Operators arrive able to read a hospital and weak on capital. Financiers arrive able to read a balance sheet and weak on why the ward is behind. Both are appointable; neither is complete.
Our own project · Meridian Hospital Group is a constructed operator; the instrument and its figures are real
Meridian Hospital Group · Group
Chief Executive
Holds the programme, allocates the capital, and is the point at which every cost the organisation can see converges and every cost it cannot see does not.
Chapter 1 · Group
What they actually do
Decides which sites get built, in what order, and who runs them. Owns the relationship with investors and the board, sets the pace of the programme, and answers for what each hospital is worth when it is sold.
Day to day the job is allocation and appointment: where the money goes, and who is trusted with it. Both are exercised through other people's reports, which makes the quality of the reporting the real constraint on the quality of the decisions.
- Answers for
- The whole programme: which sites are built, in what order, and what each is worth at disposal.
- Can actually move
- Capital allocation, site selection, senior appointments, and the pace of the programme.
- Sees the cost of
- Measured and attributed cost in full. Misattributed cost as a workforce line. Unmeasured cost not at all, unless somebody builds the instrument that shows it.
Chapter 2 · From arriving to moving on
Growth in the role
Most arrive from operations or finance, and the two backgrounds fail differently, which is worth knowing before appointing one.
The first two years are about carrying clinical, operational and financial performance simultaneously without letting the one you understand best crowd out the others.
The difference between an adequate and a good chief executive in this business is whether they commission the measurement nobody has asked for, particularly the ones that will make their own figures look worse.
Usually to a board seat, a private equity portfolio role, or a larger group. Rarely back down the scale, which is part of why the scale persists.
Chapter 3 · And how it is usually settled
Where this role is in conflict
Most of this role's conflicts are with its own timescale. The programme runs in quarters and the building runs in decades.
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With The patient
Over Where the variability lands- Why it is structural
- Spare capacity is a cost on the accounts. Patient waiting is not. Every close call therefore resolves toward higher occupancy unless something forces the other column onto the page.
- How it is settled today
- By arithmetic rather than by argument, which is why it needs a structural fix rather than a better intention.
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With The Chief Medical Officer
Over Stopping something that is working financially- Why it is structural
- A clinical veto with a cost attached is the only real test of whether clinical authority is genuine in this company.
- How it is settled today
- Publicly, and the whole organisation reads the result. One reversal teaches every clinician more than a decade of published values.
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With The Director of Workforce
Over Whether turnover is a workforce problem- Why it is structural
- Accepting that an agency bill was caused by a layout or an establishment decision means accepting that a previous capital decision was wrong.
- How it is settled today
- Usually by filing it under workforce and funding a recruitment campaign, which treats the symptom annually.
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With The Director of Development
Over Programme against operating consequence- Why it is structural
- Development is measured on time and budget. Asking it to run a configuration before committing costs both.
- How it is settled today
- In favour of programme, almost always, because the cost of the delay is visible this year and the cost of the layout is not visible for five.
Chapter 4 · Actor one
How this reaches the patient
No patient meets a chief executive. Every patient meets the consequences of one.
The decisions with the longest reach are theirs: the parcel, the massing, the department mix, the staffing model and whether the organisation is allowed to plan on goodwill. A chief executive who accepts a business case that only works if the ward finishes late has made a decision about somebody's Tuesday evening two years from now, and will never see it.
Chapter 5 · Actor two
How this reaches the rest of the provider
Sets what every other role is measured on, which is the most powerful lever in the structure and the least examined. An organisation optimises toward whatever its chief executive asks about twice.
Also sets the reporting culture. Where an unwelcome number is met with curiosity, the organisation keeps producing them. Where it is met with pressure, the organisation produces fewer, and the chief executive's own picture of the business degrades in exact proportion.
Every role, side by side
The full hierarchy, and where accountability and control come apart.
Back to people and hierarchy