Group Title: concept of management development
Title: A Concept of management development
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 Material Information
Title: A Concept of management development applications for a health center
Physical Description: xi, 687 leaves. : ; 28 cm.
Language: English
Creator: White, Harold Clifford, 1931-
Publication Date: 1966
Copyright Date: 1966
 Subjects
Subject: Hospital administrators   ( lcsh )
Economics and Business Administration thesis Ph. D
Dissertations, Academic -- Economics and Business Administration -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis -- University of Florida.
Bibliography: Bibliography: leaves 630-686.
Additional Physical Form: Also available on World Wide Web
General Note: Manuscript copy.
General Note: Vita.
 Record Information
Bibliographic ID: UF00097886
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 - 000559183
oclc - 13445955
notis - ACY4631

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PT OF AIANAGEMEI\IT

VVELOPMENT;

rS FOR A HEALTH CENTER




















By

HAROLD CLIFFORD WHITE




...........




................

TATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERITY OF.FLORIDA
TIAL FULFILLMENT OF THE REQUIREM ENTS FOR THE
OF DOr-TOR OF PHILOSOPHY










UNIVEM11Y Or FLORIDA

1966











ACKNOWLEDGMENTS


I wish first to thank Dr. William V. Wilmot, Jr.,

who, as both Committee Chairman and Department Head, has

given encouragement at the most appropriate times, and

criticism and guidance when most needed. I deeply appreci-

ate the courtesy and interest shown by all members of the

Committee. I am especially indebted to L. Russell Jordan,

former Director, J. Hillis Miller Teaching Hospital and

Clinics,for having encouraged me to pursue this study. I

want also to thank those of the Teaching Hospital and

Clinics, as well as the various representatives of other

hospitals cited in this study, who have given their time

and effort to make material available to me. Also, to the

Teaching Hospital and Clinics and to the College of Business

Administration, my appreciation for the opportunity to be on

this campus and the financial support provided to sustain me

during my stay. To Mrs. E. N. Johnston, who has shown such

diligence and excellence in providing this study in finished

form, my continued gratitude.

Finally, and always, to Lucile, my wife, and Angela,

our daughter, thank you.












TABLE OF CONTENTS


ACKNOWLEDGMENTS . . . . . .

LIST OF TABLES. . . . . . . .

LIST OF FIGURES . . . . . . .

LIST OF CHARTS. . . . . . . .

PART I. INTRODUCTION, NATURE, AND SCOPE OF
PROBLEM

Chapter

I. INTRODUCTION. . . . . . .

The Problem . . . . . .

The Nature and Scope of the Problem

The Hypothesis. . . . . .

The Methodology . . . . .

Sources of Information. . ....

The Plan of Study . . . . .

II. NATURE AND SCOPE OF THE PROBLEM: THE

Historical Development of Hospitals

Complexity of the Hospital. . .

Organization Personnel. . . .

Comparison of Business and Industry
Hospitals. . . . . . .


Page

.* . ii

S.. ix



* xi

THE




. . S 1v

* S S * 1

. . 1

* * 5 5

S 5

* . . 7

. . 9

HOSPITAL 11'

. . . 11

* . 17

. * 37

to


III. NATURE AND SCOPE OF THE PROBLEM: MANAGEMENT

"Professional" Hospital Management. . .

Duties of Hospital Management . . .

iii


53

55
537

57-






Chapter

Evaluation of Hospital Management . . .

Management Education. . . . . .

PART II. PHILOSOPHY OF MANAGEMENT

IV. A GENERAL PHILOSOPHY OF MANAGEMENT. . . .

Introduction. . . . . . . . .

Philosophy and Conduct. . . . . . .

Publics . . . . . . . .

V. THE ROLE OF THE MANAGER . . . . .

Personal Characteristics. . . . . .

Functions of Management . . . . . .

Authority . . . . . . . .

Summary . . . . . . ..

VI. A PHILOSOPHY OF lMAAGEMENT IN THE HOSPITAL. .

The Philosophy of the Hospital Manager .

Philosophy of Management in Practice. .

Summary of a Philosophy of Management . .

PART III. LEADERSHIP


VII. THE LEADER. . . . .

Introduction. . . . .

The Leader. . . . .

Functions of Leadership .

VIII. THE INDIVIDUAL. . . .

Introduction. . . . .

Individual Traits and Needs

Attitudes Toward Leadership

iv


. . .. . .. 185

. . . . 183

. . . . 187

. . . . . 200

. . . . . 205

S. . .. . . 203

. . . . 2042

. . . . 221


Page

66





86

86

88

106

122

122

125

150

159

160

160

166

179







Chapter

Changing of Personality . . . . .

Summary . ......

II. GROUPS, ORGANIZATIONS, AND TASKS. . . .

Groups and the Organization . . . ..

The Task. . . . . . . . . .

Leadership and Attitudes. . . .... .

Summary . . . . . . . .

X. LEADERSHIP: A METHOD . . . . . .

Leadership Patterns . . . . . ..

The Effective Leader. . . . . . .

Summary . . . . . . . . . .

XI. LEADERSHIP: CRITICISM AND INTERPRETATION .

Limitations to Applying Democratic Leadership

Resolving the Conflict Concerning Democratic
Leadership . . . . . . . .

Applying Democratic Leadership. . . . .

Summary . . . . . . . . . .

XII. THE HOSPITAL. . . . . . . . .

Introduction. . . . . . . . .

Hospital Departments.. . . . ..

Individuals, Groups,and Tasks . . . .

Summary . . . . . . . . .

XIII. HOSPITAL LEADERSHIP . . . . . . .


Introduction. . . . .

The Manager . . . . .

v


a. .


S S


. *.


Page

226

227

228

228

244

248

252

253

253

262

274

276

276


286

295

306

308

308

309-'

317-

331 -

333

333

334








Chapter


Difficulties of Introducing Democratic
Leadership . . . . . . . .

Need for Democratic Leadership in the


Hospital


. * *


The Democratic Hospital Leader.

Summary . . . . . .

PART IV. LEARNING


XIV. PERSONALITY THEORY. .

Introduction. . . .

Personality Theories. .

The Perceptual Approach

XV. LEARNING. ... .

Introduction. . .

Definitions of Learning

Types of Learning . .

Conditions for Learning

Environmental Influences

Forms of Learning . .

Motivation and Learning

Learning Curves . .

XVI. LEARNING, BEHAVIOR, AND

Behavior and Learning .

Perception and Learning

Change Through Learning

Attitudes . . .

Summary ........

vi


U


.*

*

.*

*

o

*

,*

.*

PE

*

*

.*

.

*


* C

* C


Page


343


. . 3. 51

. . 3 56

. . 361


. . . . 369

. . . . 369

. . . . 370

. . . . 3 77

. . . . . 390

. . . . . 390

. . . . 392

. . . . 394

. . . . 595

f Learning. . . 405

S . . . . 409

. . . . . 412

. . . . 414

RSONALITY . 417

. .. . . 417

. . . . 419

. . . . 426

. . . . 429

. . . . . 432


. . a








Chapter


The Adequate Self . . . . .

XVII. LEARNING AND MANAGEMENT TRAINING. . .

Introduction. . . . . . .

Implications for Human Relations . .

Approach to Change. . . ....

The Learning Situation. . . ..

Guide for the Trainer . . . .

Summary . . . . . .

PART V. MANAGEMENT DEVELOPMENT PROGRAMS

XVIII. MANAGEMENT DEVELOPMENT: CONSIDERATIONS
ALTERNATIVES . . . . .


Page

S. 433

. . 436

. . 436

. . 436

. . 441

. . 442

. . 449

. . 462


AND
a .


Introduction. . . . . . . .

Considerations for Management Development .

Survey of Development Programs. . . .

Weaknesses and Difficulties of Management
Development . . . . . . .

Summary . . . . . .

XIX. MANAGEMENT DEVELOPMENT: IDENTIFICATION AND
EVALUATION . . . . . . . .

Search for the Ideal Program . . .

Determining Training Needs . . . .

Evaluation of Management Development . .

XX. MANAGEMENT DEVELOPMENT IN THE HOSPITAL. .

Introduction . .. . .

Considerations of Management Development..

The Hospital Management Training Program. .

vii


468

468

469

478


487

499


501

501

505

509

521

521

521

528








Chapter Page

IXI. TECHNIQUES OF MANAGEMENT DEVELOPMENT. . . 535

Introduction. . . . . . . . 535

Training Techniques . . . . . . 538

XXII. TECHNIQUES OF MANAGEMENT DEVELOPMENT:
CONTINUED. . . . . . . . . 567

Training Techniques: Continued . . . 567

Management Development On-The-Job . ... 582

Summary . . . . . . . . . 589

PART VI. CONCLUSION

XXIII. CONCLUSIONS ON A CONCEPT OF MANAGEMENT
DEVELOPMENT WITH APPLICATIONS FOR A HEALTH
CENTER . . . . . . . .... .. 590

Criteria. . . . . .. . . . 590

Objectives of Management Development. . . 593

Preparing a Management Development Program. 593

The Management Development Program. . . 599

Evaluation of Training . . . 608

Conclusions . . . . . . . . 610

APPENDICES. . . . . . . . . . . 613

APPENDIX A. THE HOSPITAL ADMINISTRATOR'S CODE OF
ETHICS . . . . . . 614

APPENDIX B. TRAINING PROGRAM OUTLINES . . . 616

APPENDIX C. EVALUATION OF HANAGEMIENT TRAINING 627

BIBLIOGRAPHY. . . . . . .... . .. 630

BIOGRAPHICAL SKETCH . . . . . . . 687


viii











LIST OF TABLES


Page


3-1 Analysis of Training Need Areas for Hospital
Supervisors . . . . . . . . .


Table











LIST OF FIGURES


Figure Page

7-1 Determinants of group effectiveness . . 186

9-1 Communication nets. . . ... . 242

9-2 All channel nets. . . . ... . 243

10-1 Continuum of leadership behavior. . . . 254

10-2 Relationship of agency performance to
management practices shown by favorable
comments of agents on their managers'
behavior. . . . . . . . 264

10-3 Foremen's reaction to a poor job as reported
by their men. . . . . . . . . 266

11-1 Recognition given for good work as seen by
the supervisor and the employees. . . . 290

15-la Learning curves of negative accelerated
curves. . . . . . a . 415

15-1b Learning curves of positive accelerated
curves . . . . . . . 415











LIST OF CHARTS

Chart Page

2-1 Hospital Administration and Medical Staff . 24

2-2 Hospital Staff Positions. . . . . . 25

2-3 Medical . . .. . . . . ... 26

2-4a Nursing Service Department, Nursing Education 27

2-4b Nursing Service Department, Nursing Service . 28

2-5a Professional Services Department. . . . 29

2-5b Professional Services Department (Cont.). . 30

2-6a Administrative Services, Operations . . .. 31

2-6b Administrative Services, Operations (Cont.) . 52

2-6c Administrative Services, Medical, . . ... 33

2-7 Business Department . . . . . ... 34

2-8 Dietary Department. . . . . . . . 55










PART I. INTRODUCTION, NATURE, LND SCOPE OF THE PROBLEM

CHAPTER I

INTRODUCTION

The Problem


The purpose of this project is to design criteria for

a development program that will have application, in general,

to all management personnel, and, specifically, application

to management personnel of hospitals and health related

institutions. The approach to be suggested is conceived to

be applicable to all levels in the hospital organizational

hierarchy and to both medical and non-medical personnel in

supervisory positions. Indeed, it has been concluded that

to the extent that all levels and all groups are not in-

cluded, the value of the proposed program would have

reduced effectiveness.


