Figure 5–1. Conventional hospital structure (simplified).

Nursing staffs in large healthcare delivery settings have a similar, though less pronounced, structure of clinical autonomy, with self-governance mechanisms, nursing union rules, or government regulations insulating certain activities, particularly with regard to healthcare quality, from administrative control. For example, several states have laws that specify a minimum level of nurse staffing or require staffing plans that meet certain criteria. The Magnet Recognition Program, which awards certification to hospitals deemed exceptional places for nurses to work, rewards nurse self-governance and autonomy.

The many clinical professions in complex delivery settings other than medicine and nursing, while not self-governing, are protected from administrative control to a certain degree by their esoteric knowledge bases and specialized training and certification or licensure. A consequence is that healthcare administrators generally shy away from interference in clinical affairs of all clinical health professions.

The concept of a professional bureaucracy, first depicted by management scholar Henry Mintzberg (1979), goes far in explaining this state of affairs. The notion of a bureaucracy is time-worn and well understood by most people, including health professionals. In the eyes of professionals, bureaucracies are hierarchical organizations with myriad rules and policies and centralized control by those higher up in the hierarchy. Bureaucracies often are perceived as impersonal, slow, and stifling. But the concept of the professional bureaucracy is one that most clinicians will find more attractive. The professional bureaucracy is composed of a strategic apex and middle management (the administrators), support and technical staff, and the operating core. Unlike the operating core in the traditional machine bureaucracy (for example, a large manufacturing company), the operating core in the professional bureaucracy primarily consists of professional workers. Instead of rules, policies, and central direction emanating from administration, the professional bureaucracy relies for coordination on standardization of skills, training, and socialization within each of the professions. Control over work is entrusted to those professions. The administration does not interfere with the daily operations of the operating core, and the information that administration uses to plan staffing and capacity for technical and support services is comprised largely of information requested from individual clinical professionals. The needs of the operating core, for example, for new technology and staff, are difficult for administrators to assess. Coordination between professionals in the same profession or specialty is handled by standardization of skills and knowledge among professional colleagues. (As we argue throughout this book, coordination between and among professions or specialties is often poorly handled.) The quality and performance standards of the professional bureaucracy, such as practice guidelines and protocols, originate largely from outside the administrative structure. They are developed by external associations of health professionals or by professionals inside the organization. The professional bureaucracy emphasizes the power of expertise, rather than the power of administrative position.

Administrative professionals in a healthcare professional bureaucracy serve important functions—strategic planning, information systems, financial analysis, marketing, human resource management, for example—but they are viewed as facilitators or enhancers of the core work of professionals. In contrast, in a machine bureaucracy, administrators are seen as “directors,” not facilitators, of the core work. Former clinicians fill many of the administrative roles in a healthcare professional bureaucracy, reflecting the value of understanding of clinical processes in effective management. For example, managers of clinical service and support service units, such as nursing, pharmacy, and social work, frequently are clinical professionals themselves, who have taken on management responsibilities. Often, clinical professionals perceive the professional bureaucracy, with its associated autonomy for clinicians, to contribute positively to the quality of their work life.

However, there are severe problems with the professional bureaucracy in the delivery of team-based care. Within professions, loyalty to peers within one’s profession conflicts with the need for transparency and accountability for patient services that transcend the boundaries of a single profession. Communication, collaboration, and conflict management among different professionals in different clinical departments can be difficult. Patients are forced to give the same information to caregivers of different professions. Patient safety errors are more likely to occur due to shortfalls in communication and collaboration.

The fact that administrators are not full partners on clinical teams is related to their status in the hierarchy of professions. Administrators in the United States in general are not viewed as full professionals, certainly not at the level of physicians or lawyers (Barker, 2010). The competencies of effective administration are too diverse and complex to codify into an exclusive knowledge base that would serve as a basis for requisite entry-level education and certification. In addition, the scientific evidence base of administration, which could anchor and legitimate its body of knowledge, is young and highly limited. Proficient administrators typically require years of on-the-job learning and experience to perform at a high level. To the extent that formal barriers to entry are used to distinguish professions from other occupations, the occupational category healthcare administration suffers in comparison to most clinical occupations. There is no requirement for advanced formal education for administrators in any sector of the economy, including health care. While in the healthcare sector many administrators do hold an advanced degree in healthcare management, there is no legal or regulatory requirement for the degree, unlike the requirements for practicing virtually all forms of clinical care. Only administrators of nursing homes are held to educational and licensing requirements, and the education level required is baccalaureate.

