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Alignment Theory

Mention the concept of "alignment," and the phrase "buzzword du jour" might come to mind. Behind the jargon, though, lies an imperative discussion of critical issues.

Driven by the panoply of challenges that health care faces, alignment focuses on how the component parts of academic medicine can work together more efficiently, productively, cohesively, and collaboratively. The end goal is to better serve academic medicine's many constituencies including patients' needs for better health care.

Definitions of alignment differ. One way to the heart of the concept is to list characteristics of academic medical centers that are out of alignment. As AAMC President and CEO Darrell G. Kirch, M.D., observed last October, these might include "fragmented decision making [and] departments working at cross purposes with one another financially or programmatically." Other signs are when institutional goals are not widely shared across units or when there is little transparency in information sharing.

Getting to alignment is part structure, part process, part leadership, and part organizational culture. It means reshaping administrative practices, such as how revenues flow and incentives are awarded, to help units work together productively. But alignment also means changing workplace cultures to promote goal sharing, more openness in decision making, and broader collaboration overall.

The AAMC delved into some of these issues in a discussion held last September with 30 institutional leaders from academic medicine. The conversation was summarized in the AAMC report, "Integrative Leadership: Critical Conversations for Changing Times." The AAMC is also pilot-testing an institutional selfassessment that includes a series of qualitative questions related to alignment.

"We spend a lot of time visiting institutions, and that's the number-one thing they want to know who has changed how they do business to be more integrated and what alignment looks like in practice," said Joanne Conroy, M.D., AAMC's chief health care officer.

Virtual alignment

The challenge for Lilly Marks, senior associate dean for administration and finance at the University of Colorado School of Medicine, is to align four entities a medical school, two hospitals, and a practice plan. Because the four components have distinct governance restrictions, some set by legislation, Marks strives for what she calls virtual alignment.

To the extent possible given existing structural constraints, she works to create systems of shared bottom lines, mutual decision making, and cross-institutional revenue flows.

Given that structural changes are generally not an option, Marks says alignment at Colorado tends to come from agreements worked out personally between individual executives who manage the different entities. That has led, for example, to some joint strategic planning and to the creation of "clinical enterprise" committees whose members and responsibilities crosscut Colorado's four units. The committees try to prioritize programming and investment in ways that best serve mutual interests of the different components. "It really is a question of what we can jointly venture or mutually support," Marks said.

Where possible, joint management can also help Marks herself, for example, serves both as chief financial officer of the school of medicine and as executive director of the practice plan.

Marks believes that the intense financial pressures that permeate health care today highlight the interdependence of units.

"The practical reality is that without every component being successful, none of them will ultimately be successful," she said. "We have to keep finding ways to be more collaborative, efficient, and effective."

Edward D. Miller, M.D., dean of the school of medicine at Johns Hopkins University, was hired with alignment in mind. He was appointed in 1997 to be the first CEO of Johns Hopkins Medicine, an organization that formally integrates operations and planning in the medical school with the Johns Hopkins Health System and Hospital.

At a basic level, Miller sees alignment as getting physicians and hospitals working toward common goals and creating scenarios where all parties win more or less equally. To that end, he views part of his role as CEO as presenting "a balanced view of the concerns of the hospital and health system and the concerns of the faculty in the school of medicine, and how that relates to the university."

He also pushes all parties to work collaboratively in deciding priorities for Johns Hopkins Medicine as a whole.

"The biggest thing we have done is to plan effectively," Miller said.

Miller said he tries to help people from different corners of the Hopkins medical system to see that if people collaborate across units and achieve profitability, "then those profits can then come back to make it easier for you to do your job and for the hospital to be more efficient."

Few secrets

Miller nurtures a culture where information is shared rather than hoarded. He has worked, for example, to make financial numbers and decision making more public. Hopkins restructured its clinical practice operations, for example, putting departments under a central board of governors a system that is "very open," Miller said, "with very few secrets."

Miller opened doors for better transparency through key appointments of top-level staff. As section chairs and directors completed their terms, for example, Miller and colleagues carefully selected new people who could plan effectively together. The recruitment process, Miller said, has been effective in screening out individuals who may not have shared Hopkins's vision for collaboration.

Miller takes pride in knowing as much about Hopkins's hospital's operations as the hospital's president knows about operations inside the medical school. "He can finish my sentences, and vice versa," Miller said.

Miller has also worked to establish and support a culture where parties respect each other even if they disagree. "If you don't attack that head on," he said, "you can't move forward."

Ralph W. Muller, CEO of the University of Pennsylvania Health System, defines alignment as advancing the multiple missions of academic medicine in a complementary way, "so that better patient care, better research, and better teaching all go hand in hand."

Variety of tools

Muller uses a variety of tools to help foster alignment at Penn. Like Miller, he leverages recruiting to find staff who show a propensity for teamwork.

In addition, Muller said, coaching and training of staff at all levels can help employees see how their work contributes to the system beyond their department or specific role. Typically, he said, staff advance in academic medicine through such channels as teaching, research, or administration, "but they haven't been coached or taught that well across those missions." Training can fill those gaps, he suggests, serving as another tool to help orient the culture toward alignment and integration.

"We're constantly figuring out how to get people to act in concert, and do it through common incentives and performance criteria rather than directives," Muller said. Many of the top leaders across the Penn system including Muller himself and department heads have incentive packages that intentionally support crosssystem goals, including patient care outcomes and patient satisfaction, research objectives, and educational outcomes. The incentives encourage the managerial team to advance an integrated approach to missions across the system.

"We're all measured by common metrics and how well we advance those purposes," Muller said.

Muller also uses organizational structure to promote alignment. Penn helps individual staff members align with teams that incorporate experts from across units to focus on a specific area, such as cancer, neuroscience, the heart, or children's care.

"Having people feel they are part of a team that is identified with a specific patient cohort is another way of changing the culture" to promote alignment, Muller said.

Penn also uses budgeting as a lever. Resources can be allocated, Muller said, so that funds flow in ways that support cohesiveness and cooperation across research, patient care, and teaching.

Muller believes that academic medicine needs to practice alignment continuously, not just in periodic staff meetings.

"The activities of everyday management show how deeply you are committed to these complementary processes," he said. "We have to focus constantly on how to bring [units] together toward common purposes. You have to do that in every meeting you attend, every day."

By Stephen G. Pelletier, special to the Reporter