The Nature and Scope of the Problem


Health care has received increased attention in

recent years and it is to be expected this trend will

continue in the future. The implications for the need of

a healthy population are obvious. Research has provided





2

greater means to prevent and cure disease, increasingly

widespread education has provided greater numbers of

qualified people in the various medical and pariaedical

professions, a more affluent society is better able to sup-

port more adequate health services, and a better informed

public is demanding more prompt and expert treatment.

Impact of hospitals.-As would be expected, the growth
in the number of hospitals and hospital employees has been

steady. In 1963, there were 7,138 hospitals in the United

States with 1,840,000 full-time employees (Hospitals, 1964,

p. 469), ranking hospitals fourth in employing industries

in the United States. Significantly, since 1946, employment

in hospitals has more than doubled. Between 1953 and 1958,

hospitals were responsible for 25 per cent of the net in-

crease in the total labor force in this country. Approxi-

mately 2.5 per cent of all employed in the United States

work in hospitals (Hospitals, 1962, p. 414). Employees

include a broad spectrum of skills and educational back-

grounds ranging from the unskilled janitor and maid, through

the skilled technician, to the highly skilled surgeon. Two-

thirds of hospital employees are directly involved with

patient care. In 1963, 100 million outpatients and 26

million inpatients received hospital care. Of total

hospital expenditures amounting to nearly eleven billion

dollars, approximately two-thirds are allocated to employee







salaries and wages, and the percentage for employee compen-

sation continues to rise.

Of all hospitals, the greatest number are classified

as short-term general hospitals; of this group, nearly 60

per cent have fewer than 100 beds, while only about 2.5 per

cent have over 500 beds. With an average of 2.18 to 2.53

employees per bed, the majority of hospitals employ fewer

than 250 employees and few of the larger hospitals would

exceed 1200 to 1500 employees.


The hospital as an institution


Brown (1961) points out that the present-day hospital

is more than a place set aside for curing the ill and in-

jured. It may also be one or more of the following:

1. An Economic Enterprise. The average hospital employs
approximately one of every 50 employees of the community
in which it is located. Its payroll and purchasing
power have created a significant impact on the community.
Hospital administration must be aware of the importance
of budgets and costs in managing their institution.

2. A Professional Enterpriso. Many decisions are made
for the hospital by those who are not a part of the
hospital itself. Typically, about twenty professions
are represented in a medium-sized hospital, each with a
national organization. Often it is the profession that
can best evaluate its members. (This does not neces-
sarily mean that the professional organization can
always best judge the total situation.)

3. An Educational Enterprise. There are approximately
.250,600 full time students participating in formal
education in hospitals in the United States. To pro-
vide this education costs the nation's hospitals
$200,000,000 annually.








4. A Social Enterprise. The hospital, unlike most
social agencies, sells its services. The hospital, in
creating its services, is productive. Regardless of
the individual's ability to pay, the hospital is ex-
pected to serve all who need its aid. However, the
hospital administration must not confuse the concept
of "non-profit" hospital with a lack of financial
responsibility.

5. A Religious Enterprise. One-fourth of the nation's
hospitals have a formal chaplaincy program, and, what
is more significant, one-third of all persons seeking
hospital care are admitted to church-owned institutions.

6. A Research Enterprise. Hospitals have the skilled
personnel and are rapidly increasing their ownership
of facilities for research. Presently, about one-half
billion dollars is being spent for research in hospitals.

7. A Community Enterprise. Hospitals exist as a re-
sponse to the community's desire to provide its citi-
zens with a full range of medical service. For any
given community, the hospital can be a symbol of civic
concern and accomplishment. In fact, the hospital in
some instances may be a symbol of community ambition.

8. A Public Enterprise. Typically, the hospital is
under local control and enjoys a certain amount of
local autonomy. This public aspect is limited, expanded,
confused, or supported by the quality and quantity of
third party financing and regulation provided by state
and federal governments and by private medical plans.

If the hospitals are valuable and their increased

contributions are to be encouraged and management plays the

vital role to organize and motivate for hospital success,

it may be concluded that the greatest single contribution

that can be made to further this goal would be to contribute

to more effective hospital management. The problem is to

find what knowledge and attitudes the manager is to possess

to be the most effective, and to find the most efficient

methods by which the knowledge can be learned and the atti-

tudes developed.






5

The Hypothesis


The hypothesis upon which this study is based is

twofold:

1. There is one basic manager pattern of behavior that
is most appropriate for organizational effectiveness.

2. This pattern of behavior can be learned through a
proper program of management development.


The Methodology


It would be fairly convenient, and it is believed

fairly satisfactory, to develop a management training pro-

gram based on outlines of programs now in use by a number

of organizations in and out of the hospital field. However,

it is also believed that much of this material is based more

on a "me-too" philosophy and less on a well-considered,

systematic development of a comprehensive program to meet

specific needs of a given institution. It is believed that

there are universals of effective organization structure

and management behavior. To this extent, all well-conceived

programs will have elements similar to all other programs.

Any manager receiving a general program of this nature

would be expected to benefit regardless of the organization

or his position in the organization. However, each type of

organization and each individual is unique in various ways.

Of considerable importance are variables such as the

personality of the leader, the personalities of the








subordinates, the organization structure, the organization

goals, the historic background and development of the

organization, and the publics with which the organization

must deal.

There is considerable discussion in the literature

related to content of specific programmin management develop-

ment, of which representative examples will be presented.

It is believed that little of a permanent nature is gained

by a "one-shot" approach. Training and development, to be

effective, must be continuous. Also, there appears to be an

assumption by many that a program can be directed solely to

one group of managers- usually lower level management and

thereby solve most, if not all, management problems. More

comprehensive evidence indicates that for management train-

ing to be effective, all managers at all levels in the

organization must participate. A lower level manager has

little opportunity to practice newly learned knowledge which

lacks higher management support. Further, at each management

level, those trained in a class situation need instruction

and guidance from their immediate superiors. Management

training must be interpreted in terms of behavior. Leader-

ship behavior may be considered as a skill and, thus,

management training may logically be expected to require

practice for learning, as is required for any skill. Train-

ing involves learning; therefore, the most effective forms







of learning require the application of material through

practice. In addition, management training cannot be con-

sidered as separate from the manager's on-the-job duties.

Training must relate to the role of the manager. Manage-

ment development requires more than a management training

program. It requires continuous development and self de-

velopment. Finally, as a guide for training and on-the-job

behavior and as a measure of training effectiveness, a well-

conceived program requires some method or methods of

measurement.

Emphasis on Leadership rather than on the Functions

of Management is believed to be the key area of attention.

This is not to indicate a lesser importance of Functions,

but it is believed that concentration on Leadership behavior

will lead directly to more effective overall practices of

the manager.


Sources of Information

Based upon the stated hypothesis, a thorough search

of the literature is of value in beginning a study for the

proposed program. Books and articles in the fields of

philosophy, management, organization, leadership, and

learning theory, presented by educators, researchers, and

practicing managers are of considerable value. Articles

on the philosophy of management and theories of learning,







expressions of beliefs and experiences of the practicing

manager, and results of leadership and organization studies

both in the laboratory setting and on-the-job, all con-

tribute to the development of an effective program.

Interviews with practicing managers, especially in the

hospital field, are of value, In addition to this writer's

interviewing for earlier studies and interviews for this

study, a considerable amount of "interviewing" has been

accomplished by others which is found in the literature.

Contacts with those having experience in management

development, such as universities with active management

development programs, management consulting firms, testing

services, and businesses, industries, hospitals, and

their associations, provide much information. Unfortunate-

ly, most of these organizations are reluctant to share

their experiences and knowledge with others. Even those

who publish extensively have limited the exactness of

their reporting to such an extent that it would be diffi-

cult for the reader to take any one article or series of

articles and duplicate the training programs with any

assurance of exactness. On close examination, there tends

to be a vagueness of content, presentation, measurement, etc.

However, even here one is able to detect certain patterns.

Based on known effectiveness of certain programs or on known

success -of organizations utilizing certain programs, the







reader is able, indirectly, to make evaluations of their

probable effectiveness. It is to the extensive literature

that major emphasis will be made in preparing the recommenda-

tions to be presented.


The Plan of Study


In support of the stated hypothesis for the develop-

ment of the management development program, the procedure

to be used will be to consider each of the following areas:

1. Philosophy of Management: Accepting that any
particular management pattern will be successful only
to the extent that it is compatible with the philosophy
of the leader, his subordinates, and the publics with
whom they come in contact, this philosophy, or these
philosophies, must be understood. In the United States,
most individuals have their attitudes and norms shaped
by the general philosophy of the Western tradition.
This philosophy will be considered as it relates to
management in general and to hospital management in
particular.

2. Leadership Patterns: Having established the phil-
osophy in which the manager is to operate, the next
step is to find what leadership pattern, or which
leadership patterns, are the most successful. This
will be attempted by reviewing the literature related
to studies of leadership behavior of various types to
find which is the most successful under a variety of
situations. From this, a better decision can be made
as to what type of leadership is to be learned and then
applied on the job by the manager.

3. Learning Theory: it is not sufficient to be able
merely to tell the manager what form of leadership
behavior is the most successful. Training of the
manager needs to be efficient in any organization
where time and manpower are an expense; time and man-
power are especially critical in the hospital where
their uses are related to the reduction of pain and
the treatment of the ill and injured. A study will be
made of theories and techniques of learning in an at-
tempt to find those methods most efficient in relating
what is known about leadership to the manager who is to
practice leadership.








4. Training Programs. With the volume of material
written about management training programs in and
out of the hospital field, it is appropriate to re-
view what types of programs have been conducted. The
review will be concerned with sucn factors as: course
content, methods of instruction, student selection,
Instructor selection, training facilities, and results
of the training. From this review, it is believed that
various patterns of successful and unsuccessful train-
ing programs will be found. The successful forms can
be combined and related to the specific problems of
the hospital. All programs can be related to the
philosophy of management, leadership patterns, and
learning theory.

5. A Management Development Program for the Hospital:
Following the above analysis, one will be able to de-
rive, if not the ultimate in a training program for
managers, at least a training program with a high
probability of success. Such a program would relate
to demands and expectations of society, to the needs
and attitudes of the clientele served, to the hospital
employees, and to the managers as the focus of attention.

Having arrived at the most effective methods of

leadership and the most effective technique of teaching these

methods, the challenge is to adapt them to a management pro-

gram. In its broadest concepts, the basic approach would be

applicable to all organizations; specifically, an exact pro-

gram of management development will be suggested for all

management personnel in the hospital.

Final interpretation and evaluation is left for the

writer. It is believed that the reader the administrator

or training director who will use this program as a guide -

will also need to adapt suggestions made to his specific

organization with its unique needs. The value will be that

the program presented will provide more guidance and will be

devised on a more firm foundation than has been found in the
literature.










CHAPTER II


NATURE AND SCOPE OF THE PROBLEM: THE HOSPITAL


Before a meaningful management development program

can be suggested an appreciation and understanding of the

hospital as an institution and of the hospital manager as

a guiding influence must be established. That is the pur-

pose of this and the following chapter.


Historical Development of Hospitals


Early beginnings.-To fully appreciate the hospital

as it is today, it is of value to consider, briefly, the

historical development of the hospital. Understandably,

the hospital is a product of its background as well as of

its current environment. The following discussion is drawn

heavily from Rosen (1963), although the major points are

found included in most reviews of hospital history.

"Medicine" in some form has been practiced in all

cultures for all of recorded time. However, the first

attempts toward hospitals in any form approximating present

day concepts, began, in the Western world, during the third

and fourth centuries under Roman influence. During medieval

times, hospitals were founded for religious and social








reasons. Often travelers, especially the ill, sought

monasteries as shelter. The resident monks became the

medical practitioners, and their herb gardens their source

of medication. By the end of the 15th century, Europe was

"covered with a network" of hospitals financed through

charity alms, endowments, legacies, donations, and offer-

ings. Patrons of these institutions acted much as the

present-day hospital Board of Trustees, appointing the

administrator, establishing rules, often administering dis-

cipline, and, in some cases, selecting clientele. By the

end of the middle ages, many of these institutions had

developed into institutions resembling present-day nursing

homes boarding homes for the aged.

