Physicians at each of the two 20-bed critical access hospitals, located in rural Utah, made persuasive arguments for why their facility should house the new 16-slice CT scanner. Those at Delta Community Medical Center, 130 miles southwest of Salt Lake City, pointed out that their hospital reached a larger service area, roughly 8,500 residents, twice the number served by Fillmore Community Medical Center. The physicians at Fillmore countered that their hospital sits along Interstate 15, and that brings in major trauma cases from traffic accidents.

It was a sensitive situation for Jim Beckstrand, who has been sole administrator of both facilities since 1992, and it underscores the challenges of running two hospitals that are located in the same county and are even part of the same system, Intermountain Healthcare, but that continue to root their identities—including sports rivalries—in towns 40 miles apart. "It's kind of like trying to parent a large family and keep all of the children happy," Beckstrand says. After considering all factors, Beckstrand and the board of trustees OK'd the scanner for Delta Community last year.

Welcome to a select club: Administrators who simultaneously lead two or sometimes three hospitals. They walk a tightrope, balancing the needs of each hospital and making decisions that may delight staff at one place and dismay those at another. They work with multiple sets of trustees, clock long hours and put excessive wear on their tires—all the while making sure they're always accessible to every facility in their charge. "I know where each cell tower stops and starts in this area of Georgia," quips Keith Petersen, the chief executive officer of three hospitals.

In interviews for this story, five hospital chiefs describe both the potential advantages and drawbacks of running multiple hospitals. On one hand, for instance, it can be easier to consolidate or share costly services and expertise, they say. On the other, temporary leadership gaps can emerge when an urgent matter erupts at one hospital and the person in charge is somewhere else.

"I believe there is no substitute for on-the-ground leadership," says Hoyt Skabelund, the administrator of two hospitals separated by 85 miles near the New Mexico-Texas border. "George Washington, through the radio, couldn't have inspired the troops at Valley Forge."

Bridging the Divide

Many of these hospital leaders work in rather remote—albeit picturesque—corners of the United States and must cope with the challenges that presents.

In far eastern Tennessee, the two hospitals that Fred Pelle leads can call on Wellmont Health System's helicopter service if a patient requires more specialized care. But bad weather and the mountainous terrain can make pickup unfeasible. So Pelle looks for a particular breed of emergency physician. "Our physicians have to be very comfortable with being decisive and making decisions without a lot of specialist support on-site," he says.

For some administrators, the challenge is even bigger: to bring a hospital back from the brink of closure—or beyond.

Petersen was already the chief executive of two hospitals in Southwest Georgia, part of the Phoebe Putney Health System, when he was asked to literally resurrect a third. After a tornado demolished 143-bed Sumter Regional Hospital in March 2007, the Americus community went without a hospital for 13 months, and since spring 2008, made do with a temporary facility.

In November, the same month Petersen was named Sumter's chief executive, ground was broken on a 76-bed, $125 million replacement hospital. For the foreseeable future, Petersen says his primary focus will be the new hospital—not just the bricks and mortar itself, but also replacing the experienced physicians and other clinicians who left the area following the tornado. That focus, he says, would not be feasible without on-site help at his other two facilities—a chief operating officer at 25-bed Southwest Georgia Regional Medical Center in Cuthbert and a long-time chief nursing officer at 25-bed Phoebe Worth Medical Center in Sylvester.

Some hospital leaders designate specific days they spend at each facility, typically devoting more time at the larger site. Others divvy up their schedules as needed. Beckstrand tried a set schedule, but that routine lasted maybe a month because, as he puts it, "Issues came up."

In all cases, running more than one hospital requires a huge amount of time. Craig Val Davidson, chief executive of two Utah hospitals located just south of the Intermountain facilities, says a typical week approaches 75 hours. "Administrators in a small community tend to work those hours," he says. "It's not in one clump—it's more like you are always working."

Designated Backups

To ease the strain, some hospital chiefs are grooming a designated on-site leader, a step that Skabelund wishes he'd taken sooner. Since 2008, Skabelund has managed two New Mexico hospitals in the not-for-profit Presbyterian Healthcare Services system, 106-bed Plains Regional Medical Center in Clovis and Dr. Dan C. Trigg Memorial Hospital in Tucumcari, a critical access hospital 85 miles away. The Trigg hospital is located on a major interstate, I-40, which runs from Texas through Albuquerque, N.M., and beyond.

