Physician executives: where they are and what they do - Medical Management

An "average" medical director has been described as a 54-yearold male (only 9 percent of physician executives in the nation are female)(1) He has been in management for 18 plus years and has held his current position for 7 years. He devotes about 65 percent of his time to management functions and 21 percent to patient care. He is likely to be board certified (73 percent of the nation's medical directors are board certified). He does not think coursework or a graduate degree in management should be required for the position (only 22 percent would require this degree). However, he agrees (62 percent)that it is advisable to have that background or training. He should be able to speak the language of both physicians and administrators and serves as an interface person communicating and negotiating between the two groups. Most of the time, he reports directly to the CEO. He is a representative of the medical staff but is really accountable to the hospital trustees(2) His responsibilities include enforcement of medical bylaws and utilization review, strategic planning, medical education, and medical staff organization and development.

Chief of Staff

According to a national survey released in November 1989, Chief of Staff is the most commonly used title (57 percent) for elected medical executives, followed by Medical Staff President (38 percent), and other titles (5 percent).(3) Almost all U.S. hospitals (98 percent) have chiefs of staff who are normally (95 percent) elected by the full medical staff and approved (64 percent) by the governing body. Only one fifth (19 percent) of them have to be approved by CEOs. Almost all the chiefs of staff (99 percent) must be licensed and be in active medical practice (96 percent). About half of them (56 percent) are required to be on staff for a specified period before assuming the position. Most chiefs of staff serve on a nonpaid basis (88 percent) and work part-time (92 percent). Frequently, they report to the governing body (86 percent) and to the CEO (84 percent). The responsibilities of chiefs of staff include:

* Representing views and needs of medical staff (90 percent).

* Enforcing medical standards and hospital policies (82 percent).

* Quality of patient care (80 percent).

* Utilization review (51 percent).

* JCAHO accreditation (48 percent).

* Medical education (33 percent).

* Peer Review Organization (33 percent).

Medical Director

Although some states have started to require that all hospitals have designated medical directors, only about one-third (30 percent) of this nations' hospitals have medical directors.(3) It is necessary to point out, however, that, as states, i.e., New York, begin to require all hospitals to designate a medical director on their management teams, the percentage of hospitals with a medical director is likely to rise. The candidates for medical director are mostly proposed by CEOs (69 percent) and governing bodies (50 percent) and are approved by CEOs (64 percent) and governing bodies (64 percent). Most medical directors are required to be licensed physicians (91 percent). They are also required to join the active medical staff (78 percent) and to be in active practice (46 percent). Half of the hospitals (50 percent) require prior management experience. More than half (58 percent) of medical directors work full-time. Among compensated medical directors, almost all (97 percent) received compensation from hospital administration. Medical directors usually have multiple reporting relationships. A high percentage of hospitals surveyed have indicated that their medical directors report to CEOs (88 percent), to medical executive committees (78 percent), to hospital governing bodies (77 percent), and to chiefs of staff (72 percent). The responsibilities of medical directors include:

* Enforcement of administration policies (84 percent).

* Quality of patient care (81 percent).

* Representing views and needs of medical staff(77 percent).

* JCAHO accreditation (74 percent).

* Utilization review/quality assurance (74 percent).

* Enforcement of medical staff bylaws (73 percent).

* Medical education (56 percent).

* Peer Review Organization (56 percent).

* Recruiting physicians (52 percent).

Survey of Staffing Models

There has been little discussion in the literature regarding staffing models for physician executives. To study this topic, a survey was conducted. Sixteen university teaching hospitals with 300-400 beds (all members of the Council of Teaching Hospitals of the Association of American Medical Colleges) were included in the sample. Ten of them responded.

Models:

Most of the university teaching hospitals use combination models of chief of staff, medical director, and vice dean, etc. (figure 1, page 32). Five of the 10 hospitals have only one dedicated medical executive with either a single title or multiple titles. Each of the other five hospitals has an add|tional individual as chief of staff or medical staff president. This apparently agrees with the studies reviewed earlier that there is no single pattern of staffing or titles for physician executives.

Compensation:

The majority of the physician executives surveyed have multiple compensation sources for their management positions as well as their clinical practices. Chief of staff positions are mostly unpaid. However, some receive stipends. In hospitals where the chief of staff is the only dedicated physician executive, this individual is more likely to be paid.

Placement:

In the survey, most administrative positions are appointed and normally proposed by the president, dean, or CEO and approved by the governing body. However, chiefs of staff are usually elected by hospital medical staffs.

Hospital-University Relationship:

Traditionally, a university teaching hospital is part of the university. In the survey sample, four of the 10 hospitals are exceptions. One hospital began as a separate entity, and two had recently separated from universities. The fourth is owned by the county but managed by the university.

