Ask an Advisor: Who should a chief nursing officer report to in a large medical group?

As medical groups increase in size, the complexity of governance grows, too. In an organization that has a sizable operations staff alongside hundreds or even thousands of clinical team members, it can be a challenge to determine how best to structure teams effectively. This is especially true for organizations large enough for a director of nursing or chief nursing officer (CNO) position. 

CNO duties generally involve: 

• Providing leadership to assure standardization of clinical care work processes through collaboration of all organization disciplines 

• Possessing current licensure as a registered nurse (RN) 

• Responsibility for the overall direction of patient care services, monitoring standards of patient care and setting facility performance goals. 

A member recently posed this question to the MGMA Ask an Advisor program: 

Do you have sample organizational charts for medical practice structures? We are a large physician practice with nearly 1,000 providers and 130 locations. We have a nursing resources department that is run by an RN. In most organizations, does that director of nursing report to the chief medical officer (CMO) or to an operations position? 

Organizations structure their administrators and employees in numerous ways, but generally they are either a flat (horizontal) or tall (vertical) structure:  

• Flat/horizontal structures often organize with practice or service line managers reporting to the chief executive officer (CEO), with teams of workers or groups reporting to each practice/service line manager. In some cases, these flat structures are modified into a matrix structure, with specific vice presidents (VPs) for finance, operations, technology and marketing, and specialty managers each reporting to multiple VPs. This matrix structure can add complexity and confusion due to the various reporting arrangements.  

• Tall/vertical structures are most common in large organizations such as where this member works. In our experience working in and with large organizations or practices, an organization generally would have a chief executive officer (CEO)/vice president (VP) at the top, followed by a director of operations, area practice managers (or “directors” at some companies), practice managers/leads, and then all support staff.  A CMO or CNO would generally report to the CEO/VP directly. 

Here is a sample of this in an organization with a CNO: 

Another example of a tall/vertical structure for a larger organization would have an executive committee or hospital CEO atop the organizational chart, with a system medical director reporting to that committee or CEO. That system director would then have a director of nursing as a direct report, as well as an executive director of medical groups who oversees administrative units such as operations and billing. 

For practice leaders looking to hire a CNO or update the role as part of an organizational change, MGMA Careers has a sample job descriptions page to aid the process. The MGMA Member Community is another resource to ask fellow MGMA members how they approach organizational structure. 

Other resources and sample organizational charts are available from: 

• The Primary Care Practice Facilitation Curriculum via AHRQ (PDF) 

• Physicians Practice 

• The American Academy of Pediatrics 

• Kansas Bureau of Community Health Systems (PDF) 

Additional resources: 

• “Essentials of Organizational Governance 100 Level” (Online course) 

• “How effective is your medical group governance?” (Insight article) 

What’s your question? 

Do you have a crucial question or need help with a complicated medical practice management issue? With MGMA’s Ask an Advisor program, you can depend on our team of experts to provide answers, recommendations and the tools you need to be successful.