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ABSTRACT The recent and profound changes in the American health care delivery system have
created a need for physicians who are trained and willing to assume a high level of
responsibility for managing evolving health care organizations. Yet most physicians receive
no formal training in medical administration and management because changes in
medical school and residency education have lagged behind changes in clinical practice
and reimbursement. To avoid haphazard approaches and unnecessary duplication of
resources, it is important for physicians involved in managerial medicine to collectively
identify competencies in this area needed in the marketplace. The American College of
Preventive Medicine (ACPM), with funding from the Health Resources and Services
Administration (HRSA), undertook an effort to identify competencies essential for
physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort
to develop core competencies in preventive medicine, this project drew upon the
theoretical model of competency-based education. This article describes the strategy we
followed in reaching consensus among a diverse group of physician executives and
preventive medicine residency program directors, and includes the list of medical
management competencies and performance indicators developed. Recurrent issues that
can sidetrack competency development projects are also presented as well as suggestions
for overcoming them. The competencies can serve as a framework for expanding current
core preventive medicine training in management and administration and for developing
new training programs to equip physicians with the special expertise they will need to
provide management leadership within the changing landscape of health care delivery.
Medical Subject Headings (MeSH): competency-based education, preventive medicine,
organization and administration. (Am J Prev Med 1998;14:229 –236) © 1998 American
Journal of Preventive Medicine
T
he recent and profound changes in the Ameri-
ethicists. In this increasingly complex arena, there is an
can health care delivery and reimbursement
urgent need for physicians with expertise in medical
systems have created a need for physicians who
are trained and willing to assume a high level of management.
responsibility for managing evolving health care orga- Yet most physicians receive no formal preparation in
nizations. Physician leadership is critical for attaining the management of health care services and systems.
balance among conflicting pressures for quality of care Changes in medical school and residency education
versus cost containment, prevention versus high-tech- have lagged behind the changes in the landscape of
nology medical intervention, and application of special- clinical practice and reimbursement. A survey con-
ized versus primary care. Physicians must be involved in ducted more than a decade ago revealed that more
resource allocation because of their knowledge of the than 80% of physicians who work in administrative
clinical implications of management decisions. Individ- positions believe that formal management training
ual physicians’ decisions about medical care are now should either be required (22%) or is advisable (62%)
challenged by third-party payers, lawyers, legislators, for physician administrators.1 The authors concluded
that integrating management principles in a medical
context is the best way to provide this training, which
From the Department of Preventive Medicine, School of Medicine, State
University of New York at Stony Brook, (Lane) Stony Brook, New York, they predicted will become even more important in the
USA 11794-8036. (Ross) 116 Garden Lane, Decatur, Georgia 30030. future. Recent surveys of both young physicians and
Address correspondence to Dorothy S. Lane, MD, MPH, Depart-
ment of Preventive Medicine, School of Medicine, HSC 3-086, State
health management organization (HMO) administra-
University of New York at Stony Brook, Stony Brook, NY 11794-8036. tors have concluded that medical training is not ade-
ing in this field of practice. In addition, the work group ments that suggested additional detail for the same
reviewed and updated the existing core preventive performance indicator, on the other. This dichotomy
medicine competencies in management and adminis- particularly applied to areas relating to financial man-
tration for residents of all preventive medicine resi- agement and evidence of leadership abilities. Through
dency training programs. discussion and additional written feedback to reach
The results of the working session were discussed at consensus, the work group agreed on the revised final
the Annual Workshop of Preventive Medicine Resi- version presented below in Results.
dency Program Directors held later that month and in In the competency development sessions, providing
various forums held in conjunction with the national committees with lists of possible verbs useful for formu-
Prevention ’97 conference. In addition, the medical lating competencies facilitated the development pro-
management competencies and related updated man- cess. A suggested list of verbs is displayed in Table 1.
agement and administration core competencies were Our experience also led us to identify several recurring
mailed for comment to a broad audience of interested tendencies that can potentially sidetrack the process of
parties: preventive medicine residency program direc- competency development by a committee, as illustrated
tors in all three specialty areas; members of the Board in Table 2.
of Regents of the ACPM; members of the ABPM;
members of the Residency Review Committee (RRC)
Results
for Preventive Medicine of the ACGME; members of
the Board of Directors of both the ABMM and the
Medical Management Competencies
ACPE; and other individuals interested in training in Delivery of Health Care
medical management. Numerous comments were re-
1. Design, manage, and evaluate health service delivery
ceived on the draft. While virtually all included positive
programs to improve the health of a defined popu-
remarks and appreciation for the work that was being
lation.
done, a few respondents expressed a particular con-
cern. The concerns noted were: the feasibility of devis- This reflects demonstrated ability in:
ing managerial experience in which residents can ac- a. planning and implementation of strategies for
complish these competencies during training; the health promotion, disease prevention, demand
status of medical management as a legitimate medical management (self-care), and disease management
field; whether preventive medicine should embrace in a health care organization.
medical management as a primary, separate branch b. design, implementation, and evaluation of clinical
within the field and whether the competencies are the practice guidelines, quality management/quality im-
exclusive domain of preventive medicine. A particular provement programs, utilization management, case
challenge in finalizing the competencies and perfor- management, and other activities to enhance an
mance indicators involved balancing comments that organization’s performance and reduce practice
residents could not be expected to master a particular variation.
