Working with Hospital Administration: Strategies for Success

Abstract

Organizational structure has evolved over the past several decades, with physicians assuming more or fewer leadership positions over time. Regardless of the role of physicians in health care organizational leadership, constant meaningful communication with the hospital, radiology group, or greater physician group administrative leadership is vital for any group of IR physicians to be successful. Understanding what is considered important to hospital administration and, in particular, being closely aligned with the C-suite leadership, is paramount to having successful communication with these stakeholders. Although each situation will obligatorily be unique, certain themes can be followed to optimize the working relationship between an interventional radiology service and organizational administration. This article provides guidelines and suggestions specifically in communicating with health care system leadership.

Interventional radiology (IR) practices vary in many respects—size, scope of practice, relationship with diagnostic radiology or other clinical services, rural versus urban, hybrid versus solely IR, etc. The site of service also varies, with practices operating solely as office-based labs (OBL) to solely hospital-based practices, and everything in between. While OBLs are not altogether uncommon, the majority of IRs continue to work in practices that are at least somewhat hospital based. In this setting, whether private practice or academic groups working in hospitals, those who contract services with hospitals, or those wholly employed, the relationship between the IR group and hospital administration is vital to the success of the IR physician. ¹

Even in the setting of non-employed physicians working within health care systems, there are inevitable needs that must be met by both sides to deliver safe, quality, and appropriate care to patients. Bringing the value of IR to a health care delivery system is an important foundational component to any discussion revolving around contribution to an organization, ² but it is only one necessary step. In some systems, other physician-system alignments are also necessary, such as those seen with faith-based organizations. While no organization or physician will make an argument that quality is not necessary, other issues may be far less clear to either or both sides. However, given that the main driver for health care systems remains physicians bringing patients into the system, it is imperative for hospitals to be able to create the environment for providers to feel that they are appropriately delivering care to patients. This is true not just for physicians, but for anyone (nurses, advanced practice providers [APPs], therapists, etc.) delivering care. However, the relationship of physicians and their groups with the health care system is unique with respect to the negotiations and compromises that occur between the two bodies.

The act of negotiating with hospital administration varies so widely from system to system and person to person that any attempt at boiling the process down to the basics can be difficult if not misleading. The art of negotiation is every bit as important as the scientific argument to be made, which is a concept many physicians have a difficult time with; through their training and natural proclivities, doctors are data-driven and seek firm answers through scientific vetting. However, arguments often made by physicians when talking to administration can fall on deaf—partial or complete—ears because of this single-minded focus by practitioners on data. This is not being dismissive toward administrators—the opposite in fact. Hospital administration is every bit as focused on data as the provider making an argument for more resources, for more support, for more space, etc. The difference is not in the focus on data, but rather on the focus of the type of data sought. And it is in this setting that physicians often lose the argument they make in seeking resources—they simply are not making the argument that is needed, even if they have the necessary data at their fingertips.

While negotiations are always two-way streets, this article will discuss some strategies that may be helpful with discussions with hospital administration while seeking resources. It is not intended to be a complete list, and many of these strategies will likely not work in some health care systems or with some physician groups. However, it is the author's hope that some of these hints will help the reader to obtain what they need to optimize health care delivery to their patients.

The Pathway to Hospital Administration

There is a trend in today's healthcare workforce to focus more on physicians taking leadership positions within healthcare systems. This trend seems to wax and wane with some regularity. Several decades ago, not only were physicians commonly in the C-suite but were actual owners of hospitals. This role for physicians is no longer common, and in fact is very significantly limited following the passage of the Affordable Care Act. In the interest of preventing self-referral, physician-owned hospitals now must request a waiver from the Centers for Medicare and Medicaid Services (CMS), and limitations exist that preclude growth of such institutions. ³ During the latter half of the 20th century, hospital administration become a field of its own with specific training programs (often general Master of Business Administration) typically needed to advance to higher levels of leadership within the health care system. During this transition, it was not uncommon to find physician leaders in a dyad leadership structure with individuals straight from the business world. Soon thereafter, however, there was a general trend to separate the leadership structure into the clinical and business missions of the enterprise. This migration likely occurred at least in part due to the complexities of both—medicine became far more convoluted, and navigating the business of running health care systems could not be considered an add-on to one's clinical practice. In short, whether right or wrong during this time, health care delivery became “big business.” By the year 2000 or so, it was unusual to find a practicing clinician also serving as the CEO or president of a hospital or health care system.

