I want to welcome everybody to our conversation today. I'm Dr. David Steinberg. Sir, who are you? Oh, I'm sorry. My name is Greg Warsiewicz. Well, that's great. Yeah, we're thrilled to be talking today about what it is to be a medical director. We are presenting to you as part of the AAPMNR Medical Director Course, Governance with Formal and Informal Organizational Structures. We have an agenda built out we think you'll really enjoy into three parts. We're going to be talking first about formal structures for roughly 15 minutes or so, and Dr. Warsiewicz will take that lead. I'll then present some information about informal structures, and then together we'll talk about misalignments and how these things kind of, how you work together in a very effective way for leadership in a medical director role. Dr. Warsiewicz and I have no disclosures, so. All right. Well, thank you, David. Yes, it's really being a medical director, to be or not to be. Like David mentioned, I have no disclosures. I have multiple thank yous. My assistant, Jamie Cox, and Brian Thompson from the AAPMNR and David Steinberg received gold medals for working with me. And the organizers of the overall course, I'd like to thank Kathy Bell and Mike Lupinacci and all of you that are participating. Kind of a little bit about my past so you know where I come from, what I've done. I've worked in multiple settings, including Gainesville, Florida, in a private practice where I mainly did inpatient rehabilitation. I worked at Rutgers Robert Wood Johnson Medical School doing inpatient rehab, then work in a skilled nursing facility and consult service. During that time, I went back and got a master's in business and decided, ah, let me try and use it. And I went to the University of Missouri in Columbia, go Mizzou. For 19 years, I was the chair of the department. And for 10 years, I was the chair of the over 600 doctor practice plan. So got a lot of experience working there. And currently, over the past three years, I've been at Mayo Clinic here in Jacksonville, Florida, primarily doing hospital consults. So a variety of administrative and clinical jobs. A couple of things I always would say, always, always know the field you're playing in or the organizational structure. In each of my settings, it's been a little bit different. And whether I now I work at Mayo Clinic, which is a very matrix structure. And you got to know, if I'm playing with the organization, such as a medical director, I better know the rules. What are the rules? As medical director, you're going to be in charge and a lot of people are going to come to you. What's the difference between an IRF and a SNF? What are the documentation deadlines? Is it, wow, I got to sign it before they come in? Wow, do I have to sign plan of care within a certain amount of time? Because you're going to be asked at times potentially to enforce or talk with other physicians and you need to know why and when. Just saying, well, I think so. Or if I say, wow, the CEO wants me to. Usually that's not going to cut it with physicians. You need to have the data, know it and present it in a way confidently and define your role. As Dr. Steinberg is going to show, there's a lot to being a medical director, both formally and informally. So oftentimes you want to know going in, let's set the ground rules. What are my targets? What am I responsible for? And get a feel going in, who are the players? And I think David's going to talk to you quite a bit about that. So how to play go, a beginner's to expert guide to learn the game of go. Hopefully this will help you with your journey. First of all, know the numbers. What type of rehab center am I working in? We know by Medicare numbers, IRFs do pretty good, a 13.7% margin in 2022. But let's, what type of IRF am I going at to work at a for-profit or a not-for-profit? As you can see, some of the margins are a little different there. The non-profit being much lower than the for-profit. One of the things that's important, because this is going to be the pressure on the CEO based on where she or he is working. And I need to know that. I need to know who controls the funds flow, who's in charge of that, and how do I relate? And as the hospital gets bigger, plus 65 beds, you can see. And this is all data that's publicly available through MedPAC. And I'm going to talk about that a little later. It's a great resource. I don't know, David, if you've used some of the MedPAC data in the past or not. Well, I have. And you know, Greg, if you go back to that slide for a second, I saw that earlier and I was wondering, it's a huge difference in the margin between hospital-based and freestanding. Do you have some sense about why that might be, that big differential? Well, as you know, and I both know, your most expensive square footage is in a hospital. And oftentimes, if you are hospital-based, you want to know, is the overhead for the ORs, the overhead for other parts of the hospital system lumped into your costs, or are they separated out? That's one of my thoughts. I don't know if you have other thoughts on that. Well, that's exactly where I went to, because, you know, our margins are pretty razor thin in academic medical centers in particular. And we do have a lot of overhead depreciation and IT and, you know, that's assigned to us. And a big C-suite overhead with that, you know, comes to the territory for a hospital-based system. Yeah. And as you're going to see later, I worked at a joint venture. And while it's an academic hospital sending patients to a joint venture, that was a for-profit. So, boy, there's always that pressure, like you said, on the margins and patient population. And when I say that, that's important. Boy, what's your organizational chart on what it is? Because you got to, I kind of almost say org charts. They're important to know, but as David, you're going to show, org charts are almost like prenuptials. They're only there when you need them. When there's a problem, you refer to the org chart. Now and then, if you have to refer back to them, there's the hierarchical one person on the top, and he or she oversees everybody. It's basically a top-down. There's the matrix, which a lot of health centers like to talk about, of a dyad, of a physician, and of administrator. And now you start having multiple reports. The problems with that is, I work in a very matrix system here at Mayo, and while it is fantastic, it's sometimes hard to make quick decisions and movement on things or flat organizations. And David will expand on this. Yeah, I know, Greg, when I started my new role here, I spent a lot of time kind of studying the org chart and moving boxes around and thinking about titles and, you know, how we wanted to be structured. And in one of my first meetings with my new boss, I presented the org chart, and he looked at it for a second and pushed it back across the table and said, you know, I don't really believe in org charts. Yeah, until you need them. That's because he was the boss, and it went top down. But it sounds silly, but you want to know the playing field and who you're working for and with, because at some point in time, someone has to be the boss and take the lead and make the hard decisions. And you just want to know where, what's my role in that. Kind of like I just said, I was at a joint venture for 19 years where I was a med director, and we had a board that was made up of, from the, you know, Encompass Health, and we had a board from the system and the dean. And the ownership of the company was 75% Encompass, 25% the university. So basically staffing and personnel were all decided by Encompass. In fact, it was, we'll talk about some of this later in conflict resolution, but well, they decided on the numbers. Now I had input as medical director, but not any final decisions. The patients, however, most of them came from the University of Missouri and all the physicians on staff were University of Missouri. We had an open staff, but if most of the patients came from our university, it wasn't profitable for docs to come over to see two or