Hospital medical director. Documenting roles and responsibilities

Establishing the position of medical director for a hospital entails making a clear exposition of the role of the medical director in relation to the board, the basic administrative structure, and the medical staff. The responsibilities assigned to the medical director in one hospital may differ in more than a minimal manner from those in another institution, and the nature of these relationships may also vary because hospitals differ in their traditions, internal power relationships, and functions. Because of these differences, the need to be precise about roles and responsibilities becomes even more obvious.     

Physician executives: where they are and what they do

As hospital operations become increasingly complex, so does the institution's management and organizational structure. Physician executives with titles of medical director, vice president for medical affairs, medical administrator, chief of staff, medical staff president, etc., are playing more important roles than ever before. This article will briefly review some recent literature describing physician executive profiles. The results from a survey of ten university teaching hospitals are also presented as supplementary information regarding current staffing models. Finally, several physician executive staffing-related issues will be discussed in light of the literature and the survey results.     

Seven lessons in medical management

In more than 15 years of functioning as a medical director, addressing the needs and wants of patients, physicians, hospitals, and ancillary health care suppliers, I have accumulated pieces of ?wisdom? that I now feel I should share with others in medical management. The concepts are fairly simple, but they are of significant value in the ?real-life? management of people. The seven simple ideas outlined in this article are not meant to be the end-all to management philosophy. Books have been written about each idea, and there are hundreds of good ideas in many sources I do not touch on here. However, I have found these seven items of significant value in dealing with others and hope others find them similarly useful.     

Strategically integrating hospital/home care services for improved profitability

Because hospitals and home health agencies have been predominantly separate organizations, coordination of their efforts has not been optimized. However, with the recent proliferation of hospital-based home health agencies, opportunities to integrate these health care service delivery systems have increased. Bethesda Memorial Hospital, Boynton Beach, Fla., is a 362-bed not-for-profit community hospital with a Medicare-certified home health agency organized as a department of the hospital. Until recently, the home health agency was generally perceived as a separate entity whose services were distinct from hospital services. Progress toward integration of hospital and home care services was given impetus through collaboration of the home health agency administrator and a newly appointed director of medical affairs who was given the responsibility as medical director of the home health agency. A prime responsibility of the director of medical affairs was to reduce length of stay and hospital costs through appropriate resource management.     

Chief of staff and medical director: conflict or cooperation?

Inevitably as the role of the medical director expands, it will directly affect power structures already existing in the hospital hierarchy, including department chiefs, other administrators, and the chief of staff. This article will attempt to define the roles of the medical director and the chief of staff, explore possible conflicts, and provide suggestions to help avoid confrontation. Finally, an attempt will be made to look into the future direction of the medical director's position.     

Managing health care quality.

Using the cited principles of professional staff credentialing and quality assurance, a department chairman, medical director, or other health care executive will be in an excellent position to assess quality of care against established standards and manage problems in the routine provision of medically appropriate care. He or she will also be able to assure the hospital's board that the hospital and its medical staff are well positioned to meet future challenges to provide effective quality, utilization, and risk management.     

Hospital management's linchpin: the medical director.

The practice of medicine has become increasingly complex in this era of diagnosis-related groups (DRGs) and other direct government involvement in health care; complex and seemingly inappropriate legal decisions; liability chaos; and increasing competition from peers, entrepreneurs, and other health care organizations. In this new environment, an old player, the medical director (vice president of medical affairs) has been given new visibility and increased responsibilities to help physicians live with and overcome these environmental factors. In showing how the medical director can be of assistance in putting these factors into perspective, it is helpful to take a look at some aspects of the history of medicine, analyze the education process for physicians, point out where the profession began to be driven off course, and identify some of the overall problems of the profession and of the health care field. It is my intent here to project the position of medical director as a vital, frequently missing, link in the attempt to maximize communications, understanding, and achievement in health care organizations.     

An evolving medical leadership position. Tomorrow's Vice President for Medical Affairs

The role of medical leadership in hospitals and health systems is under constant scrutiny and change. The nature of the Vice President for Medical Affairs (VPMA) position and its relationship to leadership in the health care system is explored through a national panel survey conducted recently. The effective VPMA will: be an aggressive manager able to implement change, address strategic planning and quality of care issues; have a high level of integrity; and be a good communicator and problem solver. The results of the research are presented in three sections. The first section describes the background characteristics and compensation of the VPMAs who participated in the survey. The second section focuses on the current role of the VPMA, including duties and responsibilities, job performance barriers and required skills. The final section addresses respondents' perceptions regarding areas for improvement in the role of the VPMA, as well as projections for future changes in this position.     

