' ' - . ¢ A SURVEY OF MICHIGAN HOSPITAL ADMINISTRATORS' OPINIONS ON HOSPITAL ADMINISTRATION Thesis for the Degree cf M. A. MICHIGAN STATE UNIVERSITY William Gone KeIIefi‘, B. $.N. Ad., M.'N. Ad. I960 III/III!!!III/lIl/l/llI/ll/III/I/ III/11W! III/WI ' 3 1293 10498 5456 LIBRARY Michigan State University (1) kW 5“. ”9,52 @dx’ff/é A SURVEY OF MICHIGAN HOSPITAL ADMINISTRATORS' OPINIONS ON HOSPITAL ADMINISTRATION By William Gene Kellett, B.S.N.Ad., M.N.Ad. AN ABSTRACT Submitted to the College of Business and Public Service Michigan State University of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Hotel, Restaurant and Institutional Management 1960 Approved C. Introduction: Hospital administration has developed into a science primarily due to the increased demands placed upon the hospital ad- ministrator. The demands are extensive and complex because of the number of specialized groups and systems which the modern hosPital has had to employ and utilize. The role of the hospital adminis- trator has been altered since the advent of the specialty groups into the hospital and logically the administrator has reacted and responded to these groups. From the literature the attitude of the administrator toward his position can be determined for those who were administrators of hospitals in the carly part of this century. In an effort to determine the attitude of the administrator toward his position, a questionnaire was sent to a sample group from which data was obtained for such a determination. Problem: This is a Study of the job of the hospital administrator with emphasis on the personal traits and preparation for the job as visualized by practicing hospital administrators. It is a study, also, of the hospital administrators' opinion of how others regard the position of hospital administrator and the hospital administra- tor's opinion of his own job. Purpose: A survey of hospital administrators' opinions in five areas of hospital administration. These areas include 1) the job of the hospital administrator, 2) the preparation needed for the job of the administrator, 3) the personal qualifications which the hospital administrator must have or must develop, 4) the opinions of others about hospital administration and 5) the opinions of the hospital administrator about his own job. D. Design and Sampling: Method: A questionnaire was sent to each of the 249 adminis- trators. A follow-up questionnaire was sent to each of the administrators who failed to respond to the first question- naire. Sampling: 116 hospital administrators of "listed" Michigan hospitals, out of a total of 249 Hichigan hospital adminis- trators. 46.6 per cent of the total group of administrators responded to the questionnaire and were used in the study analysis. E. Results: The results of the study are included in the conclusions from the analysis of the data contained in the study: 1. 3. The duties performed by the hospital administrator depend upon the bed size of the hOSpital of which the administrator is the head. The division of duties occurs between hospitals of fewer than one hundred beds and those of more than one hun- dred beds. The duties which an administrator of a small hospital (less than one hundred beds) performs are mainly operational in nature but the administrator of the small hospital also be- comes engaged in performing the General Administrative Duties as well as the Public Relations Duties. The administrator of a large hospital (more than one hundred beds) is primarily engaged in performing the General Adminis- trative Duties and the Public Relations Duties. The background preparation of the administrator does not, of itself, determine the duties which an administrator performs 10. except as the background preparation assists the administrator in becoming the head of a large hospital or keeps him from it. Those administrators having a medical background tend to be selected as the administrators of large hospitals while those administrators having non-specific background preparations tend to be selected as administrators of the small hospitals. There is no agreement by hospital administrators as to what they believe constitutes the best background experience. Hospital administrators tend to believe that the experience which they have had is the best. There is no evidence from the data in the study that any single background experience provides the most desirable preparation for the administrator. Any type of hospital experience seems to be the kind of experience considered best by hospital administrators. The hospital administrators agree that an academic background preparation in Hospital Administration would be the best aca- demic preparation for the hospital administrator. The hospital administrators agree that seminars, workshops and institutes constitute the best supplemental training ex- perience for the hospital administrator. The hospital administrators agree that the best method by which to learn how to perform management duties is on-the-job work experience. The hospital administrators agree that the personal traits most essential to the hospital administrator are fairness, diplomacy, integrity and honesty. 11. 12. 13. 14. 15. 16. 17. The personal traits which the hospital administrators have selected as essential to themselves are the same traits which would be essential to any administrator in any type of business. The most important personal trait for an individual hos- pital administrator is determined primarily on an individual need basis. There is no One trait which can be considered to be the most important for every hospital administrator. The hospital administrators consider that childhood training, on-the-job training, self discipline and academic learning experiences constitute the best means by which to develop personal traits. The degree of job satisfaction is high among Michigan hos- pital administrators. They have generally been in their positions for five or more years. They indicate that their position is satisfying, rewarding and challenging. One-half of the Michigan hospital administrators indicate that there are financial limitations to the job of hospital administration. The hospital administrators are favorably regarded and respected by doctors, nurses, the community and by members of the non-medical professions. There is some degree of enmity between the medical doctors and the hospital administrators, however. The data contained in the study supports the findings in the literature regarding the gradual shift away from the medical and nursing perSOnnel as hospital administrators in favor of specially trained administrators. The hospital administra- tors indicate a great support of this shift but only a small part of the administrative group have special hospital admin- istration training. All but the state and federal hospitals have moved in this direction. The governmental hospitals continue to favor doctors of medicine as administrators of these institutions. A SURVEY OF MICHIGAN HOSPITAL ADMINISTRATORS' OPINIONS ON HOSPITAL ADMINISTRATION By WILLIAM GENE KELLETT A THESIS Submitted to the College of Business and Public Service Michigan State University of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Hotel, Restaurant and Institutional Management ACKNOWLEDGMENTS I wish to express my appreciation to all the people who so generously contributed their