Skabelund had managed Trigg Memorial previously, so he already knew many of the staffers. But he decided that he alone wasn't sufficient. Last summer, he hired MBA-credentialed nurse Barbara Connett to serve as an assistant administrator. She reports to him but provides a daily presence, and that's done wonders for morale, Skabelund says.

Connett says that an on-site leader can be there to praise clinicians and staffers, as well as to intervene when problems percolate and tempers flare. "Sometimes you need to be present, especially when there are a lot of emotions flying," she says. "When you are on the phone, you don't see people's expressions and you don't see their body language."

Linkages and Disconnects

In 2003, Milford Memorial Hospital was teetering on the brink of closure, Davidson says, when nearby 49-bed Beaver Valley Hospital assumed its management. Davidson, Beaver Valley's longtime chief executive, became chief executive of both hospitals.

To stay afloat, Milford obtained a waiver from the state to cut some services, such as obstetrics. The hospital also applied to become a critical access facility to help improve its finances. And the communities, located about 32 miles apart, put their locally entrenched rivalries on the back burner. "Milford was in dire need," he says. "They needed some solution to keeping health care in their community."

The two hospitals try to avoid duplicating services, wherever possible, Davidson says, echoing a point made by the other administrators. Physicians from the Beaver community, for example, now rotate through Milford's family medicine clinic.

The computer systems have been linked and, in 2009, so were the phone systems, enabling Davidson to dial an extension and reach anyone at either hospital.

In Tennessee, Pelle, president of the 50-bed Hawkins County Memorial Hospital in Rogersville and, since 2008, the 10-bed Hancock County Hospital in Sneedville, also has taken steps to expand links and crossover responsibilities between his facilities.

"We are trying to basically take the best of both teams and build a team with an expanded role," he says.

Pelle has broadened the role of the chief nursing officer at Hawkins County Memorial, giving her some oversight of clinical issues at Hancock County. The staffer who handled medical staff credentialing at Hancock now has responsibility for both facilities.

Doctors are automatically credentialed at both hospitals, so they can step in at a moment's notice, Pelle says.

At the same time, clinical processes are being standardized. Both facilities, for example, share a quality committee.

Beckstrand describes similar dual roles. Key employees, including a hospital pharmacist, an infection control nurse and a human resources staffer, work at both of his hospitals, traveling back and forth. But giving one director of nursing services oversight at both hospitals "failed miserably," he says. Nursing involves too many daily issues for there not to be a leadership director on-site, he says.

Docs and Boards

Settling physician concerns can become particularly dicey if a high-ranking administrator isn't on-site, according to several hospital leaders interviewed. Physicians prefer to go directly to the top. The temporary leadership gap at Trigg Memorial, prior to Connett's arrival, "allowed physicians to have more authority than might be healthy in some cases," Skabelund says.

Physicians prefer to talk face-to-face, Beckstrand notes. "Physicians won't call," he says. "If they have an issue, they will come right into your office and stand in the doorway. And so when you are not there, their frustration, it grows."

Frequently, running multiple hospitals means attending multiple board meetings. Each of the three hospitals Petersen leads has its own board. Plus, he attends meetings for Phoebe Putney Health System's board.

The two Intermountain facilities share a single board of trustees. While the trustees hail from different communities with some long-standing rivalries, through the years, the board members have developed a more united mindset, Beckstrand says, adding that "each time you bring a new board member on, the education and orientation process starts all over."

"It's about trying to take a logical approach," he says. "And basically say, 'Let's take a step back and look at what is truly for the best good of the entire county rather than one particular community.' If we work together, we will get to our goal. But it may not be in the same time frame that some may want."

The board members have no doubt what's at stake, given tight budgets and sometimes limited patient volumes. At Fillmore Community, the doors of the emergency department remain open around the clock. But some days physicians may only treat two or three patients, Beckstrand says.

Closing the ED and perhaps operating an urgent care-style center instead has been discussed in the past; it's not currently on the table, Beckstrand says, but "it's never been completely removed."

If emergency services are curtailed, residents facing a medical crisis would be forced to travel at least 40 miles, and possibly much further, for life-saving treatment.

Charlotte Huff is a medical writer in Fort Worth, Texas.