Fifty years ago, the belief that physicians and managers could effectively share responsibility and accountability for overall performance of health systems brought the wrath of the American medical establishment down on the first generation of Permanente physicians, who were excluded from their local medical societies. Then, the hard work of making such a partnership succeed nearly destroyed Kaiser Permanente in its first decade.
The outcome became the key to the success of Kaiser Permanente today, as well as one of the organisation's most distinctive characteristics: an organisational culture that transcends the traditional conflicts between “medicine” and “management.” That culture has been nurtured over decades of continuous negotiation by hundreds of committees and leadership councils that jointly manage the organisation on a daily basis. Today, the mutual commitment to an exclusive partnership between the physicians and management is deeply ingrained in the organisation. Many factors may be credited for this success, but three stand out.
Joint leadership—From the earliest days, leaders of physicians and management within Kaiser Permanente have acknowledged their mutual dependency. Having this propensity for partnership explicitly modelled at the highest levels of the organisation has guided behaviour at all levels, including frontline care givers and their counterparts in management.
Alignment—Without an explicit mutual alignment of mission and strategy, the partnership would have collapsed amid the traditional gaps between medicine and management. Most of the highly fragmented, disaggregated healthcare structures in the United States suffer from just this condition—conflicting incentives and goals among physicians, insurers, and hospital administrators. Physicians focusing solely on patient care and administrators focusing solely on use of resources and productivity are destined for collision. Bringing both sides into a mutually interdependent relationship, where the success of each side is in the hands of the other, forces a powerful alignment of interests that transcends professional or cultural differences.
Management training for physicians—It makes no sense to send managers to medical school, but there are good reasons to train physicians in management or at least those on a leadership track. Collaboration and cooperation, negotiation and persuasion, and delegation and teamwork are just some of the critical skills in the management of large and complex organisations that are lacking in the training and development of physicians. If physicians are to work as truly effective partners in the management of their practices they need to take the time to acquire these skills, either through in house training programmes or at outside educational institutions. At Kaiser Permanente a range of such programmes ensures that physician leaders now understand both the bedside and the boardroom and make competent partners for similarly well trained managers.
Footnotes
Competing interests: FJC is the executive director of the Permanente Federation, the national umbrella organisation of the eight Permanente Medical Groups that make up the physician side of the Kaiser Permanente organisation.