One of the wonderful privileges of being a guest blogger on Hospital Impact is that any time I need inspiration, I have always been able to find it in someone else's posts. So it was with Christopher Cornue's insightful, "Where did all the strategists go?"

Chris makes the point that as a result of the recession, people who plan strategy have become an endangered species, as hospitals focus on cost-containment and daily survival. His comments have prompted me to tell my own story. Like a news reporter who warns the audience before showing graphic footage, I apologize ahead of time to anyone who finds the edgy content or language offensive.

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In retrospect, I was guilty of the same hubris that prompted many of my colleagues to boast earlier that healthcare was recession-proof. I had never been busier speaking and consulting on physician-hospital relations than during the first quarter of 2009 and angered the gods by telling my wife three months ago, "I think that 2009 may be my best year yet."

In April, my business comet crashed through the atmosphere in a fiery blaze as one client "postponed" an oncology practice merger when one of the groups went bankrupt and a CEO vetoed a planned speaking engagement in favor of an internal speaker whom he did not plan to pay. I had been categorized "discretionary expense."

In contrast to the Elizabeth Kubler-Ross model, I bypassed denial and went straight to anger as I talked with a colleague in Tennessee who was kindly helping me improve a column on physician recruiting and contracting published recently in the Journal of Healthcare Management. He related that his 13-hospital system was in hunker-down mode for the next two years. "Do you mean to tell me that if the orthopedists and/or neurosurgeons decided to contract with an outside vendor to establish an ambulatory surgical center, people would say, 'So be the will of God?'" He laughed and said, "No, we just go from crisis to crisis, spending as little as we can to plug holes in the levee."

I do not know how many steps are in my ultimate plan, but my first step was to admit that I did not have the answers. In retrospect, I have been fortunate that this recession is the first one that limited demand for my services. I have no prior experience to call upon.

I made up a survey for my final Journal of Healthcare Management column on innovation in the face of recession and asked senior healthcare leaders what they were experiencing, what was helping, what was not helpful, and if I were a genie, what three wishes would they want me to grant.

I hired a coach who motivated me to do activities that I had avoided previously, like calling people. It is so much safer to use email. I had even convinced myself that email was a more efficient use of my limited time. When I work in isolation, I can convince myself of anything. At the end of these telephone interviews, I asked senior healthcare leaders what they thought I should do. They unanimously offered a two-part strategy:

• In the short term (next three months): Ride it out, earn income any way you can, and don't waste a lot of time trying to reason with people who live in fear.
• In the medium term (next year): Keep doing what you are doing to help physicians and community hospitals make sense of what is happening, offering practical strategies to deal with widespread disruptive changes.

In the short term, I hired a publicist who booked 21 radio interviews and one TV interview. I led with "healthcare's hidden drain," that we could save money if physicians and hospital leaders worked more interdependently and discussed 10 steps that we can take now to improve communication and collaboration.

I revised my ACHE seminar "Practical Strategies for Engaging Physicians" to include more information on how to engage physicians to cut costs and improve clinical outcomes, and how hospital leaders could support employed physicians without alienating independent physicians. To celebrate the courage of hospital leaders who continue to invest in their education and networking with colleagues, I am offering for the first time a lawyer-proof guarantee whereby I provide free consultation to anyone who does not achieve a hundred-fold return on their seminar fee in terms of decreased expenses and increased revenues within one to two years. It is my way of influencing events over which I have little control.

In the long term, I feel blessed that I can still work as a general surgeon in New Hampshire, Vermont and Maine, where I can reconnect with the feelings that attracted me to healthcare in a previous century. This unexpected time off from the speaking and consulting circuit has given me time to plan a talk that I will give September 13 of this year on Transitioning to Non-Clinical Careers and to develop a website, http://thedoctorpreneur.com in support of aspiring physician entrepreneurs like me.

As a result of my recent night journey, this year may be my best yet. A mentor confided, "Change feels like failure when we are in the middle of it," something that achievement-oriented professionals like me are programmed to resist. I have learned, as Christopher Cornue alluded that:

• We all face danger of extinction in this troubled economy.
• Making oneself indispensable requires active, ongoing effort.
• Email alone is insufficient for staying in touch with a rapidly changing marketplace.
• Pain can be a powerful motivator.
• Daily exercise boosts serotonin and can keep depression manageable.
• Forcing myself to write down three things for which I am grateful every night helps me keep my present helplessness in perspective.
• I can permit myself to grieve (briefly); as a colleague advised, "It's OK to visit pity city as long as you don't live there."
• More importantly, I can reward myself at the time and place of my choosing, which has helped the local ice cream parlor thrive despite difficult times.
• I can be in touch with the majority of my body composition that is liquid and flow in occasionally different directions when a customary route is dammed.
• In "The Question Behind the Question", John Miller points out that the only question that matters does not begin with "who" or "why," but "what can I do?" or "how can I help?"; perhaps my experience is teaching me to substitute "I" for "they" when I form the words, "If only...."

