Brandeis University Heller Leadership Program in Health Policy and Management provides an education on the business side of surgery

Until the 1990s, physician leaders were primarily self-taught managers, honing leadership skills as part of their daily responsibilities, according to Jon Chilingerian, PhD, health care management professor and founding program director at Brandeis University, Waltham, MA. “When I studied physicians who became managers and hospital chief executives as part of my doctoral dissertation at MIT [Massachusetts Institute of Technology, Cambridge], most clinicians learned how to manage while on the job,” Dr. Chilingerian said. “Clinicians were tapped for high-level leadership roles because they got along with people and because they built a successful clinical department that generated revenues. Gradually, as opportunities and challenges arose [during the course of their careers], these physician leaders would learn about corporate strategy, conflict resolution, and interpreting financial statements,” he explained.

Today, delivering safe, efficient, high-quality care requires a broad range of conceptual, technical, analytical, and leadership skills that physicians can no longer master on their own, according to Dr. Chilingerian. To respond to the need for health care professionals to develop a more sophisticated business and health policy acumen, Dr. Chilingerian helped establish the Heller Leadership Program in Health Policy and Management at Brandeis. This program offers surgeons intensive training in change management, conflict negotiation, financial literacy skills, and health care policy development.

Originally presented at Brandeis’ Heller School for Social Policy and Management, this annual six-day program provides surgeon leaders with the opportunity to participate in simulation exercises emphasizing effective leadership skills and to review case studies highlighting current national health policy issues.^1,2

The American College of Surgeons (ACS) has partnered with 16 surgical specialty groups to help design the course and award scholarships to surgeons who are ACS Fellows and members in good standing of these organizations.³ At press time, more than 200 clinicians have graduated from the Heller Leadership Program. In this article, four graduates of the program describe how the course influenced their role as surgeon leaders.

Robert R. Lorenz, MD, MBA, FACS

ACS/American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Health Policy Scholar

“Brandeis is known for [its] approach to alternative payment models, and I wanted to figure out how I could be of assistance to the College in developing these models,” Dr. Lorenz said, medical director, payment reform, risk, and contracting, Cleveland Clinic, OH. “This course was my first exposure, in a comprehensive way, to the history of health care insurance payment and [Centers for Medicare & Medicaid Services] payment methodology, and I found this quite helpful for understanding where we can go in the future.”

As both a member of the ACS Health Policy and Advocacy Group and the current co-chair of the AAO-HNS physician payment policy workgroup, Dr. Lorenz was engaged in health care policy development before attending the course in 2013.⁴ By participating in the program, however, Dr. Lorenz acquired essential leadership skills to advocate for his colleagues to embrace alternative payment models.

“A lot of these models are voluntary, and you have to be able to move physicians from their comfort zone, which is fee for service, toward some kind of risk-based payment format,” Dr. Lorenz said. “In order to do that, you have to do a lot of convincing—not just one or two people—but you have to convince a body of professionals. That’s not just the president or director of an organization, but it is also key opinion leaders throughout the organization.” According to Dr. Lorenz, Change Pro—the learning tool employed by the Heller Leadership Program—was particularly helpful toward this end.

The Change Pro simulation involves physicians working in small groups with 120 “days” to convince 24 members of an organization’s top management team to adopt a Six Sigma quality improvement system.⁵ The goal is to get as many adopters as possible, even if participants have no formal authority in the organization. “There is official influence and unofficial influence, and the ability to understand and really leverage all those different roles was highlighted in the simulation. I had never been exposed to this concept before taking this course,” Dr. Lorenz said.

The Heller Leadership Program attracts a mélange of health care professionals, including private practitioners, academics, front-line surgeons not yet in leadership positions, as well as seasoned surgical leaders, according to Dr. Lorenz. The mix also includes good subspecialty representation. “There was a tremendous amount of learning over meals and after hours where people talked about their own challenges within their subspecialty and within their organization. I don’t know of any other venues where that happens as efficiently as it did through this course.”

Dr. Lorenz said when the AAO-HNS introduces a policy on a national or regional level, he taps fellow Heller scholars for feedback. “I will make contact with this network and say, ‘What are you doing in Texas?’ or ‘How is this going in Florida?’”

