prevent you from learning the lessons as slowly as I did.

So with that, I humbly offer you these ten lessons that either I've learned myself, or that were shared with me from other physician leaders :

1. Don't think being a doctor prepares you for this leadership role. Medical school teaches us a lot about anatomy, physiology, pathology, and histology. Residency teaches us a lot about medicine, surgery, OB-GYN, pediatrics. Fellowship teaches us a lot about pulmonary/critical care, neurosurgery, and cardiology. Experience may teach us how to do our job, or lead a clinical team to a successful surgery. That education and experience will serve you well in this new role, but there is still much to learn. Leading a clinical team through a surgery is very different than leading a whole department or a clinical service. Always be humble and thankful for the people who teach you new things. In my opinion, as physicians, we should always strive to be both teachers and students for the rest of our lives.
2. Set high standards for yourself. You have one shot at this. Don't just be "good enough." Be "good enough for your children." Attention to detail can be the difference between success and failure, and we need you to be successful in your new role. Don't just aim to succeed - Distinguish yourself by aiming to succeed and wow. Don't just try to meet legal standards, try to meet ethical standards.
3. Learn some basic parliamentary procedure. Buy yourself a copy of "Roberts' Rules of Order" and read it. Keep your copy in your new office. Knowing how to run a good meeting is a critical skill that not everyone has. When the opportunity arises, being able to correctly discuss the difference between a primary motion and a secondary motion is very impressive. You will also need to know this if you have to make any big changes, which will invariably involve politics and governance.
4. Know how to write a really good committee charter, meeting agenda, and minutes. These tools are so essential to success, and still many physician leaders don't pay much attention to them. If you really care about these documents, you will be empowered by knowing how to run really good meetings where people show up and things get done.
5. Control your documents, don't let them control you. Simply put, documentation matters. First, make sure you read your organizational chart, bylaws, rules and regulations, and policies (at least once), and make sure you understand what they all do. Physician leaders sometimes fail because they don't know or understand their governing and operational documents. Next, make sure you know how to develop a really good document - Starting from your idea, to your regulatory/policy/literature search, to your stakeholder list, to your well-designed template, to your first DRAFT, to your stakeholder review, to your final draft, to your FINAL document approval, to your document publication and monitoring - Every step is essential to making a good document. It doesn't matter how good and well-planned your idea is - If it's not properly developed and documented, then it's likely to fail. Finally, keep all of your computer documents somewhere where other people can find them. If you keep all of your tools on your local C: drive, or your email, then nobody else can see them, read them, or collaborate on them. And if you get sick or leave - They may be lost forever! A much better place to keep them is an internal, secure, shared network drive that many people in your organization have access to - It facilitates collaboration, and someone else can find things if you're sick!
6. "Workflow" is everything. While this term is often used when trying to implement an EMR, everyone should know what it means and why it's important. Workflow is actually deceptively simple. It's a procedure. The success (or failure) of your projects and departments will depend on having good, clear, well-designed, cost-effective workflows that build best-practices into your daily routines. To document your current and future workflows, some people try to make elaborate Visio diagrams or flowcharts, but it doesn't need to be that complex, and sometimes the complex diagrams can leave out important details. You may still need expert help when trying to fix workflows, but as a start, try studying food recipes to see how easy it can be to write good procedures. By design, food recipes/procedures/workflows are generally very 'lean' (in process, not necessarily nutrition - Sorry, no pun intended!) You may still need expert help when trying to fix workflows, but you can start writing a good procedure/workflow, line-by-line, using the general format [ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ], where the bold parts are mandatory and the italic parts are optional (and only used when needed.) Once you have your current state workflows documented in this manner, you'll quickly see where it can be streamlined to develop your future state.
7. Don't just make the future good, make it excellent. It's easy to get lost in trying to preserve the past. Sure, there are some things you'll want to keep (like good patient care, compassion, and continuity), but some of healthcare was broken. Make sure you're not trying to preserve the stuff that was broken. (This is especially important when trying to go electronic - You do not want to build bad workflows into your new electronic system!) Remember - Doctors will still be doctors after healthcare reform. We may look a little different, work a little different, and even get paid a little different, but patients will still need us to help them. Plan to make the future excellent for both patients and caregivers.
8. Finance matters. Through medical school, residency, and fellowship, most doctors don't pay much attention to financial issues (other than student debt!), but at the end of the day, clinical decisions need to make financial sense, and many hospitals close because of insufficient funds. Every penny counts. To make sure everything you do has value, and your projects are well-planned and financially sound, always include someone from finance/accounting early in your clinical discussions. Doctors have as much to learn from finance as finance has to learn from doctors. 
9. Prepare for shared governance. Let's face it - In the old days, doctors 'ruled' the hospital, while nurses actually kept it alive and functioning. That model doesn't work anymore - You were hired because the nurses can't do it alone. Some people mourn the passing of those days. Personally, I don't. In the future, doctors, nurses, pharmacists, quality, regulatory, legal, and financial people will work together to break down silos, answer questions and collaborate on decisions. I love working collaboratively because I learn so much from these other team members. Working together, we reduce costs, avoid workflow problems, and make better decisions. 
10. Always let the patient guide your compass to True North. I was once given this advice by another physician leader when I asked him, "How do you always know what to do?". He basically told me, "As long as you always think about the right thing for the patient, you'll always know what to do." I've spent seven years validating his advice, and I can say that so far it has served me very well.