Changing philosophy and practices

In 1311, Pope Clement V established more exacting

controls over the religious "hospitals" by requiring that

the administrator swear to honest administration and re-

quiring him to provide financial statements to the local

bishop. Beginning with the 13th century, hospitals came

more under secular control but continued to employ religious

workers.

During this earlier period, there was an underlying

philosophy motivating care of the sick. Service was seen

as providing the greatest good to the giver both for the

patrons and the religious servant. That is, the sick








provided the religious an opportunity to serve God through

administering medical assistance. Gradually, changes

evolved. Less emphasis was placed on the donor and more

emphasis on the receiver the sick. The trend was gradually

away from the hospital as a charitable institution to the

hospital as an organized agency of public assistance. How-

ever, the charitable concept continued to be strong even to

the end of the 19th century with much of the same phil-

osophy remaining today. It has been the history of hospitals

that government has eventually taken over where private

action began. Society began to discover that patients who

received no medical attention remained longer in hospitals.

In response to this recognition, from the 14th century on,

physicians were found to be more closely associated with

hospitals.

The 16th and 17th centuries marked the introduction

of the application of science to medical care. Much re-

search, study, and application was financed through founda-

tion grants. The 18th century middle class, generally,

desired order, efficiency, and discipline, and held an

increasing concern for man's well being. Such attitudes

naturally carried over to concern for community institutions -

including hospitals.

Colonial United States was behind Europe in medical

services. The first successful general hospital in the New









World was founded in Philadelphia in 1751. New middle

class norms changed emphasis from purely medical considera-

tions to social considerations; it became the goal not

merely to relieve suffering, but to cure and to return the

sick to a productive life sickness was unproductive. In

line with this concept, the chronic, incurable, and terminal

patient was generally not acceptable in hospitals. They

were placed in separate institutions. This approach was

closely in line with much present-day practice; the volun-

tary hospital accepts acute, short term patients and separate

institutions are provided for those with chronic and in-

curable diseases.

As the trend in medical care changed from charitable

to social considerations, other factors entered into the

hospital organization. By the late 1800's, the number of

hospitals increased as the number receiving medical training

increased. Nurses became more competent through improved

training. Beginning with the turn of the present century,

greater numbers of parimedical professions entered the

hospital. Today, the hospital has become the physicians'

workshop. The current trend is lor the hospital to become

the community health center with greater responsibilities

and affecting a greater number of citizens in more and more

situations.








As late as the 1850's, the financially independent

when ill predominately remained at home for treatment, even

for operations; the poor feared the hospital as a death

sentence. The 1920's have been identified as a major turn-

ing point in the public's attitude toward hospitals. Over

the preceding years there had been a great decrease in

hospital mortality rates as new techniques, improved anti-

septics, and more effective infection control procedures

were introduced. People, increasingly, saw the hospital as

personally valuable. Increased popularity of hospitals

created increased demand for still more services. New

specialty fields wore embraced, not all considered purely

medical, such as the use of social workers, nutritionists,

and accountants. This increased complexity has brought

increased cost. Recently, there has been even more com-

plexity and change due to greater emphasis on hospital

administration, prepaid medical plans, still greater public

interest in hospital care, and the increased role of govern-

ment.


The present situation


Querido (1962) points out that "the hospital evolves

in a given society as a result of the interplay of forces

which are active in that society...determined by the level

of culture and of thought and by economic, social and

technical conditions existing at a given time." At present







he finds the major trends to be:

1. A change in emphasis from bed space to work space.

2. Differentiation between medical and nursing services.

3. A change from differentiation according to medical
specialism to differentiation according to requirements
of the patient.

4. Disappearance of class differentiation between
hospital users the patients.

The hospital of today and even more the hospital

of the future is seen as a central point where "through

new concepts of medicine, the art and science of healing

twill evolve as] a whole new image....Based on...love through

service and strength through knowledge, a hospital is no

longer a place of despair and agony, but a fortress of hope

and a temple of dedication....It is our community monument

of the Brotherhood of Man" (Landry, 1965).

The new setting has created a situation in which the

doctor requires the hospital as a place of work and the

hospital would be unrecognizable as it is now known without

the physician. The increasing reliance of the doctor on

the hospital and the increasing role of relatively new

services and specialists have added to the complexity of

hospital operation and have required many controls and an

amount of teamwork that many find unwanted. However, all

intimately involved with hospital operation have found an

increasing need for administrative efficiency, rationality,

productivity, and accountability.








Complexity of the Hospital

Power structure

Hospitals have been the object of a considerable number

of studies embracing all groups in the hospital including

the patient. Perrow (1963) has studied the power structure

at the top levels in the hospital hierarchy. The subject

of the study was a 300-bed "'representative hospital." The

author accepted the hypothesis that, in the long run, an

organization will be controlled by individuals or groups of

individuals who perform the most difficult and critical

tasks. The characteristics of the dominant group such as

social background, career, ideology, personal interests,

etc. will determine the major operating policies and goals

of the organization. The three groups found to have the

greatest power in the hospital are: the board of trustees

who control capital investment and community acceptance; the

physicians who control the increased complexity and impor-

tant critical skills; and the administrator who controls the

increased complexity of activities and is involved in in-

creased contacts outside the hospital.

In earlier developmental periods, the formal position

of the administrator was one of a passive lieutenant who

kept records and supervised plant operations and maintenance.

In the past, administrators typically possessed a background

in either nursing, management of a hospital department,








management in a business enterprise, or experience in volun-

tary organizations. More recently, the administrator has

introduced himself as a coordinator between trustees and

physicians. There has been increased respect for his

functions; therefore, the administrator has gained increased

authority and prestige.

Because of the three major power groups, the concept/

of multiple leadership is seen as a probable consequence.

Perrow sees this as creating a situation in which the

organization is less able to pursue long term goals. Further,

an organization with multiple leadership, to be stable, is

likely to exist only when there are multiple goals which

lack precise criteria of achievement and where there is

considerable tolerance with regard to achievement. Accom-

modating all power interests can lead to: organization

drift, ambiguity of purpose, and opportunism. With multiple

leadership, there is a need for some sort of facilitating

leadership that keeps "explosive issues" from erupting too

often, and maintains comparable relations between the

parties.

Smith (1955) finds that "basically, a hospital may

be conceived as an organization at cross-purposes with it-

self," because of the dual authority role between the

hospital's formal supervisory hierarchy and the impact on

the hospital by the physician. The doctor is able to exert







pressure at All levels in the hospital. This is found to

be especially true in areas that are typically not clearly

defined between administration and medical, such as pharmacy,

pathology, X-ray, patient admissions, and medical records.

It is a situation where "professional competence [of the

physician] is exercised in a matrix of lay administration."

The physician, armed with charismatic authority, defined as

the "gift of grace," is "defiant" of administrative regu-

lation. An inherent conflict often results between lay

scalar status and functional status. Employees are caught

in a conflict situation because they receive orders from

both. Smith sees the hospital possessed with opposing

values or symbols money advocated by the administration

as part of its business orientation, and service which is

the physician's major goal. (There may be those who would

choose to argue with this differentiation; many, including

administrative personnel, have been attracted to hospital

work because of the desire for service, while some physi-

cians, correctly or incorrectly, have been accused of being

more interested in personal financial gain than in providing

patient care.) As viewed by Smith, the conflict can be

further complicated in those situations where some individuals

and departments exploit the system by working the administra-

tor against the physicians. There "may be no ideal solution

to this kind of problem...[but] administrators who understand







this are better equipped to deal with the stralan of their

organizations."

Increased demands on the manager


Whistler (1964) sees additional changes involving

the administrator and others in the hospital. The intro-

duction of electronic computers for application to

operational problem-solving is seen as tending to decrease

the layers in the organization and leading to more centrali-

zation. There is greater development and application of

management practices by the use of operations research,

mathematics, and statistics. Finally, there is greater

insight into the nature and functions of organizations

through organization theory. The Western concept of the

value of education and research has led to a more educated,

critical, and mobile society with whom the administrator

must deal. Organizations that not only generate change but

adapt to change when required are seen as those which will

most effectively survive. As part of the challenge, and as

required by the situation,(Whistler (p. 55 )is "increasingly

convinced that management training must continue throughout

the career of the executive" if he is not only to keep up

but to lead in the changes.

There is an increased demand for medical care by the

citizen for himself and for his follow citizens. Hospitals

have to adjust to a broadening roln. Some of these demands








are (Klumpp, 1959): increased interest in preventive medi-

cine, studies of environmental control, the addition of

more services as the out-patient clinics, diagnostic

facilities, research activities, long term care, rehabili-

tation, and home care. Increased demands have created a

greater need for effective coordination with other community

health agencies outside the hospital. Many believe that

the hospital of the near future will be a health complex,

that is, a hospital with more than one roof, each unit pro-

viding separate, specialized services.

Management of change

As society has changed, hospitals and the roles of

the administrator and subordinate managers have been forced

to change. The administrator's role has been brought about

partly by changes outside his control, but more recently

he has been the motive force behind much of the change. He

has helped change the hospital, and, thereby, changed atti-

tudes toward the hospital by those in and outside the

hospital. In the recent past, "almost exclusively, the

concern of superintendents [administrators] was with the

internal activities and process of the hospital. They dealt

with what would be regarded today as simple problems in a

simple organization" (Bachmeyer, 1965). As in industry,

the hospital field has experienced changing concepts con-

cerning delegation, formalized reporting systems, individual








development, and interest in the activities of other

hospitals.


Importance of the manager


The importance of the role of the administrator is

well stated by Dressel (1963): "Perhaps the single most

important decision made by the hospital trustee is the

selection of a new administrator."

There are certain aspects of the management position

that appear to be common to all formal organizations, in-

cluding the hospital (Davis, 1960). The effectiveness of

leadership depends on the ability to: recognize the nature

of the situation, evaluate the significance and requirements

of the situation, face the facts concerning whatever factors

are operating to create the situation, and follow the course

of action dictated. The role of leadership is the exercise

of that combination of personal qualities which influences

people to cooperate toward some common goal because they

find it desirable to do so,

Leadership can logically be seen as separate from

the "functions" of management, although understanding and

practice of both are mandatory for effective management. It

is for the leader to establish and interpret the organiza-

tional objectives. Objectives are interpreted in terms of

satisfaction of needs or desires.







Functions in the hospital

For the hospital, the objectives may logically be

seen as: relief from disability, encouragement and main-

tenance of morale, medical care for speedy recovery, pleasant

environment, cost compatible with ability to pay, etc. In

sum, the major objective of the hospital is to provide

"Quality Patient Care." To this end, the major hospital

organizational functions are: diagnosis, advice, prescrip-

tion, application of medical procedures, direction of

nurses and medical technicians, and related medical activi-

ties. In support of these activities, hospital management

is responsible for the functions of: general administration

of nursing services, general supervision of medical facili-

tating service, general supervision of non-medical services,

operation of the hospital plant, personnel services, account-

ing and financial functions, etc. Therefore, the challenges

of the manager are both personal and organizational.

Hospital organization

The following charts (Chart 2-1 Chart 2-8) show a

hypothetical hospital organization. These charts are a

composite taken from a study made by the U.S. Employment

Service in cooperation with the American Hospital Associ-

ation (United States Department of Labor, 1952).

