Elected medical staff leaders: who needs 'em?

There are two important questions about the role of medical staff leaders in American medical centers. The first question is, "Is the traditional, antiquated, convoluted 75 year-old medical staff organization still needed?" The second question is, "Are individual physician leaders needed?"

The answer to the first question is, "No." Current requirements and common sense trends favor replacing the traditional "profusion of committees" with the concept of "individual responsibility."[1,2] See figures 1 and 2, pages 29 and 30, for an example of the difference.

The question once was, "Do we have plenty of committees so that every active staff member can pull his share of the load?" The 1990s question is, "What is the simplest, most efficient way to accomplish whatever the task is, still appreciating the need for checks and balances and guarding against abuse of authority positions?" Experience is confirming that figure 2 is a better answer to that question than is figure 1.

Unfortunately, the physician executive should not expect the "responsible individual instead of a committee" idea to include the medical executive function anytime soon. Waiting for a committee vote before executive action can be taken doesn't make much sense, but the overriding reality is that many physicians "cannot think of a single executive without thinking of a king."[3]

The answer to the second question is, "Yes, of course. Individual physician leaders are critically important to everyone's success."

Two Kinds of Physician Leaders

A physician executive is an MD or DO who, in some sequence, has gained experience and expertise in both clinical matters and organizational management. These individuals understand clinicians' concerns, yet their executive skills and organizational positions make them valuable, full-time members of the inner circle of senior executives.

A clinician leader is an MD or DO who chooses to remain primarily a clinician, but whose position (such as medical staff president or clinical department chair) requires learning and practicing organizational skills.

Effective leaders in both groups exhibit certain personal leadership traits, including vision, a reputation for objectivity and fairness (integrity), good communication skills, "problem-solving" behavior as opposed to "position-taking" behavior, and a sense of humor that often relieves tension without being flippant. Physicians are beginning to understand the importance of selecting leaders with these characteristics rather than just rotating physicians through positions of medical staff leadership.

Specific Examples of Relative Roles

The following examples illustrate the working relationship between physician executives and clinician leaders:

Appointing and Working With Committees

When a committee is needed, whether permanent or ad hoc, the elected medical staff president ordinarily appoints the committee's members and names its chair. The physician executive is a key resource with respect to both information and successful strategies, helping the committee accomplish its charge.

Chairing the Medical Executive Committee

At this writing, the role of the physician executive is to be staff to the medical executive committee. Even if, as is now true in some settings, the physician executive is referred to as the "chief operating officer of the medical staff," the elected staff president usually plans, convenes, and chairs the medical executive committee's meetings.

Reporting to the Governing Body 

As in other specific instances, following strict "organizational logic" may not work here. Who hires the physician executive? Answer: The governing body through its representative, the CEO. To whom does the physician executive report? Answer: The governing body through its representative, the CEO. Who gives the board a report of medical staff activities, presents credentials recommendations to the board, and explains to the board the results of quality initiatives of the medical staff? Answer: Often, the elected medical staff president.

Knowledgeable medical staff presidents increasingly welcome the participation of the physician executive in preparing and presenting reports to the board. The board should probably make time to hear brief reports from both individuals.

Processing Applications in the Credentialing/Recredentialing Process

The sequence of events in credentialing described in medical staff bylaws and/or related documents must be followed. There ordinarily is not a step in the process called, "Approval of the Vice President of Medical Services." The physician executive must often accept the role of encouraging fairness and objectivity in credentialing by serving as a resource on relevant clinical, ethical, and legal issues and by having rapport with staff leaders that makes reasonable suggestions welcome.

Dealing with Individual Performance Problems

Problems of performance or behavior must be addressed with staff members in the manner described in medical staff bylaws. The first contribution of a physician executive can be to seek out and share examples of modern medical staff bylaws language emphasizing positive, helpful approaches to staff members.[4] Administrative and legal remedies can thus be reserved for the truly recalcitrant or the hopelessly incompetent.

