Myths and misconceptions of the medical staff organization - hospital relations with the medical staff

In an earlier, simpler era--not really that long ago--the hospital medical staff was a relatively unmitigated blessing to the hospital bottom line. The inscription on an administrator's coffee mug, "Build Census," said it all. Success was likely to follow if a large, actively admitting staff could be attracted and at least a minimum number of leaders could perform some simple organizational tasks to maintain accreditation and licensure. While the original raison d'etre of th medical staff organization was quality assurance, quality was until recently so much assumed that the medical staff had little difficulty in perofrming this function to th satisfaction of both regulatory bodies and the public.

Times have changed. Physicians who consistently practice "expensive" medicine can inflict financial "damage" on the hospital bottom line in a prepaid and/or discounted pricing environment. Regulatory bodies, under pressure to demonstrate their ability to ensure quality in a cost-constrained environment, are demanding a far more sophisticated quality assurance capability. These converging forces are not only bringing to light the inherent weaknesses of the traditional medical staff organization, but are also placing considerable strain upon the relationship between physicians and hospitals. The dual need for a functional medical staff organization and for more collaborative relationships between physicians and hospitals had never been greater. Unfortunately, there remains considerable misunderstanding among trustees, administrators, and physicians regarding the legitimate roles and responsibilities of physicians in the hospital organization.

The following "myths and misconceptions" are used as a vehicle to explore underlying dynamics frequently found relevant to the hospital medical staff organization. The statements are an amalgam of observations and beliefs often expressed by administrators and board members, particularly adherents of "rational" management models. Each is accompanied by a brief description of what is likely to be a more accurate picture of reality. Rare is the hospital that has not been adversely affected over the years by at least one of these flawed perceptions of medical staff organizational function.

The medical staff is, in fact, an

organization.

Physicians receive in their training no exposure to organizational or management theory. They emerge exquisitely prepared to deal with complex clinical issues of their patients and with virtually no understanding of their mandated organizational roles in assuring overall quality to external accountability sources. An understanding of effective organizational function and of the specific roles of physician leaders does not come naturally, nor is such likely to be sought without active encouragement from the board and administration.

Further, physicians almost universally view their medical staff organizational obligations with disdain. These obligations are typically perceived as bureaucratic "busywork," required chiefly to fulfill the needs of a questionably legitimate source of accountability. While many physicians understand and accept a certain sense of responsibility to advise administration and to maintain licensure and accreditation, they often perceive time consumed by organizational activities as being of little relevance to their hospital practices. Virtually all physicians are, by the nature of their work, time-pressured and results-oriented. In recognition of these factors, physician organizational duties should be focused on substantive issues with the goal of producing visible impact. While more easily stated than accomplished, this goal is achievable.

Physician leaders understand

regulatory requirements and their

roles in the departmental and

committee structure.

Most physicians still emerge from their residencies with virtually no exposure to or understanding of regulatory requirements and the demands placed upon the medical staff organization. Further, such requirements could hardly be further from the interests of most physicians. Curiously, even physicians who become masters of parliamentary procedure may have a limited understanding of specific functions required of the medical staff organization, such as quality assurance. While it is not unreasonable to expect physicians to become more knowledgeable simply out of the obligation to effectively perform their organizational roles, it is naive to assume they will ascend the necessary organizational "learning curve" without the active encouragement of the board and administration.

Medical staff officers are elected to

lead.

When physicians elect leaders, they are secure in both their ability and their "right" to treat patients as they deem appropriate. They don't perceive a need to be "led." They elect leaders not as legitimate "accountability representatives" to the board and public, but as guardians of their fundamentally collegial orientation toward organizational function. In fact, there is a distinct antihierarchical bias built into physicians' need for clinical autonomy, and this bias often transfers to their organizational behavior.

The medical staff is accountable

to the board.

