At a Glance

  • Finance and clinical leaders should ensure that the appropriate stakeholders are part of planning the “how”
  • Clinicians should be included in strategy and decision making.
  • Inclusion can help leaders make decisions that best serve patients.

At a recent conference, I overheard three 30-something physicians discussing the changes occurring in our healthcare system. They were not pleased.

“What ticks me off,” said one, “is that 60-year-olds are deciding the future models of care without asking us how we want to practice medicine. We’re the ones who will have to work for the next 30 years, and we don’t even have a seat at the table.”

His companions were quick to agree. The three physicians—two emergency department (ED) physicians and an internist—then embarked on a lively discussion about how the older generation is not including them in efforts to redesign the healthcare system.

These young professionals aren’t the first group to feel excluded from setting strategy or planning tactics for the next era, which will involve clinical (and, in some cases, financial) integration among providers. Colleagues from long-term care and home health organizations complain that executives in acute care are planning the continuum of care without including them in the discussions. Ambulatory clinic leaders (including physicians of all ages) do the same. Nurses repeatedly inform me that they cannot comprehend why nonclinician executives and physicians seem to be partnering to determine what nurses will do in the future, without any input from nursing leaders. At the same time, pharmacists, social workers, and dietitians complain that nurses are planning team-based care models without consulting them.

The bottom line is that many of the key players in health care perceive that they aren’t being invited to the decision-making table. This situation is dangerous because it could affect the success of our changes down the road.

Making the Case for Change

Change theorists have different views on what drives successful change, but many agree that change is less difficult when stakeholders understand why change is occurring and have a voice in how change is implemented.

Most of us understand the primary reasons behind the transformation of our healthcare system. The quality of care in the United States, as measured by life expectancy, places us 34th among developed countries. Other measures of quality indicate that the United States has “not seen the scale of improvements in health outcomes enjoyed by most other developed countries, despite having spent increasing amounts of its economy on healthcare services.”

Specifically, the portion of the gross domestic product consumed by health care is now 17.9 percent and is projected to grow. A recent report issued by the Institute of Medicine notes, “America’s healthcare system has become far too complex and costly to continue business as usual.”b And according to the Kaiser Commission on Medicaid and the Uninsured, 48 million Americans don’t have healthcare coverage, and approximately one-fourth of these individuals go without needed care because of its cost.c

If these are the primary drivers of change, there are secondary factors as well. In addition to national reform efforts launched by the Affordable Care Act, changes at the state level (such as health insurance exchanges and the expansion of Medicaid) also are spurring shifts in care delivery. At the heart of many national and state reform efforts are changes in how healthcare providers are paid for their services, with an emphasis on value rather than volume.

Whether these efforts succeed will depend on how well healthcare leaders have engaged their fellow stakeholders (from employees to physicians to the communities they serve) and have informed stakeholders of the primary and secondary reasons for change—the “why” of change. Success will also depend on whom they invite to sit at the table to help achieve the big “how” of healthcare delivery transformation, which involves determining strategy and operationalizing change.

Deciding on Your Tablemates

A number of key questions can help determine who should sit at the table when driving change, whether the table is set for strategic or operational planning. First, leaders should ask three questions: 

  • Who will be expected to lead the change?
  • Who will have new job descriptions, work processes, work priorities, workflows, or work relationships as a result of the change?
  • Who has expertise in today’s work models (including the best and worst of the current models)?

Asking such questions has helped several Catholic Health Initiatives (CHI) hospitals and health systems invite the right people to the table. For example, TriHealth of Greater Cincinnati has determined that physicians need to be at the strategy table as the system prepares for the second curve of health care. President and CEO John Prout worked with the medical staff to establish a physician strategy council to serve as an advisory body that provides input to the board of directors on the organization’s strategic direction. This council is in addition to the physician management council, in which employed physicians offer feedback on operations, quality improvement, managed care, and network policies that affect their practices.

Another hospital that is relying on multidisciplinary input to implement change is Mercy Medical Center in Des Moines, Iowa. To reduce wait times in the ED for patients with less acute conditions, leaders at Mercy convened a multidisciplinary group, including physicians, nurses, other clinicians, revenue cycle experts, and clerical staff. The group designed a split flow process in the ED, in which patients whose conditions are seen to be less acute are directed to a separate area to receive evaluation and treatment, thereby reserving ED beds for patients whose conditions are more acute. So far, this strategy has been successful: The number of patients who leave the ED without being seen has dropped from 4 percent to 0.4 percent under the new model. These changes were spurred by input from members of Mercy’s patient and family advisory committee. It is a CHI standard that all hospitals have such a committee.

