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IN 1910, CHARLES H. Mayo, MD, observed that the previous 50 years had been marked by advances in the science of medicine and that the next 50 years would be marked by advances in the organization and coordination of healthcare delivery (paraphrased from the 1910 commencement address to Rush Medical College). Today, more than a hundred years later, Dr. Mayo might well be disappointed to see the level of fragmentation remaining in US health- care. But there is hope. As Molden, Brown, and Griffith report regarding Pied- mont Healthcare (PHC) and Leaver describes for UnityPoint Health, when in- tegrated and coordinated care is a priority, value can be significantly improved.Molden, Brown, and Griffith describe how a partnership between three cardiovascular physician practices and PHC successfully evolved into the fully integrated, physician-run entity Piedmont Heart. That example of single-silo integration can be compared to Leaver's summary of UnityPoint Health's broad effort to coordinate patient care across silos, including its experience as a pio- neer accountable care organization (ACO) and its participation in the Medi- care Shared Savings Program (MSSP) pilot. Both feature articles emphasize the importance of physician leadership and attention to metrics or benchmark targets, though neither identifies specific measures.PIEDMONT HEARTA skeptic might see the development of Piedmont Heart as the fulfillment of cardiovascular physicians' wish to preserve income and PHC's desire to drive volume. Be that as it may, Piedmont Heart's centers-of-excellence design, trunk-and-branch approach to clinical pathways, and Patient First program demonstrate its commitment to patient-centered care and ability to address highly complex medical, logistic, and cultural issues.While the infrastructure being developed at Piedmont Heart is impressive, the organization's progress over the next five years will be interesting to track. The following are among the key questions that need to be answered:* How will quality and safety metrics compare to benchmarks?* How will cost per episode of cardiovascular care compare to benchmarks?* Will population health results be measured and reported with good metrics for quality measures, annual cost of care, and admission and readmission rates?* Will bundling pilots be launched with Medicare, commercial payers, or both?* Will Piedmont Heart and PHC budgets be integrated in a way that yields reliable cost measures and comparisons?* How well will the care of patients with multiple diseases be coordinated with other specialties and clinics?* Will real-time decision support analytics help sustain improvement activities?* Will clinical pathway diffusion greatly improve standardization where appropriate, and will the quality and cost measures show definitively improved value?UNITY POINT HEALTHUnityPoint Health is developing a broad approach to coordinating care. Its efforts to develop physician leadership; focus on complex, high-cost patient populations; initiate the advanced medical team model; implement the nurse call system; focus on emergency room visits; use home care; and develop a single information technology platform are extremely promising initiatives. In addition, the system's early participation in an ACO and the related MS SP helped it to pursue the goal of merging data from insurance claims with its clinical database. The additional data enable clinicians to see how silos affect patient care and clearly illustrate how a patient progresses through the system of care and how chronic disease is managed.Many questions about UnityPoint Health will be answered over the next five years. They include the following:* How will physician relationships evolve across UnityPoint Health's many sites?* Will the system's data analytics reduce variation in quality and cost?* Will the physician leadership program improve the performance and continuity of physician leadership? …

Engaging and integrating physicians has become the veritable "brass ring" for many hospital systems: many attempts and few actual wins. This is especially true in California's managed care environment and for public entities such as Palomar Health in Escondido, California. Our commitment to engage and integrate physicians continues to be a vital element of a larger cultural shift toward delivery of care that puts the patients' needs first. A key determinant of success has been the ability to align a diverse medical staff culture with administrative priorities. This alignment involves a carefully executed strategy and a structure to build a collective identity among diverse players. Palomar Health is in the third year of the journey. Some of the critical milestones have been the implementation of a physician leadership development process, creation of a physician onboarding process to codify the desired physician culture, delineation of roles and expectations for physician leadership, and formalization of dyad and triad partnerships between physicians and their clinical and administrative partners.

Because of its ability to create real incremental value for patients and providers, physician-hospital integration will continue to play a major role in transforming the way healthcare is delivered. Integration is more than a transaction, and without developing the right culture, new integrated organizations will struggle to transform their current model of care. Confronted with regulatory and specialty-specific environmental forces, cardiovascular physicians have integrated with health systems at a higher rate than other specialties have. In 2007, Piedmont Healthcare launched Piedmont Heart as the first integrated cardiovascular care delivery program affiliated with a community healthcare system in greater Atlanta. Piedmont Healthcare had successfully brought together hospitals and cardiovascular physicians in an organizational structure that allowed for the right culture, resulting in true integration and patient-centered care. Today, Piedmont Heart is one of the largest physician groups in the United States focused on delivering high-quality outcomes, aligning multidisciplinary cardiovascular initiatives, and allowing for smart, strategic growth. It has taken Piedmont Heart nearly five years to create new, incremental value from its center-of-excellence organizational structure, clinical pathways development, and Patient First program. Piedmont Heart had the advantage of starting earlier than many other physician-hospital integrated structures. As US healthcare moves from an industry driven by volume to one focused on value, it is organizations like Piedmont Heart that continue to drive smart integration forward and focus on innovation, despite potential disruption, that will be successful.

