A COMPARATIVE ANALYSIS OF THE DECISION-MAKING PROCESS IN COMMUNITY ORGANlZATION TOWARD MAJOM HLALTH GOALS By Paul Ausborn Miller A THESIS Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology and Anthropology 1953 T"? ‘.‘ sit“ ACKNOWLEDGMENTS The duties of staff member and the obligations of graduate student Within the same Department provides a rich setting for guidance and stimulation, for sympathy and encouragement. This combination of roles I gratefully reCOgnize as an extraordinary process of maturation. As I recall scores of staff seminars and meetings, consultations as colleague and student with hundreds of sincere peOple, there is only difficulty in fixing the true nature of my indebtedness. Two persons, however, share my greatest debt. They are Dr. Charles P. Loomis, without whose first invitation and constant encouragement this work would not have been started; and my wife, Catherine, without whose patience and understanding, this work would not have been completed. To Dr. John Useem, friend and advisor, I am indebted for stimulation as to the efficacies of the decisionvmaking process for an understanding of community organization, and then to his patient counsel throughout the develOpment of this presentation. His interest always implied that the work was important, and from this I gained inSpiration. Then, for Dr. Duane L. Gibson, whom every graduate student in Sociology and Anthro- polOgy at Michigan State College must fully acknowledge, I feel deep gratitude for the always patient laying aside of his own labors to assist, in detail, the often elaborate plans which this work made necessary. The reader should know how little this presentation represents the endeavor of the author, for the project committee of the Social Research Service at Michigan State College assumed so many reaponsibilities of de- sign and execution for the larger study. Dr. Edgar A. Schuler, now of Wayne University, influenced greatly the design of the total project; Dr. Duane L. Gibson and Professor David G. Steinicke toiled on the con- struction of instruments; Dr. J. Allan Beegle led two research teams to wyoming and California at the expense of planned personal activity; Dr. John B. Holland, with no thought of reward, joined the research team to Alabama; Drs. Charles R. Hoffer and ChristOpher Sower, both members of the project committee, constantly gave of their long experience and in- sight into community processes; Mr. Joseph H. Locke, Mr. Wayne C. Rohrer, and Mr. Sheldon G. Lowry, performed, as research assistants, much of the unsung detail that every research project requires; and, finally, Mrs. Billie Holden who managed the clerical and stenographic details of the project. A most grateful acknowledgment is to be made of those hundreds of workers in the health field who made possible the national focus of this study. Too, great numbers of peOple, whom I shall probably never see, c00peratively completed questionnaires and withstood intensive interviews. {5.12.1806 ii Some of these workers are acknowledged in the body of the report. To the others, I am greatly indebted. Then, the Farm Foundation of Chicago, Illinois, in subsidizing this work and providing it counsel, is due, perhaps, the greatest debt of all. It is difficult to thank Mr. Frank Peck, Managing Director of the Farm Foundation, whose fine relationship with the Department of Sociology and AnthrOpology and with me led to a rapid acquaintanceship in health affairs. Truly this has been a c00perative process, which calls only for humility in offering the report which is to follow. %%*%%%%a**%%%*% iii Paul Anthem H1110: Molt-1 pm)“ ”ensured w civil sourcing officials with authority I. hand.“ 003mm was mainly more decisive in “amusing flu mu pd. although Montana by local people and attention in mm and appealing to the annuity was reduced. Tho film-37’ hound panda“, sponsored outside tho jurisdictions or 01111 W official, offered the reciprocal profile. Vfii‘r '7 ‘r‘1‘_ 1.4.1“. I) «a; w vii J‘I 1:7;IRODUCTIOI;.Q000.000.00-ooo-oooooooooooooooooo-Ooooooooooo 1 Dimensions of the Problem.............................. 6 COmmunity Study'hOQelS................................. 9 Heeds for Further Research............................. 12 in blaooration of the Problem.......................... 15 The Theoretical hodel.................................. 2 The Problem he-Stated.................................. 1 II P’iLmLDUIflbI-l SILI’S 11:33 LLLTIVE()DS.¢.ooooooooooooooooooooooto... LL Preliminary'MetLOQS.................................... Wu Health Facilities As dvents............................ L9 Developing Case InventoriCS............................ 52 Questionnaire DevelOpment.............................. 53 Response to Questionnaire.............................. ,5 Selecting Individual Cases for Field Stucy............. 59 Intensive Field Study Operations and hethods........... 7l Sunmary................................................ 7C III was conuuulrr OfiGLKIZATIOnLL SETTInG-FCR AOSFITLL PkCJBCTS 79 The Community Situation................................ CO Initiation of Community Activity....................... C7 The Patterns of Sponsorship............................ 93 The Practices of Sponsorship............,.............. 100 The Problem of Sponsorship............................. lCh Selected Community'hethods Employed.................... Ill -»Summary of Descriptive Comments........................ 125 Summary of Interpretative Conments..................... 132 IV SSLLCTSD DIFFfihdhCSS IN POLITICALLI AND fiOh-POLITICALLY , SPOLSCRCD hOSPITLL PhOJLCTS............................ lhb Political and hon-Political Sponsorship................ lEC Politically and hon-Politically Sponsored Projects in . the Soutneast Region................................ 159 l , ism-mayo...coo-0.0.00000.00.000.00coco-00.000000000000- iv smora).t. came .9 V VI Vv’ H VIII m-v- SPOnSCRIL.G Patterns of Sponsorship GLOLPS “I.D IanlICLS lhnTS - Continued OO...‘....O.......0.00....O. Secondary Sponsorship.............................. Selectec Characteristics of Sponsoring Grouls The Problems of Sponsorship................. ‘ smar‘EIOOOOOOOOOOOOOIOOOOOOOOIO0.00.00.00.00 ‘4' Southeast Lid-State Farwest... horwest... '7 ItiICuL SYSTLILS OF JwISIC..-LWI\IL‘.G. . . . . . . . . . . l'oreaStooooooooooooooo000000.00.000.000...o. -Cllapter Sunln—lari'oooooooooocoouooooooooooooolo THE CLPACITILS Position and Authority.. F OR DhEISIOh .l'II‘LKI-Lguoogoooooooooo Property and Influence...................... —C}lapter SLUILnlar-JrOOOOOOOOOOO'COOOOOOOOOOO0.... i-L:3.KI1~.‘G DEISIOLJS Al-ID CAIL.L. G I‘LPPROVJLL . . . . . . . . . . Decisions: Decisions: Decisions: Decisions: A TUEOnEfICaL uhD The Problem he-Stated.... Initiation of the Project....... hethods of Financing............ Composition of Sponsoring Groups Countering Unanticipated building _ Chapter Summary..................... hETnODOLOGICLL KCTS.......... Summary Conclusions......................... A ‘Llleoretical lilo-1:18.000.coo-OOOOOOQQQoooooooo A Hethodological hote.... .OOOOIOOOOIOOCOOOOO Recommended Research Problems .............. fi.pplications to Social action. .............. DELIOCIIUWLPEij-{oooooo000.000.000.000.0000000000000000...-so JEPLLDICLS -- APPEHDIX.A: AXplanatory Letters for Questionnaire.. QuGStiOnzla‘iPGOOOOOOOOO00.000.000.000... APthDIX B: :77‘ 'h‘: . luULJ-“u 10. ll. 12. 13. LIST O“ T43 28 basic Comparisons of 218 Responding Heepital Projects with 374 AOSpital Projects in Original Inventory................ Regional Location of Hospital Projects in Original and lLesponLinS; InventOI‘ifjs....goggococoooooooooooo0.0.0.0000... Iumber of Hospital Projects by Predom’nating Community Sitlla_tionrl‘:{pes and iiggionOOOO0.00.coo-ooooooooooooooooOOoo Tine Span between First Interest and Initial netion........ Reported Reasons for Delays in Initiation of hospital ProjeCtSOOOOOOOOOOOOOOOO.OOOOOOOOOOOOOOOOOOO0.0.0....000000 Initiators of EOSpital Projects............................ Occupational Position of Persons tamed Lost Active in LLOSpital ProjeCtSCCOOOCOOOOOOOOOO000......0000.00.00.00.00. Regional Variation in Occupational Position of Persons Lined host Active in Hospital Projects..................... Incidence of Occupations among The Four LOSL Active Persons Ilor Hospital ProjectSOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO....0. Centrally Important Sponsoring Groups in Hospital Projects. highest Ranked Participating Associations in Hospital PrOJCCtSOOOIOOOIOOOOOOOOOOOOOOO.0.00.0000...00.00.000.00... Organizational Formalities of Centrally Important Sponsor- ing GrouPSOOIOOOOUOOO00.00.000.000...OOOOOOOOOOOOOOOOOOOO.O hethods of hember Selection for Centrally Important Sponsoring Groups.......................................... History of Sponsoring Group Activity....................... Internal and Interpersonal Problems of Sponsoring Groups... Community Problems of Sponsoring Groups.................... Problems Confronted by Sponsoring Groups with Other Individuals and Groups..................................... vi \ 1’ -\‘l 92 9h 9 .[ZI 99 100 LIST OF TABLES - Continued .' /“ \ lifiififit JLUJ 18. Types of Opposition......................................... 113 l9. hethods of Fund Raising Employed............................ 115 20. number of Campaigns Employed................................ 119 21. Community Appeals Employed in Publicity Campaigns for liospital ProjeCtSOOOOCOO0......O.OOOOOOOOOOOOOOCOOOOOO.OO...120 22. Comm nication.hedia Employed in Publicity Campaigns for liospital ProjeCtSCOCOCOOCOOOOOOOOOOOOOOOOOOOOOOOOO.000......122 23. Preferred Communication Hedia for Publicity Camvaigns in EiospitalProjeCtSOOOOOOO.00.0.0.0...0.00.00.00.00.O.00......123 2h. Extent of Participating Personnel in Campaigns for Beepital ProjeCtSooooooooo0.00.0000.coo0.000.000ooooooooooooooooooooo Special Community Organizational Szrvices Employed By 3039in PI‘OjeCtsoooo000.00.000.00000000000000000000.0000... 127 26. Final Ownership of Hospital................................. 129 27. Rank Order Comparisons of Regional HOSpital Projects by POlitiCalcomponellt’SOOO.’.0......O.OO...OOOOCOOOOOOOOOOOOOOO130 l’\) C”) hank Order Comparisons of Regional Heepital Projects by hon- POlitiCalcolhtiponerltSOOOIOOOOOIIOOIOOOCOOOOOOOOOOOO0.0.0.0...139 29. Rank Order of Problems het by Regional Groupings of hospital ProjeCtSOOOOOOO0.00.0.0...OOOOOOOOIOOOOOOO0.00.0000...00.... lj—LC.) 30. Rank Order Comparisons of Regional HOSpital Groupings by Communication.hedia and Appeals............................. lh2 31. Summary of Regional Hospital Project Rankings............... lh3 32. Political Components in Politically Sponsored and hon- Politically Sponsored Heepital Projects..........,.......... 151 33. hon-Political Components in Politically Sponsored and Lon- Politieally Sponsoree Hospital Projects..................... 152 3h. Problems Encountered by Politically Sponsored and Lon- Politically Sponsored HOSpital ProjectS..................... 155 vii LIST OF TABLES - Continued “ULDER Fig; 35. Communication Media and Appeals Employed by Politically and hon-Politically Sponsored Hospital Projects.........,,,,,,,, 156 3d. Required number of Campaigns in Politically Sponsored and non-Politically Sponsored dospital PrOjectS................. 1;? 37. Politically and Lon-Politically Sponsored Hospital Projects in the Southeast Compared with the hortheast Projects by Political and hon-Political Components...................... 1J2 38. Politically and hon-Politically Sponsored hospital Projects in the Southeast Compared with the Lortheast Projects ey Community Organizational Problems........................... leh 39. Politically and hon-Politically Sponsored hospital Projects in the Southeast Compared with the northeast Projects by Communication.hedia.......,,,,,,,.................._........ 15; b0. Incidence of High Ranked Organizations in Supporting Participation for Hospital Projects (bxcepting Sponsoring (roups)00.0.000.000.000000000000000000000000000...0.0.0.0000 Id” Active and Inactive Classifications of Reported Businesses and Industries in h08pital Projects......................... 1C5 ‘32- SGI‘W'LCB I‘I‘ea Reality and Sponsorire Group History.......... 1d; 13. Per Capita Income of Service Areas for 21& hospital Projects {35'hegiOnOOOOOOOCOOOOOOO00.000.000.000...00.0.0.00.00.000.00 210 [an Percent of hural POpulation in 21; HOSpital Service Areas by Regionoooooooooooooooooooooooooocoo-00.090.00.00oooooooooooo 21-1- L5. Administrative Structure of the Area of Use for 218 hospital ProjeCtS103‘iiegionOOOOOOO.0.00.00...OCOOOOOIOOOOOOOOOOOOOOO. L12 L6. Percent of HOSpital heed.het for 21s hospital Projects by Eierfion.no.oo.00000000000000.00000000cacao-00.0.000'0°"°..°' 21‘3 L7. Total POpulation of Service Areas for 216 hospital Projects 0;”. I’LGglOnoooooooooooooooooooooo00.00.00.000...-oooooooooocoo 21’ ht. Summary of Forms of Sponsoring Groups by Five Community Situational Factors..Q...‘....QC.....O0.00...0...........O.. 21:) viii FIJL.LE Fl LISP OF FICLnQS Reporting hospital Projects by Region.................. Case Selection for Intensive Field Stub”.......,..,... J 0 {DJ Summary'of Positional Elements of wanty fiigh-Ranke D‘BCiSion-;¢a}:ersoOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOCOO Possession of Capacities by high—hanked Decisien-naTers Patterns of Initiatory negotiations.................... ix - -VJ YO \J) y; .r ‘— F" [‘0 h2c CHLAPT HR ONE CHAPTER ONE INTRODUCTION This presentation deals With an endeavor in American life usually referred to as community organization. More Specifically, it is a study of community behavior in one class of communities, or small communities relatively limited in population and resources, in which these resources have been mobilized and organized in the achievement of a major and specific health goal. The goal is that of the hOSpital. The thesis to be presented is not concerned with the hOSpital as a health facility in either a doctrinaire or historical viewpoint. Hence, little attention will be given it as an institutional arrangement, or even to the interrelationships of community and institution. Fruitful as the study of the small hOSpital in the pattern of modern health 1 services might be, it will not be undertaken here. For the reader who desires to know the relative position of the hOSpital in the former and present fabric of institutional life, a perusal of other sources will be required, for this is a Special field of endeavor in its own right.2 1See the following for sociological research Opportunities of this kind: 0. Hall, ”SociOIOgical Research in the Field of Medicine: Progress and PrOSpects,' American Sociological Review, Vol. 16, No. S, 1951, pp. 639-6hh; O. D. Duncan, "Rural Health as a Field of Socio- 10gical Research,” Rural Sociology, Vol. 9, 19bh, pp. 3-10. 2See A. C. Bachmeyer and G. Hartman, editors, The Rogpital ip Modern Society, The Commonwealth Fund, New York, l9h3; B. P. Stern, Socieqy and Medical Progress, Princeton University Press, Princeton, l9hl. In many communities with which this study deals, the hOSpital was not yet operating, but it served as a goal and an event which reverberated throughout the community; and it is these reverberations that are of present interest. Thus, an attempt will be made to classify some aSpects of action and the potentials for action, events, organization, and process within a community setting; for this has been the broad purpose of those students who have dealt with the community and its problem-solving referent of community organization. Although this study does not focus on health or health facility one should not overlook the increased attention to the sociological aspects of health. The literature of the past ten years reveals a variety of Specific health studies. Quite definite programs of research in the sociological aspects of health have been deve10ped, for example, in Ohio, Missouri, and Michigan.3 A. R. Mangush has contributed to the sociology of mental health; C. R. Hoffer and E. A. Schuler5 to the 30f. C. E. Lively, "Objectives and Methods of Rural Sociological Research at the University of Missouri," E. A. Schuler, _e___t a1. ,"Ob- jectives and Methods of Rural Sociological Research in Health at Michigan State College"; A. R. Mangus, "Objectives and Methods of Rural Sociologi- cal Research in Mental Health at Ohio State Univer31ty ," all in Rural SociOIOgy, Vol. 1h, 19h9, pp. 199-205, pp 206-211, pp. 212- 219, resPectively. bSee, for example, A. R. Mangus and J. R. Seeley, Mental Health Ne__e__ds in _a_ Rural and Semi-Rural Area of Ohio, Mimeo. Bulletin No.195, Ohio State University, Columbus, January, Elf]; also, A. R. Mangus, "Personality Adjustment of RuraI and Urban Children, American Socio- logical Review, Vol. 13, October, l9h8, pp. 566-575.. 50.11. Hoffer,_e_t 8.1., Health Needs and Health Care in Mich1 ATS Bulletin 365, Michigan State College, EasTLansing, June, I950:in C. R. Hoffer and E. A. Schuler, "Determination of Unmet Need for Medical Care Among Michigan Farm Families, " Journal of the Michig_n State Medical Societ , Vol. 116, April, 1914?, pp. LAT-DIE. measurement of unmet medical and health needs; C . E. Lively and others6 to the extent and the use of medical and health facilities. Socio- logists have recently initiated and carried out studies that deal with the ecological aSpects of medical service areas.7 Increasing attention is being given to sociological interpretations of mortality and morbid- ity trends.8 A cursory examination of the literature and the newspapers would indicate the prominence of health on the public stage. Social scien- tists have viewed these problems in differing contexts, as for example 0. W. Anderson9 in his analysis of public events in health as a continu- ing social movement, and the treatment of medical care insurance as a Specific social movement, subsidiary to which other crucial events have occurred. T. Parsons:LO has employed medical practice as the empirical 6901- example, see c. E. Lively and P. c. Beck, The Rural Health Facilities of Ross Count ,,0hio AES Bulletin 1112, October, 1927; R. B. Almack, The-F Rura 1 He th Facilities of Lewis Count ,Missouri, AES Bulletin-3'55, U'fiiversity of Missouri, C ouml bia, 3. 