Survey of Current Relationship and Perceived Areas of Conflict between Pediatric Academic Department Chairs and Chief Executive Officers of Children's Hospitals
Article Outline
Stress and burnout are major issues among current and previous academic pediatric department chairs (PDC).1 In a 2005 survey by AMSPDC, relationships between the PDC and senior hospital administrators were noted as important contributors.1 As a result, during 2006, AMSPDC and the National Association of Children's Hospitals and Related Institutions (NACHRI) conducted a more in-depth cross-sectional survey of these relationships. This article summarizes the findings of the survey and highlights areas that warrant special attention in minimizing stress and enhancing the relationship of PDC and chief executive officers (CEO).
Methods
The survey material was designed jointly by NACHRI and AMSPDC and administered by NACHRI with the web-based Zoomerang tool (http://info.zoomerang.com). The survey asked similar questions to CEOs and PDCs and included sections on demographics, duration in position, perceived roles and importance of the roles of the PDC, and areas considered important and problematic in the CEO-PDC relationship. Both CEOs and PDCs were asked to indicate areas of importance in terms of having a successful relationship and what changes could be made to improve relationships. Allowed responses included a combination of Likert or ordinal rating scales and open-ended questions. The study was waived for Ethics approval by the Human Subjects Review Board at Michigan State University.
Statistics
We used the χ2 test or Fisher exact test to compare group proportions and considered a P value < .05 to be significant.
Results
The survey was sent to 105 CEOs/senior administrators of children's hospitals (CHs) and 125 PDCs. The response rates were 54% and 48% for CEOs and PDCs, respectively; 41% of the CHs were free-standing; and 59% were hospitals within a larger system. Most CEO (54%) and PDC (63%) respondents worked in CHs within a larger system. Slightly more than half (53%) of the CEOs were in position for <5 years, and most PDCs (60%) had been in position for >5 years (Figure 1; available at www.jpeds.com). However, 12% of the CEOs versus 0% of the PDCs had been in position for >20 years. PDCs reporting both to their Dean and hospital CEO were more likely (74%) to serve on the CH or medical school board than those reporting only to the dean (24%) or other administrator (20%) (P < .01).
Figure 1.
Years in current position.
Although there was consensus between both groups for reporting roles on the hospital leadership team, a higher percentage (93% vs 77%, P < .02) of the PDCs viewed their role as part of the hospital leadership team as being extremely important (Table I; available at www.jpeds.com). CEOs and PDCs both valued the PDC role in helping balance the clinical and academic missions of the hospital, in strategic and service planning (Table II; available at www.jpeds.com). However, PDCs viewed their roles in hospital finances and fundraising to be of greater importance than did CEOs, and CEOs ranked physician recruitment and retention higher. Half of the CEOs versus 67% of PDCs perceived a net flow of funds in favor of the PD, 33% versus 15% believed it was neutral, and 17% versus 21%, respectively, believed it was in favor of the hospital.
Table I. Perceptions of PDC roles
| Question | CEO Response | PDC Response |
|---|---|---|
| To whom does PDC report? | Dean: 51.8% | Dean: 50% |
| CEO: 1.8% | CEO: 0% | |
| Both: 35.7% | Both: 33.3% | |
| Other: 10.7% | Other: 16.7% | |
| Importance of PDC as part of hospital leadership team | Extremely: 77% | Extremely: 93% |
| Very: 14% | Very: 3% | |
| Is PDC a member of hospital leadership team? | Yes: 88% | Yes: 85% |
| PDC regularly attends hospital senior administrative meetings | Yes: 75% | Yes: 83% |
| PDC sits on governing board of hospital or medical school | Yes: 47% | Yes: 40% |
Table II. Areas perceived to be of most importance for CEO-PDC relationship
| CEO (item rank) | PDC (item rank) | |
|---|---|---|
| Balancing clinical and academic missions of children's hospital | 89.5% (1) | 82.7%(4) |
| Pediatric clinical service planning and development | 89.5%(1) | 90.0%(2) |
| Children's Hospital strategic Planning | 87.7%(3) | 95.0%(1) |
| Physician Recruitment | 86.9%(4) | |
| Physician Retention | 86.7%(5) | |
| Funding faculty and physicians | 78.9%(6) | 81.7%(5) |
| Children's Hospital Finances | 83.3%(3) | |
| Children's Hospital Fundraising | 75.0%(6) |
Similar levels of conflict were reported for the areas of funding department activities, funding faculty and physicians, and balancing the clinical and academic missions of the CH (Figure 2; available at www.jpeds.com). There was a trend for PDCs who reported to their deans alone (35%) to find it more challenging to balance missions than peers who reported both to their deans and CEO (15%) or to other administrator (11%), (P = .07). PDCs viewed pediatric research funding (P < .02) and involvement in the CH strategic planning (P = .03) as being greater sources of conflict than CEOs. In contrast, compared with PDCs, CEOs perceived more conflict in the areas of management of physicians and productivity (P = .02). PDCs who reported to their deans alone were more likely to identify pediatric research funding (39%) as conflict areas than those who reported to both the dean and CEO (24%) or other administrator (22%) (P = .04). The trends were similar, but not significant (P = .07), in the reporting lines of PDCs and their perception of a problem with CH strategic planning.
