Critical Condition

he news about the boss was profoundly disturbing to Kenneth Madsen, chief of administration at Federal Hospital. Apparently, the director's return to work after his surgery was premature.

"Dr. A. just about fell over at his desk this morning," personnel director Hedy Ellsworth said. "The doctors say not to expect him back for at least three months... if at all." Madsen winced. Alton Ackerbein, the legendary founding director of the sprawling, dynamic hospital in which he now lay seriously ill, was the glue that had held the place together for 26 years. His prestige and credibility in the health community and at both ends of Pennsylvania Avenue had shielded the facility from cutbacks and consolidation. And his engaging personality had kept the high-powered, fractious medical staff united and reasonably content. Madsen wondered how long it would last without Dr. A.

To make matters worse, Dr. A. had governed without a deputy for more than a year, resisting pressure from the hospital's parent organization, the U.S. Health Agency, and the White House to hire candidates he considered less than outstanding. When Ackerbein had entered the hospital for surgery less than a month earlier, he had appointed Madsen acting director, primarily because Dr. Ellen Ross, the chief of staff, had been overseas at a conference.

Madsen had no problems with the ceremonial and routine duties of the director's position, but his presence commanded nothing more than amiable acknowledgment from the medical power figures. Anyway, Dr. Ross was back, and the hospital faced a challenging and unprecedented situation.

"That stalemate on the deputy position may be coming home to roost, Hedy," Madsen worried aloud. He knew the hospital would need more than a caretaker acting director in the next few months, especially with budget hearings and the agency strategic planning review. "Dr. A. ate that stuff up," he said. "but I don't remember Ellen getting much involved."

"But she seemed really interested in management and planning issues at our executive development seminar last fall," Ellsworth replied. "She asked excellent questions and joined in the evening bull sessions." Ross even had recommended that more executives be exposed to those issues earlier in their careers, the personnel chief added.

Madsen was encouraged. However, two weeks of executive training hardly equipped Ross to take on the agency, with the Office of Management and Budget and Congress eyeing the hospital's budget and strategic plan. But it was a start, and what alternatives did they have? Madsen's brief experience as acting director hardly had prepared him to take the helm, either.

For now, some immediate action was needed in the wake of the director's relapse. First, the Health Agency administrator had to be informed. He probably would ask for recommendations on interim management of the hospital and for statements to the press and staff. This was the time to go talk to Ross about administrative imperatives.

The chief of staff welcomed Madsen's visit. At the suggestion of Ackerbein's secretary, she already had informed the Health Agency administrator of the situation. The administrator had asked Ross to act as director for the time being and to provide a draft press statement within the hour.

Ross often had reminded Madsen that Dr. A. had designated her as his backup. Dr. A. had spent a good deal of time with Ross discussing his management priorities and sent her to executive training. The director wanted Ross to shadow him at key meetings and conferences but had been reluctant to publicize her understudy role. He feared it would resurrect the deputy issue with his agency superiors and the White House.

However, Ross confided: "I'm a novice when it comes to budgets, strategic plans and organization. I can manage the medical side of the house, but I'll have to lean on you heavily for administration-more heavily than Dr. A. does." Ross said she could show up at budget hearings and read a statement, but she'd have to defer to Madsen and his staff on most questions.

Madsen, recalling the combative Ackerbein's spellbinding appearances at budget hearings and his enthusiasm for the give-and-take of the budget and management review processes, had a sinking feeling. We're going to get chewed up in this environment of scarce resources, he thought, if Ellen and I are deferring to each other where Ackerbein used to project assurance and urgency.

And what did the Health Agency administrator mean by asking Ellen to be acting director for the time being? Was he talking a few days, while he lined up an interim director from outside, perhaps from his own staff?

What, Madsen wondered, can the two of us do to provide continuity in the management of the hospital? Should we say we're confident that we can take over quickly and keep the place running as effectively as ever? That would be something of a risk. For one thing, Ellen would have to rapidly develop some of Ackerbein's qualities to protect the hospital and make it thrive. Conversely, should we ask the administrator to help find outside talent? Or is there a middle ground?

David Hornestay, a Washington-area consultant, served in government for more than 30 years, primarily in human resources and institutional management.