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Clinical leadership and hospitalperformance: assessing the evidence baseF. Sarto1* and G. Veronesi2
Abstract
Background: A widespread assumption across health systems suggests that greater clinicians’ involvement ingovernance and management roles would have wider benefits for the efficiency and effectiveness of healthcareorganisations. However, despite growing interest around the topic, it is still poorly understood how managers witha clinical background might specifically affect healthcare performance outcomes. The purpose of this review is,therefore, to map out and critically appraise quantitatively-oriented studies investigating this phenomenon withinthe acute hospital sector.
Methods: The review has focused on scientific papers published in English in international journals and conferenceproceedings. The articles have been extracted through a Boolean search strategy from ISI Web of Science citationand search source. No time constraints were imposed. A manual search by keywords and citation tracking was alsoconducted concentrating on highly ranked public sector governance and management journals. Nineteen paperswere identified as a match for the research criteria and, subsequently, were classified on the basis of six items.Finally, a thematic mapping has been carried out leading to identify three main research sub-streams on the basisof the types of performance outcomes investigated.
Results and contribution: The analysis of the extant literature has revealed that research focusing on clinicians’involvement in leadership positions has explored its implications for the management of financial resources, thequality of care offered and the social performance of service providers. In general terms, the findings show apositive impact of clinical leadership on different types of outcome measures, with only a handful of studieshighlighting a negative impact on financial and social performance. Therefore, this review lends support to theprevalent move across health systems towards increasing the presence of clinicians in leadership positions inhealthcare organisations. Furthermore, we present an explanatory model summarising the reasons offered inthe reviewed studies to justify the findings and provide suggestions for future research.
Keywords: Clinical leadership, Hospital performance, Narrative review
BackgroundOver the last three decades healthcare organisations (inparticular hospitals) have progressively adopted modelsof governance alternative to the traditional ‘professionalbureaucracy’ [1], which are influenced by the manager-ialist ideology [2]. In the public sector, these changeshave signified a ‘corporatisation’ of hospitals towards abusiness-like form [3], in the aim to extend the inde-pendence of decision making’ [4]. This shift has impliedthe introduction of significant structural changes in
leadership positions, namely the creation of the ChiefExecutive Officer (CEO) role and the appointment ofboards of directors [5]. Following the fundamentalunderlying assumption in corporate governance that bet-ter governance mechanisms lead to greater efficiencyand effectiveness of organisations, the adoption of thesebusiness-like governance arrangements has been seen ascrucial for performance improvements in private (profitand non-profit) and public hospitals.While these reforms have been largely supported in re-
lation to increased organisational autonomy and greaterindependence in strategic decision making processes [6],what is the most effective bundle of expertise and skillsof hospital senior leaders has remained an open issue. In
* Correspondence: [email protected] of Economics, Management, Institutions, “Federico II” Universityof Naples, Naples, ItalyFull list of author information is available at the end of the article
© 2016 Sarto and Veronesi. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169DOI 10.1186/s12913-016-1395-5
this sense, scholars and practitioners have questionedwhether the hospital CEO and the board directorsshould be clinically-trained top managers [7–10]. Empir-ical evidence suggests that the extent to which cliniciansare involved in leadership positions varies greatly acrosscountries. For instance, analysing a sample of 6,500 UShospitals Gunderman and Kanter [11] report that only235 organisations were led by doctors. Similar conclu-sions are drawn in the UK, where Veronesi et al. [12]suggest that on average individuals with a clinical back-ground make up over a quarter of the board members(26.03 %) and represent about 22 % of the hospitalCEOs. Markedly different conclusions are, on the otherhand, reported in relation to healthcare organisations incontinental Europe. Indeed, comparative research high-lights how doctors represent the majority of senior man-agers in most European hospital systems such as Italy(50 %), France (63 %) and Germany (71 %) [13].What the available research has in the main suggested
is that greater clinicians involvement in leadership posi-tions, especially at the strategic level, has potentially im-portant benefits for healthcare outcomes [12, 14–17].Accordingly, it has been pointed out that ‘in a healthcaresystem that is complex, troubled, and challenging, thedoctor CEOs and board directors bring a unique set ofskills to the business of medicine’ [10], as they betterunderstand clinical challenges and general patients’needs [18, 19]. Additionally, they can ensure better com-munication with clinically-qualified personnel as well asenjoying greater legitimacy [13, 20]. Thus, throughgreater involvement of clinicians at the strategic level,hospitals not only will benefit from a higher quality ofstrategic decisions, but also from a more concrete imple-mentation of decisions taken.Yet, although the evidence shown in these studies
seems supportive, questions remain about the impact ofclinical leadership on overall hospital performance. Forinstance, concerning the consequences of clinical in-volvement for the quality of the service provided, whileGoodall [7] reports a significant relationship betweenclinical CEOs and organisational performance in the US,Veronesi et al. [12] do not observe any significant associ-ation between the clinical background of the CEO andservice quality. The apparent inconclusiveness of the ex-tant research is even more obvious if we consider theimpact of clinical leadership on hospital financial per-formance. On the one hand, a number of studies showthat clinically-qualified managers positively affect hos-pital financial efficiency [14]. Conversely, other studiesin the US and Italy highlight a negative impact of clinicalleadership on the efficient management of hospital re-sources [21, 22].Thus, while the possibility that clinicians’ involvement
could be beneficial for hospital has been recognized [13],
to what extent managers with a clinical backgroundmight specifically affect different types of hospital per-formance outcomes is still poorly understood. Indeed, toour knowledge there has been no systematic review ofthe quantitative evidence investigating this phenomenon.Therefore, the purpose of the paper is to fill this gap bymapping out and critically appraise quantitatively-orientedstudies analysing the association between clinicians’ in-volvement in senior leadership positions (i.e. CEO, topmanagement and board of directors) and hospital perform-ance. This represents a much needed contribution consid-ering that a positive impact on performance outcomesunderpins the widespread drive for enhancing clinical lead-ership in healthcare organisations [23]. Furthermore, thepaper builds on the evidence reported by presenting anexplanatory model, where reasons for the positive/negativeimpact of clinical leadership are offered.The remainder of this paper is structured as follows.
