Medical Staff

Department Chairs v. Medical Directors: Which type of leadership is right for you?

Medical Staff Leader Insider, July 21, 2011

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Today’s medical staffs have many challenges that previous generations did not such as, increased scrutiny of patient safety, the need for clinical and economic integration, increasing standardization of best practices, and accountability for service to name a few. In the past, the organized medical staff was comprised of elected officers and leaders who volunteered their free time in an effort to give back to the community and to benefit their individual practices. Today’s leadership responsibilities are far more demanding and require that individuals excel not only in the traditional skills of clinical management but in other skills including, credentialing/privileging, peer review, quality oversight, patient safety, OPPE/FPPE (for Joint Commission-accredited organizations), and accountability for nationally recognized standards of quality, safety, and service. These are not skills taught in medical school, and you cannot assume that a clinical competent individual will be a competent leader. Thus, medical staffs are re-thinking the concept of leadership and who should exercise leadership roles.

In the past, the organized medical staff was accountable directly to the governing board. Since the 1980s, Joint Commission-accredited organizations created a medical executive committee (MEC) accountable to the governing board on behalf of the organized medical staff. Small medical staffs may act as their own MEC by creating a “committee of the whole” in which the medical staff-at-large performs all the required medical staff functions, such as credentialing/privileging, peer review, and quality oversight. This accountability system is outlined in medical staff bylaws, which are a legally binding contract or compact (depending on the state) between the organized medical staff and the governing board.

Interestingly, many medical staffs ignore this bylaws accountability and instead focus on traditional silos of clinical departments. Clinical departments essentially ran the show for years with surgeons overseeing surgeons, internists overseeing internists etc. with little, if any, accountability to the MEC. In fact, the MEC has been traditionally made up of medical staff officers and department chairs, and they often saw their role on MEC as advocating for and protecting each others’ political and economic  interests.  How many times does MEC hold a department chair accountable when he or she does not feel comfortable dealing with a politically or economically powerful colleague’s performance issues? This is the classic challenge of the ‘tail wagging the dog’—the political and economic interests within a clinical department dictate the level to which a physician is held accountable for performance issues although those issues impact patient quality and safety.

In order the address this political issue, many organizations create medical director positions to oversee clinical areas. A medical director is different from a department chair in that the medical director:
Reports to a senior manager (chief medical officer, vice president for medical affairs, or chief executive officer) rather than the MEC
Has accountabilities articulated through a professional services agreement (PSA) that usually provides compensation in exchange for leadership responsibilities
Has protected time to perform leadership and administrative responsibilities
Often has a job descriptions, specific performance expectations, and annual or semi-annual performance evaluations

Thus a medical director is a management position and not a medical staff position. To contrast this, a department chair is a medical staff position that:

Reports to the MEC through the president of the medical staff/chief of staff
Has accountabilities articulated through medical staff bylaws and often receives little if any compensation
Has little if any protected time to perform leadership and administrative responsibilities
Often does not have specific performance expectations nor an annual or semi-annual performance evaluation

So, if this is the case, why not convert all of the department chairs to medical directors? There are several political and economic reasons why this has not been done. First, because a medical director is under management’s control, the medical staff is not likely to support eliminating medical staff oversight and accountability for fear that the clinical expertise of the medical staff will play a secondary role to operational and financial performance. Second, most medical staffs do not have a large number of leaders who are interested in a high level of accountability, and leaders themselves may resist the idea of working more closely with senior management. Third, there is often a delicate political balance between senior management and the medical staff that may become destabilized by this leadership shift.

Finally, although medical directors report directly to senior management, they are still accountable to the organized medical staff (through the MEC) for the conduct and care of all practitioners granted privileges by the organized medical staff. This is a matter of federal law as outlined in CMS’s Conditions of Participation, which state:
§482.12(a)(5) Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients;
Interpretive Guidelines §482.12(a)(5)
The governing body must ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The governing body is responsible for the conduct of the hospital and this conduct includes the quality of care provided to patients.

Thus, medical directors have dual accountabilities: The first is to senior management (as outlined in their PSA or contract), and the second is to the MEC/organized medical staff (as outlined in the medical staff bylaws, contract, or compact). Can senior management place many of the medical staff bylaws expectations into a PSA/contract? Yes; however, the dual accountabilities still exist.

Department chairs, on the other hand, are only accountable VIA the medical staff bylaws to the MEC through the president of the medical staff/chief of staff and have no direct accountability to senior management, including the chief medical officer/vice president for medical affairs.

So, what is the right answer for you: medical directors, department chairs, or medical directors and department chairs? A lot depends on your political environment and the rapport and mutual support between the medical staff and senior management. When trust is high, medical directors provide an excellent way for the MEC and senior management to collaborate on the oversight of clinical quality and conduct; when trust is low, this may be problematic.

Either way, the governing board must be assured through both the medical staff and senior management that leaders are doing the right thing and are protecting the interests of patients and the community. More than ever, we need leaders who will work with senior management to achieve a high level of quality and safety at a reduced cost. This is hard to do and whether leaders are medical staff- or management-based. What is important is that they are able to lead and to help the medical staff and hospital to succeed.

Jonathan H. Burroughs, MD, MBA, FACPE, CMSL is a senior consultant at The Greeley Company, a division of HCPro, Inc. in Danvers, MA.

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