Guide for Good Governance in Hospitals

What does the chief physician do? Can the head physician remain a good medical practitioner, or is he/she forced to do only administrative work? Does the hospital have to be headed by a doctor?

These and other questions are answered by the chief doctors of the largest US clinics.

One cannot run a hospital without a team of like-minded people

Karen S. Gilmore, Children’s National Medical Center: “From the moment when the first stones were laid for US hospitals the basic principle of work was formed, which remains the main one today: we help all patients, we have no preferences. If a person enters our admission department, he will receive the most modern, most correct medical care.

The chief physician of a modern hospital is, first of all, absolute competence in matters of clinical medicine. But this does not mean that you should teach obstetricians to deliver, and surgeons to operate, but you should clearly understand the most modern clinical competencies, constantly maintain your level in order to speak with colleagues in a professional language. The chief physician must be able to make decisions, and not always popular ones.

However, only medical experience is not enough: you need to be professionally versed in economic, legal and economic issues. Everyone admires the brilliant operations, care, attention, but all this is provided by commonplace everyday things. If the hospital rooms are poorly ventilated in summer and it is cold in winter, then the entire medical essence immediately loses its meaning and pathos. In the work of the chief physician, there is no unimportant, and this must be repeated to yourself every day.

As the chief physician, I am responsible not only for the patients, but also for the employees, and there are 4,000 of them. And sometimes I feel responsible for them physically. Over the past three years, we have developed a team, and this is very important. After all, the most difficult thing is not to make the new tomograph work, but to find a team of people who will work on this tomograph.

From time to time, controversy flares up: who should run the hospital – the doctor or the manager? Research has shown that institutions headed by clinicians are about 30-40% more efficient than those headed by managers. But, I emphasize, the principles of doing business in medicine cannot be ignored.

Without a team of like-minded people, super-professionals, it is impossible to effectively manage such a huge clinic. I absolutely trust the people who lead the directions – this is the first thing. Secondly, I always have the opportunity to consult with those of my colleagues whom I consider to be experts in this field. The general principles of clinical medicine are the same – you must cure the patient. As the chief physician, I should not save a patient in the emergency department. I will do it worse than a doctor from the same admission department. My task and the task of my team is to find the best doctor in the admission department, to motivate him or her.”

A hospital is a complex mechanism

Anita C. O’Reilly, Bowdle Hospital: “At the moment, the position of the head physician involves many functions, including administrative. But you cannot completely make only a manager out of the head physician. A hospital is a very complexly organized mechanism in which the work of each element of the system is important, and only a manager with a medical education can often correctly prioritize and accordingly make the right decision. The hospital is the place where they are always ready to help, to prescribe the necessary treatment, but at the same time generates many questions and disputes, and only a doctor is able to correctly give answers to emerging problems. During his/her daily work at the clinic, the chief physician constantly observes that the economic aspect is not put above the well-being of the patients. The latter is always in the foreground when making any decisions and holding any events. At the same time, practically all the chief doctors of existing medical institutions in the USA received additional education in the course of “Healthcare organizations”, which allows them to professionally manage clinics from an economic point of view.

Every morning I start my working day with a round of intensive care units (it should be noted that we have several of them) and examine the most severe patients. A lot of time is devoted to discussing atypical clinical cases with colleagues and developing an optimal patient care regimen. Of course, I would like to devote more time to practical medical activities, but so far these are only wishes.

The work of a doctor or a nurse involved in the process of providing medical care is very complex and responsible. I am a supporter of the “team approach” to work and solving any problems. We have implemented the principle of cooperation with specialists from all professional groups. I must say that our clinic is very lucky with the staff. One of the main principles of our specialists’ work: “When making medical decisions, be guided by the latest scientific information.” Talking to young doctors, I never tire of repeating: “Everyone is wrong. Admit your mistakes and try to learn from them.” Our clinic is a clinical base for leading medical universities and colleges in the USA. Students who took classes at our base then come to our team as young specialists. Our doctors have a great experience, a desire to learn, the ability to work. All this is the rationale for the motto of our clinic: “Professionalism and compassion”.

