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The Administrator’s Desk: Who’s in Charge?


As a practice expands, so do its management needs. Here’s how to delegate authority while retaining overall control.

You’ve worked there. We all have. The office with too many cooks in the kitchen. Clerical staff who report to team leaders who report to managers who report to supervisors. They have meetings to discuss their meetings, but nothing ever seems to get done.

Or perhaps you’ve spent some time treading water in the other end of the management pitfall pool - the one struggling to get by with too few workers. Either way, such offices are characterized by the crazed looks in employees’ eyes, chronic morale problems, and a steady stream of resignation letters.

As practice administrator, of course, you know first-hand how challenging it is to strike the perfect personnel balance - one that maximizes your resources yet fits comfortably within your budget. Partly, that’s because your need for mid-level managers is constantly in flux. Your practice expansion very often means having to create additional layers of hierarchy within your staff.

“It’s not always how fast your office is growing, but how complex a specific job is,” says Liz Wertz-Evans, CEO of Pediatric Alliance, a 42-physician, independent practice with 14 locations throughout Pittsburgh. Her office, for example, recently created a management position to oversee implementation of its new EMR system. “Even though our EMR vendor provided us a project manager, I pushed for an internal manager because of the magnitude of this project.”

It worked for Pediatric Alliance. But how can you avoid over- or under-appointing people in charge?

Time to ramp up?

Determining when to create additional layers of hierarchy, of course, depends on multiple factors, including your specialty, your workload, and your projections for growth. If your front desk clerks or billing staff are coming to you daily with complaints or questions, it may be time to empower someone with strong leadership skills to head up individual departments.

Promoting people to department-head status can both lighten your load and ensure your office remains current with regulations and insurance. For example, in addition to its EMR manager, Pediatric Alliance also recently brought on a human resources manager to handle personnel matters. “Initially, we all divided those responsibilities, but the jobs were too scattered among our employees and no one had enough time to devote to it to really do it right,” says Wertz-Evans. “There are so many federal laws for the Family and Medical Leave Act alone, and there are exact procedures you need to follow when you discipline or fire an employee, so we felt we needed someone with experience.”

The basics

To operate efficiently, a medical practice should have at least the following basic structure: an office manager or administrator running the business end of the practice, a front desk clerk, a nurse or medical assistant, and the physician. Many also require a designated billing clerk to enter charges and ensure insurance claims are filed correctly. Everyone under that management structure, except the physicians, should report to the administrator, ensuring one person maintains responsibility and accountability.

As your practice grows, and you create additional layers of hierarchy, it’s the department heads who then report to the administrator. “The person running the practice should have the authority, responsibility, and the accountability for the practice,” says Sarah Holt, administrator of Doctor’s Park, a 35-acre medical campus with all specialties represented, as well as practice administrator of Cape Surgical Clinic within the park. “It all has to go back to somebody.”

As administrator of the clinic, Holt notes, she can get by with minimal layers of hierarchy if she clearly communicates to the staff what their job responsibilities are - and aren’t. “In medical practices, everyone needs to know what their responsibilities are and everyone needs to respect their co-workers,” says Holt. “Many physician practices have grown up as mom and pop shops, so the person who is running the practice is not necessarily the person who is designated to run it.” For example, one person (usually a veteran employee) may run the office by dissent, saying things like ‘I’m not going to do it that way.’ “Practices that allow that to exist are rewarding bad behavior,” says Holt.

You know you’ve got too many managers in the mix if you feel like you spend your days twirling in circles. “If people are running around not knowing what they are supposed to be doing, either you haven’t done a good job training them, you haven’t defined their roles, or there are just too many people taking responsibility for too much,” says Holt. “In small- to mid-size practices, I think the fewer managers, the better.”

For her part, Holt designates a responsible lead employee in each of the office departments - front desk, billing, etc. “I don’t have layers of hierarchy,” she says.

Whatever your system of governance, Holt insists, it must be formalized and systematic. “You can’t behave one way today and another way tomorrow,” she says. “Whoever is in charge today must be the person who makes the calls tomorrow. It’s not as important who is in charge as much as everyone understands someone is in charge.”

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on,, and Healthy Family magazine. She can be reached via

This article originally appeared in the July/August 2008 issue of Physicians Practice.

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