7H. L. Hitt and A. L. Bertrand, The Social Aspects 9;. Hospital Planning, Louisiana Study Series No. 1, Health and HOSpital Division, Office of the Governor, Baton Rouge, August, 19117. 8H. F. Dorn, Maternal Mortality in Rural and Urban Areas, Public Health Reports, V01. 5h, April 28,1939; P. M. Houser, Mortality Differentials in Michi an, unpublished Ph. D. Dissertation, Michigan State College, 1958. 90.14. Anderson, ”Compulsory Medical Care Insurance, 1910-1950, " Lhe Annals, January, 1951; B. J. Stern, Social Factors in Medical Progess, Columbia University Press, New York, 1927. lOT. Parsons, The Social System, The Free Press, Glencoe, Illinois, 1951, (Ch. 1: ”Social Structure and Dynamic Process: The Case of Modern Medical Practice") , pp. 1128-1173. referent in theoretical formulations of social structure and process. Health developments in the public scene have encouraged studies in public Opinion and a rather full documentation could be made.11 Finally, increasing attention has been given to specialized studies of the highly institutionalized setting of medical practice.12 This presentation Will not consider the history of the community movement and the continuing concern with community organization. This vmuld be, in itself, a major task. J. F. Steiner,13 E. D. Sanderson and IL A. Polson,lh'EL C. Lindeman15 and A. Hillmanl6 are but a few of the studentS'who have Specifically traced the development of the community Imwement and the definition of community organization as a process of gaining consensus in public affairs. A frequently cited definitive llSee, for example, the following: "The Fortune Survey ," Fortune, Vol. 26, July, 19112; National Opinion Research Center, "Social Security," Public gpinion Quarterly, Vol. 19113; C. F. Reuss, Farmer Views on the Medical Situation, AES Bulletin7 V. Ciro .) 20, State College ofThshington, Pman, 1935; R. W. Roskelley, The Rural Citizen and Medical Care, AES Bulletin 1:95, State College of Washington, Pullman—19117. 12 T. Parsons, 92. c___it. ., pp. 1428-1173; 0. Hall, "The Stages of a Medical Career, " American Journal 9__f SOCiOlOg,VOl. 53,19h8, pp. 327- 336; O. Garceau, The Political Life of the American Medical Association, Harvard University Press, Cambridge, 19E;—0 .Hall, "Types of Medical Careers, " American Journal of Sociolo ,Vol. 55, 19119, pp. 2113- 253; A. Joseph, "Physician and Patient, ‘5 Applied AnthrOpolog, Vol. 1,19142, PP. 1-17. . 13J. F. Steiner, Community Organization, The Appleton-Century Co., New York, 1930 (Revised). HE. D. Sanderson and R. A. Polson, Rural Community 0r anization, John Wiley and Sons, New York, 1939. 15E. C. Lindeman, The Community: An Introduction to th__e_ Study__ of Com Immunity Leadership _a__nd Organization, Association Press, New York, 1921. 16A. Hillman, Community Organization and Plann nning, The Macmillan Co ., New York, 1950. ~..._.__, _. b“ statement from E. D. Sanderson and R. A. Polson throughout these works is: "Community organization is a technique for obtaining a consensus concerning both the values that are most important for the common welfare and the best means of obtaining them."17 The purpose of this study is to view the process of community organization with the perspective of decision-making. It is an attempt to apply frequently employed concepts of political science to the events in the mobilization of community resources toward a specific goal. Although the remainder of this chapter Will elaborate the problem, certain minimal definitions are in order here. Certain references will be made throughout to process, to community organization, and to the political process. By process is meant the ordering of events, i.e., forms of social relationships, to time as they apply to the culmination in a given end.18 Process gives consideration to the changing aspects of social phenomena. Community organization, as held here, is the stimulation of local (community) need, the mobilization of human and other resources, their Organization for action, the development of plans, policies, and procedures relative to a Specific goal, and subsequent execution. By political process is meant the decision making function: or, for present purposes, the deployment of authority and influence in social situations of goal-oriented behavior. 17%. 2E0, ppo 5.6. 18See R. Bain, "The Concept of Social Process," in Social Problems and Social Processes (E. S. Bogardus, ed.), University of Chicago Press, Chicago, 1933, pp. 103-1oh. All of this, however, is examined within the setting of "the connnunity." Although there is no intent here to repeat or necessarily to elaborate the various definitions of community, some clarification in the manner of its present use is necessary. For the purposes at hand, community is considered as a localized group related to a geo- graphically identifiable area and expressing a commonality of interest, focused in one or more patterns of services, communication, and formal and informal controls .19 To a large extent the concept Of community will be used throughout in an Operational sense, as the geOgraphical area encompassing those who have an interest in, look forward to, or receive the services Of a hOSpital. The concern here is with the service com- munity of a particular hOSpital, and unless otherwise Specified the notion of community will be used in this way. Less attention will be paid in this presentation to the total community, as defined above, than Will be given to the components and subgroupings within the community.20 I. Dimensions of the Problem The development of a research problem must recognize, if focus is to be achieved, certain Operational limits to the sc0pe that is 19Acknowledgaments are due the influence of the following for an orientation to the idea of community: R. M. MacIver, Societ : A Text- book of Societ , Farrar and Rinehart, New York, 1937, p. 255.; C. C. fififibr, “Techniques Of‘Community Study and Analysis as Applied to Modern Civilized Societies ," in R. Linton (ed.) The Science of M32 _1_n 313 World Crisis, Columbia University Press, 1916: pp. 1135-1563. ee also L. A. Cook, ”Meaning of Community," Educational Method, Vol. 18, 1939, pp. 259-262, for a cryptic definition of community; afso E. T. Killer, “The Community as a Social Group ," American Sociological Review, Vol. 6, 19111, pp. 189-202, for a summary of various definitions of community. 203cc H. Alpert, ”Operational Definitions in Sociology," American Sociological Review, Vol. 3, 1938, pp. 855-861. envisioned. These limits, or dimensions, serve to identify the pro- jected problem in its relationship to the body of knowledge which the appropriate discipline represents. The following three dimensions of the present study may enable the identification Of the scepe of the present study. Community. The first dimension is that of community. The major concern is with the conception of the community as a totality in re- lation to a given action context. The contention of the present study is that the multiplicity of social units which comprise the community have varying degrees of relevance to goal-oriented action. For instance, the town and the‘country may not always be parts of the same community system in an action program, and the factors of age, sex, and social class may make a difference in participation. Not to be overlooked is the relevance to community action of kinship, friendship, political process, and, perhaps, social power. It is in order here to question the relevance Of all segments and subgroups of the community to the community organization process; and to look for social zones within the Community which constitute vehicles by which community action is aChieved. If such social zones exist, then varying community goals may call forth different leaders, different groups, and different procedures. Extra-Community Levels. A second dimension is the influence of larger patterns of behavior on a particular community within a given action context. A present contention is that certain features of com- munity action are conditioned by patterns of behavior occurring on wider sociocultural levels. For instance, hOSpital programs have been deve10ped through centralized planning on the national level and have been administered through state and regional instrumentalities. The . impact of national health planning undoubtedly had direct implications for community behavior and action.21 One might assume that the adminis- trative efforts in this process have tended to standardize local action tdward a hOSpital, and to this extent could be defined as a form of absentee control. Due to socioeconomic variation designing hospital services for the urbanized Northeast is one matter, and planning for the Great Plains is still a different one. Agency. A third dimension of the problem is the concept of agency. {Mn notion of an extra-community agency would mean, to most peOple, shmfly'a.governnental agency. However, it is assumed that a variety of oUmr organized groups actually fall under an agency definition. lbmmples here are the host of voluntary health and welfare organizations, amiservice clubs which, while locally oriented, join in complex state aum.national organizations and serve as agents of community change.22 ltneover, the various private and service organizations, such as lumpitals, retail chain stores, and manufacturing groups, all have agency connotations. Meat workers in the community field would be interested tithe differential impact upon community action of the small independent tmsiness firm within the community as compared with the firm as a 21See 0. R. Ewing, The Nation's Health: A Ten Year PrOgram, deeral Security Agency, Washington, D. 0., 1958. 22One author states: "From the experience of our survey (on libraries), the influence of the service clubs in cities under 200,000 gmpulation would seem to be greater than has been generally reCOgnized." (o. Garceau, 1132 Public Libr 333 the Political Proce_s_s, Columbia University Press, New York, 1 9, p. 11h.) subsidiary of a larger industrial pattern. Agencies in American life would seem to be meaningfully related to the definition of needs and services for local areas; develOping the tactics and strategies by which plans of community procedure are formed; performing an important part of the decisionamaking in community procedures; devising the means by which such decisions are given approval, carried out, and enforced; and occupying the determinant positions through which resources flow from extra-community sources to intra-community uses, II. Community Study Models The literature provides abundant evidence of the interests of social scientists regarding the concept of the community. Yet, these interests do not always take the same form. The following classification is an attempt to set forth the modal types of investigatory interests in com- munity study. Ethnographic. One model, (or modal type of investigatory interest, of community study design aims to describe the major cultural aSpects of the community. Such studies have been amply qualitative, but with a minimum of interest in comparative data on a quantitative basis. Within the American scene such studies are characterized by the works of the Lynds dealing with the totality of cultural aSpects within a community; and still later, their portrayal of adjustments in this totality to the impact of changing economic and social conditions.23 Other examples of 23R. S. Lynd and H. M. Lynd, Middletown; A Study in Mtempgrfl Erica Culture, Harcourt, Brace and (50., New York, 1929; Middletown in. Transition: 5 Study 3.}; Cultural Conflicts , Harcourt, Brace and Co. , New York, 1937. 10 this method have been West's Plainville,2h the works of Redfield deal- ing with the folk culture of Yucatan, and Yang's The Chinese Village.25 Analfiical. A second model of community studies has dealt less with a descriptive assessment of the characteristics of the community, but has attempted to conduct certain analyses of these characteristics. Perhaps the prime examples of these studies are those of Warner and his colleagues dealing with the structure of the community in terms Of 26 Within this same clique, associational, and social class behavior. category, but with a specific concern with race relations, fall the works of Powdermaker, Davis and Gardner, Drake and Cayton, and Bollard.27 Summarily, these works place an analytical emphasis upon social re- - lations considered within the context of social status and caste distinction. Stability. A third model of community study design deals with many contributions of the rural sociOIOgists, namely, to view the community ‘ __.— 2hJ. West, Plainville, Columbia University Press, New York, 1915. 253. Redfield, The Folk Culture of Yucatan, University of Chicago Press, Chicago, 19141; M. Yang, The Chinese Village, Columbia University Press, New York, 1915. 26See, for example, the first in the Series: W. W. Warner and P. 3. Lunt, The Social Life p_i:__ a Modern Community, Yale University Press, New Haven, 1911.1. 27H. Powdermaker, Aft___e__r Freedom: A Cultural Study in t__1__1e Deep South, The Viking Press, New York, “1939; A. Davis and B. B. and_ M. R. Gardner, 932...... South: A Social AnthrOpological Study of Caste and Class, University of Chicago Press, Chicago, 19M; S. C. Drake and H. R. Cayton, Black Metropolis, Harcourt, Brace and Co., New York, 19115; and J. Bollard, aste and Class in a Southern Town, Yale University Press, New Haven, m..— l“.— 11 as to its measure of stability or instability. These studies have re- lated certain changing aSpects of the community--population, economics, group life, social visiting patterns-“to variations in community stability. The implied assumption behind them is that the successful execution Of farm prOgrams, for example, depends on a measure of com- munity stability. As an example of this approach, reference could be made to the Rural Life Studies of the Bureau of Agricultural Economics, United States Department of Agriculture.28 Applied. A final group of community studies deals with the rules and methods by whiCh to stimulate, mobilize, and allocate community re- sources toward some "desirable objective." Although these studies build on a wide range of factual information, it cannot be said that their recommendations follow after rigorous experimentation and investi- gation. They have been modeled lar; gely for pOpular review by community workers. One large category of this model is that of presentations dealing with community leadership.29 Other eMples include Morgan's 280. Leonard and C. P. Loomis, El Cerrito, New Mexico, NO. 1, 191113 E. H. Bell, Sublette, Kansas, NO. 2, 19112; K. hacLeish and K. Young, Landoff, New Hampshire, No. 3, 19112; W. M. Kollmorgan, The Old Amish of Lancaster County, Pennsylvania, No. 11,19112; E. O. Moe and C. C. Taylor, Irwin, Lowa, NO. 5,—19112; W. Wynne, Harmony, Georgia, No. 6, 191433 See also C. C. *Taylor, "Techniques of Community Study and Analyses Applied to Modern CivilizedSocieties ," pp. 932., pp. 1119-11211; for a critical appraisal Of these and other studies, see A. B. Hollingshead, "Community Research: Development and Present Condition ," American Sociological R_8_____View, Vol. 13, pp. 139-1110. 29For example, T. N. Whitehead, Leadership in a Free Society, Harvard University Press, Cambridge, 1936; P. Pigors, leader51_ip or Domination, Houghton Mifflin Company, New York, 19353 G. B. de Huzar, Practical Applications of Democracy, Harper and Bros. , New York, 19115; 0. Tead, T__l__1e Ar___t_ _o__f Leadership, McGraw-Hill, New York, 1935. . o.— 12 works on the small community, the develOpments in Virginia summarized by the Ogdens, and more recently the compilation of reports edited by Sanders .30 III. Needs for Further Research A review Of the broad categories or models of community studies briefly noted above suggests certain theoretical and methodolOgical needs in.p1anning additional research. Some of the needs which are Of particular relevance to the present study are presented below. Specific action contexts. Contemporary community studies have emphasized the major characteristics of the community rather than a consideration of a Specific action context, i.e., obtaining a hOSpital. This is especially true Of factual studies of community process as it applies to health. Some work has been done in the application of com- munity organization to social welfare, but with a minimum emphasis on 31 specifically and rigorously conceived studies. In those community studies that do deal with action and the potentials for action, little comparative work has been accomplished regarding community action toward a Specific and identical community action goal, but rather, if community action is involved in the study at all, a focus has frequently been —‘ __‘_ 30Jess and Jean Ogden, These Things We Tried, University of Virginia Extension, Charlottesville, 19117; , Small Communities in Action, Harper and Bros., New York, 19146; I. T. Sanders (edj, Making Goo—d 93:3- munities Better, University of Kentucky Press, Lexington, 1950; A. Hillman, Community Organization and Planning, The Macmillan Co. , New York, 19 0° see also W. J. Ha s The Small Communit Look head "arcourt Brice and’Co., New York, {gm-1r: mrfi'fif’rfiéxfififigfi‘fiufiifi, Harper and Bros., New York, 19112. 