Them {qr flu Dag!” ef Pk B MtCHiGAN STATE UNWERSITY James P Harkness 1961 "’l,’ 'THEss This is to certify that the thesis entitled Hospital Organization in Transition: A Sociological Analysis of Interlocking Social Systems presented by James P. Harkness has been accepted towards fulfillment of the requirements for Ph.D. degree in_$o.ci_(1_l_o.g.¥ 8 Anthropology /' l l I / " L." . / /l/ / \ "’1 h . ’ " . \.- ' v ‘ 1/ (‘L “’1' if y!\ I ‘1 \‘b; V a-.. \ —’_v I Major professor Ihne August 17. 1961 0-169 LIBRARY Michigan State University ABSTRACT HOSPITAL ORGANIZATION IN TRANSITION: A SOCIOLOGICAL t 'ANALYSIS OF INTERLOCKING SOCIAL SYSTEMS By James P. Harkness The major growth in demand for community-centered, hospital care since World War II has led to increased pressures upon the community, non-profit hospital. Chief among the factors within the hospital affected by such increased demand has been the hospital organi- zation itself. Previous studies of the organization have been frequently concerned with individual role conflict or the disparity between the individual and the organization. Examining organizational continuity and change in the face of pressures external to the hospital demanded the_g§§.9£w n organizational theory“ that emphasized persistent elements within the organi- M" " line-cup. zational structure.. A combination and modification -—. ‘1. U- c w- ‘- of the theoretical ideas of Talcott Parsons and Alvin W. Gouldner provided a point of departure for the exami- nation of persistence and change in the hospital organi- zation. The organization in this modified form is viewed as'a set of sub-systems, each with a different set of actors and a different value pattern. Out of this framework, a series of hypothesis were constructed to test the theory that actors within the sub-systems Abstract could differentially view the goal and the output of the hospital, but, nevertheless, the sub-systems inter- lock to provide continuity for the organization. A case study of a community hospital provided the evidence used to test the theories of organizational persistence and change. In order that increased demand upon facilities could be clearly established, one cri- terion used in the selection of the research site was population stability of the community studied. The main variables of the study were the three sub- systems of the hospital -- the board of directors, the administration and the medical staff. Significant aspects of these variables, including the value pattern of each, were determined by interviews from a sample of actors within the sub-systems. Additional field techniques used to secure the necessary information for this study included interviewing hospital personnel and community members, and reading and recording hospital records and local newspaper accounts of the hospital. The general findings reveal that an organization can persist, expand and change while actors within sig- nificant, decision-making sub-systems do not use or agree upon a major goal or purpose. Furthermore, goal evaluations which are used in crucial decision-making situations are not always related to the output of the organization. These general findings raise serious questions about the nature of organizational theory as Abstract could differentially view the goal and the output of the hospital, but, nevertheless, the sub-systems inter- lock to provide continuity for the organization. A case study of a community hospital provided the evidence used to test the theories of organizational persistence and change. In order that increased demand upon facilities could be clearly established, one cri- terion used in the selection of the research site was population stability of the community studied. The main variables of the study were the three sub- systems of the hospital -- the board of directors, the administration and the medical staff. Significant aspects of these variables, including the value pattern of each, were determined by interviews from a sample of actors within the sub-systems. Additional field techniques used to secure the necessary information for this study included interviewing hospital personnel and community members, and reading and recording hospital records and local newspaper accounts of the hospital. The general findings reveal that an organization can persist, expand and change while actors within sig- nificant, decision-making sub-systems do not use or agree upon a major goal or purpose. Furthermore, goal evaluations which are used in crucial decision-making situations are not always related to the output of the organization. These general findings raise serious questions about the nature of organizational theory as Abstract it stands today. First of all, it means that at least two general kinds of organizational models should exist; one for the examination of non-profit; community organi- zations and one for the examination of profit-making organizations. Not only does goal evaluation and its relationship to output constitute an important differ- ence between these two types, but also the general forces which define the limits of organizational ac- tivity appear to be important distinguishing factor between the types. HOSPITAL ORGANIZATION IN TRANSITION: A SOCIOLOGICAL ‘ I'ANALYSIS or INTERLOCKING SOCIAL SYSTEMS by l. vs .\ ‘ \ James P: Harkness A THESIS Submitted to Michigan State university in partial fulfillment of the requirements for a degree of DOCTOR OF PHILOSOPHY Department of Sociology and AnthrOpology 1961 5/2¢/éa ACKNOWLEDGMENTS I wish to acknowledge the encouragement and guidance I received from Dr. Duane L. Gibson, my major advisor. Also I want to thank Dr. Walter E. Freeman and Jay W. Artis for their helpful assistance throughout the study. Gratitude is also extended to Dr. Charles P. Loomis, Dr. Charles R. Hoffer and Dr. William J. Callaghan for their critical review of the thesis. My appreciation is also expressed to Dr. Ruth Hill Useem, Alexander J. Muntean, Robert G. Holloway and Gary w. King for their many critical discussions and helpful suggestions. II Table of Contents Page List of Tables...................................... VI List of Appendices.................................. VII Chapter I. The Scope of the Problem and the Method..... 1 Field Techniques and Instruments.......... 7 Source of Data-...........IOOOIOOOOootfibifiO 9 l l \ II. The Community and the Hospital Setting...... 11 IntroductionolOUOI.........00.000.00.00... 11 The Community............................. 11 The Hospital in the Community............. 17 Technological Change and Increased Patient Loads............... ............ 21 . Pressures for Increased Hospital Usage. ... 24 1 The Increase of Hospital Use.............. 27 The Effects of Increased Hospital Use..... 28 Characteristics of Board Members.......... 30” Age and SeXOOOO....OOO'OOOQIIOOIIOIOOO 30 Educational Background................ 32 Residence............................. 32 Occupation............................ 33 Organizational Membership............. 34 Summary............................... 34 The Medical Staff......................... 35 Age and Sex........................... 35 Residence............................. 35 Occupation............................ 37 Social Organization................... 37 ; Summary............................... 38 w The Administrator..................... 38 3 Summary............................... 39 III. Variables in the Situation: The Hospital Board....II.....OIOOIOOOCOO......OIOOOOOIODO 141 Introduction.............................. 41 Parson's Organizational Model............. A2 ‘ A Model for Hospital Organization......... 43 The Board of Directors.................... 45 Board Recruitment..................... A5 The Community Activists............... hé III Page Technically Knowledgeables............ 47 Recruitment of the Community Activists........................... 48 Recruitment of the Technically Knowledgeables...................... 48 The Recruitment Process in General.... 50 Economic Resources........................ 53 Sufficiency of Endowment.............. 53 Public Solicitation for Funds......... 54 Unpaid Hospital Bills................. 55 Legitimation of Resource Procurement...... 57 The Board and Medical Care................ 59 The Joint Conference Committee........ 61 The Tissue Committee........... ....... 63 Board Members' Concern With Medical Care................................ 63 Ability to Make Medical Decisions..... 64 Learning about the Technical Aspects of Medical Care..................... 66 Knowledge of Malpractice.............. 67 The Board's Evaluation of Medical Care “'Summary............................... 68 Summary................................... 70 IV. Variables in the Situation: The Hospital Administrator............................... 71 Introductionoholi...IIQIQOQOOOOOOOIOCOOIOOO 71 Hiring the Administrator................... 71 The Administrator and the Medical Staff.... 76 The Administrator and his Administration... 79 Administrator -- Value Pattern............. 81 Administrator -- Summary................... 82 V. Variables in the Situation: The Medical StaffOOOODOIUOOCDIOOIOOOOOOOCOIOOOOOOOOIIOOOI 81'" Introduction............................... 84 Recruitment Ideal for Board Members as Expressed by the Physician............... 84 The Board of Directors and the Practice of Medicine.............................. 86 A Physician on the Board of Directors...... 87 The Physician's View of the Administrator.. 91 The Physician and the Practice of Medicine -- The Specialist............ ....... 92 The Physician and the Practice of Medicine. 96 The "Open“ and "Closed" Medical Staff.. 96 The Physician.and Hospital Finances........ 98 The Physician's View of the Nursing Staff, Practical Nurses and Volunteers.......... 100 The Dismissed Pathologist: A case in point.. 101 summaryooccooeoocl coeocc-ooooooooeoo 105 Summary of the Situation Variables......... 106 IV Page Chapter VI. The Analysis of the Variables, The Hypo— thesis, and a Suggested Mechanism for the Study of Community Organization......... 111 Hypothesis l.............................. 125 Hypothesis 2.............................. 128 Hypothesis 3.............................. 134 Hypothesis 4.00.00.00.00...IOIOOOOOQOOOOOO 136 Hypothesis 5.............................. 142 Hypothesis 6.............................. 147 Suggested Mechanisms for Persistence and Cohesion in the Community Organization.. 150 VII. ConclusionOIOIOCCCI0.0.0.0...60.00.000.00... 156 Bibliography...O......OOCCOOOOOOIOOOOOOOOICOOOOOOOIO 192 List of Tables Table Page I. Number of Employees in Major Establish- ments by Industrial Types for Warren county: 19u7_5700001I00O0000000......QOCOQI 12 II. Population, with Percent Change, for the county and State: 1900-1956....IOOOOOOOICI. 13 III. Population Density Per Square Mile for the County and State........................ 15 IV. Racial and Ethnic Characteristics for the County, 1950............................ 15 V. Hospital Patient Admissions, Patient Days, Days Per Patient and Patients Per BEdZ 1952-195900‘0o00c-a0-0000.0.0.0... 29 VI. Apportionment of Operating Expenses for the Hospital: 1952-1959 (By thousands of dollars)....................... 31 VI Appendices Appendix Page A. A Joint Conference Committee Meeting......... 161 B. The Value Pattern of the Physician........... 163 C. Questionnaire Tabulation..................... 166 D. Consensus of Responses....................... 187 VII The Scope Of The Problem And The Method Chapter One One of the outstanding changes that has occurred in health practice in the United States Since the end of World war II has been the increased use of health facilities-- particularly the use of the general, short-term hospital. Concurrent with this mounting hospital use has been the in- creased involvement Of public interest in hospital service. Public appeals for fund contributions to hospital construc- tion or expansion of existing hospital services demonstrate the desire for better facilities for medical care in the community. Sociological studies of the community process in accomplishing major health goals indicate that, although patterns of community participation vary from one region to another, there is, nevertheless, a broad base of community involvement in the decision-making process which leads to thertablishment of local hospitals*. Not only are more people involved in establishing hospi- tals, but also community members today seem to manifest a greater degree of active partipipation in hospital affairs than ever before. This increased participation can be traced to two sources: peOple today are more keenly aware of the advantages available in modern treatment, and a larger share 3! EIIIer, Iaul A., Cbmmunit Health Acthn, ESSt LanSIng, Michigan State College Press, 9 3. 2 of the financial responsibility of the community hospital has been laid at the feet of the public. Generally speaking, the hospital of the past was con— sidered an isolated community agency, a place where indigent sick and dying were sent. Originally, illness was cared for in the confines of one's home, while those not able to pro- vide for themselves were recipients of health care in hospitals financed by wealthy individuals in the community. The local voluntary hospital, which started as a benevolent institution, now is more likely to be supported by the collective efforts of broad community participation. Anthropologists and sociologists have long beenconcerned with changes in social practices, particularly as these changes take place within the institutional settings of family, religion, education and health. Persistence and change in the institutionalized forms themselves, moreover, have been an established subject matter for the sciences of society. Sociological and anthropological theory, moreover, have been continually occupied with the delineation of such forms, culminating at the present time in sociology with the social system. Thus, the study of institutional forms of social behavior with the accompanying attempt to define "form," as well as to refine established definitions, is representatives of both past and present anthropological and sociological inquires. In this thesis institutionalized forms of behavior will be examined as they are found within the hospital organization of a particular community hospital. Preliminary 3 investigation of hospital literature, consultation with those experienced in the hospital field, and visits to hospital sites throughout the county substantiated that the community hospital is, in fact, ordinarily an organizae tion of tripartite control. Where all three of these inter- locking subsystems (governing board, administrator, and physicians) are found in the hospital, control over such im- portant features as, for example, the hospital's Operational budget, capital expenditures, any medical care may reside variously within the sub-systems. The governing board, made up of lay persons from the hospital's community, illustrates one of the vital parts of hospital-community relations, particularly when board members commonly, but not invariably, are expected to make decisions about the major functionsof the hospital. The administrative staff and, in particular, the ad- ministrator are central figures in the hospital. Through the administrator, day-to-day implementation of board policies is obtained. In addition, administrators may them- selves initiate policies through rule-making; but there are, of course, wide variations in the extent to which this is done. More important is the way in which an administrator can shape the general policies of the board, through such elements as his greater knowledge of the situation and personal influence at the moment of decision. Finally, the physician is also a key actor in the hospital, especially in regard to hospital policies and direction. Important in the sphere of the physician's 4 influence is not his ability to heal patients, vital as this factor may be interms of the broad goal of all health institutions; rather, in this thesis, concentration will be placed upon the physician's general position with respect to the major policies of the hospital, in relationship to the other significant sub-systems. The major substantive material for this thesis is the result of an intensive examination of these three sub-systems, especially in respect to the way in which they are both differentiated and interrelated by decision-making procedures. Two critical events flow through the examination of the sub- stantive material -- the increase of demand upon medical care in the hospital and the introduction of a professional admin- istrator. Features of hospital persistence and change with- in the selected units of the hospital, therefore, receive particular attention in their relationship to these crucial events. In essence, then, the task of this thesis is the examina- tion of the community hospital's organizational structure with particular emphasis upon persistence and change. Accompanying this investigation is the refinement of efltab- lished organizational elements of sociological theory which will hopefully lead to a more predicable model of change and persistence. The theoretical base line for the study of the hospital organization has been found within the work of Max Weber, 5 falcott Parsons and Alvin W. Gouldner.* By combining their ideas with research findings in the area of the organization a frame of reference was constructed from which the selection and delineation of the thesis problem was drawn. Undoubtedly other theoretical approaches could be used to study the hospital, but the general area of 'organizational theory" has proven to be most fruitful for the kind of overview of hospital persistence and change that was desired. Detailed examination of the relationship between the theoretical and methodological problems that had to be re- solved in the thesis will be explored in a later chapter, but the general relationship between the two problems will be set forth in order to make clear the framework within which the data was gathered. In general, organizational theory and research, especially following Weber, has been almost exclusively focused upon conflict. In a search for persistent and regulatory elements of the organization for our argument the theoretical works of Parsons were found to be particularly helpful. Within Parsons' framework, however, few new paths have been broken inactual research endeavors.** *2 A complete review of which takes place in Chapter Six. *3 Gross, Heal, mason, Ward 3., and McEachern Alexander W., Explorations in Role Anal sis, Rew York, John Wiley and Sons Inc.,*l§§82 ’In‘the analys s of the role of the school super- intendent the authors state that they are using Parsons' conceptual scheme of the organization. Here, again, however, the general focus of the study is upon role conflict and not uponlgggggisational persistence as such. See especially Pp. "' e 6 During the period of interplay between research design, theoretical considerations and preliminary hospital field investigations it was decided that a flexible model of the organization would best supply testable hypotheses of persis- tence and change. Drawn from the theorists we have mentioned, this model generally demanded that two main sources of infor- mation had to be examined. First, the general forces that impinge upon the organization and over which the members of the organization may have little or no control. (Sources of information that were used are presented in Chapter Two and reviewed in Chapter Six as "conditional requisites" which set the general limits of organizational activity). Secondly, the main variables or sub-systems had to be treated from several points of view, but special attention was given to value patterns of each sub-system. The necessity of this approach can be underlined here. Documenting only incidents of conflict and procedural decisions, while necessary for predictive statements, is not sufficient. This is especially true if only a limited time may be spent to investigate overt behavior. Predicting human behavior under these conditions of investigation requires that decisions or actions must be anticipated from a value pattern or an orientation which supplies the researcher with a notion of what kind of posture an individual or group will take in a particular kind of situation. ‘Value patterns also supply the "rationale" of decisions and thereby help to explain the grounds upon which decisions are justified. From this kind of understanding, important clues to the total persistence of the organisational 7 procedure are made available to the researcher. In addition to these two important sources of infor- mation, one of the most reliable ways in which to test organ- izational hypothesis of persistence and change was found by anchoring the value patterns to two main areas of hospital resource decisions -- the procurement and the allocation of hospital resources. Finally the methodological problem of organizational persistence and change was resolved by casting the resource decisions and their accompanying value patterns into a general framework of organizational goals as they exist within the sub-systems of the hospital. Looking upon the sub-system goals as different, yet cohesive, elements of the organization allowed some goals to be related to "output" while others were articulated in a borader, community frame of reference. This methodological arrangement provided the theoretical capstone to the central problem of organisational persistence and change. Field Technigues and Instruments A medium-size community in northwestern Pennsylvania was chosen for the site of this study of hospital organi- zation for three reasons: First, the community has only one hospital facility, an important factor for studying noncom- petitive elements in hospital operation. Second, the popu- lation of this city has remained constant for several decades, a phenomenon which facilitates the study of increased hospital usage arising from a clear shift in orientation toward health care rather than from a mere change of numbers. (Although 8 the character of the population may well have varied over the several decades, the gigs has remained constant).* Finally, the selection of the community was affected by the willingness of hospital authorities and community leaders to cooperate with the study. Although "willingness to be studied" may result in an atypical community, it was decided that this disadvantage would be outweighed by the opportunity to establish a "base line" of information from a setting which would yield extensive data so as to enable comparison with data from subsequent studies of other hospitals in the com- munity setting. To chart the relationships between and among the con- trolling aspects of the hospital organization, particular attention in the field investigation was given to what, after preliminary investion, were established to be the three major sub-systems of the hospital -- the administrative staff, the board of directors, and the medical staff. To facilitate the examination of these three major groups of the hospital, an interview outline was constructed which was primarily designed to elicit information regarding the manner in which individuals became associated with the hospital, main issues of the hospital, responsibilities of individuals as they viewed them, community relations with the hospital, changes within the hospital organization *h A study which outlines the change in population structure while the population size remains the same was carried out in another Pennsylvania city by: Goldstein, Sidney, Patterns of Mobility, 1910-1950: the Norristown Study, Philadelphia, ‘Uhivcrsity of Pennsylvanii"?ress,l§§3. 9 thought to be desirable, evaluation of the expressed purpose of the hospital, methods of obtaining desired goals, and individual background data. Each of these categories of data was directed to the testing of hypotheses of organi- zational change and persistence. The questionnaire was administered in an intensive inter- view. Extensive notes were taken by the interviewer. These (notes were used immediately after the interview as a basis for machine recording the data secured from the interview. Finally typewritten transcriptions were made from the machine recordings. Later, a questionnaire was filled out by board, admin- istrative and medical staff members which consisted basically of a modification of parts of a schedule used by Gross and others. Data from this questionnaire were used to measure the consensus of goal evaluation of individuals in the hospi- tal organization.* Sources of Data Individuals within the hospital (board members, adminis- trative and medical staff members) comprise the major source of data for the study. At the same time, the researcher, as much as possible, spent time with other hospital personal *5 The instrument used is based upon a questionnaire by Gross, Mason and McEachern, 92- cit., as adapted for a study of hospitals in Denver, Colorado, by Robert C. Hanson. In this, the Pennsylvania Study, the questionnaire was submitted to the administrative staff, board and medical staff of one hospital. In the Denver Study, the questionnaire was sub- mitted to board members and administrators of several hospitals. 10 and persons related to the hospital on a voluntary basis. Community members not directly connected with the hospital were also interviewed to provide a perspective on the hospital' and its setting. Included were the superintendent of the community school system, newspaper editors, state officials and, of course, the myriad of lay citizens one visits with when living in a community. Written records also make up an important source of data for this thesis. Among these records are newspaper and magazine articles, the hospital records, including financial statements and patient loads, and the written minutes of the meetings of the board of directors. The Community Setting And The Hospital Chapter Two Intrgduction The first chapter examined the major problem of the thesis, both in terms of relevant theoretical development and specific hypotheses to be tested. The purpose of this chapter is to familiarize the reader with the substantive aspects of a non-profit, short~term, community hospital. Following a brief history of the hospital in the community setting, this chapter presents evidence of the forces which have increased the demand for community-centered hospital care, after which a brief description will be given of each sub-system; board, administration, and medical staff. The intent of this chapter, then, is to supply the reader with back-ground knowledge of a hospital. (A more analytical treatment of thedata follows in subsequent chapters). With such knowledge one is able to understand the major operations of the hospital procedure and, most important, some of the stress and strain which develop be- tween individuals (and groups) when patient loads soar and the responsibilities of hospital direction rapidly increase. The Communigy Warren County, the service area for the Warren General Hospital, lies in the northwestern section of Pennsylvania, and, although it is not the most mountainous region of the state, parts of the county are hilly and broken. Lumber, both timber extraction and timber milling, led to the settle- ment of the region in the early 19th century and continued as 11 12 the dominant industry until oil was discovered in area during the last quarter of the 1800's. In the present century both lumber and oil have been overtaken by the manufacturing of steel products and electronics, plastics and related industries as the economic backbone of the county. By using number of employees as an index of industrial development, Table I indicates that steel products manu- facturing and electronics, plastics and related industries increased rapidly in the past ten year period, 19u7-1957, while the industries that established the area have declined as indicated*. Table I** lumber of Employees in Major Establishments by Industrial Types for Warren County; 19h7-57 Industrial Types No. of EstaEs. 1947 1957 No. % No. % Furniture (non-metal 2 230 8.2 207 h.6 011 1 320 11.5 '320 7.3 Steel Products (inc one 6 1715 61.5 212k h7.6 metal furniture) Electronics, Plastics and M 525 18.8 1808 40.5 Related .__ Totals 13 2790 100.0 4459 100.0 *1 One consequence of the changing industrial pattern that was mentioned again and again by informants as an important "trend" was the influx of "middle management" men into the community. It was reported that these men, and their families, have taken an active interest in “civic" affairs and by doing so have added a new dimension to developments in the school system, Chamber of Commerce projects, YMCA, library, Com- munity Chest and hospital affairs. **2 Source: Manual of Facts for Industrial Development, Warren County, Penn., finder Supervision of Arthur D. Little Inc., Cambridge Massachusetts, Pp 50-52. 13 Table II Population, with Percent Change, for the County and State; 1900-1956.* Year County Population 2 Change State Population 3 Change 1900 38, 91:6 - 6 , 302, 115 - 1910 39,573 41.6 7, 665,111 421.6 1920 £10,021; +1.1 8,720,017 ”3.8 1930 ‘ 141,153 +3.6 9,631,350 +1o.5 19110 £12,789 43.1 9,900,180 +2.8 1950 42,698 -o.2 10, 1498,012 + 6.0 1956 £15,600" +7.0 11,132,000" + 6.0 With respect to population, Table II clearly indicates that Warren County, the essential service area of the hospi- tal, has been remarkably stable in population size compared to the state and has only shown modest signs of growth in the last decade. As was indicated in Chapter 1, one crit- erion used in selecting this particular community hospital for study was that of relative stability of population size in the hospital service area. Selecting an area of relativeb' constant population size, it was pointed out, was a means of controlling one factor in the myriad of factors one must deal with in the analysis of social phenomena. *3 Source: 5.8. Bureau of the Census, Census of Population, 1950, vol. 11, Part 38, p. 70, and, statistical Abstract 6? in; v.3. - 1956, p. 12-13. **M Source: Pennsylvania Department of Health, Natalit and lortality, Statistical Supplement and Annual Report, 1955, p.1. 1n ‘Yery important to the study of hospital use is the fact that by holding population size nearly constant it is possible to demonstrate that-the increased use in this community fac- ility was in large part the result of a new pattern of health care highly stimulated by the upsurge in health insurance*. Two other population characteristics of the area which complete the demographic description are the population density and racial and ethnic characteristics of the service area. Since the area has remained stable in population as well as in size since 1930, the density of population has remained almost constant, but lower than the state as shown in Table III. The large proportion of native-born white population in the hospital service area is revealed by an examination of Table IV. . In addition to the statistical facts documenting change in Warren over the years, selected responses from various informants (bankers, Chamber of Commerce officials, school superintendents, newspaper editors and the like) offer a com posite impression of the city to give the reader a since of the "character" of the community. ‘5 5? course, to rely upon constant population size as a complete measure of control" for hospital use would in it- self be ecologically.naive. .In a rather exhaustive study of occupational mobility in another Pennsylvania city Goldstein suggests the two factors of population change -- occupational mobility and migration, ". . . have served to complement each other and in so doing.have Jointly served to meet the changing needs of the local cconom and thereby to effect changes in the labor force structure . Goldstein, Sidney, 0P. Cite, pp. 19A'950 15 Table III Population Density Per Square Mile for the County and State* County §E2£g. Year Population Per Population Per Square Mile Square Mile 1930 45.6 213.8 1940 47.0 219.6 1950 46.9 233.1 Table IV Racial and Ethnic Characteristics For the County, 1950** Native Born White 94.2% Foreign-born White 5.7% Negro 0.0% All Other Races __9;1$ 100.0% 36 Source: His: Bureau of the Census,5§nsus 0T7Population, 1950, Vol. II, Part 38, p. 8: and Statistical IBstract ET‘EEé U08. 1956, P. 14.15. *7 Source: 8.8. Bureau of the Census, Census of Po ulation, 1959, V01. 11, Characteristics of the Population, Part 38 Pa., p. 200. 