He suggested surgeons new to health policy development keep in mind that “advocacy is a marathon and not a sprint,” and that there are likely to be more losses than wins. “Just because one initiative does not meet with success, don’t let it dissuade you. You are in it for the long term, and right now it is awkward. We are getting paid for volume, but in an era in which we are going to take on risk for disease prevention and hospitalization readmission prevention, we’re going to be in alternative payment models that will be specifically in contradiction to fee for service. It is our professional responsibility to preserve the quality of care while managing this transition as best we are able. Our advocacy efforts need to keep the patient and patient care as its North Star, and if we can accomplish that, we’ll ultimately be successful in the evolution of health care delivery.”

John Maa, MD, FACS

ACS Health Policy Scholarship for General Surgeons

After attending the Heller Leadership Program in 2009, Dr. Maa participated in more than 100 Capitol Hill visits during a yearlong health policy sabbatical, which included a six-month tenure in the College’s Washington, DC, office.

“In May of 2010, I arrived in the DC office to bring the surgical perspective to the front lines of policymaking. The value to the DC ACS staff was to have a surgeon who could share the practicing surgeon’s insights into proposed legislation,” Dr. Maa said, Immediate Past-President of the ACS Northern California Chapter and chair, University of California (UC) Office of the President Tobacco-Related Disease Research Program Scientific Advisory Committee. “We worked on a number of projects, including the pediatric loan repayment program, the general surgery rural care bonus, and—the issue I became most involved with—scope of practice regarding optometrists and ophthalmologists.”

Before the Heller course, Dr. Maa was not involved in public policy, focusing more on surgical program development, specifically the surgical hospitalist program at UC San Francisco Medical Center—an innovative approach to the delivery of emergency surgical care. After being encouraged to pursue the fellowship by his mentor, former ACS Executive Director Thomas R. Russell, MD, FACS, Dr. Maa applied for the fellowship five consecutive times.

“I believed that the Brandeis course would foster a deeper understanding of health policy outside of the surgical arena and operating room [OR],” Dr. Maa said. “The course leaders are nationally recognized, with significant experience in Washington, DC, and I believed they would be excellent teachers and mentors.”

The Heller Leadership Program provided Dr. Maa with successful strategies for managing health care teams outside of the OR and the skills to make complex management decisions with limited information.

“In the OR, you’re making vital decisions for a single patient, but as a surgeon leader, your decisions can affect many more individuals simultaneously,” Dr. Maa said. “An exercise that Dr. Chilingerian led was a theoretical business case modeled after the Challenger Space Shuttle disaster that highlighted the steps and decisions that contributed to the tragic outcome on that day. Taught in the business school style, the activity illustrated how to manage a negative outcome and how to determine what went wrong. We explored the decision-making process involved in terminating a project and issuing the press release.

“The exercise underscored that when a surgeon moves beyond the OR and seeks to make larger policy decisions, the input and perspectives of many different people are required. Ultimately, however, there will be an executive who is responsible and accountable for the endeavor,” said Dr. Maa. “Being involved in leadership, catalyzing change, and working in advocacy, public policy, and politics are essential to the future success of the fields of medicine and surgery,” he added. “The skill sets required are different from those that produce success in the OR.”

Another important component of the course, according to Dr. Maa, was an overview of the history of health care economics in the U.S. and the competencies necessary to understand financial reports.

“The program taught me to be thoughtful and analytical in interpreting the economic reports that are being presented to you. First, surgeons should understand how these reports are prepared and their format—and have a basic understanding of accounting principles. It’s similar to interpreting an operative record—surgeons understand the blood pressure and heart rate information that is communicated in the anesthesiologist’s notes. Similarly, for health economic reports, surgeons should have a basic understanding of concepts such as net assets, liabilities, and profit margins, though it’s foreign to us. They don’t really teach this in medical school or residency,” Dr. Maa explained.

In his role at the UC Office of the President Tobacco-Related Disease Research Program, Dr. Maa helps oversee the statewide tobacco tax grant funds collected via Proposition 99. “We fund the tobacco control research, epidemiology, and educational programs across the state of California. It is a very different world from the OR. Our meeting proceedings are recorded, and the work is overseen by attorneys. We carefully evaluate laws and provide scientific feedback, which involves leading multidisciplinary teams, having a long-range time frame, and carefully analyzing budgets.”

“Most importantly, what I’ve learned both through the Heller course and through my time in DC is the [value] of time and patience. Progress in the public policy arena involves a lengthy time frame. In the OR, events happen quickly. When a surgeon needs something and requests it, the expectation is that it will be available immediately to save the patient’s life. In the public policy world, success requires substantially more time, as it can take years for cases to be reviewed and for laws to be passed,” Dr. Maa said.

