Friday, September 11, 2009

More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?

Both Roy Poses and I have written on a plague of healthcare mismanagement and perhaps malfeasance in part due to leadership by domain amateurs, i.e., healthcare leadership profoundly lacking in biomedical education and experience.

Examples of recent posts about the risks posed by domain neutral biomedical leadership are:

"NY Times Proclaims Anyone Can Run a Health Care Organization with a Little Studying Up" (Poses)

"Health Care Leaders: Don't Know Much About Health Care" (Poses)

"On Optimal Expertise for Leadership in Biomedicine" (me)

"Informatics, or Infomagic? Health IT Cannot Flourish When Everybody is an Expert" (me)

and "Pfizer/Wyeth Merger And Sacrificing The Future: Laying Off Scientific Staff All Over The Place" (me).

I have also written of a cross-occupational invasion of healthcare by the IT profession, in the form of power and territorial grabs over clinicians with regard to the tools clinicians increasingly need in order to provide patient care.

These leadership inversions, where domain neutral personnel are viewed as best able to lead any endeavor as if the world consists of interchangeable, faceless resources following equally interchangeable processes, are due to attitudinal laxity and permissiveness on the part of medical leadership, a takeover of healthcare by those with primary pecuniary interests, and perhaps a lack of appreciation for the value of domain expertise as sign of a waning western culture.

In a recent hospital CIO interview, in this case of CIO Avery Cloud at New Hanover Regional Medical Center in Wilmington, NC, we see both of these elements - supportive views towards healthcare leadership by domain amateurs, and towards a cross-occupational invasion of healthcare by IT personnel - combined:

Q: Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

A: That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital [wow - ed.] A good example is that nobody is surprised when the CFO runs the pharmacy department [i.e., nobody in this CIO's limited circles - ed.], or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same [In fact, it likely would be a big surprise to many -ed.] A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division [this is, in fact, stunning and should be a cause of great concern to healthcare regulators if true - ed.]

I'm sure CIO's would like to think that they could "run any of the departments in a hospital."

(How about: Legal? Risk management? Health Information Management a.k.a. Medical Records? Biomedical engineering? Nursing? Trauma? Diagnostic Imaging? Neurosurgery?)

The question is this: is this a realistic view? Or, is it an extreme form of hubris and the Dunning Kruger effect? Can they run complex departments far outside their core competencies optimally? Or will they more likely be running an area they know little about by the seat of their pants?

Further, do leadership roles in organizations such as NIH or the Centers for Disease Control call merely for an MBA and domain neutral backgrounds? If not, why not?

Why are hospitals exempt from a requirement for domain specific expertise in their leadership?

As to CIO's (and, for that matter, CFO's) running hospital pharmacies, let's show the knowledge gaps graphically by first exploring the prerequisite training of a typical Pharm.D. pharmacist:

Professional Degree (Pharm.D. Degree) Curriculum
Class of 2011, 2012, & 2013
(Admitted Fall 2007, 2008 & 2009)

First Year, Fall Semester

NBAN 301 Principles of Human Anatomy 3 credit hours
PSIO 743 Fundamentals of Physiology 5 credit hours
PHAR 700 Pharmacy as a Profession 1 credit hour
PHAR 701 Pharmaceutical Care Lab 1 2 credit hours
PHAR 702 Physical Pharmacy 3 credit hours
PHAR 703 Intro Pharmacy Practice Experiences 1 1 credit hour
PHAR 720 Patient Health Education 2 credit hours

Total hours 17 hours

First Year, Spring Semester

BIOC 531 General Biochemistry 4 credit hours
PHAR 708 Pharmaceutics 3 credit hours
PHAR 709 Immunology and Biotechnology 2 credit hours
PHAR 710 Intro Pharmacy Practice Experiences 2 1 credit hour
PHAR 711 Chemical Properties of Drugs 2 credit hours
PHAR 712 Pharmaceutical Care Lab 2 2 credit hours
PHAR 737 Disease Prevention and Health Promotion 2 credit hours

Elective 2-3 credit hours

Total hours 18-19 hours

First Year, Late Spring – after spring term concludes

PHAR 714 Introductory Community Rotation (2 weeks) 2 credit hours

Second Year, Fall Semester

PCOL 743 Pharmacology 1 3 credit hours
PHAR 715 Pathophysiology & Therapeutics 1 4 credit hours
PHAR 716 Chemistry of Drug Action 1 3 credit hours
PHAR 717 Intro Pharmacy Practice Experiences 3 1 credit hour
PHAR 723 Pharmaceutical Care Lab 3 1 credit hour
PHAR 727 Medical Literature Evaluation 2 credit hours

