PT OF AIANAGEMEI\IT
rS FOR A HEALTH CENTER
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
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
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. . . . . . .
.* . ii
. . S 1v
* S S * 1
. . 1
* * 5 5
* . . 7
. . 9
. . . 11
* . 17
. * 37
III. NATURE AND SCOPE OF THE PROBLEM: MANAGEMENT
"Professional" Hospital Management. . .
Duties of Hospital Management . . .
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
. . .. . .. 185
. . . . 183
. . . . 187
. . . . . 200
. . . . . 205
S. . .. . . 203
. . . . 2042
. . . . 221
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 . . . . .
Difficulties of Introducing Democratic
Leadership . . . . . . . .
Need for Democratic Leadership in the
. * *
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
Forms of Learning . .
Motivation and Learning
Learning Curves . .
XVI. LEARNING, BEHAVIOR, AND
Behavior and Learning .
Perception and Learning
Change Through Learning
Attitudes . . .
. . 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
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 . . . . .
. . 436
. . 436
. . 436
. . 441
. . 442
. . 449
. . 462
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. .
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
LIST OF TABLES
3-1 Analysis of Training Need Areas for Hospital
Supervisors . . . . . . . . .
LIST OF FIGURES
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
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
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
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
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
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
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-
The hypothesis upon which this study is based is
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.
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
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
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
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
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
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
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
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
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
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 -
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-
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
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-
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
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
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
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
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.
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
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.
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,
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,
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
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.
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
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
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
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).
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
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
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
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.
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
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
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
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
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-
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.
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-
"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
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
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-
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-
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
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
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
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
of dynamic leadership and is a prerequisite in the
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
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
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
The situation 4.6
Types of communication used:
No communication 12.8
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:
Public relations 7.2
Check standards and progress 3.7
Knowledge required to perform
General administrative know-
% of Time
Observations were limited to normal working hours,
therefore it is not surprising that "prolonged and close"
attention to additional duties was required during other
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
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
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;
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
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
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
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...,
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
3. To provide and implement a departmental plan of
administrative authority which clearly delineates
the responsibilities and duties of each category of
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
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-
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
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.
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.
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).
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
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
3. A clear definition of areas of authority and
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
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
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
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
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
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
ANALYSIS OF TRAINING NEED AREAS FOR HOSPITAL SUPERVISORS
Selection by Level of Supervision
3. How to Evaluate Super-
4. Principles of
5. Philosophy and Con-
cept of Management
6. Functions of
7. Objectives of
8. How to Change
9. Tools of
10. How to Build Good
11. The Supervisor's Role
12. How to Justify
15. Qualifications for the
14. How to Foster Good
15. Evaluating Effective-
ness of Supervision
16. Responsibilities of
17. Leadership Applied
18. Preparing an
19 How to Control Dele-
20. How to Motivate a
2. Functions of the
3. Philosophy and Con-
cept of Management
4. Functions of
5. Preparing an Organi-
7. How to Train
.8. How to Select
9. How to Evaluate Super-
10. Objectives of
11. How to Justify
12. Evaluating Effective-
ness of Supervision
13. Qualifications for
14. How to Communicate
15. Principles of
16. Responsibilities of
17. Objectives of
18. Tools of
19. How to Improve Inter-
20. How to Develop Job Pride
Table 3-1 (continued)
2. How to Motivate
3. How to Build Good
4. Objectives of
5. Functions of the
6. How to Evaluate Super-
7. Philosophy and Con-
cept of Management
8. How to Communicate
9. The Supervisor's Role
10. How to Handle Em-
Staff or Minor Supervisor
2. How to Build Good
3. Evaluating Effective-
ness of Supervision
4. Functions of the
6. Principles of
7. The Supervisors' Role
8. Leadership Applied
9. Philosophy and Con-
cept of Management
12. How to Evaluate Em-
14. Functions of
15. How to Determine Number
16. How to Fit People
17. How to Schedule
18. How to Improve
19. How to Promote
11. Objectives of
12. Objectives of
13. How to Evaluate Em-
14. Functions of
15. How to Evaluate Super-
16. How to Handle
17. How to Organize
18. How to Deal with Your
19. How to Change
20. How to Reprimand
Table 3-1 (continued)
Selection by Size Hospital
2. How to Build Good
3. Philosophy and Con-
cept of Management
4. How to Evaluate Super-
6. Functions of
7. How to Communicate
8. How to Motivate
9. Principles of
10. Qualifications for
12. Functions of the
13. Evaluating Effective-
ness of Supervision
14. Objectives of
15. Tools of
16. Objectives of
17. Leadership Applied
18. The Supervisor's Role
19. How to Evaluate Em-
20. How to Develop Job Price
2. Philosophy and Con-
cept of Management
4. How to Build Good
5. How to Evaluate Super-
6. Functions of
7. Principles of
8. Functions of the
9. Evaluating Effective-
ness of Supervision
10. The Supervisor's Role
11. Objectives of
12. How to Motivate
13. How to Communicate
15. Qualifications for
16. Objectives of
17. Tools of
18. Leadership Applied
19. How to Develop Job Pride
20. Preparing an Organiza-
table 3-1 continuedd)
2. How to Evaluate Super-
3. Philosophy and Con-
cept of Management
4. Functions of
5. Functions of the
7. Principles of
8. How to Build Good
9. Qualifications for
11. How to Motivate
12. How to Communicate
15. The Supervisor's Role
14. Leadership Applied
15. Objectives of
16. Objectives of
17. Tools of
18. Evaluating Effective-
ness of Supervision
19. Preparing an Organiza-
20. How to Justify
1. Objectives of
2. Evaluating Effective-
ness of Supervision
3. The Supervisor's Role
4. How to Justify
5. Objectives of
6. Tools of
7. Leadership Applied
8. How to Communicate
10. How to Control Dele-
11. Preparing an
12. How to Control
15. Qualifications for
14. How to Motivate
16. How to Train
17. How to Improve Inter-
18. How to Understand
19. How to Handle
20. How to Change
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
How to Solve Supervisory Problems
Controlling Use of Supplies
Setting Performance Standards
How to Control Waste
Dealing with Insubordination
How to Evaluate Operating Policy
Detecting Risks and Job Hazards
How to Determine What is to be Done
Getting Employee Loyalty
Supervisors Role in Disaster Plans
Responsibility for Maintenance and Housekeeping
Training for Promotion
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
Understanding Differences in Job Relationships
Developing a Safety Program
Introducing the New Worker to the Department
Making Flow Charts
Training an Understudy
Job Relations Training
Training for Self Promotion
Physically Handicapped Workers
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
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.
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
A GENERAL PHILOSOPHY OF MANAGEMENT
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
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
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
A true philosophy must contain elements applicable
for all organizations, for all situations, for all individual