What do you think?

• Have current events prompted you to feel like an endangered species?
• How have you dealt with those feelings?
• What have you found helpful?

We are all in this together. Please send me your input.

Ken is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching and consulting on physician-hospital relations. Learn more about what he does by visiting http://healthcarecollaboration.com.

Over the past several months, I've noticed a significant shortage of a very important role in hospitals--that of the strategist or planner. These are the folks that understand the market dynamics, the new innovative approaches to care, niches that may exist for evolving technology and are able to collaborate with leadership to develop a vision for the organization's future.

I believe this type of individual is absolutely necessary for the success of an organization, especially during this "economic downturn"--what better way for a hospital to stay ahead of their competition and leverage ripe opportunities for growth, new service development and revisions of current services than to have dedicated folks remain one step ahead of everyone else.

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In these turbulent times, while the leadership is busy ensuring that patients have the best experience/outcomes, cost-control efforts are in place, employee/physician morale remains high, and the organization can weather the storm, it's critical that another individual is able to dedicate time and energy to parallel these efforts. Too often, this is one of the first individuals to be made redundant, or let go when the cost saving efforts turn to labor.

I know of several independent hospitals where this has occurred. I argue that this is one of the last individuals that should be let go for the reasons already stated. Hospital strategists and planners are becoming a rare animal out there, and I think it's time we protect this endangered species!

With the recent release of Apple's iPhone 3G S, FierceMobileHealthcare decided to take a brief look at 15 commonly used free healthcare apps for the iPhone according to sites like apptism, iAppHealth and Apple.

Click here to get started.

Marketing and promoting a hospital or health system is not just a marketing department's responsibility these days--I believe that it is the responsibility (and obligation) of all of the employees. In other words, a "Village" is needed to market and promote the great things that are going on in hospitals on a daily basis.

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With the ongoing technology and Internet revolution, the tools that are available to market and promote hospitals are ever changing. Today social media (aka SoMe) is fast becoming part of our everyday world. SoMe tools are being adopted and implemented by hospitals and healthcare organizations at a very fast pace. Various healthcare organizations are using these tools to broadcast surgeries, promote events, healthy messages, news, and much more.

SoMe is being described as the Web 2.0--with the Internet evolving into a much more real-time environment. Web 1.0 was mainly structured around organizations, people and businesses having a website. Websites are typically very static, with infrequent updates and changes. They also are great tools for communicating the basic "who/what/where/when/why and how" answers. Still, websites also are somewhat archaic, and typically change infrequently, meaning they do not create much opportunity for community or relationship building.

SoMe Web 2.0 tools are very dynamic and real time--and provide an excellent opportunity to develop a community of followers--a "Village." People on Facebook can become a "fan" of hospitals, a "follower" on Twitter and a "subscriber" on YouTube and a blog. With hospitals participating in all of these tools, this is their opportunity to build an online community and create our their own engaged "Village."

John Domansky has worked in the field of healthcare financial management for nearly 25 years in various places across the country. He currently serves as Chief Financial Officer for Knoxville Hospital & Clinics in Knoxville, Iowa--a rural, non-profit critical access hospital. John has a very broad background in both for-profit and non-profit hospitals.

Frontiers of Health Services Management published its summer 2009 report on Bullying in Healthcare recently. In this edition, they took an in-depth look into the problems of bullying in the workplace. As many of you know, I have been pontificating about the devastating impact of bullying for a dozen years now, and between the Joint Commission's stand and features like this one, the topic is finally beginning to get the attention that is needed to address the absolutely horrible outcomes prompted by those individuals in healthcare who have long lived as bullies.

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With 20-plus years in healthcare executive management, I've seen all levels of this practice, from nurses to physicians to top management. It is always disruptive, and usually marks ineffectiveness in communication skills. Most times, it represents true psychiatric disorders like narcissistic personality disorder, depression/bipolar disorder, and even dementia.

One of the major issues that did not seem to be addressed in this comprehensive treatise was that of "the CEO as a hostage." During my tenure as a CEO, we addressed this bullying issue as often as possible, but invariably, there were always one or two physicians, managers, or staff in the untouchable, protected class. No matter how disruptive, how obnoxious, or how horrendous their behavior, their peers and superiors turned a blind eye to their behavior. Hence the hostage scenario.