Section 2 presents the review method. Section 3 illustratesthe findings and the literature systematization. Section 4concludes by presenting the explanatory model and offer-ing suggestions for future research on this topic.
Review methodFollowing previous literature [24, 25], our systematic re-view is based on a narrative approach. This is consistentwith the aim of our study of summarizing and interpret-ing key findings of research exploring the involvementof clinicians in governance roles and its impact onhospital performance, as well as recognizing differentnarratives of the phenomenon. To identify the relevantarticles, we have focused on scientific papers publishedin English in both peer-reviewed international journalsand conference proceedings. This is a standard practicein literature reviews since these sources are considered‘certified knowledge’ which enhances the reliability ofthe analysis [26]. We have not imposed time constraintson the search process to be able to capture all relevantcontributions until June 2015 (Fig. 1).In order to extract relevant papers, we have conducted
Boolean searches using truncated combinations of twogroups of search strings [27]. While one string coversthe performance realm, the other one includes keywordsreferred to clinical leadership. We applied these criteriato the ISI Web of Science citation and search source.We searched for all papers whose title, publication, ab-stract and keywords included at least a string belongingto one of the two selected sets. We have opted for thisdatabase because it is considered the largest, most com-monly used and generally accepted source for literaturereviews [26, 27]. After removing potentially duplicatedarticles, the search returned 253 papers. To assess therelevance and consistency of these studies with the se-lection criteria, each of them was evaluated in relation
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 86 of 109
to title, keywords, abstract and, when necessary, full text.This selection process was carried out by the two au-thors only focusing on quantitative empirical studies.We decided to not consider qualitatively-oriented arti-cles as their findings are not generalizable. Eventually,we excluded 245 not relevant articles. Furthermore, fol-lowing the process adopted in previous literature reviews[28], our search was completed by manually looking andtracking citations for additional relevant articles inhighly ranked healthcare management journals. There-fore, the final sample consists of 19 papers (8 identifiedthrough database search and 11 from the manual searchand citation tracking phase).Following a standard approach in systematic literature
reviews [26, 27], we have analysed and classified theselected papers according to the following criteria: re-search settings, type of organisation, type of analysis,sample size, leadership position, performance dimension,
performance proxy, and effect of clinical leadership onorganisational performance. Finally, in order to betterinterpret the findings of the studies included in thefinal sample and to fully understand the explanationsprovided for the reported results, a thematic mappingof the articles was carried out [24]. We iterativelyidentified the key themes and independently analyzedthe articles and discussed their conclusions. Thisprocess has allowed us distinguishing three main re-search sub-streams according to the performance out-comes used as dependent variable(s): (i) managementof financial and operational resources, (ii) quality ofthe care provided and (iii) social performance of thehospital. More specifically, while articles belonging tothe first stream investigate the implication of clini-cians’ involvement in leadership positions for financialperformance, the second and the third ones mainlyexplore the effect on non-financial performance.
