If the new palliative care service is to be part of a larger health care facility (hospital, medical centre or community service) its management structure will be dictated by the existing system. It then becomes essential that the palliative care service has, at its head, someone with both an understanding of, and experience in, palliative care.
If the service is ‘free-standing’ or ‘independent’ then it is important to choose the most appropriate and efficient management structure. Basically there are 3 models
Model 1
It is assumed that, whatever the management model, there is a Board of Governors / Trustees with overall legal responsibility for the running of the service. Under them and answering to them is a triumvirate of Medical Director (responsible for medical matters, education, research), a Nursing Director (responsible for nurses, domestic matters ) and an Administrative Director (responsible for administration, finance, public relations). In this model management decisions are shared equally without one person having to bear too heavy a responsibility. The model breaks down if relations are poor between the directors or one dominates.
Model 2
In this model there is a single Chief Executive Officer (CEO) / General Manager in overall charge of the unit and directly accountable and answerable to the Board of Governors /Trustees... Beneath him / her and answerable to the CEO are the Senior Doctor and Senior Nurse and, sometimes a third manager for Finance (and fund-raising). This is an effective model when the CEO is both an experienced and capable manager and knowledgeable about palliative and health care services generally. It can, however, leave medical, nursing and other staff feeling that their work and needs are not understood and that they are powerless to influence decisions. It places almost total power in the hands of one person.
Model 3
This 3rd model is very different from the others. The person with control over all aspects of the service is the Chief Executive Officer, someone with management and administrative training and skills; from any background – medical, nursing, social work, management, commerce, law etc.
All clinicians are represented by a Clinical Director (usually alternating every two year between a nurse and a senior doctor) also responsible for research and education. Also reporting directly to the CEO is a general manager overseeing finance, fund-raising, and all non-clinical aspects of the unit.
The success of this model - whether it succeeds or fails – rests with the personality, the interpersonal skills and the management skills of the CEO. It can reduce the time that senior clinicians spend on committees but with only one clinical director there can be less-than-optimal communication and cooperation between the health professions and resentment that clinical matters were not brought directly to the CEO from the clinical discipline concerned.
The Board of Trustees / Governors
The legal responsibilities of such a Board will be laid down in the statute books of the country where the service is based . They are legally binding.
Membership of a board is laid down by its Articles of Memorandum and Constitution.
The chairperson is usually someone with a track record of such leadership, coming from any of the learned professions or commerce or academia. It is useful if the members can represent medicine, nursing, law, local or national government, the general public, the media and the church. Sitting in on its meetings but not legally trustees or governors no-one in the employ of the organisation can sit on such a body) can be the CEO, and media, nursing and administrative directors.
Professional Advisory Committee
One of the most useful committees yet often seldom set up by those ‘getting started’ is this committee. Usually with 8-12 members, they should present general practice, hospital medicine, university, community nursing, social work, chaplaincy / local churches, professionals allied to medicine and specialist palliative medicine/care. Initially most members will be invited by the founders of the service because of their interest in palliative care or their standing in their profession, locally or nationally.
Such a committee usually meets quarterly for the first few years of a new service then twice yearly when it is established.
The committee usually has no executive powers but is, as its name implies, an advisory body. It initiates some discussions at the request of the clinicians of the new service. It advises on matters referred to it by the Trustees / Governors. Such matters would include staffing matters, research, records, and service provision – anything that relates to the care programme of the new service.
The period that members serve is decided by them in consultation with trustees. The selection of chairperson is also usually discussed with trustees
Staff Handbook
By law every member of staff will have to be given a legally binding contract. This will be drawn up by the trustees and their representatives with the guidance of a legal / human resources adviser.
In addition it is useful for every member of staff, no matter how small the staff, to be provided with a handbook. In it will be given information about the aims of the service, its staffing, its management structure, its committees, uniforms, discipline and appeal procedure, lines of responsibility and communication, ethical guidelines etc.
Such a handbook is as much for the administrators / managers and trustees as for clinical staff members, enabling them all to feel part of this new and exciting venture. It should be so worded that readers feel welcome and excited to be part of something exciting.
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