16 The early oil and lumber leaders were pictured, for the most part, as “robber barons" -- primarily characterized as adventure capitalists. These men were reported to have stated, as late as l922, that the area would soon be exhaustei of its natural resources and would suffer economic collapse. Interest in developing, or even maintaining, the area on the part of early economic leaders was very low. Apparently, it was only the fact that furniture industries had started in the area on the basis of early timber growth and production that the city was able to keep economically "alive“ during the transition period from extraction to production. The slow and somewhat painful shift from extractive industries to production industries was stated to have left a conserva- tive orientation upon those residents interested in controlling the future economic development of the community. The feeling that the town had been marked by a relatively con- servative growth was a dominant theme among informants and constituted a basic attitude among all those interviewed. The major community goals were usually summarized as consisting of regulated economic development, area planning, and indep- endence from larger governmental units. Several informants mentioned that the "small town" at- mosphere was a feature of the community that its leaders took pride in maintaining and that rapid growth in population would be looked upon as an objectionable development. As was mentioned above, however, several informants voiced the opinion that the new middle-management people were harbingers 17 of a new attitude that was replacing the extreme conservative viewpoint towards community change and development which had characterized the past. Whether or not this kind of change will affect the total nature of the community remains to be seen, but certain aspects of change related to the hospital in connection with this new group already can be observed and will be mentioned below. The Hospital in the Community Tracing the development of the hospital against this community back-ground provides a means for understanding how present structural relationships within the hospital are rooted in the history of the community, and, at the same time, helps to explain how structural changes within the hospital are related to factors in the community. The community hospital under consideration first opened its doors in 1881 as a charity home for unwed mothers. When the home became a general service hospital in 1898, local direction and control remained in the hands of a board of trustees composed of high status women in the community who had founded the original institution. In step with the technological advances in medical care at the turn of the century, the hospital expanded its range of services to an increasing proportion of the population in the service area. As community demand for hospital care mounted, the women increasingly felt inadequate to cope with the accom- panying complexities and responsibilities and turned to their social counterparts, prominent men in the community, 18 for help, particularly in the financial direction of the institution. With the introduction of male control over financial matters, the charitable nature of the institution gradually diminished. More and more, the ideas of "sound business" practice were injected into the day-to—day op- erationa of the hospital. Starting in the late nineteenth century as a charitable institution serving a small group of patients, the hospital, by the early twentieth century, emerged as a vital community health center, financially sustained by patient charged. With the early history of the hospital in mind, some general statements concerning community legitimation of the hospital can be made and implications of this process for the present can be given. Initiation of the idea of having a hospital came from the upper-class women of the community, according to infor- mants. Fundamentally, it was a peripheral endeavor in the community, rating far below the commercial and industrial system in community importance and somewhat lower than such other community organizations as government and education in the minds of those who would evaluate the importance of community institutions. While the nursing home was legitimized by the support of the women, by their time and funds, it was not legitimized by any major section of the community; it was not as highly functional a mechanism of community in- tegration, as for example, were the political, religious or education systems. 19 While work in the hospital required a substantial amount of time and effort, the volunteer work contributed by women could not be conceived to be their primary voca- tional interest in life and, therefore, was not legitimized in their own eyes as a primary life goal. The hospital, founded on a particular need, did not receive the strong community legitimation realized by other,particularly tax supported, institutions. The precise manner in which the operation of the hospi- tal was turned over to the upper-class men of the community was difficult to ascertain. Suffice it to say, the decision to retain control of the hospital in the hands of the com- munity ~- or at least that part of the community which had sufficient resources to financially support it entirely out of their own incomes -- was an important one. This decision meant that the hospital, in contrast to the school system for example, was in sole control of one community group. And unlike the school system, the hospital was financially supported through a fee-for-service basis and "backstopped" by the wealthy board members in periods of financial crisis. Another prime consideration, which can be seen in the early development of the hospital, is the basis upon which the “leading male citizens" were called upon to assist in correcting -- "the financial mess the women had gotten them- selves in". Thus in the beginning, the primary responsibility of a hospital board member was stated to be financial. The financial "watchdog" role of the board member emphasizes the 2O fadt that from the inception of the hospital to the present day, requirements of board membership had little or nothing to do with being expert in the general goal of the hospital itself (medical care), but was focused upon the ability to undorstand and solve financial problems*. For almost a half a century hospital operation in the community was controlled by two major groups: (1) the board of trustees, made up of male influentials in the community who carried on after the abdication of the women, and (2) the medical staff, who discharged the technological take of medical care. Face-to-face, informal relations between the medical staff and the board of trustees pro- vided a workable administrative decision-making arrangement during this time. Important decisions regarding hospital policy were informally resolved at the country club, while routine decisions of hospital management were assigned to a hospital superintendent. Two distinct areas of hospital responsibility assigned the board and medical staff, were, respectively, the Operation of a public institution for the welfare of the community and the preservation of medical standards for hospital patients. As long as these two groups successfully complemented one another, as appears to have been the case during this period, hospital operations proceeded without friction. *8 6? course this same statement also applies to lay boards of other community, non-profit organizations, as for example, school boards, YMCA boards and to some extent,boards of profit-making organizations. 21 technological Ghangg_and Increased Patient Loads. The early board-medical staff pattern, at first ade- quate for hospital decision-making, was challenged by the advent of technological forces upon the hospital scene. It is now necessary to examine these forces as a pattern of technological change. Technological change, viewed as a force outside the com- munity which impinges upon the internal structure of a particular community institution, has received the attention of a number of sociologists. Warner, for example, points out how the technological shifts in methods of production have affected community social organization and maintains that the community is helpless in caping with these shifts without outside help from the larger society.* Walker remarks that one of the basic problems in a country where technological deve10pment outstrips the social organization upon which technique is based, as in the U.S., is the retention of cultural systems and the accumulated values which are being dissolved or greatly modified.** In both the Walker and Warner studies each of their com- munities had felt the impact of technological change by a loss of industry (or at least a threatened loss). In both Modern Factory, New Haven, Yale Uhivers y ress, , p. . **10 Walker, Charles, R., Steeltown, Yale Labor and Manage- ment Center Series, Harper and Eros., 1950, pp. 179-80. studies change in tochnology had decreased thifioctoct of ’ the respective community lnddstry. A different dimension of change has taken place on the hospital scene, however. Here technological change, in medicine and medical economics has increased the demand for hospital care and has in turn thrown parts of the social order into disequilibruim. The two different kinds of organization -- the organi- zation that provides goods consumed nationally (as the shoe factory) and the organization that serves community area residents (as the hospital) -- can also be compared and contrasted. £1353, comparing similar features of each type of organization, we see that the stimulus for output change (contraction and expansion of output) comes from outside the community itself. This means that the communities had no measure of direct control over the output change; each organization had to adapt to forces that originated from beyond the community. Although each type of organization had felt impact of national economic and social changes, a second common feature of the community organizations is particularistic in nature. Community members, tend to ignore the larger social and economic framework in which these organizations ultimately rest and look upon the indus- trial and service organizations as indigenous andeven some- what sacred to their own community (e.g., Lansing is the Eggs of Oldsmobile). Output changes, even though initiated by extra-community factors are generally thought of as community_yariations by the local citizenry. /. / 23 These two different kinds of organizations can also be contrasted. In the organizations geared to economic production (as they were in Yankee City and Steeltown), local factory production can be controlled -- increased or decreased -- despite fluctuations in demand in the larger society. Management can, for instance, decide to increase production in a northern community and decrease production in a southern one.* .This ability to change the site of production means that location of the productive unit is a flexible compon- ent of the production organization. Community service organizations, on the other hand, are more closely geared to the needs and demands of those who reside within the organizational service area. Technological developments at the national level, which increase demands for services at the community level, must be accomodated by the com- munity service organization in_gitg, Flexibility of loca- tion, in order to adjust demand forces, therefore, is not possible for the local community organization.** 711 This observation must, however, be tempered by noting, .as Warner did, a crucial difference in ownership: namely local versus absentee ownership. The local owner, by virtue of the fact that he holds membership in the community, owes allegiance to the community. He depends upon the community for his social status and must mitigate "ruthless” decisions dictated by the market place. Warner and Low, 92, cit., p. 118. **12 This is part of the rationale for establishing an organi- zation such as the Michigan Office of Hospital Survey and Construction. That is, to decide, on the most scientific basis available, the expenditure for new hospital sites and expansion of old facilities. This procedure is partially based upon the fact that re-establishment and re-allocation of hospital sites are exceedingly difficult, compared to similar changes in the industrial world. 2h Pressures for Increased Hospital Usage Technological forces, initiated at the national scene and reflected in Warren, have meant an increased demand for community-centered, institutionalized medical care. Exam- ination of these forces reveals how, year after year, the community hospital under consideration, despite stability of service area population size, has had to service more and more patients. Before examining the result of these forces, a review of the kinds of pressures the local hospi- tal has had to cope with will be offered. First, among the many factors that have swelled the demand for hospital beds in the country, as well as in the community studied, is the increased use of pre-paid hospi- talization costs or hospitalization insurance. The first survey of voluntary health insurance coverage, conducted by The Health Information Foundation in 1953, estimated that at least 57% of the total 0.8. population (not counting family members protected by individual policies) had some hospital service protection and at least #8% of the 0.8. population were protected against surgical and other physician's costs in part. Comparable figures for a 1958 survey demonstrate an increase of health insurance coverage to 65% and quite a startling increase for surgical-medical coverage to at least 6M1 of the total 0.3. population.* 313 Reported in3Fro rose in FEEItE_§ervices, ivoluntary Health Insurance: 95 an 195 , o . , We. 5, (may 1959), Health Information Foundation. 25 Similar increases were reported for the Warren hospital; 63‘ of the patients admitted had hospitalization insurance (1959).* Another related pressure upon hospital bed use is the policy of many hospitalization insurance policies with re- gard to hospital-centered diagnositic procedures. Several physicians mentioned that patients, when required to have hospital laboratory tests made for diagnosis (x-ray or blood tests, for example) were resistant unless they were admitted to thehospital as a patient. The desire to become a patient results from the fact that many insurance companies will not cover the costs of these diagnostic tests unless the individual is admitted as a patient. The usual reaction of a patient faced with the prospect of having a series of diagnostic tests, physidans asserted, was a demand for hospital admittance during diagnosis. Prepayment of hospital coverage, then, represents a rt- technological change in the method of financing the cost ' of medical care and has, without question, increased the use of the community hospital. 3IE—Every attemptiwas made to secure a history of hospi- talization insurance for hospital patients, but, due to the manner in which hospital admittances were recorded, past records were not available. There is little doubt, however, that the figure for hospitalization insurance has been in- creasing each year, and, according to the hospital comp- troller, many local plants had insurance coverage for em- ployees. One of the fastest growing industries had a most liberal medical protection plan which not onlycovered the hospital costs of the worker but also offered his immediate family hospital payment protection. 26 Closely related to this discussion is another pressure upon the hospital for bed use, in this case related to ad- vances in medical technology rather than financial change. The younger doctor, as well as the typical specialist, insists upon extensive diagnosic procedures available only in the hospital. As one physician, who had been practicing 4; since the early 1930's states; "Years ago, when my father ‘ practiced medicine, he walked into the house and said, 'Smells like measles to me.’ In my time more and more tests were given and now these younger doctors ask the hospital to run every test possible on a patient". Medical achievements during World War II, such as the development of drugs to combat post-operative infections (penicillin, for example) has increased the frequency,of " IL“ A ' «...-F . ‘1’ ‘fi: . . .' f I‘ b '; ‘ . _ .“, "I I . "ll...” _. ‘I v J 51' {.2 *sF-EM‘F-ézivm- 1. 1‘ mm.) M . AM or r ‘J " 3.1L ‘ I". 475, A a 1‘33) 33“" ck. ‘ my ' hospital use . L" ' i‘ ‘ :3. 'c 'U Still anotherkforce, impinging upon the use of hospital beds, is the national trend in medical specialization. Specialization in obstetrics, pathology, radiology and other %“ fields of medicine means increased and more extensive use of the hospital facility. One final factor, not a technological force as such, but a shift in cultural values, is the general increased faith and confidence in the use of the hospital as a curative institution on the part of the general public. As has often been remarked, a few years ago many looked upon the hospital as a last resort for treatment -- a place to go and die. At the present time, while hospital stays 27 are not routinized parts of every individual's experience,x , such things as appendectomies, tonsillectomies and child- if birth are almost universal hospital procedures in the county studied, as they tend also to be all over America. The Increase of Hospital Use Having examined national forces, reflected in the local community, which have increased the use of the hospital, it is now time to chart the various kinds of increases them- selves. The mounting number of hospital patients has meant that more hospital beds are in use (the most ready index of hospital use) and, at the same time, each bed is used for more patients. While pointing out that over the country as a whole, general and special hospitals have increased their patient load 18% from 193M to 1953, Block mentions that, nevertheless. bed increase h§g_ngt_kept pace. A combination of two factors has produced this situation; ". . . better utilization of hospital beds today and/or patients. . . not staying in hospitals for as long a period as they did in the past."* Shifting directly to the case study, some of the same kinds of increased bed usage are now documented. Table V notes that in the short period from 1952 to 1959 the 122 bed hospital has increased its patient load 38.8%. Table V also shows that the average patient stay has remained somewhat constant during the seven-year interval, indicating $15 Elock, fouls, Hospital Trends, ahicago, Ill., Hospital Topics, 1956, p. 36 28 that continued increase in admissions would force expansion of the facility in the nextffew years if admissions increase at the same rate and if the same standards of medical treat- ment are to be maintained.* Another measurement of the change in patient load upon the hospital is the increase in the patient per bed ratio. Again referring to Table V, the figure has increased from 30.3 patients per bed (annual average) in 1952 to h3.3 patients per bed in 1959.** The Effects of Increased Hospital Use There is little question that forces beyond the community, national changes in medical financing and medical practice, have been mirrored in this community hospital. The effects of these changes upon the relationships between major actors in the hospital is the major part of this thesis. A few words, however, may be added in this "background" chapter to illustrate the kinds of effects increased patient load has had upon the economic apportionment of hospital funds. By examining the expenses apportioned to major hospital departments, as depicted in Table VI, two different kinds of *16 The national average for nonprofit hospitals in'l9EE was7.5 days per patient. This national figure is some- what higher than the 6.6 days in 1954 and 7.0 days in 1959 as noted in Table V in reference to the Warren Hospital. **17 For a comparative examination of this same statistic in another hospital for an earlier period, as well as a discussion of trends in the general hospital, see, "The General Hospital in Transition", Pro rose in Health Service, New York, Health Information FoundatEon, Vol. VI, Ho. 7, Sept. 1957. 29 Table V, Hospital Patient Admissions, Patient Days, Days Per Patient, and Patients Per Bed Admissionsl9 1952 1953 Adults .3,700 h,300 New Born fl 210 Total h,h30 5,070 Year 195h 1955 a,aoo n.6oo 160 180 5,160 5.1.80 Percent Increase, 1952-1959 - 38.8 Patient Dgzsl9 Adults 27,600 25,400 29,200 33,500 N. Born 5,800 5,299 5,100 5,600 Total 32,1.00 30,900 33,900 38,100 DgzslPer’Pgtient Adults 7o5 5o9 New Born .é‘é ‘6‘; Total 7.3 6.0 Patients For Bed19a TOtfll 30o3 3502 606 703 2.2 2.2 6.6 7.0 36.1 37.7 18 1956 1., 600 .119 5,310 32,900 L202 36,900 7.2 6.9 37.7 1957 h,800 830 5,630 35,900 §,§OO 40,400 7.5 2.2!: 7.2 39.3 1958 h,900 800 5,700 36,600 550.9 41,000 7.5 5.1.5. 7.2 h0.2 1959 5,300 6, 150 38, 5w 51:92 42,900 7.3 2:3 7.0 43.3 18 Source, Hospital.Records. 19Rounded to nearest hundred (except "new born" under Admissions). 19“total beds, 122. ........ 30 increased expenditures can be seen. 0n the one hand, the increased cost of administering the institution and, on the other, increased costs allocated to diagnostic departments (x-ray and laboratory) are apparent in the table. And the economic impact of increased hospital demand can also be seen -- the general expenditures of the hospital increase each year (l2l.5$ increases from 1952 to 1959, see Table VI). Characteristics of Board Members Shifting now from the ”situation" to the "actors", upon whose shoulders the responsibility for meeting this medical demand has fallen, the board, medical staff and administrator are introduced by briefly outlining the back- ground characteristics of each, beginning withthe board of trustees. Age and Sex 0f the 21 board members, three are women and eighteen are men. All offices on the board and the committee chair~ manships are held by men, except for the secretary of the board. Age of Board Members (Total 21) 2.2222 W 30-39 8 u0-u9 3 50-60 10 Median Age h7.8 Years In brief, it can be said that the board is dominated by male members, and that most of these members are older 31 Table VI, Apportioment of Operating Expenses for the Hospital: 1952-1959 (By Thousands of Dollars)20 Ho gpital Department Year 5% Change 1952-59 1952 1953 19516 1955 1956 1957 1958 1959 Administration 21..1 28.3 30.1, 38 0.1. 56.0 66.8 67.0 +215. 35 Z of total (5.4) (5.5) (5.3) (6. 3) $7.1) (7.1) (7.1) (7.7) Nursing 102.7 122.0 132.8 167.3 168.2 215.1. 22.1.1. 286.8 +179.25 x of total(23.0)(23.9)(23.2)(27.3)(23.7)(27.h)(27.7)(29.0) Housekeeping 25. 2 29.9 211.9 19.3 18.0 26.0 33.0 1.1.1 +61.3 5 01’ total (5. 6) (5. 9) (M3) (3.1) (2. 5) (3 3) (3.8) (MI) Laboratory 27.8 34.0 1.5. 7 52.0 52.9 52. 2 51.5 62.6 +125.17 x of total (6.2) (6. 7) (8.0) (8.5) (7.1.) (6. 6) (5. 9) (7.0) I-rsy 14.3 14.1 19.7 21.1: 2h.8 31.5 35.1 3h.9 +lld+.0 M a s Supplies 12.8 14.1. 10.1. 12.8 22.0 22.9 21..6 30.7 +139.8 )6 of total (2.8) (2.8) (1.8) (2.1) (3.1) (2.9) (2.8) (3.1.) Dietary 64.1» 73.2 87.7 88.9 97.3 98.9102.0113.9 +76.8 :6 or total(11+.h)(1h.h)(15.3)(14.5)(13.7)(12.6)(11.7)(12.7) Pharmacy 29.0 26.6 25.8 30.6 33.1 37.2 1.2.8 1.9.3 +7o.o )5 of total (6.5) (5.3) (11.5) (5.0) (4.6) (4.8) (M9) (5.5) Out Patient 62o9 “o7 85o3 62o? 9309 92o1 93oo 87o8 +3901} :6 of total (14.1)(12.6)(u.8)(10.3)(13.4)(11.8)(lo.7)(5.7) Other21 82.0 102.5 110.9 118.9 149.6 153.1. 1.80.6 203.1. +lz.8.o % of total(18.l.)(20.1)(19.3)(19.A)(21.0)(19.5)(20.7)(20.6) Total 1.1.5.5 510.0 573.8 612.9 710.7 785.8 871.2 987.0 +121.5 Total 5 (100) (100) (100) (100) (100) (100) (100) (100) 20Source, Hospital Records. ZlIncludes; Laundry, Nursery, Plant Operation, Anesthesia, EKG, Oper- ating Room, Delivery Room, Medical Records, Physiotherapy, Depre- ciation and Fixed Charges. 32 adults, But there is a strong representation of younger adults on the board. Educational Background Looking for a moment at the educational background of the board members, it is evident that, almost without exception, all have received a greater amount of formal education than would be expected if a random sample of adults were selected from the hospital service area. Education Background of Board Members (Total 19) Education . Number No college* 1 Have had some college 18 Have BA or BS degree 12 Have Law Degree 2 *Advanced training after high school, however Residence In examining the place of residence of board members, one finds that the city in which the hospital is located is excessively represented on the board although the hospi- tal serves the entire county and the city makes up only 33% of the population of the total service area. Nineteen of the 21 board members come from the city itself. One of the two members residing outside the city lives about eight miles east, the other about ten miles south. ' Host of the members are life-long residents of the community. Only three board members have lived fewer than twenty years in the area. Predominantly then, board members 33 are lifetime residents or long-standing residents of the community. Occupation The following table shows the occupational pattern for the board. Occupation of Board Members (Including Husband's Occupation for Women) Occupation Number 0wner or top manage, large industry 4 Supervisor, large industry 2 Owner, medium-sized business or industry 6 Owner, small business 2 Bank executive 1 Judge 1 Retired investor 2 Lawyer 1 Chamber of Commerce Executive 1 High School Principal _l__ 21 It is quite apparent from the occupational position of board members that they do not represent a broad cross section of county's occupational structure. About twelve are owners or have managerial positions in business and industry. Two are professionals. The remainder hold or have held executive or managerial positions. It is inter- esting to note that neither labor nor religious interests are represented on the board, and that business interests 39 generally are not of the small independent type. grinnizational Membership Although the board members may have belonged to a number of clubs or organizations, significant for our purposes here is an examination of membership in two clubs -- the Town Club and the Country Club. These two organi- zations are considered locally to be the "elite" institu- tions of the area. or the board members, sixteen are members of the Country Club and six are members of the Town Club. According to several informants, membership in the Town Club is somewhat difficulttn achieve, even for those in the ”social set". 5 These affiliations reveal a great deal about the selectivity involved in choosing board members. It should be noted that, according to some informants, the fact that a few of the new board members are 322 members of the Country cash is indicative of the trend away from hospital control by the "Country Club Set". The latter title was said to be a long-standing description of former boards. Summary If, then, the characteristics of the hospital board are summarized, it can be seen that it is predominantly male, tending toward maturity, but with a strong represen- tation of younger adult men. For the most part, board members are long-standing or life residents of the city. They are persons who are owners or from the managerial section of the city's industry and business. And, most 35 certainly, the board is made up of persons who have achieved membership in what are considered the out-standing social organizations in town. The Medical Staff At the time this study was made the hospital medical staff numbered twenty-seven physicians. Fortunately, for purposes of interviewing accessibility, the hospital required one physician to reside overnight at the hospital. This policy made it possible to interview, during the period of intensive field investigation, almost half of the entire medical staff or thirteen doctors. Background information for this representative group of doctors depicts the second major sub-system of the hospital -- the medical staff. figs and Sex The male staff are grouped according to age as follows: is: 29112122.: 34-39 5 40-49 u 50-59 11 15 Median Age; nu.0 years. Compared to board members, doctors are somewhat younger and more evenly distributed by age group. Residence Generally, doctors were relative "newcomers" to the com- munity as compared with board members.- Two men were born in warren and two others were reared in nearby communities. 36 The remainder had come to Warren after completing their medical training. The following breakdown indicates years of association with the hospital. Hospital tenureerearp) Number 2-10 4 11-20 5 21-30 .3 13 Median Tenure: 15.5 Years Eight of the thirteen doctors questioned received their college training in the state or an adJacent state. An interesting sidelight on residency was elicited by asking these men why had they chosen this particular town for practicing medicine. About half were drawn by some type of family tie (e.s., "Hy wife's family lives here and she wanted to come back"). There was a striking difference in reason given byolder men as compared to men who had Just recently received the M.D. Men in their midofifties located on the basis of economic reasons. "Things weren't so com- petitive here as in Pittsburgh" was a typical answer for the middle aged doctor. Ybunger men did not apparently worry too much about economic factors in their choice of location. The youngest physician asserted, “my wife and I drove all around the tri-state area and decided we liked Youngsville (a nearby community, in the hospital service area) best." Another anecdote about located concerned a doctor who was urged to locate in a nearby community by a local druggist 37 The druggist complained that the doctor in town, at that time, wrote about one precription a week and dispensed his own medicine. This doctor accepted the invitation to practice in this town with the added inducement of an office about the drugstore. Occupation While all doctors are part of the same occupational group, differences exist as to the degree of their speciali- zation and kind of practice among them. Five of the thirteen interviewed were specialists; an ophthamologist, a pediatrician, a pathologist, an obstetrician and an anesthesiologist. One man had passed his beard examination in the speciality he was practicing and the remainder were board qualified.* Social Organization Nine of the thirteen physicians were members of the Country Club and four were members of the Town Club. Phy- sicians were also members of the Masons, Knight Templars, Elks and "rod and gun" clubs. After responding to the question of organizational membership over half asserted that they had little time to devote to activities outside their professional life if they wanted to spend any time at all with their families. The economic stimulus for spending long hours practicing medicine, moreover, was considerable. As one physician said, Any doctor can make twenty-five thousand dollars a year if he wants to work sixty to eighty hours a we k. *22 for a full review 0? board certification r3} physidians see the section in chapter Three of this thesis entitled, The physician and the practice of medicine -- the specialist. 