Fig. 1 Research Design
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 87 of 109
Analysis of the literatureTable 1 provides an overview of the selected articles.These studies have been conducted between 1993 and2015, with the majority of them (63 %) published in thelast decade (2006–2015). The results of the categorisa-tion process show that most of the articles focused onUS settings (74 %). Nevertheless, studies based on theGerman, Italian and British health systems are also rep-resented in the final sample. Concerning the type oforganisations investigated, most papers (60 %) focusedon private healthcare organisations, in both for-profitand not-for-profit sectors, while relative less attentionhas been devoted to public sector hospitals (35 %). Thiscan be explained by the fact that the early studies almostexclusive concentrated on the US health system. Regard-ing the type of analysis conducted, the majority of thestudies (84 %) have employed a cross-sectional approach,with a minor percentage adopting longitudinal data ana-lysis (11 %) and simulation techniques (5 %). The aver-age size of the investigated samples stood at around 237organizations, although there are wide variations be-tween studies (from 2 to 1,220). With reference to lead-ership positions, the extant literature has mainlyinvestigated the involvement of clinicians in boards ofdirectors (60 %) and in CEO positions (20 %), with a re-sidual percentage focusing on top executives, qualitycommittee and medical director positions. Finally, withregard to the performance dimension, most studies havefocused on the impact of clinically-qualified managerson financial or operational performance (59 %), which isnot too surprising considering the prevalence of privateorganisations as research setting. Furthermore, althoughthe majority of the studies analysed only one dimensionof organisational performance, some articles have fo-cused on both financial and non-financial (includingsocial) performance outcomes (21 %) (Fig. 2).Beyond these stylised facts, in the large majority of the 19
identified papers the effect of clinical involvement in leader-ship positions on organisational performance was found tobe positive. Only three articles showed a negative impact ofclinical leadership on organisational outcomes and morespecifically on financial performance, and one studyhighlighted a negative effect on social performance. In thefollowing sub-sections, we present the three sub-streams ofthe literature that emerged from the thematic mapping ofthe papers. This analysis suggests that the extant literaturehas mainly focused on the influence of clinical leadershipon the efficient management of resources, the quality ofcare provided and the social performance of the hospital.
Clinical leadership and the management of financial andoperational resourcesAmong the studies exploring the impact of clinical lead-ership on organisational performance, the earliest
research sub-stream has focused on its implications forthe efficient management of financial and operationalresources. These performance outcomes have been typ-ically associated with measures of profitability (such asoperating margin and overall profit generated), oper-ational efficiency (bed occupancy rate) and, in few cases,market power (market share). This line of research wasfirstly developed in the US, where a notable proportionof the acute care provision was (and still is) delivered inprivate hospitals. However, more recently, this attentionto bottom line profitability and competitiveness has alsoemerged in Europe, in particular as a consequence ofthe new public management reforms. These reformshave indeed given prominence to efficiency improve-ments in public sector hospitals in order to make themmore business-like [4]. The findings of the studies classi-fied into this sub-stream are not unanimous.Thus, Goes and Zhan [29] empirically show that
greater doctor involvement in the governance of US pri-vate acute care hospitals leads to higher bed occupancyand operating margins. Similar conclusions are reportedby Molinari et al. [30], who highlight how greater med-ical staff representation on the board of directors issignificantly associated with improved hospital finan-cial performance in terms of profitability, liquidity aswell as capital structure and intensity. In a later study,the same authors reinforce these findings by showingthat boards with clinicians have significantly better fi-nancial performance than boards without any doctorparticipation [31]. Also focusing on US settings, Prybil[32] finds that non-profit general hospitals outperformthe private sector counterparts in terms of overallprofitability when doctor involvement in governanceroles is higher.Other studies have investigated the effect of clinician
involvement in governance roles for hospital oper-ational efficiency. Accordingly, Goldstein and Ward[33] empirically test the implications of the involve-ment of doctors in top management positions. Theirresults support the hypothesis of improved hospitalperformance in terms of operational efficiency mea-sured as beds occupancy rate and market share. Simi-lar results are reported by Veronesi et al. [14] in astudy focused on the English National Health Service(NHS). More specifically, the authors highlight a posi-tive impact of clinical participation on boards of direc-tors of acute care hospital trusts on the financialmanagement of their resources.Several explanations are offered to motivate the bene-
fits of clinical leadership for the management of financialand operational resources. On the one hand, it is saidthat clinician involvement in hospital managementhas been partially driven by pragmatic concernsassociated with pressures to control expenditure [12].