31W. McMiJlen, Community Organization for Social Welfare, University of Chicago Press, Chicago, 1911?. 13 made on a wide range of activities found in process in the community at the time Of the study. Community action may be addressed to all types of local problems, but this leads to difficulty in designing a comparative approach to studies of community action. This comment assumes that the goal, itself, may condition the quality and extent of 32 the community action process. Comparative. Due to obvious limitations the great bulk of community studies has been concerned with studies of individual communities, or at best a small number. Such discrete studies have prevented quantita- tive analyses of community processes in a wide variety Of community situations. The use of a considerable number of communities to compara- tively study community action toward an identical goal has not been developed as a method in community research.33 The present study, eSpecially in methodological form, has attempted to be mindful Of this particular need. Higher level integration. The communities that have been studied in the above mentioned categories, or models, have usually been con- sidered independent and isolated, and little attempt has been made to relate them to larger social or cultural areas, such as the region, smate, and nation. There is a need to view the community in its relation 32See the following for some comments on the validity Of this assumption: R. T. LaPiere, Collective Behavior, McGraw—Hill, New York, 1938, p. hl. 33One must be able to compare before he can classify. For this emphasis as a basic consideration for social science, see A. R. Radcliffe- Brown, The Nature of a Theoretical Natural Science of Society, University Of’ChicagO Bookstore, Chicago, l9u8; "Classification, implicit in all our thinking and talking, is an absolute essential in our science. " (p. 8) lb to the larger society; eSpecially so, when the process of community action is viewed amidst the influences of extra-community forces. Few communities are any longer confined to their own geographical limits for the stimulation, mobilization, and organization of local resources. National, state, and regional agencies provide a vast network of com- munication in which communities large and small are involved. Steward has this to say on this point: The Lynds were the first to reCOgnize that one of its (Middletown) principal shortcomings was its failure tO relate the town more explicitly and completely to the larger extra- community society. How to remedy this deficiency in such studies has not yet been resolved: the theoretical and methodological bases for placing any community in its larger setting have yet to be worked out.) IV. An Elaboration of the Problem The gpneral ppoblem. The general purpose Of this study is to focus on community action with Special reference to the political process. This more general purpose gives consideration to the notion that com- munity organization, beyond its usual definition, is a deployment of authority and influence in social situations of goal-oriented behavior. Authority and influence constitute the key analytical concepts, but both are subsumed under the process of making decisions, or the decision- making process. Acquiring an expensive hOSpital is an event Of 3hJ. H. Steward, Area Research: Theory and Practice, Social Science Research Council, Bulletin 6*, 1950. Recognition, either for purposes of sampling within larger areas or ascertaining the inter-play between individual communities and larger sociocultural areas, is given in the following: C. M. Arensberg and S. T. Kimball, Family and Communipypip Ireland, Harvard University Press, Cambridge, l9hO; recent Peruvian studies in the Andean highlands; and in regional studies in Puerto Rico (J. H. Steward, pp, 333., pp. 133-139). law?” ‘ - #4 .‘fl ‘ 15 considerable implication for the community. Given peOple and leaders, community needs and resources, the hOSpital will not concretely result until some one or some group acts; and to act is to decide. The de- cisions that result channel the efforts of the peOple, limit them to specific courses Of action, and prescribe certain community methods. The total group of community residents does not make the decisions. The peOple in general may suggest the need for action and for decision, may render approval, and may share in carrying them out, but all do not participate in the same way. James Bryce said: In all assemblies and groups and organized bodies of men, from a nation down to a committee Of a club, direction and decisions rest in the hands of a small percentage, less and less in prOportion to the larger size of the body, till in a great pOpulation it becomes an infinitesimally small prOportion Of the whole number.35 Community organization and action toward any goal, whatsoever, is a.problem of order; and, in this sense, this thesis deals with one phase of order, namely, the integrative pattern of authority and influence.36 R. M. MacIver has succinctly stated: 35J. Br e, The Modern Democracies, (on. 75, “Oligarchies Within Immocracies” ,Vol. 2, Macmillan, 1923, p. 5h2. 36For a statement regarding integrative patterns leading to order, of which one is authority, see T. Parsons, "Toward a Common Language for the.Area Of Social Science, " in Essars in Sociological Theory Pure and Applied, The Free Press, Glencoe, Illinois, l9h9, p. 50. He states: I'The power-fOrce-territory complex is important to all concrete human relationshipS". . . .But it is particularly crucial in the patterning of the large-scale social systems which approach most closely to full self-sufficiency." Not to be overlooked are the integrative imperatives of B.1Malinowski,_A Scientific Theopy_of'Culture, University of North Carolina Press, Chapel Hill, l9HH. 16 Authority exists in every Sphere for every group accord- ing to its kind. There is authority in religion, in education, in business, in science, in the arts. There is authority with- in every organization, or it could carry on no function whatever. There is authority inside the groups that fight against author- ity. There is authority among the boys who skirmish with the boys in the next street, and there is authority in an anarchist assembly; There is no order without authority. This authority is vested in.persons whether as accepted superiors or as agents of organized groups.37 The specific problem. This study prOposes to treat the process of decision-making within the context of community organization in two ways. The first is to describe the community organizational setting within which both hospitals evolve and decision-making takes place. The second way is to compare the authority and influence content of decision-making in varying community organization settings and varying community situ— ations. The first step is based on the recognition that one way to view community organization is in relation to its temporal aspects, for in one sense community organization and action is a succession or flow of events, a sequence of happenings. This we would term the horizontal plane of community organization, or the panorama of peOple, groups, policies, and methods that fit together to form the action plan for the 37R” M. MacIver, The E29 of Government, The Macmillan.Co., New York, 1997: PP- 83-8h. R. Michels is—even more pointed when he states: "By a universally applicable social law, every organ of the collectivity brought into existence through the need for the division of labor, creates for itself, as soon as it becomes consolidated, interests peculiar to itself. The existence of these Special interests involves a necessary conflict with the interests of the collectivity," R. Michele, Political Parties, Hearst's International Library, 1915, p. 389; the universality of such divisiveness of interest is countered with qualifications by some authors; as, for example, H. D. Lasswell and A. Kaplan, Power and Society, Yale University Press, New Haven, 1950, p. Ll. 17 community.38 Since such events are ordered to time, attention.must be given to broad classifications of events. For the purposes here such events will be classified into stages of community action, and one of the purposes will be to learn the characteristics of these stages of community action in local efforts toward securing small hOSpitals. Four stages of community action will be utilized to portray the community organizational setting for decision—making in order to describe some of the institutional patterns and limitations. One stage will be that of prior community situation, dealing with the early and particular circumstances of community need. Important, too, are the effects of financial resources, possible and available, the restrictions imposed on the community through legislation, and the character of the delays and Oppositions which render a time Span between the formulation of the idea , and its initiation into an action pro gram.39 38An examination of almost any case study of community action found in the literature will reveal presentations of events ordered to time. CF., for example, the various case studies found in E. D. Sanderson and RW.A. Polson,‘gp, gii,, for this descriptive ordering of events to come. Throughout the works of H. D. Lasswell is found a skepticism of stOpping analysis once events are ordered to time, although, as he says, this is a.legitimate method of political inquiry: "The empirical grounding of political abstractions may be expressed by formulating the subject matter of political science in terms of a certain class of events (including 'subjective' events), rather than timeless institutions or political patterns. we deal with power as a process in time, constituted by ex- perientially localized and observable acts. . . .This orientation in political inquiry may be designated the principle of tempprality." (H. D. Lasswell and A. Kaplan, Power and Society, Yale University Press, New Haven, 1950, p. XIV; see also H. D. Lasswell,‘World Politics and Personal Insecurity, McGraw-Hill, New York, 1935, pp. 3-107 3' 39Reference may be made to the classic concept of "definition of the situation," generally accredited to W} I. Thomas. See, for example, E. H. Volkart, Social Behavior and Personality, Social Science Research Council, New YOrk, 1951, pp. 1-32, 37-58, 80-81, and pp. 170-175; see also other interpretations, R. E. Park and E. E. Burgess, Introuuction 22 the Science 22 SociOIOgy, University of Chicago Press, Chicago, 1921, p. 763; E'. c. Lindeman, 92. 331., pp. 121-123. c:-. 18 A second stage deals with the initiation 2£_acticn. This is a matter of individual or group initiation, gaining approval for the idea, meeting the problems of initiation. Attention will be given to an understanding of both the process of initiation and the characteristics of the initiators. A third stage is the pattern pf sponsorship, dealing with the primary Sponsoring groups that assume official re5ponsibility, and the secondary groups that give approval and provide resources to a Specific community project. To understand Sponsorship is to know Something about the Sponsoring groups, the problems of Sponsorship, and related organiza- tion and practice. A fourth stage is that of community organization methods, dealing with the methods of mobilizing community resources, and the use of various communication media and the content of appeals to the community. This stage has to do with the methods employed to encourage participation and support on the part of community residents. The foregoing stages of community action become segments along the time schedule of the flow of community action, and are proposed to aid a descriptive account of the community organizational setting for obtain— ing hospitals. Although each stage is a particular state of affairs of the entire community organization plan, each is meshed with the other. The second Specific problem of the study is to study the decision- making process within varied community organizational settings or situ- ations. This process we term the vertical plane of community action, in that it deals with persons or groups having higher or lower authority, higher or lower influence, higher or lower skill. It is assumed that if . .a ‘ VI .. .. ,l A~ ~ ‘ .2 . . 19 the community organization and action process is conceptually stopped or slowed (as a flow of action through a sequence of events) certain variables will be found systematically related; and that a set of vari- ables may characterize the decision-making process. To ascertain this set of variables, and to focus on the relationships in varying situations is a specific problem of this thesis.ho To accomplish this specific purpose, five cases of community action involved with obtaining a hospital have been intensively studied. These cases were approached with a tentative conceptual model which directed the empiric methods of field investigation. The remainder of this chapter will deal with a more detailed formulation of the conceptual apparatus that has been employed in the case studies, and which will be utilized in the analysis to follow. This will be an attempt at conceptual clari- fication. ”. . . the clarification of concepts, commonly considered a province peculiar to the theorist, is a frequent result of empirical research. Research sensitive to its own needs cannot avoid this pressure for conceptual clarification. For a basic requirement of research is that the concepts, the variables, be defined with sufficient clarity to enable hoSee H. D. Lasswell and A. Kaplan, pp, cit., pp. xiv-xv, who state: Whisome cases a set of variables interact 'syEEematically'--they con- stitute a system in that they tend toward the maintenance of a particular pattern of interaction. . . .The standpoint of equilibrium analysis di- rects inquiry to the isolation of such systems and investigation of the comfijions fOr their maintenance: disturbances may lead to a reestablish- nent of equilibrium or the disruption of the system." Note, further, a statement of R. K. Merton, Social Theory and Social Structure, The Free Press, Glencoe, Illinois, 19D9, p. 9: 'I believe that our major task today is to develOp Special theories applicable to limited ranges of data-- theories, for example, of class dynamics, of conflicting group pressures, OI‘UEBfIOW of power and the exercise of interpersonal influence-~rather tman'u>seek at once, the 'integrated' conceptual structure adequate to derive all these and other theories." 20 the research to proceed, a requirement easily and unwittingly not met in the kind of discursive exposition which is often miscalled 'sociological theory.tuhl At the risk of falling to the error of post factum plausibilitth certain empirical references to the case materials available for the study will be made in order to illuminate and strive for definition. Such illustrations are neither analysis nor conclusion but empirical comments regarding particular concepts. This may assist in demonstrat— ing the way in which the research was focused; while, at the same time, the concept may be clarified with a degree of Operational perspective. This, of course, admits of an interplay between an evolving theoretical scheme and empiric exposure, which has, indeed, been the case. V. The Theoretical Model The following definitive treatment is proposed in order to satisfy three functions: (1) to enter the forthcoming analysis with a conceptual guide, i.e., the data will be manipulated according to the dictates of the scheme; (2) to strive for an economy of concepts; and (3) to tenta- tively suggest that the following concepts are theoretically inter- related to the extent that the determinant aSpects of a selected social Inpcess may be delineated and illuminated. The extent to which these fiumtions are realized, in the treatment of the data, will indicate the maliciency of the concepts as a model for continued investigation. The thalization of the model will be directed toward an isolation of the 1‘112. K. Merton, 92. 23.3., p. 109. lamid” p. 90. 21 variables associated with decision-making systems and processes, not, indeed, a depicting of the totality of realities that enter into com- munity pursuit of a hOSpital. The DecisionrMaking Process Decision. The first concept is that of decision. H. D. Lasswell,h3 with the political context assumed, states: "A decision is a policy involving Severe sanctions (deprivations). . ; .Since a decision is an effective determination of policy, it involves the total process of bringing about a Specified course of action." Again within the political context Lasswell has stated at another point: "It is convenient to re- serve the word 'decision' for choices potentially or actually sanctioned M; by coercion." R. M. MacIver uses decision and policy as follows: "Policy-making depends on the assessing of alternatives with a view to translating one of them into action."h5 In a recent statement, R. Bierstedt relates the manipulation of courses of action to the applica- tion of force, when he says, "Force, again in the sociological sense, means the reduction or limitation or closure or even total elimination of alternatives to the social action of another person or group."146 L3H. D. Lasswell and A. Kaplan, 353. 