Systems-based practice: The role of the case management physician advisor

One of the six core competencies for physicians, as defined by the Joint Commission, is systems-based practice. To meet this competency, physicians must demonstrate an understanding of the contexts and systems in which healthcare is provided. The two major systems that physicians interact with in the hospital setting are patient safety and resource management. Both systems require cooperation and compliance with policies so that the individual physician’s actions will not be detrimental to the system as a whole. In this column, I'd like to focus on resource management and the key role that the case management physician advisor plays in assisting physicians effectively use hospital resources.

Over the past 15 years, many hospitals have recognized that in order to effectively influence physician practice regarding resource management, there needs to be a physician who explains to other physicians the rules and criteria for effective case management and the alternative approaches that are available. This role is often called the physician advisor. The physician advisor is critical to enhancing the clinical credibility of case management to the medical staff. Typically the physician advisor is an individual on the medical staff who the hospital pays to perform this function. However, some hospitals outsource this function if the physician advisor is not present onsite nor is a member of the medical staff.

With either approach, leverage the physician advisor to the fullest extent by asking them to perform five main functions:

• To assist the case management staff in accurately interpreting resource use criteria and effectively interacting with the physicians to build positive relationships
• To assist nursing and ancillary care staff to implement these decisions in a timely manner
• To collaborate with individual physicians on specific patient issues identified by case managers after case managers failed to obtain an appropriate response from the physician
• To work with individual physicians in the medical staff as a whole on resource use patterns using length of stay and cost per case data
• To work the physician and the hospital on denials received from external payers

One of the difficult aspects of this role is that when attempting to help the medical staff make the right choices, the physician advisor usually does not have any direct authority over patient care decisions. As a result, a skilled physician advisor must learn to manage by influence rather than by authority. This requires a delicate balance between collegiality and firmness relative to the issues at hand. It also requires the ability to provide reasonable alternatives rather than indicating what can't be done.

So, what are the qualifications of an effective physician advisor? I would like to address this from the standpoint of a physician advisor who is an internal member of the medical staff. Typically in my experience in directing case management programs, I found the following characteristics to be helpful:

• Member of the medical staff who others respect for his/her clinical expertise
• An established record of effective clinical resource use
• Good interpersonal skills and approach peers in a non-confrontational manner.
• Capacity to understand and accept that he or she manages only by influence and has no direct authority
• Good working relationships with the nursing staff and is viewed as cooperative and supportive
• Sufficient time available to meet the communication commitments of the position

Effective resource use is a physician competency that most physicians did not focus on in medical school or residency training. In our current society where healthcare resources are under greater scrutiny than ever, physicians need all the assistance they can get in achieving this competency. The physician advisor is someone who can help the practicing physician do so. So be kind to your physician advisor, they really are here to help.