For surgeons new to the public policy arena, Dr. Maa said, learning to communicate with the public is key. “When you speak to Congress and to the general public, or when you write letters or editorials, learn to be concise and to write in a language that the general public can comprehend,” Dr. Maa advised. “You have to also learn to communicate with policymakers—many of whom are lawyers—in their language that is different from the vocabulary of surgery, if your intent is for them to respond to you.”

Patricia L. Roberts, MD, FACS

ACS/American Society of Colon and Rectal Surgeons Health Policy Scholarship

“As surgeons we often have a ‘command and control’ approach to leadership,” said Dr. Roberts, chair, division of surgery, Lahey Hospital and Medical Center (LHMC), Burlington, MA. “However, successful leadership in 2015 increasingly involves the ability to negotiate, build consensus, and work in teams.” Dr. Roberts’ experience as a 2008 health policy scholar enhanced her ability to lead a number of initiatives, including the restructuring of perioperative services at LHMC in 2012.

As a result of the restructuring initiative, the OR is managed by an executive team that Dr. Roberts chairs. The team uses a shared governance model that includes the chair of the department of anesthesia, the associate chief nursing officer for perioperative services, and the vice-president of surgical services. This group has implemented a number of processes that have enhanced OR throughput, including improved start time and turnover time, according to Dr. Roberts.

“I think every team has its own character,” Dr. Roberts said. “You don’t have to be best friends with everyone on the team, but you do have to respect each other and communicate clearly and effectively. All team members should [have the freedom] to bring issues to the group, engage in frank and open discussions, and be able to reach an agreement and support each other.”

As chair of surgery, Dr. Roberts currently leads more than 100 surgeons who perform an estimated 22,000 operations a year, and mentoring future surgical leaders is a large component of this role. “On a personal level, the [Heller] program gave me greater insight into my leadership style and the need to identify and develop the next generation of leaders in the department,” Dr. Roberts said.⁶ In 2010 she received the Mentor Award from the Young Researchers Committee of the American Society of Colon and Rectal Surgeons Research Foundation. And in 2013, Dr. Roberts presented the keynote address at the 2013 Olga Jonasson Symposium at the University of Illinois, Chicago, on the topic of leadership challenges for the next generation of surgeon leaders.

Leadership, strategic thinking, and negotiation skills are essential for surgeon leaders, according to Dr. Roberts. “I also think emotional intelligence is key to effectively working with people, particularly one’s ability to work in teams. In today’s health care environment, it is increasingly less about the single surgeon and more about the dozens of member of the health care team and the ability to work together,” she said.

Steven D. Schwaitzberg, MD, FACS

ACS Health Policy Scholarship for General Surgeons

“What I learned from Jon Chilingerian is that there is a science to change management,” said Dr. Schwaitzberg, professor of surgery, Harvard Medical School; chief of surgery, Cambridge Health Alliance, MA; and past-president, Society of American Gastrointestinal and Endoscopic Surgeons. “Doctors are very smart people. We think we know everything, but what I took from this [program] is that if you want to lead change, you have to study change.”

A 2010 health policy scholar, Dr. Schwaitzberg was working on an initiative that year to bring the surgical checklist into the OR. “We were having trouble. I wouldn’t say it was going badly, but it clearly wasn’t going well. After taking the course, I realized I had gone about this change management effort at my own hospital without the best processes in place. Jon taught us to define barriers, find the connectors to the barriers, and identify potential champions, and this allowed us to completely reboot how we were trying to implement the checklist. Using these techniques, we completely renovated our approach to getting buy-in to the checklist. It’s 2015, and everybody uses the checklist now, but in 2010 it was a big change,” Dr. Schwaitzberg noted.

Overcoming resistance to change through an understanding of social dynamics is a fundamental component of the Change Pro simulation mentioned earlier in this article and was a particularly meaningful experience for Dr. Schwaitzberg.

“Change Pro was amazing. What you learn is that you can’t just walk into the [chief executive officer’s] office and mandate [the implementation of a new initiative] across the company,” he said. “You have to find who the influencers are and identify the connections and the barriers. In this simulation, you learn a lot about each division’s leader, their characteristics, and who they are connected with. You learn about the formal network structure and the informal network structure—both of which are important to leading change.”

Resolving differences is typically an integral part of successful change management. Individual attitudes regarding a new process can facilitate, slow down, or erode the diffusion of, for example, a clinical idea or new medical technology.

“When we adopted the in-patient electronic medical record, there was a lot of distrust, discouragement, and unrest. The process of leading the department through this change involved conflict resolution and identifying who was going to have a problem with this—and who will love this? Who will influence change? The tools as outlined by the Heller program have become a part of the way we do business on a daily basis,” Dr. Schwaitzberg said.

