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Better Healthcare Quality At Hospitals Run by Doctors

The top-performing hospitals in the US are more likely to be headed by a physician than a non-physician. That is the major finding of a cross-sectional study1 by Amanda Goodall, PhD, which examined the association between the ranked quality of a hospital and whether the Chief Executive Officer (CEO) is a medical doctor.

To be published in the influential journal Social Science & Medicine, this study identified the top-100 US hospitals in three specialties—Cancer, Digestive Disorders, and Heart and Heart Surgery—as determined by quality ranking used in the US News and World Report’s “Best Hospitals” 2009. The Index of Hospital Quality (IHQ) scores used incorporated three areas of healthcare performance: structure, process, and outcomes. Then, data on each hospital’s CEO were collected and the CEO was classified as ether a physician-leader (trained in medicine) or a non-physician manager. Nurses were categorized as non-physicians.

For each of the three specialties, the mean hospital-quality scores were significantly higher for physician-headed hospitals than for non-physician-headed hospitals. Among “Honor Roll” hospitals, 16 out of 21 hospitals were led by physician CEOs. In this select group of hospitals, those that were run by physicians had a mean IHQ score of 18.38, compared with a mean score of 12.60 for non-physician-led hospitals.

Three points:

  1. There appears to be a trend toward hiring non-physicians to lead hospitals in the US and the United Kingdom. Other countries might also be following suit. Although this study does not prove that medical doctors make better leaders, it does provide some empirical evidence (the first of its kind to be published) to support the hypothesis. In Malaysia, the majority of public hospitals are headed by medical doctors. Subject to a fair amount of criticism (by non-physician managers) recently, this long-standing practice seems to be vindicated by the findings of this study.
  2. Medical doctors may be more effective leaders for a number of reasons: acting as role models, having a better understanding of clinical processes, balancing the focus on patient safety and clinical outcomes with the need to grow revenues and the bottomline, etc. Whatever the underlying mechanism(s), it seems sensible to place medically-trained personnel in leadership positions to improve patient care, and by extension, hospital performance.
  3. One limitation of Goodall’s study is the potential for confounding, e.g. by the wealth of the hospitals. In other words, the hospitals with the deepest pockets and/or highest reputation have the greatest choice of candidates to lead their organizations and the financial ability to hire physician executives. Therefore, the relationship between physician leaders and top-performing hospitals may be a function of the wealth and/or prestige of the hospitals rather than the managerial abilities of the physicians.

Reference

  1. Goodall AH. Physician-leaders and hospital performance: Is there an association? Social Science and Medicine, 2011; DOI: 10.1016/j.socscimed.2011.06.025.
{ 4 comments… add one }
  • PolicyMedical July 11, 2011, 11:16 pm

    We see a similar effect in our work with hospitals. As vendors of policy management solutions, you would think that the best people to work with us to set up the software would be CIOs or someone in HIT, but we’ve seen the more often than not, the best person to spearhead the initiative is actually in nursing. Why? Similar to your theory, ours is that they have a thorough understanding of processes in the hospital, they interact on the daily with many different departments in the hospital, and they have a focus on the outcomes that HIT needs to bring about (eg. patient safety). I can’t comment on the limitations of Goodall’s study – perhaps it amplifies the the results – but I think your second point appeals to our common sense in explaining the results.
    Cheers,
    Daisy

    • Andy Teh July 12, 2011, 5:39 am

      @PolicyMedical—Hi Daisy, Thank you for sharing your experience. That’s an interesting observation. We too have come across organizations that place the leadership responsibility of implementing IT solutions (e.g., electronic medical records, CPOE, barcode medication administration) on their CIOs. That’s very often a mistake. A multidisciplinary team, led by a clinician with good knowledge of the relevant processes, tends to yield more satisfactory results.

  • Etim Essien December 5, 2011, 10:29 pm

    The question of the leadership of Public Hospitals in Nigeria is not the priority question now. This is a distraction.The real question is the quality of service delivered at any specific point in the system. It is common knowledge to all that the quality of service that is provided in public Health establishments in the country is generally below expectation. This has to do with [a] the knowledge base and skills that are available in the system, [b] the quality of facilities available in the system, [c] the general attitude of the care givers to their responsibilities to the system and to its customers ie the patients. This is the real problemthat we face and everyone in the system should devote full time to address this problems: indiscipline and other ills. The Americans have established competent, efficient, functional system. We need to set ours up before struggling for leadership of the sector.

  • Andy Teh December 11, 2011, 1:49 am

    @Etim Essien—Thank you for your comment. Our approach to quality management takes into account structure (including leadership, governance, human resource), processes, and outcomes. Structure supports processes, which in turn lead to outcomes. For example, if an organization doesn’t make the necessary investment in training programs (structure), it might be extremely difficult to build capacity to improve. In addition, without sufficient leadership support, many improvement initiatives will probably fail to deliver the desired outcomes. Leadership has an enormous influence on organizational culture , i.e. the attitudes, beliefs, values, and behaviour of staff. I would not discount the role of leadership in any improvement effort.

    Therefore, I think one has to look at improvement holistically and address it at different levels and from various perspectives.

    I would also hazard to use the U.S. healthcare system as a benchmark – by some estimates, the U.S. has the worst performance in some key measures of health status among industrialized countries!

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