An extract from the paper presented at the Conference “The Profession of the Medical Manager and Company Management” organised by the Milan Province Association of Physicians Surgeons and Odontologists - 2002. In the past, sensation was caused by legal proceedings following which a Head of Department in a large hospital had been found guilty for having ignored and neglected his functions “in vigilando and in diligendo” concerning subordinate staff, and had been sentenced to reimburse damages claimed by the nurse; neither the hospital nor the Consultant’s personal insurance companies had been involved, since the professional tort liability policy did not include possible damage resulting from the Consultant’s position as employer; indeed facts lied outside medical activity in the strict sense of the word.
The episode, which incidentally the medical category did not seem to attach much importance to at the time, was shelved for several years; however, recently, following the transformation of the hospital medical practitioner’s position from that of an ordinary professional to that of a medical manager, insurance companies have started providing for risk coverage extensions, to include, in addition to damage relating to the medical activity, also risks associated with the new and atypical managerial position of hospital medical practitioners as employers; however, these extensions certainly do not provide for the risks related to this new position from an administration and management point of view with regards to the attainment of the proposed goals in terms of figures rather than in terms of health.

Recent reformations, concerning both state and healthcare employees, have led many people to claim that in hospitals viewed as enterprises, as health manufacturing facilities, the position of medical practitioners should follow the same pattern as that of managers operating in the private sector.
But to what extent is a medical manager really a manager with responsibilities and honour rather than having responsibilities and no powers? Up to what extent can we allow the healthcare “aziendalizzazione” process, the process whereby emphasis is placed on healthcare business-like management, to lapse into the standards regulating productive activities?
Do managers and medical practitioners tackle decision-making processes in the same manner? Let us not forget that, whilst a doctor’s job focuses on people, a manger’s job focuses on the organisation.
The doctor’s interest is first of all concerned with the individual patient, whereas the managers’ goal is to maximise corporate income. If, as it appears, a difference exists, how can this be overcome? The outcome of healthcare activities is not a sellable or visible product, but rather a form of welfare: individual health, which cannot be appreciated by the general public but only by a single individual, even though it is in the interest of the general public, is an asset protected by the constitution.



A healthcare enterprise is an atypical industry, where an extremely high number of highly professional people work. Hospitals no longer are holy places designed for dying or poor people, but health manufacturing facilities; today healthcare distinguishes itself for its technological complexity, for constantly evolving environments, by ever more sophisticated specialisations, with the resulting need to design organised facilities, which are rich from a coordination point of view and integrated by reliable and flexible management tools. Besides, the age of plentiful resources is now over, even though the demand for goods and services is increasing, and hence cuts, restrictions and waste control procedures are required; in short, expense rationalisation aimed at ensuring that a lower expense increase may result in an improvement in the quality and quantity of services. Doctors had for a long time been kept away from economical responsibilities, whereas they are now requested to report in terms of results and resource employment; at the same time and in many respects they seem to have to bear the load of administration staff who, whilst requesting on one side cuts even in the number of health workers, on the other hand multiply to check on consumptions, accounts and the performance of medical managers, who are sometimes obliged to carry out tasks whose competence may be found to be questionable. f