three patients. So even the patients from the private institute were cared for us. And again, as medical director, I needed to make sure that those patients got sent back to their private physicians, because as you know, that's a quick way to lose referrals. And I did look at org charts. And as I slowly learned again, org charts are only when you're concerned with an issue. I had a great job offer once where I was going to be a physician executive, and it's still a great organization, but the way it was set up, I would answer to the CEO, not the chair of the organization or the leader. And it was probably me more than them, but I didn't like the structure. I asked for it to answer the physician executive to have a dual reporting up to the chair. Um, for me, that would have made it go for the organization. It didn't. And I just was not comfortable. My, my gut told me this wasn't the right, I would be frustrated and have problems based on past, you know, reporting structures. So it didn't work. It's great, still organization, but I'm glad, uh, sometimes you have to pass. All right, now we've looked at the structure, but most important, you gotta know the rules. And we know that IRFs have certain rules, certain times to sign plan of cares. This is straight off, uh, CMS.gov files and documents. If you have questions, if you don't know them, there's a lot of easy ways to familiarize yourself with the federal register. I once said, what the heck is a federal register? Well, it's where the rules are kept. So such things as medical necessity, therapy services, others, as medical director, you're the clinical lead for the institute or for the department. You gotta know these. And again, there's annual updates to this and why is this important? Because you're going to change some of the payment rates, some of the CMGs, some of the different comorbidities, and it doesn't have to be the bulk of your day. The CEO and others are going to be working with this, but you need to have a, where is it coming from? Why is it changed? What do we need to do? So it's much easier to try and make change if you have buy-in based on the facts. I'll take one minute. This boy was probably the biggest change because things change. You know, back in early 2000s, we had the CMS-10 and people weren't compliant and they did audits and it was, you know, it was a question whether rehab centers were compliant. Well, we went to CMS-13 and where 60% have to be within these diagnoses. I know I'm preaching to the choir, but you have to know these. You have to make sure who is making this diagnosis, who is in the chart coding it? Is it the physician or is it the system or somebody else? But I was a stickler. It had to be the physician who made the diagnosis, whether it was a CMS-13 or other medically complex diagnosis. So know the rules, follow the rules, and stick to the rules. Because if you get a little loose, it hurts you. And there's pressure at times. You're going to, as medical director, you're going to, when the census is low, I guarantee you the CEO or somebody, the marketing or liaisons will be on the phone. Hey, we got to get this in. We got to get this in, which I understand. We do need to help people, but you can't stretch them too far. An unfortunate case was in 2007, Medicare rules, the one large company was fined $48 million because they used a diagnosis called disuse myopathy. Now I could never find that listed as a myopathy in any of my textbooks. And they also, there was no clinical evidence for this diagnosis. Two important take-homes. Make sure the diagnosis is one you're familiar with, you can defend, and make sure when doctors see patients, they have their physical exam or their history that's going to match up with diagnosis. You have to do that. Because who makes the admission decision? Is it the liaison or the physician? It has to be the physician. And he or she has to be able to understand that if I can't handle this, I can't take it in. And there's pressure. And what is the admitting diagnosis? Make sure it's accurate and appropriate. Yeah. Greg, I was on a discussion yesterday about potential conflicts with administrators. And this topic came up specifically about when you get pressure from administration to stretch the rules or maybe cut some corners. And it was a really great session the academy hosted that really highlighted the dilemma that medical directors can sometimes find themselves in, in balancing the needs of the patient, the needs of the program, their own personal relationship, their professional authority. And, you know, it's a tricky thing to navigate. But I think that, you know, what's gotten you so successful over the years, I think, is having that self-awareness or, you know, situational awareness, the ability to develop a strong relationship with people, even in times you might butt heads or disagree, you're able to kind of navigate through that. And at the end of the day, you're the doctor, right? You're the leader, the physician leader of an organization. You've got to be able to have some level of input there, right? Yeah, I think you're spot on there, David. I think, and you know this, there's even times as medical directors, you're under pressure or other things, and you may have to go to one of your own physician colleagues and discuss the case, just like you said. And then eventually as medical director, where the rubber hits the road, you're going to, you may be put in that final call decision. So it's a tough one. One of the things you want to be aware of is, wow, we're facing all sorts of pressures, whether Medicare Advantage or, wow, retrospective reviews on charts and payments from Medicare. And you want to know, one of the big things coming up is a review choice demonstration for inpatient rehab facilities, where programs can choose to participate in pre-claim review or post-payment review. I know it started in a couple of states. Again, there's online references to look at it. I would, familiars, if you're a medical director, if you can understand what's happening and the pressures that your CEO is under or the system, you can work as a team together rather than, oh, that's your problem. I'm not going to worry about this. This is part, going to be one of your duties. So I love to think about what are the big issues hitting? And what do I think? Well, we know pre-op and physician turnaround, our academy and other organizations are pushing hard to have CMS change some of the turnaround times. Uh, staffing and nursing. Well, I don't have a direct impact on it. If I don't feel it's appropriately staffed for my high complex patients, or if we're too thin, my nurses are getting burned out. Uh, you know, as medical director, I need to address that. I need to be seen and, you know, I need to be the patient advocate. And sometimes that's advocating for your nursing staff, Medicare advantage. We've more than heard about, um, and oftentimes having to do peer to peers. I've heard some rehab centers or physicians will do the peer-to-peer. Where I'm at, we always had the physicians in the hospital do the peer-to-peers. So you need to know that. Subacute rehab is a term I don't agree with. It's not one of the CMS PAC but people will often use it. The definition of a rehab doc. I know our Academy has pushed hard that we feel like, wow, this needs a rehab doc needs to have specialized PM&R training. And right now it's listed that the acute the acute rehab hospital will determine if the person's had a licensed doc. We'll go over a little bit of that. And has two years exposure to training in quote some form of rehab setting. Certificate of need, medical advances, complex patients. I do I deal with an unusual but growing population of transplants. And now when I send them to rehab, boy, they have to be diagnosed other than something of transplant to get the appropriate resources or link to stay. Differences and the choice demonstration. I don't know about you, David, you probably learn about something new every day. But oftentimes I'm sure the docs come to you about it. With questions