• TABLE OF CONTENTS
HIDE
 Title Page
 Acknowledgement
 Table of Contents
 List of Tables
 Abstract
 Introduction
 Methodology
 Research results
 Summary, conclusions, and implications...
 Bibliography
 Biographical sketch














Title: Career patterns in health and hospital administration
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Permanent Link: http://ufdc.ufl.edu/UF00097649/00001
 Material Information
Title: Career patterns in health and hospital administration
Physical Description: x, 95 leaves. : illus. ; 28 cm.
Language: English
Creator: Wesbury, Stuart Arnold, 1933-
Publication Date: 1972
Copyright Date: 1972
 Subjects
Subject: Hospitals -- Administration -- Vocational guidance   ( lcsh )
Public health -- Vocational guidance   ( lcsh )
Management and Business Law thesis Ph. D   ( lcsh )
Dissertations, Academic -- Management and Business Law -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis--University of Florida.
Bibliography: Bibliography: leaves 90-93.
Additional Physical Form: Also available on World Wide Web
Statement of Responsibility: by Stuart A. Wesbury.
General Note: Typescript.
General Note: Vita.
 Record Information
Bibliographic ID: UF00097649
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000582663
oclc - 14158381
notis - ADB1041

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Table of Contents
    Title Page
        Page i
    Acknowledgement
        Page ii
    Table of Contents
        Page iii
        Page iv
    List of Tables
        Page v
        Page vi
    Abstract
        Page vii
        Page viii
        Page ix
        Page x
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
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        Page 11
        Page 12
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        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
    Methodology
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
    Research results
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
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        Page 69
        Page 70
        Page 71
    Summary, conclusions, and implications for further research
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
        Page 79
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        Page 83
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        Page 86
        Page 87
        Page 88
        Page 89
    Bibliography
        Page 90
        Page 91
        Page 92
        Page 93
    Biographical sketch
        Page 94
        Page 95
        Page 96
        Page 97
        Page 98
Full Text














CAREER PATTERNS IN HEALTH AND
HOSPITAL ADMINISTRATION

















by

STUART A. WESBURY, JR.











A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA
1972














ACKNOWLEDGEMENTS


The author wishes to express his appreciation to his

Supervisory Committee for their interest and support

throughout his doctoral program. The efforts of Dr. Wilmot,

Dr. Champion, Dr. Blodgett, and Dr. Fristoe, both in the

classroom and in the role of advisor and counselor, have

proven invaluable in so many ways.

A special word of appreciation is in order for Dr. John

Thornby who assisted the author in the statistical analyses.

His support was freely given and proved extremely valuable.

In addition, a large group of secretaries have provided

significant input toward the development of this disserta-

tion through the preparation of the many drafts and assis-

tance in data collection. Gail Jobe, Karen Harrell, Sarah

Weil, Jane Kelly, Vicki Dueber, and Lin Chen all struggled

hard to correct the author's mistakes and keep the project

on schedule. Their efforts are also sincerely appreciated.

Finally, the author must recognize sacrifices made by

his wife, June, and sons, Brian, Brent, Bruce, and Bradford.

It is obvious that these supportive family members have

suffered the most during the last three years of study and

research. Their sacrifice has made this study possible.








TABLE OF CONTENTS



Page

ACKNOWLEDGEMENTS . . . . . . . . . ii

LIST OF TABLES . . . . . . . . . . v

ABSTRACT . . . . . . . . . . . vii

CHAPTER

I. INTRODUCTION, LITERATURE SEARCH, AND STUDY
OBJECTIVES. . . . . . . . . 1

Introduction . . . . . . . . 1
Changing Patterns of Health Care. . . . 2
The Development of Careers in Health
Administration . . . . . . . 7
Education for Careers in Health
Administration . . . . . . . 13
Study Objectives. . . . . . .. 19
Hypotheses. . . . . . . . .. 23

II. METHODOLOGY . . . . . . . . . 25

Sample Selection. . . . . . . .. 25
Data Collection . . . . . . . 30
Data Analysis Procedure . . . . . 31
Group I Hypotheses . . . . . . 32
Hypothesis I-1. . . . . . 32
Hypothesis 1-2. . . . . .. 32
Group II Hypotheses. . . . . ... 33
Hypothesis II-1 . . . . . 33
Hypothesis 11-2 . . . . . . 33
Hypothesis 11-3 . . . . . .. 34
Group III Hypotheses . . . . . 34
Hypothesis III-1. . . . . . 34
Hypothesis III-2. . . . . .. 35
Hypothesis III-3. . . . . .. 36
Hypothesis III-4. . . . . .. 36

III. RESEARCH RESULTS. . . . . . . ... 38

Introduction . . . . . . . .. 38
The Results of Group I Hypotheses . . . 46
Hypothesis I-1 . . . . . . . 46
Hypothesis 1-2 . . . . . . . 49
The Results of Group II Hypotheses. . .... 49
Hypothesis II-1. . . . . . . 49








CHAPTER Page

Hypothesis 11-2. . . . . . .. 51
Hypothesis 11-3. . . . . . .. 54
The Results of Group III Hypotheses . . 54
Hypothesis III-i . . . . . . 56
Hypothesis III-2 . . . . . . 56
Hypothesis III-3 . . . . . . 65
Hypothesis III-4 . . . . . . 67

IV. SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR
FURTHER RESEARCH. . . . . . .. 72

Summary . . . . . . . . . 72
Introduction . . . . . . . 72
Hypotheses . . . . . . . 73
Methodology and Sample . . . . . 74
Statistical Analysis and Results . . 76
Hypothesis I-1. . . . . .. 76
Hypothesis 1-2. . . . . .. 76
Hypothesis II-1 . . . . . . 77
Hypothesis 11-2 . . . . . . 77
Hypothesis 11-3 . . . . . . 78
Hypothesis III-1. . . . . . 79
Hypothesis III-2. . . . . .. 80
Hypothesis III-3. . . . . .. 81
Hypothesis III-4. . . . . .. 81
Conclusions . . . . ........... 83
On the Educational Background of Health
Administrators Outside Hospitals. . 83
On the Impact of Graduate Programs in
Health and Hospital Administration
on Hospital Administration. . . . 84
On the Impact of Leveraging. . . ... 85
Implications for Further Research . . . 88

BIBLIOGRAPHY . . . . . . . . . . 90

BIOGRAPHICAL SKETCH. . . . . . . . .. 94








LIST OF TABLES


TABLE Page

1. Response to Mailed Questionnaires . . . 39

2. Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators (Characteristic
Tested Bed Size) . . . . . . 42

3. Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators (Characteristic
Tested Control) . . . . . . . 43

4. Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators (Characteristic
Tested Service) . . . . . . . 44

5. Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators (Characteristic
Tested Length of Stay) . . . . 45

6. Hypothesis I-1; Health Administrators without
Master's Degrees in Health Administration . 47

7. Hypothesis 1-2; Physicians without Master's
Degrees in Health Administration. . . . 50

8. Hypothesis II-l; Proportion of Hospital
Administrators Possessing a Master's
Degree in Health Administration . . . 52

9. Hypothesis 11-2; Years of Age Comparisons-
Hospital Administrators . . . . . 53

10. Hypothesis 11-3; Appointments to Position
of Hospital Administrator . . . . . 55

11. Hypothesis III-l; Leveraging Among
Employment Categories . . . . . . 57

12. Hypothesis III-1; Persons Employed in More
Than One Study Category . . . . . 60

13. Hypothesis III-2; Frequency of Leveraging
Among Hospital Administrators . . . . 63







TABLE Page

14. Hypothesis III-3; Frequency of Leveraging
Back to a Previous Employer Among
Hospital Administrators . . . . . 66

15. Hypothesis III-4; Tenure Comparisons -
Hospital Administrators . . . . . 68








Abstract of Dissertation Presented to the Graduate
Council of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy




CAREER PATTERNS IN HEALTH AND
HOSPITAL ADMINISTRATION







by

Stuart A. Wesbury, Jr.

August, 1972



Chairman: Dr. William V. Wilmot, Jr.
Co-Chairman: Dr. John M. Champion
Major Department: Department of Management and Business Law




Introduction


Since 1900, significant changes have occurred in the

health care system. Patient care has been transformed from

a primarily physician-patient relationship to a complex

relationship involving the patient, physicians, other allied

health personnel, and health organizations. These major

changes in the delivery of health care have been accompanied

by increasing need for administrative leadership in organi-

zations. In the early 1900's, physicians and nurses were

looked to for the provision of the necessary leadership.

However, as the developing organizations became more


vii







complex, leadership needs could not be filled in this

manner. In 1934, the first graduate program in health ad-

ministration was established by the University of Chicago.

Since that time, more than 30 additional graduate programs

have been established.

This study was designed to investigate the impact of

such graduate programs on the field of hospital administra-

tion and to study the continued involvement of physicians

in the administration of certain types of health programs.

Several prior studies revealed the variety of employment

situations currently filled by program graduates. However,

little attention seems to have been paid to examining wheth-

er such graduates are filling the top administrative po-

sitions in such organizations. Also, in view of growing

concern about employee loyalty to his employer, this study

investigated several aspects of corporate loyalty.



Health Administrative Positions Studied


Educational and employment backgrounds of the adminis-

trators of the following health organizations were studied:

a) Hospital administrators

b) Blue Cross chief executives

c) Comprehensive health planning area-wide directors

d) Regional Medical Programs directors and adminis-
trative officers

e) State health department directors

f) Other state agency directors








g) U. S. Department of Health, Education and Welfare
health-related executives

h) Hospital association directors

i) Miscellaneous health organization chief executives

j) Medical group practice administrators



Results and Conclusions


Graduates of programs in health administration were

found not to occupy more than 20 per cent of the health

leadership positions outside hospitals. In addition, phy-

sicians, without master's degrees in health administration,

were found to occupy not less than 50 per cent of the

leadership positions in state and federal health-related

non-hospital programs.

In the last 11 years, the proportion of persons with

master's degrees appointed to hospital administrator posi-

tions has not increased. Also, the proportion of hospital

administrators with master's degrees did not demonstrate a

direct increasing relationship with increasing hospital size.

Hospital administrators with master's degrees tended to be

younger than those without such a degree.

Health administrators tended to maintain their employ-

ment in only one health administrative employment cate-

gory. However, most health administrators were found to

have had more than one health employer,with administrators

having master's degrees in health administration demons-

trating more employment changes than those without such







degrees. Even though many employment changes were noted,

few hospital administrators were found to have returned to

a former employer having once served that employer in an

administrative position. Length of tenure in hospital ad-

ministrative positions was found to vary from 4.0 years to

5.4 years in previous positions and from 3.9 to 9.9 years in

current positions. Hospital administrators with master's

degrees in health administration tended to demonstrate

shorter tenure than those without such a degree.














CHAPTER I

INTRODUCTION, LITERATURE SEARCH,
AND STUDY OBJECTIVES



Introduction

Interest in careers in health administration is not a

new or temporary hobby with this author. A close attachment

with various segments of the nation's health care industry,

extending back more than 20 years, has created for him a

continuing and growing interest in those occupying, or pre-

paring to occupy, health leadership positions. This period

of time has seen a significant increase in the devotion of

the nation's resources to health care and has also seen a

growing interest on the part of many persons and organiza-

tions, including the federal government, in how the system

functions and how it might be made to function more effi-

ciently and more effectively. The pages that follow will

document these changes and, more specifically, will take a

look at those persons who occupy positions of leadership in

health administration. It is felt that such a study will

prove useful to several groups of people. First, existing

health administrators should be able to learn more about

those with whom they associate, as peers, in their normal

working activities. Such knowledge should provide a







better understanding of points of view and provide greater

appreciation for individual backgrounds. Second, programs

of academic instruction at all levels might be provided with

specific information related to career development. Such

information might lead to curriculum alteration as well as

improved counseling of students working toward a career in

health administration. Third, individuals planning careers

in health administration might find such information valu-

able as they plan their educational and employment programs.