Elective 2-3 credit hours

Total hours 16-17 hours

Second Year, Spring Semester

PCOL 744 Pharmacology 2 3 credit hours
PHAR 719 Intro Pharmacy Practice Experience 4 1 credit hour
PHAR 724 Pharmaceutical Care Lab 4 2 credit hours
PHAR 725 Pathophysiology & Therapeutics 4 credit hours
PHAR 726 Chemistry of Drug Action 2 2 credit hours
PHAR 728 Pharmacy Management 2 credit hours

Elective 2-3 credit hours

Total hours 16-17 hours

Second Year, Late Spring – after spring term concludes

PHAR 729 Introductory Institutional Rotation (2 weeks) 2 credit hours

Third Year, Fall Semester

PHAR 730 Pathophysiology & Therapeutics 3 4 credit hours
PHAR 731 Biopharmaceutics & Pharmacokinetics 3 credit hours
PHAR 732 Non-Prescription Drugs 3 credit hours
PHAR 733 Pharmacy Systems 2 credit hours
PHAR 735 Pharmaceutical Care Lab 5 1 credit hour
PHAR 742 Intro Pharmacy Practice Experiences 5 1 credit hour

Elective 2-3 hours

Total hours 16-17 hours

Third Year, Spring Semester

PHAR 734 Pharmacy Law and Ethics 3 credit hours
PHAR 736 Pharmaceutical Care Lab 6 1 credit hour
PHAR 738 Outcomes Assessment/Quality Improvement 2 credit hours
PHAR 739 Therapeutic Patient Monitoring 3 credit hours
PHAR 740 Pathophysiology & Therapeutics 4 4 credit hours
PHAR 741 Clinical Pharmacokinetics 3 credit hours
PHAR 746 Intro Pharmacy Practice Experiences 6 1 credit hour

Elective 0-2 credit hours

Total hours 17-19 hours

Fourth Year

Students complete eight five-week experiences beginning in the summer preceding their fourth year. Students will have required experiences, such as ambulatory care and acute care, and elective experiences.

Students are required to complete at least 10 professional elective hours selected from an approved course list during their first, second, or third professional year and prior to fourth year experiential rotations. With the exception of Fall semester in the first professional year, one elective can be taken each semester of the didactic program. Electives are intended to complement the required curriculum and allow students to select courses based on professional interests. Students wishing to take electives during summer terms may do so after their first professional year on any of the campuses in the WVU system (Morgantown, Parkersburg, Potomac State, West Virginia Tech) provided the courses are selected from the list of professional electives or are deemed equivalent by the University. Students wishing to receive course credit for courses taken outside of the WVU system must have pre-approval by the Curriculum Committee.

Of course, even assuming no requirement for a Dissertation defense (which is a typical Ph.D. requirement), the candidate needs to take state and/or federal exams for licensure:

Licensure. A license to practice pharmacy is required in all States, the District of Columbia, and all U.S. territories. To obtain a license, a prospective pharmacist must graduate from a college of pharmacy that is accredited by the ACPE and pass a series of examinations. All States, U.S. territories, and the District of Columbia require the North American Pharmacist Licensure Exam (NAPLEX), which tests pharmacy skills and knowledge. Forty-four States and the District of Columbia also require the Multistate Pharmacy Jurisprudence Exam (MPJE), which tests pharmacy law. Both exams are administered by the National Association of Boards of Pharmacy (NABP). Each of the eight States and territories that do not require the MJPE has its own pharmacy law exam. In addition to the NAPLEX and MPJE, some States and territories require additional exams that are unique to their jurisdiction.

(I can add that the typical M.D. curriculum, such as at the medical school I attended, is even more rigorous. That is prior to the medical internship, residency, and postdoctoral fellowship(s) most physicians also must perform, where they become intimately familiar with the services of many hospital departments).

Now, let's explore the comparable pharmacy science/biomedical training of the typical hospital CIO or CFO (or CEO for that matter):

(This, of course, is the mathematical symbol for the null set.)

For comparison and contrast, see Roy Poses' post "What is Not Taught About Leadership in Healthcare" for the healthcare MBA curriculum at a prominent School of Management, namely Yale's. Dr. Poses observed:

... So what is missing? There seem to be two obvious areas that are not taught.

The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." ... The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.

In the first of my posts linked above I wrote:

... Those in charge [and who lack domain credentials -ed.] cannot see that which the domain specialist sees.

They cannot see because they lack the training, experience, and what is described as 'meta-competence' (in this brilliant article on competence [the Dunning-Kruger effect - ed.]) essential to seeing that which is obvious. Obvious, that is, to those who do not lack these characteristics. In addition, I've also observed that some lack the fundamental analytical abilities essential to understanding and managing the complexities of biomedical R&D.