Studies have revealed that physicians actually perceive a downward accountability pathway. That is, even physician leaders perceive that their accountability is downward through the institutional structure, to the physicians who elect them rather than upward to the board of trustees. The practical result is that physician leaders commonly perceive that their "charge" is to represent the "medical staff agenda" to the board, not to be accountable to the board for quality of care, as accreditation and legal standards dictate.

The difficulty the medical staff often

has in dealing with difficult

issues relates to its highly democratic

orientation.

Medical staff leaders typically do not perceive that they have the "power" to pass judgment on important policy and organizational matters without the express consent of those who elected them. Leaders feel that they cannot act without virtually 100 percent endorsement by their colleagues, so that what action does take place can be inordinately slow. Collegial deference can be so great that either a small group of vocally "dissident" physicians, or even a single powerful individual, can effectively block actions favored by the majority. Organizational paralysis is the result of such a situation. While medical staffs embrace democracy as their proclaimed political structure, the term anarchy more accurately describes the true state of affairs.

Medical staffs conspire to maintain

the status quo by rapid turnover

of leadership.

Some believe that physicians consciously create short leadership terms so that no one is able to gain experience and effectiveness in a leadership role. In other words, physicians actively conspire toward organizational paralysis explicitly to maintain the status quo. In fact, most physicians are neither organizationally sophisticated nor Machiavellian. Most simply disdain organizational responsibility and create short terms to make the burden of leadership as painless as possible.

Most physicians have long since

given up their "doctor's workshop"

conception of the hospital and realize

that their individual interests

must be deferential to the hospital

as a community resource.

Medical care is viewed as a basic human right in our society, but the resulting implicit mission of the community hospital to ensure access to this right has not fully penetrated the physician psyche. In fact, hospitals have evolved as increasingly complex technological extensions of physician/medical practice; they are still, in most physicians' minds--especially the "high technology" specialists--"doctors' workshops" first and community resources second. Thus, while physicians by and large have a cognitive understanding of community service, modern hospital complexity, and the need for professional management, their intrinsic sense of hospitals as institutional extensions of their practices remains powerful.

Trustees, on the other hand, correctly see their fundamental role as overseers of a public trust. It is understandable that they might be incompletely aware that physicians view the board's primary responsibility as ensuring the availability of the resources by which physicians can optimally practice their profession. As a derivative of the workshop model, physicians tend to equate what is good for the community with what they perceive as supportive of medical practice. These different perceptions of the community hospital can be a source of major misunderstanding and potential conflict between the hospital and medical staff. This perceptual dissonance between physicians and hospital governance regarding hospital mission may be the single greatest "root cause" of physician-hospital conflict.

Sending physicians away to educational

programs will result in

better performance of their medical

staff roles.

While allocating resources for physician education is vitally important, there are no "easy fixes" regarding improved physician organizational involvement. Particularly in view of a growing body of literature regarding effective adult learning, it is naive to expect that physicians can be sent away to educational programs and return as more effective leaders. External education must occur in the context of a visible institutional commitment to physician leadership effectiveness. This will require actual joint participation in educational activities, both external and on-site, by top management and trustees.

If medical staff leaders are kept

well informed, they will communicate

their knowledge to their colleagues

through the departmental

and committee structure.

Physician leaders simply don't consistently communicate board and management agenda and decisions to their colleagues. While physician board members, the chief of staff, and physicians serving on the joint conference committee may be well informed and fully understand the reasons behind institutional decisions that may, on the surface, appear antithetical to physician interests, it is not axiomatic that they will convey their understanding and support to their rank-and-file colleagues. As already noted, physician leaders tend to see their accountability directed downward to their colleagues. They cannot be assumed to be willing to communicate potentially "bad news" to their colleagues. Revelation that the hospital is to open an ambulatory care center in potential competition with physicians on the medical staff is likely to be greeted by, "What were you doing to defend our interests?" as displeased physicians vent their anger toward leaders who have "failed" them.

All administrators favor educated,

involved physicians in leadership

roles in order to assist them in

establishing strong overall hospital

leadership.