333., p. 7t. m‘H. D. Lasswell, Ag Anal sis pf Political Behavior, Oxford Uni- versity Press, New'York, 1937, pp. 37-36. —_ 145R. M. MacIver, The Egg Government, 22. .<_:_i_t_., p. 9. héR. Bierstedt, "An Analysis of Social Power," American Sociological Review, Vol. 15, 1950, p. 733. 22 For the purposes of this study a decision is the provocation of consequences which serve to reduce the alternative courses of action available to persons or groups in the community organization process. If enacted, the decision becomes a policy, which directs community action along Specific avenues of activity. The community hospital results from Specific kinds of procedures being carried out. Reducing these pro- cedures to the point that people agree to accept and move toward Specific activity is the result of decisions being made. Legitimacy and approval. The process of making decisions and their enactment into policy, within the context of community organization, must appear "rightful" to those to whom the decisions are to be promul- gated and applied. The "rightful" nature of the decision may be in some instances at once determined, i.e., becomes legitimate, because of the particular roles played and statuses held by those who make them. Legitimacy refers to the sanctioned rights of some persons to make decisions; and draws on certain capacities of "rightfulness" possessed by the maker of decisions. Legitimacy in deciSionrmaking for purposes of community organization is an institutionalized aSpect of the process, with the loci of such institutionalized patterns found in the roles played by certain individuals within the community. Max weber,'with the perSpective of historical periods, viewed legitimacy as three ideal constructions and construed them as modes of social organization in relatively permanent and stable societies.h7 mSee his analysis in H. H. Gerth and C. W. Mills, From Max Weber: Essays_ in Sociology, Oxford'University Press, Neerork, 1956;" and for a critical appraisal see T. Parsons, "Weber, Institutionalization of Author- ity,‘ in Essays in Sociological Theory Pure and Applied, pp. 118-139; also‘H. Goldhamer and E. Shils, "Types of Power and Status, " American Journal 91.: Sociolo , September, 1939, passim. .._,.‘ 23 The first type is that of rational—legal authority, based on a body of generalized rules which define and limit the jurisdictions of authori- tative functions (decisions). This capacity for legitimacy extends to those individuals who hold a Specific status, one of the rights of which is prescribed to be the making of decisions. The making of decisions is thus constituted through formal and impersonal rules. The second type is that of traditional authority, or the integration of the statuses in such a way that the rights of the incumbent are be- lieved through historical usage, and not necessarily impersonal rules, to include the legitimate exercise of authority. The holder of tradi- tional authority is not so limited by precise rules as is rational-legal authority. Thus, the essence of rational-legal authority would seem to be the logical prescription of rules by an agency, and for traditional authority the sentiments of historical usage. The third type is that of charismatic authority, or the rights attached to the individual leader through a symbolic constellation of personal attributes. Heber's constructs were formed through a sensitivity to broad and sweeping social movements and change. The process of community organiza- tion, by definition relatively unstructured, and the demands of mobiliz- ing total community consensus hardly seem to lend to the autonomy of Weber's concepts. Perhaps Parson's statement is c0gent at this point: "(Weber) tends to treat the Sphere of the organization of authority as analytically autonomous in a way which obscures this continuity of pattern throughout the social System as a whole. What'weber seems to have done 2b is illegitimately to hypostatize a certain mode of structuring of social systems as an independent entity."L8 MacIver views legitimacy in decision-making as the justification of authority.h9 Hillenbrand Speaks of it as an "ethical sanction" for authority.50 G. Ferrero Speaks of legitimacy in regard to government when he says, ". . .a government is. . . .legitimate if the power is con- fined or exercised according to principles and rules accepted without discussion by those who must obey. . . .a principle of legitimacy is never isolated. . . .it is always in harmony with the customs, the culture, 'the science, the religion, the economic interests of an age."S1 But legitimacy as a capacity of "rightful" decision.making may not be built into the statuses of position and office, or the role of an agent for the impersonal order. Instead, the process of approval seems relevant for the community organization context. Approval may be given by certain groups in the community, by certain persons, or by all the peOple (through referendum, etc.). The approval of one person or one group may be all that is necessary for some decisions, while, at other times, all the people in the community may be required. When correct approval is secured, the decision appears right and becomes legitimate to those that are involved in the application or execution of the decision. haT. Parsons, Essays ip Sociological Theogy) pp. cit., p. 136. hgb'iaclver, 313E}; p_f_ Government, pp. pip” p. 225. DQM. J. Hillenbrand, Power and Morals, Columbia University Press, New York, 19b9, pp. 1311-191 51G; Ferrero, The Principles pg Power, New'York, l9h2, p. 135. 25 Case study comment. In one hospital case intensively studied two members of the local hospital board, interested in the success of hospital fund-raising in a nearby community, decided that the employment of a professional fund-raiser was the necessary course of action to solve the particular local problem. The two members contacted the professional fund-raiser, invited him to look over the community and to estimate financial re- sources-—all this without any communication with other members of the hOSpital board or other persons in the community. The professional fund-raiser finally appeared before a meeting of the hospital board which officially approved his employment. Thus, the two members made a decision, the hospital board gave its approval, and the decision became a legitimate one. Com- munity informants agreed: "The hospital board knows best about the hOSpital situation, and it was their reSponsibility to do something about it." Execution. The reduction of alternative courses of action to persons or groups brings into the decision—making process those to whom the decisions apply. Lasswell and Kaplan state: "Since a decision is an effective determination of policy, it involves the total process of bringing about a Specified course of action. In.decision-making only those participate whose acts do in fact matter. we do not Speak of a vote being cast--save as an operation--if the ballot is not counted. And since the decision-making process includes application as well as formulation and promulgation of policy, those whose acts are affected also participate in decision-making: by conformity to or disregard of the policy they help determine whether it is or is not in fact a de- cision. Laws are not made by legislatures alone, but by the law-abiding as well: a statute ceases to embody a law. . . .in the degree that it is widely disregarded."52 52H. D. Lasswell and A. Kaplan, pp, 223,, pp. 7h-75. ..\~ .7 - . we 1 vow .. ,. -.-.-_ .. ‘ .c _ . .. .. 26 Conformity to the decision brings implementation and this means, within the context of community organization, the allocation or manipu- lation of social and economic community resources. Disregard of decisions made produces unintended consequences from the vantage point, at least, of the decision-maker. The unexpected reSponse of those for whom the decisions apply may add a dysfunctional element to the decisionemaking process. This may be in the many forms, for instance the production of unintended sentiments and the formation of passive and active resistances; or there may occur unexpected align- ments of decision-makers which prevent or deter the enactment of de- cision into policy. Contrariwise, an unintended consequence of particular decisions made may hasten the policy enactment.53 An intended consequence of decisionemaking in community organization iS to gain the consensus of subgroups within the community, and, for some purposes, the total community. The alteration of this consequence by those to whom decisions apply is an.important matter, from the vantage point of the decision-maker, in decisions being executed. 53R. K. Merton, pp. 933., p. 67: "In Short, it is suggested that the distinctivp intellectual contributions of the sociologist are found primarily in the study of unintended consequences (among which are latent functions) of a given practice, as well as in the study of anticipated consequences (among which are manifest functions)." For such studies see A. K. Davis, "Bureaucratic Patterns in Navy Officer Corps." Social Forces, Vol. 27, l9h8, pp. lh3-153; F. J. Roethlisberger and W. J._Dickson, Management and the Worker, Harvard University Press, Cambridge, 1939; P. Selznick, TVA and the Grass Roots, University of California Press, Berkeley, 1939? and basic is the classic concept of "conspicuous consumption" by T. Veblen, The Theory pg the Leisure Class, Vanguard Press, New York, 1928. ..c t 27 Case study comment. In the hOSpital project mentioned in the illustration above, the professional fund-raiser was employed after hospital board approval. To carry out the implications of this decision brought the necessity of contacting and dis- cussing the plan of the professional fund-raiser with a multitude of persons and community groups. To carry out the decision meant that a complex organization had to be deve10ped in the community to accomplish the fund raising task. This activity led to many organized parts of the community, in town and country, but was not concerned with acceptance or re- jection of the professional fund raising plan, but with the need to get many others to agree to help make the plan a success. Capacities for DecisionéMaking A. Authority Beyond the decisions is the identity of those who make them. These may be termed the decision-makers, or the actor in the decision-making process.514 To identify the decisionemaker is to isolate the possessor of certain capacities of ”rightfulness." For the present problem two major sources or capacities of "rightful" decision-making are authority and influence. Decisions may be made through the capacity of authority, through the capacity of influence, and, of course, through combinations of both. Authority consists of the rights and privileges given certain roles and positions within the formal associational life of the community. For example, in every formally constituted group there are offices which suThe notion of actor could be likened to the "actor" of T. Parsons' theory of action systems, pp, p23,, pp. 3-23; ". . .a social system con— Sists in a plurality of individual actors interacting with each other in a situation which has at least a physical or environmental aSpect, actors who are motivated in terms of a tendency to the IOptimization of gratifi- cation' and whose relation to their situations, including each other, is defined and mediated in terms of a System of culturally structured and shared symbols.” (pp. 5-6) 28 give the incumbents Special privilege in the making of decisions. As MacIver points out, "By authority we mean the established EEEEE: within any social order, to determine policies, to pronounce judgments on relevant issues, and to settle controversies, or, more broadly, to act as leader or guide to other men. 'When we broadly Speak of pp authority we mean a person or body of persons possessed of this right. The accent is primarily on right, not power. Power alone has no legitimacy, no mandate, no office. Even the most ruthless tyrant gets nowhere unless he can clothe himself with authority."55 Lasswell and Kaplan make this comment: "Authority. . .is subjective: its existence depends on some- one's think-so, though not, to be sure, simply on the think-so of the person having the authority. This subjectivity results from the Symbolic status characteristic of the formal as such, and may be ascribed to other formal concepts, for example, law, as well as authority0n56 Office. Authority derives from the constellation of positions possessed by the decisionemaker. Position is not only the offices of formally constituted groups, but is also based on other positional eflements. But the concept of office is crucial. The cogent analysis by Hiller is illustrative . Within all associations there is some type of ordination. . . between offices and between these and the general membership. This ordination depends on the authority vested in the offices by the association itself. Authority is the sanction, that is, the intention, of the group with reference to aims and interests to which it is committed. The relative likelihood that one person (even the office-holder) can assert his own will over 55R. M. MacIver, Thpljpp _o_f_ Governmept, pp. p_i_p., p. 83. 56H. D. Lasswell and A. Kaplan, pp, 322,, p. 133. 29 another person is domination which rests on.power or force. It is thus the Opposite of authority which is the adherence to collective aims. . . .Authority rests implicitly on the allegiance all owe to the association, and is enforced by social constraint or even coercion. . . .Authority rests on the awareness that the office-holder who issues an order and the one to whom the order is given are alike serving the association. . . .The function of an office is to organize selected efforts of the members of the association, not to control or manage all phases of their lives. 5 In this sense office is considered an adjunct of the formally con- Stituted group, and, within the context of community organization, is localized in the formal associational life of the community. Lasswell and Kaplan summarize the concept of office when they say, "An agency is an authority structure; and pfgipp a position of authority."58 Other positional elements. Other elements contribute to the total position.of the decisionemaker. 'Whether he is an old or new resident of the community may determine the rights and privileges on the basis of £32331 position. Being a member of a high prestige kinship group in the community is related to the former, but may be conceptually considered as a positional element; and finally, his socioeconomic pppppp may con- tribute Similarly359 In this sense the total position pattern consists of a body of rights to participate in the decision-making process. 57E. T. Hiller, Social Relations and Structures, Harper and Bros. New'York, 19b7, pp. 582-583. For a statement of difference between social power, authority, and dominance, see R. Bierstedt, pp_. cit. ., pp. 732-733; i.e., "Power is a sociological, dominance a psychOIOgical con- cept. . . .The locus of power is in groups and it expresses itself in interdpersonal relations. Power appears in the statuses which people occupy in formal organizationg dominance in the roles they play in in- formal organization." (p. 732 . 58H. D. Lasswell and A. Kaplan, pp. pip., p. 198. 59W. W. Warner and P. Lunt, pp. 933., passim. '0. . no. 30 Case study comment. Note the following sample statements made about the office of probate judge in one of the hOSpital cases intensively studied. "You would expect him to be active (in the hOSpital project), being chairman of the Court of County Commissioners." "After all, all county affairs have to end up sometime with the probate judge, because he's the one on tOp." One author has stated in a study dealing with political organization in a southern county: "The significance of the phrase, probate judge county, as applied to Black Belt should by now be reasonably clear. The term derives meaning in part from the statutory duties of the judge, who from the very nature of his office knows intimately the county and its peOple, It takes added substance from the established pattern of politi- cal and governmental leadership, which is facilitated by the law but goes far beyond it."60 B. Influence Influence is the possession of attributes by the decision-maker tibich are valued as relevant by the community—at-large. For purposes of “‘7 ‘ . v" 53 HOSpital Survey and.Construction Act.h The Hill-Burton projects were selected after an intensive perusal of the files of the Hospital Facilities Division, U. 8. Public Health Service, in washington, D. C. As of November 1919,5 when the selection was finally made, there was estimated to be 37b hOSpital projects that were being deve10ped under provision of federal legislation, all of which were located in town sites of less than 7,500 pOpulation. Although a majority of the universe of hOSpital cases fulfilling Hill-Burton legislation in November l9b9 and meeting the population criterion reported, these hOSpital projects are not intended to represent a sample of small communities that have con- structed hospitals in the past ten years, or of communities in the United States that have town centers of less than 7,500 pOpulation. Questionnaire Deve10pment Procedure. The first step in develOping questionnaires to be completed by representatives of the projects in the three inventories ¥ES that of informal consultation. This was performed primarily with 14Due to the advent of this legislation Specifically allocating federal funds to assist with the construction costs of local hospitals meeting certain required standards, the number of such projects would Weigh heavily in any inventory of recent small town hOSpital develOpments. This was so much the case that it seemed best to limit this particular treatment to Hill-Burton hOSpitals entirely, providing an additional basis of comparability. For the details of the legislative program to provide partial assistance (originally one-third of the total cost) to local kmspital projects, see Congress of the United States, "HOSpital Survey and Construction Act, Public Law 725, " United States Statutes At Large, Vol. 60, Part I, pp. thO-L9, U. S. Gov't. Printing Office, washington. SCf. Federal Security Agency, National HOSpital Program, Status Re ort, NOV'. 