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 l,1989.(1) While a strong case can be made for this position in hospitals, its value has long been recognized by a wide variety of organizations.

Although regulatory adoption of the medical director position in hospitals appeared unique when New York State took the action last year, the need for(2) and the value of (3,4)" such a position in health care organizations has been acknowledged and implemented by many well-established health care centers of excellence for over a decade. Without using the title "medical director," the mandate for such direction was formalized in 1986 by the Health Care Financing Administration (HCFA) of the Department of Health and Human Services as a condition of participation in the Medicare program: "...responsibility for organization and conduct of the medical staff must be assigned only [emphasis added] to an individual doctor of medicine or osteopathy."(5) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) still does not include the position of "medical director" in the Hospital Accreditation Manual

1990)6 as a standard in the management or medical staff chapters.

While it has been suggested that only physicians can grasp the professional nuances peculiar to the activities and governance of the organized medical staff, the same can be said of the professional manager regarding the administrative skills necessary for application of sound management practices in health care facilities.' It is also true that the majority of hospital medical staffs function primarily as membership organizations, where preservation of individual freedom is the driving force. There is less emphasis on the effective management necessary to apply medical standards in credentialing and peer problem-solving, with concomitant accountability to the governing body.(8,9) Due process and parliamentary rules take precedence over effective decision-making principles of participative management.10 For the organized medical staff to transform itself from a fraternal representative association requires a major shift in its culture. Professional organization and management of the medical staff must be acknowledged as adding value to the group and not just as an additional expense of operations.(8-11) Recent literature supports the premise that a well-organized and -directed medical staff is a structural indicator of quality.(10,12-15) Efforts to identify the impaired or "troubled" physician have been intensified by statutory mandates and regulatory means. A "national clearing house" will shortly come online as the repository for all sanctions imposed on and negligent acts attributed to physicians.(16)

New York State has had such reporting requirements since 1975.(17) However, the more basic question about the competency of the organization that has spawned and nurtured the impaired practitioner has just begun to be asked (18) Brook, speaking before the Group Health Association of America in 1987, reinforced the concern over the incomplete search for causation in quality and safety" issues. He stated that "most organizations spend their efforts finding the 'troubled' physician and not addressing how to change the 'troubled' system."

Benchmarks in judging an institution's commitment to system repair, as well as to a search for "bad apples," will be seen in the manner in which the governing body and the organized medical staff select, train, and reward physician leadership. Restrictions and ambiguous qualifications for leadership of the medical staff organization and its subsidiary units will need to be reexamined to ensure their relevance in securing effective management. While formal clinical credentials will still be a sine qua non," a record of participation in structured learning experiences directed to acquiring system-building and organizational dynamics skills will have ever increasing weight in the selection process. The learning process will need to be correlated with a track record of effectiveness in managing change, both behavioral and systems. The institution will have to be willing to commit resources to leadership development and to provide motivation for those interested. For its part, the organized medical staff must ensure attendance by its members at such learning experiences." The New York State Health Department had encouraged hospitals to use the services of appointed medical directors prior to the adoption of the regulatory amendment. In several instances, where the department's survey process identified medical staff and quality assurance deficiencies in association with poor patient outcomes resulting from substandard practices, this encouragement took the form of mandated corrective action. The department's perspective in these instances was that medical staff problems-often involving failure to adhere to medical staff bylaws and rules and the hospital's quality assurance plan--could be addressed, at least in part, with the appointment of a physician responsible for direction of the medical staff organization.

In order to monitor implementation of this statewide mandate, consideration of the resource pool of trained and knowledgeable physicians available for appointment had to be considered. At the end of 1987, 144 New York physicians were members of the American College of Physician Executives. College records show that 121 New York physicians had attended College programs and received educational credit. Of this group, 52 had attended or enrolled in the "Physician in Management" seminars offered by the college. By the end of 1989, these numbers had increased to 352 New York members, 317 with educational credits and 98 in training program for physician executives (table 1, below). Of the current 352 College members in New York, 171 are affiliated with acute care hospitals, 83 have educational credits (does not include those attending "on-site" programs in the state), and 36 have completed or are enrolled in the College Physician in Managment 'seminars.(19) These numbers do not take into consideration physicians who have obtained advanced professional degrees, who have obtained system-building skills through other executive education programs, or who are capable of leadership roles because of recognized experience.