time, effort and patience to assist me in the writing of this study. First, I would like to thank the one hundred and sixteen Michigan hospital administrators who provided me with the data for this paper by completing the questionnaires sent to them. Secondly, I extend my gratitude to the six hospital administrators and assistant administrators in the Kansas City area who pretested the questionnaire. Also, I wish to thank my wife who patiently encouraged me during the long months of preparation and writing. Finally, I wish to thank Df. Ralph D. Wilson without whose assistance, guidance and advice this thesis could not have been written. iii TABLE OF CONTENTS ACKBOWLEDGPIETITS O O O O O O O O O O O O O O O O O I I 0 LIST OF TABLES O O O C O C O C O O O O O O O O C . C O 0 Chapter I. INTRODUCTION 0 O O O O O O O O O O O O O O I O 0 Problem 0 o o o o o o o o o o o o o o o o o 0 Purpose . . . . . . . . . . . . . . . . . . . Scope and Delimitations . . . . . . . . . . . Method 0 o o o o o o o c o o o o o o o o o 0 Definition of Terms . . . . . . . . . . . . . Review of Literature . . . . . . . . . . . . Summary 0 o o o o o o o o o o o o o o o o 0 II. ANALYSIS OF STUDY GROUP . . . . . . . . . . . . SuerOOOOOIOOOOOOOOOOOOO III. AN ANALYSIS OF THE POSITION OF HOSPITAL ADMINISTRATOR An Analysis of the Duties Performed by the Hospital Administrator . . . . . . . Sumary.........o........ An Analysis of th Preparation Needed for the Job of Hospital Administrator . . . sumaryooooocooooooooocoo An Analysis of the Personal Qualifications Which the HOSpital Administrator Must Have or Must Develop . . . . . . . . . . . . . . Summary . . . . . . . . . . . o . . . . . . Summary . . . . . . . . . . . . . . . . . . . IV. AN ANALYSIS OF THE OPINIONS ON THE POSITION OF HOSPITAL ADMINISTRATION . . . . . . What Others Think About the Position of Hospital Administration . . . . The Hospital Administrator's Opinion of His Own Job . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . iv Page iii vi H 0303045wa 31 33 34 4O 41 47 48 55 56 58 58 6O 62 Chapter V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS. Summary . . . . ConclusiOns . . Recommendations APPENDIX A O O O O O O . APPENDIX B . . . . . . . APPENDIX C . . . . o o o BIBLIOGRAPHY. . . . . . . Page 64 64 65 68 70 71 75 76 LIST OF TABLES Table Page 1. Relationsnip of Sample to Population According to Bed: Size 0 O O O O O O O O O O O O O I O O I O O O 23 2. Distribution of Administrators According to Bed Size and Length of Time as an Administrator . . . . . . . 25 3. Distribution of Administrators According to Academic Background Preparation and Length of Time as an AdminiStratorooocoooo00000000000. 27 4. Distribution of Administrators According to Academic Background Preparation and Bed Size of Hospital . . . 29 5. Management Duties Selected as Part of the Administrator'SJOIJ.o............... 35 6. Community Activities Selected as a Part of the Administrator's JOb o o o o o o o o o o o o o c o o o 37 7. Management Duties Performed Best by Hospital AdmiUiStrators0.0000000000000000. 42 8. Work Experience Most Beneficial to the Hospital AdmiIIiStratoroooooo00000000000000 44 9. Academic Program Considered Best for Hospital Administrator.................... 45 10. Best Supplemental Experiences for the Hospital Administrator 0 O O O O O O O C C O O I O O O O O O O 46 11. Means 0f DeVEIOPiUg PerSOiial Traits o o o o o c o o o o 48 12. Personal Traits Considered Most Important to the Hospital AdminiStrator o o o o o o o o o o o o o 5]. vi CHAPTER I INTRODUCTION Although the initial effort to promote a special background prep- aration for the aspirant to the position of hospital administrator began in 1899, it was not until 1930 that serious and wide spread atten- tion was given to this matter. In 1934 the first university course in Hospital Administration was begun at the University of Chicago. The real demand for specially trained administrators, however, came after World War II when the need for administrators who could handle the increasingly complex business of running a hospital became very great. Nine (9) degree-granting programs were set up in the United States between 1945-1950. By 1958 there were fourteen (14) such degree grant- ing courses.1 Until approximately thirty years ago about one-half of all hospitals had either a nurse or a physician as the administrator. With the onset of the depression and subsequent period of reduced philanthropy to hospitals,3 it became necessary for hospital managers to learn and to apply the techniques of business management. The need to learn better techniques of business management coupled with the 1American Council on Education, University Education for Administra- tion i3 Hos itals, A Report of the Commission on University Education in Hospital Administration (Washington, D.C.: American Council on Education, 1954) p. 10. 2 Robert Neff, A Survey pf the Hospital Administrator (Chicago: Physi- cian's Record Company, 1932) p. 19. 3E. H. L. Corwin, The American Hospital (New York: The Commonwealth Fund, 1946) p. 44. -1- increased complexity of the hospital has made necessary a functional division within the organizational pattern of the hospital. The result of this has been a decrease in the demand for nurse trained persons and physicians as administrators and an increase in the demand for specially trained managers.1 Starting in 1934 the Special university courses in hospital administration were begun with the purpose of giving to the stu- dent in this field a knowledge of the fundamental principles of hospital administration and organization and to acquaint him with sound adminis- trative practices.2 Even though there is a growing demand for specially trained persons to manage the complex modern hospital, it should be pointed out that at the present time some hospitals are managed by nurses, physicians, per- sons with training in para-medical fields, specially trained administra- tors and persons with no formal training.3 Problem Due to the great alteration in hOSpital function and the ensuing demand for specially trained managers, there have arisen a multitude of criteria for use in determining who can best perform the duties of the hospital administrator. Special committees and agencies have published suggestions for selecting persons either to be trained or hired as admin- istrators. Furthermore, individual hospital boards of trustees have 1 Commission on Hospital Care, HOSpital Care $2 the United States (New York, The Commonwealth Fund, 1947) p. 512. 2 Arthur C. Bachmeyer and Gerhard Hartman (Ed.) Hospital Trends and Developments 1940-1946 (Cambridge, Massachusetts, Harvard University Press, 1948) p. 208. 