It is felt that knowledge of what others have done before

them could provide appropriate direction and possibly stim-

ulus to those interested in health administration careers.

It is with these goals in mind that this research

project was initiated.



Changing Patterns of Health Care


Health care in the United States in the twentieth cen-

tury is characterized by significant change. As described

by Dr. Sidney Garfield, in 1900 only the very sick received

physician care and, if hospitalization was required, limited

nursing care provided the full spectrum of services avail-

able to that patient. Health care was essentially a person-

to-person service and patient contacts with organizations

existed only when hospitalization was required (1).

By 1935, the health picture had grown more complicated.







The field of medicine was adopting a more specialized ap-

proach to patient care and new paramedical roles brought

increasing numbers of new personnel into the health care

process. New and expanded use of diagnostic and treatment

services added a great deal of complexity to the health

care system. Sophistication of anesthesia techniques and

the development of antibiotics greatly increased the demand

for hospital services and made many operative and treatment

procedures possible (2). From 1935 to date we have seen an

acceleration of this process of change with more and more

medical specialities evolving and much greater dependance

upon the use of ancillary personnel to assist the physician

(1). Throughout this process, organizations have taken a

more important role in the provision of health services.

The proliferation of ancillary personnel has necessitated

a high level of coordination among these personnel (3).

Thus, the patient has found himself more dependent upon

groups of professionals and institutions such as hospitals

and less upon face-to-face contact with his individual

physician.

Along with the increased complexity of the health care

delivery system, the financing of health care has undergone

significant change (4). In the early 1900's, patients

paid physicians directly for services rendered and, if

hospitalization was required, it often occurred in a

charitable institution without charge to the patient. It

should be remembered that the patient usually wanted to be








treated at home because the hospital was essentially a place

to die rather than a place to find a cure for illness (2).

As services expanded and new techniques developed, the

hospital became far more popular as a source of treatment.

With this increased utilization, the charitable nature of

hospitals slowly disappeared and routine billing of patients

was initiated. This process promoted the creation of Blue

Cross/Blue Shield and health insurance programs to assist

the patient to pay for the rapidly expanded services pro-

vided by the health care system. Today, this system is

financed by a great variety of sources including individual

patients, Blue Cross/Blue Shield, insurance companies,

philanthropy, and government at all levels (5). In 1970,

7.0 per cent of the nation's gross national product was

devoted to health, while in 1950 only 4.6 per cent of the

gross national product was so devoted (5). Today, the

health care system is the third largest industry in the

United States (6).

In addition to these many changes in our health care

system, there has been a drastic change in our attitudes

concerning a person's "right" to receive health care.

Whereas in the early 1900's, health care was either paid

for by the patient or, hopefully, provided by charitable

means for those unable to pay, today health care has

emerged in the minds of many, as a "right" to be provided

for all citizens without regard to their ability to pay

(2,7). As such, health care has become a major political








topic which has certainly added to complexity of the health

care system. However, though increased in intensity, this

political interest is not new. In fact, Theodore Roosevelt

in his presidential platform in 1912 made national health

insurance one of his major planks (7). Eventually, this

concept reached fruition in the form of Medicare legislation

in 1965. With the broad array of federal health programs

including such programs as the Hill-Burton hospital construc-

tion program, Medicare, Medicaid, armed forces health ser-

vice programs, research support and educational programs,

the federal government's investment in health is already at

the level of over 30 per cent of all money spent for health

care and associated health activities in this country (8).

However, in spite of this dramatic participation in the

health care system, it appears that more federal government

participation is in the offing. At the present time there

are numerous bills before Congress that would affect changes

in the federal government's involvement in the health care

system (9). For example, the Kennedy-Griffiths bill would

totally restructure our health care system and essentially

nationalize all health care delivery in this country. On

the opposite end of the spectrum, the American Medical

Association's "Medicredit" proposal provides for little

system change but improves the ability of the individual

to pay for his care through tax credits. Essentially,

all other proposals fall between these two extremes.

With the forthcoming presidential election, these many








proposals will be discussed and altered before Congress

commits itself to one proposal or another, if any. However,

the consensus seems to be that the nation will see the

adoption of some proposal, on a national scale, which will

broaden the health benefits now available to many Americans

and also affect the way in which health care is delivered

(9).

President Nixon's administration is currently favoring

the adoption of the concept of the "health maintenance

organization" (HMO) (10). This concept is essentially

patterned after the Kaiser-Permanente system operating pri-

marily in the western portion of the United States which has

demonstrated that comprehensive care, functioning under a

prepayment mechanism, may be provided at a lower cost, at

least for the selected populations involved (10). As of

December 31, 1971, 46 grants for HMO planning and develop-

ment were awarded by the Department of Health, Education,

and Welfare (11). Thus, even without the passage of pending

legislation, the government is becoming still further in-

volved in the provision of health care through the mechanism

of the development of the HMO.

As can be seen by the above discussion, the current

health care system differs in many aspects with the provi-

sion of health care just 20 years ago. For the health

administrator, the key point seems to be the movement away

from person-to-person health care to person-to-organization

health care. As a result, more attention has been and will








have to be paid to appropriately administrating the various

agencies and organizations providing such health care. For

the field of health administration, this appears to be one

of its greatest challenges (3).



The Development of Careers in
Health Administration


Careers in health administration have essentially

paralleled the increasing complexity in the provision of

health care. In the early 1900's, little need existed for

health administrators since virtually all care was provided

on a person-to-person basis and relatively little use was

made of organizations other than hospitals. Even the use of

hospitals was severely restricted and the limited services

offered as well as the charitable financing structure

created little need for sophisticated health administrators

(12). Essentially, physicians and nurses provided the

necessary institutional leadership for hospitals as well as

for those few health organizations existing outside of hos-

pitals at this point in time (13).

The first major thrust in the development of health

administration came in the early 1930's and primarily in-

volved hospitals. The increased use of hospitals, as noted

above, and the increased complexities in the financing of

hospital care demonstrated that using physicians and nurses

in administrative capacities was inadequate to the needs of

the institution (12). Where physicians and nurses retained








the overall control of hospitals, the position of business

manager was frequently created in order to have someone on

the administrative staff competent to handle these newly

developing problems (12). In 1932, the National Committee

on the Cost of Medical Care offered a significant recommen-

dation. The Committee report stated:

Hospitals and clinics are not only medi-
cal institutions, they are also social and
business enterprises, sometimes very large
ones. It is important, therefore, that they
be directed by administrators who are trained
for their responsibilities and can understand
and integrate the various professional, eco-
nomic, and social factors involved. If the
Committee's recommendations regarding com-
munity medical centers and local and state
coordinating boards are realized, there will
be a demand for medical statesmen of high
order. Definite opportunities should be pro-
vided, either in universities or in institu-
tes of hospital administration connected
with universities, for the theoretical and
practical training of such administrators.
The administration of hospitals and medical
centers should be developed as a career
which will attract high-grade students (14).

Within two years after this report, one of the Com-

mittee members, Michael M. Davis, founded the Graduate Pro-

gram in Hospital Administration at the University of Chicago

(15). This committee's recommendation, the creation of a

graduate school for hospital administration, and the general

needs of the time, essentially created the environment for

the birth of health administration.

The movement to lay administrators in hospitals has

been slow but steady. As will be demonstrated in the next

section of this chapter, the educational output of graduate








programs was very small in the earlier years but has now

reached much higher levels. However, the search for hos-

pital administrators has included more than just program

graduates but, more dependence is being placed on formal

educational programs (16).

Hospitals have not proven to be the only area in the

health care industry requiring a development of administra-

tors. For example, the birth of Blue Cross and the proli-

feration of Blue Cross programs throughout the country

opened up a large potential for health administrator roles.

In addition, the increased importance of hospitals and the

increased cost of running such institutions created the need

for area, state, and nationwide associations to assist hos-

pitals to explore common problems. Increased involvement of

government at all levels in health care has also created

many new roles in health administration. City, county, and

state programs all require leadership as well as large staff

groups to plan, implement, and review programs. Programs

within these governmental levels vary considerably and range

all the way from purely public health type measures to the

actual provision of health services for large segments of a

population for both indigents and non-indigents. In

addition, groups of health professionals have banded togeth-

er and many have hired executive directors who have been

experienced administrators or have demonstrated exceptional

leadership talents. In summary, there is an impressive

array, both in numbers and kinds, of administrative roles







available in the health field (4,17).

From a broader view point, our country has had a con-

tinuing interest in the area of public health. In 1948, the

American Medical Association defined public health as,

The art and science of maintaining, protecting
and improving the health of the people through
organized community efforts. It includes those
arrangements whereby the community provides
medical services for special groups of persons
and is concerned with the prevention or control
of disease, with persons requiring hospitali-
zation to protect the community and with the
medically indigent (18).

Public health efforts were initiated and carried out under

the auspices of local, state and federal government pro-

grams and had considerable impact on increasing longevity

and providing a healthier population (18). By 1964, approx-

imately 70,000 persons were employed by state and local

health departments (19). This large number of personnel

were responsible for a wide variety of duties related to

the improvement of the health of citizens throughout the

country. Many of these persons served in administrative

roles and were responsible for the supervision of projects

and personnel within their respective programs.

Throughout the development of these many careers, many

changes have been seen in the role of the respective admin-

istrator. In hospitals, for example, the original role

was essentially that of administering the internal affairs

of the institution. The physician primarily determined

what services should be provided and the administrative staff

then worked to satisfy these needs. However, today we








find the role of the hospital administrator expanded to in-

clude much community involvement (20). With the growing

dependence upon organizations for the delivery of health

care, the hospital administrator takes on new significance

in his own community. He is looked to as one who can re-

commend new patterns of care and organization for care (21).

In many communities, this role is difficult to carry out

because of its break with tradition. Walter McNerney has

identified the person occupying this role as a "Health Care

Statesman" (22). The presence of such a person in the

community, who is in position to recommend, encourage and

help implement change in health delivery systems, is a re-

latively new phenomenon. However, the noticeable trend to-

ward the clarification of the chief administrative role in

a hospital as "president" or "executive vice president" is

identification of the fact that the boards of trustees have

recognized this expanded role and are attempting to identify

the administrator as one who is responsible for extending

beyond the institution and involving himself in the total

health care delivery care system of the community (23).

Another complicating factor in the community is the de-

velopment of health care as a "right." There are many com-

munities still clinging to a "dual standard" of care and they

have attempted to maintain separate systems depending on the

individual's ability to pay. The broadening of national

health care plans, such as Medicare and Medicaid, have de-

monstrated in many areas that we should be working toward







one inclusive system of care involving all persons in the

community rather than defending and maintaining segmented

programs. Often, the presence of a hospital in a community

represents the only organization providing care for the

broad segment of a community's population (7).

The many changes still anticipated in the health care

system will carry with them additional roles in health

administration. Although we cannot identify the nature of

these roles at this point in time, it is safe to assume that

they will continue to broaden the overall aspect of health

administration since they will involve leaders far beyond

the confines of the institution's walls and attempt to in-

corporate the needs of the entire community, or at least

large segments of the community, in a rational plan for the

delivery of health care (21).

Numerous other roles in the health administrative

sector have been identified and currently provide a source

of employment for many individuals. Examples are consulting,

teaching and research, medical group practice administration

and extended care facility administration (19).

