John Hartline, MD, FAAP

Administrative responsibilities in an NICU or other hospital unit, in a division or department, or in a practice are time-consuming and essential. Many of the needed skills often are excluded from the training process. Overall, administration consumes about 1/3 of the non-clinical time of the "average" neonatology practice, with considerable variation among practices. In that each intensive care or special care unit requires a medical director and each covered hospital will need director(s) for its nursery unit(s), administration time varies directly with the number of units and hospitals covered by the practice. As leadership roles in this area usually follow some experience in practice, more senior associates usually will fulfill these roles.

Administrative responsibilities should be expressly discussed among group members when the workload of the practice is evaluated or allocated. Unless the time spent on administration is discussed and documented, often non-director associates "wonder what the director does with his/her time" and may question his/her contribution to the total practice workload. On the other hand, expecting directors to do that job, and to take "equal" shifts clinically, teach as often, or commit to scholarly pursuits as often as others, results in an overwork shift in the directors' direction. As some colleagues have interest and special skills in interpersonal and interprofessional communication, time management, budgeting, and overall organization, it serves the practice to seek directors who cherish that experience, yet remain accountable to the group. 

 

Administrative Responsibilities:

  • Practice administration
    • Scheduling
    • Financial
    • Outcomes analysis (may be considered clinical as well)
    • Compliance
    • Workforce analysis
    • Strategic planning
    • Discipline
    • Interaction with hospital(s), university, or practice plan
  • Neonatal Intensive Care Unit
    • Medical Director
    • Multidisciplinary committees
    • Quality assurance
  • Hospital or Hospitals
    • Intensive care unit directorship(s)
    • Committees, eg, infectious disease, pharmacy & therapeutics, credentials, etc.
    • Medical staff administration
    • Departmental (Pediatrics)
  • Medical School or University
    • Training program directorship (fellows and/or residents)
    • Medical student coordination
    • Faculty committees of various types
  • Health Plan
    • Liason​​​​

All members of the practice will need to participate in meetings and/or committees; some will assume leadership roles in administration. Understanding these roles and how they are assigned is an important component of any practice. Obviously, these roles will differ considerably when comparing a local private practice group with a large national practice management company, a hospital-owned practice, or a university faculty. Nevertheless, understanding practice administration is essential to being able to function and succeed within a practice.

 

Administrative Accountability

Clinical skills and performance are often evaluated; administrative performance often goes unevaluated.

  • Does the practice review the effectiveness of those performing its administrative responsibilities?
  • How are administrators held accountable?
  • How are new responsibilities reviewed and incorporated into the practice workload?

Although individual members may have certain administrative roles, the governance of a practice may range from autocracy to the pure democracy of a town-meeting. Individuals in administrative positions are expected to act on behalf of the practice and in accordance with practice policy. Practices that include accountability to the group as an expectation of leadership will bring more creative ideas into play than those that depend exclusively on individuals.

For those neonatologists working for a hospital, a university, or a physician management organization, an understanding of who is the ultimate "boss" and knowing the means the physician can use to interact with and impact the administrative processes are key to being able to participate effectively. This is especially important if the physicians are individually employed by the hospital. The medical director position may be separately-compensated, leaving the practice members little control over practice leadership and little recourse when problems arise.

Each neonatal intensive, intermediate, or general care nursery must have a designated medical director. These responsibilities, especially for specialty (level II) or subspecialty (level III) nurseries, generally fall to neonatologists. Fellowship training offers limited exposure to the interactive process among medicine, nursing, hospital departments, and nursing that confronts one in a medical directorship role. The Section on Perinatal Pediatrics Spring Workshop supports colleagues in these roles by regular presentation of topics relating to the multiplicity of interpersonal and interprofessional relationships needing oversight and management by a medical director. If you assume a directorship role, be sure to secure a mentor or added training as needed.

 

Questions for Discussion about Administrative Duties

Administrative responsibilities of the practice: some talking points

  • How are administrative duties distributed among members of the group?
    • Who is considered the "boss?" and is he/she appointed, elected, designated, or entitled?
    • Is this position permanent, elected, or rotated among group members?
  • Are the job descriptions of the administrative roles written out?
    • What is the administrative mode of communication?
    • How is administrative job performance evaluated and rated, and by whom?
  • Which administrative duties
    • pertain to the practice itself
    • relate to the NICU,
    • serve the hospital
    • belong to the department or faculty, the university,
    • interact with physicians' management organization, or managed health plan?
  • Duty scheduling:
    • Scheduling process
    • Time from publication to duty
    • Flexibility
    • Is time for individual's administrative duties included within the scheduled work calendar?
    • How often are there regular administrative meetings and how is the agenda determined?
  • Reimbursement for administration.
    • Does the practice get directors' fees as part of total practice income?