3 American Council on Education, University Education for Administra- tion ip Hospitals, A Report of the Commission on University Education in Hospital Administration (Washington, D.C.: American Council on Education, 1954) p. 16. established their own selection standards. However, there is not a unified set of criteria for this purpose. In large part, the lack of uniformity can directly be associated with the lack of agreement among hospital administrators, hospital boards of trustees and study agencies as to what constitutes the job of the administrator and what preparation is most desirable for that position. The problem with which the author of this paper is concerned is to study the job of the hospital administrator with emphasis on the personal traits and preparation for the job as visualized by practicing hospital administrators. The author is also interested in the hospital adminis- trators' opinion of how others regard the position of hospital adminis- trator and the hospital administrators' opinion of his own job. Purpose The purpose of this study is to learn what Michigan hospital adminis- trators believe make up their duties and who can best perform the duties of that office. Specifically, the purpose of this paper is an investiga- tion of five aspects of hospital administration. These are: 1. A determination of what the job of the hospital administrator consists. 2. A determination of the personal qualifications which the hos- pital administrator must have or develop. 3. A determination of what constitutes the best preparation for the hospital administrator. 4. A determination of the hospital administrators' opinion of how others regard the position of hospital administrator. 5. A determination of the hospital administrators' opinion of his own job. From the investigation of these five areas conclusions will be formulated which will represent administrators' thinking and opinions about their profession. Scope and Delimitations Ideally this study would be one of several sub-studies designed to determine what various groups other than hospital administrators think of the profession of hospital administration. This overall study would include responses from a representative sample of hospital administra- tors, hospital boards of trustees, educators in courses in hospital ad- ministration, students of hospital administration, and of doctors and other professional groups associated with hospitals. The scope of the study would be extended to include a comparison of the responses of the various groups. Such an energetic project would require, however, great expense and time and the efforts of several investigators. This study can only be a small part of such a large project. A single group was included as a part of the population to be studied and that group was limited to include only hospital administrators in the State of Michigan. The hospitals "listed" by the American HOSpital Association1 were used which places further limitations on the number of administrators contacted and consequently on the amount of information gathered. A single means of contact, by mail, with the hospital administra- tors was utilized and this, too, places some limits on the quantity and quality of the information available for use in the study. Method A questionnaire (Appendix B) was constructed for use in gathering data for this study. Prior to mailing the questionnaire to the group 1See definition in Definition of Terms, p. 7. selected for study a pre-test was conducted in the Kansas City area. Six (6) questionnaires were given to hospital administrators and administra- tive assistants in Kansas City, Missouri hospitals. Adjustments were made in the questionnaire following the return by this test group and before the questionnaire was mailed out to the study group. The group selected for study included only the hospital administra- tors of the American Hospital Association ”listed" hospitals in the State of Michigan1 as of February 16, 1959. A letter explaining the purpose of the questionnaires (Appendix A) accompanied each questionnaire. The letter and questionnaire were sent to each of the two hundred and forty-nine (249) administrators of American Hospital Association "listed” hospitals in Michigan. A follow-up letter (Appendix C) and questionnaire (Appendix B) were mailed to Michigan hOSpital administrators who had not answered and returned the original questionnaire. The data received was tabulated as follows: 1. The total number of administrators selecting each choice to the questions in the questionnaire was tabulated. 2. The total number of administrators in each hospital size cate- gory selecting each choice to the questions was tabulated. The hospital size categories are: (1) 6-49 beds, (2) 50-99 beds, (3) 100-199 beds, (4) 200-399 beds, (5) 400 and more beds. 3. The total number of administrators in each background prepara- tion category selecting each choice to the questions was tabulated. The background preparation categories are: (1) Medicine, (2) Nursing, 1 ”Listing of Hospitals”, Hospitals, XXXIII, 15, part 2 (August 1, 1959) pp. 103-110. (3) Business Administration, (4) Hospital Administration, (5) Business and Hospital Administration, (6) Nursing or Medicine or Para-Medical Training (Medical Sciences) and Hospital Administration and (7) Others. 4. The total number of administrators in each length of service category selecting each choice to the questions was tabulated. The length of service categories are: (1) less than one year, (2) 1-4 years, (3) 5-9 years, (4) 10-19 years and (5) over 20 years. Summaries were made from the data tabulated in each of the above categories. The tabulated data was then analyzed and the facts and assumptions were assimilated in order to make a determination of the job of the administrator, the personal traits needed, the preparation desired, the opinions of others of the position of hOSpital administra- tor and the administrators' opinion of their own job. Conclusions were drawn from the analyses. Definition pf Egggg Hospital Administration: The art of directing and managing the general activities and functions of the hospital groups so that they will be able to achieve the hospital's objectives of service to the sick, of education, of research and of public welfare, with efficiency, with economy and with satisfaction.1 Board pf Trustees: The Board of Trustees or the Board of Directors is the governing board of the hospital. It is this governing board which 1John R. McGibony, Principles pf Hospital Administration (New York: G. P. Putnam‘s Sons, 1952) p. 88. is regarded as the supreme authority in the hospital, the body to which the administrator, the medical staff, the personnel, and all auxiliary organizations are directly and indirectly responsible.1 Hospital Administrator: The hospital administrator is the executive director of the hospital and the deputy of the Board of Trustees. His functions consist of all activities necessary to effectively direct and manage the affairs of the hospital.2 American Hospital Association Listing: The primary aim of the American Hospital Association's Program of Accepting Hospitals for "listing” is to provide a cenSus of hospitals. The requirements for listing are as follows: 1. The hospital shall have at least six beds for the care of patients who are nonrelated, who are sick, and who stay on the average in excess of 24 hours per admission. 2. The hospital shall be licensed in those states and prov- inces having licensing laws. 3. Only doctors of medicine shall practice in hospitals listed by the American Hospital Association. 4. Duly authorized by-laws for the medical staff shall be adopted by the hospital. 5. The hospital shall submit evidence of regular medical supervision of patients. 6. Records of clinical work shall be maintained by the hospital on all patients and shall be available for reference. 7. Registered nurse supervision and such other nursing service as is necessary to provide patient care around the clock shall be available at the hospital. 