Some of the more recent federal programs have opened

up additional opportunities in health administration. The

Comprehensive Health Planning Act (P.L. 89-749) has placed

new emphasis on the important role of planning in a commu-

nity. The role of planning in a community has been seen as

a very important function and the federal government has

devoted itself to the development of this vital role in the








health care program of communities (24). Another federal

effort, Regional Medical Programs (P.L. 89-239), has pro-

vided significant opportunities for health administrators.

In this program, efforts have been devoted to shortening the

time between the discovery of new treatment and diagnostic

techniques in the area of heart disease, cancer and stroke

and the actual implementation of these new techniques in the

field. Significant leadership has been needed in this area

because of the involvement of so many diverse groups over

large geographic areas. These programs offer significant

potential for the expansion of health services and improve-

ment of health services throughout the nation (25).



Education for Careers in
Health Administration


The first program in health administration to be estab-

lished and to admit students was at Marquette University

(26). In 1924, a college of Hospital Administration was

created at Marquette. This program continued until 1928

having awarded only two degrees. No new academic ventures

in health administration were attempted until Michael M.

Davis initiated a graduate program at the University of

Chicago in 1934 (17). It is interesting that Mr. Davis was

a member of the Committee on Cost of Medical Care that re-

commended, in 1932, that academic programs be established to

train administrators for hospitals and clinics. Another

long period elapsed before the second graduate program was








established in 1943 at Northwestern University (27). Be-

ginning in 1945, new programs began to appear on the aca-

demic scene with some degree of regularity and in 1971, 33

graduate programs held either full or associate membership

in the Association of University Programs in Hospital Admin-

istration (AUPHA) in North America (28). These 33 programs,

along with several discontinued programs, have already grad-

uated 6,839 students, 613 of these receiving their degrees

in 1970. Current enrollment in graduate programs indicates

that about 800 graduates per year can be expected from

these programs by 1972. It was known, in 1971, that several

additional universities were planning graduate programs in

health and hospital administration and that several univer-

sities and/or colleges had already established or were

planning undergraduate programs in the field (29).

As early as 1910, degrees in public health were offered

by universities in the United States. While many pursuing

such degrees were not candidates for administrative posi-

tions, many persons in or seeking public health administra-

tive roles sought such educational programs (18). In the

academic year 1968-69, 1,381 master's degrees in public

health were awarded (19). No estimate is available of the

number of those graduates who are or will be seeking admin-

istrative positions. If only 200 such graduates assume

administrative positions, when added to the anticipated

output of graduate programs in health administration, more

than 1,000 master's level graduates will be seeking health








administrative positions each year by 1972.

A very interesting phenomenon can be observed in re-

viewing the history of graduate programs in health and

hospital administration. This phenomenon relates to the

broadening of the educational objectives of the programs

from the education of potential hospital administrators

to the education of health administrators (30). This

change, in one program (Iowa) reflected "the premise that

the interest of its graduates should embrace all elements

of the health care industry and not just the hospital" (31).

In 1959, all but one of the 17 existing programs used the

phrase, "hospital administration" with no broader term in

their title and/or offered the master's in hospital admin-

istration degree (27). Ten years later, in 1969, nine of

the 28-AUPHA member programs included the phrase "health

administration" or some similar phrase, in place of, or in

addition to, "hospital administration" (32).

One of the interesting debates in the field has con-

cerned the appropriate academic setting for graduate pro-

grams. In 1948, the Joint Commission on Education issued a

report entitled The College Curriculum in Hospital Admin-

istration (Prall Report) (33). This report stated that

schools of public health were the appropriate academic

setting for graduate programs. In contrast to this, in

1954, the report of the Commission on University Education

in Hospital Administration entitled University Education

for Administration in Hospitals (Olsen Report) recommended







that such graduate programs be founded in business schools

(4). Neither of these recommendations was followed in full

and, as a result, the 33 programs affiliated with the AUPHA

are found in the following academic settings (28):

In schools of public health 11

In graduate schools of business and/or 8
public administration

In graduate schools 4

In schools of medicine 3

Joint business and health-related professions 2

Joint medicine and business 1

Joint medicine and graduate college 1

In school of allied health professions 1

Joint medicine, business and public 1
administration

In school of community and allied health 1
resources


Total 33

Though multiple settings seem to exist, the field of

health and hospital administration appears to accept master's

degrees from any of the various settings as the essential

equivalent and graduates from all programs are usually

classified under the general heading of "program graduates'

(18).

The broadening of educational objectives seems to have

occurred after the recognition that many graduates were

accepting positions in the health field outside of hospital

administration. For example, in 1954, it was reported in








the Olsen Report that,

As of January 1, 1953, more than 76 per cent of the
persons completing graduate work in programs in hos-
pital administration since their inception in 1934
have remained in hospital work. The remaining 24 per
cent have, for the most part, removed themselves to
administrative endeavors in peripheral fields of
activity (4).

The Olsen Report further identified the peripheral

fields as:

Voluntary agencies
Governmental, non-federal agencies
Federal agencies
Military
Consultation and research
University programs in hospital administration
Clinics
Blood banks
Prepayment plans
Hospital supply business
Own business
Foreign

Summarizing the occupational fields of graduates of

university programs in hospital administration, the Olsen

Report revealed the following employment pattern for 842

graduates:

Hospital administration 76.1%
Peripheral fields 16.1%
Miscellaneous 7.7%
Total 99.9%

(Total does not equal 100% due to rounding error)

A study published eight years later, 1962, showed the

following employment pattern for 3,120 graduates (19):

Administrator 70.9%
Allied health fields 21.5%
Miscellaneous 7.6%
Total 100.0%

As part of this author's research project, in 1971, the








employment pattern of 3,165 graduates was studied revealing

the following:

Hospital administration 70.4%
Non-hospital health fields employment 16.1%
Other or unknown employment 13.5%
Total 100.0%

Unfortunately, direct comparison of the results of each

study cannot be made because of methodological differences

among the studies. However, in each study, the large number

of graduates (about one out of five) employed in non-

hospital but health-related fields, underlines that program

graduates are entering health related fields outside hos-

pital administration.

In summary, education of health administrators has

changed greatly over the years. Programs have expanded cur-

riculums to prepare students for administrative positions in

more than just hospitals and surveys have demonstrated that

their graduates are now serving in a wide variety of admin-

istrative roles outside hospitals. Though these changes

have been widely discussed, it has been noted that,

The last major study of hospital administration
education in the U.S. and Canada was the Olsen Report
in 1954. As I reported to you last year, there
has been growing interest in a new and more
thorough examination of the entire administration
education field (29).

This statement, by the executive director of the AUPHA,

indicates that much more must be known about the educational

needs for health administration.








Study Objectives


While much attention has been paid to the role of pro-

gram graduates in hospitals, much less attention has been

paid to the role of program graduates in organizations out-

side of hospitals. Also, while the studies mentioned above

indicate that approximately 20 per cent of program graduates

are in health organizations other than hospitals, it is not

known whether such graduates are occupying the top leader-

ship position in those organizations. If the program grad-

uates are not occupying these positions, what is the edu-

cation and/or experience background of those persons oc-

cupying the top leadership positions outside hospitals?

Examination of directories of health-related organizations

and agencies had led this author to believe that the vast

majority of top leadership positions are not occupied by

program graduates and that most governmental agencies and

programs utilize physicians in these positions. Thus, a

part of this study will be devoted to examining the career

patterns of those persons occupying the top leadership po-

sitions within and outside of hospitals. This study should

provide information which will aid in the determination of

potential curriculum changes in graduate education as re-

lated to the basic objectives of graduate programs. The

hypotheses of Group I are directed toward these questions.

A second major area of study will be that of the de-

termination of impact of graduate programs on hospital







administration (Group II hypotheses). This subject has re-

ceived attention in the past but it is felt that available

information is outdated and interesting comparisons can be

made with the older data. For example, in 1959, Richard L.

Johnson stated, "By 1970, with the exception of small rural

hospitals, the curve indicates that it may be virtually im-

possible for non-course persons to enter the field of hos-

pital administration" (18). The question to be raised is,

"To what extent is this true?" One national hospital execu-

tive search consultant in personal discussion with this

author stated that many boards of trustees are considering

non-course persons for employment in top hospital adminis-

trative positions in large hospitals. This is especailly

true when the hospital involved has a specific problem

(e.g., financial difficulty) and a specific skill (e.g.,

financial management) is deemed desirable (34). In fact,

this consultant frequently includes a non-course person in

the final group of recommended applicants for a position if

he has been able to identify such a specific need. It is

not the purpose of this study to contrast the hospital em-

ployment patterns in rural and urban areas. However, it is

proposed that hospital employment patterns be studied in

relationship to bed size, age of the administrator and edu-

cational background of the administrator.

The third major segment of this study (Group III hypo-

theses) will be devoted to an analysis of the impact of

leveraging on career patterns in health administration.








Leveraging is a term used to mean the act of changing jobs

from one corporation (specific employer entity) to another.

A study in 1965 indicated that the median tenure in hospital

administrative positions for program graduates was 3.5 years

while non-program graduates had a median tenure of 7.5

years (35). Thus, it can be readily seen that hospital ad-

ministrators, as a group, experience many job and employer

changes during their careers. In non-health related em-

ployment areas, this job changing pattern has been exten-

sively studied, particularly among the large corporations of

the nation, with the conclusion that, "there seems to be a

shift in prime loyalties from the firm to the career" (36).

Jennings, an active researcher in this area, has devised a

new discipline that he calls "mobilography" as a means of

studying the mobility patterns of managers and executives

(37). His examination of the trend toward increased mobi-

lity has led him to the conclusion that, "... by 1970 every

(corporation) president will have leveraged at least once,

and 60 per cent will have leveraged twice." It is proposed

that this conclusion be tested among those holding the top

administrative position in hospitals. Associated with this

aspect of leveraging is the question of an administrator

returning to employment status with a former employer. If

career versus employer loyalty is an issue, will a former

employer invite an administrator back to employment? Thus,

it is proposed to investigate this question.

Returning to the tenure issue, it is proposed that this








be studied by comparing the tenure of program graduates and

non-graduates to determine if the 1965 study results, stated

above, still hold.

The last hypothesis in this group is designed to in-

vestigate the mobility, or lack thereof, of administrators

among various employment categories. While it is noted that

tenure is short in hospital administrative positions, does

this mean that administrators are simply moving from one

hospital to another or are they moving among and back and

forth among the several health related employment oppor-

tunities? No information has been found on this subject by

this author to date. Thus, it appears that this question

has received little or no attention. Research in this area

should identify the opportunity, or lack of opportunity, as

indicated by past experience, to move freely among the

several health related employment opportunities. This area

of study may also reveal the success, or lack thereof, of

graduate programs in preparing their graduates for moving

freely among the various employment opportunities.

The need for effective health administration in our

nation's health organizations cannot be over-emphasized.

The large segment of our gross national product that is de-

voted to health care itself demands a high priority for such

study. While this study does not have the broad scope of

the Olsen Report, it does address itself to many of the

issues included in that report and could provide information

currently lacking in the health administrative field and








provide base line information for other studies that may be

initiated in the future. Thus, this study would be a par-

tial response to the need expressed by the executive direc-

tor of the AUPHA as mentioned above.



Hypotheses


As stated above, the hypotheses have been combined to

form three groups, each group focusing upon one basic topic.

Group I Educational backgrounds of health adminis-
trators outside hospitals

1) Graduates of master's programs in
health administration occupy 20 per
cent or more of the health leadership
positions outside hospitals.

2) Physicians without master's degrees in
health administration fill the minority
of top administrative positions in
federal and state government agencies
and Regional Medical Programs.