38 Summary- Physicians, as a group, differ from board members (at least those board members who were part of the socialelite) in that their status was achieved mostly through professional training and becoming physicians. Fathers of five of the thirteen doctors interviewed were workers in machine plants, foundries or oil fields. A few were from families who owned small businessss, one doctor's father was a railroad agent and two doctors were second generation medical doctors. Generally speaking, then, the medical staff did not represent the "old wealth" of the community and their high income would class them as nouveau giggg, The Administrator I It was mentioned earlier that until a few years ago the hospital's administration was carried out by a hospital supervisor, often a registered nurse. The salary paid for this earlier position varied around $5,000.00 per year and responsibilities were rather directly limited to hospital supply purchasing and personnel hiring confined to a strictly supervised budget; policy-making and direct concern with medical care was not part of the role of the superintendent. The man who now occupies the position of hospital admin- istrator is a professional, having been trained at a recognized school of hospital administration and after interning at a large New York hospital, received a Master's of Arts Degree in the field. By the time he was in his mid-thirties he had served with the American Hospital Association in a staff 39 capacity as field representative, and through this experience brought to the local community hospital a wealth of comparative knowledge of national conditions. His salary is well above $10,000.00 per year and is augmented by free housing on the hospital grounds. His position, training and experience are somewhat anomalous for a community hospital of this size. He could, apparently, easily secure a Job in a much larger hospital and command a larger salary. However, in addition to the com- fortable physical circumstances offered him, he has been givel membership in the two leading community clubs -- the Town Club and the Country Club. His position is also unique in that he has no reference group of other middle-management lprofessionals in the community. (One would expect to find 7a.group of such professionals in school, government, com- rnunity chest organizations, etc., in a larger city of 100,000 «or more). As a result he is somewhat socially isolated from 'the remainder of the community in that his salary, housing and general life style is not commensurate with others (as some board members) in whose "circle" he travels. Summary I The review of the hospital in the community demonstrates 110'! the demand for increased hospital usage is a force Which has "imposed" itself upon the community institution. The background of the three important sub-systems of the r“Dapital, demonstrates the kinds of educational, residential the! social experiences they each bring to the hospital 40 decision-making scene. The next two chapters will focus upon the qualitative differences between these three sub- systems by explaining, through processes common to hospital procedure, the value pattern of each. Variables In The Situation: The Hospital Board Chapter Three Introduction The variables used in this thesis to test hypotheses of organizational persistence and change are not exclusively quantitative in nature. The main substantive source of material is the analysis of "depth" interviews with members of the board, administrative and medical staff of the Warren community hospital. Just as it is necessary to carefully describe the nature and meaning of Quantitative variables used in the tests of sociological hypotheses, it is also necessary to specify the parameters and significance of the qualitative material we have choosen to test out hypo- theses of hospital organization. Chapters three, four and five thoroughly examine the three important variables crucial to the hospital organi- zation and each chapter will, respectively, describe the three substantive sub-systems of the hospital; the board, administration and medical staff. Chapter six will present the major hypotheses of the thesis which will be tested by the qualitative variables and further tested by quantitative materials secured.from a questionnaire administered to selected member of each sub-system. In this chapter, therefore, a detailed examination of the first qualitative variable, the board of directors, will 41 42 be given particular attention in terms of specific hospital processes. Reviewing hospital processes connected with economics, medical care and individual involvement makes it possible to discern the major persistent elements of hospital procedure as they impinge upon the board of directors At the same time, the examination of the organizational "machinery at work" lays the foundation for later analysis of areas of organizational stress and change also paramount to the central argument of the thesis. Prefacing this description of the board of directors, however, since it is useful as a framework within which to view the data obtained, is a brief review of Parson's model of the organization. Following this, a modified version of Parson' organizational model is presented and then used as a theoretical point of departure for the examination of the board of directors. Parsons' Orggnizational Model Parsons maintains that any particular organization, like other organized human endeavors, fulfills a specific need.* The task which the organization performs for the society, whether it be religious, health serving, protective or educational, in turn adds a measure of persistence to the society. At the same time elements of the society *I For a compltte explanation of this model, see, Parsons, Talcott, "Suggestions for a Sociological Approach to the Theory of Organization" (Part I and II) Administrative Science guarterly, 1 (June 1956), 63-85, and II, (Sept. 43 reciprocate by fostering conditions which help the organizatin to persist. This is the general organizational setting, as Parsons sees it. As for the organization itself, Parsons asserts that it is drawn together by a unity of purpose and can be defined in terms of this purpose, or goal. The major ”value pattern" of the organization fulfills a dual purpose, according to Parsons. 0n the one hand it legitimizes the existence of the organization in the society, but more important for our purposes, it also legitimates certain ”main functional patterns" germane to the operation of an organization. These patterns include, (1) procurement of resources (2) allocation of resources and (3) limitation of individual commitment to the organization. It is unnecessary to expand these ideas any further at this point for they will be discussed more fully in Chapter Six. He are now ready to examine a more detailed, yet modified, model of organizational structure which will explain our viewpoint on the establishment of sub-systems within hospitals as a vehicle for understanding the hospital organization. A model for Hospital Organization The description of this particular model of hospital organization departs from the more generic model of Parsons since it ismore convenient as we will see, more valid, to treat process within the hospital as a tripartite system. It is not enough to assert that each sub-system is 44 differentiated by the procurement and allocation of re- sources, alone. Each group has brought to the hospital, as we shall see, a different outlook, a different value pattern, as to what exactly ought to be the major points of emphasis in hospital procedure. Differences in procure- ment and allocation of hospital resources, as well as indiv- idual commitment to the hospital, go beyond instrumental, ends-means decisions contingent upon effective medical care in the hospital. Instead of relying upon one particular value pattern for analysis, this examination will search out other major values used in reaching hospital decisions. Some of these values will lead our attention to relevant but tangential parts of the community (especially in the case of the board), while other values will be traced to particular professional orientations (in the case of the physician and the administrator). While some operational aspects of the sub-systems can be separately described, they are inter-related and must be finally "fitted together" since sometimes two sub-systems conbimed, or all three sub-systems bear upon the same pro- blem or issue. It is the combination of the three inter- locking sub-systems (as sets of actors who control decisions concerning the major hospital processes) that makes up the over-all organization orientation. And, by the same token, there is not one particular value pattern which legitimates these major processes, but a combination or interlocking of value patterns as the three sub-systems are activated by 45 decisions. The Board of Directors Board Recruitment The recruitment process which operates for the selection of board members is a complex set of practices interlaced with community values and traditions. To complicate matters considerably, the entire process is in a state of change. In a recent study of community power structure by Schulze and Hunter have brought forward the thesis that top community in- fluentials have been retreating from the overt community posts and have continued to exercise power and influence in a covert fashion, "behind the scenes".* Recruitment policies in our study support these findings; within certain prescribei areas of board activity, older, top community leaders in Warren are being replaced by "middle management" men who are "technically knowledgeables", particularly in the areas of personnel management and public relations. Our task in this section, however, goes beyond the documentation of the broader picture of community change for we are looking more directly at the organizational aspects of the hospital itself. Our efforts, therefore, will concentrate upon the recruitment policy of the board as it relates to board structure and, in turn, the relationship of this structure to the other two sub-systems of administration and medical *2 Robert 5. Schulze, “The hole of Economic ioninants in Community Power Structure," American Sociological Review, 46 staff. Until recently the Warren board was, in a g£_f22§2_ sense, self-perpetuating; board membership had been deter- mined by a nominating committee from the board itself. The local hospital association rules, the gg_jg£§_base for all board action, provide a legal alternative; nomination of board members from the "floor" of the annual meeting. This method of nomination had only recently been exercised by a medical coalition in an unsuccessful attempt to attain board membership for a physician. In addition to the physicians' threat of modifying established procedures for board selection, actual board selection has been modified in recent years by board members themselves. The modification in the selection process has resulted in a new type of board member which can be isolated and differentiated from those of past boards. An under- standing of the established recruitment process, with its modifications, is greatly facilitated by first describing the two types of board members. The Community Activists I The majority of the board members (15 of the 21) re- present industrial interests in the community: they know one another socially and collectively make up the community organizational and social leadership of the town; they are the peOple whose names appear on the membership lists of the Country Club, the Town Club, women's clubs and on the board of library, YMCA, Community Chest and various community 47 fund drives. These people feel that their selection to the hospital board is a natural concomitant of their social position. Many have close social contact with physicians on the hospital medical staff. When one woman from this group was asked whether she discussed hospital problems with her friends, her reply summarized the position of the hospital in relationship to other community organizations for this group, "Oh, no, we never have to go into details about our problems, when we get together we know our com- munity projects have similar problems". This group, for convenience of reference will becalled "community activists". Technically Knowledgeables I Six of the more recent additions to the board indicate a new kind of board member that deviates from the community activists. Two members are highly experienced personnel directors of large industry; two others own their own businesses; another man is secretary of the local Chamber of Commerce and one man is the principal of a high school in a nearby community. Only one of the six men of this group is a member of the Country Club; no one in the group is a member of the Town Club. As a group, they neither know one another very well nor do they socially interact with other members of the board or its medical staff. Each man has had extensive technical experience in a particular "middle management" level either as a business manager, personnel directoerr school official. For purposes of classification, we will call these men "technically know- 48 ledgeables". Recruitment of the Community Activists When members of the community activists group were asked how they were selected to serve on the board, most reflected a while then had to admit that theydid not quite know how they were chosen. Perhaps, they observed, it was due to their affiliations in other community acti- vities. Further probing revealed some of the mechanics of board selection for the community activist. When first approached, it is best that the prospective candidate be somewhat reluctant, and he should have to be convinced that hespital board membership is a worthwhile position. This procedure, according to those who outlined it, protects the hospital from those who may be eager to serve because they have special interests to serve. In the words of one in- formant, "It guarantees that you don't get someone who has an ax to grind against the hospital." Incidentially, it also excludes all those who might have an interest in the hespital, such as medical doctors.* Recruitment of the Technically Knowledgeables The is x men who are classified as technically know- *§ The question of having an M.D. on the hospital boardlwas an issue facing the hospital during the time of this study. and will appear in more detail below. Suffice it to say in this connection that some board members were adamant in their stand that no physician be allowed on the board because the hospital was "too close to the doctor's source of income“. others felt that there was some necessity for a doctors'. representative on the board, at least as a consultant on medical matters. 49 ledgeables are relatively recent additions to the board and their selection indicates a new trend in board mem- bership. Their image of the recruitment process differs from the community activists view. The two personnel managers of large industries felt definitely that they were asked to become board members to solve a specific per- sonnel problem that was current in the hospital at the time they became members. The secretary of the chamber of commerce gave a similar reasons for being asked tojoin; that is, he had specialized knowledge in public relations and felt this was the reason he was asked to become a board member. Two business men claimed they were asked to join as part of a general trend calculated to involve younger men in the community. The high school principal reported that he was invited tojoin the board in order that his community would be represented; he had no previous social contact with other board members. The president of the beard is somewhat of an exception to the older pattern; although quarried by previous experience and social standing to belong to the community activists, he is a direct repre- sentative of a particular large industry which asked for board representation because it had contributed a substantial sum of money to the hospital, it was reported. Many board members felt that the board president, working through the administrator, had "engineered" these recent appointments with the belief that these people are necessary for certain kinds of board decisions and policy- 50 making practices. This group, obviously does not "travel in the same circles” as the first and some were very surprised at being appointed to the board. The Recruitment Process in General A further, detailed inspection of the board recruitment process, as it is seen by board members themselves, can be made by analysis of the responses to a question directed at finding out what kind of person would be chosen as a board member. Three themes run through the responses to the query, (1) personal virtues or qualities (such as honesty) of individuals that would be selected and, (2) crucial community experiences (such as membership on the public library boardO that develop technical skills and a feeling of responsibility felt necessary for a board member, and (3) experience in business or familiarity with practices and values of the commercial world. Personal qualities mentioned included reasonable common sense, reliability, ability to maintain confidence, honesty, social consciousness, insight, and drive. The most immediate reactions to the questions about the kind of person they would select were in terms of these personality traits rather than in terms of the particular attributes of age, sex, occupation, training and social standing employed in our distinction of board types. Although board members emphasized specified personality traits as criteria for board member selection, the cemmunity activists segment of the board stressed the desirability of 51 certain kinds of social experiences for the prospective member. The most frequently mentioned training ground was nmmbership in other community organizations and business experience. Experience in Community Chest, Scout groups, YICA and similar community organizations all prepared one for and provided one with the necessary responsibility and experience for the hospital board position, these respon- dants maintained. Business experience provided another necessary training ground since many of the board decisions were related to financial aspects of the hospital, it was pointed out by these members. One respondent said that he would like to see an "average working man" on the board, but lack of civic experience would probably make him a "failure" as a board member. Summarizing one aspect of the recruitment process in terms of the organizational model proposed; two kinds of board recruitment patterns have emerged, (1) the selection of community activists (those from the town's social set, and (2) the selection of technically knowledgeables (indiv- iduals asked to join for their specialized knowledge). In the same fashion, two different types of value patterns developed, congruent with these selection processes. The first process is most parallel to a value pattern that we will call, "community-commercial". In this pattern the hospital is only one among several other community organi- zations that certain kinds of people (community activists) enter into as participants. In explaining this process of 52 recruitment, board members pointed out that a similar method is used in other community organizations and the process includes consideration of the candidates social background, business experience and initial reluctance to join. -The qualifications for the prospective hospital board recruit, therefore, are based upon some of the same general criteria used in the selection of board members for other community organizations and are not peculiar to the hospital alone. The other selection pattern -- initiated by the new board president and the relatively new professional admin- istrator -- is the recruitment of technically proficient personnel for board membership and this pattern we will call "organizational instrumentation". This pattern uses the evaluative "yardstick" of proficiency and experience in a particular area of hospital procedure. Although we will examine the theoretical implications of this selection process in more detail in later chapters, it may be noted here that the hospital is difficult to conceptually isolate from other community organizations on the basis of the labor procurement process for board members when one considers the first selection pattern (community- commercial). In addition, this first selection pattern also substantiates the general theoretical notion proposed in this thesis; that the value patterns used in hospital processes transcend the organizational pattern of effective medical care by reaching out into other areas of community life. 53 It is the more recent trend of recruitment for board members (which has yet to shape general board policies) that more closely fits the instrumental model of effective- ness of medical care and can be directly related to the organization pgg_gg. Finally, it should be pointed out that the persistence of the community hospital organization, up to the most recent date, has not been contingent upon a value pattern of effective medical care for the legitimation of one main functional pattern of resource procurement -- the selection of the hospital board member. Economic Resources The procurement of labor resources (board members) is obviously vital to the persistence of the present hospital organizational structure. Another equally important re- source for the hospital is financial support. The following economic areas of the hospital were explored with board ' members: (1) sufficiency of endowment; (2) public solici- tation for funds; (3) unpaid hospital bills. Responses elicited to questions in these areas of the hospital organ- ization bear upon an important organizational process -- the procurement (and to some degree the allocation) of capital resources. Sufficiency of Endowment When board members were asked if they felt the hospital was sufficiently endowed, almost all asserted it was. It was explained that the interest earned by the endowment fund 54 is spent on capital improvement when it is deemdd necessary, and, if needed, the money may be used for operating expenses but only in an extreme emergency.* The community activists group proudly pointed out that the stock portfolio of the endowment, although conservatively invested, had yielded a substantial interest over the years. These same board members seem to take a special pride in revealing the size of the investment and its lucrative return to the new technically knowledgeables who expressed frank amazement over the size and income of the endowment. Through their discussion of the endowment the community activists were expressing a patriarchical feeling toward the community. The fact that the endowment size and invest- ment return was neither publicized nor widely known among other members of the community (including physicians on the medical staff) placed the board member in the unique position of one who knew the hospital was economically "sound". This position gave the community activists a posture of benevolence and protective watchfulness in their economic control of the hospital and thus a position in the community of the partriarch through hospital board membership. Public Solicitation for Funds Quite a few board members suggested that since the dndow- *fl‘TEE‘IfitE$3Et'TFEE‘EEE‘EEHEifiofit‘IE'Iarge enough—to have allowed financing the complete renovation of a two- story building into a fifteen bed, chronic illness facility. The building is well furnished with a handsomely appointed lobby and connecting corridor to the main hospital. The complete payment for the renovation would take three years from the interest. 55 ment was sufficient it meant, among other things, that the hospital did not have to rely upon the greater community for funds. Most felt that this was a desirable situation. Board members asserted that direct, public appeal for funds should only be solicited for capital expenditures (a new nursing home budlding, for exampled and never for hospital operating expenses. Two board members ruled out any approach for public support of the hospital; one mentioned that the en- dowment was adequate, another that the public had been recently approached (during the last fund drive for the present hospital renovation in 1951). Others, with respect to public support, expressed the feeling that the public should be called upon if the occasion presented itself. At the present time, however, these same board members considerei the endowment sufficient for operation, despite the fact that the interest from the fund has been "mortgaged" for three years. I I If a real crisis arose, the community activists ex- plained, a nucleus of present board members and community leaders could "reach down in their pockets and 'bail out' the hospital".- This statement re-emphasizes the partriarchial feeling these community activists felt toward the community and in particular toward the hospital. Unpaid Hospital BiIb Another resource important to a hospital is that of collecting obligations to the hospital to assure its financial soundness. The question as to how unpaid hospital bills 56 should be managed prompted considerable discussion which included comments regarding economic responsibility, institutional policies and the general question of public support and charity. Generally, board members were well informed about the problems connected with unpaid hospital bills and were well aware of the various issues and viewpoints connected with the over-all problems. It waspointed out that in recent years the hospital had changed its traditional stand on the matter of due bills. Inthe recent past , the hospital was reluctant to take action upon overdue bills; thethought of a collection agency seemed odious, while court action seemed completely inappropriate. The present procedure, they related, is to turn the bill over to a collection agency. Court action was still held to be too drastic by most, while a few (technically knowledgeables) did endorse this measure. Detailed administrative knowledge associated with bill collection was manifested by board members.For example, mentioned the difficulty involved in screening patients. That is , in the present systems of admission to the hospital, the admittance clerk merely asks the patient if he is able to pay his bills. This is nonsense, according to the informants, since many of those who are not able to pay will notadmit their inability; and secondly; those who can well afford to pay are insulted by the question.It was proposed that the patient be investigated through the usual credit references and then a decision 57 be made by the hospital as to whether or not he be admitted "regular patient". as "staff” (charity) or a . Another board member mentioned that staff patients do not have their choice of physicians and are assigned one when admitted on the staff status. If a patient has had a history of delinquent bills, he can be placed on staff until his credit is once again established. This technique often works, it was observed, since patients generally prefer their own choice of physicians and readily pay their bill in order to again be treated by their own doctor. Newcomers to the board (particularly technically know- ledgeables) were dismayed and distrubed at the amount of accounts receivable and the ”lame attempts", as they put it, that have been made to collect past-due bills. Longer- standing board members with the community activists orien- tation were somewhat unconcerned about the situation and observed that many citizens regarded hospital debts as un- important and would only settle their bill if "forced against the wall". These same board members thought it would be inappropriate for the hospital to press these people too hard at the expense of losing face. Eggitimation of Resource Procurement The board member's viewpoint on hospital resource pro- curement is revealed by his response to the questions above. Again the board is divided into the two categories of com- munity activists and technically knowledgeables. The first group have a patriarchal fondness for the institution with 58 an accompanying confidence that they, if the occasion should arise, could always underwrite the hospital expenses. Even the suggestion of soliciting the community for funds seemed to disturb them. The patriarchal feeling toward the hospital even extended to the collection of unpaid bills -- charity, the founding stone of the original institution, was still part of the present day structure in their minds. This was not only direct charity such as would benefit a staff patient, but also a feeling that those who chose to ignore the bills that were assumed in good faith as a responsibility should be treated in much the same fashion as those who did not assume this responsibility. Later on we will demonstrate that part of the attitude toward unpaid bills was also an expression of the "commercial" aspect of the “community-commercial" value pattern of the board. Suffice to say here that in some ways the board looked upon the unpaid bill situation as a business expediency. It is interesting to again note that legitimation for the requisition of funds -- the value pattern which Justi- fies the procurement of funds ~~ is not connected to effective , organization for medical care, but is more closely associated to a value pattern of community paternalism. As in so many other areas of hospital procedure, other community organizations provided an anchorage for Justifing policies on unpaid hospital bills for the community activists. New board members, particularly those whome we have called technically knowledgeables, were more instrumentally 59 oriented to the acquisition of hospital funds. Even though amazed at the size of the endowment fund when they attained board membership, this group was not as reticent as the other in recommending that all the service area residents should shoulder the economic responsibility of the hospital. This same group further expressed indignation about the previous shipshod methods of bill collecting. Hospital "face" was not as important to them as the injustice done to those who did pay their bills, it was expressed. Once more, it was evident that the technically know- ledgeables had not brought to the hospital a pro-conceived, culturally acquired value pattern about community organization as had the community activists. These newer members did not use other community organizations as a reference source for legitimating their viewpoint on policies concerned with unpaid hospital bills. Continual questioning of board members revealed that most areas of hospital board responsibility, including the economic one, were clearly articulated and understood by the community activists. 0n the other hand, the newer" technical knowledgeables had only a fragmentary grasp of some areas -— and were only well versed in those particular areas forwhich they had been called upon to participate. The economic determination of hospital was not one of these areas. The Board and Medical Care Medical care in this thesis is defined as the kind of 60 cans rendered by the medical profession in the hospital -- the registered nurse and the medical doctor. It means specifically diagnosis and treatment of the hospital by those professionals. The term "medical care" however is not a concise one, a fact readily admitted by those involved in the day-to-day activities of the hospital.* If the board is charged with the major responsibility of the hospital how do board members define the limits of medical care and measure the effectiveness of medical care in the hospital? It is easy to understand that most laymen have little rational basis to evaluate the particular organizational structure of a hospital in terms of medical care. It would appear that most people are introduced to the idea of hospital admittance by their physician. If one assumes that the patient must rely upon the physician and other secondary sources of knowledge for his belief that the hospital organization is the most effective manner in which medical care can be administered, it is not difficult to see why the board member also uses the same set of criteria for his Judgment of effective medical care. One would assume, however, that board members would have some *5 C§5II G. Sfiefis, 5.5., the administrator of the 36th Israel Hospital in Boston, Massachusetts, on a consultative visit to Michigan State University, pointed out that "medical care" can include parking facilities for medical doctors and birthday cards for patients. In the primacy of things done for the patient, the purpose of the hospital is healing or curing, and the assurance that the patient is receiving the highest standards of surgical treatment, medical treatment and nursing care possible, according to Sheps. 61 objective measures of effective medical care that would go beyond the word of the medical staff or the printed material that they might read in the Saturday Evening £253 or the Ladies Eggs Journal. If, on the other hand one did not wish to assume that board members had a rational means of measuring medical care at least one might assume that they would have an interest and first hand "working" knowledge of the subject. Either assumption in the hospital studied would be incorrect. To examine this element, questions were asked about four different aspects of medical care, (1) to determine whether board members felt qualified to make medical care decisions, (2) to determine the ability of board members to make medical care decisions, (3) to find the source of knowledge from which board members learn about the tech- nicalities of medical care and (4) to discover the means by which board members learn about malpractice. Before these responses are summarized however, the function of two committees in the hospital studied warrant our attention. The Joint Conference Committee and the Tissue Committee are both organized around the principle that the board should have a "voice“ in the medical affairs of the hospital. An understanding of the working relations between the board and the medical staff through these two committees facilitiaes our subsequent discussion of board members' views on medical affairs. The Joint Conference Committee Four board members, four physicians from the medical #7 62 staff and the hospital administrator form the membership for the Joint Conference Committee. It was said that the committee was established to overcome one of the major shortcomings of past hospital arrangement -- strained relationships between the board and the medical staff. Primarily, the committee is charged with a liaison function between the two groups in a bi-monthly meeting held at the hospital. It is somewhat difficult to predict what this committee I will accomplish on the basis of a short (6 month) record. ) Some notion of what board members hope or feel it can do are as follows; directly face the problem of medical care I by reviewing doctors' appointment to the medical staff (permission to practice medicine in the hospital); inform doctors how the board feels about critical issues relevant to the interest of the medical staff -- providing a direct "pipeline" between the board and the medical staff. Board membdrs felt that the establishment of the liaison committee would end agitation from the medical staff to have a doctor on the board of directors. Up to this time, although eager to do so, doctors had never been allowed to serve on the board. The birth of the liaison committee has not ended this matter; on the whole the medical staff is more deter- mined than ever in its resolve to secure representation on the board.