Compensation for chiefs of staff: a '90s phenomenon

As part of its annual survey of physician executive compensation levels, the Physician Executive Management Center, a Tampa, Fla.-based physician executive search firm, sought information on compensation of medical staff leaders. In this report, the Center's findings are summarized. Forty percent of the responding hospitals compensate these leaders in cash, with an additional 34 percent providing noncash benefits. Three-quarters of the hospitals thus indicate recognition that some kind of compensation for voluntary medical staff leaders is warranted.     

Quality management remains top medical manager responsibility

Earlier this year, the Physician Executive Management Center conducted a survey of physician executives in management positions in hospitals, group practices, managed care organizations, and industry. Information was obtained for physician executives in both full-time and part-time roles. In addition to gathering compensation information, the survey sought to define the scope and intensity of the responsibilities of physician CEOs and senior medical managers (medical directors or the equivalent) in these organizations. In this article, the authors summarize the findings on responsibilities for senior medical managers in hospitals, group practices, and managed care organizations.     

IT Governance Characteristics,Electronic Medical Records Sophistication,and Financial Performance in U.S. Hospitals: An Empirical Investigation

As a result of a recent federal government mandate, an increasing number of hospitals have decided to adopt electronic medical record (EMR) systems. This initiative is expected to lead toward more efficient and higher quality health care; however, little is known about governance characteristics and organizational performance for EMR adopters. Our goal is to inform theory and practice by examining hospitals with a sophisticated EMR and comparing those hospitals to similar hospitals (with a less sophisticated EMR) to understand the association between information technology (IT) governance characteristics and the implications on financial performance. Leveraging elements of the upper echelon theory, we posit that hospitals in which the chief information officer (CIO) reports to the chief executive officer, CIO turnover is low, and an IT steering committee is present are more likely to have a sophisticated EMR. We argue that EMR sophistication leads to improved financial performance. Our results underscore the importance of continuity in the CIO position on successful EMR implementations. Results also show that hospital size and financial performance are strongly associated with EMR sophistication. In addition, we find that a sophisticated EMR appears to be a fundamental element in improving hospitals’ revenue cycle management. Moreover, we find that hospitals with a sophisticated EMR appear to be more profitable. Finally, we observe that total payroll expense adjusted by total discharges drops among the sophisticated hospitals, potentially due to an increase in employee productivity. These insights can serve as a basis for tempering expectations relative to the financial impact of EMR adoption.     

A strategy to enhance accountability in health care delivery

The New York State Department of Health surprised many in the hospital industry and medical community when, in June 1987, it proposed as regulation that the governing body of each acute care hospital appoint a medical director who would be assigned responsibility for the direction of the organized medical staff. Such a proposal, without modification, has been incorporated in the New York State Hospital Code--Minimum Standards, effective January 1, 1989. While a strong case can be made for this position in hospitals, its value has long been recognized by a wide variety of organizations.     

Part-time medical director: way station or end of the line?

This article is mostly directed to physicians who are contemplating a career change into management. You may be one of those persons who is contemplating taking a part-time position and continuing part-time clinical practice to see if you might enjoy management. It is important to understand that a part time medical director is there primarily because management perceives a need for a physician's skills and license. When a physician is hired on a part-time basis, it is unlikely that management realizes the larger benefits that can accrue to the organization from the physician manager's knowledge of health care and unique approach to the problems and opportunities in the delivery of that health care. Part-time medical directors seldom have an opportunity to be exposed to real management issues and activities and are usually sequestered and limited to functions that a naive management team thinks are most appropriate to a physician's skills and temperament. Be cautious in extrapolating a part-time experience to a full-time role. Consider taking the plunge to full-time management without a part-time transition phase.     

HOSPITAL ADMINISTRATOR FELT NEEDS FOR INTERORGANIZATIONAL COOPERATION AND ACTUAL COOPERATIVE OUTCOMES BY THEIR HOSPITALS

This paper presents an empirical analysis of the determinants of interorganizational cooperation among hospitals. Hospital administrator felt needs for programs of interhospital cooperation and actual cooperative outcomes by their hospitals are examined. A combination of survey and archival data is used to test several research hypotheses. Results support separating the interorganizational activities of hospitals into those related to medical and those related to ancillary service areas. Felt needs to cooperate in both service areas are influenced by administrators' concerns for hospital autonomy and image in interorganizational relations. Perceived availability of cooperation partners affects felt needs to cooperate only in the area of medical services. Actual levels of cooperative activity in medical services are related to perceived manpower resource scarcity, historical levels of cooperation, and concerns for hospital image in interorganizational relations. In ancillary services, actual levels of cooperation were related to perceived financial resource scarcity, historical levels of cooperation, and perceived availability of cooperation partners. Felt needs to cooperate were not associated with actual cooperative outcomes in either service area. The results contain implications for future research into the decision processes that give rise to interorganizational relationships of cooperation.     

