Health systems face rising costs, workforce strain, delayed access, and a steadily expanding administrative burden. Yet in many hospitals, no single person is clearly accountable for system-wide efficiency. The chief operating officer (COO) manages operations and throughput; the chief financial officer (CFO) oversees financial stewardship; and the chief medical officer (CMO) and chief quality officer (CQO) focus on clinical quality and safety. These are essential roles, but they do not always create clear ownership for the friction that sits between them: duplicated work, delayed decisions, avoidable handoffs, poorly aligned workflows, and the daily operational drag that makes care harder to deliver. This is the gap I am addressing.

The language matters. Governance refers to the structures through which boards and governing bodies set direction, authorise priorities, and hold organisations to account. Leadership is the work of setting purpose, aligning people, and mobilising change across the institution. Management is the operational work of executing plans, coordinating resources, and maintaining performance in daily practice. These functions overlap, but they are not identical. Hospitals may have strong governance, committed leaders, and hardworking managers, yet still lack clear accountability for efficiency across the seams of care delivery [1,2].

That missing concept is accountability. Accountability has long meant more than blame or upward reporting. It includes clear assignment of responsibility, the expectation that performance can be explained and reviewed, and the capacity to respond when goals are not met [11,12]. More recent thinking goes further: accountability is not only the state of being held to account, but also a professional virtue that includes welcoming responsibility and welcoming input from others [13]. That broader understanding is especially relevant here. Efficiency should not be treated as an afterthought or a side project. It should be an explicit leadership responsibility.

For that reason, I believe that every hospital should have a designated efficiency officer. Regardless of the what title is given to that person, what matters is that one accountable leader is explicitly charged with reducing operational friction, simplifying administrative work, improving flow, and connecting clinical, operational, and financial decisions around how care is actually delivered.

This should be physician-led, but not physician-only. The case for physician leadership here is not hierarchical; it is practical and collaborative. Many of the inefficiencies that make hospital care difficult are embedded in clinical workflows: documentation burden, discharge delays, prior-authorisation loops, referral bottlenecks, operating room turnover, scheduling mismatch, and variation in common pathways. A physician leader can translate these failures into their consequences for patient care, professional time, and clinical judgment. At the same time, this role must work in close partnership with nursing leadership, operations, finance, quality, information technology (IT), and frontline staff. The argument is therefore for collaborative physician leadership, not physician exclusivity [1,9,10].

The ethical case is straightforward. Efficiency is not merely a managerial concern. It is an ethical one. Every unnecessary form, every redundant click, every avoidable delay in discharge, and every preventable handoff consumes patient time and clinician attention. Administrative complexity has become a major source of waste in healthcare, and time-motion work has shown how much physician effort is diverted away from direct patient care toward documentation and desk work [3,4]. When inefficiency becomes routine, it contributes to frustration, moral distress, and erosion of professional trust. Framing efficiency as an ethical obligation is therefore not rhetorical flourish. It reflects the lived reality of modern care delivery [6,13].

An efficiency officer would not replace the COO, CFO, CMO, or CQO. The role would connect them. Throughput problems are rarely only operational. Waste is rarely only financial. Documentation burden is rarely only an IT issue. Delayed discharge is rarely only a case management issue. These are seam problems. When no one owns the seams, frontline teams absorb the burden. The purpose of an efficiency officer is to make those seams visible, actionable, and reviewable across the hospital. As shown in Table 1, this function complements existing executive responsibilities rather than displacing them.

The practical framework should also reflect what we have learned from systems and complexity thinking. Large institutions rarely improve through a single sweeping intervention. They improve by identifying recurring points of friction, testing changes in context, learning quickly, and scaling what proves useful [14]. For that reason, hospitals should begin not with grand redesign, but with small, visible, fail-safe tests in high-friction areas. These might include one discharge bottleneck, one redundant documentation step, one referral loop, one operating room turnover delay, or one scheduling mismatch between demand and capacity. The point is not to be timid. It is to build credibility, reduce the risk of unintended consequences, and create a disciplined cycle of learning.

A practical approach can be framed in three phases. Phase 1 is to define and diagnose the friction using existing data and frontline experience. Phase 2 is to test small, reversible interventions that are meaningful enough to matter but contained enough to adapt if they fail. Phase 3 is to scale what works, review progress regularly, and make the results visible to both leadership and frontline teams. In this way, efficiency becomes a hospital capability rather than another disconnected initiative.

This matters culturally as much as operationally. Clinicians do not rally around the language of cost containment. They do respond to leadership that respects their time, reduces preventable frustration, and makes care easier to deliver. If hospitals want to reduce burnout, improve trust, and protect access, they need to treat efficiency as part of professional respect rather than as a narrow financial exercise. Psychological safety is essential. Staff must be able to identify waste and operational friction without fear of blame. Leaders must also close the loop visibly. If people speak up and nothing changes, cynicism deepens. If they see that barriers can be removed and work can become more coherent, trust begins to return [5,10].

This article is not an outcomes study. It is a leadership proposition. But it is a practical one. Hospitals have invested heavily in quality, safety, and financial oversight while too often leaving system efficiency as everyone’s secondary concern and no one’s primary responsibility. That is no longer sustainable.

In this era of rising administrative harm and constrained resources, that leader should be an efficiency officer. Not because efficiency is peripheral to care, but because it is now central to whether hospitals can remain humane, effective, and worthy of the people who work in them.

References

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8. Shortell SM. Value management in health care organizations. Health Aff (Millwood). 2021;40(4):607-614. 
9. Saxena A, Meschino D, Hazelton L, et al. Power and physician leadership. BMJ Leader. 2019;3(3):92-98. 
10. Loving V. Optimising doctor-administrator leadership dyads in healthcare organisations. BMJ Leader. 2025;9:1-3. 
11. Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239. 
12. Denis JL. Accountability in healthcare organizations and systems. Healthc Policy. 2014;10(Spec issue):8-11. 
13. Peteet JR, Witvliet CVO, Glas G, Frush BW. Accountability as a virtue in medicine: from theory to practice. Philos Ethics Humanit Med. 2023;18(1):1. 
14. Khalil H, Peters MDJ, Godfrey C, McInerney P, Soares CB, Parker D. Using systems thinking methodologies to address health care sustainability: a systematic review. JBI Evid Synth. 2021;19(12):3087-3143. 

Table 1. Hospital efficiency officer and relationship to existing executive roles

Author
Jeffrey H. Shuhaiber
Jeffrey is a cardiothoracic surgeon and physician leader with a growing focus on ethical healthcare system performance, cost discipline, and operational efficiency. His work centres on aligning clinical care, administration, and resource stewardship to improve how care is delivered at scale.