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 88 of 109
Table
1Articlesanalysis
Stud
ySetting
Type
oforganisatio
nType
ofanalysis
Sample
size
Leadership
positio
nPerfo
rmance
dimen
sion
Perfo
rmance
proxy
Effect
Emerging
Stream
Bai[44]
US
Private(fo
r-profit)
hospitals
Cross-sectio
nal
analysis
137
BoDa
Non
-financial
Com
mun
ityBene
fits(uncom
pensated
care
cost,net
educationexpe
nse,and
netresearch
expe
nse,scaled
byho
spital
grosspatient
revenu
es)
+SocialPerfo
rmance
Baiand
Krishn
an[36]
US
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
142
BoD
Non
-financial
Qualityof
Care(process
ofcare
quality
ratin
g)+
SocialPerfo
rmance
Brickley
etal.[47]
US
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
228
BoD
Financial
Don
ations
−SocialPerfo
rmance
DeAnd
rade
Costa
[45]
US
Private(not-fo
r-profit)
hospitals
Private(fo
r-profit)
hospitals
Long
itudinal
data
analysis
281
BoD
Non
-financial
Commun
ityBenefits(uncom
pensated
care)
+SocialPerfo
rmance
Goe
sandZh
an[29]
US
Private(fo
r-profit)
hospitals
Long
itudinal
data
analysis
300
BoD
Financial
OperationalProfitability(operatingmargin)
Occup
ancy
(average
daily
occupancy)
HospitalCosts(operatingexpenses/1000
patient-days)
+Managem
entof
financialand
operationalresou
rces
Goldstein
andWard[33]
US
Publicho
spitals
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
200
Executives
Non
-financial
Ope
ratio
nalEfficien
cy(occup
ancy
rate,
marketshare)
+Managem
entof
financialand
operationalresou
rces
Goo
dallet
al.[37]
US
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
10CEO
Non
-financial
Repu
tatio
nwith
specialists(survey)
+Qualityof
care
Goo
dall[7]
US
Publicho
spitals
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
100
CEO
Non
-financial
Inde
xof
HospitalQ
ualityin
thearea
ofHospitalStructure
(availabilityof
resources),O
utcomes
(mortalityrate,
patient
safety
inde
x)andProcess
(repu
tatio
nscores
basedon
survey)
+Qualityof
care
Jiang
etal.[15]
US
Publicho
spitals
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
490
Quality
Com
mittee
Non
-financial
Qualityof
CareProcess(20measures
coverin
ghe
artattack,heartfailure,
pneumon
ia,and
surgicalinfection
preven
tion)
Qualityof
CareOutcomes
(mortalityrate
inthearea
ofhe
artattack,h
eartfailure,
pneumon
ia)
+Qualityof
care
KuntzandScho
ltes[40]
Germany
Publicho
spitals
Cross-sectio
nal
analysis
604
MDb
Non
-financial
ClinicalQuality(nurses-to-patientsratio
andph
ysicians-to-patientsratio
).+
Qualityof
care
Molinarietal.[30]
US
Publicho
spitals
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
190
BoD
Financial
Profitability(hospitalo
peratin
gmargin,
netincometo
patient
revenu
es,return
ontotalasset)
Liqu
idity
(daysin
accoun
tsreceivable)
CapitalStructure
(long
-term
debt
tototal
assets,b
adde
btandcharity)
CapitalIntensity(netplant,prop
ertyand
equipm
entp
erbed;hospitaloccupancy
rate)
+Managem
entof
financialand
operationalresou
rces
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 89 of 109
Table
1Articlesanalysis(Con
tinued)
Molinarietal.[31]
US
Private(fo
r-profit)
hospitals
Cross-sectio
nal
analysis
190
BoD
Financial
Profitability(ope
ratin
gmargin)
+Managem
entof
financialand
operationalresou
rces
Prybil[32]
US
Publicho
spitals
Private(fo
r-profit)
hospital
Cross-sectio
nal
analysis
14Bo
DFinancial&
Non
-Financial
Qualityof
Careratin
g(m
ortalityinde
x,complications
inde
x,patient
safety
inde
x,core
measuresscore,readmission
rate,
leng
thof
stay,case-mixandwage-
adjusted
inpatient
expe
nsepe
radjusted
discharge)
Profitability(ope
ratin
gprofitmargin)
Patient
Satisfaction(patient
ratin
gs)
+Managem
entof
financialand
operationalresou
rces
Qualityof
care
Sartoet
al.[22]
Italy
Publicho
spitals
Cross-sectio
nal
analysis
96CEO
Financial&
Non
-Financial
Profitability(ope
ratin
gmargin)
FinancialEfficiency
(expenses-to-bedsratio)
Qualityof
care(app
ropriateness)
Efficiencyof
care
(leng
thof
stay)
+/−
Managem
entof
financialand
operationalresou
rces
Qualityof
care
Schu
ltzandPal[38]
US
Privateintegrated
healthcare
organisatio
nsSimulation
Stud
y2
CEO
Financial&
Non
-Financial
Profitability(net
income)
Qualityof
Care
ndManagem
entof
financialand
operationalresou
rces
Qualityof
care
Succiand
Alexand
er[21]
US
Publicho
spitals
Private(fo
r-profit)
hospitals
Private(not-fo
r-profit)
hospitals
Cross-sectio
nal
analysis
1,220
BoD
Executives
Financial
Ope
ratio
nalEfficien
cy(ratio
oftotal
operatingexpe
nses
divide
dby
adjusted
hospitaladm
ission
s)
−Managem
entof
financialand
operationalresou
rces
Verone
siet
al.[12]
UK
Publicho
spitals
Cross-sectio
nal
analysis
102
BoD
Non
-Financial
Qualityof
care
rate
(com
pliancewith
core
standardsin
thearea
ofhe
alth
and
well-b
eing
,clinicaleffectiven
ess,safety
andpatient
focus,ease
andeq
uity
ofaccess)
+Qualityof
care
Verone
siet
al.[14]
UK
Publicho
spitals
Cross-sectio
nal
analysis
102
BoD
Financial
Financialresou
rces
managem
ent(qu
ality
ofthefinancialresource