Group II Impact of graduate programs in health
administration on hospital administration

1) The larger the hospital, the more
likely the administrator possesses a
master's degree in health administra-
tion.

2) There is no difference in the average
age of hospital administrators with
master's degrees in health administra-
tion as compared to hospital adminis-
trators without such a degree.

3) Each year, starting in 1960, the per-
centage of persons with master's
degrees in health administration
appointed to the top administrative
positions in hospitals has not changed.

Group III Impact of leveraging




24



1) Leveraging, when it occurs, will
usually take place within a given ca-
tegory of the employment (e.g., among
similar employers), rather than among
various categories (mobility is pri-
marily limited to within a specific
category of employment).

2) All hospital administrators have lever-
aged at least once and at least 60 per
cent have leveraged two or more times
from previous administrative positions
in hospitals.

3) Less than 1 per cent of the hospital
administrators surveyed leveraged back
into a hospital with which they were
previously associated in an adminis-
trative position.

4) There is no difference in the tenure
of those in hospital administration
positions between those administrators
possessing master's degrees in health
administration as compared to those
without such a degree.














CHAPTER II

METHODOLOGY




Sample Selection


The health administrators selected for this study fell

into the following employment categories:

a) Hospital administrators

b) Blue Cross chief executives

c) Comprehensive health planning area-wide directors

d) Regional Medical Program directors and administra-
tive officers

e) State health department directors

f) Other state agency directors

g) U. S. Department of Health, Education and Welfare
health-related executives

h) Hospital association directors

i) Miscellaneous health organization chief executives

j) Medical group practice administrators

With two exceptions, the above list was derived from

the August 1, 1971, Guide Issue of the American Hospital

Association (38). The Guide Issue was utilized as the basis

of category selection because of its coverage of a large

number and wide variety of organizations and agencies di-

rectly involved in the health of the nation. The inclusion








of Regional Medical Program administrators and medical group

practice administrators was based upon the growing influence

of both of these groups upon the delivery of health care in

this country. Regional Medical Program activities now span

the entire country and involve the efforts of a wide variety

of health personnel. This federal program is aimed at im-

proving the health care of persons suffering from heart

disease, cancer, and stroke. Also, the federal government

has promoted the group practice of medicine (39) and en-

couraged the establishment of health maintenance organiza-

tions (HMO's) as part of an effort to provide more compre-

hensive health care for the population of the country. Thus,

administrators in both types of organizations should serve

in increasingly important roles.

Compared with previous research of this author which

identified the nature of the employment of graduates of

selected AUPHA member programs, the following health-related

employment categories were not included in this study:

a) Graduate program in health administration faculty

b) Local (non-federal and non-state) officials not
involved in hospital administration

c) Consultants

d) Educational administrators

e) Other academic/research personnel

f) Extended care facility administrators

The exclusion of the above six groups represents less

than 7.5 per cent of all health-related employed graduates

of the selected AUPHA member programs. Specifically, the








only persons in these groups that could be identified as

administering health service organizations would be found in

the local government agencies and in extended care facility

administration. Together, these two groups represented less

than 1.4 per cent of the total.

The determination of sample sizes and the selection of

each sample were accomplished as follows:

a) Hospital administrators: 7,280 hospitals were

listed in the Guide Issue. It was determined that

a 10 per cent sample of this group would be chosen.

Considering the number of hospitals, generaliza-

tions could be made for this group through the use

of an appropriately selected 10 per cent sample.

The 728 hospitals were selected by random sampling

after numbering the list of hospitals in the Guide

Issue from one to 7,280. The hospitals appeared in

alphabetical order by city or town within an alpha-

betical ordering of the states. Selection of

specific hospitals was accomplished by taking con-

secutive numbers from a random sample table until

728 hospitals were identified (40). The names of

the hospital administrators of each of the hos-

pitals so selected by the random process were then

checked to determine those affiliated with American

College of Hospital Administrators. Biographical

information for such persons was obtained from the

Directory of the American College of Hospital








Administrators (41). For the remainder, question-

naires were sent to obtain the necessary informa-

tion.

b) Blue Cross chief executives: Questionnaires were

sent to all chief executives of Blue Cross Plans.

At the time of the study, the total number was 74.

c) Comprehensive health planning area-wide directors:

Questionnaires were sent to all comprehensive health

planning area-wide directors. At the time of the

study, such persons numbered 173.

d) Regional Medical Program directors and administra-

tive officers: Questionnaires were sent to all

Regional Medical Programs. The Directory of State,

Territorial, and Regional Health Authorities, 1970

(42) was utilized to obtain mailing information.

Fifty-four specific agencies were listed. Ques-

tionnaires were sent to all agency directors and

to the chief administrative officer reporting to

each director.

e) State health department directors: Questionnaires

were sent to all identified state health depart-

ment directors who numbered 47 at the time of the

study.

f) Other state health agency directors: Question-

naires were sent to all other state health agency

directors identified in the Guide Issue. At the

time of the study, these numbered 312.








g) U. S. Department of Health, Education and Welfare

health-related executives: In order to limit the

study to appropriate executives in this category,

the researcher contacted the Interim Deputy Admin-

istrator for Prevention and Consumer Services of the

United States Public Health Service. This officer

was known to the researcher and after discussing

the purpose and scope of the project, he was able

to identify those federal executives who filled

positions essentially comparable with those being

studied in other agencies and organizations. The

list he provided included 50 such officials.

Questionnaires were sent to all.

h) Hospital association directors: Questionnaires

were sent to all hospital association directors

listed in the Guide Issue involved in both state-

wide and metropolitan associations. Seventy-nine

such persons were identified at the time of the

study.

i) Miscellaneous health organizations: From the Guide

Issue's list of international, national, and re-

gional associations, 26 persons were identified as

chief executive officers of associations involved

with health administration. Questionnaires were

sent to all.

j) Medical group practice administrators: From the

International Directory of the Medical Group








Management Association (43), listing 790 members,

a 10 per cent sample was selected in the same

manner as for hospital administrators as noted

above. This resulted in sending 79 questionnaires.

The above categories included the agencies and organiza-

tions employing more than 92 per cent of all graduates of

selected AUPHA member programs. Also, it included all health

delivery related organizations listed in the Guide Issue and

excluded only those directly involved with a specific health

discipline or licensure program. With the exception of hos-

pital administrators and medical group practice administra-

tors, 100 per cent of all persons listed in such health ad-

ministrative roles were sent questionnaires. In the case of

hospital administrators and medical group practice adminis-

trators, a 10 per cent sample of each group was selected

for study.



Data Collection


The data used for the study were derived from published

biographical listings in the Directory of the American

College of Hospital Administrators or from returned ques-

tionnaires providing the appropriate biographical infor-

mation. Specific information sought for each individual

was as follows:

a) Year of birth

b) Education (for each degree earned post-high school)








1) Degree

2) Institution awarding degree

3) Date degree awarded

c) Employment (for each employer and/or position
change)

1) Title

2) Organization type

3) Dates of employment

4) Bed size (if hospital 1960 to date)

d) Status in American College of Hospital Administra-
tors (only for those identified as hospital admin-
istrators.)

Seeking only the above information allowed for the de-

velopment of a relatively simple questionnaire and cover

letter. Simplification of the questionnaire was desirable

in order to encourage response from those sent the question-

naire. The envelopes were addressed to the individual

filling the specific role and the questionnaire itself

included the person's name written in the appropriate space

along with a code number to simplify the recording of in-

formation. Also included in the mailing was a stamped

self-addressed return envelope. Thus, each questionnaire

was personalized for the individual intended to receive it

in order to assure maximum response.



Data Analysis Procedure


The data analysis will be discussed in the same order

as the hypotheses were previously presented. In all cases,








statistical significance at the level of 5 per cent or less

was required to accept or reject hypotheses.

Group I Hypotheses: Educational backgrounds of health ad-
ministrators outside hospitals.

This group of two hypotheses was intended to identify

the proportions of health administrators in specific groups

who held master's degrees in health administration. Such

information would test the impact that such graduate pro-

grams have had on the field of health administration outside

hospitals. The determination of the number of persons with

and without master's degrees in health administration in

the selected categories was the method by which the hypo-

theses were tested.

Hypothesis 1-1

Graduates of master's programs in health administration
occupy 20 per cent or more of the health leadership
positions outside hospitals.

To test this hypothesis, the percentage of persons

occupying the top leadership positions in all groups studied,

with the exception of hospital administrators, was deter-

mined and from this, the percentage of those with master's

degrees in health administration was calculated and com-

pared with that stated in the hypothesis.

Hypothesis 1-2

Physicians without master's degrees in health adminis-
tration fill the minority of top administrative posi-
tions in federal and state government agencies and
Regional Medical Programs.

Four categories (Regional Medical Program directors,

state health directors, other state health agency directors








and U. S. Department of Health, Education and Welfare

health-related executives) were analyzed to determine the

number of physicians without master's degrees in health ad-

ministration who occupy the top administrative roles in each

group. Thus, by determining the total percentage of such

physicians in the total sample, this hypothesis was tested.

Group II Hypotheses: Impact of graduate programs in health
administration on hospital administra-
tion.

If graduate programs in health and hospital administra-

tion had established themselves as the primary source for

hospital administrators, it was felt that their influence

would be felt in several specific areas as noted by the

following hypotheses:

Hypothesis II-1

The larger the hospital, the more likely the adminis-
trator possesses a master's degree in health adminis-
tration.

To test this hypothesis, hospitals were arrayed by bed-

size from smallest to largest in specific groupings and the

percentage of administrators with master's degrees in health

administration in each group was calculated. Thus, it was

determined whether the percentage of administrators with

master's degrees in health administration increased along

with the increased size of hospitals.

Hypothesis 11-2

There is no difference in the average age of hospital
administrators with master's degrees in health adminis-
tration as compared to hospital administrators without
such a degree.








This hypothesis was tested by the calculation of the

mean age of hospital administrators with and without a

master's degree in health administration with the differ-

ences of the two means tested to determine if a statis-

tically significant difference existed.

Hypothesis 11-3

Each year, starting in 1960, the percentage of persons
with master's degrees in health administration ap-
pointed to the top administrative positions in hos-
pitals has not changed.

The testing of this hypothesis was accomplished by re-

cording, for each appointment to the position of hospital ad-

ministrator noted in this study, the year of the appointment

and the educational status of the appointee. From this, the

percentage of persons with a master's degree in health ad-

ministration appointed by year since 1960 was calculated.

By a testing of the significance of the difference of these

percentages, it was possible to determine whether the pro-

portion of persons with master's degrees in health adminis-

tration appointed to the top hospital administrative posi-

tions has increased, decreased, or showed stability during

the ten-year period.

Group III Hypotheses: Impact of leveraging

This group of hypotheses was intended to explore the

mobility, or lack thereof, of administrators among various

employment categories.

Hypothesis III-1

Leveraging, when it occurs, will usually take place
within a given category of employment (e.g., among








similar employers), rather than among various cate-
gories (mobility is primarily limited to within a
specific category of employment).

To test this hypothesis, the careers of the health ad-

ministrators in each of the ten employment categories were

analyzed. This analysis involved a determination of the

categories of employment before and after each employment

change. Thus, the ability of health administrators to move

in and out of and among the various health administration

fields was examined. No statistical testing was carried out

for this hypothesis. The analysis identified frequency in

which changes were made to and from the various categories

of health-related and non-health-related employment.

It was originally intended that the number of employ-

ment changes within each category be determined. Unfor-

tunately, the data, both from the Directory of the American

College of Hospital Administrators and from the returned

questionnaires were not complete enough to accomplish this

analysis. However, it was possible to determine the various

categories of employment with which each person was asso-

ciated.

