Involving medical doctors in hospital governance improves quality management



The researchers assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems.


This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems.


The findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.


M. Rotar, D. Botje, N. S. Klazinga, K. M. Lombarts, O. Groene, R. Sunol and T. Plochg (2016). The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries. BMC Health Services Research.


Expert opinion Ludwig Hoeksema 

The study presents also an interesting overview of similarities and differences in Medical Doctor (MD) roles in 19 OECD countries and a more in depth description for seven OECD countries. This overview reflects the challenges in balancing the “scorecard” of any hospital. Three dimensions recur in the composition of the top management team: the quality of cure represented by MD influence; the quality of care represented by nurse influence and the quality of business management represented by “managers” and economists. Balancing those in hospital governance is an ongoing game.


The study also supports the idea that doctors are self-evident leaders of clinical outcome and hospital performance. The correlation between the formal roles of doctors in decision making and the level of quality management is comparable to “catching a bird by putting salt on its tail”. If you want to improve quality, it implicates the involvement of doctors, simply because their behavior and leadership constitute quality. The study proves that everybody who thinks that it is better to let doctors cure and leave hospital leadership to “real” managers is wrong. Of course, the competences of economists, business managers or other specialist may be very helpful in running a hospital, but denying the obvious leadership role of doctors will eventually harm quality and safety.



One of the practical implications of the study is that a more structural role of doctors in hospital governance is required. However, this is not a common reality yet. Several factors can be identified which might explain this situation:

  • Motivational factors
  • Competence
  • Social factors
  • Institutional factors


Motivational factors

Doctors are professionals. Hospital doctors are often well paid specialists. Leadership roles are often seen as a non-motivating, beastly jobs. These jobs are not rewarding in terms of recognition and personal growth and come with a lot of hassle. So why give up the profession you love, and you invested many years of your live in to master, for a job which pays less and comes with more hustle and bustle. A part time contribution is the best which may be expected.


Notwithstanding the fact that doctors are self-evident leaders, they are often not trained to do so. Consequently, a hospital may expect a wide variety of “natural” leadership styles among the medical staff. Establishing a common understanding and practice regarding quality, safety, communication, et cetera, can be a big challenge. Discussing the individual differences and “Instruction manual” of doctors may become a parlor game of other personnel.

Social factors

A third complication is the ‘clan’ culture of doctors. Physicians have strong social norms comparable to medieval guilds or the old family clan. These are very effective in educating people to mastery and maintaining high standards. But clans and guilds also have strong mechanisms of group control and reciprocal altruism, which may harm openness and genuine feedback mechanisms. Adopting a position in which you are obliged to openly confront colleagues with mistakes which require learning and improvement brings hazard to the membership of the clan.

Institutional factors

Finally, there are institutional factors which may prevent physicians from adopting their role in governance. Sometimes executive incomes are regulated to a maximum. Specialists may receive (far) more. Insurance companies may require a distinction between the medical costs and the hospital bill both from the perspective of cure as from the perspective of claim if anything goes wrong. Adopting a management role might bring higher exposure to risk.


Given the outcome of the study it is worthwhile to look for ways to overcome these problems. Despite all these barriers many physicians are already involved in strategic decision making. The success factors can be drawn from the problems identified:

  • Alignment between medical leadership roles and pathway-oriented management of information, quality, investments, etc. makes it more motivating to participate in;
  • Joint learning in “balanced” (medical, care and business management) teams establishes common standards and values regarding strategy execution and subsequent (quality and safety) behavior;
  • Hospital governance needs to balance medical, business and care perspectives regardless of the legal structure of the “hospital” and the way medical specialists are “contracted”.



  1. Groene O, Kringos D, Sunol R on behalf of the DUQuE Project. Seven ways to improve quality and safety in hospitals. An evidence-based guide. DUQuE Collaboration, 2014,



Edited by Eline Ammeraal 



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