Over the past several years, there has been an increased call for physician leadership within C-suites of hospitals. The etiology of this trend is uncertain, but physician leaders are no longer relegated to the chief medical officer role or leadership roles within the medical staff office. Increasingly, CEOs, presidents, strategy officers, quality officers, diversity officers, and even operating and information officers increasingly have MD or DO after their signature. How long this trend will continue is uncertain, but an increase in physician health care system leadership in the business literature would suggest that we remain in the growth phase of this change. ^{4 5 6}

One can make an argument that while having physicians in charge of hospitals is advantageous because of their understanding of the clinical care delivery side of the equation, one can just as easily argue that physicians are generally ill-equipped to run complex healthcare delivery systems due to their experience, or lack thereof. Many physician leaders rise through the ranks of academia or private practice by being chairs and deans, private practice presidents, and multispecialty group officers. Even those who do hold C-suite positions such as chief medical or chief quality officer are typically focused on one particular aspect of the hospital system, and rarely are involved in high-level financial, or sometimes even more broad strategic, discussions. Being CEO of an organization requires a skill set that takes decades to develop, and for physicians this may require advanced formal education as a starting point. While the practice of medicine is complex and difficult to master, the same can be said for running a health care system—it simply is not a job one can step into without significant experience and the lessons that come with that experience. For that reason, completion of formal programs in Master of Business Administration or Master of Health Care Administration is currently typically required to advance beyond the mid-level administrator position.

Current Challenges Facing Hospital Administrators

There are several challenges specific to health care administration that have become more acute over the past several years. First of all—administrators are poorly viewed by the general public and considered to be part of the problem rather than part of the solution with health care. While that stance may be somewhat softened for administrators in certain health care settings (systems serving underprivileged patients, pediatric hospitals, faith-based organizations, etc.), for the most part hospital systems are now considered to be too expensive, too unfriendly, and not patient-focused enough. Due to their oversight of such systems, administrators make the easiest although sometimes inappropriate targets. Some of this frustration toward hospital administrators comes from what is considered inappropriate compensation; in 2020, the average health care CEO made 253 times the salary of the average worker. ⁷

The second overwhelming challenge facing administrators in today's world is the challenge in keeping hospital systems financially solvent, much less profitable (not-for-profit hospitals do not make a profit, they simply reinvest it in the organization; not-for-profit is a tax strategy, not a financial model). Challenges existed for administrators in the past, but following the most acute COVID pandemic crisis, hospitals have been reeling financially. It was estimated by the American Hospital Association that more than 50% of all the hospitals in the United States will suffer financial losses in 2023, largely due to a growth in expenses that was more than double the increases in reimbursements from 2019 to 2022. ⁸ This dire situation has led to many hospitals, particularly those in underserved areas, to close. From 2010 to 2021, a total of 136 rural hospitals closed, including 19 in just the year 2021 alone. ⁹

Along with other health care workers, hospital administrators are increasingly leaving the workforce, making the shortage of this profession nearly as acute as the one facing the physician, nurse, and technical workforces. This shortage of health care administrations is doubly concerning given the anticipated growth in the field even before the efflux of administrators from the workforce. Just before the pandemic, the U.S. Bureau of Labor Statistics estimated a 32% growth in health care management jobs through 2029. ¹⁰ With increased demands due to workforce shortages coupled with societal disdain, one would find it difficult to imagine a more difficult situation right now than hospital administration.

The remainder of this article will focus on two vital aspects of communicating with health care system administration: what is important to an administrator, and how IR physicians can make a meaningful argument to obtain the resources they need to provide the care they want to provide to their patients.

IR from the Hospital Administrator Position

Resources are always limited. No matter the robustness of an organization, there will always be a scarcity of resources. A perfect balance is never really achieved, particularly in an organization that is growing (or contracting). If bed allocation is not an immediate concern, that is likely because census is too low. If nurse staffing is not a problem, it likely means that there are fewer personnel dollars to go to housekeeping or physician incentives. The primary job of the hospital administrator is in determining where to best place those resources to achieve the goals of the greater organization—not of one particular group of physicians or other providers. A good reminder is that in nearly all circumstances what is given to one project or group is taken from another. This is the background in which decisions are made.