In reviewing this organization, one may question

certain decisions of organizational structure, and those

























































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intimately associated with hospitals may question certain

organizational grouping, terminology used, or units in-

cluded or excluded. This is, however, the single most

complete study found and provides a point of departure for

discussion. This organization is useful to indicate more

specifically the variety of activities that may be carried

out in the hospital, and, more specifically for present

purposes, the numbers and types of supervisory personnel in

the hospital.

Anderson and Warkov (1961), in a study of organiza-

tion structure and personnel behavior in 51 Veterans'

Administration general and TB hospitals, have found that,

regardless of the type or size of hospital, approximately

12.5 per cent of the employees hold supervisory positions -

neither size nor complexity of functions appears to cause a

change in the percentage of management personnel.

With the increasing complexity and challenges, a

survey by the American Hospital Association found that

"many administrators may be using the wrong management

tools, although on the whole they are doing a good job..."

(Hospital counseling program..., 1960). It was found that

administrators were spending "too much time" with internal

operations. This was concluded to have been caused by

boards of trustees who typically evaluate the administrator

on the basis of internal operations only. In many cases







there was improper delegation, or poor understanding of

delegation, with no clear lines of authority. Too few

administrators were seen as properly using a budget; too

few understood its purposes and uses. It was found that

there were incomplete reporting systems, with an absence of

reports from service departments. Most reporting was re-

quired upward from subordinate to superior with little

downward reporting. Many hospitals were found to lack

adequate planning. Even where delegation of authority was

well carried out, it was found in many situations that

there was oor delineation of ailJhority limits between

individuals and between departments. Nursing staffs,

generally, were the most effectively organized, while X-ray

and laboratory departments were also generally well managed.

Medical staff organization was "usually adequate," and in-

cluded a well-defined formal organization structure.


Organization Personnel

Leadership and personnel

It is of value to review studies of hospitals which

suggest the complexity of interpersonal relationships.

Georgopoulos and Mann (1962) of the Survey Research Center,

have prepared the most sophisticated study found in the

literature. Major emphasis was related to the measurement

of patient care, although their general discussion, rather







than their specific aims, is of more interest to the present

discussion. While their investigation was limited to ten

hospitals located in lower Michigan, review of other

studies suggests that the discussion is fairly representa-

tive. The authors believe that "motivating organization

members towards the objectives of the organization is much

less of a problem for the hospital than for other large-

scale organizations. The goals of individual members and

the objectives of the organization are viewed as being coni

siderably more congruent in the hospital."

They find that because much of the activity within

the hospital is highly variable- and irregu-l-ar,_ itis desir-

able that much of the work be yoluatary, informal, and

expedient. 'Paradoxically, however, they have found that

most work is highly formal and quasi-bureaucratic with

formal policies, formal written rules, and formal authority.

Round-the-clock, continuous operation necessarily requires

a considerable amount of coordination between shifts and

departments, and many activities are carried out during the

absence of the physician as the instituting authority.

Hospitals tend to be authoritarian as to leadership, partly

as a result of religious and military beginnings. Hospital

leadership is expected by the authors to be authoritarian

for some time because the concern for patient health de-

mands strict attention to specific ruleS, because of the








desire for efficiency, and because of the desire to adhere

to traditions. The demand for, and the acceptance of,

authoritarian leaders comes about, in part, also from the

professionalism in many areas of the hospital which leads

to certain norms and expectations. The authors also detect

that inherent in the structure of-multiple leadership

(trustees, physicians, and administration) is a tendency

to decentralization. (It is of interest to consider this

conclusion contrasted to that of Whistler (1964), quoted

earlier, who has been led to the expectation of greater

centralization.) "Staff" is seen as having more authority

than generally found in business.

The hospital is unique in that the majority of its

supervisory positions are filled by women; on the other

hand, few women are on boards of trustees, are members of

medical staffs, or hold top administrative positions.

Typically, Registered Nurses, aides, laboratory technicians,

and X-ray technicians are women, and most are in their

20's. Of the hospitals studied, 45 per cent of the RN's

were part-time employees.

Administrative personnel tended to be less satisfied

with the training they received than were non-supervisory

employees. In further support of the need for supervisory

training, the majority of supervisory nurses, for example,

were promoted from the ranks in the organization in which








they were presently working (Georgopoulos and Mann, p. 10).

Only 24 per cent of the supervisory nurses had held similar

positions in other hospitals. Training is expensive and

demands a return. Therefore, it is encouraging to find

that 61 per cent of supervisory nurses and 60 per cent of

the administrators and department heads had been with the

hospital for five years or longer (Georgopoulos and Mann,

p. 104).

Most supervisory and non-supervisory employees feel

they have freedom on the job, but they also feel pressure;

feelings of both freedom and pressure are greatest for

those of higher rank. Thirty-four to 44 per cent of non-

supervisory employees are satisfied with their opportunities

for advancement, with technicians being the least satisfied.

Sixty-two per cent of the supervisors are satisfied with

the chance for further advancement (Georgopoulos and Mann,

p. 129).

The "majority" of personnel express "high" satis-

faction with the supervision they receive, and over 60 per

cent see the hospital as an "excellent" or "very good" place

to work.

Typically, hospital management is a highly educated

group; of all managers, department heads have the lowest

average education, but, even within this group, 40 per cent

are college graduates.








Coordination


A "large amount" of time spent by supervisory nurses

and department heads is concerned with coordination.

Georgopoulos and Mann (p. 276) find coordination the key

to effe hospital performance. Even though no plan can

explain all organizational activities, it is typically

assumed by management that the personnel will accept any

plan given. For acceptance, however, there must be a

frame of reference and a source of expectations for the

individuals concerned. The authors have concluded that

clearly defined policies, rules, and regulations improve

coordination. A general feeling of willingness to help

aids in coordination, while any form of strain has a nega-

tive effect. As has been indicated, higher level managers

experience the greatest feelings of strain, and it is at

the higher levels where coordination is most crucial.

Although the hospital administrator and the director of

nursing were found to be in the most critical positions

for relating coordination to hospital efficiency, neither

was statistically more important than other supervisory

positions.

Coordination appeared to take place when appropriate

members were aware of the importance of it. Coordination

was significantly related to the effectiveness of both

problem awareness and conflict-solving (Georgopoulos and








Mann, p. 329). Communication, as would be expected, was

found to be necessary for coordination. However, this means

a particular form of communication. Openness and complete-

ness of communication is more important than formalized,

programmed communication, while there is only a small rela-

tion of frequency of communication to coordination it is

quality rather than quantity of communication which affects

coordination.

Largeness creates its own problems; the larger the

hospital, the less coordination observed. Greater absentee-

ism for RN's, and increased turnover among aides, were

examples of consequences resulting from a lack of coordina-

tion. Effective coordjnation was carrel~at-aEd.t: sharedness
~---------- --
and complementarity of expectations, member cooperation,

openness of communication, adherence to rules, promptness

of problem solving, absence of tension, and absence of

"unreasonable" pressure (Georgopoulos and Mann, p. 352).

The importance of the human element becomes more

apparent from the following conclusions drawn from the study.

The more "affluent" hospitals were not significantly more

likely to have better material facilities, and better

facilities do not necessarily mean better patient care.

Neither was there a relationship found between average

employee wages and level of patient care. As might logically

be expected, there was a positive correlation between the







skill level and number of nurses and quality patient care.

Further, the quality of nursing care is "strongly related"

to overall hospital coordination (Georgopoulos and Mann, p.

389). Interestingly, however, performance of any given

department was found to be almost completely unrelated to

quality of performance of any other department.

Problems must be met directly. It was found that

positive attempts toward better coordination are much more

crucial for effective organizational functioning than merely

attempting to avoid disruptive behavior. Coordination and

cooperation come about not because of an absence of negative

behavior, but from positive attempts to implement coordina-

tion and cooperation, accomplished through effective

communication.

The authors divide supervisory skills into three

groups: admIntrativehiman-siatons and tec al. Of

the three, technical and administrative skills appear to be

most closely correlated, and technical and human relations

skills least correlated. Supervisors are perceived by

their subordinates as being strongest in the technical areas

and weakest in human relations. As is found in industry

generally, the desired skill mix between supervisory levels

in the hospital vary. The higher the manager in the organi-

zation, the more important are the administrative skills;

the lower the manager in the organization, the more important








are the technical skills; human relations is important at

all levels in the organization. Proficiency in all three

supervisory skills was related positively to subordinate

satisfaction (Georgopoulos and Mann, p. 446).

Employee needs

The problem of appropriate behavior is affected by

the apparent fact that different people and different groups

look for different things in their superiors. For example,

nurses were most interested in good human relations practices

of their superiors, while technicians were equally inter-

ested in both human relations and technical skills. Super-

visory nurses desired expressions of appreciation for their

work, an opportunity to express their opinions, and to be

informed about forthcoming changes. Non-supervisory nurses

looked most favorably on the supervisory nurse who under-

stood their viewpoint, with whom they can discuss personal

problems, and who is effective in planning, organizing, and

scheduling. The department headswanted from the administra-

tor, their immediate superior, understanding of their

views. They also desired an administrator who was "good in

dealing with people," good at planning and organizing, and

one to whom they could communicate their ideas. Department

heads appear less interested than nurses in receiving ex-

pressions for good work, having an opportunity to express

their opinions, or being informed of changes within the







organization. (Rather than lacking these needs, it can be

speculated that these individuals are close enough to the

administrator and are intimately involved themselves in

these functions; needs which are satisfied are not always

recognized.)

In summary, for all hospitals, it was found the most

frequently expressed needs were:

At the higher levels: getting ideas over.

At the middle levels: discussing problems and find-
ing out about changes.

At the lower levels: practicing human relations and
effectiveness of planning and organizing.

A significant result of the study was that, of 92

correlations made between supervisory skills and character-

istics and the quality of patient care, only 'our were

statistically significant; the authors observed that, by

chance alone, there would have been more than four

(Georgopoulos and Mann, p. 479). Differentiation between

good and poor patient care and between good and poor super-

vision was explained only in terms of coordination. (Co-

ordination is seen as the intervening variable.) Super-

visors were most successful in motivating subordinates to

coordinate effectively when: they asked their subordinates

about work problems, expressed appreciation for good work,

were receptive to ideas and suggestions, and kept their

subordinates informed.








Communication.-Because communication is a major ele-

ment to coordination, attention to effective communication

is critical. The more a hospital employee perceives his

position as being secure, the more he communicates with his

superior; the more the superior communicates with his sub-

ordinate, the more secure the subordinate (Georgopoulos and

Mann, p. 523). Also, the more communication between the

superior and subordinate, the greater is the percentage of

the talk between them and with their peers concerned with

patient care.

The value of informal communication has been suggested.

However, the more the communication concerning ways to im-

prove patient care was conducted in formal channels, the

better was nursing performance. Communication about patient

care became a commitment by the participants for patient

care. Commitment developed by talking about patient care

with superiors and subordinates, but much less when the

discussion was with peers. The use of formal communication

channels increased coordination and reduced tension.

Change.-Change is important in hospitals as in many

other organizations. As a social value, change is especi-

ally important because of its influences on methods related

to improved individual and community health. The desir-

ability of such change has been well instilled'in most

hospital employees. Most have favorable attitudes toward








internal hospital change. Most employees find that ac-

ceptance of change and adjustment to it occur most effec-

tively when there is: adequate information about the change,

greater communication, understanding of the problems of

other hospital members, little felt tension, a feeling of

mutual understanding between superiors and subordinates, or

a system of clearly defined rules and good coordination.