29, 19b9, Hospital Facilities Division, U. 8. Public Health Service :Washingtonfl . . , l9b9. nu .. ‘ . , - 0-1 Q‘ .v .._._ ..._ ;- 1-. .h ~ ‘ .r.‘ . . , K, ‘ . .h . “- __, v, a. . ~ ’ ‘~ a. -i ‘. ‘0 ‘ .., . . _‘ ~. Sh members of an interdisciplinary committee in the Department of Soci010gy and AnthrOpology, secondarily with various other sociologists and health educators. The 33 originally reporting community organization specialists also provided recommendations as to important questions to solve in com- munity organization studies. Such consultation, added to the interests of the interdisciplinary committee, yielded a list of questions about relevant community action procedures for develOping hospitals. Over a period of several months these questions were repeatedly formulated into the first draft of a questionnaire. During this formulative period visits were made to selected Michigan hospital develOpments in order to conduct informal interviews With local leaders of this project.6 The purpo se Imre was to view first hand the general implications of community action toward a hOSpital and to gain a necessary orientation. The questionnaire in first draft form was pretested by personal administration in three Michigan hOSpital project communities.7 A second draft formulation was mailed for pretesting purposes to seven widely distributed hOSpital projects, and the six that responded provided the basis for a third draft 8 and publication of the questionnaire in booklet form. éGreenville, Rogers City, and Newberry, all in Michigan and approxi- mating the type of community handled in this study, were visited for exploratory and orientation purposes relative to questionnaire development. 7Hegers City, Ionia, and Hastings, all in Michigan and approximating the type of community handled in this study, were utilized as sites for questionnaire pretesting. 8See Appendix (B). SS .mmmmo sampmeo so GOOpwshowcH OHOHOOHMHOOOHO mo xoma cu esp 4mm 80mm OLO> OHOHCO>CO Hwaflmfipo pom mocmpmafl zomm CH mampoe* OOH OHN OOH OOO Hmpoa OOH OHN OOH NOO Hepoe m.o m :3 magma oz N.O a O.m OH peso Oee OO O.O m .. HHOOO oz O.H O N.H O OOnoO O.O N 0.0 N OOOHuooeH 0.0 OH N.O OH mauoa 0.0 OH 0.0 OH OOOH-OOOH H.H O m.m O OO OO O.NH am O.OH OO OOHHuooOH O.H OH m.O OH mm Om m.mm mm O.mm HO OOO-OOO 0.0 Hm O.O HO Oguoe 0.0m mm O.ON ma OmauooO H.OH mm O.O NO OOnoO m.mm OO O.NO OHH OO0-00H 0.0 HO 0.0 NO ON-ON 0.0 Hm 0.0 OO OO0-00N N.Hm OHH 0.0m NHN OH-O -- -- O. H OOH-O puoopem .oa pemopem .Oa pcmopem .0: ammommm .oe mpomwopm myop20>eH pea Umez mpomfidpm MHOHSO>QH AmpmHHovv mEooCH mafiocogmmn HOSHOHLO pcmommm OGHOSOQOOA Hmeflmflno wpfidmo Lem Ampmb Hmpflmmog pcoomem¢ mend moa>mem CH pmz Oomz mo pcmopom AmmmHHopv «mad mofl>wmm mo eEOOcH Opflomo mom .Q OoH OHN OOH OOO .Hmpoe OOH OHN OOH OOO HOOOO OOH OHN OOH OOO Hmpoe m.o m In IIOHQOH oz 0.00 ON 0.00 OOH pm>o c- n: u- .. Om>o Oem OO OOO OOH N.ON O: 0.0H Ha OO-OO O. O m .. OHOOO oz m.O H O. H OOH-OOH m.mm O: O.Nm NO O0-00 O. OH OO 0.0H O: OO OO>O .. .. O. H OOH-ONH O.a NH O.a am O0-00 O. N O O.m a OO-OO O.N m O.N OH OHH-OOH 0.0 OH 0.0 Om Omuom N. O a 0.0 OH OO-OH O.H O O.H O mmuoO 0.0 OH 0.0 OH Oeuoq O. OH OO H.OH OH O0-00 0.0 OH 0.0 Om Oenoo O.H O H.H m OOIOO O. mm mm O.HO Os ON:ON N.m mm 0.0N OO mmnoe 0.0 N O. N ON-ON O. OO OO O.NO OHH OHIOH 0.0 HOH H.OH OOH OO-ON .. -- O. H OHno O. OH ON a.OH Om mouoo O.H Om H.OH OO OH-O PCmochwnH. OZ fiCmopmm pgwohmm . 0.4 Pflmohwm . OZ Pmeochnm . OZ Pfimohmna . 07H limpommopm Myopco>sH Ownsm mpommonm OHOHEO>QH cowpmadmom mpoemonm myopcmbcH .w:< mpom .02 msflpcommmm HOCHwOLO paeommm wsfiecommem Hmsfimapo mcHOCOQmed It; memm Hmpfimmom Oeccwam mo peoadz .4 iii mwp< mOObnOm :O OOHOOHOOOO no OOHHOHOO Ampcmwsogpqlmmn< OOH>pem Hmpflamom mo SOHHdeQom .n awmeeae>2H HOZHOHOO 2H meOmOomm H<9Hmmoz gem mess meoahozm HOOHmmom OZHozommnx OHN ro Ozomeameoo OHmmm H afldh A. ' a 0. .' h" a .o l '7 .9- ' . .. " , ‘a‘ 0.. f . o DI' .4UQ- . _.,~. u~ , a: - . ... ,. >3. ..-... 56 Questionnaire administration. HOSpital questionnaires were forwarded with personal covering letters to official Sponsoring agents of the projects. The names of such agents were secured during the period of in- ventory development. Sponsoring agents were found to be principally of two types. For the county hOSpital category, the presiding official of local governing bodies was listed as the official agent, and the question- naire was directed in each instance to him. The second type was that of the chairman or president of an apprOpriate hOSpital board, representing non-profit hOSpitals with a differing administrative base than that of county. It was assumed throughout that it was possible that the official agent might not be in the best position through knowledge to report on a particular local project. Although later field study checks indicated that official agents were generally active in the develOpment, covering letters included the suggestion for passing the questionnaire, if necessary, to another more fully aware of the details. Three separate mailings of the questionnaire were made. The first and second mailings included a questionnaire and a covering personal letter. The third mailing was a final personal note designed to serve as a reminder.9 ReSponse to Questionnaire ReSEOnse. Questionnaire reports were returned for 218 projects, or almost a 60 per cent reSponse. Of this number, 187 cases Were new general kmspitals, and 31 were additions to general hospitals currently Operating. 9See Appendix (A) for reproductions of initial and supplementary covering letters. 5? Characteristics. Recognizing that the hOSpital questionnaire re- turns may not be a representative sample of the universe to which the questionnaires were mailed, a statement of characteristics may permit a judgment on the descriptive qualities of the quantitative data available for this study. Reference to Table 2 will indicate that the responding hospital cases were more heavily concentrated in the Southeast and Middle States regions, due principally to the relatively greater number of projects developed originally. The Northeast and Middle States had the greatest proportion.reporting. TABLE 2 REGIONAL LOCATION OF HOSPITAL PROJECTS IN ORIGINAL AND RESPONDD.‘ G INVEJTORIES Original Reporting Per Cent Inventory Projects Reporting Region No . Per Cent* ‘ No. Per Cent Per Cent Southeast 12 3 33 52 2h 12 Southwest SO 13 25 12 50 Northeast 31 8 2h 11 77 Middle States 76 20 S8 26 76 Northwest 6h 18 hO 18 63 Far West 30 8 18 8 60 Unknown 1 1 Total 371; 100 218 100 S8 * Percentage figures will be henceforth rounded off to whole numbers. .o. . ,. . c M '- .. ‘- .. H. .. 4 m. . - n- - . Ow. . 4. 58 The responding projects represented in the inventory indicate that the reSponding projects demonstrate a marked tendency to be predominantly rural. Seventy-five per cent of the reporting hOSpital projects fell in hOSpital service areas that had more than 90 per cent of the pOpulation as rural. The economic base of the reporting hospital projects has been computed in terms of the per capita income in the reSpective hospital service area.10 Approximately 30 per cent of the hospital projects ex- hibited a per capita income of less than $600; almost 50 per cent, $600-$999 . Total pOpulation characteristics of respective hOSpital service areas show that almost US per cent possess total populations of not more than 19,000, and another US per cent, 20,000-39,000. The degree of need for a hospital was computed for the reporting hospital projects. The index of need was the ratio of total needed heapital beds to beds already available. Fifty-four per cent of the reporting hOSpital projects EXP hibited less than 19 per cent of need already met; 20 per cent ranged {from 20 to 39 per cent met need; and 26 per cent more than hO per cent of rmed met. For the 218 hOSpital projects, hS per cent were oriented to the ‘County as the area of potential use; 19 per cent to more than one county, i.e., combinations of two or more counties. Almost 20 per cent had areas of use that included several villages and their surrounding trade areas; amill.per cent of the cases reported that a Single village, town, or 1oSalesManagpment, "Survey Of Buying Power," May 102 19h7’ cepy- right, Sales Management, Inc. 59 city and its surrounding trade area was concerned. Reference to Table 1 will indicate the general uniformity of the 218 reporting projects com- pared with the original inventory of 37h projects. Selecting Individual Cases fer Field Study Selection criteria. The general purpose of the project, of which this study is a part, was to make an assessment of the community organiza- tional aSpectS of providing major health facilities for small town and rural communities throughout the United States. The inventories of projects deve10ped, and discussed heretofore, were an attempt at national inventories, within certain Specifically and arbitrarily defined limita- tions. The earlier discussion of the problem for the study (Chapter One) listed among the needs in community studies that of viewing local com- munity behavior in relation to extra-community levels, i.e., the nation, region, and state. Early reviews of the literature, and exploratory analyses of returned questionnaires, indicated that the phenomenon of health differs in various parts of the United States. In addition, particular combinations of such factors as economic resources, industriali- zation, communication, transportation, pOpulation density-~all delimit certain broad geographical areas in the United States. That these areas may be also distinguished socially and culturally is reported by many authors. Note the comments of two rural sociologists: . . .social differentials are much greater in some parts of the country than in others. Broadly Speaking, the differences are least in the Eastern, Middle Western, and high Plains areas, where practically all the population elements are from northern and central EurOpe, where either farm tenancy rates v. u' . ‘0 - I d ,r \or \ -.. '- ’-v are low or the status of tenants approximates that of resident land-owning families, and where there are relatively few hired farm workers, most of whom are recruited from neighboring farms. lhe differences are greatest in the Sduthern, South- western, and Far western areas, where the pOpulation elements are composed of widely differing cultural and racial groups, where farm tenancy rates are high and the status of tenants is low, or where numerous people who have practically no property and are unattached are used as seasonal farm wage workers. Wide regional differences are obvious where family incomes and other material criteria commonly associated with social status are regarded from the over-all national point of view‘.11 Loomis and Beegle refer, at one point, to the concept of region as follows: . these regions in most cases, however, are potential social systems. The attitude of the average southern white and Negro farmer toward race, religion, and politics has been found to differ significantly from attitudes of other sections of the country. . . . A crisis situation can, and sometimes does, lead to concerted action on the part of the regions. Threatened ruin or starvation resulting from poor creps or low prices has served to mobilize farmers of many areas in farmers' movements and uprisings. Reflections of such condi- tions are likely to be found in the voting behavior of farmers' representatives in.CongreSs. Because of similar interests, value orientations, work patterns, and social structures in areas having similar farming practices, agricultural regions are potential social systems. We may say, therefore, that the dairy, cotton, corn, wheat, range, subsistence, or livestock farmers constitute potential social systems.12 Beyond statements of basic physical, geOgraphical, and sociocultural differences, the field of health itself must be given consideration. For instance, the industrialized Northeast and its density of population pro- vokes differences in health planning when compared with the Sparsely 110. C. Taylor, st 31., from A. F. Raper, "Rural Social Differentials" (Ch. 18), Rural Life 33 the United States, Alfred H. Knopf, New York, 19h9, p. 309. 120. P. Loomis and J. A. Beegle, Rural Social Systems, Prentice-Hall, Inc., New York, 1950, pp. 2&9—250. 61 settled stretches of the Great Plains. The OOOperative devices in the Southwest for the prepayment of medical care costs and the "hospital district" legislation of the Far West are other examples of Specific instrumentalities under way in limited areas Of the country. .Another full documentation could be made of the diSparities in health facilities in certain geographical areas. That certain health agencies reOOgnize the region as an administrative unit is demonstrated by the maintenance of "Public Health Service Regional Staffs."l3 The U. S. Public Health Service has reported that organizational changes are in the direction of decentralizing administration to "22 major field stations."1h Regional health planning arrangements have been growing in number and in Operation. Mott and Roemer state in regard to such planning: Regional planning is uniting the interests of groups of states and stimulating further state action. The northern Great Plains Council has set up a multistate rural health committee and furnished'a planning coordinator. The state agricultural colleges have cOOperated with the federal Department of Agri- culture in Sponsoring rural health committees. Productive regional conferences dealing with the many facets of rural health and medical care have been held in Dallas, in San . Francisco, in.Ltlanta, in.Lincoln, and ianashington, D. C. A broad-scale Southern Rural Health Conference was held in Chattanooga. Farm and labor leaders from several nearby states joined in workshOp conferences on health services in St. Paul, Minnesota and at Jamestown, North Dakota, linking their efforts in reOOgnition of their common aims. The momen- tum of local state, and regional rural action has increased day by day.1§ 13Federal Security.Agency, Annual Rgport 2£ the Federal Security Aggncy, l9h9, U. S. Gov't. Printing Office, washington, D. C., 1930, p. 2 3. 1h Ibid., p. 266. 15F. D. Mott and.M. I. Roemer, Rural Health and Medical Care, McGraw-Hill, New York, 19148, pp. $511-$553 see also the following reports ,' ‘ - Ia . .. ' v. 4 ._ .. . f , ... o’ . o "' . ”'O. a.- ,... ~* .. - . .. .....- . ..- - O --« . -.- ,~ ..1 “‘—~v. >~ ..,, \ ~ I- o.” o y" . .‘ ‘I O. u h . .. 1 I ‘ . a n f 62 The limitations of resources for the field studies made it im- possible to conduct more than six intensive investigations in the field. In keeping with extending the data on hOSpital projects as the core of information desired, each case was arbitrarily selected for intensive study from the 218 reporting hospital projects. A plan was also needed to select cases that represented widely varying physical, economic, and social situations. At the same time, the design of the study encouraged the selection of individual cases that could be, if crudely, meaningfulLy related to broader and extra-community levels of social and cultural integration. It was in this sense that the concept of region became a criterion of location for the studies. Several~students of regionalism have presented various constructions of regions of the United States. Raper and Taylor16 have deve10ped seven types of farming areas, i.e., Wheat areas, the Corn.Be1t, Dairy areas, General and Self-Sufficing areas, Range-Livestock areas,‘Western Speciality-CrOp areas. Beck and Forster17 have reported on six:types of (Cont'd) on regional health developments: Northern Great Plains Council, Subcommittee on Health, Med.ical Care and Health Services for Farm Families of the Northern Great Plains, Lincoln, 19ES; L. B. Tate (ed._), "The South's Health: A.Picture with Promise, " Hearings before Special Sub- committee on Cotton of the Committee on Agriculture, House of Representa- tives, 80th Cong., lst Sess. WStudy of Agricultural and Economic Problems of the Cotton Belt, Gov't Printing Office, l9h7, pp .—EO8-870; a variety of regional references are made in University of Michigan, School of Public Health, Public Health Economics. A.Monthly Compilation of Events and Opinions, especially the issues of 1935, l9uO, and 19h7; see —also Regional Plannin and Develgpment, University of North Carolina., Chapel Hill, Janum ,19 951. 16C. C. Taylor, et a1. . cit. ,A. F. Raper and C. C. Taylor, "Rural Culture" (chaps. 19-27o,.pp"'"329-h91. 