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Hospital Governance: Who is in charge of this place?


Judging by the number of emails I receive from chiropractors who are confused about the organizational structure of hospitals, I thought that I should try to briefly explain the management structure of a typical hospital.  Hospitals have varied chains of governance, but frequently they resemble the governance of colleges.  Hospitals have at least three separate leadership bodies (and frequently more):  the Board of Trustees, the Corporative Executives, the Executive Committee of Medical Services (ECOMS), and in some hospitals, a Medical Director.


The individuals on a Board of Trustees (BOT) are normally respected and influential professionals who provide oversight, policies, vision, and guidance to the hospital.   A BOT typically meets monthly or quarterly and meetings are lead by a chair.  The BOT does not interact in the day-to-day management of the hospital.  However, other hospital leaders will report to the BOT from time to time.  The BOT is one of the systems of checks and balances that protect the hospital from mismanagement. 


Hospitals, even non-profit hospitals, are run with a strong interest in profitability and will almost always have a strong presence of profit-minded healthcare executives who comprise the corporate leadership of the hospital. Corporate leadership will include the CEO, CFO, and other executive officers that provide leadership in the business of running a hospital. They are concerned with profitability, utilities, supplies, union negotiations, employees, physical grounds, operations, and the day-to-day operation of the hospital. 


The Chief of Staff (COS) is typically elected by the medical staff and leads the ECOMS, presides over clinical staff meetings, develops standards of care, and represents the medical staff to the hospital.  The COS is almost always a medical doctor.  The relationship between the ECOMS and the executive officers represent a separation of powers.  While the executive offices are concerned with profitability and business policies, the ECOMS is concerned with providing high quality health care.  The ECOMS committee is not to be influenced by the business office.  They are separated by a veil of ethical constraint.


These first three leadership groups often have trouble communicating and may even seem to speak different languages. To overcome this barrier some hospitals have added another leadership position, the Medical Director.  The Medical Director’s position may vary from hospital to hospital, but it is typically a physician, employed by the business offices, who facilitates communications between the business offices and the medical staff.  A Medical Director would also be in charge of the clinical support staff of the hospital.  This position combines the clinical acumen of a physician with the business knowledge of an executive.  Medical Directors typically have advanced degrees in business or hospital management. 


So what does this knowledge mean to a chiropractor wishing to integrate into a hospital?  It allows the chiropractor to know the lingo, avoiding embarrassment, and also it allows you to know the interest of each group:  The Trustees are interested in the big picture- Does having a chiropractor aid or impede long term plans?  The Business offices want to know- Can a chiropractor increase profitability?  The ECOMS asks- What impact will a chiropractor have on the standard of care and how do we credential a chiropractor?  The Medical Director looks at-Where will I put chiropractors and how would they fit into a hospital?


A chiropractor who wishes to approach a hospital should be familiar with the fundamental leadership structure of the hospital and the particular responsibilities and interests of each tier of leadership.  A little knowledge goes a long way in communicating the correct message to a particular component of hospital leadership.