Compensation for elected hospital medical staff leadership

As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership.     

The telephone encounter: the cast of characters encountered by the physician executive

Volumes have been written about telephone productivity, decorum, behavior, and economic impact. Although every physician is skilled in telephone communication, medical directors must approach this communications modality from a different vantage point. The attending physician uses it as an information receiver and transmittal station. The medical director uses it as a negotiation platform. It is estimated that 50 to 90 percent of the medical director's time is spent on the phone. "Working smarter" can increase productivity to save time and stress. This article identifies and categorizes many of the problems that the medical director deals with on a daily basis. It pertains to phone conversations in which there is a question about a procedure, appropriateness of care, medical necessity, or quality of care.     

Physicians and economics: a commentary

This article discusses the physician in the United States in relationship to economics. Because economics forms the basis of most of the debate concerning health care in this country, it is important to look at the physician's background, position, and future as they relate to this important area. Eight economic encounters met by the physician are considered: the physician's relationships with knowledge, patients, peers, hospitals, medical technology, malpractice, managed care, and the future. The purpose is to encourage discussion and introspection and to suggest possible future avenues of education and training to address more completely the economic necessities that now are so closely entwined with the profession.     

Why and when female directors are less engaged in their board duties: An interface perspective

Female representation on boards is perhaps one of the most studied topics in board-governance research. At the same time, much is unknown about female directors' task engagement within boards. Drawing from psychological theory on societal gender beliefs, our study tests whether the impact of director gender on supervisory task engagement hinges on status dynamics in two relational interfaces: the director–board interface and the director–CEO interface. According to this perspective, female directors show less task engagement because gender is a diffuse status cue that creates status differentiation within the director–board interface. Multi-source board survey data (n = 61 boards, n = 315 directors) confirms that, within the confines of the boardroom, female directors do, indeed, receive lower-status ratings than male directors. This effect is weaker when boards have a female chair. Furthermore, lower status explains perceived lower task engagement of female directors, but this link critically hinges on the CEO–director interface. The impact of status differences is more pronounced when directors intersect with a relatively dominant CEO. All in all, the results demonstrate that relational interfaces play a key role for female directors’ task engagement in their board duties.     

The case for a physician director of the surgical suite

A typical hospital operating room can generate revenue of $1 to 3 million per year. About 30 to 40 percent of the total income of a hospital is produced in the surgical suite. This is a high-cost area in terms of personnel, equipment, and supplies, so strong management is increasingly important in the area. In the past few years, a number of hospitals have found a solution in a physician director for the surgical suite. Although the physician for this position may be of any specialty, the chief of anesthesiology or an anesthesiologist with strong management and communication skills is the best choice. Usually, an anesthesiologist spends the most time in surgery and does not have special allegiance to any surgical specialty. He or she has a vested interest in smooth functioning and success of the surgical suite.     

Benefits of Surgical Smoothing and Spare Capacity: An Econometric Analysis of Patient Flow

In this study, we examine the hospital's ability to admit patients from its emergency department. From a medical perspective, the number of patients being admitted should depend solely on the patients’ clinical conditions. Using a large‐scale econometric study that includes detailed operational and clinical data on all cardiac patient encounters from a set of 128 hospitals over a period of four years, we show that this is not the case. In particular, we find that independent of their medical condition, many emergency patients are denied hospital admission because of a lack of inpatient beds. Our analysis suggests that having one more inpatient bed at the start of a day can increase the likelihood of an emergency room patient admission by around 3% on average. We examine two policies – active discharge and demand smoothing – that can help hospitals improve patient access. We find that some hospitals actively discharge inpatients when beds become scarce; hospitals that follow such an active discharge protocol are, on average, able to admit more patients. We also investigate to what extent the hospital's ability to smooth its surgical schedule impacts hospital admissions. Hospitals tend to schedule their elective patients early in the week (Mondays and Tuesdays), and discharge them by the weekend in order to minimize weekend staffing, effectively maximizing bed occupancy during the middle of the week. This “weekend effect” artificially induces variability, and reduces effective system capacity. We find that by scheduling patients more uniformly over the week, hospitals can dramatically increase patient access, obviating the need for active discharges or additional capacity investment. Our analysis quantifies these effects, and can help hospitals make effective capacity management decisions in order to improve patient flow.