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Some Dilemmas Faced by a Hospital Chief Executive Officer

Feb 21, 2018 - J.A. McNamara


Dilemmas faced by CEO BlogIn July 2008 The Harvard Business Review wrote of hospitals:

“The most complex workplaces today are tertiary care hospitals. These vast enterprises employ tens of thousands of people who, under one roof, do everything from neurosurgery to laundry. This is complexity an order of magnitude greater than automobile assembly and anyone who has been hospitalised knows that management has thus far been unequal to the scope of the task.”

It follows that for a CEO managing such complexity, there are additional leadership challenges that are exceptional and that are not encountered in the regular world of business. Among these challenges are dilemmas that a CEO (particularly one working in the public health sector) faces on a daily basis in seeking to balance competing, and at times conflicting, demands. These dilemmas make it difficult to make decisions because of the trade-offs that inevitably occur when considering options. So what are some of these dilemmas?

In the first instance there is the constant challenge to deliver a high quality, responsive service to the population within a constrained financial envelope. The measure as to what is a quality service is constantly being uplifted by external accreditation bodies including HiQA, oftentimes with little tolerance for the reality of working within a system that is infinite in terms of demand but constrained in terms of resources. In this environment, a decision to prioritise one issue means inevitably that something else does not get addressed, or at least doesn’t get addressed until another time. On a practical level the requirement to generate (in the case of CUH) €60m of private income each year while maintaining adherence to contractual obligations is a constant dilemma.

It is not only in relation to the weighing up of different choices that a CEO faces dilemmas. The on-going challenge to streamline the care of emergency patients and to reduce the number of patients on trolleys oftentimes mean that patients are located in Assessment Units which in turn compromises the functioning of those units for the purposes for which they were intended. In this regard, ambiguity as to what national priorities are, mean that decision making is made more difficult.

One of the difficulties in the healthcare environment is dealing with the issue of the short term, which is the horizon of the political system and which often contextualizes decision making for hospital CEOs in the public system. The priority can be to deal with an issue to address an immediate problem and in the process to make a decision that compromises another situation or indeed creates a further problem that may emerge at another time.

Allied to this of course is the allocation of time that executive, clinical and nurse leadership are expected to give to the management of unscheduled care, which of course detracts from the strategic work that leaders are expected to focus on. Indeed the disproportionate amount of time given by leadership to day to day issues comes at a cost of positioning our hospitals optimally to address the myriad of strategic challenges that hospitals face. This is part of the never ending debate about the blend of management and leadership and many hospital CEOs end up spending more time on management and less on leadership which is not as it should be.

A further dilemma for a hospital CEO in the public health system is to distil (in an unbiased way) the key themes from the myriad of discussions, commentary, law and circulars that the system generates and to formulate hospital policy that reflect values such as inclusion, respect and diversity. The challenge to align the focus of many different professional staff towards the delivery of high quality, safe patient care requires making choices that promote teamworking in circumstances where the gravitational pull can be towards individualism. These are subjective processes that ultimately shape the culture of each and every hospital which does things differently.

In this regard, one of the dilemmas that a hospital CEO faces (and perhaps other CEOs too) is how to prioritise the use of their time to deal with those matters that add value to the work of the hospital and to the delivery of services for patients. In the “noise” that often characterises hospital activity, it is easy to get absorbed in to the detail of dealing with micro issues that can result in opportunities foregone to add value to the business of the hospital. One of the key dilemmas in this regard relates to the challenge to progress multiple agendae simultaneously even when some of these agendae are contradictory!

In conclusion one of the key dilemmas for a hospital CEO is to maintain one’s soul in circumstances where the gravitational pull is to become depersonalised as one responds to the myriad of competing demands on one’s time with sectional interests seeking to ensure that the issue of importance to them becomes one that is important to the CEO. We must at all times remember that we are custodians of the roles we fulfill and there is an onus on us to use the power and influence we have at our disposal to do good and to add value to the patient journey.





J.A. McNamara

Chief Executive Officer






3 Comment(s) on this page



Nicely put, Tony. I never had any concerns that your soul, or that of the organisation, was ever in jeopardy!

Conor Leonard.



Excellent article altogether inspirational no wonder CUH is such an excellent and patient focussed outfit with this kind of thought provoking leadership



Very interesting perspective. I came across it while looking for a contact point for your good self.

Ive been an inpatient in 3B since Monday, when building (or rather demolition) work started. The noise of Kango hammers hour after hour and now at 17.15 is unbearable. The builders are all wearing ear defenders as is right and proper, we patients on the far side of the wall have no relief, neither do the wonderful nursing and medical staff trying to work through the racket.
The noise level is a serious health and safety issue which I believe you need to investigate. It is at a level potentially damaging to the hearing of both staff and patients and I truly believe health and safety should act immediately to assess and deal with the risks.

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Last Modified Date: 21/02/2018 13:03:56