managem
entrating)
+Managem
entof
financialand
operationalresou
rces
Verone
siet
al.[39]
UK
Publicho
spitals
Cross-sectio
nal
analysis
99Bo
DNon
-Financial
Patient
SatisfactionRate
(labo
uraccess,
coordinatio
n,inform
ation,relatio
nships
andcomfort)
+Qualityof
care
a BoD
Boardof
Dire
ctors
bMDMed
ical
Dire
ctor
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 90 of 109
Accordingly, Succi and Alexander [21] state that theinvolvement of doctors in top management positionsis frequently sought to reinforce their ‘commitment tocost containment’; that is, doctors turned managers
would be influenced in their attitudes and behaviours,and would consequently facilitate the ‘adoption ofmore cost efficient clinical practices’. There is, indeed,evidence suggesting that clinical leadership can
Setting Type of Organisation
Type of Analysis Leadership Position
Performance Dimension Effect
0%
10%
20%
30%
40%
50%
60%
BoD CEO Executives MD Quality Committee
60,00%
20,00%
10,00%5,00% 5,00%
0%
10%
20%
30%
40%
50%
60%
70%
80%
US Germany Italy UK
73,68%
5,26% 5,26%15,79%
0% 5% 10% 15% 20% 25% 30% 35% 40%
Private (for profit) hospitals
Private (not for profit) hospitals
Public hospitals
Private Integrated Healthcare Organizations
29,03%
32,26%
35,48%
3,23%
0%10%20%30%40%50%60%70%80%90%
Cross-sectional analysis
Longitudinal data Simulation Study
84,21%
10,53%5,26%
0% 10% 20% 30% 40% 50% 60%
Both Financial and Non Financial Performance
Financial Performance
Non Financial Performance
21,05%
59,09%
19,86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Positive Negative Any
80,00%
15,00% 5,00%
Emerging Stream
0%
10%
20%
30%
40%
50%
Management of financial and operational resources
Quality of care Social Performance
40,9%
40,9%
18,2%
Fig. 2 Descriptives
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 91 of 109
positively stimulate the behaviour of front line staff.For instance, Dorgan et al. [20] posit that managerswith a clinical background have more credibilityamong clinical staff and thus they are more likely toinfluence the behaviour of their colleagues than non-medical managers. Similarly, it has been observed thatin the presence of clinical leadership front-line staffwill be less likely against adopting cost-efficient clin-ical practices as there will be less concerns that theproposed changes will negatively influence the qualityof the service provided [14].In spite of the growing number of studies supporting
the advantages generated by clinical leadership for themanagement of hospital financial and operational re-sources, some scholars have found evidence of a negativeimpact. For instance, Succi and Alexander [21] showthat the main effect of doctor involvement in hospitalmanagement is not related to greater hospital effi-ciency, but, on the opposite, to lower efficiency. Sameconclusions are drawn by Sarto et al. [22], whose find-ings indicate that CEOs with a medical backgroundhave a negative impact on financial performance,calculated as operating margin and financial efficiency,although the evidence seems to suggest that the im-pact is lower in the case of medical CEOs with previ-ous managerial expertise.Substantially, it cannot be excluded that the involve-
ment of clinicians in leadership positions can be alsocounter-productive. This is also conceptually argued bystudies not included in the sample but cited. For in-stance, Mannion et al. [34] find that in hospitalsdominated by ‘pro-professional cultures’, strategic andoperational decisions can be oriented towards meetingclinical needs at the expense of financial performancetargets. Additionally, it has been noticed that when doc-tors in governance roles gain awareness of the trade-offsfaced by managers between financial concerns and clin-ical priorities, the differences between management andmedical worlds can intensify rather than being solved[21]. Moreover, some authors argue that clinical man-agers can experience strong role conflict when movinginto managerial roles which in turn affects their strategicdecision making. In this instance, clinically-qualifiedmanagers would prioritise clinical needs at the expenseof financial efficiency and cost containment [23].In line with the findings reported by Sarto et al. [22],
an additional line of inquiry has recently suggestedthat doctors performing managerial roles could be lesseffective than managers without a clinical backgroundin the financial management of resources when theylack a proper managerial training before taking on therole [14]. Accordingly, Kippist and Fitzgerald [35] rec-ognise that among ‘barriers to the effectiveness of therole of hybrid clinician manager’ it is well recognized
‘the lack of management education and skill’. Simi-larly, Falcone and Satiani [10] state that a ‘successfulphysician leader must understand the business ofmedicine as well as or better than he or she under-stands the practice of medicine’.
