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Building a Bigger C-Suite

Molly Rowe, for HealthLeaders Magazine, May 13, 2008
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Strategy, governance, and quality positions have reached the top level of many organizations. But how many "chiefs" do you need?

Thanks to the proliferation of new senior-level titles in healthcare, the executive suite at many organizations takes up a whole floor. In addition to traditional positions like chief executive officer and chief financial officer, many C-suites now include slots for human resources, strategy, quality—even "knowledge."

Organizations add new titles for a number of reasons: to reward long-term employees, to fit hard-to-place but skilled new hires, to meet specific strategic goals. In many cases, the abundance of new senior titles reflects the industry's shifting focus on quality and transparency, physician relations, competition, and increased board involvement. But is it possible to have too many chiefs? Some executives say yes.

"When I see some of these organizational structures and some of the titles they use, I cringe. My thesis has always been that the smaller the executive staff and the more efficient you can make it, the better your results over the long run," says Robert G. Kiely, president and CEO of Middlesex Hospital in Middletown, CT.

New titles can create headaches for leaders and staff, because organizations must create a clear job description, tailor performance evaluations, and determine appropriate compensation. It sounds simple, but when a hospital adds a nontraditional title like "chief of first impressions," defining what that person does and determining salary could be difficult because there's no comparable position in the organization or elsewhere, says HR consultant Ken Kruger. Adding to the executive team can also cause what Kruger calls "title creep," where other staff expect similar title changes.

So when is it appropriate to add a new senior title—and which ones should you add?

Chief operating officer
Located outside of Hartford, Middlesex Hospital staffs 185 beds, but the bulk of its revenue comes from outpatient and home-care populations as well as three 24-hour emergency rooms. Kiely keeps his executive team lean, with vice presidents in nursing, IT, administrative services, and human resources. Although this group represents his "C-suite," until recently, Kiely was the only chief.

Last year, Middlesex restructured its management to include a chief operating officer. Although not a new title in large organizations, the COO position is becoming common even in smaller organizations as a result of changing management responsibilities and succession planning. Appointing a COO frees Kiely for mentoring and coaching and gives the COO an opportunity to learn from Kiely in preparation for Kiely's eventual retirement.

Determining whether a new position will be part of an organization's long-term strategic planning or merely a short-term "fix" is a good indicator of the position's value, Kiely says. "Our COO addition is probably short-term because we may not replace it once I retire and the COO takes over," Kiely says. However, "it's one of those short-term decisions that was made with some very long-term implications in mind," he explains.

Chief quality officer
The director of quality is a standard position in most organizations, but today, a higher level quality expert has emerged. "Just about every leading hospital and health system either has recruited or is recruiting right now for a CQO," says Deedra Hartung, vice president and practice leader for Cejka Search, an executive search firm specializing in healthcare.

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