Hospital Hierarchy: Who's Who?

by Erica Mitchell | January 22 2024 | Infection Control, Hospitals, Career | 0 Comments

hospital heirarchy-01Probably no other organizational entity has the human resources complexity of a hospital. Healthcare facilities bring together not just medical professions, but also administration, marketing, financial, and social work professionals. This convergence results in a complex hierarchy which is difficult to nail down, varies by the facility, and can change based on difficult-to-pinpoint scenarios. As a result, a post about the hierarchy of a hospital has to be broad, but we will attempt to lay out the general levels of responsibility by focusing on decision-making areas at private care facilities. 

At the top of the majority of hospital hierarchies is the Board of Directors, whose primary responsibility is governance. Made up of community leaders, with representation from doctors and nurses as well as the private sector and government offices, this group is tasked with making decisions about the long-term goals of the facility and strategic planning, but also hires and sets the salary for the CEO and other executives. They rely on data and reports from hospital executives to make their decisions, so they are in frequent dialogue with representatives from administrative, medical, and regulatory leaders.

These leaders are typically what would be considered the C-suite of the hospital, those executives with significant oversight responsibilities. These positions are similar to those found in any large business, such as Chief Executive Officer and Chief Financial Officer. They will typically also include a Chief Medical Officer, and may include Chief Nursing Officer, Chief Clinical Officer, Chief Compliance Officer, and Chief Quality Officer, all depending on the priorities and needs of the facilities. Each of these Chiefs will have a department (or departments) that report to them and for which they are the key decision-maker. They may or may not be involved in day-to-day operations, depending on the facility.

Those leaders in charge of day-to-day operations are the Directors (or VPs, Executives, or other similar titles) of various departments, both administrative and medical. These leaders have daily responsibilities in addition to decision-making and oversight duties and report to the C-suite, usually a single executive. For example, Directors of Finance report to the CFO, while Directors of Nursing report to the Chief of Nursing or the Chief Medical Officer, etc. The size of the facility impacts the number of directors needed, with larger facilities (or networks) requiring more niche directorships.

Directors rely on Managers, Coordinators, Program Directors and other professionals to supervise and oversee staff and produce reports. For example, a Nurse Manager supervises nurses on a floor or ward, and, along with all the other Nurse Managers, reports to the Director of Nursing. All the billing staff will report to the Billing Manager, who along with the Claims Manager, Accounts Payable Manager, etc. will all report to the Director of Finance, and so on.

Finally, the great majority of staff, from doctors to radiologists to cooks and cleaners, will all complete their duties and responsibilities according to the policies and procedures set forth by their direct leadership and above. Each department will have its own mini-heirarchy, with interns reporting to attending physicians, or environmental service workers reporting to shift managers, and these will vary according to facility.

One question that may arise after reading this complex organizational structure is “Who actually makes the decisions?” Much has been written about this very topic, and the result is that decision-making in a hospital is rife with challenges. Medical staff train to make the millions of day-to-day medical decisions required by their profession, but outside those decisions, ideas have to make their way through a myriad of leadership levels, sometimes in a recursive path that requires patience and determination.

Another question that may occur to the reader of this blog is “Where does infection control fit into this?” Again, this varies by facility. Some hospitals have elevated infection control and prevention to a Chief level position, but this is rare. Most hospitals have a director-level professional in IP, but not all. In some cases, a Nurse Manager position is dedicated to IP, in others, it is held at a director level. These decisions can indicate a lot about how much the facility prioritizes IP, but should not be the sole indicator. Stay tuned in as we dive deeper into decision-making in IP in a future post!

How complicated is your hospital’s hierarchy? Do you a hospital’s hierarchy should be readily accessible to the public? How much do the hospital’s leadership positions indicate about their priorities? We would love to hear your thoughts in the comments below!