Why those without domain expertise are in charge of organizations whose long term viability depends entirely on the most advanced and creative pursuit of biomedical 'miracles' [i.e., pharma - ed.] is another matter. I won't address this here, other than saying it reflects the adverse consequences of a bias that has evolved in management "science."

That bias is the belief that all the world consists of faceless labor resources performing easily definable processes upon interchangeable widgets, and that management can therefore be done by generic managers, exclusively. Some of the world is like that [i.e., fast food chains - ed.], but some isn't, such as biomedical R&D. [And clinical medicine as well - ed.]

Management in the absence of domain expertise in this industry is, in fact, mismanagement.

There is nothing here to spin, there is nothing to debate. There is nothing to discuss. This is a first principle.

Failure to accept this reality results in corporate failure.

These views apply to hospitals perhaps even more critically than to biomedical R&D. In hospitals, mistakes in judgment can result in great patient harm, and far more rapidly than in an R&D organization.

Finally, in the same CIO interview there's this:

Q: If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

A: I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one ... So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

The fact that this "customer is king" advice seems to merit constant repetition among healthcare IT leadership circles, especially when the “customers” are clinicians with patient care obligations and responsibilities, should be a cause of deep reflection and introspection among those in HIT. At the very least, they need to ask themselves - and healthcare professionals need to ask them - "who are you, and what are your motives for stepping foot in our hospital?"

It is also such a fundamental first principal that its frequent repetition suggests typical hospital CIO's are not truly fit in 2009 to lead anything in healthcare where domain expertise and viewpoints are essential, healthcare IT included. Its need for frequent repitition - dating to many HIT publication I've seen since I entered the Medical Informatics field professionally in the early 1990's - suggests they don't truly recognize that the business of hospitals is taking care of patients, the clinicians being the enablers of that business, everyone else being facilitators. The known problems and failure rates of heath IT in hospitals is corroborative of that view.

Healthcare reform will certainly require healthcare leadership reform, and the first task of that reform should be a re-evaluation of expertise required to tamper with people's lives and well being in a hospital setting.

-- SS


Anonymous said...

What grandiosity and what a man!

Pity the patients.

And I suppose he thinks he can also run a law firm, and who knows, may be even run the country.

Anonymous said...

And here are all the things that Pharm D lacks that are essential for managing a department

Management is a different skill than clinical care. I would no more want a manager performing surgery than I would want a surgeon preparing a budget analysis. The manager needs a strong understanding of clinical issues. And the clinician needs a strong understanding of business issues.

But, neither clinical training nor management training guarantees that an individual is a good health care leader.

Anonymous said...

And, by the way, I use Dunning's work in my UNDERGRADUATE courses in health administration.

Anonymous said...

So, clinical domain training provides the antidote to poor leadership.

Somebody go investigate how Richard Scrushy got his start in health care.

InformaticsMD said...

And I suppose he thinks he can also run a law firm, and who knows, may be even run the country.

I believe that a lawyer must be at the head of a law firm.

InformaticsMD said...

Anonymous wrote:

Management is a different skill than clinical care.

Perhaps an apparent lack of biomedical background blinds you to the reality that medical internship and residency impart leadership and management skills, including people management and many others, in the most demanding of settings, often comparable to training in a military environment.

This training is quite valuable to the 100's of thousands of MD's who manage their own businesses, and to those who are managers in industry at large.

For example, at Merck many MD's and PhD's advanced to management in areas where they had domain expertise. I managed an informatics (information sciences) department of more than 50 people and a budget just over $13M annually, serving over 6,000 researchers worldwide. And I managed that budget to within one half percent (0.5%) of EA.

Truth is, many medical professionals can learn management skills quite rapidly, if they did not have them in their background already as I did - from managing a hospital medical department and satellite office, and then managing medical surveillance programs for the massive regional transit authority in SE Pennsylvania.

Non-clinical professionals cannot do the reverse. They cannot learn biomedicine quickly. We need more who take the time to learn the science and the culture and the values.

I would no more want a manager performing surgery than I would want a surgeon preparing a budget analysis.

This is a defective comparison. Chairmen and chairwomen of departments of surgery, surgeons themselves, perform such tasks routinely when analyzing departmental short term needs and long range plans and submitting budgets. I agree, though, that a generalist manager performing surgery is not a good idea. (In fact, it became illegal about a century ago due to terrible outcomes.)

Heck, I, a mere internist/informaticist did so in submitting my annual LROP and budget projections, and successfully justified increasing my operational budget 25%. This facilitated a tenfold increase in the flow of scientific articles supporting new drug discovery to Merck Research Labs scientists over decade long norms - another need I identified as crucial to the business.