We desperately need you to help shape the future of healthcare, and shepherd other physicians and advanced practice clinicians (PAs, NPs, etc.) through this transition process. To help our patients, we are counting on you to be both happy and successful in your new position! Good luck, share your lessons with other people, and always remember why you applied to medical school in the first place - to help people.

Humbly submitted,

- Dirk

(fellow student, teacher, and eternally questioning physician leader)

Remember - This blog is for educational purposes only, so I always welcome opinions and feedback! Do you have any lessons you would share for a new physician leader? Leave them in the comments below!

CMIO Survival Skills

While a CMIO is there to help implement the technology, so much of the job is process, workflow, and governance. So since I've now been in the role for five years now, I thought I'd take a moment to look back and reflect on the things I've learned in the last five years that I think are valuable CMIO skills.
Here are the 13 most important skills I can think of, off the top of my head, in my usual tongue-in-cheek style : (Remember, as always - Your mileage may vary, depending on your circumstances.)

1. Hospital Governance 101 -  It's not enough to just know the clinical side of governance. You need to know the administrative side too. Both of these wings of hospital governance intersect with each other in different places, and knowing where they meet with your bylaws is vitally important. You will be navigating both, so it pays to know the landscape. Bonus points are awarded if you can diagram your committee structure by heart. :)
2. Document Management - Understanding the basics of how documents are created, drafted, approved, and published is essential. Bonus points are awarded for knowing the details of these steps well - For starters, I wrote a post on the importance of knowing the difference between DEV, TEST, and PROD - These environments typically exist for computer projects, but in reality they apply to all construction and document development (even that email you just sent!). Know them well, why they exist, and how to use them to your advantage in your organization.
3. Definitions and structure of your Clinical Tools - You should know your clinical tools like the back of your hand - Exactly how your organization defines them, drafts and builds them, tests and reviews and vets them, approves them, and publishes them. You should be able to look at them and have opinions on whether they are as effective as they can be. For starters, the CMIO's checklist is a good place to start working on this. Bonus points are awarded if you can recite your organization's definitions off the top of your head. :)
4. Compliance with State and Federal Regulations - You will need to know these well, and will probably be asked to help your organization comply with some of them. Even if you don't know them very well, you need to have a good relationship with your regulatory people, and know where to look when you have questions. Bonus points are awarded as you gradually learn this landscape better.
5. Project Management and managing 'the technical details' - You will need to know the basics of this - Whether or not you have a separate project manager to work with, you will be involved in many projects. Knowing what to expect at different stages when undertaking large month- and year-long projects is very helpful. As for the technical details, you may not want to know how sausage is made, but if you (or your organization) wants to eat sausage (pardon the metaphor), then someone will have to worry about the technical details. If it's not you, then make sure you have a good relationship with the people who understand the details, and work with them closely when undertaking new projects. 
6. Parliamentary Basics - You will probably be asked to chair a committee or two, and be a member of others. Knowing how to properly run a meeting and conduct a committee is crucial. For starters, Robert's Rules of Order is a fantastic place to start. Also make sure you have a formal, written charter - It not only establishes your authority, it establishes the chain-of-command and is essential for good performance and when questions come up. And a tip : Always publish your minutes after approving them at the next meeting. If you wait to format and approve your minutes, they will just build up and you'll have to play catch-up later.