Continuation of the separation of the clinical and administrative parts of the professional bureaucracy in healthcare delivery is driven by 5 important forces. First is the need for deep administrative expertise to direct a healthcare delivery organization successfully. Historically, clinical professionals performed most of the administrative functions of such organizations, on a part-time basis. Today, however, the complexity of administration, involving extensive external dealings with payers, vendors, regulators, and partner organizations, for example, requires full-time expertise and attention except in the smallest of organizations. Most clinicians avoid such activities, having chosen professions that are quite different, as reflected in the “enterprising” feature of healthcare administrators noted in Chapter 3. Second, as noted earlier, the work domains of clinical professionals are defined by esoteric technical knowledge that is beyond the reach of administrators. The technical specialization of clinicians is intimidating to administrators. Indeed, many clinicians prefer it this way, viewing clinical care as their turf, out of bounds to administrators. Third, related to their technical specialization, clinicians historically have not been trained to notice and alter system-level factors that affect patient care quality, such as organizational policies and practices. The person-level approach to understanding quality seeks change in the direct behavior of the clinician and the patient in order to improve clinical care. The system-level approach, which is taught to administrators, identifies conditions under which individuals work and build defenses to avert errors or mitigate their effects (Reason, 2000). A fourth reason that the professional bureaucracy is preserved is that administrators find decision making simpler if clinicians are less involved in the process. Consensus development across professions takes time and requires compromise. Finally, in most large healthcare delivery organizations in the United States, many clinical professionals are less available or interested in administrative decision making because they are not employees of the organization. In particular, most physicians are not employed by hospitals but rather are self-employed or employed by physician group practices. It is more difficult for administrators to call on such clinicians to participate in team-based initiatives in their organizations.

Arguments for maintenance of the division between clinical and administrative domains in healthcare delivery need to be recognized, but maintenance of the division is too constraining, given the need for interprofessional teamwork. Strict separation of the clinical and administrative domains means that no one is in charge of interdependent activities in the whole system (Begun et al, 2011). Administrators can both specialize in their domain and learn enough about clinical care to participate knowledgeably in team-based care. Clinicians can both specialize in their domain and learn enough about administration to participate knowledgeably in interprofessional teams that make administrative decisions. The 2 domains are so interrelated that their bonds need to be tightened, not loosened, in the interests of patient care.

OPPORTUNITIES FOR HEALTHCARE ADMINISTRATORS

Physical therapist Ankur Shukla, MPT, tried to suppress a scowl. He was sitting through another meeting of the Lutheran Rehabilitation Center’s quality improvement committee. Today the committee was reviewing diabetes care guidelines. Present were John Ash, the committee chair and Director of Quality Improvement, a recent Master of Health Administration (MHA) graduate with a business background; Melissa Sandusky, RN, a clinical nurse specialist; Alfredo Torres, MD, an endocrinologist brought in specifically for the meeting; and Jean Wyoming, MD, a family physician. Mr. Ash was pushing one of his “lean” quality improvement projects again. He wanted to use an “RPIW” to reduce waste in the provision of care for the Center’s patients with diabetes. Only one of the other committee members knew that “RPIW” stands for Rapid Process Improvement Workshop, and none of the committee members knew how an RPIW is conducted. Mr. Ash did not explain. He seemed more interested in adding to his list of cost-cutting projects than in understanding and improving diabetes care. Mr. Ash had never spent time with the rehabilitation center patients who have diabetes or with their care-givers, and he had made no attempt to understand the clinical issues. Mr. Shukla concluded that the only way that Mr. Ash would ever understand diabetes care would be if he had the disease himself.