17P. G; Beck and M. C. FOrster, Six Rural Problem Areas, Research Monograph I, Federal Emergency Relief Administration, Washington, 1935. .1 I - ... .. ~ . a I. . ... (at ’12.», . fl , . ’ H a . 'l 1 u- . _., V 1 , .. - ..- I ‘I-1 . '2 . .. .. .... . ... .L .,. 7 . . .‘-v’ u. ' ..~ .,‘ . ~ -« . ., . . 5 r._ F- .- .. s u. . . ‘4.- 0 V . ~ 1 ~ ‘- .. v u ‘l . 1‘,” ~< problem areas, i.e., winter wheat area, Spring wheat area, Eastern Cotton Belt, Texas and Oklahoma Cotton area, Appalachian-Ozark area, and the Cut- Over area of the Lake States. Odum,18 and later Odum and.Moore, employed states as units and combined them into six regions noted as "societal regions." These are termed the Northeast, Southeast, Middle States, Southwest, Northwest, and Far west." Mangus,l9 differing from Odum and Moore, has employed the county as a unit and applied seven variables to derive 3h "rural cultural regions."20 Investigation of various approaches to regionalismzl led to the acceptance and use of Odum's six regions, the Northeast, the Southeast, the Middle States, the Southwest, the Northwest, and the Far west. General reasons for this selection were as follows: 1. A sixfold classification of the 218 hOSpital cases permitted sufficient, but barely so, numbers in each regional category for purposes of analysis. 2. Since all of the hospital projects were easily identified by states, the state combination plan of Odum and.Moore removed 18H.'W'. Odum, Southern Regions of the United States, University of North Carolina Press, Chapel Hill, 1936; also, H. W. Odum and H. E. Iioore, American Regionalism, Henry Holt and Co., New York, 1938. 19A. R. jMangus, Rural Regions of the United States, Work Projects Administration, 'Washington, 19bO; see also for the develOpment of sub- areas in Ohio, C. E. Lively and R. B. Almack, A.Method of Determiring Rural Social SUh-Areas with Application to Ohio, Ohio AES himeograph ENHIEtianO. 100, January, 1938. 2»0For some critical comments on the concept of region as employed by sociologists, see 0. D. Duncan and E. F. Sharp, "Rural Sociological Research in the'Wheat Belt," Rural Sociology, Vol. 15, No. b, pp. 339-h0 and p. 351. 21For a review of some forty definitions of region and regionalism, see H. W. Odmm and H. E. Moore, 223.313-3 pp. 3-3h. 6b the concern with subregional classification. 3. The six regional groupings of states deve10ped by Odum and Moore have been studied from the vantage point of a variety of factors contributing to homogeneity. Since this is a study of process, no good reason was found to consider only types of farming areas. h. It should be pointed out that no great case is to be made for a precise regional anaLysis. Rather are regions desired to serve as broad rubrics in order to make an arbitrary selection of individual cases located in different areas of the United States. Note the following quotation by Odum in Southern Regions gf the United States: . . . the perfect region would have the natural area coincide with the cultural and administrative. Since this is never possible we must approximate the combination as best we can, allowing Within the major regions ample opportunity for de- limiting and using major sub-regions of geographic areas and of socio-economic which cut across state lines. On this basis the six major regions of the United States have been character- ized as the Northeast and the Southeast, the Northwest and the Southwest, the Middle States and the Far‘west.22 In these threefold criteria of physiography, population, and cultural history are thus seen abundant evidences for pointing up the homogeneities of the several regions. They must, of course, be liberally supplemented with socio-economic measures, but this should in no way minimize their importance.2 The above references shape the present purpose of assuming regional location as a primary criterion in the selection of cases for intensive field study. 22H“ W; Odum and H. E. Moore; 22, 233., PP- h35-h36. 23Ibid., p. huh. ()\ U1 Other selection criteria. The hOSpital cases to be selected for intensive field study were desired to crudely represent the character- istics of hOSpital projects within a particular region. Thus, the cases to be selected would get compare necessarily with all the small town situations of the region, but compare, at certain points, with the hOSpital projects of the region that otherwise met the criteria for this‘ study, i.e., Hill-Burton general hospitals and towns with less than 7,500 population. The intent was one of attempting to investigate cases in the field that roughly approximated the character of the develOpment in a particular region . The questionnaire data provided by the reSponding 218 cases indi- cated certain regional regularities as to (1) method of raising funds, (2) size of hospital goal Operationally measured by number of planned beds in the prOposed hOSpital, (3) the total population in the hOSpital service area, (h) prOportion of rural population in the service area, and (5) the percent of hOSpital need met. These four factors, size of goal, population, rurality, and need were termed the "community situation." The rule was used that high and low qualities of each factor would be 8 represented by dividing the cases in each distribution in two groups of approximately equal number, one group characterized by lower qualities, the other by higher qualities.2h The four factors of community situation 21‘Small size of goal, 127 projects each with less than 39 beds; large goal, 91 projects each with from 110-159 beds. Small pOpulation in the service area, 95 projects with less than 19,000; large population, 123 projects with 20,000 to more than 60,000 population; low rurality, 100 projects that had less than 79 per cent of the population as rural; high rurality, 118 projects with more than 80 per cent of the service area. population as rural; high hOSpital need, 118 projects with less than 19 per cent of total need met; low need, 100 projects with 20 to more than 90 per cent of total need met. Fig. (I) Reporting Hospital Projects by Region Southeast Virginia North Carolina South Carolina Georgia Florida Kentucky Tennessee Alabama Mississippi Arkansas Louisiana Middle States. Ohio Indiana Illinois Michigan Wisconsin Minnesota Iowa Missouri Southwest Oklahoma Texas New'Mexico Arizona Norohwest North Dakota South Dakota Nebraska Kansas Montana Idaho wyoming Colorado Utah Maine New Hampshire Vermont Massachusetts Rhode Island Connecticut New York New Jersey Delaware Pennsylvania Maryland West Virginia W Nevada Washington Oregon California 8.3mm 13 300?an Hwfimmom mafipnommm SUV .wE .32 :30 no nut—m log->2 9.31:0 :00 d logbgz .q. .( H o .02 xuicwfo .o no :35 3.33.13 81 09 o: ‘ 1 llllllll it'lfilttolkll IIIIII IIIIIIIIIIIIIIII I: 8n an ac. on o 6 . 1 I 311: .o 31.3 6 , IIIIIIIWIII 32.5 91:23 8 a ., .. . I} ;. a l/II 1 ..... I I II Ll-.1.1.. I .I 1 _ I. . ........ 1 l 1 .1 1 . i . .1 I: 5;) onozso om 1 I- 1 I», p _ . _ .— ......... 1 I, 1 x. . /. on 1 /. 1 1 / _ 1 1 x _ . _ ........... | ..... 1 1 ....... 1 1 ......... .I 1 I I I . ,. J. 111 1 1 . I... J .‘I.I.I.I .l ....... . s . Am £382 . 1!! 1 on 1 I... II, 7-. .1 1 1.). . 1 .1 an . .I. 1W. . ‘ , ‘ . _ .. I :I. ..|. / I.nuIrfii 1 ..I..l.. I..I m ..... I I... .. 6? yielded 16 combinations, or community situation types. One hundred fifty-four (15L) of the 218 cases were found in eight of the possible 16 community types so constructed, the remaining 6h cases distributed throughout the remaining eight situations. Employing the eight types of community situations in which the 15h cases fell, and discarding the remainder, relationships were found between the cases for a particular region and certain community types. Likewise, Specific fund raising methods were associated with certain regions. The selection of possible cases for intensive field study was limited to the predominant pattern of hospital community situation for the reSpective region and the associated method of raising funds. After such technical Operations, a limited number of cases remained in each region for se- lection. By the above process a total of 2b cases in the Northeast was reduced to eight for possible field study selection; 58 cases in the Middle States were reduced to seven; 52 cases in the Southeast were re- duced to seven; 18 cases in the Far west were reduced to three; and hO cases in the Northwest were reduced to three. The reduced categories of'cases from which a single case was to be selected represented tie :predominant community situation pattern and the principal method of fund :raising in the reSpective region. Two final criteria of selection were applied to the reduced cate- gories of cases: (1) that the municipality in which the hOSpital was to ‘bee located would be a county seat town, and by this an attempt to uni- .foxnnly'relate centers of political activity to each selected case, and (22) 'these same municipalities would be free of major institutions, such so as large colleges or universities, state hOSpitals, penal institutions, etc. As an example of selecting an individual case within a particular region, the Northeast procedure may be illustrative. Nineteen Hill- Burton hospital projects, meeting the general criteria for the entire study, had returned Questionnaires from the Northeast region. Eleven of the 19 cases fell in a community situation (III) consisting of a relatively low need for a heapital, low rurality, high population in the service area, and a large goal measured by number of beds for the Imspital. Of the 11 cases, eight had.emp10yed professional fund raisers to assist a voluntary public subscription of finances. Three of the eight were hospital projects centered in county seat towns. A case was finally selected in western New York state after the application of such judgment factors as distance and accessibility. Definite planning of field Operations was withheld until local Sponsoring agents were in- formed of the impending study and their approval and cooperation assured. (See'Table 3 and Figure II.) Selection 2; field Study cases. Five Hill-Burton hospital projects 'were selected, one for each of five regions. The Southwest was finally eldmdnated due to the 000perative hOSpital develOpment unique to this aireaw The c00perative hOSpital program has been Specifically studied by others}5 and it seemed doubtful as to the practicability of a single 25Notably among such studies of the cooperative hOSpital and fre- Chieritly attached.prepayment plan for medical care are: H. L. Johnston, {2. 213., J. Warbasse, Cooperative Medicine, hth edition, COOperative aziggie of the U. S. A., 19h6; Farm Credit Administration, "C00perative o9 wma Ha HH ma Ha NH mm Hm . mm Hmpoe Om m m H a N m m a vengeance ma m In H H In a m : pmmz mam wm In a H m m m m 0 pummzpdom an m m m I- o m a na noncom oaoeae ma II H m In In Ha m In ummmswpoz Hence Heoe Haesm anoo Hanem Heoo emcee Hoes Hesse Haoo owned Hoes amass Hooo Hesse snow Hanan .Qom Seq .aom awe: .dom :mflm .Qom 309 .Qom swam .Qom swam .mom swam .aom 304 scammm Hmadm . Honda annex Hmnsm annex annex Hmhdm Hmadm hwm> coma swam eomz swam some zwflm emoz.3oq emez nmflm pmez.zoq pmoz_zoq Umoz gmflm HHH> HH> H> . > >H HHH HH H ZOHOflx Hm mmawa ZOHBdDBHm MBHZDESOO UZHH. be He :9... emcetstflo: \/ .M. \I / Hpflamhdm I IIIII 304 no swam m odmmH emom m Lassen .300 ‘II poflfimfim ill‘ Hgfiumom HHmEm Hmpflgmo: \ .. momma mH II :oepmasdom 30A . OH eaoz sea: HHH> mam .H scape Ha. pmmE hmm deco fish QIII II I I I, no mramq Lozpflm III! III! eofimHsuom swam N 9.52” IIIOH Haas: EMHm Unom momma om ll eons 11311 \m:\ .HH> cam .>H hmgpo HH< pmwospdom \ Hmoo Hausa Idem rmpgaoar / m as 05mm no ,I w coapmasmom 30A e H e m HI\\\I mouse 0: H231 swam \mu emoz nmfim .H Emnpo Ham mmpMpm macaw: HHI\\ I\I \l I III Hose omens . I J! I m .AIIIIHH , coapwgaom 11mg. icoannomohm \ mmmwo ma Heed: Rog to. ac a... \o\ U00: 304 .HHH . H a QQGOZPHOZ szDL 32HmH<: do Domes: ZONEH: duo .noam oaflmcoch Lon noeuocamm ammo AHHV .wflm mega» scavmdpfim apflcdssoo a :H empeeflppmfie memmo emepmomwe :0 a woman defiemapflm .amom .pdm hwggzoo .“ IHHHE wHN w a“ momma Hmpoa :3 ~ momma ma pmozzpdom 71 community study in this field. In addition to an attempt at wisely allocating limited research funds, the assumption was held that the COOperative hOSpital arrangement was enough different that it could not be held in a strict comparative sense with the five Hill-Burton hOSpitals. The five selected cases for intensive field study were located in the states of New York, Indiana, Alabama,'Wyoming, and California. References to their characteristics will be made later in those chapters that deal directly with the case studies. However, from this point the five cases will be treated under the following synonyms when the Specific communities are treated: Northeast selection will be Noreast; the South- east selection will be Southeast; the Middle States Selection will be Mid-State; the Northwest selection will be Norwest; and the Far West selection will be Farwest. Intensive Field Study Operations and Methods P1an_s_ and operations. After the selection of a hOSpital case was made, certain procedures were utilized in preparing for and carrying out the field work. In the Noreast, Southeast, and Norwest studies the field research team consisted of three workerS--a staff member of the Department of Sociology and AnthrOpology as leader, and two graduate assistants. For the Farwest study, four workers formed the research team-~one staff (Cont'd) Health Articles,” reprinted from the News for Farmer C00pera- tives, Series I, revised June, 19M, Washington, D. C .; M. C. Klem, Prepayment Medical Care Organizations, Social Security Board, Bureau of Research and Statistics, Memo. 55, Federal Security Agency, June, 19145; N. Sinai, O. W. Anderson, andM. L. Dollar, Health Insurance in the United States, The Commonwealth Fund, New York, who, also, the ur’Tpub- lished studies of W. C. Rohrer, formerly of Texas Agricultural and Mechanical College, College Station, and E. L. Robinson, Texas State College for Women, Denton. leader and three graduate assistants. Mid-State served as the first exploratory study, and provided the occasion for an interdisciplinary field reconnaissance and seminar.26 It was at the latter site that the interdisciplinary project committee and consultants began to formu— late more Specifically a conceptual model that had been shaping itself throughout the develOpment of the entire project. Since the Mid-State case was exploratory, as well as serving as the initial study, a return trip was made at the close of the field study period to more rigorously complete this particular study, and to render it comparable to the others. Before passing, it should be mentioned that the second field study was in Norwest and here, too, an experimental attitude was assumed in order to proceed to refinement of both conceptual scheme and field research methods.27 One further Operational note Should be made. Although no two field research teams had identical personnel, two staff members did serve as the leaders for the five studies, and each team include at least one other member that had participated in a previous study. 25For the Northwest study, or termed Norwest, Dr. J. Allan Beegle, 1dr. Joseph Locke, and Mr. wayne C. Rohrer; for the Northeast study, or 'termed Noreast, Mr. Paul A. Miller, Mr. Joseph Locke, and Mr. Wayne C. liohrer; for the Southeast study, or termed Southeast, Mr. Paul A. Miller, Ilr. John B. Holland, and Mr. Benjamin Thompson; for the Far West study, or'termed Farwest, Dr. J. Allan Beegle, Mr. Sheldon Lowry, Mr. Frank Hall, and Mr. Benjamin Thompson; and for the Middle States study, or termed Mid-State, Mr. Paul A. Miller, Mr. Joseph Locke, Mr. Wayne C . Rohrer, and “tine field assistance of Drs. Charles R. Hoffer, John Useem Christopher Skrwer, Duane L. Gibson, J. Allan Beegle, and Mr. David G. éteinicke. 27Undoubtedly the developing experience with successive case studies r%33tilted in certain qualitative and quantitative variations in the field ‘florflc and the body of data that resulted for each field study. The planning for a particular field study included the following operations. The first step, of course, was to form the research team, and to immediately contact official agents of the prospective hospital project to gain approval, to establish arrival dates, and to provide for working and living arrangements for the team. Next followed two major tasks of the research team in preparation for the field trip. The first was that of individual team members assembling socioeconomic data for the service area of the hOSpital project--population character- istics, proximity to metropolitan centers, and extent and quality of businesses and industries. The entire team next reviewed the information as well as the questionnaire data and other documentary evidence supplied in the report from the case. The second task was a series of training meetings, during which the conceptual scheme for the field studies was reviewed and discussed in connection with previous experiences. From the data on hand certain expectations were discussed regarding the forthcoming study so that the research team would be prepared for the type of local process that might be expected. For example, the Southeast questionnaire data indicated the county—wide nature of the project and the actual participation of jpolitical officials. What this might mean in terms of the frame of :reference was then discuSsed. Equally important, however, was the xmcessary briefing on the methods of field investigation. Since the plan ins to focus on a selected process of community organization, the com- ]Darability of field methods employed by differing research teams had to lDe insured. 