on, hey, what's going on with this? I heard about this. What's going on with that? And you either, A, have to know it or, you know, be caught up on it. Yeah, I think some of it comes directly to me, those kinds of questions. And as a medical director, I feel like I need to stay very current with those things. But I also need to have my organization, other folks in the organization who are closer to that regulatory and compliance work, to have communication channels and make sure that they have a platform. They know that they can share that information, be transparent, and then also hold people accountable. You know, one of the key things for medical directors is, you know, there's a lot of criteria that must be checked off for an admission and for a system to be compliant. And, you know, we need to have that accountability kind of built into our structures. So it can't, you know, none of us can do this work alone. So we have to have a team of people who stay current on the regulations and are auditing and making sure that the documentation is accurate, that we're hitting the, getting the H&P completed within 24 hours, make sure we got the IPOCs completed within four days, make sure the meetings are held every week. You know, you know, the song and dance we got to do. Oh, yeah. Well, you're spot on with that. And you make a great point. No one can know, be an expert in all these areas or know them all. So your organization, you need to lean on them and know who to trust. And I know you're talking about that later, but also trust, but verify some of the things if you start getting concerned. So thanks. Medicare Advantage, that's one thing I know is hitting everywhere as a medical director, whether you're doing a lot of the peer-to-peer pre-ops, you know, boy, this is something we're all working on. Our Academy, I know, is lobbying heavily for access for care. I live in Jacksonville, Florida, and you can see back in 22, greater than 50% of the Medicare enrollees were enrolled in Medicare Advantage. This was where we talked about a rehab position is they've had specialized training, again, according to the Federal Register. And you don't have to bog yourself down in the Federal Register. There's many places you can find information like this. The Academy has been a great resource for me through the years on staying up to date. I think, just so you know, there are, Dave's going to go over some, there are a few things that are required of the organization to have a medical director. Again, this is off of CMS. And just that they have a director of rehab in place, that they are there present 20 hours per week or involved with involvement with the unit. And some places will ask you to document and log your hours. So then if they do have a CMS audit, it's right there. And I actually, at first I was hesitant. Now I'm, afterwards, I'm glad I did have a log of my hours and the type of activities I was doing. Because I wasn't always inside the building during my time as medical director. And whenever in doubt, you go to student doctor. And this is off a student doctor, but I found it interesting. Some, they asked directly about inpatient rehab facility, should I be just coming out of school and be a medical director? And they said, don't do it out of residency. You don't know what you're in for. I made that mistake. Or you're often involved in creating, managing protocols, policies that affect day-to-day operation. And they talk about, wow, you maybe you should get more training and education. I want to commend everybody here. That's one of the things you're doing is working on education and training. David's going to talk about, wow, the role of a medical director. Some of them are tangible. Some are intangible. So I won't spend time here. Some of your responsibilities, read your contract, read your contract. You're often called to be a leader. They talk about relationships with outside docs and outcomes. And that's easy to get mixed up with. Wow, I want you to have relationships versus you're not out there getting us enough patients to come in. I actually, you know, that's one of the things you'll be asked. Is your job have any tie-in to the finance of the hospital or not? Or do you have influence on financial decisions for resources? And David mentioned earlier, this is going to be one of the hard ones. In a sense, you're seen as the police administration. Are the records, are they compliant? Were they signed in time? Were they filled out in time? What's the system satisfaction? Do you have a target? Is it in your contract? Many of the old Medicare adjudications were the administrative law judge. You're going to be asked to do those on often records that are closed. So that is time you're spent as medical director. And you're going to be asked to do conflict resolution. Most important of the day that I'm going to end you with is educate yourself, educate yourself education. If you haven't seen, if you haven't gone to medpac.gov, I'd recommend this highly. They used to put out books. I started getting them in 2008. Now they're everything's online. And there is a separate setting for post-acute care. And they will talk about what they're recommending to Congress, which many come to fruition. And they will give you all the financial information, regulations for inpatient rehab, skilled nursing facilities, LTACs. And it's not a hard read. Other areas is our academy, you know, the position statement on definitions of rehab positions and director of rehab and inpatient rehab settings. I would recommend this read for everybody. The other is, there are a plethora of things out there. There's courses, some of the most of these are AAPM and are sponsored. There's other organizations like AMPRA that has a boot camp for medical directors, and they have the slides right on the internet. And these are all different ways to learn. And you can see documentation, admission criteria, transfer policies, how to prepare for a demonstration, how to, with the review choice, communicate. Probably the best thing is going to courses like this, going to your national meetings, talking with other individuals doing similar jobs as you. I know my informal education with talking with David and other medical directors is probably my greatest source of information and direction pointing to find this stuff. So we've talked about some of the places to get information. I'm going to let David talk some more on the formal and informal structures and getting things done as a medical director and challenges you'll face. David is the chair of the Department of Physical Medicine Rehabilitation at the University of Utah. I think that's somewhere out west. I'm not sure if Utah is still in the union or not. But David, I'm going to pass the baton to you. And thank you for your time. Well, thanks, Greg. I really feel like this is a really a journey that we're both on. And let me see if I can get my slides shared up here. Let's see. How's that look? Beautiful. Thanks, Greg. I really appreciate your background information about the nuts and bolts of being a medical director and the compliance regulatory requirements and what it really takes to be successful. You and I both are unique because we've had long careers in PM&R leadership. You and I both started in private practice world. I became a medical director six years into that journey, kind of an unexpected turn of events in my group practice back in Michigan. And then fast forward to 2018, I had another change in my career trajectory and came out here to Utah, moving from a private practice at a community teaching hospital where I served as a medical director, but also had a role as a vice chair of a large internal medicine department and a few other system roles like chief of staff. And then out here in Utah, taking over an organization as the chair of a department and ultimately leading a new rehab hospital, this Craig H. Nielsen Rehab Hospital, where I serve as the executive medical director of that facility. I think that's true for everyone. You know, you start on a road and a path and just