1Malcolm T. MacEachern, Hospital Organization and Management (Chicago: Physician's Record Co., 1957) p. 90. 2John R. McGibony, Principles 2f Hospital Administration (New York: G. P. Putnam's Sons, 1952) p. 80. 8. The hospital shall offer services more intensive than those required merely for room, board, personal services, and general nursing care. 9. Minimal surgical or obstetrical facilities (including operating or delivery room), or relatively complete diagnostic facilities and treatment facilities for medical patients, shall be available at the hospital. 10. Diagnostic x—ray services shall be regularly and con- veniently available. 11. Clinical laboratory seryices shall be regularly and conveniently available. Population: Population is the totality of all possible observations of the same kind. Sample: A sample is the number of observations which have been observed.3 Para-Medical: This refers to any of the medical or nursing supporting disciplines such as X-ray, Laboratory and Physical Therapy. Review pf Literature The underlying problems of this study have been treated in many previous studies and articles. In a review of the literature the ques- tion of choice of administrator, qualifications and preparation needed for the person chosen and the duties performed by that person has been written many times and in many different ways. It also shows the evolution of a specialized management profession. The author has selected articles which depict the changes in administrators' thinking about the profession of hospital administration. The author has also selected those articles for review in which are contained lists of duties performed by the hospital administrator and the personal traits needed by him. It is 1American Hospital Association, ”Listing of Hospitals", Hospitals XXXIII, 15, part 2 (August 1, 1959) p. 15. 2W. Allen Wallis and Harry V. Roberts, Statistics: A New Approach (Glencoe, Illinois: The Free Press, 1956) p. 101. 3Ibid. from these lists that a comparison will be made with the duties indicated as those performed by the administrators studied in this project. This review also contains opinions and recommendations on academic training programs, statistical information on the background preparation of admin- istrators, and criteria used in the selection process. In this study the author has included summaries of some of the literature reviewed. Before each summary the author and his or her article are identified. Banfield, Maud. Some Unsettled Questions i3 Hospital Administration ip the United States, Vol. XX, No. 2. American Academy pf Political Science. Edited by Emory R. Johnson, Philadelphia: The American Academy of Political and Social Science, 1902. Maud Banfield, in her article written in the early 1900's, stated that members of the medical profession determined what they believed were criteria for use in selecting the administrator of a hospital. She quoted the following article which appeared in the Philadelphia Medical Journal on August 10, 1901: "Medical men are, by very reason of their training and their profession, most tolerant, most broadminded and most judicial in their judgments, and they will yield to none a sense of greater humane consideration for the well-being of those entrusted to their care. While it is true that the physician is, largely in consequence of more important demands on his time and energy, disinclined for the details of business matters, he is often possessed of a fine and ethical business judgment; and of course, none can take his place in dealing with matters appertaining to the profes- sional aspects of Hospital Government." But there was not agreement within the medical professional group at this time. She quoted from another journal, The American Medical -10- Magazine, which published an article in 1902 with a completely opposite point of view. The author encouraged medical men to continue only in their practice of medicine. The magazine stated that the complexity of the modern hospital requires men specially trained in the management of commercial matters. "The typical busy practitioner is indeed too often like a child in such things." Further commentary from this period, 1901, centers around the training needed for the hospital superintendent (administrator): ”Teachers are taught to teach, engineers are taught engineering, preachers to preach, doctors to doctor, but to reconcile the innumerable and various elements in a large and busy hospital no previous knowledge seems to be thought necessary!" Miss Banfield points out the need for training and looks toward the nurse as a person who is a logical hospital administrator. "Some trained nurses have the ability to manage hospital business and this in combina- tion with their professional training makes her the most logical hospital superintendent." McNamara, John A. What the Hospital Trustee Should Know. Chicago: Physician's Record Company, 1931. In 1931 John A. McNamara stated that fifty percent of the hospitals were administered by nurses, thirty percent by doctors and the remaining twenty percent by business men. But, Mr. McNamara does not suggest that the percentages indicate any degree of guarantee as to the success of the administrator because the person has an M.D. or an R.N. or a business degree behind his or her name. The author does indicate that the person who will be successful must be fully aware of and sympathetic to the problem of the medical fraternity, -11- hygiene and sanitation and business economics. In addition the admin- istrator must have personality, must know how to work with the community, must know medical ethics, must know law, and must know people. Mr. McNamara suggests that the best training school for the hos- pital administrator is on-the-job training. He states that possibly the best source of supply of hospital administrators is from the assistant administrative positions. Neff, Robert E. A Survey pf the Hospital Administrator. Chicago: Physician's Record Company, 1932. Mr. Neff, in his study of hospital administrators, reveals some statistics which indicate the status of the administrative position in the 1930's. In 1932 Mr. Neff determined the following facts: (1) 19.6 per cent of the administrators had academic degrees; (2) 25.9 per cent of the administrators of hospitals were nurses, and (3) 33.6 per cent of the administrators had previous administrative training or experience. A further breakdown of Mr. Neff's study group of administrators who had academic degrees (19.6 per cent of 6,500 hospital administrators) indi- cates that 21.1 per cent had specific hospital administration courses, 15.1 per cent had business administration courses, 16.2 per cent were doctors and 12.5 per cent were nurses. The remaining 35.1 per cent had academic degrees in a wide variety of specialty areas. According to Mr. Neff, in the 1930's there continued to be an em- phasis upon the medically trained person (doctor or nurse) as the admin- istrator, however, it can be noted that persons with a business preparation or with a more-or-less specific hospital administration preparation, were almost equally in demand at that time. Mr. Neff used the entire group of hospital administrators in the -12- United States in 1931 as his population. 