Hypothesis III-2

All hospital administrators have leveraged at least
once and at least 60 per cent have leveraged two or
more times from previous administrative positions in
hospitals.

This hypothesis was based upon an assertion made by

Professor Jennings in his book as mentioned above (37). Al-

though Professor Jennings did not specify the health field

in his research, it was felt that the extension of this








assertion to the health field would assist in the determina-

tion of career versus employer loyalty. The hypothesis was

tested by determining the percentage of health administrators

who had not leveraged, those who leveraged once, and those

who leveraged more than once.

Hypothesis III-3

Less than 1 per cent of the hospital administrators
surveyed leveraged back into a hospital with which they
were previously associated in an administrative posi-
tion.

If, in fact, leveraging from one health organization to

another were to leave doubts in the former organization

about the loyalty of the health administrator, few health

administrators would return to their former employer. Ac-

cording to Freedgood, "Top flight executives . no longer

feel a prime loyalty to the corporation. There is a new set

of values at work: loyalty to a discipline or a profession

and to a personal career" (44). Thus, once a health admin-

istrator left an employer, little chance should exist of

his return to that employer at a later date. This hypo-

thesis was tested by determining the percentage of hospital

administrators who returned to a hospital having formerly

served that hospital in an administrative position. The

resulting percentage was then compared with the percentage

as stated in the hypothesis.

Hypothesis III-4

There is no difference in the tenure of those in hos-
pital administration positions between those adminis-
trators possessing master's degrees in health adminis-
tration as compared to those without such a degree.





37


It has been previously asserted that administrators

without master's degrees in health administration demons-

trate longer tenures than those with master's degree in

health administration (35). Whether or not such differences

exist was studied by comparing the tenure in currently held

administrative positions and positions held prior to the

current position by persons both with and without master's

degrees in health administration. The differences in the

means so calculated were tested for statistical signifi-

cance.














CHAPTER III

RESEARCH RESULTS




Introduction


As described earlier, the data utilized in this study

were obtained from biographical listings appearing in the

Directory of the American College of Hospital Administrators

or from returned questionnaires mailed directly to iden-

tified health administrators (Table 1 summarizes the res-

ponse to mailed questionnaires).

The analysis of data involving hospital administrators

was complicated because two sources of information were

utilized. It was found that 275 of the 728 selected hos-

pital administrators had biographical listings in the Direc-

tory of the American College of Hospital Administrators.

Of these 275, biographical listings for 259 administrators

were found to contain sufficient information to fulfill the

requirements of this study. This represented 94.1 per cent

of the selected sample of 275. The remaining hospital ad-

ministrators, 453, were sent questionnaires for completion,

and 171 usable replies were returned. This represented

37.7 per cent of the 453 persons in the mailing sample.

Because of the wide variation in availability of usable








TABLE 1


Response to Mailed Questionnaires


Employment Category

a. Hospital
Administrator

Non-ACHA-Affiliated

ACHA-Affiliated

b. Blue Cross Chief
Executives

c. Comprehensive
Health Planning
Area-Wide
Directors

d. Regional Medical
Programs

Directors

Administrative
Officers

e. State Health Dept.
Directors

f. Other State Agency
Directors

g. U. S. Dept. of HEW
Health-Related
Executives

h. Hospital Associa-
tion Directors


Questionnaires
Number Returned Percentage
Mailed and Usable Response


453

275 a

74


312


185


79 46


58.2




40


TABLE 1 continued


Number
Employment Category Mailed

i. Misc. Health Orga- 26
nization Directors

j. Medical Group Prac- 79
tice Administrators


Questionnaires
Returned Percentage
and Usable Response

14 53.8


aInformation for this group was obtained from the Directory
of the American College of Hospital Administrators








responses between the two groups, it was decided to treat

each group separately in the data analysis for those hypo-

theses involving hospital administrators. With two excep-

tions, these being hypotheses II-1 and II-3, this separate

analysis was carried out. Specific descriptions of the

analyses follow under each hypothesis.

The relatively low return of questionnaires by hospital

administrators not affiliated with the American College of

Hospital Administrators (37.7 per cent response) necessi-

tated statistically testing certain characteristics of the

total invited sample. This was done to determine if the

returned sample was similar in the selected characteristics

to the invited sample. The characteristics so compared

were bed size, control, service and length of stay. Tables

2 through 5 describe the characteristics of each group and

indicate the calculated chi square. The results of these

statistical tests revealed that on the characteristics of

control, service, and length of stay, the returned sample

and the invited sample did not differ significantly. How-

ever, with respect to bed size, a statistically significant

difference was observed. Thus, in the analysis of hypo-

thesis II-1, each bed size group was appropriately weighted

to equate the returned sample with the invited sample since

this sample was combined with that of the affiliates of the

American College of Hospital Administrators.

In the medical group practice administrator employment

category, the invited sample was 10 per cent of all persons








TABLE 2


Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators


Characteristic Tested Bed Size


Bed Size Range

0 50

51 100

101 150

151 200

201 300

301 400

401 1,000

1,000 +

TOTALS


No. Invited

198

105

41

25

24

22

20

18

453


No. Returned

70

30

18

8

9

9

14

13

171


Chi Square = 23.3

Degrees of Freedom = 7

P <.01

Difference is statistically
significant at the desired level


Percentage
Returned

35.4

28.6

43.9

32.0

37.5

40.9

70.0

72.2








TABLE 3


Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators


Characteristic Tested Control


Type

Government,
Non-Federal

Non-Government
Not-for-Profit

For-Profit

Governmental,
Federal

Osteopathic

TOTALS


No. Invited No. Returned

168 65


Chi Square = 6.94

Degrees of Freedom = 4

P >.10

Difference is not statistically
significant at the desired level


Percentage
Returned

38.7


42.1


27.4

44.4


23.8








TABLE 4


Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators


Characteristic Tested Service


No. Invited

378

28

47

453


No. Returned

139

14

18

171


Percentage
Returned

36.8

50.0

38.3


Chi Square = 1.94

Degrees of Freedom = 2

P > .10


Difference is not statistically
significant at the desired level


Type

General

Psychiatric

Other

TOTALS








TABLE 5


Comparison of Invited and Returned Sample
Questionnaires Mailed to Non-ACHA-
Affiliated Administrators


Characteristic Tested Length of Stay


No. Invited

404

49

453


No. Returned

146

25

171


Percentage
Returned

36.1

51.0


Chi Square = 3.5

Degrees of Freedom = 1

P-> .n9


Difference is not statistically
significant at the desired level


Type

Short

Long

TOTALS








known to be so employed. In all other categories the

invited sample was 100 per cent of all persons known to be

employed in the respective categories.



The Results of the Group I Hypotheses


The group I hypotheses were intended to investigate the

educational backgrounds of health administrators outside

hospitals. Particularly, they were intended to explore the

frequency with which such positions were occupied by persons

with master's degrees in health administration.


Hypothesis I-1

Graduates of master's programs in health administration
occupy 20 per cent or more of the health leadership
positions outside hospitals.

The percentage calculated to test this hypothesis was

weighted on the basis of the size of the original population.

The result of this calculation (Table 6) revealed that the

95 per cent confidence interval for the percentage of per-

sons with a master's degree in health administration and

occupying leadership positions in health administration out-

side hospitals, was between 5.2 per cent and 10.7 per cent.

When medical group practice administrators were eliminated

from the calculation, the 95 per cent confidence interval

was 10.3 per cent to 15.5 per cent. The calculated weighted

percentage for all groups combined was 8.0 per cent and for

all groups except medical group practice administrators, it

was 12.9 per cent. The difference from the hypothesized








TABLE 6


HYPOTHESIS I-1


Health Administrators without Master's Degrees
in Health Administration


Employment Category

Blue Cross Chief
Executives

Comprehensive
Health Planning
Area-Wide
Directors

Regional Medical
Programs

Directors

Administrative
Officers

State Health Dept.
Directors

Other State Agency
Directors

U. S. Dept. of HEW
Health-Related
Executives

Hospital Association
Directors


No. in Sample

36


99







32

34


34


185


35


NO. MHA's % MHA's

1


23







2

6


0


5


1




48



TABLE 6 continued


Employment Category No. in Sample

Misc. Health Organi- 14
nation Directors

Medical Group Prac- 39
tice Administrators

TOTALS 554

TOTALS without Me- 515
dical Group Prac-
tice Administrators


No. MHA's % MHA's

5


1


aDifference from hypothesized 20.0% is statistically sig-
nificant at the desired level (P < .001)

bDifference from hypothesized 20.0% is statistically sig-
nificant at the desired level (P< .001)


65 12.9b








percentage of 20 per cent was statistically significant at

the 0.1 per cent level for both percentages.

The result of these calculations reject the hypothesis

as stated.


Hypothesis 1-2

Physicians without master's degrees in health adminis-
tration fill the minority of top administrative posi-
tions in federal and state government agencies and
Regional Medical Programs.

Table 7 reports the result of the analysis of this

hypothesis. The calculated weighted percentage of persons

with a medical degree, but without a master's degree in

health administration, was 57.4 per cent. The difference

between this weighted percentage and the hypothesized value

of 50 per cent or less was statistically significant at the

1 per cent level. The 95 per cent confidence interval

ranged from 52.2 per cent to 62.7 per cent.

The result of these calculations reject the hypothesis

as stated.



The Results of the Group II Hypotheses


The group II hypotheses were intended to investigate

the impact of graduate programs in health administration on

hospital administration.


Hypothesis II-1

The larger the hospital, the more likely the adminis-
trator possesses a master's degree in health adminis-
tration.








TABLE 7


HYPOTHESIS 1-2


Physicians without Master's Degrees in
Health Administration


Employment Category

Regional Medical
Programs
Directors

State Health Dept.
Directors

Other State Agency
Directors

U. S. Dept. of HEW
Health-Related
Executives

TOTALS


No. in Sample

32



34


185


35



286


M.D.'s without
MHA %

29



34


83


21


167


57.4a


aDifference from hypothesized 50.0% is statistically sig-
nificant at the desired level (P< .01)








The result of this analysis will be found in Table 8.

No attempt was made at testing the significance of the dif-

ference of the proportion of persons with master's degrees

in health administration among the various hospital groups

based on bed size. Table 8 demonstrates that there is not

a continuously increasing relationship between bed size and

the possession of a master's degree in health administration

by the administrator.

This hypothesis was rejected because the percentage of

administrators with master's degrees in health administra-

tion did not consistently increase with increasing hospital

size throughout the range of bed size groups.


Hypothesis 11-2

There is no difference in the average age of hospital
administrators with master's degrees in health adminis-
tration as compared to hospital administrators without
such a degree.

To make this analysis, the calculations were completed

independently for those administrators affiliated with the

American College of Hospital Administrators and for those

who were not so affiliated. Table 9 reports the results in-

cluding the tests of significance. It was determined that

among those who were not affiliated with the American

College of Hospital Administrators, there was not a statis-

tically significant difference in ages between those with

and without a master's degree in health administration.

However, for those who were affiliated with the American

College of Hospital Administrators, the difference in ages








TABLE 8


HYPOTHESIS II-1


Proportion of Hospital Administrators
Possessing a Master's Degree
in Health Administration


Hospital Bed Size

0 50

51 100

101 150

151 200

201 300

301 400

401 1,000

1,000 +


Percentage of
Administrators
with MHA

4.0

25.8

43.1

45.0

50.0

46.7

38.1

16.9


NOTE: Non-ACHA-affiliated administrators and ACHA-
affiliated administrators were combined in the
above chart. In addition, the Non-ACHA sample
was adjusted to reflect the distribution, by
bed size, of hospitals in the invited sample.


