Special article
Principles and duties in the exercise of medical direction of hospitals and health centers
Principios y deberes en el ejercicio de la dirección médica de los hospitales y centros sanitarios
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Their responsibility is thus conditioned by this objective and by the privilege of enjoying the trust of the professionals and the management of the centre. In this sense, the relationship between the MD and the doctors must be based on the abovementioned trust, respect and professionalism.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In decision making, a fact that is consubstantial with the authority of the MD,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> he or she often faces the dilemma of the different loyalties resulting from being at the centre of a triangle constituted by the management (representing the governing body of the centre), doctors and patients. While it is unquestionable that, as a doctor, your first loyalty must be towards the patient, the daily work or the different dynamics prevailing in the health ecosystem can jeopardize this mission.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the Third Congress of the Medical Profession of Catalonia<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> held in Girona on 9th November 2016 and, more specifically, in the course of the presentation "Leadership and participation'', the need to have a definition of the responsibilities linked to the exercise of the MD position and the ethical aspects inherent to it, as well as some reference criteria that may be useful in conflict situations was highlighted. Based on that, the <span class="elsevierStyleItalic">Consell de Col·legis de Metges de Catalunya</span> considered it appropriate to establish the basic principles, from an ethical and professional point of view, that would have to guide the exercise of the doctor who acts as MD,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in harmony with those specified in the Code of Ethics,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> to which he or she is also subject as a doctor. The specification of the duties contracted by the MD by virtue of his/her position (management-related decisions), in addition to pursuing the optimal functioning of the health centre or institution that he or she manages, constitutes an essential reinforcement to the MD's actions in the face of potential external interference and a framework of protection in case of potential professional conflicts.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to note that the responsibilities and functions of the MD are not exactly the same in the different centres, since they are determined by the regulations governing each health institution (temporality, election mechanism, organization chart, etc.). In this sense, even though the reflections of this article intrinsically refer to the MD, these would also be applicable to the care director, a figure that the organizational chart of some centres contemplates between the general management and the medical management.</p><p id="par0030" class="elsevierStylePara elsevierViewall">For that reason, this article aims to distinguish some common reflection elements in the exercise of Medical Management,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> based on the principles and duties that are projected towards patients, professionals, the institution and its social environment.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Principles and duties towards the patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">The MD's responsibility is to seek and try to ensure a safe, qualitative and efficient medical care, respectful for the rights of patients and their families or related persons. To carry out this work, the MD must delegate duties to other managers, medical officers or professionals of the centre, in which case he/she must ensure that they follow the same principles and criteria. In this sense, the MD will rely on them and seek the support, collaboration and commitment of the rest of the institution's physicians, establishing policies and assistance protocols, selecting the most appropriate work teams, and creating the necessary clinical and care committees to guarantee the achievement of the proposed objectives.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Similarly, the MD will promote the control mechanisms necessary for the systematic and regular quality evaluations to promote the centre’s continuous improvement.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The MD must ensure coordination between care levels under the premise that the entire health organization is at the service of the patient, being especially sensitive to social problems related to the disease, chronicity and the end of life. In addition, the MD will ensure territorial equity, facilitating referrals between centres of different levels of complexity.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the event that the MD finds that the medical practice of a physician at the centre is inadequate, either due to insufficient technical skills or due to deterioration of his or her health status, and may put his or her patients at risk, or that his or her ethical or deontological behaviour is reproachable, the MD has the obligation to inform the College of Physicians, in addition to implementing internal organizational and corrective measures considered necessary to guarantee patient safety.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Principles and duties towards other professionals</span><p id="par0055" class="elsevierStylePara elsevierViewall">The MD's responsibility is to ensure compliance with the fundamental duties<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the Code of Ethics<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> on the part of all the doctors of the centre, as well as being a guarantor of respect for their ethical and deontological rights. In addition, above all hierarchical considerations, the MD must consider that any physician at the centre is a colleague who deserves a respect imposed by universal medical practice and must be treated as such.