make good decisions. And, you know, things will evolve over time. I didn't know that I would end up where I am now. And I just I love it. Now, we talked a lot about the the formal structures that you might find yourself in. Here's our organizational chart. And I told you that, you know, my my boss initially said, you know, hey, I don't put a lot of stock in the formal work chart, but you got to understand it. And those who you work with will also want to understand how that structure works in your organization, who the people are, where the dotted lines, what does that really mean to have a dotted line to somebody versus a solid line? You know, and some of that comes down to very practically who has fiscal accountability, who is what are you accountable for in terms of your outcomes? Who's going to do your annual review? What is that annual review? You know, what is it tied to? Are there incentives or other outcomes? Who has the ability to fire you? Who do you have to go to if you want budgetary approval for something? Where do you kind of like look in your organization for policies and guidelines and things of that nature? So here's our chart. And this individual right here, I put a circle on is my inpatient medical director. And I work to help mentor her in her leadership journey. Like all the docs in my organization, doing a, you know, very proactively and intentionally working towards succession planning and helping those younger folks in the organization gain skills and experiences and have autonomy and authority to make decisions and to bring creative ideas to the table. But this individual also has program directors who report to her and has relationships across the organization with our director of therapies and our director of nursing. She now serves as the president of our medical board, essentially like the medical executive committee for the hospital. She's getting an executive MBA. So these are the types of things that are important when you think about an org structure and a formal structure. So your job as a medical director is to understand your responsibilities and your accountabilities. Here's just a list of some of the types of roles that people have as medical directors. They're challenging. They're not always easy. But I got to tell you, you have to have fun and enjoy what you're doing. And I think you you also probably feel a great sense of reward and accomplishment, Greg. I certainly I love my work and I hope you do, too. Yeah, I think you're right on, David. That's it's just got to be the right fit. And those things, you know, because a lot of these things you have up there responsible for relationships are not just cut and dry hard facts. You alluded to a potential job that you ended up not taking. And I also when I was looking for new opportunities, I looked at a couple of positions and jobs and it wasn't a great fit. Some of it was geographic fit. Some of it was the organizational structure. But I got to tell you that one of the most important factors for me was culture, people and culture. And you know what they say, right? Culture needs strategy for breakfast, lunch and dinner. And that's really true. I don't have that on this list here. But I would say one of the most important roles of any medical director is to help shape the culture. You're kidding yourself if you're going to say you're going to change the culture, you're going to create a new culture. You'll have some influence over culture. But culture is very, very difficult. It's very powerful. And understanding organizational culture is critically important, as well as understanding the people you work with, the colleagues that you have, you know, up and down the organization. Your medical director jobs will be very important to lead teams. And leading teams requires you to have a certain amount of emotional intelligence, to understand great communication skills, to be a master at at leading meetings, at setting strategy, at changing strategy, adjusting to situations that you might deal with day in and day out. In the end of the day, these are the types of things that we, we do in those leadership roles. I think one of the key differences that that all of you on the call should think about is what is the difference between management and leadership? And Greg, I know that you're kind of like schooled on this to, you know, managing is, you know, managing to to a goal, you manage people, you manage processes, you you set goals, you achieve them. You are, you know, you have a list of responsibilities, you're going to set it where a leader is setting a vision, and learning when you need to change course and adapting in a very creative way to, to the situation at hand. What are your what are your thoughts about that difference, Greg, between management and leadership? And I think that's where you got to know yourself. And you hit it right on the head where culture of an organization, is it the culture there and a good fit for you to help lead in the future. Some people like taking a startup from zero to all the way some people like coming into a well established and making it a little better. Some people X, Y, or Z, but culture and leadership go hand in hand. And by being a good leader, you help form the culture. You can't afford as the medical director to be the one whining all the time. Yeah, let me do everybody's going to take you a little bit more information here about the role of the medical director. So you see in here, it's a, you know, leading a clinical care team, process improvement, program development, leading great patient care, you know, especially patient experience is so critical, leading a team of clinicians, docs, APCs, nurses, therapy, retention and recruitment, working collaboratively, you're a unit champion, ultimately, you've got to wear the colors of the organization proudly and be in an organization where you feel really proud of that. Lead out on process building for relationships, and making sure that your unit strategy aligns with the system priorities. You know, that might at times require you to, you know, make adjustments to the types of patients or the numbers of beds that you have, or the roles and the where you're going with the organization. Ultimately, you and your administrative partners are accountable for the financial viability of the unit. So that that includes being mindful of length of stay, you're not only kind of thinking about the patient in front of you, but you're thinking about the system needs. You know, you can't just keep people, you know, as long as, as you want all the time, you got to make sure that there's good throughput, because you got to create access for your system and good outcomes. Because if there's no margin, there's no mission. No matter where you are, whether you're in a for-profit organization or a nonprofit organization, you gotta be fiscally viable. So these are the examples, for instance, of some of the things that we look at when you look back over the last year, some of the accomplishments. And I would advise those earlier in their career to keep track of your accomplishments because at some point in the future, you're gonna be in an interview situation, you'll be thinking about, or you'll be talking to someone that you're accountable to, and they wanna know specifically, what have you done lately? What have you accomplished? So if you keep a running list of either projects that you've worked on and outcomes, it'll really help you in the long run. Add it into your CV or your resume so that you have sort of a working draft about, and they can eventually be turned into great stories and a narrative that you can, will help you understand your journey and leadership and the challenges that you overcome. Over a long period of time, it's sometimes hard to pull those vignettes up, but you know it, Greg, you gotta be able to tell those stories in very powerful ways. So this is just an example of some of the things that you might keep track of year to year in your journey as a medical director. David, you're spot on. One of the things we talk