Standard
Deviation

2.0

6.7

7.0

7.6

7.1

8.0

6.0

6.7








TABLE 9


HYPOTHESIS 11-2


Years of Age Comparisons Hospital Administrators




Non-ACHA-Affiliates


Non-MHA
Sample Mean Standard
Size Age Deviation

138 47.4 10.3


MHA
Sample Mean Standard
Size Age Deviation

25 44.6 9.1


t test = -1.26 (P > .05)

Difference in ages is not statistically
significant at the desired level




ACHA-Affiliates


Non-MHA
Sample Mean Standard
Size Age Deviation

131 52.8 8.9


MHA
Sample Mean Standard
Size Age Deviation

121 44.4 7.1


t test = -8.19 (P < .001)

Difference in ages is statistically
significant at the desired level







was statistically significant at the 0.1 per cent level.

The result of these calculations reveals that the hypo-

thesis was upheld with respect to those administrators who

were not affiliates of the American College of Hospital Ad-

ministrators but the hypothesis failed with respect to those

administrators who were affiliates of the American College

of Hospital Administrators. However, in both instances,

administrators with master's degrees in health administra-

tion were found to have a lower mean age.


Hypothesis 11-3

Each year, starting in 1960, the percentage of persons
with master's degrees in health administration ap-
pointed to the top administrative positions in hos-
pitals has not changed.

The result of these calculations will be found in Table

10. The test of the differences among the years showed that

there was no statistically significant difference in the

rate of those persons with master's degrees in hospital ad-

ministration appointed to hospital administrator positions

during the years studied. Thus, no consistent change in

this proportion, either increasing or decreasing, was dem-

onstrated.



The Results of the Group III Hypotheses


The group III hypotheses were intended to explore the

impact of leveraging on the careers of health administra-

tors.








TABLE 10



HYPOTHESIS II-3



Appointments to Position of Hospital Administrator


Year

1970

1969

1968

1967

1966

1965

1964

1963

1962

1961

1960


Non-MHA

37

35

19

32

16

26

13

20

8

17

14


Total

57

54

36

56

29

42

26

28

16

25

25


Percentage
MHA

35.1

35.2

47.2

42.9

44.8

38.1

50.0

28.6

50.0

32.0

44.0


Standard
Deviation

6.3

6.5

8.3

6.6

9.2

7.5

9.8

8.5

12.5

9.3

9.9


Chi Square = 6.52

Degrees of Freedom = 10

P > .05

Differences among the years are not
statistically significant at the desired level








Hypothesis III-1

Leveraging, when it occurs, will usually take place
within a given category of employment (e.g., among
similar employers), rather than among various cate-
gories (mobility is primarily limited to within a
specific category of employment).

The result of this analysis will be found in Tables 11

and 12. Clearly, only three categories were composed of

persons, the majority of which, had held employment in more

than one of the health employment categories studied. These

three categories were: comprehensive health planning area-

wide directors, hospital association directors, and mis-

cellaneous health organization chief executives. All four

subgroups within the hospital administrator employment cate-

gory demonstrated less than 10 per cent of the subgroup

with employment in more than one category. All other em-

ployment groups studied fell between 10 per cent and 41.1

per cent.

In comparing the above results with the hypothesis, a

mixed conclusion is obtained. For three employment cate-

gories as stated above, the majority of the administrators

leveraged among at least two of the health employment cate-

gories studied. In the seven other categories, leveraging,

in the majority of cases, was limited to the health em-

ployment category in which the person was currently em-

ployed.


Hypothesis III-2

All hospital administrators have leveraged at least
once and at least 60 per cent have leveraged two or











TABLE 11


HYPOTHESIS III-I


Leveraging Among Employment Categories




Employment Change Employment Categories Studieda
Classifications a.l. a.2. a.3. a.4. b c d.1. d.2. e f g h i j

One position in 0 0 10 10 0 0 0 0 0 11 7 1 0 2
current employment
category 0

More than one po- 55 10 89 70 3 1 0 0 0 19 0 0 0 0
sition in current
employment catetory

One change from 17 4 3 2 0 9 20 5 2 71 16 3 1 2
category k to cur-
rent employment
category

One change from 58 9 8 35 22 26 0 11 0 37 5 8 3 17
category 1 to cur-
rent employment
category









TABLE 11 continued




Employment Change Employment Categories Studieda
Classifications a.l. a.2. a.3. a.4. b c d.l. d.2. e f g h I I


More than one
change to and from
category k and
current employment
category

More than one
change to and from
category 1 and
current employment
category

More than one
change to and from
a combination of
categories k and 1
and current em-
ployment category


Employment only in 0
categories e and f
(public health
agencies)


2


3 4 0 0 1 0 1 7 1 0


0 0


1 0 2 2 0 0 0 0 0 2 0 0 0 0





4 0 2 1 2 5 0 4 0 5 2 1 0 1


0 0 0 0 0 0 0 6 0 0 0 0 0










TABLE 11 continued


Employment Change Employment Categories Studieda
Classifications a.l. a.2. a.3. a.4. b c d.l. d.2. e f h i

Employment in a 0 0 0 0 0 0 0 0 17 0 0 0 0 0
combination of com-
bination of cate-
gories e, f, k,
and 1

No information 2 1 0 0 2 2 0 0 0 0 0 1 0 1

Employment in more 6 1 9 9 7 56 11 14 8 33 4 32 10 16
than one of the ten
study categories
(a through j)

TOTALS 145 26 126 133 36 89 32 34 34 185 35 46 14 39


a. Hospital Administrators
1. Non-ACHA-Affiliate and N
2. Non-ACHA-Affiliate with
3. ACHA-Affiliate and Non-M
4. ACHA-Affiliate with MHA
b. Blue Cross Chief Executives
c. Comprehensive Health Plannin
Area-Wide Directors
d. Regional Medical Programs
1. Directors
2. Administrative Officers


aEmployment Categories

e. State Health Department Directors
Non-MHA f. Other State Agency Directors
MHA g. U. S. Department of HEW Health-Related
IHA Executives
h. Hospital Association Directors
i. Miscellaneous Health Organization
ng Directors
j. Medical Group Practice Administrators
k. Health-Related Employment but not a
through j above
1. Non-Health-Related Employment








TABLE 12


HYPOTHESIS III-1


Persons Employed in More Than One Study Category


Description

Persons employed in
category currently

Persons employed in
two study categories

Percentage

Persons employed in
three or more study
categories

Percentage

Accumulated percen-
tage of persons
employed in more
than one study
categories


Employment Categories Studieda
a.l. a.2. a.3. a.4. b

145 26 126 133 36


6 0 9 9 6


4.1 0

0 1


aEmployment Categories

a. Hospital Administrators
1. Non-ACHA-Affiliate and Non-MHA
2. Non-ACHA-Affiliate with MHA
3. ACHA-Affiliate and Non-MHA
4. ACHA-Affiliate with MBA
b. Blue Cross Chief Executives
c. Comprehensive Health Planning
Area-Wide Directors
d. Regional Medical Programs
1. Directors
2. Administrative Officers








TABLE 12 continued


Employment Categories
d.l. d.2. e f

32 34 34 185


Studieda
g hi

35 46


8 2 31 4 26 7 14


23.5


5.9 16.8 11.4 56.5 50.0 35.9

6 2 0 6 3 2


15.7 9.4 17.6 17.6 1.1 0

62.9 34.4 41.1 23.5 17.9 11.4


13.1 21.4 5.1

69.6 71.4 41.0


aEmployment Categories

e. State Health Department Directors
f. Other State Agency Directors
g. U. S. Department of HEW Health-
Related Executives
h. Hospital Association Directors
i. Miscellaneous Health Organization
Directors
j. Medical Group Practice Administrators


i 1

14 39


47.2 25.0

14 3








more times from previous administrative positions in
hospitals.

Table 13 presents the result of testing this hypo-

thesis. Once again, the groups of hospital administrators

were separated into those who were not affiliated with the

American College of Hospital Administrators and those who

were affiliated with the American College of Hospital Ad-

ministrators.

As can be readily seen, the portion of the hypothesis

which stated that all hospital administrators had leveraged

at least once was rejected. All subgroups studied were

found to contain a portion of administrators who had not

leveraged from previous administrative positions in hos-

pitals. The second portion of the hypothesis, that 60 per

cent of all hospital administrators had leveraged two or

more times from previous administrative positions in hos-

pitals, was also rejected. No subgroup of hospital adminis-

trators demonstrated leveraging two or more times at or

above the 60 per cent level.

A comparison of the various percentages of those hos-

pital administrators not leveraging or leveraging two or

more times between the several groupings revealed some

statistically significant differences. In the group of

hospital administrators not affiliated with the American

College of Hospital Administrators, 57.2 per cent of those

administrators without master's degrees in health adminis-

tration had never leveraged as compared to 23.1 per cent of




63



TABLE 13


HYPOTHESIS III-2


Frequency of Leveraging Among
Hospital Administrators


Times
Leveraged

0

1

2


No Information

TOTALS



% Not
Leveraging


Non-ACHA-
Affiliates
Non-MHA MHA

83 6

37 7

17 5


57.2% 23.1%

Difference statis-
tically signifi-
cant at the de-
sired level
(P< .01)


ACHA-Affiliates
Non-MHA MHA

42 18

40 45

22 33

15 20

6 7

7 2

0 0

0 0


31.6% 14.3%

Difference statisti-
cally significant at
the desired level
(P< .01)




64



TABLE 13 continued


% Leveraging
2 or more
times


14.4% 42.3%

Difference statisti-
cally significant
at the desired
level (P< .01)


38.3% 49.2%

Difference not statis-
tically significant
at the desired level
(P .05)








those administrators with master's degrees. This difference

was statistically significant at the 1 per cent level.

Also, 14.4 per cent of the members of this group without

master's degrees in health administration had leveraged two

or more times as compared with 42.3 per cent of those with

master's degrees. This difference was also statistically

significant at the 1 per cent level.

With respect to those hospital administrators af-

filiated with the American College of Hospital Administra-

tors, it was found that of these without master's degrees

in health administration, 31.6 per cent had never leveraged

as compared to 14.3 per cent of those with master's degrees

in health administration. This difference was statistically

significant at the 1 per cent level. Also, it was found

that 38.3 per cent of those without master's degrees in

health administration had leveraged two or more times as

compared to 49.2 per cent of those with master's degrees.

This difference was not statistically significant.

In summary, this hypothesis was not supported by the

data.


Hypothesis III-3

Less than 1 per cent of the hospital administrators
surveyed leveraged back into a hospital with which
they were previously associated in an administrative
position.

The result of this analysis will be found in Table 14.

It will be seen that the analysis separated those hospital

administrators directly affiliated with a religious order








TABLE 14


HYPOTHESIS III-3


Frequency of Leveraging Back to a Previous Employer
Among Hospital Administrators


Previous Position

Administrator


Non-ACHA-Affiliates

Sisters

0


Other Administrative
Position

Other Non-Administrative
Position


1 Non-MHA


ACHA-Affiliates

Previous Position Sisters

Administrator 1 MHA


Other Administrative 0
Position

Other Non-Administrative 2 Non-MHA
Position


Non-Sisters

1 Non-MHA


1 Non-MHA


Non-Sisters

2 MHA
3 1 Non-MHA

1 MHA
3 2 Non-MHA

1 Non-MHA


SUMMARY:

Eight persons leveraged back to a hospital in which
they had held an administrative position (1.9%). Five
persons leveraged back to a hospital in which they had
held a non-administrative position.








who carried the title "Sister" from those who were not so

affiliated. The reason for these groupings was an under-

standing of the author that "Sisters" had less control over

their assignments and may not be in position to seek or turn

down an offer to return to a previous institution.