It may come as a surprise to trustees that not all hospital CEOs view an educated and organizationally sophisticated medical staff leadership as an unmitigated blessing. While strong leadership can make the medical staff a more effective organization, the lack of direct accountability of physicians to the CEO can create problematic situations. Medical staff and hospital interests won't always be identical, and few CEOs would wish to risk open opposition on an issue by a well-organized and well-led medical staff. Lack of physician accountability to the CEO is one of the most difficult "facts of life" for the community hospital, and trustees should be aware of how this reality "plays out" in their own facilities. A worst case scenario can and does happen: the CEO maintains relative control by keeping the board and medical staff as distant as possible, and both in the dark regarding key policy issues.

The answer to more effective physician

leadership lies in paying staff

leaders or hiring a medical director.

One of the most frequently discussed current issues is whether to pay physicians for leadership duties or, if one doesn't already exist, to create a paid medical director role. While paying physicians certainly tightens the accountability link between physicians and administration, to believe that simply paying physicians will automatically result in improved organizational function is to engage in pure fantasy. At a deeper level, these dicussions are almost invariably about the need for more effective medical staff function.

"How can we motivate physicians to do their jobs?" is the true question on the table. Under the worst of circumstances, financial discussion can actually "drown out" dialogue over the substantive issues. The fundamental questions of this discussion should remain firmly fixed on the specific measures of effectiveness required of the medical staff and the optimal organizational structures and processes by which effectiveness can be achieved. Payment of physicians and/or creation of a specific medico-administrative position should be seen as only part of a more general strategic plan, the goal of which is improved medical staff organizational effectiveness. Instead of accomplishing improved medico-administrative function, paying physicians can worsen the situation, as "rank and file" medical staff members become suspicious of colleague physician "pipers" who now must "play the tune" of those who sign their paychecks.

Both hospital administration and

the board must give way to the

medical staff's "higher authority"

regarding the assessment and assurance

of patient care quality.

From approximately 1920 to 1985, quality review was the nearly exclusive domain of physicians. Quality review was carried out by physicians through retrospective review of individual cases, usually those who had suffered an adverse outcome of care, such as death or complication of a surgical procedure. In spite of their overall accountability for quality, few lay administrators or trustees had either the knowledge or the temerity to challenge that exclusive physician domain. This fundamentally flawed and now obsolescent method of determining "quality" is rapidly giving way to information-based methods that are interpretable to any interested party. If a trustee serves a hospital that tells him it averages a 6 percent mortality rate for coronary bypass surgery, when reference values suggest that this rate should not exceed 3 percent, he has not only the authority but also an obligation that flows from his ultimate responsibility for patient care quality to understand the reasons why patients at his hospital are experiencing higher than expected death rates for this procedure.

As a corollary to this example, if medical staff "quality assurance" at the hospital is limited to chart review and is not supported by an information capability that can generate statistical information regarding overall comparative patient outcomes (i.e., rates of mortality, morbidity, and other clinical indicators), the hospital is falling behind the information technology needed to manage quality.

There is no intrinsic reason why trustees, administrators, and physicians cannot work collaboratively, but there must be a conscious and well-thought-out design by which this collaboration takes place. Philip Crosby, the quality management "guru," has noted, "Good things happen only when planned; bad things happen on their own." Most veteran trustees have seen a few "bad things" happen with their medical staffs over the years. A retrospective analysis of such occurrences typically reveals them to have been potentially preventable had there been better communication and understanding among all parties involved. With the complexity of the modern hospital environment, and the rapidity with which this environment changes, it is prudent to take the pro-active course; actively engage physicians and the medical staff organization, try to understand the issues locally relevant, and maintain high levels of communication among physicians, administrators, and trustees.

Martin D. Merry, MD, is a Quality Assurance/Medical Staff Consultant and Project Director, Civilian External Peer Review Program, United States Department of Defense, Exeter, N.H. He is a Member of the College's Society on Managed Health Care and an Associate Member of its Forums on International Health Care and Quality Health Care.

COPYRIGHT 1991 American College of Physician Executives
COPYRIGHT 2004 Gale Group