about, and you and I have been in academics and private is, wow, CV, how many papers, how many of that? No, a lot of places wanna know a resume. What did you lead? What were some of the financial implications? What are some of the outcomes? You gotta start thinking if you wanna be medical director, and as you build it, you do, some of your QI is you can use that on your resume. A resume and CV are two different, a little bit different animals, and I'd encourage people, look them up, read the difference. You're spot on. I agree. So why is all this important? Because at the end of the day, as a medical director, you're leading out with collaboration. You're working with other people to achieve mutually important goals and outcomes. You're gonna work together to streamline operations and be efficient. It's really critical that you learn to be a good collaborator and partner. So I have a picture up on my wall of a rowing shell because I believe we're all in the same boat. We've gotta work together to achieve a great outcome. The challenges, of course, is that you're always balancing priorities and conflict because great financial outcomes don't always jive with what's best for individual patients, and you've gotta be able to make those decisions and guide your people about using the resources of the organization. You're not alone in needing to learn to manage priorities and learning to manage conflict. I think one of the most important things I heard recently is that the best time to build a strong relationship is when you're not right in the middle of a storm, right? It's better when it's very calm conditions and you're a little bit more relaxed. You can build a personal relationship with your colleagues and build a deep well of trust because when the going gets tough and you're in the midst of a battle, sometimes it's a little bit more challenging. It's good to have a base of a tight relationship. It's really important. And I mentioned before about everyone's leadership journey should include learning the nuts and bolts of negotiation, communication, especially dealing with critical, difficult, crucial conversations. So having that skillset and practice, practice, practice is really important. So what will you need to do? Well, you gotta lead people. You have to demonstrate that you yourself give the very best care. So you have to lead by example, know the evidence basis for what you're doing and why. You're gonna build a high reliability, safe, quality organization. You need to understand what that looks like, which means staying very current on a medical practice, going to conferences, not just going to conferences to learn how to negotiate, but learn how to manage a UTI and blood pressure and diabetes because the best rehabilitation physician I believe is one who has a comprehensive, deep knowledge of medical care. And as the medical director, they're gonna look to you to be the expert. So it's very important for you to stay very current on best practices. You yourself should exemplify safe, collaborative relationships at all times. Be professional, be respectful. I really believe that. And that includes how you dress and present yourself as a professional. I have known some leaders who feel like they wanna be super casual. They wanna be friends and buddies with people. They wanna wear shorts and t-shirts. But if your organization says, no sneakers and open toed sandals, you better lead the way. You've gotta know the organization's rules and make sure that you follow that, including the dress code. It's important. So again, you're gonna be providing patient care yourself and effective team management, providing oversight. I have some examples in here of the job descriptions for what the medical directors are gonna be required to do. And like you said, some of it is approving admissions, knowing their criteria. It's also working with your referring providers to make sure that people know what the capabilities of your organization is. What's the value that you're gonna present to patients and to the systems? Lots to do. I just kind of drilled it down. I think these are the six critical, essential job duties of a medical director. Safety, quality, patient experience, access, stewardship, and engaged caregivers. I think that kind of distills it. And you gotta keep track of those time logs, right? 20 hours a week. And this is an example of what was in a job description for a medical director that an organization posted online. This is the kinds of things that they expect of the medical director in those 20 hours per week. That is a CMS regulatory requirement. That doesn't mean they're gonna pay you 20 hours of administrative stipend. You see right here, administrative time is an average of four hours per week. But you gotta spend 20 hours minimum on the rehab unit. Is this a job you want to be a medical director? Sometimes at the end of the day, you feel like this. But I do think there's a lot of reward in this. But you know, organizations are not just, you know, kind of cut and dry. We talked about the formal structures and kind of what your formal job duties are. Here's a picture of my organization. You know what this is? This is called, I think it's called a murmuring of sparrows. Organizations are complex, matrixed, and dynamic. You know, I had a dynamic video of this, but I'm not gonna show it right now. But if you're interested, go look at what a sparrow murmuring looks like. It is fascinating to see how organizations shift and move. And that's the way you have to be as a leader. Understand that whatever organizational structure there, there's a lot that goes on under the surface. A lot of moving parts. You know, a lot of relationships that are very dynamic and are changing all the time. So I love this analogy. The formal organizational structure is like the skeleton. The informal organizational structure is the neural network. It's the central nervous system. It's what happens with the collective thought processes, actions, and reactions of people and business units within the organization. It's as dynamic as that cloud of sparrows flying in the sky. But at the end of the day, that informal network is what allows stuff to get done. Right? You know who to call. You know who you can trust. You know who is great at getting certain things done, how to cut through organizational hierarchies. It's really important to, because when unexpected things arise, the informal organization kicks in. We all had to do that when COVID hit. We all had to do that in other crises. These informal networks are critically important. It's a complex web. Informal structures are really critical. And as a medical director, it's very important for you to understand this, understand what the strengths are of your people. Who can you trust? Who trusts whom within the organization? I showed you that formal org structure earlier, and who I've had the pleasure to work with as my inpatient medical director, that's somebody who is not only technically fantastic at her work, but she also has deep relationships. She builds great trust across the organization. She's someone who has a characteristic that I call betweenness. Betweenness is the ability to make connections between different organizations. I know if I need to get in touch with the head of neurosurgery or medical director, I know who to ask. My medical director knows people. She's been here for a long time. She's got that deep well of relationships that's really important. I'm sure that's true for you too, Greg, right? But you recently had an organizational change, right? You moved from one where you'd been for a while to another one. I did the same thing about six years ago. To me, and you might have the same experience, when I moved here to Utah, it was like pressing on your computer keyboard, Control, Alt, Delete. You know, because my informal network that I built over two decades, gone. Starting from scratch in a new organization. I didn't know people here. I didn't know who to trust. You had to, I had to learn about the nervous system of Utah, just like