* *6 A summary of one meeting of the Joint conference Com- mittee is given in Appendix A. 63 The Tissue Committee Although recently initiated in this hospital, a sign- ificant committee for understanding the board's concern with medical care is the tissue committee. Composed of doctors from the medical staff, the function of this com- mittee is to review the state of any tissue removed during each surgical procedure. By means of this review, the com- mittee is able to evaluate each physician as he performs a number of surgical procedures. In theory, the tissue committee report offers a means by which the board members can evaluate standards of medical care. At the time of the study the first tissue report was still forthcoming, much to the distress of the administrator and certain board members -- particularly those of the Joint Conference Com- mittee -- but promises of the report were made by the medical staff at the attended meeting. Board Members' Concern with Medical Care Returning now to the role of board members and the topic of medical care, an attempt was made first to determine whether or not the board member should be concerned with medical care. In actuality this question was asked merely to establish rapport in the area of medical care and no sign- ificant results were expected from such an innocuous question as "Should a board member be concerned with medical care in the hospital?" It was thought that everyone would say something like: “Certainly, that is the main responsibilmy of the board;" or, "Medical care is the major purpose of the hospital, and therefore the fundamental concern of the 6h board." As a matter of fact, these examples are representative of the majority of responses. The exceptions to these res- ponses, however, call for an examination. Three board members definitely felt that board members were incapable of making medical care decisions. They asserted, therefore, that the board should have nothing to do with medical care. They definitely felt that medical knowledge was beyond the grasp of the layman. In their eyes, it was an impertinence for a board member to question the medicalopinion of a medical staff member. Others claimed that the board member needed the admin- istrator's opinion and advice on medical care matters. The only kinds of decisions that board members could act upon, in the minds of these persons, were matters of medical care that conformed to standards set by associations like the American Hospital Association. while a majority of board members felt that the board should be concerned with matters of medical care in the hospital, then, a few denied this was the responsibility of a board members. Ability to Make Medical Decisions The majority of the board members felt they were not qualified to make decisions in the area of medical care since they did not have this ability. Many felt that it was not necessary for the board member to be knowledgeable in this area, since the structure of the Joint Conference Committee provided a liaison between the hospital board and 65 the medical staff; items of medical care, it was stated, are the business of this committee. one board member asserted that it was not the duty of a layman to render medical decisions. Another defen- sively pointed out that it is the task of the administrator to outline the differences between good and bad medical care. Another board member. slightly taken aback by the question, replied that certain decisions on medical care could be made from knowledge gained from Trustee (a national journal directed to the problems and concerns of hospital board members) and attendance at state, regional and national meetings for board members. Board members who were frank enough to state that they did not have the ability to render decisions of a medical nature also pointed out that they were not overly concerned with this deficiency. Any apprehensiveness that they might feel, it was asserted, was mitigated by the high caliber of doctors in this hospital. Board members carefullywpointed out that their trust in the medical profession was due to a particular kind of local phenomenon3the town was fortunate in having the kind of medical people in whom everyone could place their confidence, the majority felt. It is also interesting to notice that this trust re- sulted from an intimate community feeling among board members, especially the community activists. More than once it was observed; "No one can get away with anything around here". This community cohesiveness, along with the confidence in 66 the medical competence of the local doctor, justified the board's position, in their eyes, in relinquishing control over medical care matters, and in turn, forgoing the necessity for medical care decisions. The technically knowledgeables, however, were not as confident of the medical staff but felt the same inadequacy in rendering medical decision as the community activists. Learning About the Technical Aspects of Medical Care Most board members felt that two sources were important for learning about the technical aspects of medical care; the administrator and the Joint Conference Committee. A few of the community activists pointed out that, in the past, knowledge of technical aspects of medical care was gained from direct contact with doctors. Present organizational arrangements, it was observed, had replaced the necessity of direct contact withthe doctors and if medical knowledge or opinions were sought it was best to act through "the proper channels" -- the administrator or the Joint Conference Committee. It was pointed out by one respondent that it was best for a "board member to act like a board member“ -- ex- plaining that, while a direct relationship with a doctor might be the most effective way in which to learn the technical aspects of medical care, such friendly relation- ships would undermine the authoritative position of the board, particularly for censuring the medical staff. One respondent mentioned the monthly statistical reports of the hospital (distributed by the administrator) as a 67 valuable source of medical information. At different points in the interview this respondent referred to articles in the Egll_3treet Journal, The Saturday Evening gggt_and The_ low York Times Magazine. While perhaps not deriving from authoritative sources, the man's grasp, retention, and re- cognition of possible points of application of subjects mentioned in these publications were unique among board members. It is interesting to observe that, while all board members were very willing to discuss the problem of learning medical care techniques, there was neither general consensus upon how one does go about learning the techniques of med- ical care, nor any feeling of urgency or of importance in the matter. The responses point up again that board members avoided what they considered to be the prerogative of the medical staff and as laymen felt that their contribution to medical care was limited and sketchy at best. Knowledge of Malpractice How does a board member find out if malpractice is going on in the hospital? Does the board member have any real way of checking to see if the patient is being victi- mized? Board members asserted that three sets of controls concurrently offset the possibility of malpractice in the hospital; (1) the doctors police themselves, (2) the controls of the Joint Conference Committee and the Tissue Committee are sufficient to arrest malpractice and victimization; and vinally, (3) the board member, through direct contact with 68 doctors, hears about cases of malpractice and can exert pressure to correct any abuses. A few members also men- tioned that the administrator had some control over the medical staff and exercised this control when necessary. The Board's Evaluation of Medical Care -- Summary. From the analysis of the responses on medical care it can be seen that the hospital board of directors is neither highly versed in or overly concerned with the general subject. What is most significant is that the board does not have any ”yardsticks” with which to measure the quality of medical care i- the output factor of the hospital. Justification for involvement of board members (parti- cularly the community activists) in the hospital is not based upon evaluating and affecting changes in medical care. The board members reason for being a board member is pri- marily based upon his reasons for being involved in any community, non-profit organization -~ to do ”good works" in the terminology of the Protestant Ethic. Each of the processes of hospital operation within the sphere of res- ponsibility of board is not finally dependent upon the major purpose of the institution -- medical care for the patients. It can also be seen at this Juncture that the administrd:or is somewhat of an arbitrator of medical care for the board member. One of the board members summarized the arbitration procedure in these (paraphrased) terms. Ideally, the Joint Conference Committee and the Tissue Committee reports should solve all problems of medical responsibility. The administrdbr, 69 .howeveh, has to point out to the board the quality of medical care, and it is only through the administrator's prompting that board members will understand what is going on in the day-to-day activities of the hospital. Responses to the medical care question point up the inability of a board member (or at least the feeling of in- ability by a sizeable number) to maintain daily interest in the hospital. In the tripartite control arrangement of the hospital the board is the one group without daily contact with the hospital.* A final point in this section on medical care and the board is that of allocation of responsibility which keep reappearing in the responses. While board members state that they want individual attention given to medical pro- blems, at the same time they are quick to refer to the committee system of the resolution of a particular problem. In a sense this reprsents a more advanced manner of opera- tional procedure -- a divmsion of labor according to the abilities and interests of particular individuals. On the other hand, it seems that no member feels qualified in his own mind to arrive at independent Judgments concerning medical care. In conclusion, it might be repeated that many people *7'Bospital board members are not unique in being detached, so to speak, from the hospital. Other board of institutions -- profit and non-profit alike -- are not necessarily in- volved in the daily activities of the organization over which theyhave a measure of control. 70 were somewhat affronted when it was suggested that mal- practice or victimization of patients could occur in their hospital. Board members felt that all doctors were competent men, and more importantly, that the doctors were part of a well-knit community, imbued with a spirit that would negate the possibility of malpractice. All things considered, board members felt they did not have to be concerned about mal- practice and patient victimization any more thanthey felt the necessity to control the medical staff in any further way than present organizational arrangements allowed. Summary The purpose of this chapter was to search for the value pattern that governed the various aspects of board actions in specified areas of organizational processes. We have seen that the value pattern is a community—commercial orien- tation. It has herein been documented that in processes connected with board member selection andprocurement of additional hospital funds, for example, values are more related to the basic patterns found operative within other community organizations. Neither the major goal of the organization —- (effective organization for medical care) nor the output of the organization (medical care for patients) are seemingly related to the significant processes or pro- cedures that are the responsibilities of the board member. Responses to questions in these areas reveal how the board typically evaluates his actions in terms of other community organizations or disclaims direct knowledge of concern with the subject. Variables In The Situation: The Hospital Administrator Chapter Four Introduction The second variable crucial to the testing of our hypo- theses on the organization is the sub-system of hospital administration. As noted in Chapter Two, the administrator is a recent arrival on the Warren Hospital scene. Not only is the position a new one, but the individual in the position who was the object of study, was the first person to pro- fessionally administer the office. With the introduction of the new man, basic changes occurred in the position. New procedures were initiated which were in sharp contrast to the "housekeeping" type of administration practiced by previous nurse and male supervisors. Concern with adminis~ tration in this chapter centers around particular hospital processes which include the manner in which the administrator was hired, his control over and concern with medical care, and his involvement with the board and the medical staff. Hiring the Administrator The events and circumstances connected with the hiring or the professional administrator has had, as we shall see, many important ramifications upon the nature of the hospital organization. A review of the hiring process will, there- fore, aid in understanding some organizational changes which bear upon hospital goals and goal evaluations. 71 g— 72 It is not easy to reconstruct accurately the events leading to the actual decision to hire a professional ad- ministrator since many complex circumstances surrounded the dismissal of the previous superintendent and the selection of the new man. First, dissatisfaction with the former superintendent was very evident from the interviews with board members, medical staff members and hospital personnel. Apparently this person was not suited for the pmsition. However, the decision to hire a professional at a substan- tial increase in salary and at the same time to initiate a radical change of policy cannot solely be explained by friction with the former supervisor. Secondly, it would be erroneous to assume that concern with medical care prompted the board to hire a professional administrator, in view of their lack of concern with medical care in general, as illustrated by the material presented in the last chapter. While the concern of board members over medical care may not have been the contingent factor in the selection of a professional administrator, certain aspects of the board‘s general value pattern, as we have outlined it above, are related to the selection of the new man. That part of the board orientation which is most relevant to the selection of the hospital administrator is the "commercial" and is revealed by board responses to questions on the responsi- bilities and concerns of the administrator's role. These concerns are summarized below. 73 The position of the hospital administrator can be compared to that of the plant manager; like the plant manager, the administrator must be familiar with all phases of the facility; the physical plant must be kept running efficiently and harmoniously; personnel relations must be maintained; attention must be given to accounting, maintenance, supply purchasing, and community relations; concern must be devoted to buying and selling; some time must be spent placating the board of directors. In addition, discretion, tact and proper deportment are necessary characteristics for both positions (plant manager and administrator). As they described the characteristics and duties of the administrator, most board members did not mention medical care as a pertinent or even remote function of the administrator's role.* This discussion is not intended to imply that the hiring of an administrator should or should not be dependent upon certain attributes (such as knowledge of medicalcare). The argument demonstrates, rather, that in mentioning and emphasizing the points they did, the board was revealing a value pattern connected with their selection of the pro- fessional administrator -- a value pattern of effective business organization from the world of commerce. *Ifi'Dne respondent did mention medical care as a concern of the administration by pointing out that the administrator is the only one who can operationalize medical control and prevent malpractice. He can, this respondent asserted, at the same time, direct the general medical policy of the board by his relationship with the medical staff. 7“ \ , Turning back to the situation which faced the board before they hired this professional person, it will be re- called from Chapter Two that the demand for community-cen- tered hospital care had been gaining momentum since World War II. The weight of this demand had been felt in our case study hospital despite a relatively stable population ( #74? size in the hospital service area. ”J A h s \ in which ( l The board then was faced with a situation procedural problems were ever increasing in the hospital a'” ” (particularly those concerned with budget and personnel )piiw(/ § allocation decisions). The board members felt they neede 4? ' a "plant manager", someone who had sufficient training and/f'i;o ability to deal with the ever increasing complexities of /(_'l the situation. Their experience with the superintendent had left them dissatisfied with the organizational structure x which provided for a superintendent rather than an admin- ‘ istrator. In many ways this was a familiar situation thVle many of the board members} demand for the "product" (patienty: care) had increased and the increase demanded more qualifiedr/ management than had previously been hired. The selection of the professional administrator was in terms of efficiency of production, a means to the end of increased production and was not directed to any qualitative change in the pro- duct itself (medical care). Thus, the administrator was not hired to improve the medical quality of theliospital; his task was to professionally "administer" the business problems faced by the hospital during a period of expanding 75 patient care demands. This point is emphasized in order to clearly demonstrate that the board, by hiring this man, had ndzlegitimated any efficiencies in medical care as such. The board had only legitimated procedural changes in the office procedures (budgeting, personnel, etc.). Thus it can be seen that the source of legitimation for the procurement of a labor resource (the hiring of the administrator) does not rest within the final goal of the organization (efficiency of medical care) but is found to be more coincidental to the business orientation of produc- tion efficiency. This is the second case of labor recruit- ment that we have seen that has been legitimated by values characteristic of the world of commerce (the first with board members). In each case the process of labor procure- ment has been "transplanted" from community-commercial complex into the hospital. Neither the recruitment pattern for board members nor for the professional administrator can be explained by the goal of the hospital, chartered rules of the hospital or any other criteria of the organi- zation pg;_gg, Rather, the explanation of these two processes lies outside the pale of "organizational” bounda- ries and is found within values extant in other social systems. After establishing the process by which the administra- tor was selected, we are now ready to scrutinize particular aspects of his position. We will begin by examining his relationship with the hospital medical staff. 76 The Administrator and the Medical Staff our direct consideration of the administrator begins by outlining his concern with what we have termed the major goal of the hospital -- professional medical care of the patient. After spending three months interviewing hospital personnel, reading hospital literature and observing hospi- tal activities, it became obvious that the one individual in a policy-making position in the hospital -- beyond the medical and nursing staffs -- who was vitally concerned with medical care of patients, was the administrator. Although it is somewhat difficult to treat the role of one individual as a sub-system, nevertheless, certain systemic aspects of the role can be seen in the day-to-day activities of this office, particularly as it bears upon the medical concerns of the physicians and the patient. The administrator can, and does, exercise influence and control over the hospital's medical staff. In contrast to the practice of past supervisors, he regularly attends medical staff meetings, at whth, with business-like abruptness, he informs the medical staff of the latest happenings and decisions of the board, advises physicians of the latest rules enacted by his office and makes general comments about his concern with medical and quasi-medical care. Despite the fact that the administrator had only a minimal amount of control over the medical care aspects of the hospital through an incompletely developed "adminis- 77 tration", he did exercise some direct measure of control over medical procedures through his own office. Stop-gap control was achieved chiefly through censure of medical staff activities that required hospital approval; this censure was the major kind of regulatory power he had at his command. One of the many interviews this researcher had with the administrator was interrupted by an incident in which the administrator denied permission to a particular physician to perform four hysterectomies on the same day. This professional administrator also instigated other procedures that had the general effect of medical control. one such procedure or regulation institutionalized during this study was an explicit admittance policy for the use of the emergency room. Superficially, it would seen un- necessary to discuss a policy for admitting patients to the emergency room, as it would seen reasonable to assume that such a facility would only be used for treatment of automobile, home and industrial accident cases (or the like). A recent newsrelease from Medical and Pharmaceutical Information Bureau* clarifies the growing problem connected with the use of the emergency room in the hospital. The hospital emergency room is no longer Just an "accident clinic”, according to a survey of 330 0.8. hospi- tals made by Dr..James McCarrol of Cornell University Medical School. Now it doubles as an out-patient depart- ment and also, in many cases, even substitutes for the office of the private physician. ‘2 HeaItH and ScIence Shorts", Series Ho. 95, November, 1960, p. 2 78 These facts discovered by the surveys stand out. 1) Seventy percent.of patients seen in emergency rooms have made no effort to reach a private doctor. 2) one- fourth of emergency room visits are for medical problems and abaost half are "non-emergencies". 3) Forty percent of all patients could have been treated in a doctor's office. 4) Private physicians are losing patients. The emergency room is often the first choice for medical care of any kind. Thus, throughout the country, these clinics are Jammed with a 400-600 percent Jump in patient use since World Var II. Another point, not mentioned in the above quoted re- port, is the fact that it is economically advantageous for the physician (at least it was so in our case study) to use such a facility for minor operations mainly because of health insurance coverage. With all these pressures on the emergency room it became a standard practice for physician to schedule the use of this facility for two or three days in advance. Occasionally a genuine emergency would occur and disrupt the scheduled "emergency" operations, a circumstance which left physicians with conflicting hours for the use of the room. It was reported, by several in— formants (physicians and other personnel alike),that in such cases physicians argued with one another over the right to use the facility (on one occasion a fist fight between two physicians broke out). At any rate, a new policy was inaugurated which listed a priority of admittances for the emergency room. The policy was worked out in the Joint Conference Committee under the leadership of the ad- ministrator. The resolution of this conflict demonstrates one area in which the administrator, board and medical staff worked together for a clearer conception and enactment 79 of medical care goals. The inter-relation between these two sub-systems -- administration and medical staff -- will be examined more fully and analytically in Chapter Six. The discussion above was intended to provide illus- trative background for the analysis to follow. Another sidelight to the emergency room situation came up in interview with the medical staff. It indicated the importance the medical staff attached to this facility as a medical care unit, as opposed to the minimal concern board members had with this operation of the hospital. When the present building addition was in the planning stages, the previous board president had the medical staff review the blue prints of the building's renovation. It was noticed by medical staff members that the proposed emergency room had plans for only one electrical outlet and this deficiency, along with several others listed by the medical staff, was ignored by the board president. Every physician who mentioned the lack of co-operation between the former board president and the medical staff referred to the omission of the emergency room electrical outlets and the ignored recommendations. The Administrator and His Administration An understanding of the administrative sub-system is incomplete without consideration of the kinds of relation- ships he has established with department heads and other hospital personnel of his "administration". During this man's administration he has instituted, 80 thus far, several changed in hospital procedure which have had the effect of tightening and consolidating his control (and the control of any succeeding administrator) over the affairs of the hospital. One major step in the direction of more administrative control over hospital procedures was the institutionalization of weekly department heads' meetings. These meetings were ostensibly only very routine matters of administrative concern. Each Wednesday morning in the staff/library room of the hospital the various depart- ment heads gathered; including nursing, dietary, house- keeping, maintenance, physiotherapy, records, general office, pathology (from time to time) and radiology (occasionally). Typically, this meeting was very informal, with coffee and rolls being served. While the staff awaited the usual late arrival of the administrator, a good deal of friendly banter and good-natured discussion took place. Withhis arrival, the administrator would immediately, but in a friendly manner, take command of themeeting. What a first appeared to be weekly "bull sessions", or better yet, ”gripe sessions", about hospital affairs soon revealed itself to be an ed- ucational process for most of the department heads. Little by little, the administrator was introducing many of these people to the content of articles, books, reports and seminars of hospital procedure. This knowledge offered the formally untrained staff a means by which they themselves could evaluate the kind of performance they were offering to patients. In other words, the administratively directed W‘——- a; _. 81 chats provided a frame of reference for comparative judg- ments of hospital procedures and a chance to evaluate what had always been a routine work task for the participants. It must be emphasized that these were not dry-as-dust symposia on hospital management, but were rather a series of personal discussions which, almost surreptitiously, conveyed the notion to these department heads that this hospital existed among many and could be compared and con- trasted with others. Another apparent latent function of these meetings was to develop an administrative staff, a team, which by modern management principles, could provide a ready means of communication between department heads through the administrator. Through these meetings and through direct contact with employees of the hospital, the administrator was slowly building an organization through which, in time, he anticipated being able to control aspects of medical care in the hospital. 1 Administrator -- Value Pattern Using these examples of administrative behavior it is possible to state in more concise terms the value pattern which influences administrative decisions in hospital pro- cedure. The most parsimonious manner in which the orientation of the administrator may be described is "medical-efficiency” since through his office, as seen above, procedures, rules, meetings and committees have been 82 routinized to increase the effectiveness of medical care. Medical efficiency is not evaluated within the in- stitution alone nor is it related to other community in- stitutions within the same town, but rather it is evaluated by a professional orientation to medical care interiorized by the administrator during his training and constantly re-enforced and re-evaluated by attending professional meetings, reading hospital journals and remaining in informal contact with colleagues in the field.