0f the 6,500 administrators 1,950 (30 per cent) replied to Mr. Neff's questionnaire. MacEachern, Malcolm T. ”Selection of the Administrator”, Hospital Trends and Developments 1940 - 124p. ed. Bachmeyer, Arthur C., and Hartman, Gerhard. Cambridge, Massachusetts: Harvard University Press, 1948. Dr. MacEachern has outlined the duties of the administrator of a hospital along with the qualities which he believes to be strongly needed by that administrator. His list of duties for the administrator include: 1. Those stated functions and duties which are indicated in relation to the hospital board of directors. 2. Collaboration with the medical staff. 3. Interpret and transmit policies to the medical staff and to personnel. 4. Coordinate the medical staff departments' activities with those of other departments. 5. Indicate which large items of equipment must be pur- chased. (Authorize purchase of equipment). 6. Select department heads. 7. Set standards of patient care. 8. Set fee schedules and rates. 9. Manage the business office. 10. Study of methods and systems. 11. Direct public or community relations. Dr. MacEachern continued his article by listing the essential qual- ifications of the hospital administrator. They are: l. Tact and diplomacy. 2. Firmness tempered with consideration. -13- 3. Organizing ability. 4. Leadership. 5. Dependability. 6. Honesty and fairness. 7. Knowledge of human nature. 8. Industry and interest. 9. Administrative ability. 10. Education. 11. Teaching ability. 12. Business ability. 13. Buying ability. 14. Mechanical ingenuity. 15. Personality. 16. Cooperativeness. Dr. MacEachern concludes his article by indicating the methods by which a competent administrator might be found. He suggests the use of the professional organizations such as the American College of Hospital .Adndnistrators, the American Medical Association and the American College of Surgeons. The applicant for the position might be judged, Dr. MacEachern suggests, by any of the techniques employed by men of business ‘who hire administrative persons for their particular field. Joint Commission on Education of the American Hospital Association and the American Medical Association. The College Curriculum ip.flp§- pital Administration. A Final Report by the Joint Commission on Education of the American Hospital Association and the American Medical Association. Chicago: Physician's Record Co., 1948. In 1948 the Joint Commission on Education of the American Hospital Association and the American Medical Association published its findings of a three-year investigation of hospitals' administration needs. The -14- result of this group's study reveals that the source of supply for hos- pital administrators will, very likely, be altered in the future because of the university programs in hospital administration. This alteration is not one which will be immediately significant, however. The study revealed that the greatest source of potential administra- tors still 1ies in related hospital positions such as the Business Manager and the Director of Nursing Service. Members of the medical profession will continue to be a large source of supply, especially in the specialty hospitals (tuberculosis sanitariums, children's hospitals and mental hospitals). Other groups from which hospital administrators will be drawn include Government and Military services, hotel managers, business men, engineers, salesmen and teachers. In the past these groups have contributed large numbers of hospital administrators. There does not appear to be any reason why these unrelated groups would not continue to be a big source of supply until such time as the universities can fill the needs for administrators with specially trained persons. The study group does predict, however, that the long range future for persons other than those trained in hospital administration does not look good. The study group has gone on record as saying that except for the university trained hospital administrator all persons in other hospital positions or in unrelated positions will find little or no opportunity for selection as a hOSpital administrator. Of interest is the fact that the study group also deter— mined, through investigation, that the most important facets of hospital administration include (1) Working with the Medical Staff, (2) Personnel Management, (3) Department Heads and Departmental Functioning, (4) Medical Care, (5) Business and Financial Management, (6) Community Relations and -15- (7) Legal Aspects and Litigation. The Commission emphasizes the import- ance of academic preparation and on-the-job training specifically oriented to the hospital. It is their belief that any training other than this cannot adequately prepare a person for hospital administration. American Council on Education. University Education for Administra- tionpip Hospitals. A Report of the Commission on University Education in Hospital Administration. Washington, D.C.: American Council on Education, 1954. This study group indicates the personal qualities which they believe to be required of an administrator of a hospital. These qualities are: 1. Physical qualities which include vitality, endurance, and neat appearance. 2. Psychological qualities which include integrity, humanism, responsibility, self-discipline, stability and industry. 3. Intellectual qualities which include mental capacity, ability to teach and a scientific approach to problems. 4. Motivational qualities which include social consciousness and a well defined personal philosophy. The study group had as its purpose the making of recommendations for the improvement of courses in hospital administration through a survey of existing programs and a survey of the needs for graduates from these programs. University courses in hospital administration altered their study programs as a result of this investigation. It is important, however, that the list of personal qualifications be cited because these need not necessarily be dependent upon a specific academic hospital administration program. These personal qualifications are considered a necessary part of the hospital administrator, regardless of his preparation and academic training. Scope Weekly. (Kalamazoo, Michigan), V, No. 6 (February 10, 1960) 11. In a recent publication of Scope Weekly, the question, ”What are ~16- some of the qualities you expect to find in an ideal hospital superin- tendent?” was asked of a group of doctors. The responses to the question included such items as a good sense of social consciousness, understanding of medical problems, ability to evaluate personnel, an awareness of the hospital's role in education, ability to manage fiscal matters, ability to perform the functions of good administrative practice. This group of doctors agreed that the administrators' education should be a combination of business and (academic) hospital administra- tion and should also include an exposure to medicine in some manner. Agreement seemed to be reached by all of the doctors answering that the hospital superintendent (administrator) should be energetic and tactfully diplomatic. Lentz, Edith M. and Michael, Robert G. "Some Hospital Administrators" University of Minnesota. Minneapolis, 1957. (Mimeographed) The study completed by Miss Lentz and Mr. Michaels was primarily concerned with the questions: (1) Who enters the hospital administration course? (2) Who achieves success in this field of administration? (3) Who enjoys working in this field? The study sample included only the graduates from the hospital administration course of the University of Minnesota. Because the study group is identified with a specific program in hospital administration, it is obvious that an emphasis would be placed on university courses of study in hospital administration. Of interest for this paper, however, is the fact that the University of Minnesota has selected students for their program as follows: 0f the 191 graduates of the course, 58 percent (111) had previous hospital work experience. 