you have in your organization, right? Yeah, I think I agree. I started brand new and had to, that's the hardest part of any new job, is learning, you know, the informal network. Who are the people I can go to? Who really makes things happen? And it's not always title. It's not always, you know, position. It's, and it's taken me three years now. And I, and that's probably more invaluable, like you mentioned. The work chart is there just as a fallback when someone has financial responsibility or something, but it's that informal network nervous system. I'm gonna copy you on that from now on. I copied it from someone else. And take full credit, okay, yeah. Yeah, that's the manuscript I'd recommend folks to read about, about informal networks. The company behind the company. You know, that understanding the myriad relationships that in the organization are really important. There's actually a formal way you can do this, but I wanna caution you, it's not easy or necessarily the right thing to do. There are, in this manuscript that I'm gonna refer to here, talks about three types of informal networks. The advice network, which shows who's prominent, really good at solving problems. Who's technically really good at things. The trust network, which occurs because who can share delicate information. When things get challenging in an organization, who's got your back, right? That's really important. And then the communication network, like I talked about. Who talks to whom? Who knows somebody in a different department? Who can get something done quickly? Who's got their ear to the railroad track? Who can tell you how things are going? What's the morale? What are the stressors that are going on? It's really important to understand these different types of networks. So here's that manuscript that I really have enjoyed. I actually had a course from one of the leaders, David Krakart, during my Master's of Medical Management at Carnegie Mellon. The informal network, the company behind the chart. They did a great work on this and it's published in the Harvard Business Review. It's a great manuscript. I found it really fascinating. And as I read through it, I learned a lot. So the significance of these informal networks has a lot to do with turnover. If key people in your organization who own trust, they own great communication, if they leave, they leave with a lot of power and they leave an organization sort of gutted. But they can also, if you can really identify those people and see the value that they bring and you really listen to them, you recognize that they're the kind of people you really wanna work to retain and develop over time. So here's that formal chart that you talked about. Here's an example in the manuscript. This is a communication company and they've got four different divisions and they walk you through sort of the strengths and weaknesses of the various people in the organization. And the leader, the CEO, this guy Lears, is trying to develop a new strategy. He'd wanna be successful as an organization. So he's putting together a task force to get stuff done. So take a look at this advice network, Greg. Who would you want, if you're gonna lead a new strategic initiative in your organization, these are the various names in the organization. Who are you gonna choose? Oh, you gotta go with Calder or one of the people. I don't wanna go- That's a great idea. It's got the greatest number of connections, right? So what you can do is you can actually survey, you can find out who has, who is technically the best in the organization. These are the people that I saw had the greatest number of connections that others view as technically exceptional. But here's a mistake that people make all the time, Greg, is they think that people who are really good at doing a job are the ones who are the best at leading. So I'm gonna put someone in charge of an initiative or a project or lead a committee because boy, they're the best interventionalist or the best at doing whatever. They're the most productive consultant, right? They're your best doc. The problem is that that's not necessarily the person who owns the trust and the communication. So when you ask questions, you wanna find out like, who do you talk with every day? Who do you go to for help and advice? Who would you recruit if you gotta get something done in your organization? Who would you trust to keep confidence if you wanted to talk about a work-related issue? People don't always wanna answer surveys like this honestly, so you've gotta make sure it's a safe environment. If you're gonna ask people these types of things, you gotta recognize that you wanna, because someone might, if they don't trust you, they're gonna say, I trust everybody, I like everybody, everyone's great. They don't want it to get out that they don't like Joe around the corner, what have you. So you also can ask other people, what are their impressions of the networks that are happening? You can say, hey, who do you think Steve goes to for work advice? Or, I know Susan, who do you think Susan trusts to keep confidential information? And then you can map out these advice networks, that's what this manuscript gets at. And these are the, you can understand the politics that go on in organizations. I'm not an expert in organizational psychology by any means, but it is fascinating when you think about it. So here's what's interesting, right? This guy Calder, he's the senior vice president, right? He's the leader of one of those divisions. He only has two lines when it comes to trust, right? I don't know why I failed as a leader. He's technically great, but others don't really trust him. Look at this guy, Harris. Harris is the one that the CEO chose to lead the initiative, to be the leader of this committee. You know what? He found the committee was not very successful because Harris is off on his own, he's a loner. He's technically great at his job, and the CEO thought that he was a leader in the organization that really helped him get stuff done, but he didn't. These are the people that he needed to look at, Ruiz and Benson, right in the middle of that network. They were not only technically great, but they're also, they have a high level of trust. That's critically, critically important. But what's interesting, he ultimately chose Benson, and I was trying to read about why he chose that guy to lead the committee. The reason is because the CEO is on the list. He's on here, over here on the left, I'm sorry. And he felt that Benson had the greatest deep, deep bench of leadership. But the CEO actually didn't really know until he did the study. When he first asked him, like, who do you think people trust? This is what he thought the answer was. He thought that Calder had the highest level of trust in the network. So he wasn't really as accurate as the data actually showed. I talked earlier about this concept of betweenness. Betweenness are people who bridge, right? They make connections between different elements within the organization. And they're very important people, but they're also, it's very stressful. So think of this as someone who's like a critical linchpin, like in a labor negotiation between the union and the management. This is somebody who like knows a lot of the workers and people trust them, but they also know the management. And so if there's like a critical vote that can happen in an organization, these are the people that get torn, like they get pulled in both directions. So sometimes it can be politically difficult to be a between this person between two like management and labor. Not always easy, but it can be used in different contexts. You know, being in this intermediate position, very important. So here's just an idea of what this means to be between. This person, number three in the middle, has connections between two nodes within the organization. So understanding who those people are, and that's who, for me, I saw this individual who's ultimately now our medical director, having that kind of skill. Really important to understand this concept of