Figure 2.
Areas of major conflict in CEO-PDC relationship.
For a successful CEO-PDC relationship, there was agreement between CEOs and PDCs on a need for open communication and a shared vision and educational mission of the CHs (Figure 3; available at www.jpeds.com). However, more of the PDCs perceived adequate funding (P = .02) and PDC membership of the leadership team (P < .05) to be critical. The most frequent factor noted for reducing conflict was creation of a common strategic plan and aligning of goals (18%). Next, the need to better define or to create a different management structure was viewed as important (16%). Improving communication (10%) and balancing clinical and academic missions (10%) were also frequently cited. Written comments highlighted a need for better forums for discussion, education, and conflict resolution, and better avenues of communication between the chair, faculty, and CH administration. The PDCs stressed a need for ongoing education the CH board and leadership on the importance of research as a good investment, and on the mission of the academic health center.
Figure 3.
Major areas deemed important in having a successful CEO-PDC relationship.
The respondents were asked to suggest one thing to improve relationships with their counterparts. CEOs most commonly selected more frequent contact or better communication (18%). Next was the need to work together in a more collaborative manner (16%). A smaller minority (11%) believed a change in the leadership arrangement was important. PDCs suggested similar measures, although the most important issue for them was CEOs valuing their partnership more highly (20%). Comments included: “Try to better understand and support [sic] the research component of what we do—and understand that financial support for that will help recruit faculty, which translates into better care.” “Cutting-edge research will help you ‘sell' the CH to donors”; “Understand … the role of non-money-making units in the overall reputation and balance sheet of the hospital.” Changing leadership arrangement (16%) and ensuring more frequent contact/better communication (16%) were the other frequently cited ways of improving partnership. PDCs tended to believe they should sit on the board of trustees and be given formally designated administrative positions in the CH.
Discussion
Overall, a large majority (>90%) of the respondents viewed the PDC role as part of the hospital leadership team as being either very important or extremely important. However, the PDCs tended to have a broader view of their role in leadership than did CEOs, especially in the areas of hospital finances, involvement with the board of trustees, and fundraising. The reasons for these discrepancies are unclear but may be related to pressures on the CEO by the board to maintain a positive financial margin and possibly concerns that overexposure of PDCs to CH finances may lead to escalating demands. Alternatively, there could be a misunderstanding of the rationale for why PDCs want to be engaged and CEO fears of relinquishing control. For a fruitful PDC-CEO relationship to occur, these issues need to be carefully and frequently addressed with mutual understanding of each party's underlying concerns.
The need to align the strategic plans and goals of the CH and PDC for mutual benefit were recognized as important by CEOs and PDCs. However, research funding was a clear area of conflict for PDCs that did not seem to be as important for the CEOs. Because CEOs equally viewed physician recruitment as a problematic area, the discrepancy here is most likely related to a gap in perceived importance of research in enhancing faculty recruitment or reputation. There may also be a negative consideration of overall impact of research costs on the CH finances. The latter is implied in the CEOs ranking physician clinical productivity much more highly as a conflict area. This highlights the need for PDCs to better provide ongoing education on the downstream benefits of research to the CHs, as well as concrete data on the potential and real return on research investments that CEOs are asked to make. Overall, frequent and clear communications and structural arrangements that make it easy for such communications to occur appear to be the most important features of a close relationship between a CEO and PDC. In general, PDCs who reported to their dean alone were more likely to identify problematic areas. This suggests that direct involvement of the PDC with the hospital CEO such as by sitting on a board or by some reporting relationship reduces the perception of conflict areas.
A limitation of this survey is that about half of both surveyed groups did not respond. The sample size may have limited our ability to detect other important areas. Furthermore, we did not explore the full extent of other reporting relationships of the PDC within the medical school or the hospital that may influence their perception of conflict areas. Nonetheless, we believe that the information gained from the respondents is relevant because it identifies clear areas that Chairs may focus on depending on their relationships with CEOs. It should also help AMSPDC identify key areas of advocacy and guidance as a mentorship program for new Chairs is developed.
We thank Josh Wenk for his analytic assistance.
Reference
PII: S0022-3476(07)01176-6
doi:10.1016/j.jpeds.2007.12.033
© 2008 Mosby, Inc. All rights reserved.