In a telephone survey conducted by the six Area Offices of the Office of Health Systems Management, New York State Department of Health, in April 1988, it was asked, "Does your hospital recognize a physician or other medical staff person as accountable for the medical staff organization?" An affirmative response was given by 158 (59 percent) of 267 acute care facilities (table 2, page 19). Personal observations by the authors, however, indicate that many of individuals filling the role fit the mold of the volunteer fireman" described by Goldsmith.(20)

The Department of Health, through its Bureau of Hospital Services, monitors the management of the medical staff organization of each of the now 258 acute care hospitals in New York. The monitoring covers the functions of the medical staff as delineated in the hospital code, especially the sections relevant to medical staff accountability and organization and quality assurance. Although recent publications(21-24) have suggested that medical directors are most effective when serving as liaison between the medical staff and the governing body or in a coordinating staff position within hospital management, the health department will hold the governing body, through its appointed medical director, accountable for the effective performance of the assigned responsibilities. To date, the department has focused on the establishment and appointment of the medical director, with less emphasis on the management effectiveness of these individuals.

The position of medical director, with its authority, responsibilities, and accountabilities, should be delineated in the corporate bylaws of the hospitals, but, as a minimum requirement of the hospital code, a position description is expected to be a part of personnel policies and practices. If a search committee is the vehicle of choice for selection, it needs to be composed of management, governing body, and medical staff leadership.(20-21) Individuals who control the selection process should be looking at candidates who can define goals and priorities, motivate people, evaluate the performance of subordinates, distinguish between line and staff authority, and manage others effectively.

The Department has rarely cited the medical staff leadership or the medical director for administrative ineffectiveness, although such action had been taken before the introduction of the revised code. Future surveys will increase the spotlight on management and managers for the medical staff and on quality assurance functions and will identify ineffectiveness, with attribution to the appropriate position of the organization.

Although the appointment of a medical director is an important step in exacting accountability of the organized medical staff for its delegated functions, a void can exist when specific areas requiring management pertain not only to the medical staff organization but to each of its operational subsidiaries. While each of the services or departments retains autonomy for services to its patients, the matrix reporting relationships for meeting the goals of the organization must be preserved. The solution is the physician manager who not only supervises and provides patient care but has the skills to create new administrative processes, the patience to problem-solve, and the ability to manage the operational and financial systems at the unit level.(3,8,25). Angemeir and Booth refer to this position as the "clinical unit director.(21) They present a table of organization that delineates the relationships to authority for the different functions as well as a formula for compensation of the incumbent for hospital-based services. Installing physician managers throughout the organization is replete with potential barriers. They have to have good people skills, a desire to manage, and the charisma of the "Lone Ranger." They then have to be trained, agreeing to a learning curve that climbs steeply in terms of time and commitment to the educational process, and to juggle patient load and management responsibilities without collapsing under the day-to-day pressures of conflict and crisis interventions.

In concert with the selected individual, hospital management needs to lay out a program, over time, with an explicit list of targets and priorities; develop a position description that delineates the assigned responsibilities; identify the delegated authority for implementation; and define the role to avoid conflicts of interest. More critical, however, is documentation of the commitment to the position from the governing body.

Williams and Donnelly(27) recommend that these physician managers be appointed by the governing body and be accountable to the medical director for their clinical and administrative responsibilities. The New York State hospital code recognizes this management relationship and enumerates an additional(17) potential(28) services in which the physicians are expected to, at least, direct a clinical service, evaluate the care provided against professionally recognized standards of practice, and develop and implement strategies for change when necessary to improve care. The Department of Health expects these positions to be accountable to the medical director of the hospital. Although the hospital code is silent on the method of appointment, it is acknowledged that the individual could be in the position through election by his or her peer group.

The literature and experience demonstrate that the future of quality health care delivery will hinge upon involvement and collaboration of physicians in the management control systems of hospitals and health care organizations. To have credibility at the management table, physicians must acquire the leadership and management skills necessary to participate actively and constructively in response to the internal and external environments affecting the profession. The days of the volunteer fireman" for the medical staff are not only numbered (2O) but need to be relegated to the archives of medical administration. The position has served the profession and its patrons well. The management failures in the health care revolution" cited by Herzlinger(29) must include the inadequacy of the medical profession to apply sound management principles to organization and conduct of the medical staff. A renewed strategy to ensure accountability in health care delivery, along the lines of the measure taken by New York State, is needed for correction of this failure.