performance indicator, on the one hand, versus com- c. evaluation of health service delivery through appli-
z Groups accustomed to designing curriculum tend to think in terms of knowledge rather than skills. Looking at knowledge
only makes measurement of competence difficult. (For instance, “Understand factors affecting patient compliance.”)
z An effort to make competencies as precise and measurable as possible can lead a group to reduce significant competencies
to trivial—but measurable—tasks. This tendency is called atrophy. (For instance, “List three types of health plan outcome
measures.”)
z Focusing on activities or particular learning situations can obscure the intent behind a competency. (For example,
“Accompany a health official to a legislative hearing,” “Describe the functions of the divisions within the State Department
of Public Health.”)
z Groups may exemplify contradictory tendencies toward developing, on one hand, a detailed “wish list” of desirable
competencies in the area; and on the other, a cautious, restrictive list, possibly based on concerns that these competencies
will ultimately be appropriated for use in accreditation and certification.
z In considering how to evaluate achievement of competencies, groups may suggest using a scale along which residents can
be rated at several points ranging from poor to excellent performance. We found it important to remember that
competencies do not lend themselves to this type of evaluation. One is either competent or not; rating a resident “a little
bit competent” renders the term meaningless.
z Groups often disagree about whether residents can be offered sufficient responsibility during their training or if additional
practice experience is required to assure competency in a particular area. (For example, “demonstrate effective leadership
capabilities.” In this case, demonstration of elements of leadership, e.g., “development of a shared strategy,” can be
accepted as evidence of the ability to assume real leadership roles on the job).
z Groups are often divided about whether to use current terminology or jargon in their competency definitions or whether
to use language that addresses underlying skills (for example, “TQM” versus “quality assurance”). Recognizing that the
limited use of “buzzwords” may be considered to be important evidence of relevance to current practice, it is at least as
important to use language that will be understandable to a broad, general audience and that will remain understandable
even after current buzzwords are replaced by newer ones.
cation of techniques such as process improvement, financial management reports and development of
benchmarking, outcomes assessment, and clinical recommendations to enhance organizational effec-
epidemiology. tiveness.
d. analysis of the impact of managed care (e.g., HMO, b. use of techniques such as cost-effectiveness analysis,
POS, PPO) and other health service delivery sys- cost-benefit analysis, and decision analysis (includ-
tems/reimbursement models (e.g., fee for service, ing prioritization) to allocate and manage clinical
third-party payer, managed indemnity) on the and financial resources.
health of defined populations, patient, payor, and c. preparation of a business and financial plan that
provider needs and behaviors, and organizational incorporates basic accounting principles (e.g., anal-
performance. ysis of balance sheet, income statements, proforma
e. use of marketing strategies to promote appropriate projections, statement of cash flow), and techniques
participation in a population-based health service, to such as cost accounting, pricing of services, analysis
alter patient, provider, or organizational behavior in of return on investment, market prediction and
order to improve health and the delivery of health analysis, economic valuation of service to client and
services, and/or to support the development of group, recognition of the need for capital formation
health care products or services. and budget development to evaluate current or
f. use of systematically collected data to prioritize proposed health care products or services.
system problems, identify and implement best prac-
d. assessment, negotiation, and management of pro-
tices, continue to improve service delivery, and
vider contracts, including such issues as basis of
assure appropriate utilization of services.
payment (e.g., capitation, fee-for-service), risk-shar-
g. evaluation of the effectiveness, medical necessity,
ing, and reporting requirements.
and appropriate use of products and interventions.
e. preparation of a strategic plan that analyzes the
h. design of systems of care that meet patient needs for
external environment (including competition and
access and acceptability, and measurement of pa-
legislative regulatory changes), the internal environ-
tient satisfaction with these systems.
ment (including staffing and ethical issues), and
Financial Management strengths, weaknesses, opportunities, and threats
2. Apply appropriate financial and business manage- related to the success of the enterprise.
ment techniques to assure efficient delivery of cost-
f. analysis of insurance principles (e.g., adverse selec-
effective health services.
tion, law of large numbers, risk analysis, communi-
This reflects demonstrated ability in: ty/experience rating) and ways insurance benefits
a. critical interpretation of capitation and standard are packaged, priced, and implemented to facilitate
competencies and performance indicators appear in the 4. Nash DB, Markson LE, Howell S, Hildreth EA. Evaluating
Appendix. The authors also acknowledge the important the competence of physicians in practice: from peer
contribution of Carol O’Neill, Director of Education, and review to performance assessment. Acad Med 1993;
Hazel Keimowitz, Executive Director, of the American Col- 68(Suppl 1):S19 –S22.
lege of Preventive Medicine, for providing staff support and 5. Stein DH, Salive ME. Adequacy of training in preventive
meeting management and integrating the project with ongo- medicine and public health: a national survey of resi-
ing ACPM activities. dency graduates. Acad Med 1996;71:375– 80.
6. Lane DS, Ross V. Consensus on core competencies for
preventive medicine residents. Am J Prev Med 1994;10:
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