The manager [in healthcare] needs a strong understanding of clinical issues.

Exactly. Perhaps we merely disagree on what "strong" means in this context.

But, neither clinical training nor management training guarantees that an individual is a good health care leader.

All hiring involves an element of chance and unpredictablity. I'll place my bets for superior performance on the person who has true clinical or biomedical expertise imbued by a Doctorate and Post-doctoral education and experience, who has had the rigor and self-discipline to reach such heights of education and training, and a modicum of business experience, over someone who has a modicum (or no) biomedical experience and a Master's degree from a business school. Assuming, of course, that both lack other obvious defects, such as personality disorders. (I knew both hospital execs and clinicians who clearly suffered from narcissistic personality disorders, or worse.)

I repeat: management of biomedicine by those without domain experience is mismanagement.

-- SS

Anonymous said...

This sure seems an odd time for anyone to be defending nonprofessional business people strutting around with their MBA's as if those mean anything more than having sat in some classrooms with fellow Kool aid drinkers, listening to bullshit. We are at the point of economic collapse. Our banking system, economy and major industries are in near ruins. Unemployment is at record highs.

Maybe it is time to rethink just who is running things in the business world.

Anonymous said...

Managers without domain experience that I talk to in healthcare tell me that 75% plus of their reading is in medical journals. Good clinicians can learn management and leadership. Good managers can learn much about a domain. One of the unaddressed problems with relying solely on clinician management is that it only exacerbates an existing shortage. The blinders that can come with clinical experience can also prevent the fresh view that is sometimes the advantage of the outsider.

The best management practices that I've seen in healthcare often relying on the close collaboration of both a clinician and a non-clinician. Some organizations set that up formally. Others have less formal, but still substantive involvement of both.

InformaticsMD said...

Anonymous #8 wrote:

Managers without domain experience that I talk to in healthcare tell me that 75% plus of their reading is in medical journals.

After having run a very large biomedical library in one of the world's largest pharmaceuticaql companies, that figure sounds highly doubtful.

And what of it, even if it were true?

It's time for this culture to stop denigrating the rigor of biomedical education. Without the prerequisite background in biomedicine (e.g., see the curriculum of a typical medical school at this link or Pharm.D. school as in the posting), biomedical laypeople are largely reading material above their heads. They are as likely to misunderstand or only partially understand what they read as gain useful insights, unless they are reading about very "light", non hard science topics.

Further, without such background, how can a reliable opinion be formed on the value of such a background, or the gaps its lack creates?

A dilettante who reads journals in a field in which they lack the prerequisite background for rigorous evaluation and comprehension is still a dilettante. That's why NIH, for example, has rigorous requirements for its biomedical employees and domain expert grant application reviewers. "Businessperson who reads medical journals" is generally not one of them.

The blinders that can come with clinical experience can also prevent the fresh view that is sometimes the advantage of the outsider.

This banal, platitudinous statement is inane. "Blinders?" Blinders to ... what, exactly? This statement reminds me of this equally anserine (apologies to my feathered friend pictured in this post) statement I was stunned by ten years ago:

"I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of Hard Knocks." ("Who's Growing CIO's", Healthcare Informatics, Nov. 1998, p. 88).

[Continued below due to comment length limits]

InformaticsMD said...

[continued from above]

First, clinical experience [which comes from the rigorous education and military-like multi-year practicums described earlier] doesn't "blind," it enlightens across many dimensions. In fact, I would argue that it is lack of clinical or biomedical experience that creates huge blind spots in the business of hospitals - which is, by the way, providing care to patients - or biomedical R&D.

I speak from experience such as here, as just one of numerous examples at my Drexel site, where research scientists of a multinational pharma starved for new drugs were starved of informatics tools needed for new drug discovery. Guess the background of the people who made that decision.

Second, "fresh views" can be expressed by anyone, but this does not imply that these views, especially coming from domain amateurs are valid. If the amateurs are empowered amateurs, the "fresh views" can in fact do damage. The statement that clinical experience "blinds" and lack of clinical or biomedical experience enables fresh views may be the views taught in today's "everyone is special" schools, but it is not the way the biomedical frontier was crossed.

The best management practices that I've seen in healthcare often relying on the close collaboration of both a clinician and a non-clinician.

I agree - as long as it's quite clear who is the enabler of healthcare provision (clinical professionals), and who is the facilitator (everyone else, including lay management).

As a somewhat extreme thought experiment, if WW3 happened tomorrow, clinicians could still provide care, in tents and with table utensils if necessary.

Everyone else could help set the tents up and secure the utensils, and maybe hold a fork or two serving as a retractor, but not much else.

Finally, I think these issues have been discussed enough in this thread, and I am now closing it.

-- SS