In total, it was observed that eight persons (1.9 per

cent) leveraged back to a hospital to the position of ad-

ministrator after having once served that particular hos-

pital in an administrative position. In each case, a po-

sition with a different hospital intervened between the

appointments.

The above calculation reveals that this hypothesis

failed.


Hypothesis III-4

There is no difference in the tenure of those in hos-
pital administration positions between those adminis-
trators possessing master's degrees in health adminis-
tration as compared to those without such a degree.

The result of this analysis is shown in Table 15. For

purpose of analysis, the hospital administrators were di-

vided into those who were not affiliated with the American

College of Hospital Administrators and those who were

affiliated with the American College of Hospital Adminis-

trators. With respect to those who were not affiliated

with the American College of Hospital Administrators, the

mean of the tenure in the current position of those without

master's degrees in health administration was found to be








TABLE 15


HYPOTHESIS III-4


Tenure Comparisons Hospital Administrators




Non-ACHA-Affiliates


Current Position


Non-MHA MHA
Sample Mean Standard Sample Mean Standard
Size Tenure Deviation Size Tenure Deviation

138 6.5 7.3 23 3.9 4.3



t test = -1.70 (P> .05)

Difference in tenure is not statistically
significant at the desired level



Previous Positions


Non-MHA MHA
Sample Mean Standard Sample Mean Standard
Size Tenure Deviation Size Tenure Deviation

28 5.0 4.0 11 4.1 3.0



t test = -0.69 (P> .05)

Difference in tenure is not statistically
significant at the desired level




69



TABLE 15 continued




ACHA-Affiliates


Current Position


Non-MHA MHA
Sample Mean Standard Sample Mean Standard
Size Tenure Deviation Size Tenure Deviation

133 9.9 7.5 126 6.7 5.5



t test = -3.82 (P <.001)

Difference in tenure is statistically
significant at the desired level



Previous Positions


Non-MHA MHA
Sample Mean Standard Sample Mean Standard
Size Tenure Deviation Size Tenure Deviation

61 5.4 3.8 48 4.0 3.0



t test = -2.00 (P < .05)

Difference in tenure is statistically
significant at the desired level








6.5 years while for those with master's degrees in health

administration, the mean was 3.9 years. The difference

between these two groups was found not to be statistically

significant. With respect to previous positions held by

these administrators, of the group without master's degrees

in health administration, the mean tenure was 5.0 years and

for those with master's degrees in health administration it

was found to be 4.1 years. Once again, there was not a

statistically significant difference between these means.

In the analysis of those hospital administrators

affiliated with the American College of Hospital Administra-

tors, significant differences were found. With respect to

current positions for these hospital administrators, those

without master's degrees in health administration demons-

trated a mean tenure of 9.9 years as compared to a mean

tenure of 6.7 years for those with master's degrees in

health administration. This difference was statistically

significant at the 0.1 per cent level. With respect to

previous positions, those hospital administrators without

master's degrees in health administration demonstrated a

mean tenure of 5.4 years as compared to 4.0 years for those

administrators with master's degrees in health administra-

tion. Again, this difference was statistically significant,

this time at the 5 per cent level.

Thus, the hypothesis was supported with respect to

those hospital administrators not affiliated with the

American College of Hospital Administrators but was rejected




71


with respect to those administrators affiliated with the

American College of Hospital Administrators. Though not

statistically significant in all cases, hospital adminis-

trators without master's degrees demonstrated longer tenure

in both current and previous positions.














CHAPTER IV

SUMMARY, CONCLUSIONS, AND IMPLICATIONS
FOR FURTHER RESEARCH




Summary


Introduction

Since 1900, significant changes have occurred in the

health care system. Patient care has been transformed from

a primarily physician-patient relationship to a complex re-

lationship involving the patient, physicians, other allied

health personnel, and health organizations. These major

changes in the delivery of health care have been accompanied

by increasing need for administrative leadership in orga-

nizations. In the early 1900's, physicians and nurses were

looked to for the provision of the necessary leadership.

However, as the developing organizations became more com-

plex, leadership needs could not be filled in this manner.

In 1934, the first graduate program in health administration

was established by the University of Chicago. Since that

time, more than 30 additional graduate programs have been

established. Already, 7,000 persons have graduated from

such programs and the output, by 1972, should be approxi-

mately 800 persons per year. The primary goal of these








programs is to produce administrative leaderships for the

great variety of health organizations existing in our

country.

This study was designed to investigate the impact of

such graduate programs on the field of hospital administra-

tion and to study the continued involvement of physicians in

the administration of certain types of health programs.

Several prior studies revealed the variety of employment

situations currently filled by program graduates. However,

little attention seems to have been paid to examining wheth-

er such graduates are filling the top administrative po-

sitions in such organizations. Also, in view of growing

concern about employee loyalty to his employer, this study

investigated several aspects of corporate loyalty.


Hypotheses

The following hypotheses were designed to explore the

above areas in this research project:

Group I Educational backgrounds of health adminis-
trators outside hospitals

1) Graduates of master's programs in
health administration occupy 20 per
cent or more of the health leadership
positions outside hospitals.

2) Physicians without master's degrees in
health administration fill the minority
of top administrative positions in
federal and state government agencies
and Regional Medical Programs.

Group II Impact of graduate programs in health
administration on hospital administration

1) The larger the hospital, the more








likely the administrator possesses a
master's degree in health administra-
tion.

2) There is no difference in the average
age of hospital administrators with
master's degrees in health administra-
tion as compared to hospital adminis-
trators without such a degree.

3) Each year, starting in 1960, the per-
centage of persons with master's
degrees in health administration
appointed to the top administrative
positions in hospitals has not changed.

Group III Impact of leveraging

1) Leveraging, when it occurs, will
usually take place within a given ca-
tegory of the employment (e.g., among
similar employers), rather than among
various categories (mobility is pri-
marily limited to within a specific
category of employment).

2) All hospital administrators have lever-
aged at least once and at least 60 per
cent have leveraged two or more times
from previous administrative positions
in hospitals.

3) Less than 1 per cent of the hospital
administrators surveyed leveraged back
into a hospital with which they were
previously associated in an adminis-
trative position.

4) There is no difference in the tenure of
those in hospital administration posi-
tions between those administrators
possessing master's degrees in health
administration as compared to those
without such a degree.


Methodology and Sample

The health administrators selected for this study fell

into the following employment categories:








a) Hospital administrators

b) Blue Cross chief executives

c) Comprehensive health planning area-wide directors

d) Regional Medical Program directors and administra-
tive officers

e) State health department directors

f) Other state agency directors

g) U. S. Department of Health, Education and Welfare
health-related executives

h) Hospital association directors

i) Miscellaneous health organization chief executives

j) Medical group practice administrators

The August 1, 1971 Guide Issue of the American Hospital

Association was utilized to identify the above groups.

However, two of the groups were not listed in the Guide

Issue and were added because of their growing importance in

the delivery of health care in our country. These groups

were Regional Medical Programs directors and administrative

officers and medical group practice administrators. In

total, the ten categories represented more than 92 per cent

of all known health-related employment categories of grad-

uates of selected AUPHA member programs.

With respect to sample size, 10 per cent of the hospi-

tal administrators of the nation were selected by random

sampling as were 10 per cent of the medical group practice

administrators. This resulted in sample sizes of 728 and 79

respectively. In the other eight categories the sample

selected was 100 per cent of the persons known to be








occupying such positions. Data were obtained by utilizing

biographical listings in the Directory of the American

College of Hospital Administrators for all these identified

as hospital administrators and affiliated with the college.

All other persons were sent personally addressed question-

naires requesting the necessary information.


Statistical Analysis and Results

Hypothesis I-i

Graduates of master's programs in health administration
occupy 20 per cent or more of the health leadership
positions outside hospitals.

This hypothesis was tested by determining the percen-

tage of persons with master's degrees in health administra-

tion occupying the top leadership positions in all groups

studied other than hospitals. The calculated weighted per-

centage for all groups combined was 8.0 per cent and for all

categories with the exception of medical group practice

administrators was 12.9 per cent. The difference from the

hypothesized 20 per cent was significant at the 0.1 per cent

level for both percentages. Thus, this hypothesis was

rejected.

Hypothesis 1-2

Physicians without master's degrees in health adminis-
tration fill the minority of top administrative posi-
tions in federal and state government agencies and
Regional Medical Programs.

This hypothesis was tested by determining the number

of physicians without master's degrees in health administra-

tion occupying the top leadership position in the stated








organizations. The calculated weighted percentage of per-

sons with a medical degree but without a master's degree in

health administration in the leadership role in such orga-

nizations was 57.4 per cent. The difference between this

weighted percentage and the hypothesized percentage of 50

per cent or less was significant at the 1 per cent level.

Thus, the results of these calculations reject the hypo-

thesis as stated.

Hypothesis II-1

The larger the hospital, the more likely the adminis-
trator possesses a master's degree in health adminis-
tration.

This hypothesis was tested by arraying hospitals sur-

veyed by bed size from smallest to largest in specific

groupings and calculating the percentage of administrators

of these institutions who possessed master's degrees in

health administration. The calculation demonstrated that

the proportion of hospitals with administrators who pos-

sessed master's degrees in health administration increased

from the smallest size institutions up to the category of

201 to 300 beds. Beyond this category, the percentage de-

creased. Thus, since the proportion of administrators with

master's degrees in health administration was found not to

be a continuously increasing function of bed size, this

hypothesis was rejected.

Hypothesis 11-2

There is no difference in the average age of hospital
administrators with master's degrees in health








administration as compared to hospital administrators
without such a degree.

This hypothesis was tested by calculation of mean age

of hospital administrators with and without master's degrees

in health administration and further by testing the statis-

tical significance of the differences. For the group of

hospital administrators not affiliated with the American

College of Hospital Administrators, those without master's

degrees in health administration had a mean age of 47.4.

Those with master's degrees in health administration had a

mean age of 44.6. The difference in ages between the two

groups was not statistically significant. With respect to

hospital administrators affiliated with the American College

of Hospital Administrators, those without master's degrees

in health administration had a mean age of 52.8. Those with

master's degrees in health administration had a mean age of

44.4. This difference in ages was statistically significant.

Thus, the hypothesis was supported with respect to the group

of administrators not affiliated with the American College

of Hospital Administrators but was rejected with respect to

those who were affiliated with the American College of

Hospital Administrators.

Hypothesis 11-3

Each year, starting in 1960, the percentage of persons
with master's degrees in health administration ap-
pointed to the top administrative positions in hos-
pitals has not changed.

This hypothesis was tested by noting, for each ap-

pointment to hospital administrator between the years of








1960 and 1970, whether the appointee had a master's degree

in health administration. The result of this analysis

showed that there was not a statistically significant

difference among the 11 years with respect to the percentage

of hospital administrators appointed to the position of hos-

pital administrator who possessed a master's degree in

health administration. Thus, the hypothesis was rejected.

Hypothesis III-1

Leveraging, when it occurs, will usually take place
within a given category of employment (e.g., among
similar employers), rather than among various cate-
gories (mobility is primarily limited to within a
specific category of employment).

The testing of this hypothesis was accomplished by

determining the category of employment before and after each

employment change of all persons in the survey group. Of

all employment categories, only comprehensive health

planning area-wide directors, hospital association directors,

and miscellaneous health organizations chief executives dem-

onstrated mobility to the extent that the majority of those

in each group had held employment in more than one of the

health employment categories studied. Less than 10 per cent

of the hospital administrators in each of the four sub-

groups had held employment in more than one health-related

employment category. All other employment groups studied

fell between 10 per cent and 41.1 per cent. Thus, the

hypothesis was supported for seven out of ten of the health

employment categories but was rejected in three categories.








