Establishing the Chain Of Command at Your Medical Practice

The challenges facing physicians these days have been documented at length. But far less ink has been dedicated to the plight of the office staff who support them, many of whom report to a tangled web of supervisors who more often than not convey mixed messages. Indeed, the governance structure within most medical groups is anything but linear. Clinical and clerical staff report to their supervisors, but also take orders from physicians. Physicians report to the stakeholders, and the administrator oversees all nonphysician employees - except when she's overruled by the board of directors. It’s confusing at best, dysfunctional at worst, says Marshall M. Baker, head of Physician Advisory Services in Boise, Idaho. "I think we have to recognize that medical group practices are highly matrixed organizations and it’s rare that you’re going to find hard lines for who reports to whom," he says. "There are a lot of dotted-line relationships."

That’s not to say a chain of command can’t exist. In small- to mid-sized groups, Baker says, the most effective governance model is to assign both a clinical and clerical lead who manage the staff in their departments and report to the practice administrator. That’s especially effective in practices where the administrator has no prior clinical experience. "We have certainly seen practices where the administrator oversees everything, and that can work if the administrator has clinical expertise - for example, if they were a former registered nurse," he says. "But if the administrator has no clinical background, he or she needs a management team member who can walk the walk and talk the talk."

Let them lead

No personnel matters should come to you, or the physicians, that can otherwise be resolved by the department heads, says Shari Ohland, administrator of Midwest Spine Institute in Stillwater, Minn. "If you don’t trust your managers to lead, there’s no way your hourly staff will ever respect them," she says. "When someone has an issue, they need to go to their immediate supervisor, not directly to the administrator." Employees who come to you first should be immediately instructed to resolve the matter with their supervisor, she says. "Don’t get involved until they’ve tried to solve it first, and then if you must you can bring all three of you together to work it out."

In the case of clinical support staff, who report to two bosses, the supervisor and physicians should maintain a strict reporting protocol to minimize confusion, says Tom Loughrey, compliance director of physician practices for St. Joseph Health System in Orange County, Calif. "Draw very clear lines between professional reporting responsibilities and operations reporting responsibilities," he suggests. "For issues related to education and patient care, those employees should deal with the physician, but for operational matters, such as requests for days off, they need to speak to their supervisor."

That applies to employed physicians, as well, says Rebecca Dean, executive director of Sportsmedicine Fairbanks in Alaska. "We have an organizational chart and I follow that chain of command," she says, noting her front desk, billing, and nursing managers report to her for operational decision-making, and she reports to the owners. "Our employed physicians clinically report to their medical director, but from a business and risk management side they fall under my office," she says. As such, any matters related to compliance, patient relationships, coding, or quality measurements land on her desk.

Put it in writing

One of the most effective tools for establishing managerial hierarchy is to identify in your job descriptions the reporting structure attached to each position, says Baker. "With every position title we expect to see roles, responsibilities, accountabilities, and reporting relationships clearly written out," he says. "That minimizes misunderstandings right from the moment of hire."

Ultimately, however, it’s the relationship between the physician owners and the administrator that lays the groundwork for effective governance, says Ohland. "That sets the tone for how the rest of the staff will function," she says, noting medical groups are unique because the head of business operations (the administrator) is also a worker bee. "If your staff sees that you trust each other to lead, you won’t see your divisional supervisors undermining or micromanaging their own staff." Michael Ferry, chief operating office for Halley Consulting Group in Westerville, Ohio, agrees, noting all decision-making about the practice should be made by the shareholders and administrator at the monthly board meetings. "That’s where you review performance, look at the top and bottom lines, deal with personnel issues and set priorities," he says. "That gets translated into an action plan to be implemented by the department heads. It’s their marching orders for which they will be held accountable."

Learn to delegate

According to Loughrey, one of the biggest challenges practices confront is that physician owners, who have never been trained in business management, may not know how to relinquish control to their team. It’s your job to foster a culture of autonomy. "The best run practices do a good job of delegating real responsibility to other levels of management," he says. "Physicians may reserve certain things where the buck stops with them, but the only way they can extend themselves as providers is to hire good people and delegate." Regardless of how involved the shareholders choose to be with business operations, adds Baker, the administrator must have decision-making authority over the staff. "The administrator needs to be able to hire and fire their staff," he says. Don’t forget to give your supervisors the same respect. For her part, Dean says she encourages her supervisors to problem solve on their own. "I have a rule that my managers need to bring at least three solutions with them when they come to me with an issue," she says. "They may not be solutions we can implement, and they may be solutions they’ve come up with as a team, but that way we’ve got something to talk about."

Finally, a successful chain of command is predicated on the fact that every manager in your practice is competent. Those who are not should be elevated through training - or let go. "The most progressive practices provide leadership by demonstrating that managers know their jobs, they’re interested in what’s going on, and they’re paying attention to details," says Loughrey. "That’s leadership." Medical practice management is tricky business, indeed. You can help your office run more smoothly - and minimize inefficiencies - by putting a reporting protocol into writing, and ensuring that supervisors at every level are given the green light to lead.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the June 2012 issue of Physicians Practice.