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Play by the Rules


How does your hospitalist group make decisions on important issues? There are many reasonable approaches. The best method will vary significantly depending on the group’s size and whether the doctors own their own private practice or are employees of a hospital or large multisite private hospitalist group.

Because many doctors are drawn to the profession in part seeking autonomy and independence, there is often a tension between their desire to make many decisions about business and practice operations independently and the need to set aside some personal interests in order for the group to function well. This can become apparent when the group reaches an agreement regarding a difficult issue for which there are different points of view.

Consider a hospitalist group made up of internists occasionally asked to admit teenagers younger than 17. There might be a variety of opinions about whether this is appropriate, but it will be best for everyone in the group to follow the same policy. If the majority decision is that it is reasonable to admit patients as long as they’re post-pubertal, everyone in the group should abide by this policy.

But when called by the emergency department about such a patient, a dissenting hospitalist might feel entitled to decline the admission despite the group’s decision. For this doctor, autonomy trumps cohesive group functioning.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

Group Size Matters

A look at hospitalist groups of varying sizes illustrates the growing complexity of decision-making processes.

Small groups (eight or fewer individuals): Hospitalist groups nearly always start with a small number of doctors (often between one and three at the group’s inception) and find little need for a formal governance structure. They tend to make all important decisions based on consensus.

One risk of making decisions by consensus is that the group may be limited by the lowest common denominator. Even if most doctors in the group want to change something to avoid disadvantaging a doctor with a different point of view, the group may be held back and not make the change. In essence, the group can be ruled by the minority. This may not happen often, and as long as the group keeps this risk in mind it is usually fine to operate on consensus.

Medium-size groups (nine-14): A group this size probably needs to acknowledge that it will be unable to reach consensus on a number of issues and will need a voting system. It can be uncomfortable to jump from a culture of consensus to one of majority rule because the latter means there will be winners and losers. A clear set of rules or bylaws can increase the likelihood that those on the losing end of the issue will comply with the majority.

Large groups (more than 14): A large group usuallys face more complex decisions and has a wider range of opinions. Meetings may drag on as an issue is debated and all members have their say.

For this reason, large groups should consider forming a small executive committee consisting of the group’s leader and several representatives elected by a vote of the whole group. This can be a much more efficient way for the group to reach decisions. The executive committee researches issues and forms recommendations for the whole group. For some issues it might be reasonable for the executive committee’s decisions to be final. For others, the decisions of the executive committee might be presented to the whole group as a recommendation and put to a vote of all members.

It is important for a group of any size to have a clearly designated leader to oversee its operations and meetings and represent the group to external constituents. It’s critical that all groups have a culture of physician ownership even if they are contractual employees of another entity, such as the hospital.

It is best if the leader is not viewed as a boss others work for. That will lead to an employee—not an owner—mentality on the part of the others. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He also on the faculty of SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.


By laws must be customized for each group; here’s one example of how such rules can look. They establish how the group can decide important issues for which consensus can’t be reached.

In the case of hospitalists employed by a larger entity such as a hospital or multispecialty group, these rules are not meant to suggest the hospitalist practice can make decisions independently. As employees of the hospital, the group must seek approval from the hospital and the practice medical director for all its policies and operations. However, there are many issues for which this approval can be anticipated, and the group will need a mechanism to establish how it will reach important decisions about them.

Regular Meetings

  • The whole hospitalist practice will meet monthly, or as required otherwise, to discuss and reach decisions on the group’s business; and
  • When possible, decisions will be reached by voice vote or consensus, but when these measures fail a vote (roll call or written) will be taken.

Who Can Vote

  • Any physician member of the group who works more than 0.6 of a full-time equivalent position and has been with the group for more than one year; and
  • All members are eligible to participate in discussions and make recommendations, but voting is limited to the above.

Majority Vote

  • A simple majority (more than 50%) represents a majority vote except as noted below; and
  • The medical director will have the authority to decide the outcome in cases of a tie vote that cannot be resolved with further discussion.


  • Half of group members eligible to vote represents a quorum at any meeting.

Executive Committee

  • An executive committee made up of the practice medical director and three other voting member of the practice will meet monthly as required to address group issues and develop recommendations for consideration at the monthly meetings of the group as a whole;
  • The term of each executive committee member (other than the practice director) will be two years.

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