IR is a relatively small service in the health care system. While we as practitioners understand what we can provide to our patients and how that care can potentially help patients throughout the healthcare system, it is important to understand where we are positioned from the C-suite viewpoint. At the author's institution, for example, there are approximately 800 physicians on the medical staff, plus 1,000 residents, 200 to 300 APP, and hundreds of therapists. The IR group consists of six physicians, two APPs, and two residents per year. Put into perspective, the IR group makes up far less than 1% of all care providers in the hospital ( Fig. 1 ). Other arguments can be made, of course, about the importance of the care we provide, but the numbers do not lie.

Fig. 1.

Relative size of IR section. Comparative size of IR section physicians (blue) relative to the remainder of the radiology department faculty (red), and overall physician group (yellow).

Administrators know what IR is. There has been much discussion over the past decades about how important it is that IR promote itself as a field, whether through the societies, political action committees, or advocacy groups. ^{11 12 13} While there was clearly a time when the lack of familiarity with IR was rampant, the need to focus on educating decision makers on what we can do to help patients with our clinics and procedures is much less pressing. In many instances, time would be spent better doing other activities. Administrators do understand what we do, and they do know what we can potentially add to a system. Perhaps they should be educated on the nuances of new procedures, of introducing patients to the system, to throughput in the hospital, etc. However, the idea that administration cannot correctly spell “IR” is a 15-year-old argument that either is dismissed and nonproductive or, in the worst case, is frankly offensive to administration.

The priorities of administrators may differ from IR physicians. Despite current opinion, most hospital administrators chose healthcare specifically as a field, not simply because it is a place to practice their business craft. Just like most physicians go into the medical field for the right reasons, so do most administrators. At the group level, top-level administrators and care providers all want the same thing—to provide top quality care that would be provided to their own family members. However, the goals and priorities of administrators in the C-suite differ from those of physicians at the individual level because they must. It is really no different from one specialty in medicine having different priorities than another—the way in which dermatologists, IRs, and psychiatrists go about plying their crafts to deliver the same goal of excellent care is widely disparate. That difference extends to administrators, but one should consider them in the same way that one considers another field of medicine; that is, all pulling toward the same goal but in different ways.

The challenge for hospital administrators is in advancing the entire enterprise together and moving it forward in specific ways based on two things: strategic direction and resources. There are few (if any) healthcare organizations left that can be all things to all people, especially at the highest level. Many large organizations have providers in all specialties and most subspecialties; however, strategically they must be more focused on and dedicated to a select few service lines. ^{14 15} In healthy and reliable organizations, this focus comes from the strategic plan of an organization; in less highly functioning systems, the focus may rather come from favoritism, distracted complaining, or behind-the-door handshake agreements.

Strategies for Successful Discussions with Administration

Fit into the mission and vision of the organization. This strategy is by far the most vital and effective in moving an IR department forward in a healthcare system. All successful executives use the strategic plan as a north star, as the framework within which all meaningful decisions must be made. Alignment with the mission, vision, and values of the greater organization only leads to synergies between the physician and nonphysician leaders in an organization. ¹⁶ Having a knowledge of the strategic plan during discussions gains much traction for the case being made, demonstrating to the C-suite that not only is one familiar with the plan but that one sees the importance of fitting into that plan. While a new procedure or clinical service may bring great satisfaction to us as IRs, and may even fill a current void in services provided, executives will hear dozens of arguments as to why any new service is important. And they all might be, and they all might be important to the patient population—but if the plans do not fit into the overall larger strategic goals of an organization, they will be relegated to the end of the list and may never be heard from again.

Understand local structure . Understanding the local structure and governance of an organization is vital to a successful discussion and request for resources. If one is making a plea for something specific but making it to the wrong individual, how robust the argument is will be irrelevant. Understanding that a request to administration for providing a service in the cancer space is best argued before the service line administrator, cancer center director, business development officer—not straight to the CEO. While letting the chief executive know that the request is being made might be advantageous, the heads-up should not come as a formal or even informal request. Simply letting that individual know that an initiative is being undertaken and, most importantly, that the request is going through the normal channels will both be appreciated and demonstrate a willingness to let the process work.

