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Hospital medical staffs will have to make a major transition over the next few years from quality assurance to continuous quality improvement. As this article discusses, many elements of the change are new to health care, as yet untested, and should be approached carefully.
The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.
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Hospital medical staff by-laws are important. By them the governing board of a hospital can and does confer on the medical staff the power to set up a form of organization by which that staff can give assurance of quality hospital medical care. The form of medical staff organization is patterned on familiar concepts of democratic self-government as we know it on this continent. Within the ordered society of the hospital medical staff, as in society at large, there is control of citizenship, classification of citizens as to their citizen rights, licence to do differing kinds of work, election of representatives, definition of rules for conduct, application of the cabinet principle, law enforcement by appointed judges, the right of appeal and, importantly, incentive for voluntary effort. Traditional professional freedom, self-determination and voluntary association of colleagues are guarded by this method of hospital conduct which is unique to the voluntary hospital system on this continent. Knowledge of the democratic process and of the motivation required to make it work well are essential for its preservation.
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In recent years, there has been a growing controversy surrounding the issue of so-called "independent status" for hospital physician staffs. During the late 1970s and early 1980s, some articles advanced the theory that any conduct creating the appearance of an independent status for the hospital staff separate from that of the hospital could generate the environment for an antitrust action. These early theories, however, failed to fully appreciate the basic nature of antitrust law and the changing role of the hospital medical staff. Indeed, the changing nature of the hospital medical staff and the current application of antitrust law strongly indicate the early theories are misplaced and the "independent status" of the hospital medical staff does not create cause for antitrust alarm.
Based on organization theory and the work of Roemer and Friedman, seven dimensions of hospital medical staff organization structure are proposed and examined. The data are based on a 1973 nationwide survey of hospital medical staffs conducted by the American Hospital Association. Factor analysis yielded six relatively independent dimensions supporting a multidimensional view of medical staff organization structure. The six dimensions include 1) Resource Capability, 2) Generalist Physician Contractual Orientation, 3) Communication/Control, 4) Local Staff Orientation, 5) Participation in Decision Making, and 6) Hospital-Based Physician Contractual Orientation. It is suggested that these dimensions can be used to develop an empirical typology of hospital medical staff organization structure and to investigate the relationship between medical staff organization and public policy issues related to cost containment and quality assurance.
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Using data from the 1973 American Hospital Association national survey of hospital medical staff organization, six factors of medical staff organization structure are examined in relation to each other and to hospital ownership, size, teaching status, geographic region and size of Standard Metropolitan Statistical Area (SMSA). The six factors include 1) Resource Capability; 2) Generalist Physician Contractual Orientation; 3) Communication and Control; 4) Local Staff Orientation; 5) Physician Participation in Decision Making; and 6) Hospital-Based Contractual Orientation. Several relatively distinct patterns emerged related to hospital ownership, size, teaching activity and region of the country, as well as interrelationships among the factors themselves. Differences between smaller and larger hospitals clearly emerged as well as a distinctive pattern for for-profit hospitals. All of the factors are subject to manipulation through administrative and/or public policy interventions and the findings suggest dimensions for future investigation of important policy issues related to the medical staff's role in cost containment, utilization, quality assurance and technology adoption.