Every clinic, as it matures from birth to adolescence, reaches a point where the founding ED comes to a crossroads. Most founding ED's have a medical background - an RN, MD, LPN or something, and they are not only administering the clinic, they are also running the program, the actual medical clinic itself. They are doing triage, or seeing patients, or doing eligibility, or some sort of direct service.
At some point, these two diverse roles come into conflict with each other, as something has to give. My experience has been that the clinics that make a successful transition into a larger, more sophisticated clinics are those where their ED has made the choice to become the true 'Executive Director', the administrator of the clinic, and left go of the clinical/program work they were doing, giving that up to either paid staff or volunteers.
Clinics that I have seen struggling have almost consistently had an ED trying to straddle the fence, trying to serve both roles.
I would be interested in hearing other perspectives, but i believe the admin/program issue makes or breaks many a clinic...