Is a portion of one or more group members' salaries specifically tied to administrative responsibilities? If so, who pays that salary?​

 

Questions and Topics for Discussion About Clinical Duties

Clinical Duties:

Assignment of clinical responsibility

  • How are patients admitted to the NICU assigned an attending physician?
  • Is on-going care provided by the specific attending, or is daily care responsibility determined by the rounding schedule of the practice?
  • Does the patient stay on the service until discharge, or is transfer likely before discharge?

Daily Rounds

  • How are rounds conducted, notes written and daily patient care responsbilities provided?
  • Are Neonatal Nurse Practitioners (NNPs) and/or Physician Assistants (PAs) incorporated into rounding responsibilities? If so?
  • How are they covered by the physicians and how is that coverage documented?
  • How are they supervised i.e., scheduling, conflict resolution, etc?

Recordkeeping

  • Are there stated expectations regarding daily progress notes?
  • Is there an electronic medical record?
  • Is there a dictation service?
  • Is the practice using voice recognition for dictated notes

Call Scheduling

  • For what blocks of time is the neonatologist "on-service" and what is the call schedule?
  • Is there 24-hour in-house coverage? If so, what accommodations are provided for in-house coverage?
  • If the call is from home:
    • How quickly must the physician be able to be on site and what distance limitations, if any, prevail?
    • Who provides immediate patient response and treatment?
  • What is the process of transferring clinical care among physicians?
  • What is the group's compliance program?

Clinical Responsibility Outside of the NICU

  • What are the practice's responsibilities for Level II care?
  • What are practice responsibilities for Level I care?
  • In how many different hospitals does the group see patients?
  • Does the practice staff the neurodevelopmental follow-up program, an apnea or home-monitoring program, or a chronic lung disease (BPD) clinic?
  • How is time spent in these activities weighted as compared to other activities of the practice?

Clinical Outcome Evaluation

  • Does the group have a patient database?
  • Is the database local or associated with other units, locally or nationally (e.g., Vermont Oxford)?
  • What benchmarking tools are incorporated into outcome evaluation?
  • Is outcomes analysis being related to maintenance of certification?

Incorporation of New Innovations

  • What criteria are used to introduce a new approach into clinical use?
  • How are innovations evaluated after they are introduced?

Conflicts and Disagreements in Clinical Care

  • Are controversial care decisions made by group process, or do individual physicians practice independently?
  • How do group members and the group as a whole approach and resolve conflicts in clinical management?

Clinical Load Analysis

  • How many hospitals' nurseries are staffed by the practice?
  • If more than one, at which hospitals or units are members of the practice expected to work?
  • How are time and responsibility at each unit allocated among group members?
  • Do group members have primary responsibility at one unit, and if so, at what unit will each person work?
  • How is each hospital's newborn unit classified and what is the volume of clinical activity?
  • Is the classification done locally or by state agencies or regulations?
  • How many babies are delivered at the hospital(s) annually?
  • How many obstetricians and Maternal-Fetal Medicine specialists practice at the NICU hosptials?
  • How many deliveries are considered "high risk" or are delivered by the Maternal-Fetal Medicine specialists?
  • How many babies were admitted to the NICU(s) in the past year?
  • What is counted as a "NICU admission?"
  • How many are less than 1000 grams or less than 28 weeks gestational age?
  • What is the overall distribution of diagnoses of NICU admissions for the past year?
  • How many ventilator days?
  • How many days of TPN?
  • What are the criteria for admitting or transferring an infant to or from the NICU?
  • What outcome measures are collected for the unit as a whole and are they related to a benchmarking database?
  • How are the data used?

Newborn Care Populations

  • Does the practice cover the regular well baby nursery?
  • Does the practice cover infants admitted to the general pediatric floor or pediatric intensive care unit?
  • What proportion of admitted patient stays in the practice until discharge?
  • What proportion is internally transferred to other units within the hospital, such as pediatric ICU, normal nursery, or general pediatric inpatient unit?
  • Does the practice continue to cover the patients transferred to other units?
  • How does the practice review, analyze and plan its activity?
  • How many patients per physician per day?
  • How many intensive care patients per physician?
  • What is the anticipated future caseload?
  • Is the estimate realistic in light of the demographics of the area?
  • Does the practice plan to add patient groups (such as normal newborns, infants admitted to general pediatrics, etc.)?

What changes in patient load or coverage are anticipated for the next 3 to 5 years? What practice adjustments are planned?

Educational Responsibilities »​

 
 
 
Last Updated

04/14/2022

Source

American Academy of Pediatrics