Chief of staff and medical director: conflict or cooperation?

Chief of Staff and Medical Director: Conflict or Cooperation?

Empirical quantitative data on the controversy and potential conflict between the medical director and the chief of staff are scanty and difficult to collect. The role of the medical director is well defined in the literature; that of the chief of staff is less so. Conclusions and ideas suggested in this paper will be based mainly on a review of the current literature and personal observations of the workings of a midsize community hospital over the past 11 years.

The Medical Director Role

The past decade has seen an explosive growth in the numbers of physicians entering management. The American College of Physician Executives (formerly the American Academy of Medical Directors) has grown from 64 members in 1975 to nearly 5,000 in 1989. [1] Seventy-four to 78 percent of medical directors are recruited from their own medical staff, the median age is 54 years, and they are predominantly male. [2]

A study by Witt Associates fills out the profile: "86 percent of physician managers are board certified, 5 percent hold another professional degree (MBA, PhD), and 97 percent are male. In terms of specialty background, 36 percent are internists, 22 percent are surgeons, 13 percent are family practitioners or GPs, and 10 percent are pediatricians." [3]

Most authors reviewed agree that the principal role of the medical director is as a facilitator in communications among the medical staff, administration, and the board of trustees. "The underlying rationale for the position is the belief that a physician is best equipped to facilitate communication between the medical staff and administrators, particularly in areas with direct bearing on the quality of patient care. Having a physician skilled in medical administration reassures the medical staff that administration is genuinely concerned about the unique demands physicians face in the practice of their profession. At the same time, the hospital's chief administrative officials need assurance that complex policy questions that directly affect clinical issues are being handled by a competent full-time manager who is knowledgeable about medical procedures and also aware of modern management techniques." [4]

Landgarten [5] also sees the medical director as a facilitator among the medical staff, administration, and the board of trustees. The medical director will help communication among these groups, which often "speak different languages." The medical director should also play an active role in medical education, interfacing with the community and serving as a negotiator between the administration and the medical staff.

Access to information and participation in the budget process is of paramount importance for the medical director to fulfill his or her role as facilitator. Lack of access to vital information can easily derail the effectiveness of any medical director.

Of most importance is medical director larticipation in and development of quality assurance (QA) and utilization review (UR) systems. With the advent of prospective pricing and utilization review, QA and UR have become the main functions of the medical director. They are most certainly the most critical. According to one study, "medical directors spent most of their time on utilization review/quality assurance issues, followed by those involving medical education, physician recruitment, and Peer Review Organizations (PROs)." [4]

In summary, the medical director should be an individual knowledgeable in the languages of medicine and administration. He or she should be able to assimilate diverse information from all stakeholders in the hospital and evaluate that information in light of economic reality. The medical director should have working knowledge of the implementation of QA/UR programs and be able to monitor their progress. Concurrently, he should be educating the medical staff, administration, and the board of directors on new regulations and possible future developments.

The Chief of Staff Role

The role of the chief of staff is more difficult to quantitate, as the role and responsibilities tend to vary from hospital to hospital. To a great extent, these roles depend on the relationship between the administrator, the medical staff, and the individual involved. The best way to assess the duties of the chief of staff is by examining the medical staff bylaws of different institutions. The description of chief of staff duties varies in the bylaws of different hospitals from as few as five lines to as much as a full page.

In hospitals without medical directors, most of the roles of the position are assumed by the chief of staff, even if not specified in the bylaws. Needless to say, the creation of the medical director position can create difficulties in these cases, particularly if the roles of each individual position are not well understood by all affected parties.

In general, the chief of staff is responsible for calling and presiding at all meetings of the medical staff. He or she also serves as chairman of the Executive Committee. The chief of staff is usually a member exofficio of all medical staff committees and has the authority to appoint committee members and create new committees, excluding departmental committees and the Executive Committee.

The chief of staff represents the views, policies, and grievances of the medical staff to the governing body and the chief executive officer and is also responsible for the enforcement of bylaws and regulations and for the implementation of sanctions.

Responsibility for medical staff educational activities is also under the direction and guidance of the chief of staff, particularly if no medical director exists in the hospital.

Another duty of the chief of staff is to serve as a spokesperson for the medical staff in its external professional and public relations.

Discussion

It is apparent that potential conflict exists when a new medical director is appointed. Many of the roles assigned to the medical director would have been held previously by the chief of staff.

The chief of staff's loss of administrative responsibilities could be viewed as a relief to some individuals, but others might see it as a sign of "losing turf." Anyone working in a hospital environment will probably agree that the latter view, even though confrontational, would probably be the chosen one, at least in the beginning. The newly chosen medical director will face the difficulties and diplomatic task of avoiding needless conflict and confrontation.

The medical director is ultimately a representative of the administration and not of the medical staff. The potential therefore exists of creating an adversarial relationship between the medical director and the chief of staff. The medical director must posess superb statemanship skills to minimize confrontation and maintain the support of the medical staff. The medical director is also responsible for enforcement of regulations affecting quality of care within the hospital. If no trust exists between the medical staff and the appointed medical director, an adversarial relationship could eventually develop that could seriously impair future development of the hospital.