In this vignette, healthcare administrator John Ash is playing a role as it might be enacted in the professional bureaucracy model, emphasizing his own technical competence to the detriment of collaboration with clinical professionals. His attitude and behavior, while stereotypical and fictional, are all-too-often exhibited by administrators. To add value to team-based care, administrators need to overcome defensiveness about their knowledge base and expertise and to educate and involve those who do not share it. In Chapters 6 and 7, we note the importance of clear and respectful communication among team members. Mr. Ash could communicate much more effectively if he were careful to translate administrative jargon and not to “talk down” to his colleagues on the quality improvement committee.

Increased transparency in public reporting of the quality of healthcare organizations is one trend that supports a more collaborative posture between administrators and clinicians. Patient satisfaction, patient safety, and clinical care quality measures are increasingly available to the public and to payers, who can use these data to reward or punish delivery organizations through changes in reimbursement. Leaders of healthcare organizations increasingly are aware that they must understand and manage patient outcomes as partners with clinical professionals.

At first blush, this new posture may seem improbable. However, consider the position of a chief executive officer (CEO) of a highly technical enterprise (for example, 3M or Exxon), who has spent his or her career in finance before becoming CEO. This CEO is accountable for the performance of the whole organization and needs either to acquire the necessary knowledge of the technical operations (unlikely) or to be able to interact effectively with people who do understand the technical operations. So, too, the administrator of a healthcare delivery organization can be accountable for the whole.

Accountability for the whole organization by the CEO needs to be accompanied by explicit leadership and management of the culture of the organization so that effective team-based care is encouraged and appreciated. The concept of organizational culture and the competencies needed by organizational leaders are discussed in Chapter 18. For the moment, we underscore 2 key competencies that are particularly important for healthcare administrators.

First and foremost is the need to relate effectively to clinicians. While it is more difficult for administrators who do not have clinical backgrounds, this competency can be achieved by all administrators, with education and experience. Educational needs include learning the basic terminology of clinical care, which can be imparted in a typical college-level course, taught either face-to-face or through self-instruction online, then practiced, applied, and supplemented in the particular work setting of the healthcare administrator. Administrators can observe key clinical conditions, processes, and technologies used in the clinical areas for which they are responsible, and do on-the-job learning to attain basic competency in using the relevant terminology. They can note the different healthcare professionals on the teams with which they work and study the histories and cultures of the relevant professions.

It will not be sufficient, by the way, to select administrators who are in fact clinicians. Most clinicians are not interested in or prepared to assume full-time administrative roles. Those who do wish to become administrators often seek advanced training or administration degrees. These administrators with prior clinical experience and credentials may have an easier time dealing with clinicians. However, faced with the need to decide between the interests of their clinical profession and their organization, administrators will side with their employer (the organization). From the clinicians’ viewpoint, they are often seen as having “gone over to the dark side,” as illustrated in the following vignette:

Michael Storstrand, MD, had practiced medicine in Dale Health System for 18 years. He was a pediatrician with a special interest in children with delayed cognitive development. He was well liked by his physician colleagues, by the nurses at Dale Hospital, and generally by everyone with whom he worked. He had a knack for grasping organizational disagreements quickly and was often able to bring different factions together and facilitate their coming to agreement.

After Dr. Storstrand had been at Dale Health System for 9 years, the Chair of Pediatrics retired, and the Chief Medical Officer (CMO) appointed Dr. Storstrand to be the new Chair. Dr. Storstrand began to deal with administrative issues and found, somewhat to his surprise, that the work was gratifying. He enjoyed thinking about the Pediatrics Department as a whole and guiding it to serve its patients and families while at the same time attending to the financial performance of the Department. During this time, he continued to practice pediatrics half-time.

Within 2 years, Dr. Storstrand was asked by the CEO and CMO to join the Executive Committee of Dale Health System. He became a valued member, relied upon especially for his insights into how to communicate with the whole organization effectively in good times and in strained times. Occasionally, he spoke for the Executive Committee in large meetings, and sometimes he was simply inspiring.

After Dr. Storstrand had served on the Executive Committee for 6 years, the CEO retired. The organization had a tradition of selecting its CEOs from inside the organization, and Dr. Storstrand and 2 others came forward as candidates. The board chose Dr. Storstrand as Dale Health System’s new CEO. At this point, he took up the position and decided that he could no longer practice pediatrics. Dale Health System was a large organization with annual revenues of $1.7 billion. The CEO position was a full-time job.