Hypothesis 111-2

All hospital administrators have leveraged at least
once and at least 60 per cent have leveraged two or
more times from previous administrative positions in
hospitals.

This hypothesis was tested by determining the percen-

tage of health administrators who had not leveraged, those

who leveraged once, and those who leveraged two or more

times. It was found that the hypothesis was rejected with

respect to both leveraging once and leveraging two or more

times. This result was true for all four subgroups of hos-

pital administrators, namely, those who were not affiliated

with the American College of Hospital Administrators with

or without master's degrees in health administration and for

those who were affiliated with the American College of

Hospital Administrators, with and without master's degrees.

However, further analysis of the data revealed that signi-

ficant differences existed among the subgroups of hospital

administrators. In the group of hospital administrators not

affiliated with the American College of Hospital Adminis-

trators, 57.2 per cent of those administrators without

master's degrees in health administration had never lever-

aged as compared to 23.1 per cent of those administrators

with master's degrees. This difference was statistically

significant. Also, 14.4 per cent of the members of this

group without master's degrees in health administration had

leveraged two or more times as compared with 42.3 per cent

of those with master's degrees. This difference was also








statistically significant.

With respect to those hospital administrators affili-

ated with the American College of Hospital Administrators,

of those without master's degrees in health administration,

31.6 per cent had never leveraged as compared to 14.3 per

cent of those with master's degrees in health administra-

tion. This difference was statistically significant. The

final comparison, concerning those who had leveraged two or

more times, showed that 38.3 per cent of those without

master's degrees had leveraged two or more times as com-

pared to 49.2 per cent of those with master's degrees.

This final comparison was not statistically significant.

Hypothesis III-3

Less than 1 per cent of hospital administrators sur-
veyed leveraged back into a hospital with which they
were previously associated in an administrative po-
sition.

This hypothesis was tested by determining the percen-

tage of hospital administrators who returned to a hospital

having formerly served that hospital in an administrative

position. It was found that 1.9 per cent of the hospital

administrators leveraged back to a hospital in which they

previously held an administrative position. In each case,

a position with a different hospital intervened between

the appointments. Thus, the hypothesis was rejected.

Hypothesis III-4

There is no difference in the tenure of those in hos-
pital administration positions between those adminis-
trators possessing master's degrees in health








administration as compared to those without such a
degree.

This hypothesis was tested by comparing the tenure in

currently held administrative positions and in positions

held prior to the current position by persons both with and

without master's degrees in health administration. For

this analysis, the administrators were divided into those

where who were and those who were not affiliated with the

American College of Hospital Administrators. With respect

to those who were not affiliated with the American College

of Hospital Administrators, the mean of the tenure in the

current position of those without master's degrees in health

administration was found to be 6.5 years, while for those

with master's degrees in health administration, the mean

was 3.9 years. The difference between these two groups was

not statistically significant. With respect to previous

positions held by these administrators, of the group without

master's degrees in health administration, the mean tenure

was 5.0 years and for those with master's degrees in health

administration it was found to be 4.1 years. Once again,

there was not a statistically significant difference be-

tween these means.

With respect to those hospital administrators affili-

ated with the American College of Hospital Administrators,

those administrators without master's degrees in health

administration demonstrated a mean tenure in previous po-

sitions of 9.9 years as compared to a mean tenure of 6.7








years for those with master's degrees in health adminis-

tration. This difference was statistically significant.

With respect to previous positions, those hospital adminis-

trators without master's degrees in health administration

demonstrated a mean tenure of 5.4 years as compared to 4.0

years for those administrators with master's degrees in

health administration. Again, this difference was statis-

tically significant.

Thus, the hypothesis was supported with respect to

those hospital administrators not affiliated with the

American College of Hospital Administrators, but was re-

jected with respect to those administrators affiliated with

the American College of Hospital Administrators.



Conclusions


On the Educational Background of Health Administrators
Outside Hospitals

Even though over 1,000 graduates of programs in health

administration are occupying positions in the health indus-

try outside of hospitals, it was found that such graduates

did not occupy more than 20 per cent of the top health ad-

ministrative positions. Thus, it must be assumed that the

vast majority of such graduates are occupying positions

below the top administrative positions either in assistant-

type categories or in staff roles. Whether this figure

will increase in the coming years as the mean age of gra-

duates increases is not known. However, it is obvious that








at this point in time, the majority of health administrative

positions in the country are occupied by non-graduates of

master's programs in health administration.

The proportion of physicians without master's degrees

in health administration who occupy the top leadership po-

sitions in state and federal programs was found not to be

below 50 per cent. This proportion would appear to indicate

that for these programs, medical leadership is either sought

after and/or relatively little importance is placed upon

one's possession of a master's degree in health administra-

tion. While the number of physicians with master's degrees

in health administration is not known, it is known that few

are employed in the categories studied. These roles con-

tinue to be filled by physicians without such degrees.


On the Impact of Graduate Programs in Health and Hospital
Administration on Hospital Administration

Graduates of programs in health administration as a

group do not represent the only source of candidates for the

position of administrator in hospitals. In the last 11

years, the proportion of persons with master's degrees in

health administration appointed to the top administrative

position in hospitals has shown no significant change in any

direction. It was also determined that the proportion of

persons with master's degrees in health administration

occupying the top administrative position in hospitals did

vary according to hospital bed size. However, contrary to

expectation, the variance was not directly related to








increasing hospital size. It was found that both small (0

to 50 beds) and large (over 1,000 beds) hospitals employed

course graduates less often than hospitals of bed size be-

tween the two. Thus, many hospital administrator positions

are occupied by non-course graduates and there is no evi-

dence that this situation has shown any tendency toward

change in the years 1960 to 1970.

Age differences among hospital administrators with and

without master's degrees in health administration were ob-

served. Administrators with master's degrees in health

administration were found to be younger. However, the

difference in ages was statistically significant only for

the group affiliated with the American College of Hospital

Administrators. In this group, the difference was 8.4

years demonstrating that the possession of a master's

degree in health administration may make possible one's

appointment to a position of hospital administrator at an

earlier age.


On the Impact of Leveraging

Health administrators tend to maintain their employment

in only one health administration employment category. Even

persons with master's degrees in health administration dem-

onstrate this tendency. Thus, even though graduate pro-

grams are attempting to prepare graduates for a wide

variety of health-related roles, such individuals apparently

are not being sought for or are not seeking employment in








a variety of employment categories but tend to remain em-

ployed in the category of original employment.

Hospital administrators demonstrate more employer

loyalty than suggested by Professor Eugene Jennings. In all

four subgroups of hospital administrators, Jennings asser-

tions concerning leveraging were not upheld. Between 14.3

per cent and 57.2 per cent of the hospital administrators

had never leveraged. Between 14.4 per cent and 49.2 per

cent had leveraged two or more times. These data suggest

that many administrators have worked in only one hospital

during their careers to date, either having been hired

directly into the administrator's position or working him-

self up to that position from within that hospital. A

statistically significantly greater proportion of adminis-

trators without a master's degree have followed this pattern

than have those without a master's degree. The latter

group of administrators have shown a greater tendency to

have been employed by two or more hospitals. Thus, the

possession of a master's degree in health administration

tends to make the hospital administrator more mobile or

prone to change employers.

Another assertion of Jennings was related to the po-

tential return of an individual to his former employer with

another employer intervening. The assertion was that less

than 1 per cent of the administrators leveraged back to a

hospital with which they were previously associated in an

administrative position. Among the administrators surveyed,








eight (1.9 per cent) were found to have so leveraged.

While the hypothesis was not supported, the frequency of le-

veraging back was low and indicates that little likelihood

exists for the employment of an individual in the position

of hospital administrator who had previously served that

hospital in an administrative position.

In all tenure comparisons, hospital administrators

without master's degrees in health administration demon-

strated longer tenure than those with such a degree. How-

ever, the differences were statistically significant only

for those affiliated with the American College of Hospital

Administrators. This finding can be related to an earlier

finding indicating that those administrators with master's

degrees are more mobile and tend to hold positions with

more than one employer. Thus, as a group, their tenure

would be shorter. When tenure in previous positions was

compared to tenure in the current position, differences

were also observed. In all but the subgroup of non-

affiliates of the American College of Hospital Administra-

tors with master's degrees in health administration, tenure

in the current position exceeded the tenure in previous

positions. This suggests that tenure may increase when one

reaches the top administrative position or as one moves

into subsequent top administrative positions. This

difference will become larger with time since the tenure

for current positions was cut off at the time of collecting

the research data.








Implications for Further Research


Given the state of the health care system at this point

in time, additional research in the area of health adminis-

tration is needed. While this study revealed that many

health administrative positions are filled by non-graduates

of programs in health administration, the study did not

answer the question, "Why?". Research efforts should be

directed toward analyzing the actions of governing boards or

those responsible for employing health administrators to

determine the factors involved in employing health adminis-

trators. If program graduates are not considered the prime

candidates for these roles, why are they not so considered,

and what type of person is being sought?

Another, and obvious area of additional research, would

be to repeat portions of this study at periodic intervals

in the years to come. Such studies would reveal any changes

that might be taking place with respect to health adminis-

trative careers. Such information should prove interesting

and may be able to identify the impact of graduate programs

in health administration upon the health administrative

field over time.

In the area of hospital administration, obtaining in-

formation from a larger sample of hospitals would provide

an opportunity to breakdown the analysis of backgrounds of

hospital administrators into many small subgroups. These

subgroups would provide for the analysis of the data by




89



considering the factors of control, service, length of stay

and bed size. This would make possible the comparison of

the subgroups and the determination of specific differences

among the administrators seeking positions or holding posi-

tions in the various subgroups. This current study essen-

tially treated hospital administrators in one group so that

such comparisons were not possible.

It is the author's understanding that the W. K. Kellogg

Foundation has agreed to support a national commission to

study the field of health administration. This commission

would undertake an in-depth analysis of the need for and

the education of health administrators. This author looks

forward to the ultimate report of this commission's efforts.














BIBLIOGRAPHY


1. Sidney H. Garfield, "The Delivery of Medical Care,"
Scientific American, April, 1970.

2. Malcolm T. MacEachern, Hospital Organization and Mana-
gement (Chicago: Physicians' Record Company, 1957).

3. David Mechanic, "Human Problems and the Organization
of Health Care," The Annals of the American Academy of
Political and Social Science, January, 1972.

4. American Council on Education, University Education
for Administration in Hospitals: A Report of the
Commission on University Education in Hospital Admin-
istration (Washington, D.C.: American Council on
Education, 1954).

5. U. S. Department of Health, Education, and Welfare,
The Size and Shape of the Medical Care Dollar: Chart
Book/1970 (Washington, D.C.: Superintendent of Docu-
ments, 1971).

6. Center for Health Services Research and Development,
Reference Data on Socioeconomic Issues of Health
(Chicago: American Medical Association, 1971).

7. Herman M. Somers and Anne R. Somers, Medicare and the
Hospitals: Issues and Prospects (Washington, D.C.:
The Brookings Institution, 1967).

8. Committee on Government Operations, United States
Senate, Federal Role in Health (Washington, D.C.:
U. S. Government Printing Office, 1970).

9. Anne R. Somers, Health Care in Transition: Directions
for the Future (Chicago: Hospital Research and Edu-
cational Trust, 1971).

10. National Health Strategy: The President's Message to
the Congress Proposing a Comprehensive Health Policy
for the Seventies, White House Press Release,
February 18, 1971.




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