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SECTION II - Structure of a Public Hospital District

Compiled from the PHD Legal Manual, Chapter One

A Public Hospital District’s management structure is the major difference between it and other non-profit hospitals. As mentioned in the previous section, elected commissioners serve as the hospital’s board members. The make-up of this board is considered in the first part of this section, focusing on the statutory requirements regarding the number of commissioners that may serve on the board, how commissioners may be elected, and the process that a district must go through to change either.

The remainder of this section describes the different managerial structures that may be adopted by the board in the running of the day-to-day operations of the hospital.

A. Commissioner Districts

Introduction to Commissioner Districts
As is discussed in detail in Section III of this guide, PHDs are governed by a board of district commissioners who are elected officials. Each board must have a president and a secretary. RCW 70.44.040 and RCW 70.44.053 provide that the board may be comprised of three, five, or seven members. Each commissioner may represent a particular district within the whole of the PHD (where they must reside), or hold an at-large position.

The notion of commissioner districts is common to many types of special purpose districts. In theory, the establishment of commissioner districts allows commissioners to represent geographic constituencies.

From a practical standpoint, commissioner districts do not always serve a vital purpose. This can be the case with PHDs. Therefore, commissioners may also be elected on a strictly at-large basis, or a PHD may have a combination of geographic commissioner districts and at-large positions. [RCW 70.44.040]

Creation of Public Hospital Commissioner Districts
Commissioner districts may be created at the same time that a PHD is formed. RCW 70.44.040 provides that the commissioners of the county or counties in which the proposed PHD is located must determine by resolution whether district board members will be elected from either three, five, or seven commissioner districts, or at-large positions, or both. Then the electorate chooses commissioners on the same ballot as it considers the proposition for forming a PHD. The terms of the inaugural board members are fixed by statute, ranging from one to six years, to ensure that commissioner vacancies will be staggered as evenly as possible. The terms of office are formulated so that the commissioners receiving the greater number of votes at the initial election will serve the longer term of office.

Electorate Voting
Only voters of a commissioner district may vote at a primary to nominate candidates for a commissioner district but voters of the entire public hospital district can vote at a general election to elect a commissioner of the commissioner district [RCW 70.44.040(2)].

Redistricting Commissioner Districts
State law declares that it is the responsibility of each municipal corporation to periodically redistrict its governmental unit based on population information from the most recent federal decennial census [RCW 29.70.100]. No later than eight months after receipt of federal decennial census information applicable to the district, the board of commissioners must prepare a plan for redistricting its commissioner districts [RCW 29.70.100(3)]. The necessary elements of this plan are laid out in the PHD Legal Manual (Chapter 1).

Results of Redistricting
If, as a result of redistricting, more than one commissioner resides in a redrawn commissioner district, the law allows both commissioners to complete their terms of office. When this situation arises, a commissioner or commissioners form that district, equal in number to the number of commissioners in excess of the correct number, will be assigned to a drawn district with less than the correct number. Under state law, the commissioner(s) with the shortest unexpired term(s) will be assigned. If the number of commissioners with the same terms of office exceeds the number to be assigned, the board of commissioners shall select by lot from those commissioners which one or ones are assigned. A commissioner who is assigned in this manner shall be deemed a resident of the commissioner district to which he or she has been assigned for purposes of determining whether a position is vacant. [RCW 70.44.047]

Abolishing Public Hospital Commissioner Districts
Existing commissioner districts may, by resolution of the board members, be abolished, permitting candidates for any position on the board to reside anywhere in the PHD. Commissioner districts can then be re-established at any general or special election called for that purpose, either by resolution of board members or on petition of the voters. [RCW 70.44.042]

B. Public Hospital District Management Structure

Overview and Options
A hospital district is probably best described as a municipal corporation formed within a defined geographic area to provide health care services to community residents and others in need. And, Washington law is quite clear in requiring that the elected board of commissioners oversee the general conduct of hospital district affairs and that there be a person appointed to the statutory post of superintendent to provide reports to the commissioners on the status of district operations.

However, hospital districts do have a number of options in deciding how it is they wish to directly manage the delivery of health care services. In most cases, the district commissioners hire an administrator who is also appointed the superintendent and who is responsible for the direct management of the health care facilities operated by the district. But, the district may adopt one of the following alternatives in assigning this managerial responsibility:

• The district may choose to lease the entire district and maintain only a minimal involvement in the direct decisions on health care delivery.

• The district may engage a management firm to operate the facility under the board’s guidance. Under such an arrangement, the “administrator” is assigned to the district by the management firm and is the employee of that firm (although the person is chosen with input from the board).

• The district may hire an administrator who does not serve as superintendent, or may even hire administrators for the different facilities owned and operated by the district who are separate from the superintendent.

• The district may hire a part-time administrator (this may occur when the district only operates a clinic or ambulance service).

Practical Consideration
Obviously, the choice of management strategy carries with it different consequences in terms of the scope of direct control by the board and the links to the board in terms of reporting on operational details. Districts should assure that the management style is consistent with the expectations of the community and that it facilitates the ability to render health care services in an efficient and effective manner.