Sometimes we're our own worst enemies.

Health care institutions must be people sensitive. However, the sensitivity must be balanced with sound business practices and concerns for quality. The institution must be looked at as a business (which it is) that is designed to promote an environment that is pleasant to work in (which it should be) and that provides good service and value to the consumer (which it must). It is the function of the board and administration to ensure these qualities. Of course, the institution has to provide equipment, technicians, nurses, etc. to help the medical staff, but the real goal is to assist the medical staff as a whole in caring for patients. Catering to a few individuals can be disruptive to the ultimate goal of excellent patient care.

The organized medical staff is a necessary appendage of the institution. Its input is desirable and at times necessary for the development and functioning of the institution, primarily when in derming and evaluating the quality of medical care. However, determining the direction of the institution and defining the institution's role in the community should not be under the purview of the medical staff, let alone of a few members of the staff. The character of the medical staff can change as its membership changes. The physician mix on the medical staff will vary according to the demographics of the institution, its size and the services provided, and the natural additions and attritions that occur with time. Because input from the medical staff can change drastically, responding to it can be risky, and responding to input from individual members of the medical staff is even less desirable.

Questionnaires; interviews; task forces; and development, advisory, and strategic committees should be avoided because they limit medical staff involvement. These methods give a select few too much power. The best approach is for the governing board and administration to make business decisions, such as the development of health care services and the staffing of those services, without medical staff involvement. The middle of the road approach would be to allow the entire medical staff to be involved in business decisions. The worst approach consists of methods, tactics, and strategies of limited medical staff involvement. This approach impedes growth and development of the institution, creates dissension among the medical staff when members not involved feel antagonized and/or ignored, and excludes majority input.

The Interview Process

The interview process has several shortcomings. The problems created by the interview outweigh the benefits, and the results are derived from respondents with limited knowledge. To begin with, opinions will come from three different medical staff groups: the leadership, the dissidents, and the apathetic. Usually nothing is gained by asking the leadership, because it will probably agree with administration's decision. The medical staff leadership has the involvement, training, and knowledge to realize that the administration knows how to run a hospital better than does the medical staff.

Problems are created when the leadership agrees with administration. Dissidents will promote the idea that the agreement between medical staff leadership and administration occurred because leadership was bought off by administration and seek to discredit administration and medical staff leadership. The interview process creates an opportunity to fuel the fire of disruptive forces. Dissidents will use the interview to advance their position anyway they can. The interview provides an avenue, a forum, for the dissidents to grandstand their issues, whether related to the interview or not. The apathetic group doesn't care about the interview, its substance, or its outcome.

Because most medical staff members are not privy to matters regarding the operation of the institution, they do not possess the knowledge to give valid opinions. And because most interviews do not give background information or sensitive facts, the physicians are not given enough relevant information to permit a meaningful opinion. As a practical matter, the interview has limited value because the people being interviewed have limited knowledge. As an example, suppose we interview the average medical staff member regarding a cardiology contract. To render a reliable opinion, the person interviewed should know the director's role, the services provided, the director's relationship to other cardiologists, other cardiologists' relationship to the cardiology director and cardiology services, and the director's salary and length of contract. Without this information, the person interviewed literally does not know what he is talking about, and the whole process is questionable.

As a purely political maneuver, the interview can be used to make physicians think they are part of the process. However, this ploy can backfire if the outcome is different than the consensus view of the physicians. They will realize it was just a smoke screen to the real decision making process.

Interview Extension

Task force and advisory committees are elaborate extensions of the interview process. Several people are "interviewed" in a series of sessions. In addition to the problems associated with the interview, the committee process causes delays in decision making as a group of people with diverse ideas try to come te some conclusion. These committees often have regular meetings over the course of a year. This gives the message that they do not expect to conclude any business within a few months. When the task force decision making process is in place, medical staff participants get burned out by spending too much time making too many decisions. This can be avoided by having the executive branch of the hospital make decisions based solely on its judgment.

Administration sometimes adopts the committee process as a shield to avoid being criticized for acting without medical staff input. This approach is not effective. Criticism still occurs because rank and file members of the medical staff are not aware of the committees, and still feel the medical staff was not considered in the decision. Dissidents will complain that a select few were chosen for the committee to skew the input.

Complaints can be eliminated by formally involving the medical staff, using mechanisms that are in place for handling medical staff issues. The medical staff is organized into departments and committees and can act as a whole to deal with medical staff concerns. This is the proper forum for the medical staff to give its input. Once the medical staff has resolved issues, there are mechanisms to relay this information to the governing body and administration through the joint conference committee; the medical staff executive committee, with the chief executive officer (CEO) as ex-officio member; and medical staff members who attend board meetings. Decision makers are thus advised on the medical staffs position on the issues.