7h Eigld methods 2; investigation. The methods of investigation em- ployed in the five field studies of small hospital developments were developed with the intent that (l) the decision-making process would provide the central focus, and (2) that the methodological vantage point would be the decision-makers, their decisions and Operations, rather than tracing the reverberations and reactions of the entire community organization process throughout the community. Five procedural steps or methods were employed. They will be described in the approximate order in which they were employed in the reSpective communities. It Should be stated that an average of 13 days was spent in each of the five communi- ties. Thus, a range of 39 to 52 man days was devoted to each field study, or a total of approximately 208 man days of time. The initial problem, after entering the community and apprOpriate identification and introduction were made,28 was that of constructing a detailed sequence of events for the particular hospital develOpment. This was accomplished by two methods. One was that of a detailed exami- nation of the local newspapers over the period of the project, aiming to note persons, events, plans, dates, associations, and other descriptive mnaterial that would suggest the social organization of the community. 11w information of the newspaper analysis was then ordered into a re— <:onstructed statement of the events in the local process. The second step Ifollowed from this juncture-~that of submitting the statement to members 28Letters of identification from officials of Michigan State College arm the Sponsoring organization, the Farm Foundation, in additional to a Personal letter through the mails from the Director of the Farm Founda- tion to respective sponsoring agents. .2 11.... 75 of the hospital board for full discussion and eventual redrafting. These two methods provided an orientation for field workers to both the local community and the hospital-getting proceSS and tended to establish rapport with the official representatives of the hospital project. \\‘ The third step, after the members of the research team had agreed on an adequate knowledge of the sequence of events, was that of complet- ing a schedule of questions to secure data by which the general community setting regarding the local project for a heapital might be reflected. Information was desired from community informants about (1) beliefs con- cerning already estting hospital facilities in an attempt to learn the Ifeeling of neecl’I for a new hospital; (2) attitudes regarding the manner in which the local project had been carried out (financing and the behavior of Sponsoring groups); (3) general recommendations to other com- munities attempting a similar project; and (h) the images held by the informants of the various persons and their participating roles in the process. The names of persons placed in the schedule for the elicitation of community imagery were arbitrarily selected after noting both the frequency and intensity of their participation provided by steps one and two above. This schedule was administered to the following four cate- gories of informants, which were developed in each instance from the steps above as well as other assumptions of the project. A major assump- tion was that the central core, the "inner circle", of decision-making was of primary concern, and that IeSS attention would be given to the community-wide implications and ramifications of the project. 1. The first category was the members of the hospital board. This .selection was made because of the expected high level of participation by these members, and the need to learn the reciprocal imagery of each board member of his associates. Finance campaign leaders constituted a second category of informants in those instances where concrete campaigns to raise funds were organized. This selection is based on the assumption that the matter of planning and organizing for adequate financial resources is a crucial event in the hOSpital project and provides a decision-making situation amenable for intensive study. . Selected rural leaders provided a third category of informants. The questionnaire data led to the assumption that the community plan for a hospital is largely a town (municipality) centered Operation. In order to both answer this question and to gain an expression of rural sentiment and imagery about the process, the schedule was completed with such rural leaders. In each instance these persons were selected from the service area community of the hospital by (a) arbitrary employment of the materials developed in previous steps and (b) by the addition of nominations made by profesSional agricultural workers such as the county agricultural agent. The fourth and last category was that of the formal officers of relevant associations, as revealed by the reconstruction of the sequence of events through procedures listed above. Since the concept of gaining approval for decisions made in the hospital project is assumed to relate to the fbrmal associational life of the community, justification seemed apparent to select the repre- sentatives of, in this case, the relevant segments of the formal asaociational structure. 77 As would be expected, many informants occupied more than one role as represented above. Schedules taken for each case ranged in number from 35 to hl. A fourth major field procedure was that of a series of intensive interviews with the centrally important decision-makers. From the vantage point of the decision-making process such centrally important decision- makers were selected after the completion of the procedures described above. Interviewing was deve10ped on the basis of a schematic diagram of determinant points in the reSpective community action process. By the use of this diagram the informant was asked to Speak to its impli- cations, and encouraged to elaborate or change. From this the informant could be led into the casting of a self image, and an indication of the content and form of his relationships with other decision—makers as well as with the total community. An attempt was made to elicit comments from the informant and his associated decision-makers concerning rigidi- ties and flexibilities, personal welfare and community welfare images, ”means" or "ends" orientations, and such specific skills as those, for example, characterizing the innovator or expeditor. Finally, the informant was encouraged to describe in detail the form and content of negotiations with others in which he had been engaged at certain selected points in the process. \¢ A fifth major field procedure was the development of a postcard <3uestionnaire which was mailed to a sample of the registered voters in ‘the service community prescribed for the hospital. The purpose here iias to obtain a crude measure of the awareness of the community residents 78 in the mass, or perhaps the "outer circle" of decision—making, regarding the hospital project. Information was sought as to those persons to Whom the public at large gave credit for efforts made in the hospital- getting process. Also desired was an indication of the public senti- ment as to the need for a heapital. Summary The foregoing comments have elaborated the manner in which two major research methods have been employed, the mailed questionnaire and the case study. The former was intended to produce the necessary data to reflect on the broad limits of the community organizational setting for the process of decision-making; and the latter to provide a quali- tative body of materials by which selected aSpects of decision-making may be comparatively analysed and interpreted in terms of a conceptual model. A particular social process takes place amidst the limitations of specified events and institutional arrangements. Hence, use is made of the questionnaire to set forth these Specified events and institu- tional arrangements; and the case study to permit the abstraction of particular processes for analytical and comparative purposes. '11. I“ : - ., L“. at“ . ut/‘r ”1‘ CHAPTER THREE 5. | CHAPTER THREE THE COMMUNITY ORGANIZATIONAL SETTING FOR HOSPITAL PROJECTS The purpose of this chapter is to describe a selected sequence of events in the community process of obtaining a hospital; and to attempt to delimit some of the institutional arrangements and practices in the 218 reporting Hill-Burton hospital projects; for it is within these arrangements that the decision-making process occurs. Although this presentation is primarily concerned with a descriptive profile of com— munity action for the 218 cases, some attention will be given to selected regional differences in this profile. Chapter Two discussed the concept of region as an intervening variable to be employed in this study, namely, that varying community situations would be subsumed under the more general and integrating concept of region. Thus, the reader should view this chapter as having the secondary function of indicating the influence of regional location on some aspects of the hOSpital projects considered. To be noted is the consistent ordering of the regions as employed in each table. This arrangement is suggested by an inspection of the ques— tionnaire data, which indicates an ordering which places the Southeast Region as differing most greatly from the Northeast Region. The plan of this chapter is to organize and summarize the data ob- tained from the receipt of 218 completed questionnaires for the original inventory or 37h Hill-Burton projects. For the purpose of adding illus- trative material some reference will be made to the five intensive field Z. studies. This, however, should not be considered an analysis of the case material in any sense, but simply illustrative and supplementary. The available information for the 218 hOSpital projects will be treated under four stages in the community organizational process. First of all will be the community situation that prevailed at the time the community initiated either interest or activity toward the intended goal. Next will follow the initiation of community activity or the initiating personnel and processes. Next will be a treatment of an aSpect of community planning and action toward a hOSpital, or the patterns E29 practices of sponsorship. Finally, attention will be given to a variety of community organizational methods employed throughout these communities in the hospital projects. The Community Situation Mobilization and organization of the physical, social, and economic resources of a community toward some objective spring from early, and often peculiar, intra-community circumstances. As to the matter of health a great variety of community forces affect the state of readiness on the part of the peOple to commit themselves to such tasks. For example, attitudes in the community may be highly positive or highly negative regarding the extent to which additional health facilities are really needed.1 The task of any community organization plan is that of 1See the following which stress the importance of value attitudes in local action settings: M. L. Wilson, Cultural approach to Extension @255, Extension Circular 332, washington, hay, l9hO; see also, American Association of Social workers, Community Organization, Itg Natggg Egg Setting, Community Chests and.Councils, Inc., New York. For the dynamic 81 eventually securing sufficient positive approval of the project on the part of the citizens. The extent to which this may be accomplished refers to the feeling states of these citizens in regard to the need and desirability of moving the community toward better health. In this way, the "feeling of need" on the part of community residents is a vital factor in understanding the community situation from which both interest and action flow. Beyond this is the presence of adequate financial resources and the Opportunities for assistance to be rendered by extra-community agencies. Not to be overlooked is the present or potential reservoir of experience, proficiencies, and leadership within the community which may be employed in the mobilization and organization tasks. Another aSpect of the community situation has to do with the legal and political measures which may hinder or strengthen, as the case may be, community efforts. Hill-Burton hospitals have been deve10ped within a framework of enabling legislation, which affects the standards of hospital construction and details of planning and administration. What- ever the restrictive and permissive measures may be they constitute a form of limitation or facilitation in the early community situation. Another consideration is that of the experience which the community had had previously with similar facilities or community attempts. It is possible that the history of some communities includes a continuing in- terest in vigorously attacking and solving community problems while at (Cont'd) phase of community action as the recognition of "felt needs," 588 E. D. Sanderson and R. A. Polson, op. cit.; and C. M. King, Orvanizing £2; Community Action, Harper and Bros., New York, l9h8. 82 other times little has been accomplished in developing arrangements by which such tasks are expedited.2 Finally, experiences with previously existing health facilities may lead to either positive or negative attitudes of the citizens, which have a real effect upon those who suggest that new action be taken. Tim; 313233. The 218 hOSpital projects reported considerable periods of informal discussion as having preceded successful attempts at obtaining new or additional hOSpital facilities. Eight out of ten projects reported a long gradual period of community development, while but one in ten indicated a short period of development resulting from a recognition of emergency conditions in the community. Although about one in five of these projects reported but one year from the time of the first interest to the point of initiatory action, the remainder varied from two to ten years of discussion before a plan of organized action was initiated. Reference to Table b will indicate the rather uniform discussion periods in the 218 projects prior to community action. 'With the relatively smaller number of total projects reSponding to this question, little Vjustification appears to point out regional differences in time Span between first interest (as reported) and date of initial action (as re- ported). Reasons £33 EEEE.EEEEEE- A variety of reasons was reported for the prolonged and intervening discussion between the first expression of interest and the initiation of the most recent, and eventually successful, 2For a note on community "personality," see C. C. Zimmerman, Th3 Changing Community, harper and Bros., New York, 1938, p. 836. 83 TABLE h TIME SPAN BETWEEN FIRST INTEREST AND INITIAL ACTION Region South- South- Far Middle North- North- east west West States west east Total Percent Percent Percent Percent Percent Percent Percent One year 15 3s 28 21 23‘ 17 22 Two years 15 3 ll 3 15 13 10 Three tO five years 12 15 17 9 _ 5 8 11 Six to nine years 16 8 17 22 13 8 15 More than nine years 8 16 ll 10 17 21 13 NO reply 3h 23 16 35 27 33 29 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 to 2b 218 action. The problem of inadequate community finances appeared as an obstacle throughout the early community situation Of achieving a hOSpital. Two-thirds of the hOSpital projects reported that not enough finances were available locally as a reason for prolonged discussion before action could be initiated. It would appear significant that the event of federal legislation provided an Opportunity for such communities, in that more than half indicated that the unavailability of federal financial support was a factor in extensive community discussion and delays prior to a definite plan of action. It should be noted that the advent of World War II 8b was reported, in one out of ten projects, as a delaying factor to com- munity plans that might have matured otherwise. The 218 projects report- ed a definite increase in community discussion for a hOSpital in the period just after world.war II, as is evidenced by about half which re- ported an upswing in community discussion in the years 19hh to l9h6. There should be little doubt that one of the several functions of the federal Hill-Burton legislation was that of a catalyst to the already develOping discussions and plans in many small communities. TABLE 5 REPORTED REASONS FOR DELAYS IN INITIATION OF HOSPITAL PROJECTS Region Re orted Southr South- Far Middle North— North— Reisons east west west States west east Total Percent Percent Percent Percent Percent Percent Percent Lack of local funds 71 60 72 66 65 63 67 Lack of outside ' funds L6 12 57 3h 15 29 32 Lack of federal funds 65 b8 57 50 147 Sh Sh Lack of interest 27 16 . 39 26 3O 25 27 Lack of leadership 25 2b 39 28 35 12 28 WOrld war II . 8 8 0 1h 12 12 10 No reply 6 8 6 3 5 13 6 Total percent 2&8 176 270 191 209 208 22u* Total number 52 25 19 58 ho 28 218 *Percentages do not total 100 due to multiple reporting. The total of accumulated percentages is computed in each instance to serve as an index of incidence of total reasons reported. 