0f the 191 graduates, 31 percent (59) had business training and/or experience before entering the hospital administration field. -17- Of the 191 graduates 4 per cent (8) were graduate nurses with a baccalaureate degree in either nursing education or administration. Of the 191 graduates 3 per cent (6) were doctors of medicine or had completed their pre-medical undergraduate work. Doane, Joseph I. ”Ten Attributes of a Good Administrator," Modern Hos- pital, LVIII, No. 1, (January, 1942), 55 - 56 Dr. Doane has compiled ten (10) qualifications which he terms highly essential for the "good” hospital administrator. These attri- butes include: 1. A Good Personality - Dr. Doane's suggestion to the admin- istrator is that he always be ready with a smile. 2. A Good Preparation - Dr. Doane suggests that a broad edu- cational background is best but it can be best only if learned well by the student. 3. A Good Sense of Relative Values - The hospital adminis- trator must be able to evaluate all phases of hospital work but must always consider the patient as the most important part of his work. 4. A Judicial Attitude toward Problems - Dr. Doane stresses the importance of fairness in all of the administrator's actions. 5. Common Sense. 6. Tact. 7. Leadership - The author of this article instructs the ad- ministrator to be a leader of the persons whom he has as his fellow workers. This leadership can only be had through a sincerity and honesty of action. 8. Intellectual Honesty. 9. An Unswerving Belief in the Advantage of Education - the administrator of the hOSpital should support fully the hospital school of nursing, medical education programs and community education. 10. Graciousness - Dr. Doane concludes his article by tell- ing the administrator to be well mannered and kind in his business and daily activities. Dr. Doane's attributes for the hospital administrator can apply not only to the hospital situation but to any business administrator. -18- McLane, Thomas 8. "Selecting an Administrator," Modern Hospital, LVI, No. 5 (May 1941), 82-83. Mr. McLane offers some Personal opinions about whom he believes the administrator should be for each of the several sized hospitals and the qualifications which he believes that person should have. The author believes each type of hospital (size) requires persons with different background training. The small hospital, for instance, should be man- aged by a woman with preparation in the medical social services. The medium sized (up to 250 beds) hospital should be managed by a man with a business preparation. The hospital of 250 or more beds should be managed by the medically trained man (a doctor). The author states that the administrator's primary duty is that of removing the barriers which exist between the many professional and non- professional groups within the hospital. The personal qualifications for each of the administrators for the different sized hospitals which Mr. McLane listed include: 1. Diplomacy 2. Tact 3. Sense of Humor 4. Patience Mr. McLane ends his article by stating that the only source of supply for good administrators is in the hospital field. Summary: The review of literature contains a marked historical change in the thinking of writers as to who should be a hospital administrator. In 1900 it was believed that only the medically trained person could be trust- ed to manage the affairs of a hospital. Even during this time, however, it was recognized that every doctor was not automatically prepared or qualified to manage a hospital merely because of his degree in medicine, nor was a -19- nurse automatically made capable for this work because of her education. By 1930 the break away from medical persons as administrators began to make itself evident although the large majority of administrators still had been trained in medicine or nursing. In 1948 a group of men commis- sioned to study the problem of hospital administration made recommenda- tions which they hoped would eventually remove the doctor and the nurse from administration positions except in Such cases as either the doctor or the nurse had received specialized hospital management training. It should be recognized that these are recommendations made by a group which is not able to enforce or regulate the Suggestions they had made. It should also be recognized that the process of replacing medically trained administrators must be a long term one even if the recommendations are fully acceptable to individual hOSpitals. The review of the literature has also produced a list of administrative duties and personal qualifi- cations. The published material from which the preceding excerpts were taken represent a sample of the opinions expressed by hospital administrators and other authorities about some of the same hospital administration areas which were studied in this project. Although the author did not conduct an exhaustive search for representative samples of hospital .literature, it is his belief that the works which were reviewed do ex- press the thinking regarding hospital administration at various periods of time. A portion of the review of the literature contains an expres- sion of opinions regarding the best methods by which to learn hospital administrative skills. According to the more recent literature the best means appear to be formal academic programs in hospital administration .and on-the-job residency teaching programs. -20- The areas which are included in this section on the review of the literature are also the areas which were studied and analyzed in the project. Comparisons are made between the author's investigation and the opinion found in the literature of the job of the administrator, the personal qualifications needed by the administrator and the method by which to develop administrative skills. The results of the analysis of the questionnaire sent to Michigan hospital administrators shows generally that the majority of these administrators agreed with the opinions expressed in the literature since 1930. That is, there was agreement on the duties performed, personal qualifications needed and the type or training considered best. The fact that there are opinions expressed by the Michigan group which are different than those expressed in the literature is primarily due to the fact that the articles which were reviewed were selected for their content by the author. In Chapter I background information pertinent to this study has been presented. The purpose was stated and the plan of this paper was outlined. Selected readings were reviewed which showed the historical development of hospital administration as a science. In Chapter II the study group will be analyzed. These Michigan hospital administrators will be categorized according to their back- ground preparation, according to the length of time they have been in hospital administrative