Author + information
- Edward T.A. Fry, MD, FACC, Chair, Incoming Trustee, American College of Cardiology and
- Mary Norine Walsh, MD, FACC, President, American College of Cardiology∗ ()
- ↵∗Address for correspondence:
Dr. Mary Norine Walsh, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
As 2018 approaches, the American College of Cardiology (ACC) continues to grow its commitment to patients and members through critical work on the College’s next Strategic Plan (1). Carrying forward, the central theme will be transformation of care with an emphasis on teams of care to meet the quadruple aim. Inherent to successfully navigate the rapidly changing health care environment and to improve care is the need for skilled, informed, creative, and effective system leadership.
Leadership may take many forms, and is required at all levels of the cardiovascular (CV) health care enterprise. In his book, Prescription for the Future, Ezekiel Emanuel, MD, identifies 6 essential elements of transformation: recognizing a catalyzing crisis; culture, governance, and clinician engagement; data; financial incentives; clinician and management alignment; and, most importantly, leadership (2).
So, what are the critical characteristics of effective leadership in the CV arena? Clearly, the requirements for leadership at this time of such unprecedented, accelerating change are different from those needed in a more stable or less dynamic situation. Today’s leaders must be “change managers” and visionaries. As Emanuel states, “Someone has to be pushing the change forward and deciding on the direction of the change. Someone has to wake up every day, figuring out what is needed to make that change happen, and communicating the way forward” (3). To do this, they must possess 2 specific skills: analytic expertise and emotional intelligence.
Like the general leading troops into battle, a leader’s influence and credibility is dependent on a history of shared experience. Similarly, a pedigree of a strong clinical foundation and skill as a respected clinical expert is common to most successful CV leaders. The ability to translate a strong clinical background into novel models of care allows clinician leaders to have the respect and buy-in from those they lead and the perspective of process to earn the trust of nonclinician peers.
The role and style of the cardiovascular leader is directly affected by the model of the organization to be led. Evolving models of partnered, comanaged services, cardiovascular service lines, and complete multilevel integration have given rise to the dyad model of leadership: a partnership between a clinical and an administrative leader. In the past, in a traditional CV practice, the “managing partner,” division chair, or lead cardiologist was often indistinguishable from his or her partners. The partners often made sure that the organizational chart remained very flat, resulting in many voices pulling the organization in many directions.
Today, approximately 75% of all cardiologists are employed within an integrated health care system. Accordingly, the responsibilities of the CV leader have evolved to include system finance (not just billing), operations, alignment with other service lines, system strategy, and integration of both outpatient and inpatient as well as acute and chronic care. These responsibilities are shared by CV leaders in both academic and clinical practices and institutions. This complexity necessitates a division of labor between dyad partners to evolve from a culture of “me” to a culture of “we” that includes the patient.
Within the dyad, each leadership partner brings a unique set of skills and background that complements the other, synergistically resulting in leadership talent greater than the sum of the individual parts. In today’s complex health care world, it is absolutely necessary to be able to leverage expertise in both clinical matters as well as operational and financial functions to succeed in defining, directing, and implementing care transformation. Although the administrative dyad partner is required to have these operational skills, he or she may still be a clinician by training. There are many examples of very successful “nonclinical” dyad leaders and health care executives who were cardiologists, nurses, non-CV physicians, or other care team members in a previous professional life.
Effective health care leadership is distributive. With the growth of integrated health care systems, there is a natural tendency to self-select as a leader or a follower, or as a manager or employee. However, the concept of dyad leadership need not be exclusionary. It can be applied at every level of a health care organization, from the bedside to the boardroom and everywhere in between. It is a philosophy, not a hierarchy. Most mature health care organizations represent a set of teams within a big team. Accordingly, there are leadership opportunities and needs at every turn.
The success of clinical dyad leaders, and ultimately their organizations, rests on a coordinated collaborative approach founded on trust, shared purpose, and overall system success focused on patients. Effectiveness of the clinician leader must be assessed by the same set of responsibilities, accountabilities, and performance metrics as his or her administrative dyad. Factors that may compromise success of the clinician leader include a lack of aligned incentives, a poor governance structure, favoritism by system leadership, lack of professional coaching or professional development, as well as asymmetric access to information (specifically financial) or compensation due to legal barriers, including stark laws and fair market valuation considerations.
How do busy clinicians become effective CV leaders within their organizations? To date, the process has mostly been organic and osmotic, such as by getting involved in local quality and operational initiatives, serving on hospital and system committees, as well as attending outside management courses and health executive training programs. Recognizing its members’ growing need for leadership training and nonclinical competencies, the College has developed a suite of tools including content at the CV Summit and Leadership Forum, the ACC Leadership Academy, fellow-in-training professional development programs, mentorship opportunities, and leadership positions within the College. Diversity remains a challenge within the ranks of leadership. Obstacles for female cardiologists as well as others who are under-represented with respect to leadership opportunities, have been highlighted in the recent ACC Professional Life Survey (3). Steps to remove these barriers and to include all constituents of the CV team and health system are part of the College’s new Strategic Plan development.
The almost daily news of health care mega-mergers involving various combinations of health systems, hospitals, clinician groups, payers, and venture capital firms poses a potential threat to the professionalism of physicians and care team members by reducing their value to a “commodity” (4). CV specialists must embrace the mantle of leadership to remain relevant; to advise the course of events as health care morphs rapidly; and to protect the professionalism of cardiologists, cardiac surgeons, and all CV team members. Parallels between the airline industry and health care have been cited frequently; consolidation, check lists, lack of price transparency, loss of focus on the consumer, and the relegation of the most critical member of the enterprise to that of an hourly worker. To avoid this fate, cardiac specialists must step up and lead care transformation to meet the goals of better outcomes, greater access, higher value, and optimal professional engagement. As members of the cardiac care team, we have the experience, skills, opportunities, resources, passion, and moral authority to do so successfully.
- 2018 American College of Cardiology Foundation
- ↵Vision 2023: developing the College's next strategic plan and shaping its future. Cardiology Magazine. June 21, 2017. Available at: http://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/vision-2023-developing-the-colleges-next-strategic-plan-and-shaping-its-future?w_nav=LC. Accessed December 2017.
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