betweenness. Now, sometimes things don't go well in these informal networks, and these are the types of things that can happen. You know, relationships can break down, or communication can have a negative influence on things. Sometimes employees can communicate only within their group. Sometimes they won't talk to their partners in the group. They'll only talk to people outside of their group. Sometimes the structures are very fragile. They're very temporary, and they can be broken apart easily because of either physical moves or some other change in the organization. There also can have holes in the network, and there also can be these things called bow ties, where players can be very dependent on that individual who's in the middle. I'm sure you've seen this too, Greg, like in your organizations, like you can see the dynamic changes that can occur, and guess what happens? You get a misalignment, right? Lack of poor communication in a project, you're not going to get a great outcome. I love this image, right? So one group thought they were building a bridge. The other one thought they were building a tunnel. So really important. So misalignments can happen all the time, right? You got your group practice structure, and this happened to me when I was a medical director because the hospital chose me to lead, you know, from their perspective, but within the group, I wasn't the most senior doctor in my group. I wasn't the practice administrator. I couldn't tell my partners what to do in the practice setting in the clinic. At the same time, I was seen as their boss over in the hospital. So that can be very challenging, and there's other conflicts that occur, right, that I pointed out about the formal structures and informal structures. You also get conflicts between for-profit and non-profit, contract versus employed, and, you know, this other concept. Sometimes people are here for a long time. Other people are only in an organization for a short period of time. They want to make a splash and move on. That happens a lot in the C-suite, right? Definitely happens. So here's a recommendation I would have is to learn how to be a highly effective medical director. This is published in the Physician Executive. It looks like 2001, so it's been out there for a while, but I think it's helpful as a backbone to think about, you know, how you can be most effective as a medical director, and Greg, I took a picture of you. I'm on the ground there, right? I thought you might think that, but, you know, if you learn to be a highly effective medical director and you learn how to navigate through the formal and informal structures in your organization, you'll be a champion. You know, you'll, at the end of the day, you'll be successful and you'll feel confident. You'll feel like you've achieved something, so you're not on the mat all the time. Yeah. Those are my thoughts. I've got my contact information here, Greg. I know you have your some good contact information as well, but yeah, I really enjoyed talking with you about this. Yeah. David, there's two things I wanted to point out, and you made great points, and that I'll emphasize just to everybody. You've got to build that relationship equity, and you're right, not in the conflict time. Learn about your staff. It's fun. We like people. It's good to have that because you're going to have to cash some of those chips in sometime because you're not always going to be able to remain cool and calm. You will have a hiccup now and then, and go back and, you know, recognize it. We're all people, and people will appreciate it. And there's a fine line between having good relationships and being best buddies. You got to be careful on that because then if people think, wow, are you favoring this clinician or that? They're buddies. They go out all the time together. It's a little tough as medical director. I was constantly aware of that, and when you find those people that are influencers and connectors, recognize them, but find the ones that can be honest with you. It's hard to hear, Greg, I'm not sure you did the right thing there. Are you sure? No, I think the docs are right on this. Doesn't mean you have to totally agree or follow, but you need someone who can give you some of that critical feedback, not as opposition, but as, wow, they want to make the organization better too, and that's what makes you probably a great leader. I know you have management skills, but you're exactly right. Leadership is a different quality with that, but that was a great presentation. You know, one thing I was thinking, one of the roles that's been, I think sometimes the most rewarding, but also some of the most challenging is managing performance issues. So people within the organization will come to you with concerns about your colleagues or other physicians or maybe APC performance, and you've got to manage that performance, which means you've got to confront those issues. You can't just hear about a problem and ignore it, because the problem is not going to go away. I've heard, and I really have come to understand this over time, that the culture of an organization is defined by the worst behavior it's willing to tolerate. And as a medical director, people are looking to you as a leader to hold your colleagues accountable and make sure that people are living up to the values of the organization and their performance expectations. And that doesn't always happen, which means sometimes you've got to have some difficult conversations with people. It might start with a coffee cup discussion about, hey, you know, I noticed this was going on. You might want to, you know, just giving you some feedback. What are your thoughts about this? But at some point, you're going to find yourself in one of those more difficult conversations where you have documented some performance challenges and you've got to hold someone accountable to that. And that's where that formal organizational chart comes in. Yeah. Like you said, it's when things are going a little rough and fingers start pointing, they'll go to that org chart to say, okay, you got to go in and fix this. I mean, you'll be tested as a medical director with a lot of noise and a lot of people, oh, you got to fix this. You got to talk to this. Some of it, you have to use a little benign neglect and also then recognize what are the things I need to take action on that are critical. Because if you acted on every little issue that came to you, you'd never leave the place. So I think that's where you've excelled is identifying. You got to have other people to help you, other leaders, whether they be formal or informal to really make that decision. This is something I need to act on. This has reached a point where I need to intercede. And it's tough. I think your point on the information, and this was a hard thing for me when I first went back to get my MBA, was there's a lot of science to organizations. There's a lot of science. We think, oh, we're rehab docs. We can figure it out. I would get educated on some of these things because there's tools I learned that I never thought I'd use that I found I went back and use that will help me in these situations. There's science to human behavior and organizations. Yeah, I agree. And I think I'm sure you've done this as well. I seek out advice from my partners here in leadership. So sometimes it's another chair. I can pull them aside and get some advice about something. It's my administrative director who is filled with wisdom and experience and has some great advice for me. And together, I think we're a better partnership. I can become a better leader when I can lean on others who are smart, insightful, creative. None of us can do this alone. So it's really important to lead with a sense of partnership and don't take your self too seriously. You've got to be humble. You've got to ask others for input. You've got to find internal and external mentors. Mentors are always people that are higher than you on the org chart. You can have mentors with that informal structure. And that's probably the best thing I love about