Clinical leadership and the quality of care providedA growing number of studies has focused on the impactof clinical leadership on the quality of care provided,measured by process and outcomes indicators. It is im-portant to notice that all the studies (bar one exception)included in this review have reported empirical resultsthat strongly support the positive beneficial effects of thepresence of clinicians in leadership roles for the qualityof care offered in hospitals.With reference to the US context, Prybil [32] analyses
a sample of 14 non-profit general hospitals and findsthat the top high performing hospitals are characterisedby a higher involvement of doctors in management thanthe mid-range performers where the performance indi-cators are a quality of care rating and a patient satisfac-tion score. Similarly, Bai and Krishnan [36] report thatnon-profit hospitals without doctor participation ontheir boards are more likely to deliver lower quality ofcare, proxied by the process of care quality rating of theHospital Quality Alliance. Furthermore, focusing only onhospital board quality committees, Jiang et al. [15] showthat having a higher doctor participation on committeesstrongly improves hospital performance in terms of thecare process (measured as quality of care of heart attack,heart failure, pneumonia, and surgical infection preven-tion) and mortality rates.Similarly, Goodall [7], focusing on the top 100 US hos-
pitals according to the Index of Hospital Quality rankingof the US News and World Report, finds that having aCEO with a medical background generates greater qual-ity improvements that result in a higher quality rankingfor the hospital. Comparable conclusions are also re-ported by Goodall et al. [37]. In this study, the authorshighlight how the US’s top 10 psychiatric hospitals, asranked by the US News & World Report, are exclusivelymanaged by CEOs with a medical background. Differ-ent conclusions are drawn by Schultz and Pal [38],who examine the ability of CEOs of integrated health-care organisations to make effective strategic deci-sions. More specifically, the study reveals no significantdifferences between medically-educated and managerially-educated senior managers in their ability to make strategicdecisions that maximize the quality of care provided bythe organisation.Turning our attention to the European settings,
Veronesi et al. [12] report that a greater ratio of clinicalmembers on governing boards of English hospital trustsgenerates better ratings of the quality of the service
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 92 of 109
provided, as well as being associated with a reductionin morbidity rates. In a later study, Veronesi et al.[39] also show that the involvement of clinicians onthe board of directors improves the overall patientexperience of the care provided by acute hospitalswhen clinical managers operate in a more autono-mous organisational form. A similar methodology wasalso applied to the Italian NHS, where Sarto and col-leagues [22] find a positive correlation between theclinical background of public hospital CEOs and qual-ity outcomes, measured as medical and surgical ap-propriateness as well as patient length of stay inhospital. Finally, focusing on a sample of Germanhospitals, Kuntz and Scholtes [40] suggest the exist-ence of a positive relationship between a full-time orheavily involved part-time medical director and ahigher staff-to-patient ratio, a common measure ofquality and safety of the healthcare process.By deepening also studies not included in the sample,
the positive outcomes of the presence of clinically-qualified managers for the quality of the service providedare explained in a variety of ways. First, it is suggestedthat the involvement of clinicians in strategic decisionmaking represent the most effective option to achievethe critical link between strategic planning and itsimplementation at the clinical level [33]. Accordingly,Llewellyn [41] notes that managers with a clinicalbackground are in a privileged position to bridge thehistorical divide between the worlds of cure, care andadministration. Essentially, the assumption is that doc-tors can more easily acquire management expertisewhile a non-clinical manager would find more difficultto gain sufficiently appropriate medical knowledge. Inthis sense, some authors state that the involvement ofdoctors provides unique advantages to the organisa-tional strategic decision making process due to theircrucial knowledge as well as their exclusive relation-ship with patients [18, 19]. Thus, according to Ford-Eichkoff et al. [42], increasing the number of boardmembers with clinical background provides governingboards with a greater breadth of expertise. Similarly,Dorgan et al. [13] claim that clinician involvement inhospital governance leads to an improvement in man-agerial decision making quality, as they can betterunderstand clinical challenges and general patientneeds and they can more effectively communicate withclinical staff. Additional studies suggest that high per-forming medical top management teams tend to bethose with more ‘quality-centred cultures’ [43].Finally, other authors emphasise how managers withclinical background will not only improve the qualityof hospital decision making, but they will be seen ascredible leaders and hence will be more likely to at-tract talented medical personnel [10].