positions and according to the size of the hospitals they manage. The sample group will be compared with the population. In Chapter III the qualifications and functions of the hospital administrator will be discussed and analyzed. The managerial duties Enid community activities performed by the administrators will be -21- presented as well as the background preparation and personal traits considered desirable. Chapter IV is devoted to an analysis of how the administrators regard the position of hospital administrator and how they believe others see that position. Chapter V consists of the summary, conclusions and recommend- ations. CHAPTER II ANALYSIS OF STUDY GROUP As was stated in Chapter I, the problem with which the author of this paper is concerned is a study of the job of the hospital adminis- trator and the personal and training qualifications needed by him. This problem can best be approached by a survey of hospital administrators. It was believed that the best way to survey a group of hospital administrators was by means of a questionnaire. The data obtained from reviewing the literature served as a guide for constructing a questionnaire for use in attaining the objectives of this study. In Chapter II the author presents and analyzes the study group from whom the opinions have come regarding the duties, background and personal qualifications of the administrator. Two hundred and forty- nine (249) questionnaires were sent to Michigan hospital administrators and data from the returned questionnaires was tabulated as described in the section titled Method, page 4. 0f the total number of questionnaires which were mailed, 44 per cent (110) were returned to author following the first mailing. Eleven (11) of those returned were not answered, however. A review of the reasons given by the eleven (11) administrators who returned unanswered questionnaires shows that four (4) administrators either did not have the time to complete the questionnaire or had adopted a policy of refusing to answer any questionnaires, six (6) of the adminis- trators stated that they could be of no help to the study because of the -22- -23- size or the type of a hospital of which they were the head, and one (1) administrator simply returned an unanswered questionnaire with no explana- tion as to why he did not fill in the information requested. An additional seventeen (17) questionnaires were returned following the second mailing. Totally, 51 per cent (127) of the questionnaires were returned. 0f the returned questionnaires 46.6 per cent (116) were usable in the tabulation. A question arises as to the relationship of the sample to the popula- tion. The author has compared the number of administrators of hospitals of various bed size in the sample with the number of administrators of hospitals of similar bed size in the population. The source of authority for the latter group was obtained from the American Hospital Association list of hospitals. Table 1 shows this relationship. TABLE 1 RELATIONSHIP OF SAMPLE TO POPULATION ACCORDING TO BED SIZE Bed Size Sample Population Number Percentage Number Percentage 6-49 Beds 27 23.3 69* 27.7 50-99 Beds ' 26 22.4 52* 20.9 100-199 Beds 29 25 62* 25.9 ZOO-399 Beds 22 18.9 38* 15.3 400 or more Beds 12 10.4 28* 11.2 Total 116 100 249* 100 *The number of beds in each hospital and the total number of hospitals was obtained from American Hospital Association list of hospitals. -24- As can be seen in Table 1, there are striking similarities between the number of responses from the sample group as compared to the actual number of hospitals in each of the bed size categories. Although the number of administrators in the sample group categories are not always proportional to a similar group in the population, the fact that there is not a great variance nor a preponderance of reponses from any one bed size category indicates a rather close relationship between the sample and the population. One factor which may have had some effect upon the number of hospitals in some of the bed size categories is the fact that several responding administrators, when asked the size of their hospitals, indicated either a larger or a smaller bed size than that which was indicated for that hospital by the American Hospital Association. Because the information concerning both the academic background preparation of the administrator and the length of time which each administrator has been in the field was not readily available for the population, a further comparison of sample and population according to these factors is not possible. This information is available for the sample group of administrators, however, and will be presented in Tables 2, 3, and 4. According to Table 2 one notes that all of the administrators with less than one year of experience are administrators of hospitals of ninety- nine (99) beds or less. It is noted also that ten (10) of the twelve (12) administrators of hospitals of 400 or more beds have ten (10) or more years of experience. It is also evident from the table that more than half of the administrators in the sample group have been in this field for ten (10) or more years. This would indicate that the administrative tenure is rather high. -25- TABLE 2 DISTRIBUTION OF ADMINISTRATORS ACCORDING TO BED SIZE AND LENGTH OF TIME AS AN ADMINISTRATOR I Bed Size Total 1 yr. 1-4 5-9 10-19 20 yrs. or less yrs. yrs. yrs. or more 6-49 Beds 27 2 8 9 5 3 50-99 Beds 26 2 1 7 9 7 100-199 Beds 29 O 3 10 12 4 ZOO-399 Beds 22 O 1 6 9 6 400 or more Beds 12 0 1 1 6 4 Total 116 4 14 33 41 24 The author cannot present a comparison of tenure to the chronological age of the study group because data for the latter was not obtained. Although there would obviously be a close relationship between the two, the exact nature is unknown. It appears, however, that the position of the hospital administrator tends to be a life time choice. There is verification of this from data obtained in the questionnaire analysis. Almost ninety-five (95) per cent of the respondents indicated that their job was a life time choice. It also appears that the rate of turn over for this position is relatively small. Only four (4) administrators in the sample group were introduced into the administrative group in the past year (1958-1959) and eighteen (18) in the past four (4) years. Turn over of administrators apparently means retirement from the field. The author recognizes the fact that there have been changes of administrators in some hospitals. The changes which did occur were apparently made by hospitals trading administrators rather than bringing someone new into the field. Since the number of new administrators is so small the author is -26- inclined to believe that the procedure by which most men become an administrator is first to serve as an assistant. The correlation which exists between length of service and hospital size (Table 2) indicates that the criterion of experience through service motivates both the administrator and the boards of trustees. The administrator uses his experience as a factor by which to gain a position in a larger hospital, and the boards of trustees of larger hospitals apparently seek the admin- istrator with experience when a position is vacant in their hOSpitals. Boards of trustees of large hospitals look for an administrator who has the proven ability to successfully