Understand people . Every organization is different not only in structure but also in people. While all people in an organization are hopefully aiming for the same large-level goals, how to get there may vary. For instance, if the current decision maker has a strong financial background versus rising through the ranks in information technology or nursing, the argument made should be nuanced both so that they can understand the decision before them and so that the individual making the argument best understands what follow-up information is needed. In many ways, having a discussion with someone from the business world can be easier than an IR making an argument for resources before a cardiologist, vascular surgeon, or radiation oncologist. If one is unclear about the background of an administrator or how further arguments should be packaged, simply ask. It will demonstrate an understanding of the process and a willingness to change the argument appropriately, which will advance the discussion to the next stage. For this it is best to be proactive, since whether one does or does not understand the process will quickly become evident to the administrator in short order.

Understand local politics . While it is true that at a global level one has hope that hospital administration and physicians are tightly aligned, all large organizations have local politics. Regardless of how distasteful local politics can be, one is missing an opportunity if this aspect of an organization is ignored. For those less political in nature, options are available. These would include delegating the “politics” of the larger organization to a partner more prone to politicking, whether that be an individual with much organizational history or one coming at an issue from a different direction altogether. At the very least, being aware of the politics of an organization without becoming involved in them is paramount. Partnering with those who have more organizational pull may prove to be the best alternative strategy for navigating this issue.

Local politics extend beyond the four walls of an institution. Hospitals remain community resources, ^{17 18 19} and many organizations serve as major employers as well as health care providers. ²⁰ In the 20 largest U.S. cities, for example, at least one health system is one of the top-10 employers; in underserved areas, at least one healthcare system is one of the top-5. ²¹ The politics of the local community being served may dictate the decision made regarding any particular service; the importance of this is likely more critical for underserved regions such as those in disadvantaged communities in urban areas and rural settings. The needs of the community may need to be addressed (e.g., obesity, fibroids, vascular disease) in a holistic manner before other subspecialty services can be addressed. Most larger organizations undergo intermittent community needs assessments that oftentimes are publicly available. Understanding these local or regional needs, and the politics accompanying them, will help focus arguments.

Bring something novel to the discussion. One must understand the constant requests made to the hospital administrator, and competing priorities and conflicting imperatives. Building practices that fit into the strategic goals of the organization is job number 1 for the successful administrator. One way to not accomplish this goal is to allocate resources for redundant services. To be truthful, unless there is a secondary gain, administration is not interested in whether an epidural injection is provided by anesthesiology or IR, whether pulmonary emboli are treated by cardiology or radiology, or whether nuclear cardiology studies are read by a radiologist or nuclear medicine physician. While arguments can be made when something egregious occurs and clear quality and safety concerns can be made, for the most part an administrator is most interested in being certain the service is provided in an effective, timely, less costly, and amicable manner. The argument that we as IRs are better at performing a procedure may or may not be listened to—an argument proffered without evidence will undoubtedly land in the second bucket. A good rule of thumb is to remind oneself that as one exits stage left, entering stage right is a competing service making the same request. Regardless of how strongly one feels that they may be better, faster, and less expensive than another specialty providing the same service (all of which might be true), if nothing novel or if a secondary gain is not being accomplished then the status quo will likely prevail.

A caveat to the above premise is that secondary gains may be every bit as important as the primary argument being made. An example from the author's experience is venous access. This author remembers when venous access was a new procedure for which the IR community had to fight to gain a foothold. Chest ports and tunneled lines might have been more successfully placed with fewer complications than those placed in the operating room; however, that argument was secondary; the primary argument centered around freeing up operating rooms for more invasive (and better reimbursed) procedures that could be performed in the recently vacated operating rooms.

Help solve a problem . Regardless of the degree of excitement we as IRs may have to bring something novel to an organization or to further enhance what is already provided, simply bringing something shiny and new is not enough of an argument to make. A discussion around providing a pulmonary embolism response team to the hospital administrator who is dealing with low Leapfrog scores due to high pulmonary embolism rates will gain far more traction than discussing geniculate artery embolization when there is already a solid orthopedic and primary practice dealing with knee osteoarthritis.