Being dismissed because of these disruptive individuals is not always a viable option for the CEO. The decision to take on the top protected offenders can represent a no-win decision. Thirty-year bullies who are top admitters, top notch surgeons who are impossible to replace in small and rural hospitals, and board attached friends often represent the most troublesome cases faced by the CEO. I'm proud to say that we were 98 percent effective, but that other 2 percent always came back to haunt us.

In our case, the executive committee of the medical staff took on many of these individuals, confronted them, warned them, helped them, and corrected them. Regardless, the one or two top bullies continued to prevail in their disruptive ways. Unless these problems are taken on every time--100 percent of the time with complete backing by the board of trustees--we will continue to have bullies in the workplace.

If you have been following my twitter feed, you'll know that I was laid off from the business development director role at my health system about six weeks ago. I was called into my boss's office and the HR professional was also sitting at the table. Even though I had prepared for this moment and I knew it was coming, my heart was still pumping when I heard, "Unfortunately...Your position was one of the ones that has been eliminated."

Thousands of times over, this is happening in hospital offices across the country. In fact, just in Chicagoland alone, there's probably been 1,000-plus layoffs. As such, this is obviously a pretty touchy and raw subject for many. Nonetheless, for me, at the risk of sounding a little insensitive or overly positive, I've taken this whole situation as a great opportunity, and am looking at it as great timing.

I don't get philosophical too often here at Hospital Impact, but maybe this topic deserves a bit of just that. Here are some things I've been thinking about:

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1. Being laid off has given me some much needed time to slow down a bit. Sometimes the hurry of life prevents us from really reflecting about how we're wired and what we're passionate about. I truly enjoyed my role in the health system but not for the reasons I initially thought. I know that as I step into my next chapter, I feel 10-times more equipped to find something that will fit me like a glove because I've had some time to really think things through.

At a deeper level, I think our media-junkie culture also makes it easy for us to fill up our days so much that we don't have to face ourselves. For me personally, it has been a great time to slow down and renew my faith walk. It has been both challenging and rewarding to not do anything, but rather, just be. No big titles. No accomplishments to achieve. Nothing to prove to anyone. Just enjoying being present in the moment.

2. Being laid off brings out the best and worst of people. I feel the same way about money. The famous saying among superstar athletes is that making a lot of money doesn't change people--it just amplifies who they already are. I think being laid off (or watching it happen to your colleagues) is the same. Folks that were already insecure become more so. Folks that are positive and motivated see it as an opportunity. Laid-off lemonade, so to speak. For the laid off and the left-behind, these layoffs really mess with you, especially if your value and sense of self-worth is overly-tied to your work. You really have to do some reflection about what truly motivates you, and how you define value in yourself.

3. Healthcare--and in particular hospital administration--is such a small world. Everyone literally knows everyone. I believe it now more than ever. I feel very fortunate to have met so many people through this blog, and it has definitely helped me transition into the next chapter (more on that soon). Nonetheless, 100 percent of professionals know that they need to network. My advice: Be in the 5 percent that actually do it. And do it before you need it. If you wait until you need to do it, it'll be too late. All of my leads were with people who already knew me well.

4. Hospital culture varies as much as hospitals vary. Some cultures are very execution-oriented. Some are very relational-oriented. Some are very planning-oriented. Some cultures are just nice. Some cultures are too nice.

Nonetheless, no culture is right or wrong, as long as the cultures don't get in the way of great and sustainable patient care. But, now I know more about myself and what type of cultures I will thrive in. A question I now will always ask in all my future interviews (sitting on both sides of the table): What three words best describe the culture here?

Side note: Of course, even within a hospital exists many subcultures. Some would argue that a hospital has as many cultures as it has people managers.

5. Being laid off means more time with the family this summer. I've already scoped out all of the free outings here in Chicago. This will be a memorable summer of some great day trips for me and my 3-year-old.

6. Some practical advice: Check out this savvy daddy blog post I wrote on the 20 things to prepare for the down economy--this encapsulates most of it. Hit up all the job boards (ACHE & HFMA have good ones), but more importantly see item No. 3 from above. Also check out this list of 30 websites to hit when you're laid off; it's from one of my favorite blogs, Mashable.

So, that's my laid off story, forever enshrined on the Internet for all to see. Anyone care to share their laid off story? Any tidbits of advice on getting to the next chapter?

* - Toe Knee Chin is obviously not my real name, but I'm guessing you figured out who I am. Others randomly googling me can, too, but at least, it'll take them some head scratching and savviness to figure it out.