Another view

One of the major problems in the efficient operation

of hospitals is well stated by Burling, Lentz, and Wilson

(1956). The authors point to the fact that "in a curious

sense, unmatched by any other organization, the hospital

entertains the most important actors in the medical drama,

the doctor and his patient, without being in direct command

of either" (p. 85). These authors attempt to evaluate

hospital management, and find that individuals are "not

able" to be democratic if they have been "brought up" under

authoritarian management. (If true, this suggests problems

of introducing the form of leadership as being the most

effective for hospitals suggested by Georgopoulos and Mann

(1962).) Successful head nurses were modeling their be-

havior after someone under whom they had worked previously,

while less effective head nurses could provide no clear

picture of either very good or very poor supervisors.

(Burling, Lentz, and Wilson, p. 116). In the technician and





48

nursing areas the authors found technical knowledge of the

manager to be of more importance than is indicated by the

previous study. "The theory that a supervisor should stick

to supervising may make more sense in business than in

hospitals. When techniques change rapidly, a nurse who

doesn't keep in practice may become out of date in a short

time" (p. 115). They appear to be advocating a rather strong

how-to orientation for the leader, supported by group action.

They also find that when supervisory nurses only compliment

and never reprimand, they lose their subordinates' confi-

dence, the subordinates do not ask as many questions of

them, and the subordinates neither develop greater skill

nor seek more responsibility. However, the authors do agree

with Georgopoulos and Mann that with more group participa-

tion, the supervisory nurse has more time for general super-

vision, planning and other managerial duties.


Comparison of Business and Industry to Hospitals


Less is found in the hospital literature with each

passing year advocating that hospitals are so unique that

they cannot learn from the experiences of business. More

and more hospitals are turning to outside sources for sug-

gestions, example, and guidance. However, as with most

institutions, concepts to be successfully applied need to be

adapted to the using organization. For example, Littaver






and Vaife (1949), while pointing out that hospitals have

"the same basic problems =f personnel management that

industry employers have," identify seven areas which hospital

management must keep in mind when adapting from industry:

1. Personal service. The hospital's product is patient
service which is both produced and sold on the premises.
The very fact that the patient is ill or injured makes
the situation unique.

2. Continuous operation. The hospital has less mechani-
zation and more personal service than most continuous
operation organizations. Employees are not as free to
come and go as most industry employees because of their
responsibilities to their patients.

5. Patient attitude. Patients are critical of both
hospital cost and care, and are becoming more so with
increasing affluence and more widespread lay medical
knowledge. The patient is paying for a service that
can return him to a condition no better than that which
he possessed before becoming ill. The patient, once
recovered, may not see himself as having obtained some
positive gain, but only as returning to his former
state, which may be seen more as a neutral rather than
positive condition. Further, time spent in the hospital
may be terrifying and unhappy. The patient is placed in
a new environment completely dependent on the decisions
of strangers. The emotions of patients are often trans-
ferred to the hospital employees. Many complaints of
the patients about service in general or about specific
employees in particular are often the result of pain
and fear reactions. The distress and helplessness of
patients is often magnified by their relatives and
friends who transmit the feelings of the patient to the
hospital employees.

4. Emergencies. The life and death struggle in the
hospital is made more difficult by the emergency
situations which are often a part of the hospital day.

5. Conflicting authority. Again, we find a recognition
of the "conflicting areas of control and obscure zones
of responsibility" between trustees, physicians, and
administration.







6. Deficit psychology. The concept of the "non-profit"
hospital creates, in ome administrators, an almost
automatic resistance to the :;:Jening of money to im-
prove service. (One does, however, gain the impression
in reading the more current literature that this
philosophy is much less applicable to present-day
hospitals than was true when the article was written.)

7. Divided loyalties. Jealousies and disputes often
erupt between departments and between professional and
non-professional occupations.

After review of the above list one may question,

however, whether there is, in fact, as much difference be-

tween hospitals and industry as the authors suggest. Klicka

(1961), for one, sees hospitals not only required to operate

in a businesslike manner, but argues that in many cases

hospitals are more "businesslike" than most businesses.

Any resistance to adopting good business practice is

seen by some as not only ill advised, but based merely on

unfounded, traditional attitudes (Differences..., 1961).

Hospitals were first most receptive to those business acti-

vities associated with record keeping: accounting, billing,

credits and collections, and purchasing and inventory.

However, "many people recoiled in horror [about the appli-

cation of industrial personnel practices]. But some, who

were seen by many as 'foolhardy' went ahead. They stopped

providing housing, meals, and clothing to employees and

substituted an increase in wages; they classified jobs,

established wage and salary administration, studied

industry's employment and training methods, adopted







industry's vacation and- ick leave concepts, and added other

benefits. Of course, in all these ways industry's methods

are working very well, in more and more hospitals." More

recently, hospitals have begun to add grievance procedures.

Time and motion studies and work flow studies are becoming

more common. More advanced forms of study and measurement

such as electronic data processing, computerized decision

making, and queueing theory are being introduced. Writers

in the hospital field argue for more advances of this nature.

One difference seen between the hospital and industry is

"that the hospital's ownership and purpose oblige it to

consider every proposal for improvement in method, from

whatever source, whereas industry is at liberty to make its

own choices" (Differences..., 1961). Business management,

faced with restrictions and challenges placed on them by

such groups as labor unions, government agencies, competi-

tors, consumers and suppliers, might not agree fully as to

their absolute freedom in decision making. However, it is

concluded that "the differences between industry and hospitals

will be honored most effectively when hospital people stop

emphasizing the differences and start considering the simi-

larities."

Lentz (1957) is one of the small number of more recent

writers who believes that it is not appropriate to consider

hospitals in the same manner as industries. However, in a








discussion of a typologyy of administration" which includes

social and economic roles of the institution and its in-

ternal structure, her major points are directed toward those

factors which are truly unique to hospitals and provides

less attention on those elements of organization that tend

to be more universal in nature.

Hackamack (1960), after conducting hospital consult-

ing work, concludes: "Basically there is no difference in

the administration between that which we find in industry

and that which we find in a hospital....There is an organi-

zation in existence both in the industrial setting and in

the hospital setting. The administrative problems deal

with the setting up of objectives and policies. Managers

must also set up a standard for the control of the perfor-

mance of the individuals involved."

Having reviewed briefly the development of hospitals

and observed the complexity of their organization and

functions, attention will next be turned more specifically

to the role of the hospital manager. In pursuing the goal

toward management development, it has been concluded that,

within limits, guidance can be obtained from the work done

in industry. The following will also include an analysis

of the type of training required to aid him in performing

more effectively his highly responsible duties.










CHAPTER III.


NATURE AND SCOPE OF THE PROBLEM: MANAGEMENT


To approach correctly the task of designing a

management development program, the duties of the managers

must be identified. In addition, discussion will be further

directed toward specific recognized training needs of the

hospital manager. With a general understanding of the

overall structure of the hospital in mind, as discussed

in Chapter II, this analysis can proceed in a more meaning-

ful manner.


"Professional" Hospital Management


In review of journals in numerous fields, both in and

out of hospitals, one discovers that, almost invariably,

a writer challenges the group by asking if they are members

of a "profession." No less a challenge is found in

hospital administration. Snoke (1955), for example,

desires that hospital administrators, if not all hospital

supervisory personnel, be professionals. He sees hospital

administration as "a profession not a business." (How-

ever, there are those in business who would choose to call

management a profession.) Snoke argues that because tho

53







modern hospital is a health center with an administration

which must plan for the future, and because hospital ad-

ministration should work as equals with other professionals

in the hospital, administration has to be a profession.

The administration must provide vision, leadership, and

interpretation, and be knowledgeable in public health "if

we are to be anything besides super office managers or hotel

keepers."

Wilensky (1962) takes a more sophisticated and it

is believed more realistic approach. He points out that

"all people" seek to make their work dignified. This is

attempted through establishing professional authority on a

technical basis. He suggests that of approximately 30,000

occupations, only 30 to 40 are truly professional. In-

cluded in his list are the engineer, scientist, lawyer,

physician, minister, university teacher, military commander,

architect, dentist, certified public accountant, social

worker, correctional worker, veterinary, and city planner;

on the border-line he places such occupations as public

school teacher, librarian, nurse, pharmacist, and optome-

trist. Certainly, Wilensky would agree with Snoke, that

whether the administrator is a professional or not, he must

deal with a great number of professionals and near-pro-

fessionals in the normal course of his duties.

Vilensky prescribes the following criteria for pro-

fessional status:








1. Vork done full time. The time has passed when
hospital administration is provided by a local busi-
ness man who comes to the hospital only occasionally
to direct operations and give limited instructions.
However, lower level hospital management, as in the
laboratory or X-ray departments, are in many instances
a combination of part-time technical practitioners and
part-time managers, and many smaller hospitals employ
an administrator who performs non-managerial functions
in addition to his managerial duties.

2.- Members combined to form a professional association.
The American Hospital Association and the American
College of Hospital Administrators perform this role
for the hospital administrator and other top level
hospital managerial personnel. These associations
establish standards for membership and levels of
membership standing, provide guidance to members, pro-
vide appropriate literature, perform studies, and
conduct workshops. Their actions also affect middle
and lower level hospital management directly and in-
directly.

3. Training school. There are approximately 20 gradu-
ate programs in hospital administration in the United
States. The first established at the University of
Chicago in the early 1950's and the most recent at the
University of Florida in 1964. However, there are two
major concepts of course content for these programs:
one group argues that hospital administration is medi-
cal administration, and, therefore, training should
have the strongest concentration in the health fields;
the other school of thought argues that hospital ad-
ministration is management in a specific setting,
therefore training is concentrated in management with
lesser emphasis on health services. In that there are
approximately 8000 hospitals in the United States and
only 2000 graduates of these programs, many of these
graduates holding positions below the administrator
level, it is apparent that only a minority of hospitals
are represented by those with "professional" degrees.
A strong trend is developing, however; the number of
graduates increases each year and boards of trustees
are specifying hospital administration graduates for
more positions.

4. "Divide the sheep from the goats." It is required
that there be a definition of competence. The American
Hospital Association and the American College of Hos-
pital Administrators, as well as various other groups








represented in hospitals, have attempted to set quali-
fications. Recommendations have oeen made and certain
recognition is withheld until specific requirements
are met. Participation in most of these programs or
activities is voluntary and no administrator is re-
quired to take pjrt as a requirement for holding his
position the only appeal is to the individual's ego
and a desire to be recognized within one's peer group.

5. Code of ethics. The AHA has developed a code of
ethics for hospitals as has the ACHA for administra-
tors (Appendix A). Various occupational groups in the
hospital also have developed codes.

6. Political attempt to have legal support. The
eventual goal is to have professional autonomy -
authority and freedom to regulate one's own group
members. Within limits this has been accomplished.
The requirements for acceptable hospital performance
have been established by the Joint Commission on Ac-
creditation of Hospitals, which are typically more
demanding than local, state, or federal requirements.
However, here again, participation in the program for
acceptance is left to the discretion of the individual
hospital.

In general, limitations of professionalism in hos-

pital administration are that (1) the area of competence is

not exclusive; (2) the recruitment base is heterogeneous

(Wilensky quotes a 1948 AHA study of 1000 hospital admini-

strators which found there were 131 occupational backgrounds

represented in the group); (5) administration is a service

workshop which is separate from the technical services it

renders; and (4) hospital administrators must deal with

physicians who are part of the most powerful profession in

the world. Advancement of hospital administration as a

profession will come about only when and because of: in-

creased medical care, increased use of medical and







hospitalization insurance, reorganization of medical and

parimedical services, increased group practice by physicians,

the development of regional medical facilities, increased

study of administration by the social sciences, increased

importance of preventive medicine and rehabilitation, and

an increased supply of hospital personnel and facilities.

It is also believed that as the work of the physician

increases, there will be loss time for him to resist the

advances of the administrator toward professionalism. The

administrator, much more than the physician, is able to

delegate, thus conserving his own time to organize and

plan for the future.


