National Alliance for Physician Competence Discovery Workshop

Context

Organization Design

Bryan Coffman

While we're waiting for everyone else we'll pass these out.

Now it's coming to the meat of things. There are three things to focus on. We're going to explore structure now. Think about the legal side of things as well as how you organize to accomplish the work. The third thing to think about are the simple rules or the values and principles you want to organize around.

Let's do this in five teams. Around five people per team. No fewer then that please.

Anyone else need an assignment? Any questions. Keep in mind what this group has learned so far that can be brought to bare on this assignment?

Assignment

Context: It’s not good for an organization’s structure to be ephemeral or so transitory that it remains in a constant state of chaos. However, it should be poised on the edge of chaos at times in order to remain nimble enough to survive in a chaotic landscape. Having this thought in mind, some organizations mold and adapt their structure over time by relying upon guiding principles instead of hard and fast wiring diagrams. For example, a motion picture is a large joint venture among a number of organizations that dissolves when the movie is finished. But there is a set of guiding principles (or organizing principles) that the players in the industry use to create and dissolve these projects over and over. These are usually codified into standard contracts and sample clauses that explain the interrelationships between all of the players.

Objective:

  1. How should the legal side of the National Alliance be organized? Remember that this is simply the structure or shell that allows you to relate as an organization to other organizations. Don’t get trapped in the conventional thinking about this shell.
  2. How should the National Alliance be organized to accomplish its work? Keep in mind the purpose of the National Alliance and some of the ideas you’ve talked about concerning what it does.
  3. What are the guiding principles for organizing work throughout the alliance and what role does the National Alliance itself play in this?

Process: Again, use the ideas you have heard in the last rounds of presentations to stimulate your thinking. You have about 60 minutes for this assignment.

Exchange: Do your work on marker boards. Be prepared to share your work with other teams at the end of this round.

Report Outs

Bryan

OK please come on down. Who would like to be brave and go first. After these we will have lunch.

Group Five

We had the discussion about whether this should be longer term or shorter term. The first thing is to develop the principles and then you can realign at some point and eliminate the organization if it has served its purpose.

We thought we should set up a 501c3. A 501c3 would allow outside dollars to come in to support different projects. This would be an organziation of organizations that would pay the seed costs to fund a professional staff.

As we get further out, something like the software tool like a trusted agent could be done in a coop model. The individual physician could decide if they participate in the ownership or just purchase the product. The physician at the end of their career might not want to invest in something like this. Any overage would go back to the owners (the physicians participating). The intent would be to create something they would both want to use and have a vested interest in.

The forum for discussions is the biggest product of the organization.

The forum for discussions is the biggest product of the organization. GMP document could be owned by the Alliance initially and it could be filtered out to the whole diaspora through the members at first. At some point like version 4.4 the members could decide it's ready to be let out to the rest of the diaspora.

The technology would allow things to occur that we didn't imagine five years ago. Buy-in and ownership are important to make the model move.

The original thought about the 501c3 owning a for-profit tool was the idea that once you start making money the red flags go up so the Alliance might want to advocate for that tool to be made available by a vendor.

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Group One

Our group spent some time on the principles of membership. We agree that a 501c3 is the right thing. We agree that it would be an organization of organizations. The common business of those organizations is the supporting of public accountability through physician self-regulation.

Worth mentioning is that the individual physician self-regulating at the individual level is under attack by the public. That isn't really what we mean by self-regulation and the definition we mean is being articulated by the GMP. This is a group of organizations that are committed to the public accountability through engaging individual physicians in self-regulation.

This has to be based on data. The method of data stream collection and distribution is a business opportunity.

The public needs to know that someone carrying the card has met certain standards (that vary by specialty).

The organization should be small and made up of professionals. The work is really being done by the specialty societies and licensing boards.

The conversation about who should be involved came to the fact it should be where the rubber meets the road. It could be a deligated democracy but we need to get close to the individual physician.

The stage where there is a real need is the part of a physician's life when they are in their practice.

The stage where there is a real need is the part of a physician's life when they are in their practice. We have a good method for monitoring at the medical school and at the GME/residency stage. It's the practicing phase where CME and the physician sees their home as the specialty society that needs the most help. The specialty society has a realationship with certifying boards and licensing boards.

The opportunity is to create a system where MOC can become an MOL and we can meet this common goal.

Did either of the first two groups talk about the involvment of government? We had a side bar discussion about that. This organization has to be influential enough that government will listen and there is a reciprocal relationship there.

What part of government? CMS? HCRQ? The decision point is around which it should be - the payer or the entity that should be improving care?

What about the inclusion of the public? We felt that this organization needed a way to hear the public voice. The public needs input into the processes but they may not be involved in the business of supporting physician accountability.

What about the governance of the organization?

We kept letting the stuff we have learned influence us and we think it needs to be as self-organizing as possible.

There could be some seed fee and a commitment to being held accountable to the peers of the group to keeping to the principles.

We said it would be a steering committee but then have the forums where we are coming together and we can be using technologies in between the forums.

There needs to be some way of talking to government. A 501c6 is a lobbying voice but we decided we don't want to do that.

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Group Four

Instead of a council or board the group comes together to get a function done and then they dispand once they are finished with that function.