Clinical leadership and the hospital social performanceA third sub-stream of studies that emerged from theanalysis focuses on the impact of clinical leadership onhospital social performance. These articles are generallymore recent and only focus on private healthcare organi-sations, being all based in the US.Thus, Bai [44] shows that the occupational back-
ground of board members influences the hospitalsocial performance. More specifically, the author findsthat in for-profit hospitals the presence of doctors ongoverning boards is positively correlated with hospitalsocial performance, which is measured as a multi-dimensional construct capturing hospital expenditureon community benefits. Similar results are reported ina study by De Andrade Costa [45], also focused on theprivate hospital sector. The evidence highlights howincreased medical membership of boards positively re-lates to higher levels of uncompensated care provision,thus improving the benefits for the community. Theauthor justifies these results by stating that the ethicalbeliefs and professional norms of doctors enhance theprobability of serving the best interest of patients evenin the absence of financial benefits. Considering all theabove, it can be concluded that clinical involvement intop management positions increases the pressure onthe governing board to enhance the provision of un-compensated care and, as a consequence, boosts over-all hospital social performance [46].Nevertheless, opposite conclusions are reported by
Brickley et al. [47], who investigate the potential conflictof interest in non-profit hospitals between donors anddoctors. In this instance, a negative relationship betweendoctor representation on the governing board and theamount of private donations is found. The explanationprovided for this finding is that donors would be deterredto provide resources to the hospital due to the risk thatthese were subsequently expropriated by doctors. Accord-ingly, in some studies [48] it is suggested that privatedoctors are more likely to use hospital resources tomaximize their own income rather than directing thefunding received towards the types of investment pre-ferred by donors, normally oriented towards communitybenefits at large. The risk of potential expropriation ofhospital resources leads to a reduction in the amount pri-vate donations and, hence, a lower likelihood of positivesocial performance for private hospitals [49].
ConclusionsFollowing the growing interest of policy makers andpractitioners in the involvement of clinicians in thegovernance and management of healthcare organisations[9, 50], research conducted on this topic has suggestedthat greater clinician participation at the strategic deci-sion making level potentially has a wide range of benefits
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for hospitals. This systematised review of the literaturehighlights how quantitative analyses of this phenomenonhave developed along three main sub-streams. Morespecifically, the extant research has explored the implica-tions of clinical leadership for the management of finan-cial and operational resources, the quality of careprovided and hospital social performance. Althoughbased on a relatively limited number of studies, our ana-lysis overwhelmingly supports the assumption thatgreater clinical presence is beneficial for hospital deci-sion making processes, which clearly has important im-plications for policy and practice. Fundamentally, clinicalleadership has been found to enhance efficiency andeffectiveness of hospitals along a number of performanceindicators [12, 14–17]. However, while there is a growingbody of evidence to support this conclusion, there arealso reasons to question the assumption that the influ-ence will necessarily be positive.To further understand the results of this review, in
Fig. 3 we present an explanatory model that offers a briefrecap of the evidence-base as well as the motivationsprovided for the positive and negative impact of clinicalleadership on hospital performance.As shown in the figure, it is suggested that the beneficial
impact of greater clinician involvement has been justifiedby the following reasons: (i) greater provision of criticalknowledge for the decision making process and consequentimprovement of the overall decision making quality; (ii)higher credibility of clinical leaders and related higheradoption of hospital policies by medical staff; (iii) improvedorganisational credibility and reputation and thereforehigher likelihood of attraction of talented personnel; (iv)reinforcement of medical commitment to cost contain-ment; (v) greater attention to patients needs due to ethicalbeliefs and professional norms of clinicians. Conversely, thenegative implications for the management of financial re-sources and hospital social performance have been linkedto the following motives: (i) emergence of conflicts between
clinicians-turned managers and career managers, (ii) rise ofrole conflicts in managers with a clinical backgroundand consequent decisions made at the expense of fi-nancial performance to protect clinical needs; (iii) lackof managerial and accounting expertise of clinically-qualified managers; and (iv) conflicts of interest of pri-vate doctors in leadership positions.Despite the evidence overwhelmingly pointing
towards a positive impact of clinical leadership onhospital performance, there is clearly scope to fur-ther investigate the phenomenon. First, the large majorityof the studies have used a cross-sectional approach mainlythrough OLS regressions to examine the relationship.Hence, it would be worth conducting further investigationbased on longitudinal data that adopt different methodo-logical approaches such as panel data (i.e. cross-sectionaltime series data) with the related beneficial consequences.For instance, through panel data analysis not only varia-tions between firms but also within firms (and so theirbehaviour across time) could be accounted for. Further-more, a panel data approach would control for endogene-ity issues between variables and unobserved heterogeneity.Employing a fixed-effects estimator (if appropriate) wouldfurther help with unobserved factors such organisationalculture, age of the hospital facilities and so forth. Paneldata is also suitable for including variables at differentlevels of analysis (for instance individual, organisationaland system levels). Essentially, the results of the empiricalanalysis would be more robust and generalizable.Apart from methodological concerns, it appears that
the large majority of the studies have focused on theAnglo-American context, with only a handful of papersbased on other European health systems. Without deny-ing the importance of lessons drawn from the UK andthe US health systems, there seems to be a clear need toexpand research to other countries. In this way, it wouldbe possible to analyse the impact of country-specificgovernance models. For instance, in France the hospital