In the worst case scenario, solving one problem may lead to creating another problem. Duplicative procedures dealing with the same pathology or process notoriously cause difficulties for the health system administrator. Unless incremental growth occurs, the administrator may find themselves in a “give to one by taking from another” situation. If an IR group decides to focus on portal hypertension treatment, but there is no buy-in from hepatology to focus on the same, the administrator now has another hole to fill. Likewise, if building a strong balloon-occluded retrograde transvenous obliteration referral service is an aim of the interventional service, but there is no capacity in the IR suites to assume these lengthy procedures, the opportunity cost of losing other procedures in the labs—particularly those that may better fit the overall mission of the institution—may far outweigh the small incremental benefit of offering a new or alternative service.

The second worst scenario occurs when a service is introduced but introduced only halfway. For example, it does the hospital little good to have the IR or any other service offer a new procedure, but only offer it during normal work hours. This means that either a second clinical service be held responsible for off-hours coverage, or that the service simply not be provided all hours of the day. IRs as a group know this only too well, as evidenced by the Friday afternoon procedure requests and the sudden importance of angiographic control of bleeds during off hours.

Prove you are a team player . As discussed, hospital administrators have dozens of competing priorities. Oftentimes, IR services are vital to the success of any program being built, although in many instances the IR services being offered are not the primary component necessary to make any program successful. For instance, a successful transplant program relies on IR for many of the services offered, such as drainage of perigraft fluid collections, arterial reconstruction, and diversion of biliary leaks. However important IR is in providing these services, hospital administration will still determine these clinical procedures as “ancillary” to the primary service of the transplant surgeon. Partnering with the hospital and the surgical service in this supportive role is in many ways antithetical to the approach currently being espoused by IR physicians, that we are a vital service to be prioritized; playing second fiddle is no longer in our lexicon. However, it is important to remember that there are countless “ancillary” services necessary to make any program successful, from IR to diagnostic radiology to laboratory medicine to intensivist support, etc.

In order to convince administrators that a robust IR service is necessary for their programs to succeed provides two benefits. First, arguing for resources by partnering with other services from other departments is a powerful argument that IR is not a standalone service operating as an individual unit, but rather part of the glue holding together other clinical initiatives. These arguments are always far more successful, since a team approach is being sought rather than one service asking for limited resources to bolster its own individual agenda. Second, in partnering with other services and proving a dedication to success of the health care system as a whole, when the time comes to request resources for a program being built organically in the division, the IR service will be identified as a good partner with whom to do business. Trust being built prior to the request will significantly improve the likelihood of attaining the necessary resources for successful implementation of IR-centric initiatives. ²²

In addition to the reasons expressed earlier, partnering with other services and with the system at large is important because not partnering has secondary and additive effects. If a procedure that IR can perform is refused by the section, that resource must be attained in a different way for the greater program to be successful. In the best case scenario, the hospital may be able to find that service from another department and IR might simply be considered a poor partner or parochial in their approach. In the worst case scenario, however, the contribution being refused might have to be replaced by building the service in another way, which may prove to be more expensive and/or of lower quality. An example might be performing paracenteses or venous access for inpatients. While no IR will be excited by the prospect of providing these services, by not providing them the IR physician will obligate the hospital to fill in those resources in another way. And like it or not, by being a product of our own success, IR physicians have proven that these minor procedures are performed more quickly and more safely in our hands. Refusing these procedures will simply send a message to administration that the IR service will not contribute in whatever way they can to the success of the institution (which is a message that will be solidified when the referring clinical service complains to administration about the service being refused).

Understand the importance of the corporatization of health care . With the rapid changes in the health care industry, it is vital for IR to recognize where we as a field fit into the new structure. While there are numerous opportunities for growth of IR services in the new paradigm—for instance, by providing alternatives to current clinical services that demonstrate improved quality and cost savings to the institution—there are other aspects of the changes that might be more challenging. One of those difficulties can arise by the increasing mergers and the current trend of employment of physicians. Due to both of these changes, IRs and all other clinical services will have less influence with administration than in the past. The era of private practice radiology groups, or individual IR practices approaching hospitals or systems to provide services in return for resources or concessions to the organization, is quickly coming to an end. With the increasing use of the employed physician model (modern health care site, physicians advocacy group site), there has been a shift in the power equation more toward the health care system and away from the physician groups. With this shift comes less autonomy for physicians in providing the services they want, and growing their clinical services based on new developments in their field; the focus for the hospital administration can be narrowed down to the programs they see most fit to grow.