Where we ended up was an agreement that we continue to function as an informal partnership with a caveat that we create a committed enabling structure to carry the work forward. Those resources are subsidized by the organizations in the partnership. The principles are that a simple agreement is written. The rules of engagement are relationship oriented. They are organic in nature, process oriented and adaptable. Instead of a council or board the group comes together to get a function done and then they dispand once they are finished with that function.

 

The value proposition to the owners will be:

Perhaps what the alliance can do that no independent organization can do is to create a brand that the public can relate to?

The realm of organizations that might participate in such a structure is not unlike what the previous groups have said. We made a conscious decision not to include individual patients or individual doctors but organizations that represent them.

We started discussing whether it should be profit or non-profit. We have to be cognizent of what we have learned from the past about self-regulation.

Making decisions about who is in and who is out could possibly be decided by asset size?

We can incubate the Alliance but we have to have committed enabling resources to carry the work forward.

At this point the group felt that we have only been engaged in the discussion for about a year and it could be too early to force a structure. We can incubate the Alliance but we have to have committed enabling resources to carry the work forward.

You need staff and you need money to keep the work going. The ePortfolio and the Trusted Agent and the Licensing and Certifying organizaitons conversation are two of the projects that need continued coordination. There still needs to be coordination and management and bringing the work back to the Alliance.

We don't have the luxury of waiting and we need to figure out a way to expedite getting work done without forcing an organization.

We would create project teams around the different aspects of the work and the organizations involved would provide human resources and possibly money.

We would float some projects and resources will coalesce around the projects. Once the projects are finished the resources shift.

You could fund things project by project but it might be better to ask everyone around the table to put in a certain amount at the beginning to create some stability for the group.

There is a little bit of this happening now but we are suggesting we move one more step to gather more money to support a longer project.

The brand idea is interesting. The license is not sufficient or robust enough now but there could be some point in the future where the license is the brand that assures the public of the competence of the physician. We think that if we had a robust method for establishing physician competence around GMP there would be some physicians that have a license now that don't meet that standard.

Maybe not all State Medical Boards would be members? What if a state is NOT certifying competence beyond initial certification and license?

Your groups point is to synergize the certification and licensure and to try to make the myth become a reality.

I like this model as a transition to some of the other models. You have been doing a lot of work organizing this. If we put money in a pot who would manage that? How would it work?

The dedicated resources would be shifted from what they are now. The same people would be involved.

There is one possibility to have an organziation that sub-contracts to some of the people here to do the work.

It would be separate but there is a place to go and support services to get things accomplished.

One thing is to build upon what you have. You don't want to lose all that.

The branding could be value added to the individual physician as well.

We've had a meeting today and that same thing would happen to get input from outside people and we could see that same approach to see where government might fit. We are not limited by who can be invited and we aren't limited to what we can discuss.

The attractiveness is that you have burned no bridges and you provide the opportunity to keep the momentum going under Carol's leadership and the ownership that the people participating have exemplified. This seems like a logical next step.

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Group Three

We talked about either for-profit and non-profit. We talked about whether it should be an independent entity or a hybrid model. We have to take care of the flow of money and some staff. We didn't want it ultimately to be bound to one organization.

Maybe the colony model isn't right. We're a collection of colonies. Say each one of these is colonies. Maybe there is a hover organization to figure out the coordination of the different colonies. Can we place resources in different places and this organization manages the resources?

Maybe the work is to put out pathways to resources?

The work is to talk about impediments and to discuss how we can facilitate the conversations between the colonies about these impediments.

We don't want to create another colony but one that could be unbiased and could see all of them.

We listed these projects - GMP, trusted agent, etc.

We didn't discuss membership nor did we get to governance. We talked about participation being fluid if not a membership.

Principles - we wanted this staffing group not to be biased and it should serve all members, be minimally intrusive and non-bureacratic. We are serving physicians but there is benefit for the public.

The ratio of value to burden needs to be maintained at 0 or greater.

The ratio of value to burden needs to be maintained at 0 or greater. We want to try to decrease the burden compared to what it is bound to be.

I'm intrigued by your last point. That value/burden relationship. It's a hard sell to say that the added burden is not as bad as it would have been.

If you are a physician that is not engaged you will find this burdensome. If you are engaged it is not so burdensome. Anything we do to insure competence should relate to other things - so that each group adds to the next group.

The concept of burden is interesting. Whatever comes out of this may have the unexpected outcome of lessoning burden. What's in it for me - the individual doctor - is always something I think about.

A word of caution. The EMR is not an easier way to take care of patients - in the short term. From a hospital frame of reference it is pretty passive. To make the system better there is going to be some increased burden. There is not as much burden as there needs to be in order to make the system better.

Burden versus value - we heard some physicians talk about getting patients from the VA and how nice that is because they have the information (the VA has an electronic medical record). There is a relationship of the system to the burden on the individual. The burden might be the transparency. We can use technology to make the paperwork go away but the burden on performance is what might be hard or impossible to get around.

The current system doesn't gaurantee physicians are competent. One measure is that patients come back and say I'm a good doctor. Tell me a system that will replace all that. What are we going to do to make it better? Doctors want to improve. If you are going to give me tools that make me better I will play. If you iliminate the food source the ecology goes away.

There is a peer assessment that is becoming more common. We are getting better at providing better tools to the residents and the GME process.

Bryan

We've been smelling food. There is no assignment but while you eat please think about what we need to do this afternoon.

Scribing

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