Clinical Leadership
• CEO• Board of Directors• Medical Director• Quality Committee
Benefits• Critical knowledge for decision making process
and related improvement of decision making quality
• Higher credibility and related higher adoption of hospital policies by medical staff
• Improved organizational reputation and attraction of talented personnel
• Reinforcement of medical commitment to cost containment
• Greater attention to patient needs due to clinicians’ ethical beliefs and professional norms
Quality of care
Management of financial andoperational resources
Social performance
Problems• Conflicts between clinicians and managers• Role conflict of clinical-managers and related
decisions made at the expense of financial performance
• Lack of managerial and accounting expertise• Conflict of interest of private doctors
+
Management of financial and operational resources
Social Performance
-
Fig. 3 The explanatory model
Sarto and Veronesi BMC Health Services Research 2016, 16(Suppl 2):169 Page 94 of 109
governance structure is dramatically different from theAnglo-American model with a far greater presence ofclinicians on advisory boards. However, there is no deny-ing that the hospital corporatisation process has led to awidespread adoption of the governing board model typ-ical of the Anglo-American context in countries such asBelgium, the Netherlands, Portugal, Spain, and so forth[5]. Similarly, it would be interested to draw compari-sons between health systems that follow either theBeveridge or the Bismarkian model. Additionally, wewould welcome more ambitious studies that directlytake a multi-country approach. So far, only Dorgan et al.[13] have ventured down this line of research but theirstudy is limited in scope (mainly focused on investi-gating the impact of management systems) and meth-odologically weak. As far as we are aware, there is alsoa dearth of research from countries outside NorthAmerica and Europe. This line of research could use-fully expand the emerging evidence on the importanceof hospital governing board oversight on safety andquality concerns and the role played by clinicians inthis respect [24, 51].A further line of useful (if not needed) research could be
developed by focusing at the middle and junior manage-ment levels. The role played by clinicians at the strategicdecision making level is obviously crucial, as shown by thestudies analysed in this review, however more needs to beunderstood on the type of impact clinical leadership has atthe operational level. The large majority of hospitals (atleast in the developed world) have adopted the JohnHopkins Hospital clinical directorate model, where a clin-ician is given managerial responsibilities in relation tohuman and financial resources and is held accountable forthe performance of the directorate. The extensive adop-tion of this organisational model lends itself to a compara-tive research design, especially considering that there isalready qualitative evidence suggests that the implementa-tion of clinical directorates has led to different interpreta-tions and practices across countries [52].Finally, quantitative approaches can show the exist-
ence of a positive relationship (and the direction ofinfluence) between clinical leadership and hospital per-formance, but they cannot explain the why and how. Sofar, most of the explanations provided (summarised inFig. 3) are essentially based on educated assumptionsderived from a handful of qualitative studies. Expertiseat the individual and clinical levels is undoubtedly cru-cial, but it still far from clear how far other potentialexplanatory factors relating to, for instance, the leader-ship style of clinicians, the hospital cultural context, anddirectors’ collective behaviour within boards are influen-cing the impact of clinical leadership [53]. So, we wouldalso encourage further investigation based on in-depthqualitative approaches, perhaps by observing hospital
board meetings or by interviewing/surveying hospitalsenior leaders.Besides the identifications of research gaps and the
suggestion for future studies, a reference to the theoret-ical implications of the findings reported by our reviewis worthy of note. While more work is indeed needed, wecan conclude that our explanatory model supports thereasoning underpinning clinical leadership and is in linewith the policy makers’ effort to support the developmentof clinicians in leadership position. There is also growingevidence suggesting that clinicians are increasingly seeingin positive terms their involvement in managerial posi-tions, and this hybrid role is becoming engrained in theirunderstating of professional responsibilities and duties[54, 55]. This is linked to what Noordegraaf [56] definesas ‘organizing professionalism’, essentially a new form ofhybrid professionalism. This categorisation reflects theemergence of clinical professionals who are no longersolely engaged with providing care to patients, but theyalso are involved in the organizing of the healthcareorganization they are working for. In this sense, organizingbecomes an embedded component of professional workcentring around activities such as the arrangement ofinter-professional collaboration, the design and implemen-tation of innovative projects, the management of scarceresources, the alignment of decision processes in accord-ance with financial constraints, and the management ofrelationship with multiple stakeholders.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
AbbreviationsBoD: Board of Directors; CEO: Chief Executive Officer; MD: Medical Director;NHS: National Health Service.
Competing interestsThe authors declare that they have no competing interest.
Authors’ contributionsFS and GV jointly developed the design of the study. They also interpretedand analysed the data. All authors read and approved the final manuscript.
Authors’ informationNot applicable.
DeclarationsThis publication is supported by COST. This article has been published as partof BMC Health Services Research Volume 16 Supplement 2, 2016: Medicine andmanagement in European public hospitals. The full contents of the supplementare available online at http://bmchealthservres.biomedcentral.com/articles/supplements/volume-16-supplement-2.
Author details1Department of Economics, Management, Institutions, “Federico II” Universityof Naples, Naples, Italy. 2Accounting and Finance Division, Leeds UniversityBusiness School, Leeds, UK.
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Published: 24 May 2016
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