In March of this year, WellPoint and Availity announced a strategic partnership with Availity--a health information network that connects health plans and providers. Anne Zieger, Editor of FierceHealthcare, recently chatted with WellPoint Vice President of Healthcare Management John Jesser and Availity CEO Julie Klapstein about the collaboration, what it means for both parties, and what it could mean for the future of healthcare. Click here for more...

We are entering an unprecedented season of change for the United States healthcare system. Americans are united by their desire to fundamentally reform our current system into one that delivers on the promise of freedom, equity and best outcomes for best value. In this season of reform, we will see all kinds of ideas presented from all across the political spectrum. Many of these ideas will be prescriptive, and don't harness the power of innovation to create the dramatic breakthroughs required to create a next generation health system.

We believe there is a better way.

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This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10M prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50 percent in a 10,000 person community over a three-year period.

The Healthcare X PRIZE team has released an Initial Prize Design and is actively seeking public comment. We are hoping, and encouraging everyone at every opportunity, to engage in this effort to help design a system of care that can produce dramatic breakthroughs at both an individual vitality and community health level.

Here is your opportunity to contribute:

1. Download the Initial Prize Design
2. Share your comments regarding the prize concept, the measurement framework, and the likelihood of this prize to impact health and healthcare reform.
3. Share the Initial Prize Design document with as many of your health, innovation, design, technology, academic, business, political, and patient friends as you can to provide an opportunity for their participation.

We hope this blog rally amplifies our efforts to solicit feedback from every source possible as we understand that innovation does not always have a corporate address. We hope your engagement starts a viral movement of interest driven by individual people who realize their voice can and must be included. Let's ensure that all of us--and the people we love--can have a health system that aligns health finance, care delivery, and individual incentives in a way that optimizes individual vitality and community health. Together, we can ensure the best ideas are able to come forward in a transparent competition designed to accelerate health innovation. We look forward to your participation.

"Good news," my new physician said. "You passed your cardiac stress test." "Yes," I thought. "That is REAL good news; no open heart surgery, no angioplasty, no more stents. Yeah, that is great news." Even though I know that thallium stress tests are only about 70 percent accurate, I'll take that piece of information and hold it tight while I smile a little.

"Well," he went on, "Your HDL is not where it should be, and you do have mild kidney failure. We’ll just have to keep an eye on that."

"Mild kidney failure?" I said out loud. "Wow, that was unexpected," I sighed. What did mild kidney failure mean?

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I don't know exactly how you would have felt, but this was not a phone call that I wanted to receive. At first, I couldn't even think. Then I asked, "Is it because of my high blood pressure?" He responded, "It might be." Interestingly enough, my BP has been really rather good these last several months. Then my limited medical knowledge kicked in and I began to play out different scenarios; Dialysis? Kidney transplant? Early end of life?

What the heck?

So, I decided to send my tests results to an email friend of mine who happens to be the head of cardiology at a major heart center. His response was very to the point. After he saw my list of meds, he said, "You are on two meds that, when combined, can contribute to kidney failure."

Initially, I wondered how my doctors missed this. Then, I called a pharmacist friend. He said he was unaware of this fact as well, but would be happy to check it out. Some three or so hours later, he called to inform me that a Canadian study indicated that, when combined, an ACE and an ARB could indeed accelerate the decline in kidney function. (I'm hoping that by not naming the drugs, I won't have to deal with product liability issues.)

It was the combination of these drugs that contributed to this change in only six months.

What's the point in sharing this very personal piece of information? According to a lecture that I heard some 10 or so years ago, the chances of an interaction between five or more drugs in the body is 100 percent. Well, if highly trained, extremely competent physicians and pharmacists miss the possible outcome caused by combining these two drugs, what chance does a nonmedical, nonclinical, nonscientific patient have?

Bottom line? Don't try to figure this out alone. Get help. Remember, that you are responsible for you, too. I started my diet again today, am committed to working out more and stopped my ARB. Hopefully, in six months the news will be better all around, and hopefully, you'll ask more questions when you get your test results back, too.

We usually know him when we see him: Tightly wound, a product of pedigreed training programs, a high achiever, used to getting his way. Most healthcare organizations have at least one of him. He may be the cornerstone of an institute or service line. He is the alpha doc.

The question we face is, how do we capitalize on his expertise and charisma without dreading to work with him?

Based on my 500,000 mile journey working in 40 states, I offer the following strategies from healthcare professionals who face this challenge.