Medical mangers are to make diagnoses, select therapies, organise ward staff, speak to the patients, but also manage the budget, send out purchase orders for material required over the next 12 months, and prove with accountant-like accuracy full income and expenditure precision.
Once, the head of a hospital department was involved with medicine, research, therapies, technology and examination of tests. Today, he has to be good at reckoning, and, above all, must possess the same knowledge an industrial manager has, although he has twice his responsibilities, since he also has to treat his patients.
The diagnostic-therapeutic medical act is now viewed as a process aimed at the production of the health asset, which cannot be viewed out of context, but must, on the other hand, be integrated with variables such as technology, staff, operating-facility spaces and consumption materials.
But to what extent is this possible without impacting the health asset? Who is supposed to hold the administrative sway? Why should medical practitioners, who are supposed to cure the sick, enslave part of their professionalism to handle administrative tasks? Would it not be more rational to appoint specific figures who, by closely cooperating with medical staff, and discussing their demands, may erect the administrative castle? Medical managers are to act according to a logic centring on objectives, with precise responsibilities aimed at their attainment through an efficient use of the resources available, with an inadequate training, and with a mentality, or rather an unfelt background approach which has been imposed on them.
But to what extent a hospital medical practitioner, with the manager’s medal, is really a manager? In the industrial field, a manager is a worker who covers within the company a position involving a high degree of professionalism, autonomy and decision-making power, and carries out his functions with the purpose of promoting, coordinating and handling the attainment of the company’s objectives. All managers are responsible for the results of the activity carried out by the offices they are in charge of and for the implementation of the programmes they are entrusted with.
This involves for doctors further responsibilities in addition to the traditional responsibilities associated with their activity:
· responsibility for the results of financial, technical and administration management;
· responsibility for implementing the programmes according to pre-set, and often imposed, objectives.
Of course, these additional responsibilities are adequately remunerated, but the crucial question is: what real powers does a medical manager have when he is basically supposed to struggle to make ends meet with limited resources, insufficient staff, inadequate equipment and veiled management command?
To what extent would it not be more rational to have a clear separation of the goal-related processes and responsibilities from the responsibilities for the attainment of such goals? In other words, the administration policy bodies should not interfere with the implementation of working activities, by distracting professional skills and qualities from the purposes aimed at protecting the health of patients (now described as customers), which today have to be handled by qualified staff displaying specific managerial professionalism. In the past, hospital medical staff had real management autonomy, against which the bureaucratic machine and policy had little power.
Choices where made according to professional medicals standards and could not be questioned by bureaucrats. The medical practitioner was autonomously in charge of the medical role. Now the old organisation structure has been wiped out and the hierarchic pyramid has been disjointed. So administration staff can impact and impose limitations on choices without having to bear direct responsibilities. Medical practitioners are therefore forced to undertake additional burdens and responsibilities.
Civil, administrative, penal and accounting liability remain unchanged, but managerial liabilities are also added: together with the assignment of managerial functions, doctors are subject to losing their functions in the event of ascertained managerial liability. In view of this unified role, the previously existing hierarchic managerial articulation proves superseded, as well as the principle providing for the superiority of the manager in charge of a higher-level office versus the manager in charge of a lower-level office. As a result of this, the Manager of an Operating Unit has no power to inflict censures on other Managers.
However, the manager is subject to managerial liability and it is the Evaluation Nucleus that has to conduct performance evaluations according to specific procedures: the performance appraisal may be conducted on an annual or triennial basis, or upon assignment completion and a negative evaluation may result in loss of result-related remuneration, loss of assignment according to certain modalities, or exclusion from the award of further managerial assignments corresponding to the revoked one for a period of at least two years.
But the most disturbing thing is that the performance appraisal chiefly focuses on the attainment of the cost-reduction/income increase financial results, which cannot really be reconciled with effective healthcare, and does not appear to grant priority to whether professional performance has been able to meet the actual needs of the patients: effectiveness, quality and promptness of the requested service. In performance appraisals, the achievement of financial objectives is privileged to the detriment of healthcare, quality and strategic performance.
Cost control should not result in a reduction in quality level, which should be monitored as a matter of priority and matched with an availability of resources. Careful monitoring activity should focus on eliminating waste, inefficiencies and delays. Healthcare has to bear significant costs, but how much money is actually spent on healthcare and how much is, on the other hand, wasted on the parasitology institution which feeds on health? Citizens are entitled to health protection, but it looks as if many think that it is the citizens’ duty to fall ill.
And now, before closing, an advice for my colleagues:
· Before accepting a management function, check on the resources available and on the practical chances of attaining your goals. And I would also like to ask the whole medical category:
· To claim our right to our role and avoid becoming the scapegoat for situations that were not created by us. And a statement of fact: · Hospital medical practitioners, now, are not only responsible for treatments, but also for the savings and for the reorganisations imposed by others.
ENOUGH WITH FRONT-LINE DOCTORS SENT TO CERTAIN DEFEAT!!! Administration should state clearly what resources are available and the doctors will in turn inform the citizens as to what level of Healthcare can be guaranteed.