Senior management’s role in clinical decision making
Name
DDBA 8560 - Seminar in Healthcare Managerial Decision Making
Walden University
2022
Board of Directors
A U.S. hospital is overseen by a board of directors (some hospitals may have
multiple boards) (Jha & Epstein, 2010). The board guides long-range strategic decisions,
evaluates organizational and management performance, manages the board, and directs
fundraising (Kovner, 2001). Interviews from the Kovner study indicated that the board is
involved in finance and planning, setting policy and giving direction on mission, selecting the
CEO, vision & oversight, and advising, planning, and assisting for the future. Arnwine (2002)
described the board’s role as policy establishment, strategic planning, and oversight. Previous
studies have focused on one specific aspect of the role of the board. Millar et al. (2013) described
the role that the board played in quality and patient safety. In order to assert this fundamental
governance role, the board must define priorities and objectives, craft strategies, shape their
culture, and define systems of organizational control. Culica and Prezio (2009) focused on the
role that the board played in relation to financial performance.
They argued that because “overseeing the operation of the organization and the board” is an
important part of hospital governance, the board has some responsibility for assuring the
financial health of the hospital. Previous studies have emphasized the importance of
distinguishing between governance and management. Biggs (2011) acknowledged that the board
and management have a role in strategic planning. However, management creates the
organization’s strategic plan, and the board approves, monitors, and makes suggestions for
change. Simply put, management proposes, and the board approves.
Arnwine (2002) highlighted that the board must oversee and govern, not manage, an idea that is
inconsistent amongst other papers. Longest (2012) emphasized the role the board plays in
strategic formulation, a key part of the broader process, strategic management, which also
incorporates implementation and control. Longest grouped the board with senior level managers
and acknowledged that the governance and management roles are sometimes not clearly
differentiated, defined, or mutually respected, which leads to difficulties assessing strategic
importance of information. There are many characteristics unique to hospitals that often cause
board members to be more involved in management (Anning et al., 2011). Board members and
their families are often also consumers, which can lead to them delving into matters that should
be left to management. This detracts focus and time from their responsibilities.
Senior Level Managers
Senior level managers, sometimes described as the “C suite,” include the
Chief Executive Officer (CEO), Chief Operations Officer, Chief Medical Officer, Chief
Financial Officer, and Chief Nursing Officer. They are involved in budget, resource allocation,
technology acquisition, and strategic planning. They play a part in approving budgets and
information technology (IT) resources, improvement and quality efforts, and resource allocation
decisions (Bradley, 2003). Senior managers, particularly the CEO, are the stimulus for strategic
change and are responsible for the strategic direction and financial management of the
organization (Embertson, 2006).
Friedman (2000) and Lai et al. (2014) highlighted the importance of technology acquisition
decisions, which can have significant effects on the organization. Weiner et al. (1997) identified
the effect top management had in promoting clinical quality improvement effort. They suggested
that by creating a corporate culture for quality and leading by example, senior managers could
encourage clinical staff to participate in quality improvement efforts. Results of their survey
showed that CEO involvement had a significant and positive impact in quality improvement
efforts. Guo (2003) identified three roles that senior-level healthcare managers play in decision
making: entrepreneurial strategists, disturbance handler, and resource allocator. An
entrepreneurial strategist initiates strategies for change, a disturbance handler resolves conflict,
and a resource allocator assigns job responsibilities. Li-Min et al. (2007) studied critical
management activities (via mailed questionnaire) performed by nursing managers at different
managerial levels. They found that senior-level managers were more concerned with strategic
planning issues and valued goal setting and planning more than the lower managerial levels.
Longest (2012) also acknowledged that strategic decisions, in public hospitals in particular, are
the province of senior-level managers.
Middle Managers
A middle manager bridges the gap between the doctors and senior management and professional
staff (Embertson, 2006). Previous studies focused on their responsibilities but did not describe
the decisions that they make. For example, Embertson (2006) discussed the roles that middle
managers play in juggling the budget, organization goals, and objectives. They should also make
employees feel valued by developing relationships, support, and encouragement. Embertson’s
description suggests that middle managers carry out the decisions that others have already made.
Birken et al. (2012) presented a theory of how middle managers influence healthcare innovation
implementation. They found that middle managers diffuse, disseminate, and synthesize
information regarding innovation, mediate between strategy and day-to-day activities, and sell
innovation implementation.
Studies regarding middle managers are sparse. Defining middle managers is not straightforward.
They often have diverse professional backgrounds, have diverse functions, and tend to occupy a
variety of positions (Birken et al., 2012). Li-Min (2007) found that middle level nurse managers
were more concerned with management control issues.
First-line Manager
A first-line manager, sometimes described as an administrator or supervisor, is responsible for
handling staffing issues in a specific department and day-to-day operations in a healthcare
organization. The role of the first-line manager is allocate to those for whom he is responsible
the materials and information needed to accomplish their jobs (Weaver, 1978). Although the size
of the hospital affects their role, the first-line manager is generally involved in the managing the
staff within a particular department of healthcare. First-line managers ensure that patients and
clients receive correct services in an optimal fashion. A first-line manager must also have an
understanding of medical records and make sure that patients’ medical
records are properly maintained. Begun (2011) discussed the role first-line managers have in
inter-professional care teams. He suggested that first-line managers can shape the structure,
strategies, and culture of the organization to optimize collaborative inter-professional care.
The first-line nurse manager is accountable for standards of patient care, staff
supervision and development, financial planning and control, and management of environment
(Acorn and Crawford, 1996). Acorn and Crawford found that nurse managers frequently had
responsibility for more than one nursing unit, supervised up to up to 175 staff, and managed
budgets of several million dollars. They also play a role in cultural integration and retention, and
direct staff attitudes (Kang, 2012; Mathena, 2002). Hyrkäs (2005) acknowledged that, although
first-line nursing managers in Finland were tasked with more administrative activities, they were
still expected to participate directly with an increased demand patient care. Li-Min (2007)
found that first-line nurse managers were concerned with operational management issues:
recruiting and training nurses, conducting performance evaluations, promotions and demotions,
designing and organizing workloads, settings standards, guidelines, and organization culture, and
interacting with internal and external entities. Miri et al. (2014) conducted an exploratory study,
through content analysis on results of recent studies, to describe first-line manager roles. They
first acknowledged that first-line managers were expected to manage wards while simultaneously
carrying out their patient care duties (Loo & Thorpe, 2003; Johansson et al., 2007; Skytt et al.,
2008). With regards to decision-making roles, Miri found that first-line managers did the
following: (1) developed policies for the whole organization and planned for implementation of
health standards; (2) participated and collaborated in conferences to enhance knowledge as well
as nursing research and applied research; (3) organized shift schedules and assigned tasks; (4)
planned for the delivery and development of equipment and tools; and (5) cooperated with and
accompanied senior officials and inspection group visits.
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