* Administrator -- Summary It will be recalled that the board's preception of this man's role was closer to the model of the plant manager than to a medical ”watchdogfi. The hugh influx of patients and the general explosion in demand for medical care had prompted the board to hire a professional administrator. The chief reason for which he was hired centered about the complexities of running a large "business" on a sound financial basis. Therefore, although the board felt an ultimate responsibility for medical care, still they did not see this as their main area of responsibility and did not feel capable of enforcing regulations connected with the technicalities of medical care. In the board members' eyes the administrator did not have to be a medical overseer; *3 An examination of this process in middle management men is presented by; John and Ruth Useem, "Social Stresses and Resources Among Middle Management Men", in Jaco, E. Gartly, Patients Ph sicians and Illness, The Free Press, Glencee, Illinois, I958, p. 83} 83 it was unnecessary due to the ability of the local doctors which, they felt, was almost beyond reproach. All this brings us to the consideration of an important point -- that of legitimation. The board had not openly and without reservation (or even tacitly) authorized the administrator to increase the standards of medical care in the hospital; however itdid openly demand higher standards of plant operation (purchasing, hiring, collection, etc.). Given an administrator, then, who has been trained in a normative order stressing the highest standards of medical care, in a situation without open permission to enforce such standards, we see a man who slowly and by bureaucratic techniques (also shrewdly, so as not to jeopardize his position) begins to tighten the administrative control over the medical care aspects of the hospital in the manner described above. Variables In The Situation: The Medical Staff Chapter Five Introduction To indicate the position of the medical staff as a sub-system within the total hospital, relationships be- tween the board, administrator and other significant hospital groups will be specified in this chapter. In addition, this chapter will present not only attitudes and feelings concerning important aspects of the hospi- tal, such as finances and medical care, but also related issues which, altogether, form what we will call the value pattern of the medical staff. Recruitment Ideal for Board Members as Eppressed by the r Physician The basic qualities of an "ideal" board were generally expressed in terms of social class and hospital service area representation by the physicians. Most agreed that a physician should be on the board. Also; most doctors pro- . tested that the board was too large; a figure of seven was frequently offered as Optimum. The remaining suggestions for board representation were predicated upon and different tiated by the variable of the doctor's own position within the town's social structure. One segment of the doctors' group expressed qualified satisfaction with the present board composition of community activists who belonged to the social elite. (There was a 8A 85 general unawareness, on their part, that middle management executives and independent business men had recently been added to the board.) These physicians were long established residents of the community and held membership in the Country Club and/or Town Club themselves. They explained that they considered the manner in which board members were selected was "undemocratic" but, nevertheless, offered a unique kind of informal arrangement for social interaction between-the physician and the board member that otherwise would not be possible if the board were selected from the service area at large. Casual meetings at the club made it possible for the two parties to work out problems and exchange view- points, the physician asserted. These men said they found the informal situation a better vehicle for problem re- solution and general communication than the formality of a meeting as, for example, the Joint Conference Committee meetings. This equating of statuses between physicians and board members by the physicians, however, was unilateral; the community activists did not emphasize this relationship in the same manner as the doctors did. As a matter of fact, the community activists on the board regarded the physicians with some suspicion; they often referred to their membership in "one of the strongest unions in the country". The board has a history of unfavorable reactions to physicians; the past board president constantly referred to the hospi- tal as the "doctors' workshop", much to the dismay of the 86 doctors. Another segment of the physicians' group was Quite dissatisfied with what it considered to be the uneven re— presentation of the board. These physicians insisted that other elements of the community should be included in board membership; their suggestions included representatives from labor, religion, education and someone familiar with insurance (hospitalization). Also stressed was a need for a representative from the outlying service area of the hospital. These two viewpoints on board representation can be contrasted by noting that the first group of doctors looked upon the board as a social position, one of prestige and community power, and on these grounds did not want to change its traditional composition. The other viewpoint on board make-up was based upon patient welfare and service area representation. Those espousing the latter opinion wanted to see the board as a utilitarian body directed more toward patient concern that accrued social rewards. The Board of Directors and the Practice of Medicine Most doctors asserted that regardless of how much in- formal training and experience a lay person received he would always be incapable of evaluating and clearly under- standing medical matters. Therefore, the doctors concluded that the board member had no right to meddle in the phy- sicians' affairs concerned with practice of medicine. On the other hand, one particularly outspoken member of the 87 medical staff asserted that it was a lamentable situation in which the medical staff could not police itself in terms of medical care standards. He claimed the "hand~ writing was on the wall" and it was Just a matter of time before the lay board would begin to seriously enforce standards of medical care. A few doctors expressed the hope that the Joint Confer- ence Committee would allow the board to involve itself, through the physician, in medical matters and that harmony between the board and medical staff would reign in matters of patient care. "One difficulty in self-imposed punishment for the medical staff," another physician commented, "is the en- forcement of any measures adopted: in a small town like this, where everyone knows everyone else on a personal, friendship basis, it is very hard to lay down the law to your own friends." On the one hand then, the medical staff member felt that the board was incapable of trafficking in medical affairs. On the other hand, a minority of medical staff personnel felt the close primary relationship medical doctors militated against internal discipline in the enforce- ment of standards of medical care. A Physician on the Board of Directors Another feature of board-medical staff relations has been the long-standing argument between these two groups over the issue of whether or not a physician should be on 88 the board. To more clearly understand the relationship between these two sub-systems, an exposition of the contro- versy is now presented. Continual efforts in the past two or three years by board members had been made to see that a physician would not secure board membership. During the data collection period, an attempt by the medical staff, as a group, to secure membership for a physician had failed. The mechanics of the struggle with the subsequent failure of the medical staff and the victory of the board are quite straight- forward in nature. Board selection, it will be recalled, is secured through majority voting in the local hospital association. Prior to the last annual meeting, all of the doctors secured membership in the association, thus forming a thirty-two vote bloc to back their candidate —- a member of the medical staff. The board heard of the plan and, without alerting the medical staff, solicited membership for a sufficient number of people to defeat the bloc vote of the medical staff. The board was able to keep their strategy from the doctors by the technique of securing proxy votes not only from new members‘ votes, but also from the.votes of long-standing members who were sympathetic to the board's position (the use of the proxy is legal according to the hospital association's by-laws). A few days before the voting, too late for effective action, the medical staff learned of the plan and they were not 89 surprised when their bloc of votes was inadequate to elect their nominee. In discussing the advisability of a physician on the board, some doctors made reference to the abortive attempt to gain membership upon the board of directors. Most comments about the failure were bitter denouncements and cries of deceitful practice; however, a few doctors were critical of the medical staff itself, claiming it was too politically naive to pit its force against the board of directors. ‘ All but one physician felt that at least one doctor should be on the board for the following reasons: the board does not have a good working knowledge of medical care and the addition of the physician on the board would improve this area of board responsibility; coordination would be improved between the medical staff and the board (the last hospital expansion campaign pointed up the need for such coordination); conflict between the board members and the medical staff doctors would be resolved before arguments "got out of hand" (the case of the dis- missed pathologist, below, is an example of an argument which was never satisfactorily resolved even after a rather undignified controversy had occurred). Included in these declarations that physician repre- sentation was a necessity was the expression of the doctors‘ ethical position. Board members, physicians asserted, were prone to explain all stands and actions of the doctors 90 on the basis of the doctors' desire for more money, or upon other economic factors. What the board member does not realize, doctors went on to say, was that the pro- fessional, ethical feelings of the physician take prece- dence over monetary considerations. One medical man, a specialist, explained the "professional attitude" by stating: ' ‘ I didn't know exactly what to do when the board approached me on the question of working for the hospital (setting up a department in his speciality and having him become the department head). My grounds for refusal are not even clear in my own mind. I know I would probably make more money if I did all the hospital work in this area since they would eliminate the nurses doing some of these procedures now. I guess the answer goes back to my medical training. In fact, I wanted to go back and talk to the man I studied under, I guess you could call him a "maJor professor," but unfortunately, he has passed away. I Just had to come to my own decision on this alone (after a meeting with the medical staff, according to subsequent informants). You see, the board Just can't understand that this is clearly an ethical position with me. That is, I don't believe a professional medical doctor should work for a hospital. They (the board) Just can't under~ stand this attitude of mine and feel that, really, hidden somewhere in the corner, there is a monetary explanation for my position. The medical staff's demand for a physician on the board had been continually resisted by the board president; publicly, at the meeting of the hospital association, he expressed the "conflict of interest" involved in having a medical staff member on the board of directors. HaJor conflicts would arise, he asserted, when the credentials committee report would be presented for approval by the board. In addition, the board president was reported to have said at the meeting that it would be "very embarrassing" 91 and thus difficult to have open discussion of medical affairs with staff physicians present. Physicians were well aware of the president's stand since it had been presented at a public meeting and re- peated again from time to time in hospital board meetings. Some physicians, who held that they should be represented on the board, disputed the board’s position and explained that the real reason for board refusal of doctors repre- sentation was seated in fear -- fear that the medical staff would take over the running of the board because of superior ability in medical, thus primarily hospital, affairs. The major argument for a physician on the board by the doctors, then, rests upon the notion that the board needs to understand the professional, ethical position of the doctor on various issues. This kind of knowledge, doctors asserted, would be very beneficial to the hospital since most conflicts would be prevented before the situation got out of control as in the past. At the same time, the doctors felt that their presence was needed for the assurance of good medical care for the patient. The Physician's'View of the Administrator The "middle man" position of the administrator ~- standing between the medical staff and the board of directors -- is strongly emphasized in the review of physicians' reactions to the present administrator. Notwithstanding that the administrator is hired by a board which is viewed 92 somewhat antagonistically by the medical staff, the con- sensus of doctors' Opinion about the man was warn, friendly and of the highest regard. As to the duties of the office, the medical staff was more aware of acute daily problems than board members in general. Evidence of this awareness was demonstrated by the medical doctors' obser- vation that good hospital administration rested upon the delegation of the administrator's authority. Further, they pointed out that in this particular hospital the department head, through inadequate training and as a result of a series of non-professional administrators, was the weak link in the administrative chain. One characteristic of the present administrator, highly lauded by the medical staff, was his ability to supply a "firm answer" to medical staff inquiries. Doctors were also quick to praise the administrator on the grounds that he could mix socially with board members and could participate in most community activities. Two physicians mentioned that this man was viewed by other administrators in the area as outstanding, that he was called upon to present talks at national conventions and was a nationally- known figure in the field. The Physician and the Practice of Medicine -- The Specialist In order to clarify some of the relationship between the physician, the hospital and the practice of medicine in the community studied, a knowledge of medical speciali- zation by the physician in the United States and Canada is 93 helpful and will, therefore, be briefly summarized below. First of all, the legal practice of medicine in any state or province can be carried on by any individual who has received a license to practice medicine by that state or province; there is no state, provincial or national law that requires any further training or certification, with the exception of Quebec, for the practice of medicine, whether it be the most complicated brain surgery or the removal of an ingrown hair.* In order to practice medicine in a hospital, however, there is usually the requirement that the practitioner be accepted into the local medical society and receive approval from the hospital's medical staff credentials committee, a recommendation which, in turn, must be approved by the cre- dentials committee of the governing board. Again, however, there may or may not be any further stipulations on the de- gree of specialized practice that any particular doctor may engage in from heart surgery to callus removal.** Therefore, any doctor may start to specialize in a particular field of his coice. In certain hospitals he may carry on the practice of his speciality without further training or other legal or professional requirements. Some *1 Ponton, ThomasxRitchie, The Medical Staff in the Hospi- tal, Chicago, Illinois, Physicians' Record Company, 1955, p. *lh and also, MacEachern, Malcolm T., Hospital Organiza- tion and Management, Chicago, Illinois, Physician' s Record Co., 1957, p. 164. *2 The exact legal limits of specialized practice performed by even the hospital intern or resident is not always clear according to Ponton, Ibid., p. 220. 94 hospitals, however, restrict the practice of medicine, especially for charity cases, to only those physicians who have received certification from national boards of speciality.* Of course, each hospital through the board of trustees and medical staff, together, or each alone, may establish rules to limit the practice of medicine only to physicians who are board-certified in a specialty. This is, however, no state nor provincial law that restricts the practice of specialists to those who have been certified by one of the specialty boards except in Quebec, which has a special pro- vision regarding specialists: "The law does not forbid non-specialists to undertake specialized procedures, but it provides that, 'every physician carrying a professional care, in an advertizement, a telephone directory, a publi- cation or elsewhere, a title or designation which might lead people to suppose he is a specialist, whereas he is not,‘ may be liable to revocation of his license."** At the time of the case study, neither the board of directors nor the medical staff had any rulings which res— tricted the practice of medicine to any physician, as long as the physician had become a member of the county medical staff and had been admitted to the hospital medical staff. TB—THEIspecialty boards are private organizations and ". . . recognition by such private bodes had no legal validity before the laws of the state or province." MacEachern, QR, cit., p. 16h. . *4 MacEachern, Ibid, pp. 16fl-65 95 (Although such rules were in the process of being drawn up at the time of the study.) Particular feelings about medical specializiation among the medical staff were somewhat apathetic, especially in regards to obtaining and/or having board certification from the American Boards. The one physician (out of the thirty-two) who had become board-certified in a speciality, questioned the value of the achievement. "I spent ten years of work, worry and study to pass that examination and now I can't see where it does me one bit of good, either in terms of prestige or money." He went on to say, "If I had to do it all over again, I certainly would not go through all the trouble and concern." Another doctor, who had failed the board examination in his speciality, remarked, "I would only try to pass the examination again if privileges in the hospital would be limited by not being board certified." He commented further, in regards to his own practice, "It certainly doesn't make any difference, that I can see, in my practice; I can't recall that anyone (layman) has asked me whether or not I've passed the 'boards'." Several doctors claimed that there was a growing tendency to try and limit surgical privileges in the hospi- tal to only those who were specializing in a particular branch of medicine. Arguments in the medical meetings centered upon such issues as: Should only those practicing in the area of gynecology be allowed to do breast removals. 96 One respondent, a doctor in his sixties, asserted, "They (the medical staff) will argue over the last inch of gut before they're done with it." Another doctor observed that it was a case of the older, less specialized physician against the new, more specialized man. Finally, the situation in specialization was sum- marized by one general practitioner who said, "The GP's outnumber the specialist, and as long as this is the case, we will be able to practice in the hospital. If the specialist begins to outnumber the GP, we will be forced out -- especially in surgical procedures." The Physician and the Practice of Medicine The "Open" and "Closed" Medical Staff The topics of specialized practice also proVoked a few remarks on the "open" versus the "closed" medical staff; a rather complex subject which could be, in it- self, a separate study allowing for the great amount of "traditional", and thus cultural, connotations of these two terms. Briefly, a “closed" medical staff is one which restricts the practice of medicine in the hospital to a prescribed number of physicians. The specialization aspects of a "closed" staff, apparently, occur both 9229.012 and EMS}? Each member of the "closed" medical staff is encouraged, perhaps required, to confine his work to a limited field in which he is specally trained. Rigid *5 The quotation from Ponton, Op. Cit., p. 43 97 rules governing medical staff activities are adOpted and enforced. As a result, unless they (the physicians) develop too great a superiority complex, the member of the closedstaff constantly becomes more efficient. one potential disadvantage to the "closed" staff arrangement, besides the psychological complexities that may develop among its members, is contingent upon community size; in a "one hospital town" the practice of medicine could become limited to this staff and those physicians who are not on the staff would not able able to use the hospital and it is possible that many patients, instead of getting better care would be getting marginal care at best. There are two types of "Open" medical staffs: the first has no restrictions on membership (no creditials investigation) and the second includes only community area physicians who have been appointed to the staff after application and credential clearance. The second type is representative of the medical staff in this case study. While the first type is clearly condemned as undes- irable, the second type has both advantages and dis- advantages.* A problem of the controlled "Open" staff (the second type) is that of reaching and maintaining standardized medical procedures and securing unquestioned charity practice for indigent patients by the doctors. To its credit are two maJor advantages: a continuing education in medical practic e for the physician and continual ex- *6'POnto , Ibid., p. EA. 98 posure to professional ethics on the part of physicians who might otherwise be deprived of privileges in a "closed" staff. The Physician and Hospital Finances Understandably as compared to the average board member, the average physician had neither knowledge of nor concern for the financial aspects of the hospital. Topics such as endowment size, purchase of supplies, public solicitation for funds and general financial policy which more often than not provoked a lively discussion with the board member, elicited little reaction or res- ponse from the physician. Some physicians mentioned that facts about hospital finances were difficult to discover and, even if they wanted to find out about these aspects of the hospital, board members would not reveal them. In these interviews in which the doctor did express interest in financial aspects of the hospital, concern was for the patient rather than the responsibilities of the institution within the community. Hospitalization insurance was one area of questioning which especially touched upon this aspect of patients' hospital finances. Interviews with medical staff members indicated that they had a face-to-face, everyday, working relationship with the patient and his hospitalization insurance problem. Critical comparisons between types of insurance plans were freely discussed with mention of specific aspects of these plans including exclusion, riders and experiences, terms 99 which were part of the vocabulary of these men who were continually beset with patient financial problems. One recommendation of the doctors was that hospitalization insurance should be written on the basis of local, com- munity experiences instead of the current practice of writing on national hospital use rates. The argument was backed by the belief that the local hospital use rate was much lower than the national average and local residents were in effect subsidizing other hospitals by paying a premium based upon the experience of others. Medical staff members also complained that certain insurance companies were unethical. Two kinds of practice were pointed to as decpetive in hospitalization insurance coverage: the sale of a group policy to anindustry, bank or company group at a very low rate (possibly be- cause of the low eXperience rate enJoyed by the insurance company at that point in their develOpment) and then having the company raising the rate at least 100% for renewals the folowing year; also the practice of exclusions in group policies (treating only disease common to both sexes, for example) which are not known by the working man until "too late". Some private companies were re- ported to have riders which excluded "recurring" ailments which the insured was unaware of until his claim was turned down. The phyisican looked upon these practices as abuses and strongly felt that some mechnaism, locally established through 1he hospital board of trustees, should 100 be watching out for the patient and protecting his in— terests. Physicians specifically recommended the appointment of one board member with extensive experience in hospi- talization insurance matters. It was commented, "It seems strange that some of these very men who sit on the board now are the employers of the very people who are getting bilked by these schemes and nothing is done to correct the situation." Hospitalization insurance, to the physician, should be a community responsibility and this responsibility should be discharged through the hospital board. The Physician‘s View of the Nursing Staff, Practical Nurses and Volunteers Although peripheral to the main stream of decision- making in the hospital, physicians also come into daily contact with the nurse, practical nurse and hospital vol- unteer group. Generally physicians were complacent in their reaction to all three groups. Some felt that while the quality of the nursing care was high, the quantity would become, or has already became, a problem. Opinions on the adequacy and need for practical nurse were divided. Some physicians expressed the need for practical nurses by pointing out that such nurses relieved the registered nurse from many of the more odious tasks of patient care, while others denounced the entrace of "non-pro— fessionals" into the service of medical care and simul- taneously voiced the fear that the practical nurse might lOl someday "take over" the nursing profession. Another common reaction to the practical nurse was the opinion that the nursing home and the private home was the correct place for their practice. For the most part doctors were also unconcerned about the volunteer groups (a women's volunteer group and a recently organized teen-age Candy Striper group). Two physicians, however, stated that the volunteers were a "nuisance" around the hospital, disrupting procedures and allowing confidential material of patients' illnesses to "leak out". These two complaints were definitely minority opinions, however. The Dismissed Pathologist: A case in point. The medical staff can be characterized as a unified group when facing outside competition, resistance or challenge and a heterogeneous collection of individual physicians in the resolution of internal problems related to areas of practice and individual competence. An ex- cellent example demonstrating the collective value pattern of the medical staff is an incident which occurred previous to this study -— the dismissal of the hospital pathologist. The hospital pathologist, a medical doctor under con- tract to the hospital, had been asked to accept what in effect would have been a decrease in salary. The financial conditions of his employment had originally included a contract to receive a stated percentage of patient charges for work done in the hospital laboratory. Due to the tre- 102 mendous increase in patient admittance, the actual figure (or profit) paid the man was exceeding $50,000.00 a year. One particular board member, who knew most about the financial conditions and complications of the hospital, explained that the pathologist was then app- roached and asked to accept a new contract which would adJust his percentage of the laboratory "profits" according to frequency of use but an adJustment which would still guarantee him about $M0,000.00 a year. The pathologist refused to accept this new contract and threatened to quit his post and return to a practice in a nearby city. Haggling over the matter lasted about a year until the pathologist, remaining adamant, finally resigned. The battle over the pathologist's salary brought to light many of the concerns -- values, fears and feelings -— of themedical staff. Repercussions of this conflict were still in existence at the time of the study. Many of these concerns were easily recalled by those who were staff members at the time of the in- cident (including all but two of the present staff). The main concern in the matter was expressed by a number of physicians, but was especially well-expressed by one particular physician who had publicly pleaded (over the local radio station) to retain the services of this man. This older, very successful physician ex- plained the medical staff viewpoint by saying (paraphrased): The pathologist was an expert in his field. 103 Just as in sociology, no one man knows all there is to know about the science, so it is in.rmdicine. Many times a doctor needs the advice of one who is more experienced in certain areas of medicine than he may be. When such a person is readily available, it is very comforting and reassuring. This pathologist was a teacher, a scholar (he had once taught at a medical school) who understood anatomy and much that is required to diagnose and treat disease. Every morning, right in his lab, we had a little "seminar" and he would "hold forth" while we asked questions or presented problem cases that were giving us trouble. Of course he was very helpful with cases that were ex- tremely difficult to diagnose and would spend time with patients rendering the whole situation encouraging and reassuring for us doctors and I'm sure the patients got better treatment, too. I was very upset when the board would not give in to his request, and it made me boil to think that we were going to lose this man over a few measly dollars. When I tried to defend the pathologist's actions, it was impossible for me, as a doctor, to explain how much it meant to us to have this kind of a man on our "team". .It can be readily seen that the doctors were hard pressed, but reluctant, to publicly admit that they re— lied upon this man for much of their knowledge of medical care; for as they themselves said, such an admission would have undermind the public's confidence in their medical care. While all doctors defended the position of the path- ologist against the board, not all felt that the previous pathologist was well—advised in medical matters. A younger doctor explained, "I used to sit in on those morning bull- sessions once in a while and a new staff members could never get a word in edgewise." He went on to say, "Besides, many of the things this pathologist had to say were out of date, according to what I have been taught in medical school." 104 While the qualification of the prior pathologist was questioned by some medical men, there was no question in the minds of any doctor that the board was outside its Jurisdiction when it raised a question about this man's salary. Several doctors tried to explain that it was not the money that was in dispute but the principle that the board should not interfere with medical practice. The pathologist, according to the medical staff members, had "built up" this practice, had trained the laboratory assistants and had placed the laboratory on its "feet" as a "going concern". After all, they insisted, the hospital was still making money and it was almost a miracle that thissmall hospital had a man of such calibre on the staff -- it was only for reasons of health that this exceptional person wanted to live in this small town and actually re- ceive less money than he could earn if he cared to move back to the city. A few physicians had felt that the pathologist had been too "sticky" about the whole thing and some even stated that he had become "psychopathic" in his insistence on retaining the same percentage of the laboratory fees. But to a man all agreed that the board had not the ability to Judge this man nor the ability to set up a wage scale to standards they might have at their disposal. To the medical staff, the board was completely blind to the medical ramifications of the situation, but, at the same time, no physician would explain, to either the board or 105 community in general, the exact nature of medical de- pendence upon this man. Summary The briefest way in which to describe the value pattern of the medical staff can be stated in the one word "professional". The medical staff evaluated the pathologist's situation in terms of their own ideas of medical care; which were not known to the board and were Jealously guarded by the medical staff so as not to undermine confidence in medical care for the patient. In the eyes of the medical staff, the board, administra- tor, or any other layman were Judged incompetent to understand the technicalities of his profession. In order to maintain a professional orientation one must be in contact with the profession. Several doctors complained that they were "out of touch" with medical developments and contrasted their plight with the advantages of the physician tho was working in a large city hospital attached to a university medical school. This man, they pointed out, was constantly abreast of all changes. The unusual case, the latest findings, highly specialized technical assistance, ex- tensive equipment were all at his disposal for medical research and medical care. More important, however, than the physical aspects of the medical school surroundings was the atmosphere of knowledge and scientific achievement that is part of an institution of this nature. One could, 106 so to speak, be supported by a comfortable cushion of knowledgeables colleagues without facing alone the fear and nakedness of questionable diagnosis and treatment that sometimes accompanies practice in the more isolated situation of a smaller town. These contentions sub- stantiate a point made by Merton that compares the pri- vate practice to the medical school:* As centers of research, medical schools put students more ihlly in touch with the frontiers of med- ical knowledge than many, if not most, of them are apt to be in their later years of practice. This is widely recognized. What seems to have received less notice is the correlative fact that medical students are also being systematically exposed to rofessional values and norms which are probably "higher' -- that is, more ex- acting and rigorously disinterested -- than those found in the run of medical practice. We can add to this that the practicing physician attached to the medical school as well as the medical student, has more assurance of what is "right" and "correct" in terms of diagnosis, treatment and general care than those men in the "run of medical practice." Following on with Merton's argument, for the moment, he states further that once the physician leaves the con- fines of the medical school there is little in the way of "standards" by which to gauge the quality of his practice, since neither the patient nor the colleague has the means of the accessibility to evaluate performance.