Who can possibly manage a hospital?

6 January 2016

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Management, unlike medicine, uses little science: hence it is not a profession. Or to put this another way, because illnesses in organizations, and prescriptions for their treatment, have hardly been specified with any reliability, management has to be practiced as a craft, rooted in experience, and an art, dependent on insights. Visceral understanding counts for a lot more than cerebral knowledge.

Well then, if not professional managers, how about physicians? Surely they have the visceral understanding of the operations, plus the status to be heard. Moreover, are hospitals not fundamentally about medicine? Yes to all of the above questions. But there is a lot more to managing health care than knowing medicine. In fact, there are reasons to believe that the practice of medicine is antithetical to the practice of management.

Physicians are trained mostly to act alone, individually and decisively. Every time one sees a patient, an explicit decision is made, even if that is to do nothing. Decision making in management is not only more ambiguous, but also more collaborative. A cartoon appeared some years ago showing several surgeons around an anesthetized patient, over the caption: “Who opens?” In management, that is a serious question! Add to this the facts that medicine tends to be interventionist, mostly about episodic cures, rather than continuous care; that it usually focuses on parts, not wholes; and that it strives to be scientific and evidence-based, and you have to worry about physicians running hospitals.

This leaves the nurses. Their practice is often more visceral, more engaging, and arguably closer to concern about the whole patient. Moreover, their jobs are ones of continuous care more than intermittent cure, plus they are inclined to engage in more teamwork. So some nurses at least should be rather more suited to managing hospitals.

Sure―but how to get the doctors to accept management by the nurses?

So the conclusion appears to be evident: no-one can possibly manage a hospital! Running even a complicated corporation must seem like child’s play compared with managing a general hospital: the strident doctors, the beleaguered nurses, the sick patients, the worried families, the demanding funders, the posturing politicians, the escalating costs, the accelerating technologies―all embedded in cases of life and death.

Yet people do manage hospitals and other health care institutions, sometimes with rather astonishing effectiveness. So beyond the evident answer to our question is the obvious answer: People, not categories, have to manage health care institutions. I have encountered physicians who were renowned as heads of hospitals. (One of Montreal’s most respected hospital directors was an obstetrician with an MBA.) Likewise have I seen some awfully impressive nurses managing hospitals―and imagine how many more there would be if given the chance.

My own preference is for people who have worked in the operations before moving into the management, whether that be in nursing, medicine, physiotherapy, or social work, etc. In fact, the wider the net is cast, the greater the chances of success.

That is not to conclude that training in management is irrelevant, only that it should follow experience on the job, and build on it. That is what we have been doing at McGill since 2006, with great success and delight, in our International Masters for Health Leadership (mcgill.ca/imhl), for people from all aspects of health care all over the world.

Now for the ultimate bit of administrative engineering

In a recent TWOG on managing the care of health, I discussed a number of dysfunctional forms of administrative engineering—mergers, measures, reorganizations, etc.—that are meant to fix health care where it is not broken. Some weeks ago I underwent a bypass operation in a Montreal hospital that had been administratively engineered in a particular way.

Our hospitals in Canada are mostly non-owned―they are independent trusts. But that has not necessarily stopped the provincial governments that provide most of their funding from treating them like government departments.

Last year in Quebec, the prime minister and his minister of health, both physicians, solved the problem of who should manage hospitals by deciding that no one should. They eliminated the positions of director general—head of the hospital--and indeed of most of the health care institutions in Quebec. In effect, they fired them all, and combined all these institutions into regional agglomerations, each with its own single président-directeur général (the French term for CEO).1

This is not Alice in Wonderland. In the teaching hospital where I was treated, with its 637 beds, there is no longer anyone in charge. The former directeur général was kicked upstairs—transformed into a PDG―to manage the whole agglomeration. This comprised nine (yes 9) separate institutions, across acute, community, rehabilitative, palliative, and geriatric care, etc. Think of all the money our government has saved. Think too of all the chaos that is to come.2

So I have a terrific idea. Do we really need all those government ministers? Health, Justice, Culture, Finance, Education, Agriculture, Mines, and eighteen or so more. Why don’t we just agglomerate them all, and have the prime minister run the whole works himself. Think of how much more money we could save.

© Henry Mintzberg 2016. Partly drawn from my forthcoming book Managing the Myths of Health Care.

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1 This is an unfortunately excellent example of ignoring the importance of the plural sector in society. Because of its power over funding, this government has in effect nationalized the hospitals. (The chart it drew even shows a solid line from this PDG to the minister of health, and a dotted one to the board of directors of the hospital. Dots have deep significance for bureaucrats.) As I argue in my book Rebalancing Society, professional services often attain their high levels of quality by functioning with a certain degree of independence in the plural sector, rather than the public or private ones. So much for that idea in this case.

2 Their timing might just prove to be impeccable—for the opposition parties. As I noted in my TWOG on efficiency, the cost savings of such administrative engineering show up immediately; while the negative impact on services appear later—perhaps just in time for the next election.