manage the large institutions and administrators who have the experience desire more challenge, prestige and salary which the large hospital provides. This is a logical rela- tionship and one which obviates the need for on-the-job training and experience and which tends to verify the selection processes pointed out in the literature. The fact that the number of administrators who have been in the field for relatively long periods of time is high (almost 87 per cent have been hospital administrators for five (5) years or more in Michigan hospitals according to the sample group) indicates that job satisfaction is high. Data available from the questionnaire verifies this fact. Approximately eighty-five (85) per cent of the respondents indicated that their job as a hospital administrator was satisfying, challenging and rewarding. One could expect then to find a relatively stable group of administrative persons and Table 2 indicates that such a situation exists. As can be seen from Table 3, the largest number of administrators have a Business, Medicine, combination Business and Hospital Administration, -27- TABLE 3 DISTRIBUTION OF ADMINISTRATORS ACCORDING TO ACADEMIC BACKGROUND PREPARATION AND LENGTH OF TIME AS AN ADMINISTRATOR Preparation Total ‘ 1 yr. 4 1-4 , 5-9 10-19 20 yrs. : or less yrs. ’ yrs. yrs. I or more 1 E Business I 25 0 0 7 8 7 Medicine i 20 O 1 5 9 5 Bus. & H.A. ; l7 2 O 6 8 1 Nursing g 13 O O 4 4 5 Hosp. Adm. 3 12 O 2 5 5 0 Nursing & H.A. ;, 8 o 2 2 3 1 Medicine & H.A. ' 4 O 0 l 1 2 Paramedical ;, 4 l 1 0 2 0 None 4 O 2 l l 0 Bachelor of Arts 2 0 2 0 0 0 Paramed. & H.A. 2 0 1 0 0 l Inst. Mgmt. l 1 0 O 0 0 Secretary 1 0 0 1 0 0 Law 1 0 0 l 0 0 Mech. Eng. 1 0 0 0 0 1 Teacher 1 0 0 0 0 r 1 Total 116 4 14 t 33 i 41 24 I Nursing or a Hospital Administration background. The administrators having any of these background preparations have been, to a large degree, in the field for more than five (5) years and about half of the sample group has one of these five (5) mentioned backgrounds and has been in the profession for ten (10) years or more. Administrators with a back- ground in Hospital Administration are not represented in the group having twenty (20) or more years of experience except as an administrator has combined Hospital Administration with either a Medical or Nursing background. An outstanding feature of Table 3 is the fact that there are many different backgrounds represented, none of which seems to have been -28- proven as the best. There certainly is no indication from the tabula- tion that the recommendations to utilize specially trained hospital administrators made by the Commission on Education in 1945, have had any effect upon the training or selection of hospital administrators for Michigan hospitals. And, the predominence of either Medical or Nursing personnel as administrators, a situation described by Mr. Neff in his study in 1932, only slightly manifests itself in the administrative groups which have been in hospitals for five (5) or more years. Due to the fact that the Michigan administrative group has apparently been a stable one, there may be some significance in Mr. Neff's study as it relates itself to Michigan hospitals. It appears that the administrators with a medical background (either Medicine or Nursing) were selected more often twenty (20) or more years ago. Apparently, greater reliance has been placed on the individual and the experience which the individual brought with him when seeking an administrative job than upon the academic preparation which the individual had. As mentioned previously, the most valid crite- rion used in the selection of administrators seems to be experience, i.e., proven ability. A popular preparatory background is the one in Business. It can be assumed from Table 3 and Table 4 that the administrators having a Busi— ness background were utilized as business managers of the smaller hos- pitals. The majority of these administrators are in hospitals of one hundred (100) or fewer beds and have been in the field less than twenty (20) years. Table 4 continues the analysis of the distribution of hospital administrators having a specific academic background preparation according to the size of the hospital of which each administrator is the head. -29- TABLE 4 DISTRIBUTION OF ADMINISTRATORS ACCORDING TO ACADEMIC BACKGROUND PREPARATION AND BED SIZE OF HOSPITAL Preparation rTotal I 6-49 50-99 100-199 200-399 400 Beds Beds Beds Beds Beds or Over 1 Business 25 j 10 7 5 i 3 0 Medicine 20 I 1 2 5 4 8 Bus. & H.A. 17 3 4 4 1 6 0 Nursing 13 f 5 5 3 E o 0 Hosp. Adm. 12 2 1 f 6 l 2 1 Nursing & H.A. 8 1 1 g 0 § 5 1 Medicine & H.A. 4 0 O ‘ 1 ? l 2 *Paramedical 4 l 2 l ' O 0 *None 4 2 1 1 O 0 *Bachelor of Arts 2 l 1 O O 0 *Paramed. & H.A. 2 O 0 2 O O *Inst. Mgmt. 1 0 1 0 o 0 *Secretary 1 O O l O 0 *Law . 1 o 1 0 0 0 *Mech. Eng. 3 l O O O l 0 *Teacher 1 1 O O O 0 Total 116 27 26 29 22 12 *Categorized as ”Other". It can be seen from this table that the administrator having a background in Medicine generally has been the one selected to administer the large (400 or more beds) hospital. It can also be noted that the administrators who have backgrounds classified as "Other" generally are found in the small (less than 100 beds) hospitals. The distribution of the administra- tors with the five (5) major academic background preparations ( Business, Medicine, combination Business and Hospital Administration, Nursing or Hospital Administration) is fairly even for the various sized hospitals except for the large (400 or more beds) hospitals. -30- According to Mr. Neff's study quoted earlier in this paper, the policy of selection of hospital administrators almost thirty years ago favored the person who had either a medical or a nursing background. Table 4 indicates that the medically trained administrator may still be favored as the head of the large hospital or at least is still in a majority as administrator of the large hospital. A comparison of Table 4 to Table 3 will show that the administrator with a medical back— ground is also the administrator with the longest tenure of service. Apparently the effects of the philosophy described by Mr. Neff still prevail in hospitals to some degree. The author suggests that some of the administrators of the large hospitals who responded to the question- naire for this study are the same administrators who were studied by Mr. Neff in 1930. In order to make an accurate evaluation of background preparation as a selection criterion, it will be necessary to study the administrators at a time when the influence of the 1930's will not be a factor, i.e., at such time as the present administrators with twenty- five (25) or more years of service have retired. It must also be pointed out, however, that most federal and state hospitals still require the administrator of a government institution to be a doctor of medicine. Since federal and state hospitals constitute roughly three-fourths of the total number of large hospitals (400 or more beds) in Michigan, there appears little likelihood that a gross change of selectionpolicy will occur in the immediate future. A factor which will be explained further when the duties of the administrator are analyzed becomes obvious from a study of Table 4. It will be noted that there is a relatively consistent grouping of adminis- trators with a business background in the