* Merton asserts it is for this reason that the carry-over of ethical 37 Merton, Hebert K., Reader, George G}, and KendalI, Patricia L., The Student-Physician, Harvard University Press, Cambridge, Massachusetts, 1957, p. 76 *8 Ibid., p. 77 107 standards and quality of care from the training of the physician to his practice is so important. This is quite true, but we can add from our findings that the hospital setting even in a smaller town, with few special- ists, does add some measure of evaluation for the phy- sicians' performance, and, therefore, at least theoreti- cally could do much to enforce "high medical standards". In any case, the "seminar" held by the pathologist had partially fulfilled this vacuum, especially for the older physician, and whether or not it actually improved the quality of medical care, it at least gave many physicians confidence in their practice. The loss of the pathologist had cut off this important source of pro- fessional identification for many of these men. Conveniently, for purposes of further specifying a value pattern for physicians, Merton has outlined three areas of relationships for the physician with corresponding values associates with each area.* From our findings we will add three values which govern the general area of medical practice. 1. Only licensed, practicing physicians can evaluate medical procedures. 2. Answers to all question of an "ethical nature" (remuneration for services, referrals etc.) are sought through the local, regional, state or national medical societies, or from other pro- fessional persons. *9 See Appendix B of this thesis 108 3. Medical care is highly dependent upon hospi- tal care and the more professional control over standards of medical care there are in the hospital, the more effective will be the care. Summary of the Situation Variables In these last four chapters we have learned several important things about the hospital in its community setting. First, it has been pointed out that the hospi~ tal, especially in the last two decades, has greatly in- creased its scope and intensity of medical care. Sec- ondly, we have taken a slimpse at each important decision- making sub-system of the hospital. Through the portayal of events and episodes relevant to crucial processes, salient features of each sub-system's value pattern have been exposed. These value patterns, in a theoretical sense, are more than Just simple orientations to specific situations as we have shown by viewing them in the Parsonian and Durkheimian sense of legitimation, they are quite complex; that is, they are the consensus of beliefs and attitudes that have Justified the positions that members of these sub-systems have taken in regard to specific situations. Most importantly, it has been demonstrated that it is not always the case that these particular value patterns have been congruent with what we have called the final goal of the institution--pro- fessional medical care for the patient. Rather it has 109 been the case that these value patterns have been based upon professional attitudes and community beliefs and have been at time in Opposition to the final goal of the hospital. In the case of the administrator, it has been seen that he has not received the authority from the board as a group to control the activities of the medical staff directly. Medical care, as pointed out, was not the prime concern of the board member. The administrator's need and desire to control the medical staff had come from demands within his own office and without direct endorsement of the board. The most effective way to introduce a program of good medical care, in the admin- istrator's eyes, was to "chip away" at various manageable features of the total hospital process. As suggested, this included the committee, the rule, the policy decision and the meeting. Thus, while the value pattern of high standards of medical care was part of the professional man's training, direct legitimation from the board was not forthcoming and bureaucratic means of legitimation was used instead. The medical staff, on the other hand, felt that they were the "keepers" of medical care in the hospital and were quick to point out that they were the only ones who understood all the ramifications of needing and keeping a good pathologist, for example. They also displayed an insecurity over the fact that they were no longer affiliated 110 directly with a medical school and stressed the im- portance of and desire for professional identification. The Analysis of the Variables, The Hypotheses, and a Suggested Mechanism for the Study of Community Organizations Chapter Six In the analysis of the hospital date one of the most persistent and nagging problems that occurred was the integration of the findings into a framework of the general purpose of the hospital itself. On the surface it seems almost ridiculous to declare that the purpose of the hospital organization would be a problem for any- one, let alone a researcher of the hospital. The most ready and patent answer to the question of hospital pur- pose would appear to be, medical care for the hospital patient. And, if one chose to more formal about a definition, effective daignostic and medical treatment of the hospital patient by professional medical personnel, would do. Yet, during the interviews and the subsequent analysis of the interview material, as we have indicated in earlier chapters, it became more and more apparent that the purpose, or goal of the hospital was emerging as a variable. Contrary to initial considerations in the research design, the hospital goal was not a fixed point in the relationship between the hospital sub-systems but was itself a dynamic part of the total hospital pic- ture. 111 112 Since our data demand that we consider hospital goals as an important part of our analysis it becomes necessary to look at organizational theory in the light of goal formation, evaluation and change. While a total review of organizational theory would be out of place here, it will be necessary to summarize briefly the theorists and researchers who have struggled with the problem of organi- zational goal or purpose. This discussion will be brief and general as we will want to see how specific features of organizational theory apply to our statements of organizational goals as they have been developed from our case study findings and presented below. Some of the ideas of Max Weber are relevant to this discussion of organizational goals, particularly his use of bureaucracy as a constructed type.* Through the use of two kinds of constructed types -- historical and analytical (Protestantism and bureaucracy, for example) -- *1 Several summations ofAMax WéberTs basic position have been written which include both the hisbrical aspects of bureaucracy and the methodological considerations of typological analysis, including bureaucracy. The fol- lowing summary is a synthesis of many of these sources: Weber, Max (Trans. Talcott Parsons), The Theory of Social and Economic Organization, New York, Oxford Universit Press, 1947 (esp. the introductory chapter by Parsons); Parsons, Talcott, The Structure of Social Action, Glencoe, 111., The Free Press, 1949, pp. 604ff.; Merton, Robert K., Hockey, B., and Selvin, H.C., (eds) Reader inggreaucracy, Glencoe, I11., The Free Press, 1952;-Francis, Roy 0., and Stone, Robert 0., Service and Procedure in Bureaucrac , Minneapolis, The University of Minnesota Press, 195 esp. the first and last chapters); Blau, Peter, The gynamics ngureauggacy, Chicago, 111., The Universi y o cago Press, 1955; erth, Hans, and Mills, C.W., From Max fishers Essays in Sociology, New York, Oxford University Press, 1946. 113 Weber was able to lay bare the basic ingredients which make up a particular religious movement or a type of organization. 0n bureaucracies Weber not only offered a model of bureaucratic behavior, but also outlined the main conditions under which the bureaucratic type per- sisted and expanded in western society. He asserted that two paramount conditions in modern society created an atmosphere for this persistence; the complexities of modern society and the ruthless, impersonal compe- tition of the world, economic market place. Compared to traditional or personal types of organizational be- havior, Weber maintained that the bureaucratic organi- zation is most adaptable to the conditions and character- istics of the western world. Webers approach to the bureaucratic type affords a means by which a more refined classification of bureau- cracies may be develOped by using organizational goals as a basis of classification.* While few researchers have followed through with a systematic classification of bureaucracies, it is maintained in this thesis that a consideration of the organization in terms of specific 7?‘The economic goal Sf‘profit-making is one decisive type exemplified by the giant corporations and the large business houses. Here the impersonality of the bureau- cracy can (b battle with the economic market place and can cnsregard the personal whims of individual business ownership. Weber also mentions two other types or areas of bureaucratic behavior: government (including politics) and law. Both of these types, in terms of goals, are focused upon the acquisition and retention of power and authority. 114 kinds of goal would be useful; its utility shows up sharply when one attempts to study a nonprofit, com- munity organization such as the hospital. Two significant points of similarity stand out in the empirical studies which have used Webers' approach as a theoretical point of departure. On the one hand most of the studies have emphasized role and role ex- pectation as it is found in the organizational setting. On the; dher hand there is a similarity among the kinds of organizations that have been studied. Almost in- variably the organizations studied have had the same type of goal; in general falling within the areas of health, welfare and education or within the broader category of "service organization". The emphasis upon role in the organization is exemplified by Francis and Stone in a work on govern- mental bureaucracy in a service organization.* They treat organizational goals as part of the interaction process within the day-to-day activities of individuals in the organization. From their findings they insist that the final purpose of the organization is daily in- corporated into decisions affecting other individuals within the same Jurisdiction. Their argument turns upon the point that role conflict is fundamental to individual consideration or organizational purpose. Professionals *3 Francis and Stone, _p, cit. 115 within the organization are more apt to question the nature and purpose of the organizational procedure and methods in terms of what the organization is actually supposed to accomplish than are the "bureaucratic workers", they maintain. This finding suggested two major types of orientations within an crganization, as they state, ". . . the bureaucratic mode emphasized the system of organization and the sub-ordination of the individual to it, whereas the professional mode emphasizes the role of the individual and subordinates the system of organization, to individual activity and colleague relations".* Peter Blau also has taken the Weber point of de- parture in the examination of a welfare organization and from his case study has concluded that the official is not an impersonal, disinterested rule-follower, but is one who is sensitive to other forces beyond and above the limits of the organization peruse. Implementing decisions about welfare cases by the professional welfare worker according "to the book” becomes more difficult and even odious as professional training and identification with a profession increases, he asserts. His findings further establish that the professional has his own set of "personal“ goals or ends within the organization which enemate from his profession. He concluded that in the *3 Francis and §t3ne, 92, cit., p. l§7. e \ 116 ,i dynamics of the organizational setting, the professional person builds an informal structure which overshadows the primary or manifest goal of the organization.t (EEEEE;Eelzni:E)also sees a haitus between the organizational goal and the actors within the organization. He explains a process termed "gravitation of the locus of interest" which leads to the separation of the indiv- idual and the goal of the organization. In the daily activities and decisions of officials, struggles arise over control resource allocation. Particular areas of interest "gravitates" to the officials in charge of departments (e.g. purchasing, sales, etc.), and over a period of time a "locus of interest" begins to form within the particular departments. .Finally, this pro- cess leads to the establishment of informal structures within the organization. He concludes that this new informal structure is "short sighted" and may frequently conflict with the master goal of the organization in many ways. He terms the allegiance to the informal structure a "personal orientation? which can conflict with an even supplant the "disinterested" individual commitment to the master goal that forms Weber's thesis.* Through the use of Heber's constructed type of ‘3' Blau, _p, cit. *6 Selznick, Philip, "An Approach toa Theory of Bureau- cracy" , American Sociological Review,8 (Feb. 1943) pp. 47- 54 117 bureaucracy, the researcher of"the Organization" has demonstrated that individual "disinterest" is not the crucial attribute that gives the organization cohesion, unity and continuance.* These writers point out that the "unwritten rules”, the social obligations between members, the informal structures arising from personal influence, or the security of professional identification, is the cement that holds the organization together. In these studies the master goal of the organization was found to be in contradiction to the more isolated, dis- parate goals and interests of individuals or groups. As such, these writers generally view the organization in a state of flux, in which internal forces maintain organizational equilibruim ~- the forces of individual and group interest are constantly balanced and adjusted while organizational goals (and factors affecting them) are held as constant as possible.** Also common to these research findings is the kind of organization studied. The general universe from which *7 The discovery of variations iron the constructed type does not negate the usefulness of Weber's original ex- planation, but rather enhances it and most certainly demonstrates the utility of the typological approach: The method of the constructed typology is made explicit in a chapter by: McKinney, John 0., "Constructive Typology and Social Research", in, An Introduction to Social Re- search, by Doby, John T. (edJT, Harrisburg, Pa., The Staokpole Company, 195h. **8 That this relationship also obtains in union-manage- ment relationships is proposed by, Dalton, Melville, "Unofficial Union-Management Relations", American Socio- lggical Review, 15 (Oct. 1950) pp. 611-19. 118 all these studies were selected is the "service" organi- zation. If the final goal of an organization is a cru- cial variable in organizational Operation then the generalizations from these findings are restricted to this variation. Different goals, it would appear, would be likely to affect the manner in which roles are carried out, the way evaluations of goals are perceived and the modes by which adjustments, adaptations and changes take place. On the other hand, it is possible that these writers have refined the Weberian typology of the ogganization by introducing the kinds of varia- tions suggested by service oriented goals. Turning now from those who have treated organiza- tional goals as a constant let us briefly examine a few works in which the goals are viewed as dynamic elements of the organizations. Veblen established his concept of "trained in— capacity" upon organizational goal change. A change of goal can render a formerly competent individual incompetent for new tasks brought about by the resulting organizational change. For instance, trained incapacity can occur in a military organization when war breaks out after a relatively long period of ,peace. In such instances the training, Skill and attitudes compatible to the peace-time, garrison-oriented individual in the organization may be completely inadequate in a "hot” war 119 situation.* Talcott Parsons has used the goal of the organization as a point of departure in the construction of an or- ganizational model.** The goal-oriented or "cultural— institutional" approach of Parsons shift the theoretical emphasis of organization from role and role conflict to a more comprehensive treatment of organizational process. Organizations, for example, are defined on the basis of "output” -- their contribution to the larger society (social system) in which they exist. An organization can persist in society because: (1) the organizational output is legitimized over other possible conflicting goals or interests which may occur in the organization. In addition to the legitimation process, Parsons hinges the persistence of the organization upon the institutional process as it acts through the three main structural divisions of an organization: namely, institutionalization (1) the procurement of resources, (2) in bringing the resources to bear on the goals of the organization, and (3) in patterns of activity which limit the commitment of those involved in the organization to the final goals of the organization. *9 For an example see, Warren R.L., uThe Naval Reserve Officer; A study in Assimilation", The American Socio- logical Review, 11 (April, 1946), pp. QOZ-Il. **1O Parsons, Talcott, "Suggestions for a Sociological Approach to the Theory of Organizations” (Part I and II) Administrative Sgience Quarterl , I, (June, 1956), pp. 63-85; if, (8ept., 1956), pp. 225-39. 120 Parsons maintains that actors within the organi- zation internalize a set of values and this fact also contributes to organizational consistency. The value pattern used by actors within the organization, he ex- plains, is drawn from the wider society and is consis- tent with the ends or goals of the organizational system. It is on this point that Parsons departs from the Weberian scheme of the organization. The use of the "value" pattern approach by Parsons shows that rational motivation, the foundation of Weber's model, necessarily explains only part of motivation within the organization. According to Parsons, organizations (or bureaucracies) are not underwritten by a rational modes of behavior pgr_§g_in an effort to survive in a competitive market place, as Weber characterized them. With Parsons the' {goal is the pivot point around which the organization 11s tied to the society and through which the society provides value to support the organization. While Talcott Parsons' theory of the organization embraces all the necessary elements for the explanation of persistence in an organization, it is a difficult model to use for the explanation of major shifts of emphasis that an organization may or must take from time to time. Particularly hard to explain with his model is an organizational change in goals by an internal shift within the organization itself. Alvin W. Gouldner has discussed aspects of this 121 means-ends dilemna which has a bearing here. In his summary of the work accomplished in bureaucratic organizations he distinguishes two types of theoretical approaches that have been utilized: the rational model of organizational analysis, and the naturalesystem model of organizational analysis.* The first refers to the work of Weber and the modern-day researchers who have used Weber's general methodology; the second, to the work of systemic theorists such as Parsons and Barnard. In the latter approach, as Gouldner points out, emphasis is upon the ends-means schema and the values that give credence to the goal of the organiza- tion. Criticizing this approach, Gouldner denies the possibility that an entity as an organization can have goals itself, suggesting rather that the internal strata of the organization have separate ends or goals. As we already mentioned in Chapter One, in our analysis we.have utilized Parsons' approach and intro- duced the sub-system notion of Gouldner's. It should be pointed out that neither theorist has offered us the exact conceptual means we have needed; that is, the ana- lysis of the organization which uses the goal as a variable. However, a speculative article on the organi- zation by Thompson and McEwen has discussed the possibility 311 Gouldner, Alvin W.,_'Organizational Analysis", in Merton, Broom, Cottrell (eds.), Sociologé Today,.New York, 88.816 BOOkB, 1110., 1959, pp. - e 122 of looking upon the organizational goal as a variable.* They contend that organizations vary in that the "output" of some are more difficult to measure than the pro- 1 ducts of others. This, they go on to say, means that the goal-setting process becomes more dynamic in or- ganizations which have outputs difficult to measure (such as service organizations, including hospitals). They further state that various forces are at work in determining the goal-setting process and they specify these in two categories of competitive and non-competitive. A combination of these ideas of the organization offer us a means by which we may view the behavioral and value assertive statements of the respondents in the case study of the Warren Hospital. Through the use of Parsons' basic model, Gouldner's modifications and viewing the organizational goal as a dynamic variable in the total hospital process, we are able to explicitly state hypotheses of organizational change, persistence and conflict among the three sub-systems of the case study. Although the specific use of the word "output" has been used earlier in this thesis, its appearance here, as distinct from "goal", was foreshadowed by reference to medical care and other goals of the various sub-systems *12 Thompson, James D., and Méiwen, William J., "Organi- zational Goals and Goal-setting as an Interaction Process", AmeriganISociological Review, Vol. 23 (Feb. 1958), pp. 2-3 . 123 of the hospital in the preceding chapters. At this point we are able to draw upon the information offered by the empirical case studies reviewed and the theor- etical ideas examined and supply a working definition of "output" and "goal" for the hypotheses. . We will use Parsons' definition of output as the "identifiable something" which the organization produces. The output in our case study is the professional, medical treatment and diagnosis of the hospital patient, or, more simply, medical care. A definition of goal is more complex since it is a vehicle for the consideration of values in output and at least three kinds of goal definition require sociological attention. The first, and the most gen- eral, is the functional sense of an organization adjusting to the society. The term ”functional" here is important for it denotes that the society and the organization have a symbiotic relationship: that is, the goal of the organization coincides with, as well as adds to, the persistence of the society itself. In turn the society has general goals which are interrelated with the organizational goal and facilitates the con- tinuation of the organization.* A sociological evalua- tion of an organizational goal in functional terms would *13 This definition 6?_functionalism is takenkfrom, Nadel, S.F., The Foundation of Social Anthropology, Glencoe, Illinois, The Free Press, 1953, pp. 3 -7l. 124 consider the manner in which the organization is related to the total society and gig§.ggg§§, There is a second sense in which the goals of an organization may be viewed. Instead of regarding the persistence of the organization in terms of its inte- gration into the wider society, organizational goals may be viewed as short range; in the manufacturing this would be profit; in the hospital it would be effective medical care. The evaluation of this second kind of goal, the expressed purpose, may be carried out by the individuals within the organization. And unlike the first definition of goal, the second is not based upon an understanding of the relative place of the organiza- tion in the total society. Finally, goals in an organization may be viewed as extensions or supplements to individual goals. In the industrial example this definition would be illustrated by the statement, "If the organization accrues more profits, then I will receive more renumeration". An example, for the hospital setting is illustrated by the sentence, "The more patients that are treated the more fees I will receive". Organizational goals in this sense can be individually evaluated as congruent or incongruent with personal goals. In our concern with goals we shall use the expressed purpose in the organization as a starting point (the second type). In general it wouh appear that expressed 125 goals of a service organization are not as specified in the society as the goals of a profit-making organi~ zation. Standards of educational achievement, medical care, family counciling and rehabilitation, for example, are constantly being defined and developed. In the dynamics of the on-going service organization, evalua- tion, legitimation and establishment of new goals run through the entire organization and are particularly found within those professional groups which are part of the organization. Such groups would include pro- fessional educators, social workers, hospital admin- istrators and scientists in governmental agencies. Therefore, the nature of the goal as well as its degree of its specificity of statement have consequences for the functioning of an organization. These observations lead to our first hypothesis, which states: 1. If the expressed goal of a service organization is not clearly defined, then the goal may be difficult to evaluate for some members of the organization. Starting with the conditional part of our hypothesis, we have seen that the working definition of the expressed goal is the achievement of effective medical care. Any definition of this goal, however, is arbitary and open to argument since the definition can include the work performed by non-medical or para-medical hospital per- sonnel. One difficulty in evaluating the goal of effective medical care, therefore, is the unestablished Ln. 126 parameters in the definition of the term itself, part- iuiarly for the layman and non-professional in 1he hospital. No clear definitions of effective medical care have been established and agreed upon by even those who are professionally working in the field. In a re-examination of the previous material that bears upon the first hypothesis the board of trustees becomes pertinent. Board members had stated, time and time in interviews, that they had little or no knowledge of medical care. As we pointed out above, they were not even able to detect the converse of effective medical care -- malpractice. There is np question that the board members, by and large, felt inadequate and unqualified to judge standards of pro- fessional medical activities in the hospital. Further- more, they felt they had no criteria available by which to compare the quality of care in this hospital to care in another. Finally, although the board had the legal authority to impose limitations and direct sanctions upon the physicians' practice in the hospital, they ex— pressed no interest in such matters. As we have noted, board members felt quite confident that the doctors were doing an adquate service. In the case of the board member then, the difficulty of evaluating the expressed hospital goal refers to the problem of securing objective means for evaluation and the lack of interest in applying any means now available. 126 parameters in the definition of the term itself, part- iularly for the layman and non-professional in 1he hospital. No clear definitions of effective medical care have been established and agreed upon by even those who are professionally working in the field. In a re-examination of the previous material that bears upon the first hypothesis the board of trustees becomes pertinent. Board members had stated, time and time in interviews, that they had little or no knowledge of medical care. As we pointed out above, they were not even able to detect the converse of effective medical care -- malpractice. There is no question that the board members, by and large, felt inadequate and unqualified to judge standards of pro- fessional medical activities in the hospital. Further- more, they felt they had no criteria available by which to compare the quality of care in this hospital to care in another. Finally, although the board had the legal authority to impose limitations and direct sanctions upon the physicians' practice in the hospital, they ex- pressed no interest in such matters. As we have noted, board members felt quite confident that the doctors were doing an adquate service. In the case of the board member then, the difficulty of evaluating the expressed hospital goal refers to the problem of securing objective means for evaluation and the lack of interest in applying any means now available. 127 Implications of the first hypothesis reach far into the area of board policy making in our case study. Recalling that the board of directors is responsible for the ultimate care of the patient,lack of goal de- finition in the organization and the resultant diffi- culty in evaluating goals, weakens the ties between the ultimate purpose of the organization and its structural mechanism for legitimation. The board, therefore, charged with the total responsibility of the organiation and lacking the means and interest to guage the quality of output, has had to turn to other sources to justify its actions. Specific illustrations of these ramifications may be drawn from the case study material. Not only is the board responsible, theoretically at least, for the general direction of the hospital, but also it is accountable for securing and allocating hospital resources. The board's decision to release the path- ologist cuts across both decision areas of securement allocation of available manpower resources. The board's final decision not to abide the pathologist's demand fir money did nottake into account the medical care ramifications of patient care. The decision was made and justified upon the grounds of economic expediency, yet the decision had direct and important implications for part of the medical staff's confidence in effective 128 _ medical care to patients.* Board members felt they had no way of assessing the effectiveness of the pathologist vis-a-vis the medical staff and finally the ultimate effect upon patient care. Discussion of the board's inability to asses medical care aspects of organization goals leads directly to our second hypothesis: 2. If major decision-making processes of resource allocation and procurement are not based upon the ex- pressed purpose of the organization, then linkages be- tween goal evaluation and organizational output may be \ ¥___ -- I "f (a \. rendered ineffective. Again the actions and viewpoints of board members establish the conditional part of this hypothesis. Through our review of the substantive issues we have noted that resource procurement and allocation has not been based upon goal evaluation in terms of medical care. For purposes of verification, we can point to the path- ology incident which we reviewed above. In addition to this the recruitment process of board members further affirms the assertion. In the recruitment process we 31E Like any incident of human interaction the factorsfin the situation are extremely complex. Here we are only extracting the principle that source and justification of the board's decision was, almost necessarily econo- mically based. Also, understanding these actions within the framework we have suggested does not necessarily "solve" the pathology problem. while doctors expressed little.reluctance to voice their dependence upon the pathologist to the interviewers, physicians were cautious about noting such dependence to others. 