Duties of Hospital Management


Management responsibility


Whether hospital management can be considered a

profession or not, the fact remains that the functions of

the position must be performed and the responsibilities and

demands are increasing in importance. Increased speciali-

zation which calls for greater exchange of information and

cooperation, has given rise to greater emphasis on hospital

administration. The administrator must provide leadership,

innovation, and education, as well as possess a value

system which is broader than any of the personnel he directs

(Traxler, 1961; Barrett, 1961). In meeting these challenges,








Dimoek (1957) suggests, in broad terms, The role which the

administrator must perform. ?rimirily, he sees the maximum

challenge as the need for growth on the part of administra-

tor in response to change. Change is continuous and

demands constant definition and redefinition of objectives.

Management demands innovation and definition of objectives.

The requirement to make decisions becomes more important

the higher one's position in an organization. The effective

administrator must develop a "sense of strategy" which in-

volves struggle, competition, and a well-developed sense

of timing. Strategy is the application of intellectual

pursuits, intuitive ability, and problem solving consistent

between ends and means.

Dimoek believes that the manager has the obligation

to shape the interests and values for both the organization

and its employees. The implications are that management

delegate decision-making as far down the organization

hierarchy as members are able to handle the responsibility.

This tends to broaden the subordinated' experience, stimu-

late them, establish a basis for frankness, promote growth,

give appropriate credit for performance, and develop

loyalty by giving all an opportunity to assist in the formu-

lation of policy. Although some authors quoted earlier

believe authoritarian leadership is inherent in the hospital,

Dimoek believes that democratic leadership is a necessity
I/








of dynamic leadership and is a prerequisite in the

hospital.

Finally, Dimoek encourages the administrator to

organize with the various major hospital groups to establish

goals for developing individual growth and group cohesion,

that is, the development of the whole man through the

organization. This is not brought about merely by human

relations training but requires a complete philosophy, and,

it is believed, the philosophy will not function in the

organization unless people are given the opportunity to

grow. Therefore, the administrator is viewed first as a

teacher. The administrator can best lead and teach (1) when

he is able to generalize effectively, when he has high in-

telligence, when he allows his imagination free rein, when

he is willing to look at new ideas, and when he is adventure-

some; (2) when he desires and is able to deal with those

around him; (3) when he can relate the total environmental

situation to particular jobs; and (4) when he has apprecia-

tion of the social, economic, and political implications of

his actions.

Management activities in a large hospital

If these are desirable goals, Underwood (1963) and

Saarhoff and Kuatz (1962) have asked how the administrator

goes about accomplishing them. Underwood made observations

of the activities of one administrator in a large government







general medical and surgical hospital, employing 1200 person-

nel, and with an annual operating budget of $9 million.

After a ten-day study, the following summary was obtained:

Activity % of Time

Time spent in:
Administrator's office 72.0
In hospital outside the
office 24.5
Outside the hospital 3.5

Time spent in action initiated by:
The administrator himself 38.2
Other personnel 46.7
Both the administrator and 10.5
others
The situation 4.6

Types of communication used:
No communication 12.8
Talking 62.4
STelephone 7.2
Writing 4.4
Reading mail and reports 13.2

Types of activities:
One time action 15.8
Initiating new activities 15.5
Work on continuing activities 55.6
Completed activities 13.1

General Administrative functions:
Planning 10.3
Organizing 4.9
Staffing 18.3
Directing 9.3
Coordinating 10.1
Reporting 13.1
Budget 4.3
Public relations 7.2
Check standards and progress 3.7







Activity

Specialized Administrative
functions:
Patient needs
Education
Research
Building maintenance
Space
Equipment
Trouble shooting

Knowledge required to perform
these activities:
General administrative know-
ledge
Agency organization
Hospital organization
Patient needs
Health practices
Education
Research practices
Government regulations
Special publics
Key individuals
Hospital groups


% of Time



7.1
4.3
2.8
.9
1.4
1.6
.7



45.1

4.2
10.5
7.8
5.1
2.8
2.8
4.2
7.4
4.4
5.7


Observations were limited to normal working hours,

therefore it is not surprising that "prolonged and close"

attention to additional duties was required during other

times.

Management activities in a small hospital

Although utilizing a different approach, Saarhoff

and Kuatz (1962) provide a valuable study of administrators'

activities in seven small hospitals ranging in size from 13

to 32 full-time employees. Of the seven administrators, 4

were men and 3 women, ages ranged from 23 to 61 years, and

experience as administrators varied from less than one year








to 17 years. Occupational backgrounds varied; there were

four Registered Nurses, one laboratory and X-ray technician,

one manager of a medical-hospitalization insurance office,

and one bookkeeper.

Of 147 functions performed by one or more of the

administrators, the following occurred most commonly:

Administrative: review and evaluate hospital
policies, procedures, and work methods; inter-
pret and transmit policies of the board of
trustees to the medical staff and employees;
recommend change; submit operation statements;
attend board of trustees' meetings; analyze changes;
recommend changes in equipment, facilities, and con-
struction; attend medical staff meetings; perform
liason between medical staff and trustees; author-
ize news releases; review changes in insurance
policies; approve credit extension; decide on col-
lection of overdue accounts; supervise stock
control; hire personnel; determine organizational
lines of authority and responsibility; investigate
and decide grievances.

High performance was related to time as an
administrator, not to the number of functions
performed.

No correlation was found between performance
and any of the above functions.

Complementary administrative functions: admit and
discharge patients; explain hospital policies to
patients; guide for hospital tours; give community
talks; made decisions regarding drugs.

Any one administrator tended to do either all of
the above functions or none of them.

Nursing service functions: direct the work of
nurses; orient new personnel; direct inservice
training; evaluate nursing care.

In hospitals where the administrator was a
Registered Nurse, the administrator tended to
do all of the above; administrators without
nursing experience hired a supervisor of nurses
who performed such duties.









Nursing service, general: observe and report
symptoms of patients, administer oxygen, take
temperatures, etc.

Former Rl's performed most of these duties.

Other duties performed by one or more of the
administrators: delivery and operating room;
anesthesia; medical records; laboratory; X-ray;
drug pharmacy; dietary; housekeeping; laundry;
maintenance.


It is apparent that there is not a common job description

for those studied. The role of each administrator depended

on (1) proficiency; (2) interest; and (5) circumstances in

the hospital. To the extent that circumstances the most

critical may be finances dictate the administrator's

functions, perhaps little change can be suggested. However,

selection of duties of a non-managerial nature by an admini-

strator solely on the grounds that he has the background or

the desire is obviously to deny the unique and necessary

functions of management. That the surveyed administrators

had developed dissimilar schedules, both as to types of

duties performed and time spent on these duties, is to sug-

gest that none or few are fully performing their duties to

meet their highly crucial responsibilities.

Clarifying management duties

There may be some confusion as to what is the proper

role of hospital administrator. If true, it can be expected

that confusion may also exist as to what the proper roles







for all hospital managers should be. Scott (1962) argues

that identification and clarification of duties can best

be obtained through-training. He suggests the following

steps:

1. Clarifying the manager's role: This is accomplished
through job descriptions, extending special authority,
giving status symbols, and providing incentives related
to the manager's position. A balance is required so
that the manager does not lose effective contact with
his subordinates.

2. Simplifying the manager's work: The manager's
responsibilities require that he have time available
to organize and schedule his own time and that of his
subordinates.

3. Fair pay and opportunity for promotion: Salary
should be sufficiently greater than that paid sub-
ordinates to make the extra effort and responsibility
for supervision meaningful. Opportunities need to be
provided for development through training.

4. Training adapted to job needs: The management
position itself should be considered a major training
device and job assignments should be related to class-
room instruction. Line managers should perform the
function of teacher for their subordinates both on the
job and in class. Special emphasis should be placed
on self development. On a selective basis, the hospital
should direct the individual managers to appropriate
institutes and workshops.

Clarify the departments' duties

The American Hospital Association has established

basic guide-lines for the separate hospital departments.

The individual hospital department is seen as carrying out

its functions according to the philosophy and objectives of

the hospital as established by the board of trustees and

with responsibility directly to the administrator. Functions







of the hospital department are (Statement of functions...,

1964):

1. To provide and evaluate services in support of the
Medical care pursuant to the objectives and policies
of the hospital.

2. To implement for departmental services the phil-
osophy, objectives, policies, and standards of the
hospital.

3. To provide and implement a departmental plan of
administrative authority which clearly delineates
the responsibilities and duties of each category of
personnel.

4. To participate in the coordination of the functions
of the department with the functions of all other de-
partments and services of the hospital.

5. To estimate the requirements for the department and
to recommend and implement policy and procedures to
sustain an adequate and competent staff.

6. To provide the means and methods by which personnel
can work with other groups in interpreting the objec-
tives of the hospital and the department to the patient
and community.

7. To develop and maintain an effective system of
clinical and/or administrative records and reports.

8. To estimate needs for facilities, supplies, and
equipment and to implement a system. for evaluation,
control, and maintenance.

9. To participate in and adhere to the financial plan
of operation for the hospital.

10. To initiate, utilize, and/or participate in studies
or research projects designed for the improvement of
patient care, the improvement of other administrative
and hospital services.

11. To provide and implement a program of continuing
education for all personnel.

12. To participate in and/or facilitate all educational
programs which include student experiences in the de-
partment.








13. To participate in and adhere to the safety program
of the hospital.


Evaluation of Hospital Management


Letourneau (1l56) is one of a number of writers who

finds it difficult, if not impossible, at the present time

to measure the effectiveness of efforts of either individual

departments or a combination of departments. The most

important factor must relate to patient care, but no ade-

quate method of measurement has been developed. Attempts

at objective measures still remain subjective to a con-

siderable extent. The typical measures used, as found by

Letourneau, are:

1. Standards established by the Joint Commission
on Accreditation of Hospitals.

2. Indexes of performance, such as autopsy rates,
accuracy of diagnostic procedures, etc.

3. Indexes of effective care, such as mortality rates,
postoperative infections, etc.

4. Qualitative clinical evaluations.

A fifth measure, not mentioned by Letourneau, is

that utilized by Georgopoulos and Mann (1962). These

authors have those most closely associated with the hospital -

trustees, physicians, and administrative and non-administra-

tiye employees evaluate their own institution by means of

a series of standardized questionnaires.







Letourneau believe that no measure can be truly

accurate that does not consider all of the following: the

amount of education provided by the hospital, the amount of

research conducted, the amount of rehabilitation service

provided, outside community health services available,

geographic location of the hospital, hospital ownership,

financial practices, hospital design and construction, and

the personnel units of work. Pertinent questions also con-

cern the type of patient admitted, patient turnover, and

outpatient and emergency volume. In addition, measures

should be made of personnel and administrative practices,

and the types and amount of contacts with individuals and

groups outside the hospital.

By contrast, but of equal importance, Devolites

(1955) provides a list of hospital practices to be avoided:

packing the hospital to keep up the census, indiscriminate

use of emergency admissions, scattering of patients in many

wards regardless of illness, poor work organization and

medical supervision, poor operations methods, use of many

forms and reports, inappropriate work loads and poor

scheduling, empire building, defensive attitudes, poor

communication, duplication of effort, lack of personal

attention, poor planning, ineffective directions, inade-

quate control, too many organizational elements, and lack

of labor saving devices.







Management Education

To accomplish desired results, Brown (1956), as have

others, visualizes a major solution through improved train-

ing of personnel, especially training of management

personnel, because it is they who have the greatest effect

on the operation of the hospital.