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The MD must ensure the unity between the centre’s physicians, favouring interprofessional relationships and teamwork, promoting multidisciplinary cooperation, process integration and continuity of care. More specifically, the MD must prevent and, eventually, resolve professional conflicts between doctors.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> If necessary, the MD will establish extrajudicial resolution mechanisms (arbitration, mediation, etc.) where the different medical bodies and the management of the centre are represented. Similarly, if the MD is aware that there has been an action or a decision has been made with which the doctor in charge of the patient disagrees, or has not been consulted, he must resolve the conflict with the participation of the medical supervisors involved.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The MD must act with maximum transparency and consideration in the face of organizational changes involving professionals and in defence of the common good, preventing or reducing any potential conflict.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand, the MD must favour, together with other managers and medical supervisors, the good reputation, the promotion and professional satisfaction of all the centre’s physicians. In this sense, it will promote their participation and involvement in the definition of the care objectives and the evaluation of the results. To this end, it will stimulate the involvement of professionals in the centre’s clinical management, as well as their participation in the different commissions or committees, both at an institutional level (quality, clinical safety, mortality, care ethics, etc.) and within the departments, favouring, at the same time, the perception of being a participant in the proper functioning of the centre, and the feeling of belonging and commitment to it.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally, the MD must detect, care for and promote the professional talent of the centre’s doctors. For this, it will facilitate active and permanent learning, understood as a right and an obligation of the doctors, as well as provide tools and training to favour the co-responsibility of professionals in decision making. In addition, according to the centre’s possibilities, it will promote research and innovation as implicit elements of professional practice.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Principles and duties towards the institution and its social environment</span><p id="par0080" class="elsevierStylePara elsevierViewall">The MD is responsible to ensure the good name of the institution and, therefore, its professional and ethical conduct must be exquisite and aligned with the centre’s mission, vision and values. Similarly, in the event of being aware of any inappropriate behaviour on the part of any physician that may be detrimental to the institution, the MD has the obligation to take the necessary measures to correct it or, if this is not possible, bring it to the attention of the corporate medical bodies and/or health authorities.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Health professionals, regardless of whether they perform a public or private service, have a commitment to the society to which they belong. Therefore, the MD must promote the improvement of the quality of care provided by the centre, evaluating and, eventually, requesting the health authorities or those responsible for the centre’s finances the necessary resources to carry it out. This action, however, must always be based on efficiency criteria and will be subject to the general economic conditions at the time.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">On the other hand, it will favour interaction with other health centres and academic and/or research institutions of the area to establish collaborations and synergies that may contribute to an improvement in patient care.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally, the MD will stimulate the appropriate initiatives to bring the institution closer to its social environment and, in particular, to the population, in collaboration with the rest of social welfare areas providing services to people.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflict of interests</span><p id="par0410" class="elsevierStylePara elsevierViewall">he authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Principles and duties towards the patients" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Principles and duties towards other professionals" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Principles and duties towards the institution and its social environment" ] 3 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflict of interests" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-28" "fechaAceptado" => "2019-05-02" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castells A, Bisbe E, Petit M, Soler M, Padrós J. Principios y deberes en el ejercicio de la dirección médica de los hospitales y centros sanitarios. Med Clin (Barc). 2019;153:467–469.</p>" ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">A list of the members of the Group is included in the <a class="elsevierStyleCrossRef" href="#sec0020">Appendix A</a>.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="par0110" class="elsevierStylePara elsevierViewall">Working group of the Consell de Col·legis de Metges de Catalunya for the preparation of the position paper "Principles and duties in the exercise of medical management at hospitals and health centres"</p> <p id="par0115" class="elsevierStylePara elsevierViewall">Antoni Castells (coordinator), María José Abadías, Elena Álvarez, Elvira Bisbe, Lluís Esteve, Josep Mercadé, Màrius Petit, Noemí Pou, Alessandro Sionis, Marc Soler, Josep Terés and Agustín Urrutia.</p>" "etiqueta" => "Appendix A" "identificador" => "sec0020" ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The function of a medical director in healthcare institutions: a master or a servant" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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