Not only does the potential for conflict exist between the medical director and the chief of staff but also between existing members of administration and the medical director. Traditionally, physicians have sustained an adversarial relationship with hospital administration. [6] The emergence of a physician as part of the management team can and will be viewed with suspicion and distrust by nonphysician managers. Some administrative responsibilities will have to be relinquished to the medical director by his fellow administrators. There is no reason to believe that administrators will yield responsibilities and power any easier than physicians do.

The avoidance of conflict starts at the selection process. It appears that medical directors are frequently selected on the basis of clinical achievements or political popularity. This is a crucial mistake. The appointee should be knowledgeable in management techniques and possess some background or degree in management.

Proper definition of authority and responsibilities will ensure that the chosen individual is capable of carrying out institutional and staff objectives. [7] A clear statement of duties and the expected chain of command is imperative for the avoidance of confrontation. All expected duties and roles of the medical director should be disseminated to the senior management team, the medical staff, and the board. Medical staff bylaws should reflect the new set of responsibilities of the medical director. Traditional medical staff functions should not be relinquished to the medical director. [4]

As the position of medical director becomes more demanding, it will become a full-time endeavor, eliminating the potential conflict of interests that could exist when a physician maintains a private medical practice and is also part of the administrative team. Prior experience in private medical practice is an invaluable resource to the medical director and grants credibility with peers. However, maintaining the practice while performing the duties of medical director can only lead to favoritism, mistrust, and loss of objectivity in enforcing the rules and regulations kf the hospital, particularly those pertaining to QA and UR.

A medical director can be only as good as the medical staff and administration he or she advises. Even though the position is an exercise in balancing contrasting issues and approaches, conflict can be minimized by an understanding of the roles and responsibilities of the medical director by all involved parties. A number of authors have contributed to an understanding of the roles and responsibilities of the medical director. [8-16]

In the long run, the medical director will prove to be an invaluable addition to the senior management team, but the position will not eliminate the need for a chief of staff. On the contrary, it will make the chief of staff position more necessary, in order to serve as a spokesperson for the rights of the medical staff. Without a doubt, the addition of the medical director will adversely affect the power of the chief of staff by minimizing the chief's administrative responsibilities and ready access to the CEO and board of trustees. At times, the two positions will assume an adversarial relationship, but with understanding, it can be kept to a minimum.

If seen logically, the issues confronting the chief of staff and the medical director are the same. High-quality patient care, with constraints on utilization of resources, under a highly regulated system. The solutions to these problems should not vary much if the medical director maintains an open line of communication and fulfills his duty as a facilitator among the elements of the power structures within the hospital.

References

[1] "Final 1989 Membership Data Show Continued College Growth." College Digest, Feb. 1990.

[2] Lloyd, J. "Growth in Medical Director Numbers Continues." Physician Executive 12(3):10-3, May-June 1986.

[3] Doyne, M. "Physicians as Managers." Healthcare Forum 30(5):11-3, Sept.-Oct. 1987.

[4] "Role of the Medical Director." AMA Hospital Medical Staff Section Newsletter 4(6):1-2, June 1987.

[5] Landgarten, S. "Skilled Medical Director Can Turn Conflict Into Collaboration." Hospital Medical Staff 10(5):2-9, May 1981.

[6] Griffith, J. The Well-Managed Community Hospital. Ann Arbor, Mich.: Health Administration Press, 1987, page 387.

[7] Cohn, R. "The Medical Director-The Untapped Potential of the Position." Hospital and Health Services Administration 31(6):51-61, Nov.-Dec. 1986.

[8] Burda, D. "Hiring of Physician Executives on the Rise." Modern Healthcare 18(15):40, April 8, 1988.

[9] Nelson, S. "The Rising Incomes-and Numbers- of MD Execs." Hospitals 61(18):63, Sept. 20, 1987.

[10] "Higher Pay for Managers." Health Progress 68(9):12-3, Nov. 1987.

[11] Shortell, S. "The Medical Staff of the Future: Replanting the Garden." Frontiers of Health Services Management 1(3):3-48, Feb. 1985.

[12] Brady, T., and Carpenter, C. "Defining the Management Role of the Department Medical Director." Hospital and Health Services Administration 31(5):69-85, Sept.-Oct. 1986.

[13] Cohn, R. "Hospital Management's Linchpin: the Medical Director." Physician Executive 14(2):18-20, March-April 1988.

[14] Forkosh, D. "Good Doctors Aren't Always Good Managers." Hospital Medical Staff 11(5):2-5, May 1982.

[15] Mankowitz, C. "The Role of the Hospital Medical Director Today." Hospital Topics 64(1):33-5, Jan.-Feb. 1986.

[16] Perey, B. "The Role of Physician Managers." Health Management Forum 5(3):48-55, Autumn 1984.

Raphael A. Olazagasti, MD, MPS, is in private practice in Albany, N.Y., and Assistant Professor in Family Practice at Albany Medical center. He is a surveyor of quality assurance for the State of New York Department of Health.