Over the next few months, Dr. Storstrand noticed, not to his surprise, that his relationships with other physicians in the health system were more distant. Personal conversations were less frequent, and he had the sense that some of the other pediatricians avoided him at times. The first 2 annual budgets were tight, and one year he had to explain to the physicians why there were no salary raises for them. From time to time, close colleagues told him that some of the physicians at Dale now regarded him as a “suit,” sometimes commenting that he had “gone to the dark side.” Dr. Storstrand was not disheartened by these reports, but they did sting. He was well aware that he was now viewed differently than he had been viewed as Chief of Pediatrics, that at times he was now viewed with suspicion. He recalled that the surgeon who was CEO when Dr. Storstrand joined Dale was regarded in the same way.

A second key competency for administrators in team-based organizations is to live and breathe a collaborative leadership style, exemplifying the values of teamwork. “Leadership” as described in the conventional business literature involves one individual, the leader, assuming responsibility for identifying vision, being smarter and tougher than anybody else, and saving the organization through brute will. While such a stereotype may fit a few business organizations, it is of little use in health care. Healthcare leadership involves learning about complex issues from multiple diverse angles, connecting with others to build consensus, and jointly making sense of issues such that decisions are possible (Begun and White, 2008). Learning materials for this leadership style (known variously as collaborative, integrative, adaptive, or complexity leadership) only recently are beginning to permeate the curricula of healthcare administration.

Related competencies for administrators involve shaping the structures, cultures, and resources of organizations so that they support team-based practice and decision making. These conditions include hiring, promoting, and rewarding people for teamwork, managing connections among teams and between teams and external constituencies of the organization, and providing tangible resources for teamwork, from physical meeting space to educational resources to digital technology for sharing of patient information and conducting online meetings.

Healthcare administration educators and program accreditors are showing some recognition of the growing importance of collaborative competencies, but progress is slow. For example, Shewchuk and colleagues (2005, p. 43) include “team building” in their list of 30 competencies, as well as “Knowledge of the physician education process,” while not mentioning the clinical professions other than medicine. “Communication and relationship management” is one of the 5 clusters of competencies promoted by a consortium of professional associations, the Healthcare Leadership Alliance (Stefl, 2008). Another widely disseminated competency framework for healthcare administration, developed by the National Center for Healthcare Leadership, notes the importance of collaboration, but the framework conspicuously neglects knowledge of the clinical enterprise (Calhoun et al, 2008). Graduate program accrediting criteria require that healthcare administration programs include opportunities for students to participate in team-based and interprofessional activities (http://www.cahme.org/Resources/Fall2013_Criteria_for_Accreditation.pdf).

Aside from educational preparation, many practicing administrators engage in activities that enhance collaboration with clinicians. Rounding for safety is one such example, where administrators and relevant clinicians confer on patient care units about issues that will improve patient care safety and care processes (Campbell and Thompson, 2007). Of course, rounding can be a negative experience for clinicians and administrators alike if poorly performed. Effective rounding requires planning (scouting relevant issues and personnel in advance), representative sampling to assure that all parts of the organization are included, recording of the activity in some format, follow-up to address problems, and dissemination of results, both positive and negative.

Some degree of transformation is exhibited in the educational literature for healthcare administration in the United States. In a leading healthcare administration textbook, for example, patient care teams and aggregates of patient care teams, that is, service lines, are the organizing feature of the well-managed healthcare organization (White and Griffith, 2010). Service lines are defined around patient conditions or types in which the hospital specializes, such as oncology, neuroscience, cardiac services, or women’s health. In the most extreme of the service models, employed clinicians report to the director of the service line rather than their clinical department, as they would under the conventional structure. Figure 5–2 depicts one version of service line structure (simplified), a version which retains conventional clinical departments along with service lines. Service lines typically are managed by nurses, physicians, administrators, and pharmacists, sometimes singly but often combined in a team. Interprofessional performance improvement councils, which include both clinicians and administrators, provide coordination across service lines on the quality dimension. The patient care teams, service line management teams, and performance improvement council are interprofessional by design. While administrators are not physically present on every team, particularly patient care teams, those teams are influenced positively if administrators and team members consider administrators to be critical peripheral members.

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