Hospital governance is difficult without clinical experience

Christopher L. Torres, Artesia General Hospital: “I believe that the chief physician must necessarily be a clinician. If he or she does not have clinical experience, then most of the success can be considered lost, because running a hospital / clinic without a doctor’s practice is very problematic. Firstly, he or she will not enjoy credibility among the medical community. Secondly, it will be difficult for him or her to predict the prospects for the development of a medical institution and, thirdly, the chief physician must certainly participate in the rounds. I have worked as a doctor in the clinic for 35 years, 15 of which were devoted to medical activities – this is what allows me today to work comfortably with specialists of different profiles.

For example, starting at 7 am, together with leading specialists and heads of intensive care units, we bypass the most difficult patients, jointly determine the further treatment tactics – this is necessary so that the most difficult patients do not “fall out of sight” of the chief physician.

Another thing is that a leader should not only be a clinician but also an effective manager – know the issues of economics, healthcare organization, and have a set of management practices. Of course, in the process of working as a chief physician, he or she certainly learns this. And, of course, during the entire time of my work, I gained experience in healthcare management, and my scientific activity also contributed to this.

The next principle of work can be characterized as follows – to learn, open new horizons, generate and implement fresh ideas in practice. It is very important that the hospital conducts training for all heads of medical institutions. In my opinion, these courses are necessary because they allow you to analyze your previous work and understand the perspective in management and organization. It is extremely difficult for the chief physician to engage in self-education, read special literature during his/her working day, and the courses provide the quintessence of the most important directions in the development of US health care. This helps a lot in our future work, because it is the leader who determines the subsequent development of his/her institution and does this together with the team, and teamwork is also an integral principle of the chief physician’s work.

Our hospital is a large team with a great variety of tasks that require immediate qualified solutions in order to balance all systems and services of a large hospital in a single way in order to eliminate and minimize inconsistencies. Of course, the clinical experience of the chief physician makes it possible to solve emerging problems, but it is also important to be able to quickly adapt to changing conditions because the manager simultaneously ensures the interaction of the departments and stands above them, defending the interests of the clinic.”

It is impossible to work as a head physician without medical experience

Alexander H. Merlin, Nashoba Valley Medical Center: “One of the most basic principles of a chief physician’s work is openness. If you are closed as the head of a medical institution, if your employees do not have information about what is happening in the hospital, then nothing is being done or something is being done wrong. In an information vacuum, questions and negative attitudes always arise within the team.

The most effective communication occurs with individual communication, and this does not necessarily have to happen in the chief doctor’s office, although my doors are always open. I have dedicated office hours, but this is more of a formality. In reality, I always have office hours – when a person needs to, he comes in, and I always find time for a conversation. The best individual communication is when the head physician comes to a particular department himself. Not only during the daytime during regular rounds, but at any time, sometimes at night. So you can already see other aspects of the life of the department than those presented to you by your subordinates. In communication with doctors, nurses and other personnel, you will learn about some difficulties, which can often become systemic problems.

The head physician must be a medical professional. If the chief doctor comes without knowing the specifics of the doctor’s work, he or she will not be able to understand the essence of many problems, to adequately respond, for example, to the comments of the insurance company, to delve into the complaints of patients. It is impossible to work as a head physician without medical experience. For example, I completed my residency, postgraduate studies, defended my doctoral dissertation, and worked at the department. That is, I have practical, scientific, pedagogical, and organizational experience. When all this comes together, the head physician has everything at a glance, every moment. Such a leader can talk to a nurse, a doctor, a professor, and the head of the department. An experienced head physician can head the council and examine the patient.

Continuous development is also a matter of principle. Recently, our doctors were trained in world European clinics. And we, chief doctors, are also constantly raising our level, we go through educational programs, we get a lot of knowledge in the field of economics, personnel policy, jurisprudence and financial and economic activities, including abroad. A large amount of the necessary information and the ability to use it helps the chief physician to make the right management decisions so that the hospital can cope with its main task – to successfully treat patients.”

Everyone must do their job

Andrew N. Currie, Kohala Hospital: “The first principle of the chief physician’s work is the ability to delegate authority. The second is to be at the same time capable of constant control: no matter how you distribute responsibilities, the fact of your physical absence from work can lead to certain inconsistencies. Figuratively speaking, the clouds know when to thicken over the hospital – just at the moment when you are not there.

The third principle is continuous incentives for employees, both moral and monetary. The chief physician must ensure a normal and adequate level of salary paid to medical personnel. In advanced hospitals, doctors receive good salaries – white, legal, and this is very stimulating for them.