129 have seen that the community activists were selected on the basis of cultural determinants which included social position and experience. These requisites were more important in the selection of the community activists group than any basic knowledge of, or experience with, medical care. Also the board's general attitudes on important financial aspects of the hospital, such as unpaid bills or endowment policies, were not related to medical care as such but was more closely associated with the financial stability of one amony many community institutions. Finally, the planning of the emergency room during the hospital renovation illustrates that medical care concerns were not dominant enough to activate the technical recommendations of the medical staff. Suffice it, say that reoccurring, significant decisions of hospital resources that were not primarily based upon effective medical care, have been part of the history of board action. The two hospital sub-systems most concerned with, and involved in, the actual output of the hospital are the physicians and the administration. The medical staff had the best basis for the evaluation of medical care in the hospital -- their professional training and continued practice in the field of medicine. Withinthe medical staff no institutionalized means had been es- tablished to insure that the most effective methods of medical practice currently known would be carried out in 130 the hospital. For example, when cases of admitted or obvious malpractice occurred, according to medical in~ formants, medical staff members upset about the situation had no means of enforcing rules which would prevent what they considered to be an undesirable situation. These statements suggest that with an established notion of effective medical care the medical staff was unable to call upon the board of directors as a sanction for what were considered to be shortcomings in patient treatment. Why? Because, as our hypothesis states, the board did not base its hospital decisions upon medical care evaluations. Further, the board members did not feel that they could be concerned about medical care since they would be stepping outside their own area of responsibility and jurisdiction when they did. Finally, and very important, the board members did not feel that the shortcomings of medical care, as seen by the medical staff, had any direct bearing upon their areas of decisions, as for example, how large the en- dowment should be or how the question of funded indebtness should be handled. Further evidence for verification of the second hypothesis is found as we look again at the administra- tor‘s position within the hospital. He too, through his professional training and experience, knew that certain procedures and sources of information (such as tissue committee reports, medical records, autopsies, infant l3l mortality rates, patient death rates, days of hospital occupancy and the like) could be cumulatively used as rough indices for the evaluation of medical care. As in the case of thephysician, the organizational structure of the hospital did not provide a direct g3£g_between the administrator's evaluation of the expressed goals and the actual hospital output.* Furthermore, to enforce adequate standards of medical care the administrator would have to have access to controls over the medical staff (or at least to hav e their cooperation in arriving at controls). Without altering the present structure of the hospital organization, this control would ultimately have to come from the authority of the board of directors -~ those charged with the main responsibility of the hospital. However, the administrator lacked means of control to enforce his own criterion of medical standards partly because medical staff members refused to have administrative "interference" and partly because board members were reluctant to "intenere" with the practice of medicine. . - Underlying these reasons is the fact that the board had hired the administrator for a specific purpose -- to effectively work in the area of hospital finances. Their wish was not to see his energies diverted to a concern over matters of medical care for they were seeking rational, 315 Although administrative control over some allocative decisions did provide a partial or indirect link between the two. 132 established means to expedite the pressure of financial decisions, created by the tremendous influx of patients. So again we have the case in which the board was not willing to sanction medical care decisions. To do so through the office of the administrator would entail the delegation of authority to apply sanctions to medical care decisions. Such delegation was not made since the administrator's training in hospital finances was originally secured to legitimate allocation and procurement de- cisions which were not felt to be contingent upon his control over medical care matters, especially as they were related to the practice of medicine by doctors in the hospital. Before we go on let us review the first two hypo- thesis. First, we have seen that the expressed purpose of the organization -- the goal of effective medical care -- is not clearly defined in the culture compared to the clarity by which the expressed goals of other organizations may be defined. Not only is effective medical care difficult to determine at any one particular point of time, but also rapid advancements in medical care achievement (a characteristic of the entire medical field) mean that the basis Ibr evaluation is constantly being altered. Secondly, although some aspects of effective medical care are amenable to evaluation, lack of sanctions to enforce known standards and/or lack of concern over the necessity of exercising legal authority 133 for enforcement, characterize the hospital organization studied. Actually these first two hypothesis are conditional for the major analysis of our findings. What we have demonstrated is the setting of organizational decisions in relationship to goal evaluation and output. Although important, our major concern is not the fact that the organizational structure seems to be "out of joint" in terms of unified purpose and practice. We are more con- cerned with the way in which these three major sub~systems interlock to form a total, ongoing system.* We have established, however, that using the concept of one major hospital goal clearly illustrates discrepancies in what one might g p£2£l_think to be a rather straight- forward and unidimensional organization. The case study analysis presents a series of conflicting and active forces that are dynamically inter-acting at many different strata and for different purposes. What we are seeking, in terms of a general ends-means schema, are organizational principles that will lead us to understand how these apparent discrepancies can exist in an organization that has obviously maintained itself and even enjoyed substantial growth. In other words, we must look for explanations of persistence and change which ‘16"For a more comprehensive explanation of this dilemna often reached in organizational research see; Etzioni, Amitai, "Two Approaches to Organizational Analysis: A Critque and a Suggestion," Administrative Science Quarterly, Vol. 5 (Sept. 1960), pp. 257-278. 134 are not contingent upon the dissident relationships we have found between organizational ends and means. This assignment is partially fulfilled by viewing our findings within the framework of the following hypo- thesis: 3. If the output of an organization is not re- warded in accordance with norms of a "free"market, then value patterns which legitimate the procurement and alloca- tion of resources may likewise not be sanctional by the norms of the "free“ market. Our case study is an excellent source for validation of this hypothesis. First of all, it has been demonstrated in Chapter Two that the hospital output is not subject to the competitive forces within the community, state or nation. For most community members, according to the medical staff, the hospital is the center for institu- tionalized medical care. The evidence presented to illustrate the kinds of forces which have increased the demand for local hospital service now becomes especially important. These forces stem from several sources, including pre-paid hospital plans, advancement in medical technology and increased public awareness of hospital medical care. In order to relate this variation in output demand to the hospital sub-system most responsi- ble for resource decisions -- the board -- we will use only one aspect of the total board value pattern used to legitimate a resource procurement decision. This 135 will be done by looking at the board member's attitudes about the use of the hospital endowment and procurement of hospital operating expenses. Hospital board members were unanimous in agreement that the general solicitation of funds for the hospital should only be made for building expenses and only in extreme emergency for general costs of plant operations. The use of the endowment fund was almost sacred. Under no circumstances should the endowment fund be spent for plant operation and only when absolutely necessary should the interest accrued be utilized for plant ex- pansion. This means that total operational funds had to come from patient charges. Operational expenditures had steadily increased in the last two decades which demanded that sources for operational expenditures were also increasing. The expediency used to meet this demand was increasing the patient charges for hospital use. A significant question now arises; why were board members so emphatic in their determination to protect the endowment if they had little concern over trends in hospital output? The analysis of their responses to questions in this area indicates that the board looked upon the endowment trust as a responsibility board members had to the communitliin general as Opposed to the hospital specifically, There are two important dimensions to this feeling of community responsibility; first the board viewed the 136 the hospital as one community organization among many. This means that the economic solvency of the organiza- tion was more important to them than any other hospi- tal factor. If the board had to rely upon direct public support for the operation of the hospital this, to them, would mean their ability to efficiently run the institution could be severly questioned. Secondly, the aspects of what the hospital did -— provide medical care for patients -- was not a criterion upon which this efficiency could be measured. This illustration of one aspect of resource procure- ment demonstrates the principle that the justification of policy was not related to the tremendous increase in demand for hospital services. The legitimation for endowment and community solicitation funds as resources stemmed from a value pattern extant in other community institutions, namely, that the boards of such community organizations were economically responsible for the institution and that expenditures of such funds for Operational demands would be a breach of this responsibility. Validation and discussion of this hypothesis has inadvertantly supplied some of the evidence we wish to use as proof for the next hypothesis, so it will simply be stated now. 4. If value patterns which legitimate the procure- ment and allocation of organizational resources are not related to variations in output demand, then the source 137 of these values may lie outside the organization itself. To establish the validity of this hypothesis it may be helpful to review the value pattern of the board. We are using the term "value pattern" here in the sense that behind every particular act there is a set of values, or an orientation, which remains constant and consistent through a series of social actions. The use of this conceptual tool also includes the assumption that the value pattern ties together what may, on the surface, appear to be a discrete series of actions into a conceptual unity. Also, the actions themselves can be organized around a particular value pattern to de- monstrate a social direction which may be opposed to an alternative hypothesis of direction, one of rational, economic, ends-means directiOn, for example.* The value pattern of the community activists section of the board has been termed community-commercial since there are two sources to this pattern -- the community and the commercial world. The board recuirtment process illustrates the sit- *17 It should be noted that of the’two board groups presented earlier (community activists and technically knowledgeables) we are using the value pattern of only one group, the community activists, to establish the proof of the hypothesis above. There are two reasons for this. First, the community activists are the es- tablished group in the hospital and have, over the years, been responsible for most of the resource decisions that have shaped the present hospital. Secondly, this group is more homogenous than the technically knowledgeables and therefore the extra-polation of a value pattern has more validity for proof of the conditional statement. 138 uation we have described in the fourth hypothesis. Re- cruitment of board members is a process by which the hospital procures from the community a resource necessary for the hospital -- the board member. Board members themselves explained the selection of fellow members as part of a general community pattern which was used in the recruitment of board members for other community organizations. As noted, the process was generally based upon two social factors -- experience and social rank. The source for this procurement was not related to the organization as such and was §g£_1egitimated by a value pattern which was contingent upon variation in output demands. Although we have examined the "dysfunctional" aspect of the selection process in terms of organization output 233 g3 in the second hypothesis, the functional signi- ficance of the process must not be overlooked and can be examined in the framework of this hypothesis. The community-wide selection process also common to the hospital meant that in a variety of ways the hospital was an integral part of a larger network of community organizations. As a consequence of this inte- gration, sources of influence and power which were able to mobilize community resources available to other organi- zations were also available to the hospital. The re- cruitment arrangement of the hospital also facilitated cooperation and coordination between the hospital and 139 other community organizations since the hospital board always had a representative group from a cadre of community members who sat in control of other organi- zations. Moreover, the broad base of organizational experience of board members facilitated understanding between various organizations. For example, when the hospital might have been "by-passed" for a construction fund drive, individual board members did not feel "threa- tened" since they viewed the community as a total fund source for all organizations and knew that their "turn" would eventually come. Also the recruitment process tended to select a homogeneous board, one in which members had a common ground for decision-making. This fact alone goes far in explaining the continuation of board structure over the years even in the face of the fact that the kind of men and women selected made de- cisions that were ineffective for goal-setting and achievement as measured by output. Finally, the recruitment process selected the kind of board members that insured that decision-making would be legitimated within the community. For example, even if the present location of the physical hospital plant is viewed as ineffective as measured by medical care needs, of the community, the board's decision to renovate the plant was carried out through public solicitation of funds and the present renovated structure now stands. Whether or not a new building, constructed 140 according to medical staff standards, could have been carried to completion without the board‘s legitimation is questionable. Thus it is suggested that even if the value pattern for a particular organization funds parts of its source within the broader spectrum of community organizations and if this value source proves to be ineffective in regard to resource allocation as measured by organiza- tional output, the same source of value orientation may be highly effective for resource procurement. The other part of the board's orientation +- comm- ercial -- can be examined in these same functional terms. The handling of the unpaid hospital bills by the com- munity activists is an excellent example of a commercial orientation to a financial problem, again of resource. In our previous discussion of unpaid hospital bills we mentioned how the technically knowledgeables were upset about what they felt to be lax policies in bill collection. When this conflict between the two board groups had been discovered during the interview process, intensive probing of this area of board action took place in subsequent interviews with both groups. The community activists explained their stand on bill collection by observing that a position of strength could not be over-played. Just because one has the legal right to collect, they said, does not always mean that it is a good practice to push debtors too hard. In the 141 long run, they felt, such practices would mean a financial loss rather than a gain -- "customer" good will would be lost. I Like business, hospital financial affairs are complicated, board members explained, and tax write-offs and apparent losses that can be turned into gains are not always clear to those without experience in the world of finance. Community activists painted a picture of economic give and take which they had to learn from business and were able to apply to the unpaid hospital bill situation. As long as the "firm" was financially sound (and the hospital certainly was) they felt that a little leeway in bill collecting was good advertising especially since the hospital was reimbursed by the state for charity or staff patients. Both the third and fourt hypothesis have explained how a value pattern which is incongruent with specific aspects of hospital output can be functionally inagrated into the hospital organization. Not only can the community-commercial value pattern be used to explain persistent policies of resource procurement, but it also suggests a means of understanding an organizational change which is taking place in the case study hospital in recent years. Viewing the total organization in light of value patterns which are rooted within particular sub-systems, as we have done in the last four hypothesis, raises the 142 important question of how organizational change can occur. Explaining organizational change is particular difficult in face of the two facts already mentioned above: many hospital decisions have been carried out goal evaluation not related to medical care; medical care demands have been ever-increasing in the local hospital. Therefore, the question becomes, if alarming changes in output de- mands have not been sufficient to produce a consideration of hospital goals, what kinds of mechanisms exist in the hospital that will elicit such considerations.* We will assert that the introduction of another sub- system concerned with goal evaluation on the basis of output (besides the already established medical staff) can occur as an unanticipated consequence of a board decision. The general statement of an hypothesis which might test this matter could be stated somewhat as follows: 5. If evaluations of goals on the basis of output are introduced into a non-profit organization as a means for resource decisions, then the source of introduction *18 Perhaps right here we EEOuld mentionfhospital—accre- ditation. Although this hospital has been accredited by the Joint Committee on Hospital Accreditation, sources available to this study suggest that accreditation only guarantees that minimal standards of care will be observed. Furthermore, accreditation did not seem to play an im- portant part in the general medical orientation of the board or medical staff. (The sources include; informal interviews with members of, The American Hospital Associa- tion, a national cross-section of hospital administrators, and physicians on the local medical staff). 143 originates from considerations which are not related to output evaluations. Since this hypothesis rather concisely summarizes a complicated set of factors and circumstances it may be helpful to illustrate what is stated by looking at the reverse situation commonly found in a profit-making situation. In profit-making organizations, expressed goals of profit are usually evaluated on output or production. If for some reason, however, this did not occur then certainly the introduction of such an evalua- tion would be made by considering the product; that is, evaluating its qualities in terms of resources consumed to produce it, distribute it, and so forth. We are simply suggesting in the hypothesis that in the non- profit organization, evaluation of goals on the basis of output may be introduced without using gutput con- siderations, especially quality of output, as a source of introduction. Examining some of the assumptions behind the hypo- thesis will further illuminate its contents. We have suggested at the beginning of this chapter that the competitive forces of the economic market place do not seem to be a contingent variable in explaining the structural qualities of the community hospital studied. This hypothesis fully rests upon this assumption,. Since our main problem in the explanation of hospital persis- tence and change has been to find variables which related the various parts of the organization so that we can see 144 a structural unity, we have turned to a value orientation within sub-systems of the hospital as a significant variable for explaining continuation of and change in policy decisions. In this way we have been able to avoid the economic assumptions of a competitive output model and its assumptions which has not been applicable to our case study setting. Again in this hypothesis we are using a value orientation approach independent of competition as a basic assumption. Here, however, we are illuminating the manner in which a new value pattern has been intro- duced into the organization instead of explaining the steady flow of decision-making, the substance of our previous hypothesis. Further, it is being asserted that this new value pattern has had consequences for total goal evaluation which in turn has affected output quality in the hospital. We are asserting that the introduction of this new evaluation occurred without the consideration of hospital output as a competitive, market-place element by those who have introduced it. The hiring of the professional administrator is the case in point used to verify our assertion. Primarily, most board members thought that the hiring of a professional person would create changes which would bring about more efficient allocative, economic policies (which it did) but also the introduction of a professional man led to the establishment of policies which were designed to 145 routinize the medical care_aspects of the hospital. The main point is simply this; the hospital is not designed as an efficient production unit in compe- tition with other production units as would be, for example, a furniture factory. The hospital is designed to render a medical service in the community and through- out the history of the hospital board decisions had not been contingent upon the evaluation of this service. - The new evaluation of output on the part of the admin- istrator was inadvertent in the sense that the board members had not hired the man with an eye to changing the effectiveness of the hospital medical services. The board had expected that the means to established goals would be more effective with the addition of a professional person -- the economic allocative decisions of the hospi- tal. Pressures for efficiencies in medical care was not a force that occurred as a result of the organization striving to survive in the "market place" of medical care. The driving force that was introducing effective- ness in medical care standards was part of the value pattern of the administrator. What is more important, the administrator's control over the means of resource allocation (a responsibility of the position) allowed him to effectively introduce changed which would have a bearing upon the output of the hospital. Without control over some the allocative decisions 146 of hospital resources, the administrator would have been in the same position as the medical staff -- knowledge and interest in medical care but without the means of enforcing medical care standards. Thus, while the physician might have the desire for higher standards of hospital goal achievement, he lacked (or felt he lacked) the means for such enforcement. The physician, moreover, expressed the opinion that standards of medical care were more contingent upon hospital loca~ tion (near a medical school, for example) than upon individual ability. In effect, the physician felt isolated from the mainstream of professional achievement and knowledge in medical matters. The prime force which began to alter the viewpoint of goal evaluation and goal-setting, to borrow a term from Weber, can be viewed as charismatic. The adminis- trator, in this case study, can be looked upon as a charismatic leader. Instead of a group of ”followers" to place his "creed" into practice, this administrator has by-passed Weber‘s procedural step and has moved directly to the bureaucratic model to set into motion procedures which may eventually be routinized behavior to achieve his envisioned goal of effective medical care in the local hospital. We are now ready to state our final hypohhesis which examines the relationships between all three sub-systems and the major purpose of the hospital. 147 6. If consensus Of goal evaluation among organi- zational sub-systems, variously responsible for the all- ocation and procurement of resources, is not related to variations in organizational output, then such con- sensus is not contingent upon the persistence of the organization. Unfortunately affirmation of this hypothesis will not explain organizational persistence as such. It does suggest that other organizational elements are the key to persistence; elements which lie beyond the consensus Of goal evaluation by organizational decision- makers. Following the discussion Of this hypothesis, such suggestions will be offered. A questionnaire administered to hospital board members, medical staff members and administrative per- sonnel Offers a means by which a quantitative measure Of consensus of goal evaluation can be expressed.* Before a measure of evaluation can be presented, how- ever, we must make a number of assumptions about the results Of the instrument used. First, ease of evalu- ation is equated with high consensus of opinion. That is, we are assuming that if all three groups had a high consensus of a particular item (question) then the evaluation of this item was made with reasonable ease. Conversely, we will assume that if all three groups had a low consensus of Opinion on a particular item, *19 A complete listing ofresponses to the questionnaire are listed in Appendix C. 148 they had difficulty in evaluating the item. The variance score Of each item is looked upon a s a measure of consensus.* Thus, for example, if the respondents substantially agreed on a certain item that the admins istrator "absolutely must" or "preferably should" follow a course Of action, then little variation was present in the answers and the variance score was "low" (lower than .486, the median variance in the total distribution of items for all three groups). If, on the other hand, the answers ranged considerably from "absolutely must" to "absolutely must not“ then the variation was greater and rated as "hggh" (higher than .486). Items in which all three grOups had either "high" or "low" consensus were then grouped according to the following categories (1) Community (2) Medical (3) Procedural-policy and (4) Administrative. The following distribution of items according to these categories resulted:* Brocedural Admini s- Community Medical 'Policy trative High Consensus 5 3 l2 5 Low Consensus lO 5 7 - Inspection Of this distribution suggests that higher consensus obtains in the Procedural-policy and Administra- *20 Cross, Neal and McEachern,‘§p, cit,p. 150.6(Also see the reference in Chapter One for the source of the questionnaire. *21 A separate list of these items appear in Appendix D. 149 tive items than in the Community and Medical items. If we follow the line Of reasoning that the Community and Medical items more closely approach the expressed goals Of the hospital (the ends) and the Procedural- policy and Administrative items more closely represent the means to these expressed goals the following dis- tribution results: Community-medical Procedural-policy Medical High Consensus 8 17 Low Consensus 15 7 Chi Square 4.77 P is less than .05 These results, with this assumptions, support the assertion that goal consensus is not related to output demand since we have already established that demands upon the hospital have markedly increased. Since we have found a measurable lack of consensus among hospi- tal decision-makers on what hospital goals should be, we therefore are able to assert that the persistence of the organization is not related to a consensus Of goal evaluation. If it can be assumed that our case study material supports the more general notion that output considera- tions are not a prerequisite for goal-setting and goal- evaluation in the non-profit, community organization, let us now turn to other possible sources of organiza- tional "unity" suggested by our findings. 150 Suggested Mechanisms for Persistence and Cohesion in the Community Organization. For convenience, we will look at the general re- quisite factors of organizational persistence and co- hesion in two categories; (1) conditional requisites -- those requisites which are a result of total societal factors in which the organization rests, and (2) a main functiOnal requisite which integrates the organization. The first conditional requisite for organizational persistence and unity is one which has been discussed at some length above -- the non-competitive aspect of output in the hospital. This may be formalized by stating: The output Of the community, non-profit or- ganization is not subject to the competitive forces Of the society. One corollary to this requisite is the fact that institutional location cannot be shifted according to demand. Thus, the unit of production is bound to the service area and the "product" must be "consumed" at the place of "manufacture". The second conditional requisite for organizational persistence and unity is the source Of output variation: Sources which effect output variations primarily originate in the society. The major exception to this statement is stimulation by the physician for hospital use. However, this too can 151 be viewed as a general trend in itself and certainly has been contingent upon the other sources of demand within the society such as pre-paid hospitalization insurance. The third factor which provides a bridge between conditional factors and the main functional requisite has to do with the patient -- the "consumer" Of output. Recipients of organizational services lack consistent and objective means of evaluating such services. We must assume that if the patient (or the potential patient) had a ready means Of either evaluating hospital goals or of rating the quality of medical care, then the hospital, as we have described it, might not exist. While this kind Of assertion is speculative, it does suggest that if patient evaluation entered the hospital scene as a force, much in the same way that patient de- mand for service has, the entire hospital organization might be called upon to organize its resource decisions around evaluations Of output quality.