One additional key question can help leaders identify key individuals—rather than groups of professionals—to invite to the decision-making table: Who comes to mind as being a “different” kind of thinker—as being innovative and visionary?

This individual does not need to be part of the group leaders, experts, and other people who will operationalize the change. The goal should be to identify forward-thinking people who are not emotionally invested in traditional ways of doing things—and these people often will be “outsiders.” Such individuals can bring a fresh perspective to the table, even if their main contribution is to challenge the status quo. For example, a few years ago, the CHI board of trustees’ quality and safety committee added an airline pilot to offer a new perspective to their group.

Identifying Gaps on the Team

When initial tablemates are determined from the answers to these questions, there are a few more to ask: Who is not on this guest list? Who are we forgetting? Is our group of stakeholders diverse, representing different professions and demographics? Asking these types of questions can help identify missing viewpoints or experiences that would help leaders make better future-oriented decisions.

In 2012, we asked these questions at CHI. We realized that a lack of integrated decision making was leading to duplicated work efforts in some areas. (We found, for example, that leaders in clinical services and purchasing services had been working separately on ideas for reducing supply costs.) In addition, our leaders were often working in silos by sticking with their own clinical groups when it came to strategy. To remedy this problem, CHI’s clinical leadership council, the governing body for systemwide clinical decisions, added nonclinicians who are heavily invested in such strategic decisions. Among the new voting representatives on the council are a CFO, a COO, a CEO, and a materials management leader. So far, this change has resulted in improved decisions about systemwide clinical leader job descriptions and methods of change management across CHI clinical practices, and in greater consideration of the balance needed between costs and quality when systemwide changes are made to clinical practices.

Sometimes, the question of who should be at the integration table is not easily answered. That said, it is important that leaders avoid getting mired in traditional perceptions and definitions of clinically integrated delivery systems. For example, federal government agencies, in an attempt to define relationships that can make health care less fragmented but not violate anticompetitive policies under antitrust law, have determined that clinically integrated delivery systems are networks of collaborating physicians and hospitals.d Although that definition serves a legal purpose, it is rather limiting when it comes to strategy.

Just ask patients: They recognize that clinically integrated delivery systems involve more than hospitals and physicians. Many understand that such systems include home health, long-term care, and others. To develop models of the future without full participation of these players is short sighted and certainly does not put the users of health care at the center of decision making.

Serving the Patient

As we prepare for the changes ahead, all of us should question our own perceptions about who should be at the decision-making table. Many of our systems now recognize that physicians cannot speak for nurses any more than nurses can speak for respiratory therapists, pharmacists, dietitians, and others. To design the most value-added models of care, we will need input from experts at every level.

Make no mistake: The need for inclusion is not about respect or empowerment alone. Ultimately, it is about our responsibility to make the best decisions to serve patients, now and in the future. It is a shared accountability, so we all have a personal stake in having the table well set for the appropriate guests.

This point brings me back to the young physicians I overhead at the conference. In hindsight, I wished I had told them: “If you feel excluded from the table, ask yourself, what have you done to get to that table? You have to be passionate about what you can contribute. Then, once you are there, I hope you have a clear answer to a very important question: Who is it you intend to serve?”

Kathleen D. Sanford, RN, DBA, MBA, MA, FACHE, is senior vice president and chief nursing officer, Catholic Health Initiatives, Denver, and a member of HFMA’s Colorado Chapter (


a. Bezruchka, S., “The Hurrider I Go the Behinder I Get: The Deteriorating International Ranking of U.S. Health Status,” Annual Review of Public Health, April 2012

b. Committeee on the Learning Health Care System in America, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, Smith, M., Saunders, R., Stuckhardt, L., and McGinnis, J.M., editors, Institute of Medicine, Sept. 6, 2012.

c. “Five Facts About the Uninsured Population,” Issue Brief, Kaiser Commission on Medicaid and the Uninsured, Sept. 14, 2012.

d. “Statement 8: Enforcement Policy on Physician Network Joint Ventures,” U.S. Department of Justice and Federal Trade Commission, revised August 1996 (web page updated July 8, 2009).

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