going to meetings or learning. I meet people like you where I can learn from, hey, I had this problem. Hey, how did they handle something like this? And I can take your advice or I can throw it away, but at least I'm getting input. It's another set. Well, I was going to ask you, you know, we talked about misalignments and that's based on your org area and things. What's been probably one of the toughest you've dealt with to this point? Well, you know, one of the early misalignments I had to deal with were related to how our practice was achieving our success or organizational structure, you know, goals with using advanced practice clinicians and how the hospital was achieving their goals. And there was achieving their goals and there was a regulatory mismatch there because we had to make some changes to our contract with the hospital that was financially difficult for the practice. This was a time when initially all the APCs were first employed by the hospital. And for regulatory compliance, we needed to move them to the practice employment. And it was a very sticky, you know, navigation through the contractual facets. And I had a foot in both worlds, right? Because I was very, you know, involved in the hospital and compliance and the medical staff leadership, but also in my practice. And I knew that taking on all these additional costs was going to be financially very, very difficult, but it was the right thing to do. So there's a misalignment there that I had to deal with, you know, kind of a lot of backroom discussions with different people to make a good outcome there. I've also seen a misalignment in regard to getting big initiatives done where I thought I was on the right path, but I realized that there was a different level of within the organization of people who are resisting change. And I had to learn about what that change was. I needed to know who to go to and who to talk with to understand that maybe my ideas needed to be modified. How about you, Greg? What experience have you had with misalignment? Probably one is our rehab center, you know, was based with a for-profit company and there were some very good things. They could move quickly and I could get things done and not a lot of red tape. But at times I'd have, you know, do I bring this patient or not? Do we have enough staffing to handle this patient, whether it be nursing or whatever? And at points in times, you know, you're always going to have the docs if they want their way, they want everything, which is great. But like, you know, you got to draw a line. Well, you have a fiduciary responsibility, you know, to the organization and making it work. But we'd get so short on staffing at times, we would halt admissions. That's where it was important to know who had control of the admissions. My stick was, well, let's make it better. Only if it's unsafe when you halt admissions, not just, I want to go home early. No, that's no way. And fortunately, I was, the way my org structure was, I was employed by the university and I couldn't be fired by our partner. So that's how I had my influence. Now, at times my CEO might say of my medical school might say, why aren't you taking him? We need to get him out of our hospital. And once again, you develop your relational chips with the CEO of your system or with your dean, or whoever is above you in your org chart. Or if you're the head of the practice, you're going to have to make that tough decision. No, we can't take it. And, you know, it was pretty low when the CEO of our rehab center agreed with us. And I didn't get a lot of the kickback because not only was it for the patient, but we're burning our nurses out. It's a tough one. What's the right number? What do you use? And my only leverage was, wow, we can't handle it. So we're not going to bring them. Yeah. I've had very similar challenge recently with the changes in nursing ratios and having to really call on that informal network to navigate through those decisions. Because, you know, we're part of a very large organization and sometimes the med-surg ratios really don't apply to a rehab environment. They don't understand necessarily all the factors that we have to deal with because from the outside looking in, we don't look like we, you know, it's rehab, right? It's easy. But we know the burden of care for our staff and very challenging with, you know, agitated brain injury patients or spinal cord injury patients who have a lot of care needs. You know, the burden of care is not always told by the number of IVs that you're hanging in or, you know, the meds that you're getting. So acute care ratios don't always work when you apply it to rehab. So that's when we had to reach out, not only within the organization, but outside the organization to ask other programs, what are the appropriate nurse patient ratios? And how do you navigate through that within your organization when you don't have a dotted line? It's not under your direct control. You've got to have influence. You have to explain to people, use evidence-based, use examples, you know, benchmarks from other organizations. Yeah. Oh, yeah. Because it was, I mean, ultimately if we couldn't bring in admissions and it impacted my bottom line for my group of physicians, because we're highly clinically, you know, funded off our clinical activity. So it's tough. I mean, those are my hardest decisions. And just like you said, no margin, no mission. Well, I often say no mission, no margin. You can't get people to buy in if they don't feel good about the culture or what they're doing. Hopefully, you know, they have to feel a little driven on, you know, this is what I want to do. This is how I want to help people. And yeah, this isn't a job. It's a profession. You know, it gets kind of sappy, but that is what helps drive great programs. It's the people that you have, you know, doing that. I agree. Greg, even beyond that, you know, I have thought a lot about it. It's not just a profession. Hopefully, it's a calling. Yeah. So ultimately, that's why we come to work every day. And we, you know, try to do a good job for ourselves, for our patients, our organizations, our families. It's really important. Yeah. And I think that's why building that personal relationship with different people, you build up that equity that you want to cash in later. When you ask he or she to do something, they know you're not doing it out of, hey, and I think it is important. Like, I know you, you got, as a leader, you got to be in the mix at times and do some of the grunt work too. We know, Greg, I always come away from these conversations with you feeling smarter. You know, you add so much, you help me think about problems in a different way. And I really appreciate the opportunity to meet and present to this group at the AAP Menar. Folks are going to be future leaders of our profession and our field. And, you know, it's been great. So thank you very much for participating in this. Well, I thank you. I feel the same way, David. And actually, I want to thank the people that are participating because they're going to be the future leaders taking care of you and me in the future. And I'm excited that you guys are putting the time and effort in. Make it fun. Make it fun. It's not the destination, it's the journey. As David and I both, if you'd ever said I was back here where I grew up, I would have never said that. But find your, let it flow and enjoy. It's been, it's a great activity. So David, I feel the same way. Thank you for all you've done, all you continue to do. And hopefully the people on this call will get to meet each other in the future and build some of the relationships we've had the ability to enjoy. So I think we're going to be present after they do the live, this presentation. So hopefully if you have questions, we can take some then. Great. Yeah. Looking forward to it. Thanks, Greg. Thanks, David.

Medical Director

AAPMNR

Governance

Organizational Structures

Medicare

CMS Regulations

Inpatient Rehabilitation Facilities

Leadership

Trust Networks

Communication

Professional Development