In approaching specific individuals, an effective physician executive may suggest to a chief of staff or a clinical department chair, "If you'll let me borrow your authority, we can sit down with Jack together, and I'll take the lead in the conversation." In most settings, the truly effective physician executive does not presume the authority to deal with such situations directly, going "around" elected staff leaders.

Planning Business Strategies

Medical staff members in most settings do not have confidence that the physician executive adequately represents medical staff interests in meetings of senior executives and of planning committees. Thus, the physician executive may work with the chief of staff and the CEO to convene a medical advisory group.

Even if a physicians' advisory group is convened just for "political" reasons, the result is often useful and valid input. "Physicians are the clinical experts on the local market. They are an invaluable source of information on a variety of topics, including clinical trends, competitive strengths and weaknesses, and opportunities for the hospital to increase volume."[5]

Two-Way Communication With a System's Corporate Office

It's important that a system corporate office maintain systematic communication with medical staff members in component hospitals. Rarely do elected officials of each hospital's medical staff assume the role of primary contact, because of busy clinical practice schedules. Medical staff leaders are beginning to appreciate the role of the physician executive in maintaining these corporate information channels.

Summary

Individual clinician leaders are still needed, even though the antiquated/convoluted medical staff organization isn't.[6] Increasing acceptance and continuing evolution of the physician executive position depends in large part on the ability of the present generation of physician executives to work with elected physician leaders.

Official recognition of the Physician Executive Role

One way to acknowledge the relationship of the physician executive to elected medical staff leaders is in medical staff or board bylaws or in a related document. The following language should be supplemented with a more detailed job description.

Selection and Duties

The Governing Body and the CEO, considering Medical Executive Committee (MEC) input, may establish a position description for and select a Medical Director/Vice President of Medical Services who shall:

* Be an ex officio member of the MEC (specify with or without vote).

* Be responsible to the CEO (reporting relationship), yet work effectively with

and assist the Medical Staff President, Medical Executive Committee, and clinical

department chairs to fulfil their organizational functions/responsibilities.

* Be concerned, among other duties, with medical-administrative aspects of

patient care provided in or under the auspices of the hospital and with coordination

of organizational functions of the Medical Staff, such as establishing a variety

of quality initiatives (working with the Medical Staff President, the MEC,

department chairs, and the CEO or his or her designee).

Removal

Removal of the Medical Director/Vice President of Medical Services shall be by the Governing Body/CEO, according to terms of the individuals contract, after consultation with the MEC.

Responsiveness to the Medical Staff

Although the reporting relationship of the Medical Director/Vice President of Medical Services is to the Board through the CEO, his or her job description shall require, and the annual evaluation shall be based in part upon, responding to reasonable concerns of Medical Staff leaders and members.

References

[1] "Medical Staff Standards." Accreditation Manual for Hospitals. Oak Brook, Ill.: Joint Commission on Accreditation of Healthcare Organizations. 1993. [2] Thompson, R. The Medical Staff Leaders' Practical Guide. Marblehead, Mass.: Opus Communications, 1992, p. 81. [3] Van Doren, C. The Great Rehearsal: The Story of the Making and Ratifying of the Constitution of the United States. New York, N.Y.: Penguin Books, 1986, p. 53-9. [4] Thompson, R. Op. cit., p. 152. [5] Personal communication. Thomas Wilson, Cambridge Research Institute, Cambridge, Mass. [6] Thompson, R. The Organized Medical Staff: Blueprint for Change. La Jolla, Calif.: Governance Institute, 1993.

Richard E. Thompson, MD, is President of Thompson/Mohr and Associates, Inc., a health care consulting firm in Dunedin, Fla. He is the author of Keys to Winning Physician Support (ACPE, 1991) and The Medical Staff Leader's Practical Guide (Opus Communications, 1992), and Health Care Reform as Social Change (ACPE, 1993).