References 1. 10 NYCRR, Part 405: Section 405.2, & 405.4. (Amended 1988) 2. Kralewski, J. The Physician Manager and the Evolving Health System.' in The Physician in Management. Schenke R., Editor. Tampa, Fla.: American College of Physician Executives, 1981. 3. Heyssel, R., and others. Decentralized Management in a Teaching Hospital. A Special Report.' New England Journal of Medicine 310(22):1477-80, May 31, 1984. 4. Ottensmeyer, D., and Key, M. The Unique Contribution of the Physician Executive to Health Care Management.'In Now Leadership in Health Care Management.- The Physician Executive, Curry, W., Editor. Tampa, Fla.: American College of Physician Executives, 1988. 5. Medicare and Medicaid Program, Conditions of Participation for Hospitals.' Federal Register 57(116):22044, June 17,1986. 6. Accreditation Manual for Hospitals 1990. Chicago, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 1990. 7. Lorsch, L., and Mathias, P. When Professional Have to Manage (Producing Managers). Harvard Business Review 65(4): 78-83, July-Aug. 1987. 8. Rubin, 1. Organizations Have to Grow up." Physician Executive 13(2):2-6, March-April 1987. 9. Hospital----Medical Staff Relationships: The Report of the Joint Task Force. Chicago, Ill: American Hospital Association and American Medical Association, Feb. 1985. 10. Delbecq, A., and Gill, S. Justice as a Prelude to Teamwork in Medical Centers.' Health Care Management Review 10(l):45-5 1, Winter 1985. 11. Ellis, W. Diagnosis Related Groups (DRGs): A Symptom in Search of Treatment.' New York Pediatrician 2:3, Winter 1984. 12. Palmer, R., and others. 'Individual and Institutional Variables Which May Serve as indicators of Quality of Medical Care.' Medical Care 17(7):693, July 1979. 13. Brodendorf, F., and Mackey, F. A Hospital's IQ: Indicators of Quality. Tusfin, Calif.: Orange County Health Planning Council, 1986. 14. U.S. Congress, Office of Technology Assessment. The Quality, of Medical Care: Information for Consumers, OTA-H-386. Washington, D.C.: U.S. Printing Office, June 1988. 15. Soott, W. Managing Professional Work: Three Models of Control of Health Organizations.' Health Services Research 17(3):213-40, Fall 1982.

16. Health Care Quality improvement Act of 1986, Part B:Reporting of Information. 17. Medical Malpractice Relief Act of 1975, New York State. 18. Rubin, I. "Management of the Impaired Physician: An Issue of Integrity.' Physician Executive 13(6):6-10, Nov.-Dec. 1987. 19. Personal communication. Dory, R., American College of Physician Executives, Tampa, Fla., 1988 and 1990. 20. Goldsmith, J. Farewell to the Volunteer Fireman.' Harvard Business Review 57(3):14, May-June 1979. 21. Landgarten, S. Skilled Medical Director Can Turn Conflict into Collaboration.' Hospital Medical Staff 10(5):2-9, May 1981. 22. Cohn, R. Hospital Management Linchpin: The Medical Director.' Physician Executive 14(2):18-20, March-April 1988. 23. Bloom, D. The Chief of Staff and the Medical Director.' Physician Executive 16(l):21-2, Jan.Feb. 1990. 24. Olazagasti, R. "Chief of Staff and Medical Director: Conflict or Cooperation.' Physician Executive. 16(2):33-5, March-April 1990. 25. Kurtz, M. The Role of the Physician as a Manager.' Physical Medicine and Rehabilitation: State of the Art Review 1:2, May 1987. 26. Angemeier, I., and Booth, R. 'Establishing an Appropriate Role for Physician Involvement in Hospital Department Operations.' Hospital and Health Services Administration. 28(6):59-76 Nov.-Dec. 1983. 27. Williams, K., and Donnelly, P. Medical Care Quality and the Public Trust Chicago, Ill.: Pluribus Press, Division of Teach'em, Inc., 1982. 28. 10 NYCRR, Part 405: (Sections.11, 12,.13, .14,.16,.18,.l9,.20,.21,.22) (Amended 1988). 29. Herzlinger, R. The Failed Revolution in Health Care-The Role of Management.' Harvard Business Review 67(2):99-103, March-April 1989.