Programs available

The AHA and various professional groups represented

in hospitals provide a number of training programs for

supervisory and non-supervisory personnel in specialized,

administrative, and leadership subjects. A recent list of

workshops sponsored by the AHA is informative (Check

list..., 1965). For one year, there were programs for:

administrative secretaries, credits and collections, dental

service, design and construction, dietary service, disaster

planning, education, engineering, governing boards, house-

keeping, labor, laundry, law, librarianship, long term care

facilities, medical records, nursing service, occupational

therapy, personnel practices, pharmacy, physical therapy,

planning, purchasing, rehabilitation, social service,

volunteer services, and others. Specifically for management

personnel, there were programs in: communication, manage-

ment, and supervision.








There are also three advanced courses each year in

hospital administration: The Hospital Administrator's

Development Program at Cornell University, which lasts for

four weeks and is intended to develop professional know-

ledge, explore new advancements in hospital administration,

and broaden points of view; The Program of Continuing Edu-

cation at Columbia University for top hospital management

personnel in hospitals of 100 beds or less, which includes

a two-week resident program, an eleven-month home study

course, and a second two-week review session; and the

Chicago Institutes at the University of Chicago sponsored

by the American College of Hospital Administrators which

includes a beginning ten-day program and a five-day ad-

vanced program. In addition, Xavier University in Cincin-

nati, provides an extension course in hospital administra-

tion. Correspondence courses and resident courses in

accounting, business law, business administration, public

health, etc., are generally considered by hospital authori-

ties as appropriate and desirable approaches for study in

the development of supervisory hospital employees.

The various hospital associations are also highly

active in most parts of the nation in utilizing workshops

and seminars during district, state, and regional meetings.

The hospital field is also served by a number of journals

of both general and specific nature. At intervals, these







journals provide articles on training ranging from the

general philosophy of learning to "how-to" programs for

specific purposes (Berke, 1960; Bushnell, 1957; Chase, 1965;

Coulter, 1963; Groner, 1961; Hill, 1959; McQuilla, 1962; Sr.

Mary Agnes, 1960; Scates, 1961).

Inservice training

The importance of training hospital personnel, especi-

ally in providing training within the hospital itself, is

pointed up by the creation of an organization within the AHA

for hospital training directors (Hospital training director's

role..., 1965). The W. K. Kellogg Foundation, long active

in the support of hospital programs, has made a contribution

toward beginning a central clearing house and centralized

development of more effective hospital employee training

both in and outside the hospital (Kellogg grant..., 1964).

The goal of this project is to "strengthen continuing edu-

cation in the hospital field." So interested is the Founda-

tion in this project that the five-year commitment of

$1,500,000 is the largest grant yet made by Kellogg in the

hospital field. However, after a year in existence, in

reply to a request for assistance in providing material on

managerial development programs, it could only be stated

that "it will be some months before either program [a

clearing house for educational materials or a publication

entitled 'A Guilde to Establishing and Conducting Hospital







Personnel Development Programs] will be operational....[and]

I know of no single source for such information short of

hiring an educational consultant who is well versed in

hospital functions and operations."l

Encouragement for supervisory training is sought by

Sister Miriam Eveline (1964). Training is seen as a basic

requirement for both growth and change. It has been found

in hospitals, as in industry, that managers cannot expect

to learn all that is required simply by performing their

jobs on a day-to-day basis. There is need for a systematic

and formalized training that permits the individual to re-

main current and that will allow him to prepare for future

responsibilities. "Development is not the result of a one-

time effort or a single approach. Man is a many leveled,

many divisional creature." She believes that the most

critical element for learning is the desire of the individual

to learn.

In general terms, Mottershead (1954) suggests that a

supervisory training program should contain material on

such topics as: understanding the duties of management;

delegation and acceptance of authority and responsibility;

skills in instruction, improving job methods, and in

handling people; considerations of the relations between


Letter to L. R. Jordan, Director, J. Hillis Miller
Health Center, University of Florida, Gainesville, by R. L.
Watt, Division of Education, American Hospital Assn.,
Chicago, March 18, 1965.







line and staff; and contributions of staff to employee

training. It is recommended that the measure of a training

program be based on improved service and decreased cost.

The AHA, through its consulting service, has sug-

gested criteria for evaluation of management performance

which deserves considering when designing content and

measuring the effectiveness of management training programs

(AHA offers management consulting..., 1959). The recom-

mended criteria are:

1. The board of trustees accepts responsibility to
provide the community with hospital service.

2. The hospital is operated within policies set by
the board.

3. A clear definition of areas of authority and
responsibility.

4. Standard procedures and practices are established.

5. Predictability of financial operations.

6. Reporting systems to provide adequate information
to all levels.

7. The hospital accepts responsibility for standards
of hospital medical practices.

8. Coordinate hospital activities with health and
welfare agencies.

9. The hospital environment shows administrative
elements support patient care.

10. There exists the organization and administration
of a formal education program.







Catholic Hospital Association study

The most comprehensive stuly of supervisory needs in

hospitals that has been found in the literature has been

conducted by the Catholic Hospital Association and financed

by a grant from the U.S. Public Health Service (Christopher,

1961). The study involved discussions, and interviews with,

and questionnaires from over 2000 members of management in

20 hospitals. The goal was to find in what areas management

believed it needed training. Although all levels of

management were considered, it was believed major emphasis

should be on middle and lower management because:

Experience as well as formal education has been im-
proving this top or administrative level of managerial
competence. The era of the professional administra-
tor, if not already here, is at least near. But what
is being done at the middle and lower levels of the
management group to improve their managerial capabili-
ties? At these levels there usually is less experience,
perhaps due to the relative youth of these groups.
Frequently, there also is less formal education, where
such formal education does exist, it has been directed
toward a professional area or specific discipline
other than management. Thus, the nurse who is a good
nurse may become head nurse, not because of her special
qualifications or ability to manage and supervise, but
because of her stability or consistency of employment.
And this situation can be equally true in the business
office, the laboratory, the dietary department, etc.

For purposes of the CHA study, a manager has been

defined as:

One who gets others to do what is to be done, when it
is to be done, in the way it is to be done, and in
such a way that both the supervisor and the supervised
get personal satisfaction out of the job while the job\
is being performed.







Managers surveyed in the CHA study were divided into

the following groups:

Administrators and Assistant Administrators: Those
persons in key management positions not restricted to
any one function.

Department Heads: Those persons in full charge of a
major hospital function and reporting to top administra-
tion; these included: (a) director of nursing service;
(b) director of medical service; (c) financial or busi-
ness manager; (d) dietary supervisor; (e) administrative
or executive housekeeper; (f) building or plant super-
intendent or maintenance engineer.

Supervisors: Those reporting to one of the department
heads, responsible for supervising either subordinate
supervisors or non-supervisory personnel.

Persons classified as SuDervisors: Those who have no
personnel to supervise or who are responsible for only
a small unit, office, or function; as, for example,
the personnel director, pharmacist, occupational thera-
pist, chief switchboard operator, social worker, etc.

A total of 29,260 areas or topics of training needs

were listed by respondents. There was an average of over

14 training need areas listed per reply, ranging from one

to 19 items per supervisor response. The indicated needs

were divided into 111 separate items by the researchers; of

these 111 items, the most often mentioned was listed by 932

managers and the least mentioned item brought 13 responses.

Christopher (1961) observes that the comments and

selections of the surveyed group brought out the following

points:

1. No indication was given by the respondents for
specialized knowledge or skill in their basic core of
training. That is, they did not ask for more training
in their professional area, but sought information
dealing with "management" or "supervision."






2, The expression of neels covered many areas, showing
a "broad scope of need."

3. A predominance of needs were directly related to
areas of "personnel management" rather than management
of other factors of production. Human relations was
considered most important.

4. Top management tended to recognize a need mostly
for training in the area of "management," while lower
level management were more concerned with "personnel
management."

5. Smaller hospitals recognize more a need for training
in personnel-centered factors. Larger institutions tend
more to recognize the "pure" management factors.

6. Topics were interpreted as meaning a greater concern
for procedure rather than principle skill rather than
knowledge.

In Table 3-1 is the list developed by the Catholic

Hospital Association. Listings are divided as to level of

supervision and size of hospital. Table 3-1 is adapted

from the original CHA presentation. From the list of 111

items, those selected by each group from the first choice

through the twentieth are shown in the table. At the end

of the table are the remainder of the items selected.

After compiling this list, the researchers presented

it to "various business and industrial leaders and their

training specialists." Upon completing their examination

and evaluation, "each of these leaders commented that the

needs listed were not training needs, but hiring specifica-

tions that the areas specified actually constituted

qualifications for one.who would be a supervisor or manager







TABLE 3-1

ANALYSIS OF TRAINING NEED AREAS FOR HOSPITAL SUPERVISORS

Selection by Level of Supervision

Administration


1. Understanding
Human Relations
2. Responsibilities
of Management
3. How to Evaluate Super-
visors' Performance
4. Principles of
Management
5. Philosophy and Con-
cept of Management
6. Functions of
Management
7. Objectives of
Management
8. How to Change
Attitudes
9. Tools of
Management
10. How to Build Good
Employee Relations


11. The Supervisor's Role
in Management
12. How to Justify
Budget Needs
15. Qualifications for the
the Supervisor
14. How to Foster Good
Public Relations
15. Evaluating Effective-
ness of Supervision
16. Responsibilities of
Supervision
17. Leadership Applied
to Management
18. Preparing an
Organization Chart
19 How to Control Dele-
gated Responsibility
20. How to Motivate a
Subordinate


Department Heads


1. Understanding
Human Relations
2. Functions of the
Supervisor
3. Philosophy and Con-
cept of Management
4. Functions of
Management
5. Preparing an Organi-
zation Chart
6. Responsibilities
of Management
7. How to Train
a Supervisor
.8. How to Select
a Supervisor
9. How to Evaluate Super-
visors' Performance
10. Objectives of
Supervision


11. How to Justify
Budget Needs
12. Evaluating Effective-
ness of Supervision
13. Qualifications for
Supervision
14. How to Communicate
with Subordinates
15. Principles of
Management
16. Responsibilities of
Supervision
17. Objectives of
Management
18. Tools of
Management
19. How to Improve Inter-
departmental Relations
20. How to Develop Job Pride
Among Subordinates








Table 3-1 (continued)

Middle Surervisor


1. Understanding
Human Relations
2. How to Motivate
a Subordinate
3. How to Build Good
Employee Relations
4. Objectives of
Supervision
5. Functions of the
Supervisor
6. How to Evaluate Super-
visors' Performance
7. Philosophy and Con-
cept of Management
8. How to Communicate
with Subordinates
9. The Supervisor's Role
in Management
10. How to Handle Em-
ployee Grievances

Staff or Minor Supervisor

1. Understanding
Human Relations
2. How to Build Good
Employee Relations
3. Evaluating Effective-
ness of Supervision
4. Functions of the
Supervisor
5. Responsibilities
of Management
6. Principles of
Management
7. The Supervisors' Role
in Management
8. Leadership Applied
to Management
9. Philosophy and Con-
cept of Management
10. Job
Analysis


11. Work
Measurement
12. How to Evaluate Em-
ployee Performance
13. Responsibilities
of Management
14. Functions of
Management
15. How to Determine Number
of Subordinates
16. How to Fit People
to Jobs
17. How to Schedule
Work
18. How to Improve
Job Performance
19. How to Promote
Supervisors
20. Qualifications
for Supervisor


11. Objectives of
Management
12. Objectives of
Supervision
13. How to Evaluate Em-
ployee Performance
14. Functions of
Management
15. How to Evaluate Super-
visors' Performance
16. How to Handle
Behavior Problems
17. How to Organize
Work
18. How to Deal with Your
Own Supervisor
19. How to Change
Attitudes
20. How to Reprimand
a Subordinate






Table 3-1 (continued)