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• Humor: The OR staff asked a Director of Nursing in Minnesota to address a spine surgeon's negative behavior and "get him off their backs." The 6'7" surgeon towered over the 5'1" nursing director. Upon entering her office, he began complaining angrily about what was wrong with the OR, when she interrupted him, "Doctor, please sit down so we can talk eye-to-eye!" He stopped and started to grin, then laughed, and sat down. (She had to remain standing to make eye-to-eye contact). He became affable, and they discussed what he needed, how the OR staff could help, and what he might do differently when dissatisfied. From that day on, he remained gracious and friendly and the staff stopped complaining about him (Cohn KH, Algeo S, Stackpoole K. "What Physicians and Administrators Can Learn from Nurses." In Cohn KH. Better Communication for Better Care, 69.)

• Healthy competition: In Collaborative Competition, I wrote that cardiologists at a Connecticut hospital reduced variation in procedure times and outcomes for their six-person group to within one standard deviation, decreased their vendors to two, and cut costs substantially, while improving clinical outcomes, in just four months. All of this occurred after their chief wondered aloud about posting their results with cardiologists’ names visible in the cath lab lounge if they did not make progress within six months. One of the cardiologists explained, "None of us wanted to be an outlier, except on the positive side."

• Social networking: In Collaborative Champions, I defined physician champions as outstanding clinicians who have earned the respect of their peers by caring for patients in a consistent and reliable fashion, delivering great clinical outcomes. They are the people we turn to when we need medical care. They are also seasoned professionals looking to leverage their knowledge and experience to improve care for their community. Physician champions may have leverage with alpha docs, especially if the champions refer patients to the alpha docs.

• Inside knowledge: Knowing about an alpha doc's outside interests may be another way to connect with him. A hospital CEO in Ohio found himself arguing unsuccessfully with an orthopedic surgeon about locating an ambulatory surgery center (ASC) on campus rather than having the orthopedist use a national vendor. With 25 percent of his bottom line at stake, and knowing that the orthopedist was a Civil War buff, the CEO said, "This is beginning to look a lot like Antietam," (the bloodiest single-day Civil War battle with over 22,000 casualties September 17, 1862), to which the orthopedist replied, "This is the first time you showed me that you knew anything." They developed a bond as a result of this skirmish that led to a jointly ventured ASC on campus and a lasting collaboration.

• Collegial data-driven feedback: In "Managing Difficult and Disruptive Physicians," Harmon and Lapenta discussed the use of 360-degree feedback to change behavior (in KH Cohn and DE Hough, editors, The Business of Healthcare, v.1, 80-81). In this process, the physician rates himself on a variety of motivating variables, such as "Treats people with respect" and disruptive variables, such as, "Gets sarcastic when asked important questions." The same survey is sent to the alpha doc's colleagues, and the two responses are compared. Such a survey also permits colleagues to offer suggestions confidentially, which a neutral facilitator reviews with the alpha doc to draw up an action plan.

In my two-day seminar on Practical Strategies for Engaging Physicians, I note that conflict is inevitable in a rapidly changing marketplace, and talk about how people surfacing and resolving conflict can lead to a sustainable competitive advantage. "Going to the balcony" is a widely used tool in diplomacy to escape the passions of the moment and focus on each party's interests rather than stake out antagonistic positions (Ury WL. 1991. Getting Past No. New York: Bantam).

In Crucial Confrontations, the authors point out that if we do not talk out our differences, we act out our differences. (Patterson K, Grenny J, McMillan R, Switzler A. 2005. New York: McGraw Hill.) People can confront alpha docs safely if they:

• Start from a position of safety.
• Maintain respect.
• Use contrasting to reassure what is not going to happen.
• Establish mutual purpose.
• End with a question.

Here is an example that clarifies the suggested steps: "I am concerned about a problem that is affecting all of us. One of our veteran OR nurses has asked for a transfer because she felt that the stress in the room was affecting her health. This is not a witch-hunt. I value your service to the hospital, just as I value hers. I would like to understand better if there is anything that I can do to limit the stress that builds up here. I welcome your suggestions. Is there a time next week that might be convenient for us to discuss the situation?"

What do you think?

• Do you have any stories about alpha docs that you can share?
• Based on your experience, what steps do you recommend?
• Upon what successes can we build that will allow us to provide patient care that is safe, effective, timely, efficient, and equitable, in line with the recommendations of the Institute of Medicine?

As always, I welcome your input.

Ken is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching and consulting on physician-hospital relations. Learn more about what he does by visiting http://healthcarecollaboration.com.

To learn more about this subject, please read Cohn KH. Turn Irritation into Inspiration: Six Ways to Put Physicians’ Perspectives to Work in Your Practice.