The need for new venues for physician-hospital collaboration is significant and growing, especially between independent physicians and health systems. Often physicians and hospitals act independently of each other, even though maintaining and sustaining a productive relationship between physicians and hospitals is essential to good patient care and improving the health status of the communities we serve. The tension in physician-hospital relationships is a long-standing and widely acknowledged concern. The old model of hospital-physician relationships, governed by the rules of the organized medical staff structure, doesn't work in the current environment, which has grown increasingly complex as a result of economic, legal, and care-delivery changes. These complexities make relationship management challenging. Hospitals and physicians struggle to align behaviors to achieve cost and quality goals. The need has never been greater for hospitals and physicians to work together as a joint clinical enterprise to improve quality, reduce practice variation, and control the cost of healthcare. This article explores the challenges and some options for improving the physician-hospital relationship in the current environment.

For healthcare organizations (HCOs), successfully partnering with physicians is the strategic imperative. A number of misperceptions and limiting beliefs compromise partnering initiatives. To pursue a more successful approach to partnering, it is important to understand some of the forces that are affecting the healthcare industry. The accelerating pace of change demands that healthcare leaders serve as change agents, evoking resentment from the majority of healthcare stakeholders. Demands for measured accountability and the shift of control from provider to consumer threaten the physician perception as "captain of the ship." Cultural differences between the expert culture of physicians and the affiliative culture of the HCO perpetuate feelings of distrust and compromise efforts to actualize interdependencies. Economic pressures and an unwillingness to make time to engage in dialog prevent the provider community from serving as a creative force in shaping its own future and restrict the ability to build the mutual trust that is necessary for the establishment of successful relationships. Measures that would enhance the likelihood of forming successful and lasting relationships include the following. Adopting an orchestration model would allow a flexible way to bring services to a community. It may be the only way to simultaneously integrate and specialize. Budgeting to reflect service-line functioning would allow the systematic integration of patient care throughput and provide a necessary metric for assessing clinical and operational performance. Segmenting the medical staff would allow the establishment of pluralistic relationships based on shared goals and values and allow change agents to lead to critical mass rather than consensus. Focusing on the customer would ensure relevance in the changing medical marketplace. Adopting a complexity science metaphor rather than continuing in a command-and-control, top-down organizational structure would enhance adaptability and help maximize human capital. Most importantly, forming relationships that center around shared purpose and values will lay the foundation for excellence and sustainability while restoring a sense of meaning, pride, and joy to the healthcare professions.

Many of the issues confronting healthcare organizations require physician involvement and understanding, and the physician executive is a tool to achieving physician participation. Physician leaders can become the mediators between physicians and organizational management, minimizing miscommunication and maximizing agreement and understanding. Yet few doctors seem willing to stand up and speak positively for the plans and proposals that will move the institution forward, and healthcare executives are often frustrated by physician leadership that fails to articulate and implement the vision and objectives of the organization. Understanding physician leadership and exploring the challenges in managing and leading physicians require an understanding of the physician mindset--a completely different mindset than that of the typical healthcare executive. Beginning with a discussion of the unique situation faced by physicians in leadership positions, this article attempts to define the obstacles faced by both the physician and the executive in developing the role of physician executive. After reviewing the opportunities open to physician executives for improving leadership ability, the author presents the essential characteristics and core skills for effective leadership. The second half of the article suggests ways in which an organization can reemphasize physician leadership development within an organization from selection of potential candidates to creating training and networking opportunities and offering appropriate incentives.

Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.

Today's successful community hospitals should and will evolve into integrated health care organizations (IHCOs) that will share several common characteristics. IHCOs will have a community--not a membership--orientation, and this will be a distinguishing characteristic and a source of market appeal. The transition to IHCO will be a slow one, and to prosper, the IHCO will have to accommodate both price-oriented markets and traditional ones. Successful IHCOs will expand technical skills and capabilities to control costs and quality. New strategic competencies will have to be developed, and to do this, emerging IHCOs will improve the ability of managers to support decisions and sell them both to the buyers and the public at large. Excellent patient care will rest upon better trained, advised, and informed management teams. Making the change to an IHCO will take time and money, but organizations that make steady progress are likely to succeed.