Selection by Size Hospital


1-100 Beds


1. Understanding
Human Relations
2. How to Build Good
Employee Relations
3. Philosophy and Con-
cept of Management
4. How to Evaluate Super-
visors' Performance
5. Responsibilities
of Management
6. Functions of
Management
7. How to Communicate
with Subordinates
8. How to Motivate
a Subordinate
9. Principles of
Management
10. Qualifications for
the Supervisor


11. Responsibilities
of Supervision
12. Functions of the
Supervisor
13. Evaluating Effective-
ness of Supervision
14. Objectives of
Management
15. Tools of
Management
16. Objectives of
Supervision
17. Leadership Applied
to Management
18. The Supervisor's Role
in Management
19. How to Evaluate Em-
ployee Performance
20. How to Develop Job Price
among Subordinates


101-200 Beds


1. Understanding
Human Relations
2. Philosophy and Con-
cept of Management
3. Responsibilities
of Management
4. How to Build Good
Employee Relations
5. How to Evaluate Super-
visors' Performance
6. Functions of
Management
7. Principles of
Management
8. Functions of the
Supervisor
9. Evaluating Effective-
ness of Supervision
10. The Supervisor's Role
in Management


11. Objectives of
Supervision
12. How to Motivate
a Subordinate
13. How to Communicate
with Subordinates
14. Responsibilities
of Supervision
15. Qualifications for
the Supervisor
16. Objectives of
Management
17. Tools of
Management
18. Leadership Applied
to Management
19. How to Develop Job Pride
among Subordinates
20. Preparing an Organiza-
tion Chart







table 3-1 continuedd)

201-400 Beds


1. Understanding
Human Relations
2. How to Evaluate Super-
visors' Performance
3. Philosophy and Con-
cept of Management
4. Functions of
Management
5. Functions of the
Supervisor
6. Responsibilities
of Management
7. Principles of
Management
8. How to Build Good
Employee Relations
9. Qualifications for
the Supervisor
10. Responsibilities
of Supervision


11. How to Motivate
a Subordinate
12. How to Communicate
with Subordinates
15. The Supervisor's Role
in Management
14. Leadership Applied
to Management
15. Objectives of
Supervision
16. Objectives of
Management
17. Tools of
Management
18. Evaluating Effective-
ness of Supervision
19. Preparing an Organiza-
tional Chart
20. How to Justify
Budget Needs


401-Plus Beds


1. Objectives of
Management
2. Evaluating Effective-
ness of Supervision
3. The Supervisor's Role
in Management
4. How to Justify
Budget Needs
5. Objectives of
Supervision
6. Tools of
Management
7. Leadership Applied
to Management
8. How to Communicate
with Subordinates
9. Responsibilities
of Supervision
10. How to Control Dele-
gated Responsibility


11. Preparing an
Organization Chart
12. How to Control
Costs
15. Qualifications for
Supervision
14. How to Motivate
a Subordinate
15. Work
Measurement
16. How to Train
a Supervisor
17. How to Improve Inter-
departmental Relations
18. How to Understand
Subordinates
19. How to Handle
Employee Grievances
20. How to Change
Attitudes







Table 3-1 (continued)

Training Need Areas Not Included in the First 20
Choices by any Group, but Selected by Most Groups


How to Delegate or Assign Responsibility
How to Determine Needed Space or Facilities
How to Create Efficiency
How to Maintain Morale
How to Pla.n Management Team Functions

How to Gain Cooperation
How to Determine Workers Training Needs
Determining Need for Equipment
How to Overcome Tradition
How to Deal with Older Workers

Evaluating Financial Data
How to Work with Supervisors of Other Departments
Getting the Most Out of a Job
Work Simplification
Executive Qualifications

How to Solve Supervisory Problems
Counseling Subordinates
Controlling Use of Supplies
Setting Performance Standards
Fire Prevention

How to Control Waste
Dealing with Insubordination
Planning Work
How to Evaluate Operating Policy
Detecting Risks and Job Hazards

How to Determine What is to be Done
Getting Employee Loyalty
Decision Making
Two-Way Communication
Job-Instruction Training

Supervisors Role in Disaster Plans
Responsibility for Maintenance and Housekeeping
Delegating Authority
'Work Distribution
Job Relationships
Executive Selection
Job Evaluation
Inservice Training
Training for Promotion
Disciplining Supervisors







Table 3-1 (continued)


Effective Personnel Practices
How to Control Work
Organizing a New Job
How to Solve Problems in Another Department
Orienting Workers to the Hospital

Setting up Job Specification
Job Induction Training
Dealing with Chronic Employee Problems
Trends, Techniques, Skills in Technical or Professional
Occupation
Understanding Differences in Job Relationships

Methods Analysis
Developing a Safety Program
Introducing the New Worker to the Department
Safety Training
Making Flow Charts

Preventing Accidents
Executive Training
Self-Development
Training an Understudy
Directing Workers

Job Relations Training
Training for Self Promotion
Re-training Programs
Physically Handicapped Workers
Problem Workers

Pre-Job Training
Setting Job Titles







at some level in the organization. People without these

qualifications ought not to be in supervisory or managerial

capacities....The industrial and business leaders con-

sidered the list of 111 needs as pre-job rather than in-

service training needs....For them, supervisory development

meant taking personnel who already met certain qualifica-

tions...and placing them in a training situation where they

might learn to utilize their knowledge and skills to solve

a variety of management problems."

One may question such evaluations by these business

representatives. As shall be discussed later, the topics

shown in the CHA list are basically the same as a repre-

sentative outline for a management training program for

business concerns. These are areas of required knowledge

that business management has not yet solved completely for

their own organization, but, at best, may have only pre-

ceeded hospital management in recognizing the needs.

However, the point by Christopher in summarizing his

review of the list is appropriate: "If a hospital is to

have him [the 'better qualified' future supervisor], then

that hospital must train and develop him, preferably through

improvement programs for those currently employed. But with

an eye to the future, that hospital must also plan and exe-

cute a program of training for those to come." For training,

the challenge is identified as being three-fold:








1. Provide management personnel already on the job
with training in the 111 areas of knowledge and skill
listed.

2. When these managers have been trained, they should
be provided with "problem solving" training as another
essential phase of their supervisory development.

3. Hospitals should critically analyze the positions
of supervisory personnel, extracting realistic posi-
tion specifications, so that in the future, through
better recruitment, pre-job training and promotion,
they will be able to introduce on the management team
persons qualified at least in basic knowledge and skills
for the job.

Christopher (1962) has also identified those areas

which he believes are generally overlooked in most manage-

ment development programs. They are:

1. Job analysis: to clarify the functions and role
of the supervisor by identifying the what, how, why,
authority, standards. The supervisor, in turn, must
identify for his subordinates, in writing, the stand-
ards, quality quantity, time, cost allocations, and
final appearance of the work. Such information is
found through observation and interview.

2. Clarifying accountability: this is arrived at
through agreement between the superior and his sub-
ordinate. Assigning authority and accountability will
stimulate work improvement.

3. Performance requirements: job analysis is required
to point out special qualifications needed for any
given position, to include tasks, methods, and objec-
tives. Such analysis will indicate knowledge, skill,
mental ability, physical ability, educational level,
experience, etc., needed for the job. Any lack found
in the individual of needed knowledge or skill points
up needs for training.

4. Performance appraisal: there is a need seen for
merit ratings. The author finds that "many" hospitals
have such ratings for non-supervisory employees but not
for management personnel.








5. Delegation of responsibility: it is desirable to
require the individual to be responsible for up-grading
his position. Gradually, adding to responsibility
permits an opportunity to ooserve if the employee will
accept new challenges, if he is resourceful, and if he
will respond to the responsibility in a positive manner.

6. Review area objectives and management practices:
this is to be done periolically by the superior and is
to include: objectives of the department, plans,
organization, and controls.

7. Problem solving: the superior has the subordinate
manager make his own decisions and the superior then
-reviews these decisions with his manager.

8. Pressure for results rather than pressure to use
specific tools: the author suggests that in developing
improvement, it is natural to look to tools, but it is
the results obtained that are what are important and
should be measured.

9. Conferences: conferences are to be used between
superiors and their subordinates at all levels and to
look at and solve problems.

10. Learning by teaching: the manager, by teaching
his subordinates, develops his own knowledge and skills
and performs one of his most important duties of de-
veloping the knowledge and skills of his subordinates.

11. Stimulate interest in self development: in addition
to providing more effective knowledge and performance
this also leads to the subordinate's independence.

The problem

It has been observed that both their contributions

to the community and their combined size make hospitals a

vital and significant institution of society. Discussion

has centered to this point around studies and observations

by those closely associated with the hospital field, recog-

nizing that these individuals have the most intimate







knowledge of the topic. Although it has been noted all do

not agree on certain specific areas, there is a general

consensus that hospitals will continue to accept further

responsibilities and will continue to provide even more

contributions to society. The extensive literature indi-

cates both the importance of the problem and the extent

of interest. There is detected a difference of opinion

concerning the form of leadership required, but all appear

to agree that effective leadership is the key to both day-

to-day operations and long range developments.

Having established the value of searching for the

most effective means of management development in the

hospital, the next task will be an attempt to identify a

philosophy of hospital management as an overall framework

in which a management development program can be designed.










PART II. PHILOSOPHY UF MANAGEMENT


CHAPTER IV

A GENERAL PHILOSOPHY OF MANAGEMENT

Introduction


Purpose

Man conducts most of his activities through group

action within organizations. Management provides direction

and stimulates motivation in these organizations.

Neither organizations nor leadership are unique to

the modern world. All societies at all times have had

need to organize. Men join together for companionship and

for aid in obtaining common goals. However, increased

interest in the subject of management has occurred mainly

because the development of larger 'organizations has

created increased organizational complexities and has

separated individual members of the organization from the

decision making functions. These developments have forced

attention on analysis of managerial duties, organizational

structure, and interpersonal behavior patterns.

The basic assumptions believed to be most crucial

to 'a Philosophy of Management are that people are the most








important asset of an organization and those performing the

duties of management have'the greatest impact on the

organization.

Definition of terms

Philosophy has been defined as "the science which

investigates the facts and principles of reality and of

human nature and conduct" (Websters New Collegiate Dic-

tionary. Springfield, Mass.: G. and C. Merriam Co., 1949).

Is this definition is applied, it is assumed that manage-

ment is a science. From the literature, there is not

common agreement as to whether this is true; if not a

science, many question if it can ever become one. It is

sufficient, however, to accept that if management is not a

science, it is through the most effective utilization of

the sciences that management makes much of its contribution.

The definition of a philosophy also requires the investiga-

tion of facts and principles. It is from facts that

principles are derived, and principles are accepted when

they are found to be factual. Further, the definition in-

cludes the study of reality. Certainly, a philosophy is of

practical interest only to the extent that it can be applied;

a philosophy is sought that is useful. Finally, philosophy

deals with human nature and human conduct. This is a basic

premise on which a. Philosophy of Management should be based.







The organization is people and only through people will the

organizational goals be reached.

Writers tend to use the terms "philosophy," "creed,"

and "ethics" often when referring to the same concepts.

This should cause little difficulty to the discussion. A

creed may be defined as "a summary of principles and opinions

professed and adhered to." A creed, then, is that which is

believed as a philosophy, and, perhaps most important, what

is practiced. Ethics are concerned with moral qualities

which are used to interpret and apply principles and

practices. Further, the term Management has been defined

most often in the literature as "accomplishing goals through

people."

Therefore, a Philosophy of Management which is sought,

by definition, envisions the attitudes related to the

investigation and practices involved with the practical

application of principles to be applied by a leader in his

relations with other individuals in the organization for the

accomplishing of organizational purposes. It is upon this

concept that the following analysis is directed.


Philosophy and Conduct

General considerations

A true philosophy must contain elements applicable

for all organizations, for all situations, for all individual




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