Discussion

Conceptions about Chief of Staff/Medical DirectorNice Dean:

Certain conceptions have developed over time about medical executives in different positions. As a representative and speaker for the medical staff, the chief of staff is often perceived as an honorary position. This position's leadership and authority lie in the individual's professional quality and personality as well as in his or her association with the administration and board. Usually, the medical director is appointed by the CEO and is a full-time, paid position. The individual in this position is often a strong delegate of the administration in handling medical affairs and in interacting with the medical staff. However, this position can be perceived as a "watch dog" position, which weakens its legitimacy with the medical staff. The position of vice dean for clinical affairs can have both strong administrative authority and legitimacy in representing the medical staff. Nonetheless, the academic associations accompanying this position sometimes let the individual's loyalty to the medical school outweigh loyalty to the hospital.

Organizational Structure and Position Designation:

As discussed earlier, many university teaching hospitals are part of the universities. In these hospitals, administration is only part of the function of the medical college. The hospital administrator or associate dean for clinical affairs reports to the dean or the president of the medical school, who is often a physician. Under these circumstances, the chief of staff or medical director is more likely to be a nominal or honorable position, or an additional title carried by the associate dean or vice president for clinical affairs. Where the hospital is a separate entity, the representation of medical authority in administration becomes necessary and important. The objective is to achieve an integration of medical and administrative authorities to fulfill their common missions in a collaborative manner.

Titles and Duties:

Although titles are often associated with certain duties and responsibilities, this is not so much the case when comparing the positions of chief of staff and medical director. The job descriptions or duties and responsibilities from bylaws of the surveyed hospitals show variations and differences from one hospital to another. However, the aggregation of common elements from those documents show little differences in duties and responsibilities between the chief of staff and medical director (figure 2, page 33). Their functions are basically identical. Whether or not the position was designated as medical director or as chief of staff has more to do with institutional traditions, organizational structures, position emphasis, candidate backgrounds, the desiguator's preferences, etc.

Compensation and Accountability:

Most medical directors are paid by and are accountable to administration. In contrast, most chiefs of staff are voluntary. The lack of pay is probably why many perceive the chief of staff position to be an honorary position, especially in hospitals where there is a paid physician executive. Some unconventional models have been proposed. For an example, suppose that a single-individual model is recognized as more suitable to achieve better integration and communication between hospital management and medical staff than a two-individual model (i.e., with a medical director as well as a chief of staff). In implementing the singleindividual model, the position may be called chief of staff, with the salary paid by administration. Or the position may have dual titles, chief of staff/medical director, and the individual may be paid jointly by the medical staff and administration. The literature shows that, in current practice, only 12 percent of chiefs of staff in the nation are paid. Among them, 41 percent are paid by the medical staff (from dues and special assessment), 37 percent are paid by administration, and the remaining 22 percent are paid jointly by the medical staff and administration?

Placement Mechanism:

In the survey, a number of hospitals show that at one individual serves in the physician executive role with a combination title of chief of staff, medical director. associate dean. or vice president. If dedicating one individual to serve the medical executive role is desirable in an organization, the mechanism of placing an individual who is acceptable to all parties becomes complex and critical. For example, in the scenario of an administration-paid chief of staff, the representative elected by the medical staff may not match the candidate preferred by administration. In such a situation, conflict is bound to arise. The key for success lies in establishing a compromising placement mechanism that integrates and accommodates the divergent interests of all parties. The governing body's role in resolving any conflicts and facilitating the process is obviously both essential and appropriate.

Summary

The role of physician executives in today's health care environment is relatively new, despite the rapid rise of its prominence. The duties and qualifications of physician executives are still evolving and are developing unevenly among health care organizations of different types and sizes. Few patterns can be observed from the survey with regard to physician executive staffing models. Yet this study has identified that organizational structure and position designation, titles and duties, compensation and accountability, and placement mechanism are some key issues in the study of physician executive staffing models.

References

1. Permut, R. "Medical Director, An Evolving and Expanding Role of the PhysicianExecutive." Group Practice Journal 38(1):52,54,59-60,62, Jan./Feb. 1989.

2. Gill, R. "Chief of Medical Staff: Role and Responsibilities." Hospital Trustee 7(3):201 May-June 1983.

3. Hospital Medical Staff Section. Survey of Hospital Medical Staff Organization. Chicago, Ill.: American Medical Association, Nov, 1989.

4. Bloom, D. "The Chief of Staff and the Medical Director." Physician Executive 16(1):21-2, Jan./Feb. 1990.

COPYRIGHT 1992 American College of Physician Executives
COPYRIGHT 2004 Gale Group