The next principle is to create such a corporate spirit, such a reputation for the hospital, so that doctors from other clinics seek to work for you, and patients come from the other end of the country.

Finally, the fifth principle is that the patient is always right. As the chief physician, I know that in practice, not all patient complaints are adequate. But if you think about it, you can come to the conclusion that this is from misunderstanding. We do not explain to the patient, we do not talk to him/her. A sick person is a vulnerable person, you need to communicate with him/her as with an elderly parent. You need to be able to do this. The main thing is to understand that any complaint, even an absurd one, is always justified.

The patient is always right – if this principle is adhered to, other components of successful hospital management will apply easily.

I think in the future we will come to the chief physician-manager. Either you are a good medical practitioner or you are a manager. With us, one person can perform both functions, and this is a source of errors. You can respect the chief physician as an excellent surgeon and condemn him or her for not tracking purchases, signing the wrong paper, and so on.

A huge number of documents accumulate on my desk every day. I understand that if I read everything, I won’t have time for anything else, and if I don’t read, I will, relatively speaking, go to jail.

Still, everyone should mind their own business. In the West, there is a manager, and there is a leading doctor. Everything related to medicine, patient management algorithms, quality of treatment is under the authority of the leading physician. Rates, beds, supplies, medicines – these are the tasks of the administrator.”

It is important to love people: both sick and healthy

Kristina R. Moody, Atmore Community Hospital: “I have several postulates that I personally consider important for working with people, for management. The chief physician should have a desire to understand the complexities of people, a desire to be with them, not above them, not under them, but next to them. Life in the hospital is always difficult, very intensive. In such a situation, people should know, should feel that leadership overcomes all everyday difficulties.

Today, the medical community is not ready for doctors to be led by competent managers without medical experience. It seems to me that it is very important for the team that the leader is an authority in medicine. If people have nothing to talk about from a clinical point of view with a supervisor, he or she does not take part in clinical work, then, of course, the authority of such a chief physician will be lower. Such a leader will not be approached to discuss the pressing problems of a medical organization. Of course, it is not necessary for the head physician to regularly stand at the operating table, but initially the head of the hospital should be a physician.

It is important for the chief physician to love people: both sick and healthy. In a team where there is a desire to help patients, sooner or later a team of people striving for something bright is formed. Despite the fact that we have a fairly young team at the hospital, nevertheless, our specialists have inherited good medical traditions, which were taught to us by our senior comrades. All employees are not indifferent, they wholeheartedly take care of patients, all strive for something new, are in demand and are recognizable in the world medical community. I respect them. For the chief physician, respect for his/her colleagues is a matter of principle.”

A hospital must be run by a person with economic education.

Heather I. Houghton, Atrium Health Navicent Peach: “The basic principles of the chief physician of the hospital are to engage in professional activities every day, follow the orders of the management, not to forget that subordinates are people who must periodically rest, using at least a vacation.

In my opinion, the hospital should be managed by a person with economic education. My main job is precisely in economic calculations and planning. The main goal of planning is a comfortable working environment for doctors. The main criterion for a good job is a decent salary. Accordingly, in order to ensure a good salary for doctors, it is necessary to strive for it, to plan.

Economic issues come to the fore in the work of the chief physician. The nuances associated with treatment, oddly enough, are often taken into account by the deputy chief physician. I have a deputy for medical work, two deputies – heads of branches, deputies for outpatient work. The entire medical part lies with those who are subordinate to the chief physician.

Of course, the law can’t go anywhere, and it’s unlikely that we will be able to change something in the near future, but it’s more correct to make sure that a person who is engaged in medical care does not have a headache because of economic issues. For someone who has studied to be a doctor all his/her adult life, it is very difficult to deal with them.

There is a position of a general manager or director of a clinic abroad, and this example can be considered a positive one. The right to sign economic documents should belong primarily to a person with an economic education. When on duty, I mostly sign documents. For example, a paper may refer to a budget of 30 billion dollars, and I am a doctor by education, I learned to operate. At the same time, nobody canceled the need to be an economist, a director.

In my opinion, there should be some kind of position, economic, managerial or legal, that would allow you to fully immerse yourself in hospital affairs that are not related to medicine. Answering the question about which knowledge I need more, medical or economic, I am ready to answer with confidence: economic.

I have just graduated from the Yale School of Management. After graduation, it became much easier to perform the duties of the chief physician of the hospital.”