An example of successful medical staff involvement begins with a series of one liners in an administrative report outlining what is on the future agenda, providing an update on subjects already introduced, and summarizing final decisions. This report can be given at a general staff meeting, a medical staff executive committee meeting, or in a physicians' newsletter. Medical staff members can respond to the administration and the board through the medical staff structure and established channels of communication.

When the medical staff acts in unison, it cannot be said that a few select physicians were chosen for the decision making committee and did not act on behalf of the entire staff. Decision making will also benefit by having a larger group involved in the fact-finding and brainstorming processes.

The Philosophical Dilemma

Should we promote high-quality medical care or make politically correct decisions? When the medical staff is involved in the decision making process, a decision is often politically motivated and does not lead to the highest quality care. Granted, a politically motivated decision can result in high-quality care, but not with some medical staffs. As a whole, medical staffs are emotional, do not know all the facts, have their own agendas and personal interests, and are not sophisticated enough to recognize high-quality medical care as defined by third-party payers and "industry standards." From a quality perspective, administration must act alone when making decisions involving the types of services the institution will provide, when and where the services will be provided, and who will provide those services.

Only administration knows all the details of the job description and can determine who is most qualified to staff a service. If the right person is not in the community, the administration must recruit someone. Quality must be the only concern, and administration cannot be intimidated by the threat of medical staff repercussions when appointing or recruiting physicians.

Selection or recruitment of highquality physicians is often viewed as political suicide, and is another source for the quality or politics dilemma. Unfortunately, quality or politics must be picked (unless it is the unusual circumstance when both concerns will be satisfied). A compromise is not an option, unless one is willing to compromise on a commitment to quality. As leaders in health care, that is not a respectable, responsible, popular, or acceptable standard.

The Direction of the Future

The governing board and upper-level management must decide where they want to be and what type of people will get them there. If an institution is to be a center of excellence, it must provide excellent service and have excellent physicians. After the institution positions itself by implementing desired service areas, it must look hard at the type of physicians on staff. If there is any doubt as to the quality of the physicians who will staff these services, changes must be made. Contracting with physicians represents an opportunity for change. A contract allows an institution to bring in physicians to provide exclusive services and to establish the standard of care for the institution. Joint ventures, a hospital-sponsored independent practice association (IPA), etc. are other areas in which the institution can establish high standards of care by controlling the services provided and the participants in those services.

These changes will not be politically safe. Complaints of favoritism, restraint of trade, and poor choices may be lodged. However, if the deci- sions are based upon impeccable qualifications and credentials, there will be no basis for those complaints.

Unfounded Fears

Business decisions should he made without fear of retaliation from memhers of the medical staff. Medical staff leaders will usually stand by the decision. Apathetic physicians, by their very nature, will not retaliate. Retaliation, if it comes from anywhere, will come from the dissident physicians. If dissident physicians decide to practice elsewhere, good riddance. But usually they will continue to practice at a particular facility because they cannot or do not like to practice anyplace else. Dissidents will continue to use the facility where they are most accepted. Antagonizing the dissidents by making decisions without their input may have a secondary benefit of prompting them to practice some place else.

Most primary care physicians practice at one hospital, and will continue to use that facility. Physicians who are on multiple hospital medical staffs will usually practice at the hospital that is most convenient, regardless of politics. Fear of a declining census, or a decrease in utilization of services, because of boycotts by disgruntled physicians will not happen. On the contrary, the census should rise as the institution is recognized as being of high quality.

One should not be fearful of making politically unfavorable decisions when quality is at stake. High-quality medical care bestows rewards and positive effects upon an institution. Quality breeds a successful reputation, customer satisfaction, good outcomes, and an improved bottom line. Physicians and patients who stayed way because of a lack in quality and services will return.

Conclusion

The governing hoard and administration have to be in charge when it comes to maldng decisions regarding the services the hospital provides and who is most qualified to provide them. The governing board and administration are most knowledgeable in these areas. The governing board and administration must focus on quality as their sole concern. It is appropriate for the governing board and administration to determine how they want to run the institution. A hesitancy to adopt that position may exist because of fears of political pressure, divisiveness, and claims of favoritism and illegal acts. These fears are generally unwarranted if the institution has a policy of providing the highest quality medical care attainable, and bases its decisions on that policy. If there was a failure of this policy in the past, it would be caused by poor administration of the policy.

If decisions that result in highquality medical care also satisfy political concerns, all the better. But political concerns cannot be considered when they will affect quality of care. Yielding to special interest groups should only be considered when it is ethically and/or legally correct.