Another example of staff unrest that can occur in any health care system is the arrival of a new chief of surgery. “One of the hardest things for a new chief is to learn how to deal with conflict,” Dr. Schwaitzberg said. “A new chief comes into an organization—particularly if they come in from the outside—and he or she has to deal with many people who are well entrenched in their institution and who may have seen their fair share of chiefs come and go. Most people are a pleasure and a breeze, but there will be a small percentage who have not jumped onto your vision or have set up their own little fiefdom. Learning to deal with those challenges requires training and reinforcement. The goal is to lead people, which is very different than simply being in charge.”

Conflict resolution, according to Dr. Schwaitzberg, is about persuasion and reason, and these skills are not necessarily taught in residency and medical school. “If young surgeons want to be effective change agents in their environment, big or small, the study of leadership and change is a good investment of their time,” he explained.

In addition to change management and conflict resolution instruction, the Heller Leadership Program’s focus on advocacy and health care policy were especially germane to Dr. Schwaitzberg as the leader of one of the last publicly funded hospitals in Massachusetts.

“How the legislature makes public policy has a dramatic impact on publicly funded hospitals, so I was interested in the Heller program,” Dr. Schwaitzberg said. “I knew these policies impacted the hospital’s ability to even stay open. I actually applied for the scholarship twice. The first time I wrote about what I thought the scholarship would do for me, and I didn’t get it. The second time I wrote about issues I thought were important in public policy, and that obviously resonated much better with the review group.”

Dr. Schwaitzberg suggested the development of a follow-up to the Heller Leadership Program—a course available specifically to Heller course graduates featuring advanced study in the areas of change management, conflict resolution, and advocacy.

“Leading change effectively requires an investment to study the process, and one of the great things about the Heller course is that it gives you the opportunity to engage in the kind of deep thinking that we rarely have time for in our daily lives,” Dr. Schwaitzberg noted.

Next level of specialized education

Successful surgeon leaders understand the complexities involved in managing change, negotiating and resolving conflict, and assisting the College and other organizations with health policy and advocacy activities. Specialized education through the Heller Leadership Program is a proven way to develop surgeon leaders and enhance this leadership skill set.

For graduates of this program seeking an advanced level of training in health care management, as well as other physicians interested in this topic, Brandeis University is developing The Heller School’s Executive Master of Business Administration (EMBA) for Physicians.⁷ The program, which admits its first cohort in January 2016, is designed for practicing physicians who are currently in management positions and for those who are interested in pursuing these roles, according to Dr. Chilingerian. The EMBA for Physicians is an accelerated 16-month program that integrates the student’s medical expertise with training in areas ranging from health policy and economics to operational systems management, high-performance leadership, and health care innovation.

For more information visit the Heller Leadership Program in Health Policy and Management and The Heller School’s EMBA for Physicians program.

---

References

1. Brandeis University. The Heller School for Social Policy and Management. Leadership Program for Health Policy and Management. Available at: http://heller.brandeis.edu/executive-education/programs/leadership-hpm.html. Accessed February 27, 2015.
2. Steinberg SM, Zinner MJ, Ellison EC. Health policy program produces surgeon advocates and leaders. Bull Am Coll Surg. 2014;99(3):21-27. Available at: bulletin.facs.org/2014/03/health-policy-program/. Accessed February 27, 2015.
3. American College of Surgeons. Member services. Past health policy scholarship awardees. Available at: www.facs.org/member-services/scholarships/health-policy/past-hp-winners. Accessed February 27, 2015.
4. Cleveland Clinic. Resources for medical professionals. Robert Lorenz, MD. Available at: http://my.clevelandclinic.org/staff_directory/staff_display?doctorid=4447. Accessed February 27, 2015.
5. Brandeis University. The Heller School for Social Policy and Management. Leading change in complex systems: A simulation. Available at: http://heller.brandeis.edu/executive-education/pdfs/May2014MassMed/JON702/JON702AALeadingChangeinComplexSystems1.pdf.
   Accessed February 27, 2015.
6. The American Society of Colon and Rectal Surgeons. ASCRS News. Spring 2009. Available at: www.fascrsnews.org/issues/2009Spring.pdf. Accessed February 27, 2015.
7. Brandeis University. The Heller executive education program. Available at: http://heller.brandeis.edu/executive-education/physicians-emba/index.html. Accessed March 23, 2015.