* While these conditional factors are necessary to explain the continuation and unity of the organization they are not, in themsélves, sufficient. Alone, however, these conditional factors do explain the keystone to the *22 The dependent role of the sick person as a social isolate and deviant, partially explains why patients are unable to evaluate care. See Parsons, Talcott, "Definitions Of Health and Illness in the Light of American Values and Social Structure", Jaco, Op, 215, pp. 176 ff. 152 main functional requisite Of the organization; the or- ganization can persist without a single goal orientation. With this assumption we can state the main functional requisite of the organization: The procurement Of resources, the allocation of resources and the individual commitment to the organization all may be legitimated by. different sub-systems and with different orientations. While this kind of organizational structure can lead to conflicts between sub-systems (as we have seen above) it also allows for a great measure of independence and interdependence within :ub-system. For example, medical staff members are not called upon to justify procedures to board members who themselves are not using the evaluations of such procedures to arrive at their own decisions. Although a few medical staff members complained of certain conditions within the hospital related to the quality of medical care, by and large the medical staff fought to maintain their own professional identity. As we have mentioned, the medical staff did not want the board to evaluate their services -- they felt it was beyond the ability Of any layman to do so. And again, since the board did not feel it was necessary to legitimate their decisions through the effectiveness Of medical care standards, evaluation of the physician's performance was not necessary. At the 153 same time, the hospital provided the board members, especially the community activists, with one more organization through which they could articulate their social rank and prestige within the community. 'Thus the total organization was interlocked since the two sub-systems never came to grips with the same problem on the same plane and therefore, no conflict situation could threaten the existence Of the total organization. For example, we may assume that the board member would not want to "pay the price“ of learning. the technicalities of medical care to accrue rewards he was already receiving from his position without such knowledge. Moreover, it can be seen that the medical staff member's orientation to a profession did not entail a deeper commitment to the hospital than he already had. Finally, this arrangement allowed members of each sub-system to be most effective in their own areas Of strength since these areas coincided with their own value orientation. Any re-arrangement of the organiza- tion could jeopardize their effectiveness. The intro- duction of the technically knowledgeables on the board, for example, will probably mean a loss of procurement powers by the board (for fund drives, endowment commit- ments, etc.). Also, if a new organizational structure insists that medical care standards be controlled by board regulations rather than through the present system 154 of medical staff enforcement, conflicts could be created which may have detrimental consequences for the total hospital care program. It must already be apparent that the professional administrator is the "disfunctional" element in the structural arrangement form this frame of reference. If the administrator's orientation to hospital proce- dures would have been based upon an economic value pattern, then his appointment would not have been a potential source of conflict. Or, in other words, a non-medical orientation to hospital . . . procedures would have made the administrative sub-system integrative with the board sub-system and through them with the medical sub-system. The professional administrative orientation, however, demanded that medical care standards had to be considered by the administrator in arriving at allocative decisions. Since the admin- istrator was not hired for the purpose of enforcing such standards it was not easy for him to secure board legi- timation for the implementation of decisions which were based upon medical care standards. Suffice it say, it was necessary for the administrator to simultaneously secure medical staff cooperation and gradually "educate" the board that it was in their area of responsibility to consider and control medical care standards Of the hospi- tal, before he could implement a total program of medical care improvement. The monumental nature Of this task 155 cannot be minimized; board members apparently were not anxious to become involved in complex decisions without any additional social rewards, especially in the face of known resistance from an established medical staff. What we are suggesting is that the functional unity of a community non-profit organization can occur in a situation in which goal evaluation and goal setting are not related to output quality. One of the cohesive elements in such an arrangement is the fact that procure- ment and allocative decisions can be legitimated by orientations which are outside the immediate organizational framework. And finally we are proposing that these orientations can be as stable and as effective as any other conceived orientation based upon organizational goals per.§g, Conclusion Chapter Seven We shall conclude this case study Of a community- non-profit hospital by commenting on the problems of the researcher of the organization and 1y suggesting some further areas for research investigation. Using the sub-system approach as a vehicle for the analysis of hospital change and persistence in our case study has, perhaps, unduly emphasized partitions between the sub-systems and divisions within the organi- zation. As one begins to examine an organization with some care there seems to be a tendency to investigate and even view with alarm the discrepancies and incon- sistencies that are found. This is especially true if the initial investigation is launched with the viewpoint that the subject matter is a unified entity. Perhaps, then it would be helpful to begin our concluding remarks by looking more closely at the unity of the hospital as it appears to take shape for those outside the organiza- tion rather than re-emphasizing the divisions that are found by an internal examination of the organization. Some of Erving Gofmman's remarks are particularly salient in this regard and we find it worthwhile to quote him at some length.* *1 Goffman, Erving, The Presentation Of Self in Evegyday Life, Garden City, Newaork, Doubleday and Company, Inc., (Anchor Books), 1959, pp. 82-83. 156 157 It is apparent that individuals who are members of the same team will find themselves, by virtue of this fact, in an important re- lationship to one another. Two basic compo- nents of this relationship may be cited. First, it would seem that while a team- performance is in progress, any member of the team has the power to give the show away or to disrupt it by inappropriate conduct. Each teammate is forced to rely on the good conduct and behavior Of his fellows, and they, in turn, are forced to rely on him. There is then, per- force, a bond Of reciprocal dependence linking teammates to one another. When members of a team have different formal statuses and rank in a social establishment, as is Often the case, then we can see that the mutual dependence created by membership in the team is likely to cut across structunal or social cleavages in the establishment. Where staff and line statuses tend to divide an organization, per- formance teams may tend tO integrate the divi- sions. Secondly, it is apparent that if members Of a team must cooperate to maintain a given definition of the situation before their audience, they will hardly be in a position to maintain that particular impression before one another. Accomplices in the maintenance Of a particular appearance of things, they are forced to define one another as persons "in the know", as persons before whom a particular front cannot be maintained. . . . . . Goffman suggests that the team can "pull itself together" to face the public or the outside, but within the very process there develops a kind Of "honesty" among teammates that disallows the same mechanism of "together- ness" to be used on one another. (Being accepted and working for some time as a re- searcher in an organization can also place one "in the know". In such a position the researcher may easily lose the feeling of organizational unity that the team presents 158 to the outsider. His growing image Of a disparate, sectionalized organization is constantly reinforced since, upon him, team members cannot use their front -- he is "one of them". These Observations lead us to interject a word of caution to those who choose to study the organization. The researcher must have a "balanced" outlook and should not conclude that organizational unity does not exist on the basis of a study of the internal structure alone. Some of the best clues for such unity may lie outside the organization and rest within those who are only ex- posed to the team's outward-facing front. Our findings also suggest another area of organiza- tional, and especially hospital, research that could be further pursued. We have seen that the hospital admin- istrator and his incipient sub-system of administrative personnel may possibly introduce a new element in the case study hospital organization; control over resource procurement and decisions to allocate resources on the basis of output considerations. If this change is indicative Of development in other hospitals, than an important question arises; where does this orientation come from and how is it maintained? We can generally Offer that the professional training of the hospital administrator is an important part Of his total socialization process, however, a review of the mechanisms in his training that develOp his orientation is a clear 159 problem for further research. A comprehensive examination of the way in which a professional identification is maintained is also a challenging research proposal. It would seem, for example, that even if an administrator acquired a strong orientation to effective medical care during his training, the job situation has placed before him a series of road— blocks to prevent the implementation of this orientation. In our case study, the board, from which the administrator secures his legitimate power, had little interest in effective medical care, and the medical staff's orienta- tion precluded hospital directed involvement in such matters. In any study of an organization it is important to know the forces which shape the main direction Of the organization. Sociologists are primarily committed to the study of human interaction and values by the nature of the historical developments normative orientation and conceptual tools of the science. It is not beyond the scope Of the science, however, to chart the direction of forces that set limits to human interaction or values in one or another general sphere Of action. Thus if a re- search problem is concerned with health, education or any other area of institutionalized human behavior, pre- dictions Of such behavior will be more valid if the parameters Of forces are known. Furthermore, well charted limits of behavior can be used as points of departure 160 for the study Of variations of actions which occur within these limits. ‘ This study has demonstrated that an organization can persist, expand and change while actors within significant decision-making sub-systems do not use or agree upon a major goal or purpose. Furthermore, goal evaluations which are used in crucial decision-making situations are not always related to the output of the organization. These general findings raise serious questions about the nature Of organizational theory as it stands today. First of all it means that at least two general kinds of organizational models should exist; one for the examination of non-profit, community organizations and one for the examination of profit-making organizations. Not only does goal evaluation and its relationship to output constitute an important difference between these two types, but also the general forces which define the limits of organizational activity of the types appear to be important differentiating factor. A Joint Conference Committee Meeting Appendix A Time and Place: 12:00 Noon, beginning with a luncheon at the hospital conference room. Present: Three board members, the administrator, three doctors from the medical staff and the field investigator for the study. Agenda: Items discussed (1) Practical Nurses' unforms E2) Loudspeaker paging system in the hospital 3 Head nurse of the operating room. Items mentioned but not discussed at length (1) Tissue Committee report (2) Public relations for chronic illness ward (3) Admittance policy for the chronic illness ward. The meeting, chaired by the administrator, was Opened by the chairman Of the medical staff -- co-chairman of the liaison committee -- by Opposing the request of the practical nurses to wear white uniforms. Patient con- fusion and loss Of status for the registered nurses were the two main points against the request. The board members asserted the validity of the argument and the request was denied. The discussion Of the loudspeaker paging system was interminable. As in the case of all other items intro- duced, preliminary statements were carefully made until a full discussion brought the general issue into focus. One the issue was laid bare, there was a prolonged, detailed discussion; remarks were made that included individual ex- perience of annoyance with the present paging method and a host of suggested alternatives to replace the present 161 162 arrangement were offered. Most of the meeting was taken up with this topic. The discussion of the head nurse in the operating room was loosely centered around the general point that certain personalities in any organization must be dealt with -- particularly those kind of peOple who can con- strue their role into one of a "prima donna" status. Board members, althcugh unable to compare the role with similar roles in other hospitals, did point out that "middle management" people, like department heads, often became cantankerous and difficult to deal with. At the same time, they noted these same people may be highly skilled in their particular position, making it difficult to replace them. Two general points can be made about the committee‘s work. First, the introduction of each tOpic was formal and somewhat stressful. Secondly, it did not appear to be the kind Of setting in which fundamental issues of the hospital could be resolved. The Value Pattern of the Physician* Appendix B Values Governing the Physician's Self-Image 1. The physician should continue his self-education throughout his career in order to keep pace with the radidly advancing frontiers of medical knowledge. gut; he also has a primary obligation to make as much time as possible available for the care of his patient. 2. The student-physician should be interested in enlarging his medical responsibilities as he advances through medical school. Egg} he must not prematurely take a measure of responsibility for which he is not adequately prepared (or, at least, is not legally qualified to undertake). 3. The physician must maintain a self-critical attitude and be disciplined in the scientific appraisal of evidence. E22} he must be decisive and not pospone decisions beyond what the situation requires, even when the scien- tific evidence is inadequate. u. The physician must have a sense of autonomy; he must take the burden of responsibility and act as the situation, in his bestKJudgment, requires. gut; autonomy must not be allowed to become com- placency or smug self-assurance; autonomy must be coupled with a due sense of humility. 5. The physician must have the kind of detailed know- ledge which often requires specialized education. E22? he must not become a narrowly specialized man; he should be a well rounded and broadly-educated man. 6. The physician should have a strong moral character with abiding commitments to basic moral values. But: he must avoid passing moral Judgments on patient-Z 7. The physician should attach great value to doing what he can to advance medical knowledge; such accomplish- *l’Merton,Reader,*KendalIT'_p, citl, pp. 73-75 163 164 ments deserve full recognition. But: he should not express a competitive spirit toward his fellows. Values Governing The Physician-Patient Relationship 8. The physician must be emotionally detached in his attitudes toward patients, keeping "his emotions on ice" and not becoming "overly identified" with patients. E23; he must avoid becoming callous through ex- cessive detachment, and should have compassionate con- cern for the patient. 9. The physician must not prefer one type of patient over another, and must curb hostilities toward patients (even those who prove to be uncooperative or who do not respond to his therapeutic efforts). g3}; the most regarding experience for the physi- cian is effective solution of a patient's health problems. 10. The physician must gain and maintain the confi- dence of the patient. gut; he must avoid the mere bedside manner which can quickly degenerate into expedient and self-interested salesmanship. 11. The physician must recognize the diagnosis is often provisional. But: he must have the meriter confidence of the patient—who wants "to know what is really wrong" with him. 12. The physician must provide adequate and unhurried medical care for each patient. But: he should not allow any patient to usurp so much 3f_his limited time as to have this be at the ex- pense of other patients. 13. The physician should come to know patients as persons and give substantial attention to their psycho- logical and social circumstances. gut; this too should not be so time consuming a matter as to interfere with the provision of suitable care for other patients. 14. The physician should institute all the scien- tific tests needed to reach a sound diagnosis. .222? he should be discriminating in the use of these tests, since these are often costly and may impose a sizable_financial burden on patients. 165 15. The physician has a right to expect a "reason- able fee" ,depending upon the care he has given and the conomic circumstances of the patients. gut; he must not "soak the rich“ in order to "provide for the poor" 16. The physician should see to it that medical care is available for his patients whenever it is required. But: he, too, has a right to a "normal life" which he shares with his family. Values Governing The Relation To Colleagues And The Community 17. The physician must respect the reputation of his colleagues, not holding them up to obloquy or ridicule before associates or patients. But: he is obligated to see to it that high standards of practice are maintained by others in the profession as well as by himself. 18. The physician must collaborate with others of the medical team rather than dominate them (nurses, social workers, technicians). But: he has final responsibility for the team and must see to it that his associates meet high standards. 19. The physician should call in consultants, when- ever needed. ggt; he should be persuaded that these are really required, and not add unnecessarily to the costs of medical care. 20. The physician, as a responsible professional man, should take due part in the civic life of his community. ESE? he should not get involved in political squabbles or spend too much ‘flme in activities unrelated to his profession. 21. The physician must do all he can to prevent, and not only to help cure, illness. But: society more largely rewards medical men for the therapy—they effect as practitioners and only secondarily rewards those engaged in the prevention of illness, parti- cularly since preventon is not as readily visable to .patients who do not know that they remain healthy because of preventive measures. Questionnaire Tabulation Appendix C This section depicts the responses from a question- naire administered to a sample of the administrative staff, board of directors and medical staff of the hospi- tal studied. The questionnaire, is with editorial re- visions, a replication of one used by Robert C. Hanson in a study of hospitals in Denver, Colorado. Hanson's ques— tionnaire is a modification of one originally constructed for a study of school superintendents.* Questions, responses to the questions and two summary statistics are presented in the tables that follow. The presentation of the tables is divided into three section; Duties and Responsibilities of the Hospital Administrator, Duties and Responsibilities of the Board and Division of Labor. The total sample size is noted between column (1) and ' (2) on each table. This size remains constant throughout; the Hospital Administrative Staff (HAS)-9, the Hospital Board (HB):12, and the Medical Staff (MS)=9. Directions on the questionnaire called for two types of responses for each question, on the one hand a response to the "ideal" situation in a hospital of the same kind and on the other hand a response to the "actual" situation in this hospital today. .The two headings, "Expectation" and "Behavior" respectively correspond to the two types of responses, "Ideal" and "Actual". *1 Gross, 92:_Cit., Appendix A. 166 167 .1 Duties and Responsibilities of the Hospital Administrator. Column Headings (1) The item (the question) (2) Number: The size of the sample group responding to the item from which the statistics were computed; this number does not in- clude the No Answer (NA) (3) - (8) Expectation response categories 3 AM - Absolutely must A PS - Preferably should 5 MMN - May or may not 6 PSN ~ Preferably should not (7 AMN - Absolutely must not 8 NA - No Answer (9) The mean response (i), for this expectation res- ponses, (AM = 1, PS a 2, MMN = 3, PSN a h, AMN:5) I (10) The variance (32), of the expectation responses (computed from the same weights as above) (11) ~ (15) The behavior responses to the items 11 Y ~ Yes 12 PT - Partly True 13 N - No 14 DNA - Does Not Apply 15 NA - No Answer Duties and Responsibilities cf Hospital Board Members. Column numbers, headings and computation correspond to the section above. Division of Labor 0n items 1-5, column numbers vary according to titles indicated on table, computation of the mean and variance are as above. 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SH I I 54. $4 I I mam. 0TH I I I m I m m I 39H “NA I N aan RIM I 4 434 NN.N I I «a m «2 mom 91908 333.5 83 A3 NHM Lima mpv ‘mmnpnoa “" III-ma WV ’9 SH 23 Ir-lr-l IFIl-I NI-I ‘Ktmn wees H “’~* AS H m H 90H>uno I m N I .H 0 N a H QOHadpoomN I H N I .4 I I H m .HOHbaso I H N I ..H I. I H m 0% WV WY. I m m H n. ..m mum mm WWW ob h.‘ n IN MNHmmN a) mom mpv NI I nadadpoomfim 3v A3 as AS 3% w NHHHQ .3333 NH m: a £5 mfihnfioo no 09230 HH.H «H m mg on: 9330 93336 535.53 a NH ION g m: mp: m4: m. m2 305 3.393 NH m: 93 300: 0.80 H.333: hogan—co m m§ NHH—noon you 0335939 3H 25 .mH 2 33H AS 3 Items in Which All Three Groups Had High Consensus Appendix D Community (5 items) (Duties and Responsibilities of the Hospital Administrator) Direction of Consensus 5. Be willing to schedule, on appoint- Should ment, a meeting with any member of the community on legitimate hospital questions. 39. Be willing to subordinate a planned Should expansion to a long-range community plan for hospital care. (Duties and Responsibilities of the Hospital Board Member) 4. Take a stand on need for improving Should hospital facilities despite community leader opposition. 9. Comply with wishes of community in- Should Not fluencials who want to fire administrator for failing to give their firm contracts. 16. On request, provide hospital statis- Should tics needed for develOpment of overall plan to meet future hospital needs of community. Medical (3 items) (Duties and Responsibilities of the Hospital Administrator) 29. Report the wishes of the mediccl staff Should to the board even when he is not is agree- ment with same. (Duties and Responsibilities of the Hospital Board Member) 7. 0n advise of medical staff, chief, dis- Should Not miss physician from medical staff without further investigation. 14. Permit the use of the hbspital for leg- Should itimate state or national research projects. 187 188 (Duties and Responsibilities of the Hospital Administrator) Direction of Consensus 9. Have on paper a long-range building plan. 17. Fight any attacts on hospital pro- cedure which he knows to be sound. 22. Personally and regularly inspect all hospital departments. 28. Personally investigate any unusual purchase requests. 31. Require periodic examination of all hospital personnel to assure their phy- sical fittness. 34. Have in writing, Job specifications, listing duties and responsibilities of all hospital personnel. 36. Establish a system procedure to keep medical records up-to-date, and provide for their custody. 35. Require periodic balance sheets from the accounting department detailing re- ceipts and expenditures, profits and losses. 38. Have in writing, a policy statement on personnel hiring, promoting and dis- charge. Should Should Should Should Should Should Should Should Should (Duties and Responsibilities of the Hospital Board Member) 8. See that hospital personnel salaries are high or higher than in other cities. (Division of Labor) 1. How is the budget drawn up before it is finally approved by the board? 3. When a particular piece of equipment is needed, the board. . . Should Adm + Board Usually OK's Adm 189 Professional Administrator (5 items) (Duties and Responsibilities of the Hospital Administrator) Direction of Consensus 23. Read professional Journals regularly Should 26. Work on committees sponsored by state Should or national professional organizations. 32. Freely give his point of View at Should board meetings even though he knows it will be Opposed. (Duties and Responsibilities of the Hospital Board Member) 5. Approve funds for meetings, visits Should to keep hospital administrator up—to- date on profession. 28. Require the hospital administrator Should to attend all meetings of the board. 190 Items in Which all Three Groups Had Low Consensus Community (10 items) (Duties and Responsibilities of the Hospital Administrator) 3. Favor local firms in the awarding of hospital contracts even though it may increase hospital expenditures. 11. Give consideration to local values or feelings re- garding race, religion and national origin in selecting personnel. 13. Resist policy suggestions from influencial community leaders when they disagree with administrator's hospital policies. 19. Make no major expansion plans without first seeking community support. 21. Take a neutral stand on community-wide issues involving health standards, e.g., water fluoridation. (Duties and Responsibilities of the Hospital Board Member) 11. Always award construction contracts or supply orders to lowest bidder regardless of location. 13. Require patients to be admitted to answer all questions on race, religion and nationality origin. (Division of Labor) 16. Who takes the responsibility for administering a public relations program? 17. Who initiates co-operative action for planning future hospital needs of the city? 19. Who is responsible for seeing that community hospital care needs are actually being met? Medical (5 items) (Duties and Responsibilities of the Hospital Administrator) 7. Make hospital records and facilities available to re- searchers who are attempting to advance knowledge in the field. {Duties and Responsibilities of the Hospital Board Member) 1. Appoint to medical staff only physicians nominated or 191 approved by board. 20. Make changes in rates and fees without consulting the medical staff. 21. Discuss hospital matters individually with members of the medical staff. (Division of Labor) 7. Who is ultimately responsible for the pr0per care of the patients? Procedural-policy (7 items) (Duties and Responsibilities of the Hospital Administrator) 1. Consider factors other than merit about appointment decisions, promotions or dismissals of subordinates. 2. Carry out decisions of the hospital board which he believes to be unsound. l2. Cary out directions given by president of board even though the subject may not have bean brought to the attention of the entire board. 33. Make transfer of funds from one department to another when expedient. (Duties and Responsibilities of the Hospital Board) 23. Sometimes reach hospital decisions informally in a small group prior to the regular meeting. (Division of Labor) 5. Who is responsible for presenting to the board a recommendation of increased salaries for hospital em- ployees? 14. Who decides what goes on the agenda of board meetings? Professional administrator (no items) Bibliography Books Block, Lguis, Hospital Trends, Chicago, Hospital Topics, 195 . Burling, Temple, Lentz, Edith M. and Wilson, Robert N., The Give and Take in Hospitals, New York, G.P. Putnam's Sons, 1956. Doby, John T., (ed.) An Introduction to Social Research, Harrisburg, The Stackpole Company, 1954. Francis, Roy C. and Stone, Robert 0., Service and Procedure in Bureaucracy, Minneapolis, The University of: Minnesota Press, 1956. Goldstein, Sidney, Patterns of Mobility, 1910-1950: The Norristown Study, Philadelphia, University of Pennsylvania Press, 1958. Gross, Neal, Mason, Ward 3., McEachern, Alexander W., Explorations in Role Analysis, New York, John Wiley and Sons, Inc., 1958. Jaco, E. Gartly (ed.) Patients, Physicians and Illness, Glencoe, The Free Press, 1958. MacEachern, Malcolm T., Hospital Organization and Management, Chicago, PhysiciansT Record 06,, 1957. Merton, R.K., Gray, A.P., Hockey, B., Selvin, H.C., (eds.) Reader in Bureaucracy, Glencoe, The Free Press, 1952. Merton, R.K., Reader, G.G., Kendall, Patrician L., The Student-Physician, Cambridge, Harvard University Press,,l957. Miller, Paul A., Community Health Action, East Lansing, Michigan State College Press, 1953. Parsons, Talcott, The Structure of Social Action, Glencoe, The Free Press, 1949. Ponton, Thomas Ritchie, The Medical Staff in the Hospital, Chicago, Physicians‘ Record Company, 1955. Walker, Charles, R., Steeltown, New York, Harper and Bros., 1950. Warner, Lloyd W., and Low, J.0., The Social System of the Modern Factory, New Haven, Yale University Press, 1947. 192 193 Weber, Max, (Gerth, H.H., and Mills, C.W., trans and eds.) From Max Weber: Essays in Sociolggy, New York, Oxford University Press, 1946. , The Theor of Social and Economic 0r anization, Talcott Parsons trans. and ed.) New York, Exford University Press, 1947. Articles Bendix, Reinhart, "Bureaucracy: The Problem and Its Setting," American Sociological Review, Vol. 8, (Feb. 1943). Brown, Paula, "Bureaucracy in a Government Laboratory", Social Forces, Vol. 32 (March 1954.) Dalton, Melville, "Unofficial Union—Management Relations", The American Sociological Review, Vol. 15, (Oct. 1950). Etzioni, Amitai, "Two Approaches to Organizational Analysis: A Critique and a Su gestion," Administrative Science Quarterly, Vol. 5, Sept. 1960). Guver, Isreal and Bensman, Joseph, "Toward a Sociolog of Expertness," Social Forces, Vol. 32, (March 1954). Parsons, Talcott, "Suggestions for a Sociological Approach to the Theory of Organizations, Parts I and II,’ Administrative Science Quarterly, (June and Sept. 1956). Schulze, Robert 0., "The Role of Economic Dominants in Community Power Structure,“ American Sociological Review, Vol. 23 (Feb. 1958) Selznick, P., "An Approach to a Theory of Bureaucracy", American Sociological Review, Vol. 8, (Feb. 1943). Thompson, James D., and MCEwen, William J., "Organizational Goals and Environment: Goal-setting as an Interaction Process," American Sociological Review, Vol. 23 (Feb. 1958). "W Warren, R.L., "The Naval Reserve Officer: A study in Assimilation," The American Sociological Review, Vol. 11, (April 194E). Others "Health and Science Shorts" Mediggl and Pharmaceutical Information Bureau, Series 95, (Nbv. 1960). 194 Manual of Facts for_Industria1 Development, Warren County, Pennsylvania, Cambridge, Arthur D. Little, Inc. Natality_and Mortalipy, Harrisburg, Pennsylvania Department of Health, 1956. "The General Hospital in Transition," Proggess in Health Service, Vol. 6, (Sept. 1957). "Voluntary Health Insurance: 1953 and 1958," Proggess in Health Services, Vol. 8, (May 1959). Census of Population, 1950, Volume 11, Washington, D.C., U.S.VBUreau of the Census. ROOM U5: Dust. ”'TITliiLHITtLfljfllfllfilfl){Hjfinlfil'ifliflflfijmfl'Es