The other effect that corporatization has on the provision of clinical services is that the term “hospital administration” takes on different meaning. While the C-suite of an individual hospital may be focused on aspects such as community service and the local market environment, the C-suite of a major system will be focused on the organization as a whole. This focus may require downplaying or even sacrificing services at one hospital in favor of another. This organization-wide prioritization can have significant influence on what services might be offered or necessary for IR to provide. For instance, it might be determined that transplantation services or stroke services will all be performed at a major tertiary care center in the system rather than at community hospitals. Mergers and acquisitions, and now private equity interests, will continue to chip away at the autonomy and authority of physicians to develop practices in the way they best see fit.

Assume leadership positions in health care systems. As discussed earlier, there is an increasing push to have physicians assume more authority in hospitals and health care systems. While this is a complex and debatable approach, it is a certainty that as physicians assume more of a leadership role, IRs must strive to be part of that leadership paradigm change. Perhaps a greater existential challenge for IR services exists by having another (perhaps IR unfriendly) type of MD/DO assume C-suite positions than having an MBA in charge of the organization. It is paramount that IRs develop to assume positions of authority in hospital systems.

Perhaps three of the greatest hurdles to achieving this goal are predictable: time, training, and money. These three factors are inextricable. Individuals do not simply rise to a C-suite level position without putting in significant time and a dedicated effort to rising through the administrative ranks. While general leadership skills obtained through experience or formal training are advantageous, specific training focused on health care is becoming necessary with the increased complexity of delivery of health services. ⁵ Such leadership opportunities may be home grown and intramural rather than external; education at such a grass roots level may lead to more directed education for the physician and closer alignment with the goals of the system. ²³ Assuming increasingly influential positions starts with committee assignments, the majority of which are uncompensated—if compensated, they are often benchmarked to a lower paid specialty than that of the IR physician. Individual IRs or their groups need to be convinced of the importance of this progression, which will take years to develop to the point of significant influence within the organization. Add to this the need for further formal and informal training in the business aspects of health care administration, and the time commitment necessary to elevate to the C-suite is substantial and typically requires some sort of subsidy from one's partners. Without an understanding of, and support for, this sacrifice IRs will continue to be shut out of leadership positions.

Recognize the power balance. As alluded to, the power differential between the hospital administrator and the physician is increasingly tilted toward the former. Physicians are typically considered de facto leaders in their institutions, regardless of skill set or even desire to be leaders within their organizations. Whether sought or not, these leadership positions are increasingly being trumped by hospital administration ( Fig. 2 ). Mergers, employment strategies, competing initiatives, and infighting among physicians all lead to a less coordinated effort on the physician side of the equation. The traditional belief by physicians that they are performing vital work to society and that hospital administration simply needs to be supportive or simply get out of the way is no longer valid; in many ways, health care systems do not need to get out of the way of physicians as much as physicians need to get out of the way of themselves. Looking at system, CEOs as partners or even as bosses is a new paradigm, and one that is difficult for generations of physicians to accept. However, partnering is absolutely essential, and the idea of saying “thank you” at the end of each conversation is not as antithetical as it once was.

Fig. 2.

( a, b ) Physician leadership. Physicians are the de facto leaders of hospital and clinic organizations. However, physicians are increasingly being superseded in the organizational structure by other decision-makers in the C-suite.

Table 1 outlines the strategies for successful discussions with administrators.

Table 1. Strategies for successful discussions with administrators.

Strategy
Fit into the mission and vision of the organization
Understand local structure
Understand local politics
Bring something novel to the discussion
Help solve a problem
Prove you are a team player
Understand the importance of the corporatization of health care
Assume leadership positions in health care systems
Recognize the power balance

Conclusion

The environment in which IRs practice is constantly changing. The importance of building relationships with hospital and health system administrators has never been greater. Only by proving that one, or one's group, is interested in partnering with systems and helping to advance forward the greater mission of the organization will IRs be able to gain significant traction to advance their own clinical and nonclinical influence and agendas on behalf of the patients whom they serve.