7. Meaningful Use, emerging Health IT Trends, and Workflow Analysis - It's almost impossible to keep on top of every detail, but you should have a good understanding of the Meaningful Use rules, timelines, and how your organization is responding to them. You should also understand the basics and be able to comment on various existing and emerging HealthIT, clinical, and legal trends, including your statewide HIE effort, NHIN, ICD-10, clinical decision support, mobile devices, HIPAA, eDiscovery, etc. Finally, you should understand the basics of workflow analysis and why it's necessary to implement all of this technology. A good way to learn to think in a linear fashion is to read food recipes - This will help you think about the relationship between process and outcomes, and help teach you to write a good procedure.
8. Safety through Information - Safety is not just resident workforce hours and barcoding your medications. Safety needs to be built into all of the documents and information you're overseeing. First, know what a good order set and a good protocol look like - Then learn what good documentation, good policies, good procedures, good guidelines, and good workflows look like. This is one of the big reasons organizations look for a CMIO, so always look for opportunities to improve safety with every tool you see.
9. Networking - Virtually every hospital is going through Meaningful Use together. You will help save yourself a lot of headache if you know the other CMIOs in your area. Use social networking (e.g. Twitter), or call them up, introduce yourself, and meet them just to talk shop every once in a while. The Interstate 91 Informatics group I've set up has been invaluable to me and others in helping to share lessons and best practices. Look to see if there's any regular gatherings in your area, and try to get to at least one of the national conferences every year (e.g. HIMSS).
10. Teambuilding, cheerleading, politics - You will undoubtedly meet other doctors, nurses, pharmacists, and other ancillary staff, and need to meet with them. Often, EMRs demand more collaboration between clinical specialties, so you will have to know how to encourage people to work together. Don't try to play sides or favorites - Treat everyone equally and you'll be able to build those teams.
11. Budgeting realities - Implementing an EMR is expensive. There are costs at every step of the way - Technical costs, training costs, costs to change workflows, staffing costs. "Flexible budgeting" is optimal, but in today's climate, most organizations are focused on cutting costs. Be prepared to work with your budgeting people, and always ask yourself, "What if we don't get everything we ask for?"
12. Informatics Education - Whether you're the "Chief Medical Information Officer" or the "Chief Medical Informatics Officer", you will be discussing Informatics with many people, probably while you are defining this emerging role in your organization. The term is sometimes frightening to people, until they start to understand it. Don't try to teach too much at once - Small, frequent feedings are better, so try to meet with leadership for frequent, short meetings. Bonus points are awarded if you help set up an entire Informatics department.
13. Statistics and Process Improvement - After your EMR go-live, you will probably be asked to help optimize the EMR - That means, looking at the results from go-live, and looking for ways to improve results, e.g. higher achievement of core measures, higher CPOE rate, etc. Learn how to get utilization data out of your EMR, and look for statistical relationships that help you improve your processes. Know what a Venn diagram, control chart, pareto diagram, and fishbone diagram are. Bonus points are awarded if you can write your own SQL code! :)

It has been enormously rewarding to me, and if you find yourself in the role, I hope it's equally rewarding to you. Although the first CMIOs appeared on the scene back in the 1990s, it's still a relatively new position (especially in the northeast), so be prepared for a lot of change and ambiguity when you start down the road. 

As always, I enjoy simultaneous teaching and learning - Feel free to leave questions, comments, or thoughts below!