85 Reference to Table 5 will indicate that it was the Southeast that experienced the greatest financial obstacle, and reported that the lack of extra-community resources was a delaying factor. Contrariwise, al- though the Northeast projects felt the financial problem, a smaller prOportion reported the unavailability of federal funds to assist local hospital projects. In the five cases studied intensively it was found that the com- munity situation prior to the initiation of action was often characterized by peculiar and individual factors within each respective community. In two of the five cases community concern had developed when local peOple observed that physicians in the area were departing. In one community this exodus eventually depleted the community entirely of medical prac- titioners, and in both instances there was local understanding of the relation of modern hOSpital facilities to attracting and maintaining competent medical personnel. In two other cases the crucial factor appeared to be the increasing dissatisfaction with already existing and privately Operated hospitals. In one community local citizens reported a growth in suspicion of the practices under way in the local hospital, which became focused when two leading citizens, after having visited a friend in a local private hospital, observed what they believed to be inadequate care of this patient. They were provoked to immediately remove this friend from the local hospital to a larger facility some b0 miles distant. These persons, after this event, served as the core of an initiatory movement within the community to improve local hospital facilities. 86 In another intensively studied case, it was reported that people had been rumoring for some time about the conditions of the already existing hOSpital, a converted dwelling. As one informant declared, "Going to the hospital was like Spending a period in the refrigerator. They would mend your leg but you would have pneumonia when you were dis- charged.“ Another person exclaimed, "It had become so crowded there that I heard they were using bathtubs for beds." As another informant put it, "When I was at the hospital recently I Spent most of my time attempting to dodge the water that was dripping from the roof." In this same community considerable discussion had occurred of the event of a local resident seriously injured in an accident, who was unable to gain space in the local hOSpital, was taken to another but eventually died. Such events stimulated the develOpment of street corner gossip and argument.3 The foregoing remarks may indicate the range of situational factors and events which influence a particular community situation prior to the initiation of a definite community action plan. They also suggest one of the contemporary impacts of national and state-wide agencies, as embodied in the Hill-Burton provisions for hOSpital construction. Also, adult education within the community may assist in the formation of a particular community situation and its attending organization of senti- ments and beliefs about the specific issue, i.e., a hospital. The efforts of public health educators, medical societies, universities, and the many 31mportant in any community situation for which community action and organization develOpS is what people really believe to be true irre- Spective of what the actual facts of the matter may be. other agencies of education in health have had much to do with the shap- ing of the community situation to a state of readiness for action projects in health.)4 Initiation of Community Activity The initiation and develOpment of a particular action plan for the community may be viewed as a flow of action from a prevailing community situation. Always a real problem of interest to both the investigator and the community worker is to understand how major projects such as the hospital are initiated and, even more Specifically, who are the initiators. The initiators. The 218 reporting hospital projects indicate, in 32 per cent of the cases, that one person should be credited with actively encouraging a concrete action plan leading to a hOSpital. In 28 per cent of the reporting cases credit was given to "several persons working tOgether." An organized group was named as the initiator in 12 per cent hHealth education is an important and growing field of endeavor, as evidenced by a great variety of agencies and programs See, for example, W. G. Smillie, Public Health Administration in the United States, The Macmillan Co. ., New York,II9h7; W. W. Bauer and T. G. Hull, Health Edu- cation and the Public, W. B. Saunders, 2nd Edition, l9b2. For some of the devices employed. in community health education, see I. A. Hiscock, __y__ to Communi_y Health Education, The Commonwealth Fund, Oxford Univer- sity Press, New York, 1939; M. Eugen, "werking Together for Better Health Educatior " Journal of Educational Socioloqy, Vol. 22, pp. 51-59; A. Oppen- heim, "Health Education in Action, " American Journal of Puolic Health, Vol.33, l9h3;B . .Harvey, et_ai., "The Community health“ Education Program, ” American bJournal of Puolic Health, Vol. 31, pp. 310-318; C. E. Turner, Community Organization for Health Education The Technology Press, l9hl; also developing is the emphasis on rural health extension work in sixteen Land Grant Colleges, within the reSpective Cooperative Agricul— tural Extension Services; and see E. L. Anderson, 3p. git. 88 of the cases. It is somewhat striking that in half the reporting cases acknowledgment is given to an individual or a group of individuals not formally organized as having played the initiating roles. Reference to Table 6 will also point out the number (58 per cent) of projects that acknowledge some combination of an individual, individuals, or groups. It is of significant interest that local business or industrial firms were but incidentally reported as having bridged the gap between a readied community situation and an initiated project. Two percent of the report- ing hospital projects indicated that a business or industrial firm pro- vided the original impetus. However the relatively small size of the communities studied probably means that the extent of industrial firms is limited. Note from Table 6 that the projects located in the Northeast and the Northwest report the higher incidence of organized groups as the initiators of community action; and that the Southwest, Middle States, and Southeast projects indicate a higher incidence of individuals and informal groups of individuals. Occupation. The five intensive case studies indicated that those persons who at first initiated the project in the community likewise shared major reSponsibilities in carrying through to completion. For the purposes at hand, it is particularly useful to use occupation as a 5 characteristic of the initiating persons. SSee E. T. Hiller, 2p. git., p. h79: "Next to age and sex, occu- pation appears to be the most general basis on which rights and duties are assigned; for although no one escapes classification by age and sex, not everyone is assigned a vocational status." See also, D. C. Miller 89 TABLE 6 INITIATORS OF HOSPITAL PROJECTS Region South- South- Far Middle North- North- Initiators east west west States west east Total Percent Percent Percent Percent Percent Percent Percent 'One person 33 36 33 38 15 h2 32 Several persons 33 to 22 29 20 21 28 An organized group 23 2h 28 29' 57 37 12 All the peOple together 8 OO 11 3 5 h 5 Business or industry u 00 00 2 00 h 2 Some combination hh 6h 61 57 65 71 58 No reply 2 00 6 2 00 OO 1 Total percent 1h? 16h 161 160 162 179 138 Total number 52 25 19 58 to 2b 218 From both the evidence gained from the reports of 218 hospital projects and the five case studies it seems apparent that the active persons in an initiating sense were not only predominantly male but also, through an occupational analysis, town centered in residence and partici- pation. Thirty-four per cent of the 670 persons termed most active were self employed businessmen. Next in prevalence were professional persons, to the extent of 28 per cent of the total named. Nine per cent of the (Cont'd) and'W} H. Form, Industrial Sociology, Harper and Bros., New York, 1951, pp. 120-121; and W. W. Warner and P. S. Lunt, op. cit., p. 261; J. H. Locke, The Participation of Occupational Groups in_Local Efforts 22 Obtain Hospital Services,—finpublished M. A. Thesis, Michigan State College, East Lansing, 1951. 90 most active persons were medical doctors, and almost 16 per cent were employed managers or executives. In this way more than two-thirds of the 670 persons named most active were either self employed businessmen, professionals, or managers and executives. Ten per cent of the persons named most active were farm owners or operators and eight per cent were civil officials. Significantly enough, but four per cent of the most active persons were non-supervisory employees.6 Attention to Table 8 will reveal certain differences in the regional distributions of occupational characteristics for the most active persons. Self employed businessmen are associated more greatly with the urbanized Northeast, the Southwest, and. the Northwest and least greatly in the Middle States. The incidence of professionals seems relatively uniform excepting the somewhat lower reporting in the Northwest and Far West and Somewhat higher reporting in the Southeast and Southwest regions. Employed managers and executives were most highly reported as active Persons in the Middle States and the Northeast, least reported in the Northwest and Southwest. Farm owners and Operators were apparently rela- tively more active in the Far West than any other region and relatively less active in the Northeast. It is indeed significant that with but four per cent of the 670 persons named most active as non-supervisory employees, 13 per cent of these named for the Far West were of this occu- pational classification. \ r 6Another important community health goal, the public health depart- ment, was associated with a different occupational configuration, with flmost three times the incidence of professionals, and 17 per cent of those named as housewives. 91 TABLE 7 OCCUPATIONAL POSITION OF PERSONS NAMED MOST ACTIVE IN HOSPITAL PROJECTS duployeo Workerse o pital Projects Kale Labor Force Occupation Number Percent Percent Self employed businessman . 231 3b 7se Professional 150 28 5 Employed manager 107 16 h%** Farm owner or Operator 69 10 1h Civil official 55 8 Owwwa Non-supervisory employee 27 h S7*¥*%* Total 670 100 87swwsss * Estimated from the ftllowing: "Percent Distribution, by Social-Economic Groups, of Employedeorkers (Except on Public Emergency'work), By Sex, for Divisions and States, l9hO (Table XXXI), " Comparative Occupation Statistics for the United States, 1870 to l9hO, Sixteenth Census of the United States, 1980, p. 19h. The computation of Employed Workers in the male labor force is, of course, not strictly comparable to the computation for the 218 re- porting hospital projects, since the latter represents one class of com- Inunities in the United States, while the forner is irreSpective of community 5129. -*%Represents an estimate between two socioeconomic classifications "whole- sale and retail dealers, " (5. 3 per cent of the employed.workers in the male Ilabor force) and "other proprietors, managers, and officials, " (L. 9 per (zent of tre employed workers in the male labor force). *"**Represents an estimate of the classification, "other proprietors, man- Eigers, and officials" (h. 9 per cent of the employed workers in the male labor force). 'kerwsPepresents an estimate calculated on the basis of 61,712 "county and llbcal, " and "city" officials, and a total male labor force of hO, 28L, OOO Ewarsons,1bid.., p. 50, Table 2; and p. 12, Table l. Weiss-Represents an estimate of three totaled socioeconomic classifications, "Eflfilled workers and foremen, " (15.0 per cent), "semi-skilled workers" (1L8.2 per cent), and "unskilled workers" (23. 0 per cent). ~vax~a.The dii ference 01' 12. 8 per cent represents the classification of “clerks and kindred workers. " . o dosoo oz O O p :*# .OQOHpmcflnEoo OHequooaHmHOom MO coapwcmagxm tom 5 mHOOB mo opocpoom op pmwmm .mdmcmo esp mp Omaoaosm mmCHosopm Opmpm mo mmmOOCOopmg spa: OmpwHOQLOPCH new smhoamEm mCOHmms Ram esp CH mmpwpm mo mommpcoonmo mo Hmpop m>Hpmaszdo map.xg Ompdo -EOO mmmH .O .OOOH .OOOOOO OOOHOO OOO Oo mOmOOO OOOOO+MHO .OOOH op ONOH .OOOOOO OOOHOO OOO toe OOHOOHOOOO deflpmmaooo o>HpmnwmsOo =.AHNNx mapwav Gama “mesmem was meHmH>HQ pom “Rom he .Axnoz homemsmem oeansm so pomome mnmxpoz.pmmoaosm mo .mosono OHEocoomIHmHoom hp .CoOQSDOAQOHQ pcoonmm= Scam Ompdosoo «hfico mmmeprme ma mmH ONH Om ma OOH nOOesc HOOOO HO OO MO OO OO aO OOH OOH OOH OOH OOH OOH Osmosma HOOOH HO Hm om mm mm Om : N O ma H O momoamEm anomw>nmmdmncoz sio O O O O O m O OH O O OH HOHOHOOO HHsHO m mH OH a mm am O mH HH OH O HH OOOOOOOO to amaze Esme O O O O O m OH OH ON OH NH OH panacea emsOHOea m O O O m m mm Om mm ON mm Om HOOOHOOOOOOO O a a O O O Om OO ON mm mm Hm qwemmOOHmOO OOOOHOEO OHOO pcoosmm ‘11 sowpmmmooo 1wmwm pmms mopmpm pmma .pmm3 pmwm pmmm pews mmpmpm ewe? pmmz pmwm Izwhoz tango: oHOOHE omm nzpdom Izosom aspho: Izphom canoes ham uspdom Ispsom QOHmmm mm COHmwmINm *oonom pocwq mama msmxsoz OmmonEfl mpomhopm Hmpflomom meoawoxm QHBD¢.HmO£_Qfl343 mzomxflm mo ZOHBHmom A¢ZCHB A¢zoaomx w MAQOdy and the process of Sponsorship stands at the core of the community c’I‘ganizational scheme. It is the sponsoring body that provides a channel (If communication to extra-community agencies and persons related to the IIPoject. The Sponsoring body assumes the reSponsibility of securing 9b m m.HH m.mm HNH OOOOOOO HOOOO o m 0 NH nommcee no obflpoomxm o O m.o o omhoaosm meomfi>pogdmazoz o m.o m ma OmonQEO .Hmsoemmmmosm O m.O a . mm Umhoamsm AcmHOHmmsQasodv chowmmmmohm o m.o m ma popooo HOOHOOE o m m OH posse COHpmpcmHo no seesaw m 0 ma Om mesmmocflmdn UOAOHQEO mamm Adom mo mocmOHocH omega no mocmcfiosH 03% mo mucouflocH moo mo mocmewocH QOHpmddooo mcflppommm pcmommm msprOQOM peoopmm mcflppooem pesosmm mcflppoomm unmommm mBOflwOfim AdaHmmom row naommdm MbHBod HmO£.£DOb Ema 62024 mulodeODO m0 mozmQHOZH a OOOOO continuing approval from the citizens at large in the community and from the organized associations which they represent. The sponsoring group is constantly concerned with the need to sense potential Opposition to the project, to prevent it if neceSSary, and to reduce it if it becomes active. Sponsorship includes the formulation of such policy as to affect decisions ranging from those of construction and finance to the appeals used to secure community interest. Types pf sponsorship. The most prevalent Sponsoring group for the 218 hospital projects was that of previously existing or newly formed hOSpital boards. In 61 per cent of the projects, hospital boards or associations were reported. The evidence suggests that the growth of new hOSpitalS quite frequently developed from a previously existing facility and that the associated managing body continued as a Sponsoring agent for the new hOSpital. The incidence of political Sponsorship is relatively high, with both county and municipal governing groups active in the roles of official Sponsors. Thirteen per cent of the 218 hospital projects reported a <:ounty political body in this role, and eight per cent a town political IDody. The latter incidence of municipal governing bodies suggests that :Larger administrative units are important in hOSpital develOpment in Ennall communities rather than local municipalities. Reference to Table 10 will indicate that in 20 per cent of the projects c"Immunity wide councils were reported as Sponsors, of which health councils, ‘SIDecifically, were reported by three per cent of the projects. 96 TAOLE lO CENTRALLY IMPORTANT SPONSORING GhOUPS IN HOSPITAL PHOJLCTS Region Type of South- South- Far Middle North- North- Sponsoring east west west States west east Total Gro up Percent Percent Percent Percent Percent Percent Percent HoSpital boards or associations 5h 6h 39 65 51 83 61 Political 38 , 36 11 19 10 OO 21 Service clubs 15 2O 29 l? hS OO 21 WOmen's clubs 00 h 00_ 3 7 h 3 Citizens councils 23 2O 33 17 12 25 20 ' No reply 15 8 28 20 Lo 8 21 Total th 152 1b0 1h1 '165 120 1b? Number 52 25 19 58 hO 2b 218 The importance of service and civic organizations has been felt in community organizational plans for hOSpitals. Twenty-one per cent of 'the 218 projects reported, Specifically, a.Chamber of Commerce or some (Dther form of service club as the official sponsoring agent, and three Iber cent reported some form of womenls club. There was a small incidence <>nly of famm organizations, churches, and councils of social agencies in tfiie role of Sponsorship. The regional patterns of sponsorship indicate certain interesting ciifferences. AS shown by Table 10 the incidence of county and town IDolitical bodies is highest in the Southeast and Southwest, and entirely 97 lacking in the Northeast. Hospital boards are associated with by far the majority of projects in the Northeast, and tOgether with hOSpital associations, form more than 80 per cent of the Sponsoring groups represented. Although all regional locations demonstrate the importance of the Specifically formed hospital board or association, the Far West and Southeast are relatively lowest in this regard. Community citizens councils are most highly reported in the Far West, Northeast, and South- east; while least reported as Sponsoring groups in the Southwest, Middle States, and Northwest. The above evidence suggests that the problems of organization and finance in small community hospital projects have been borne by Specific- ally formed hospital boards and associations and existing political groups, and that the Northeast has almost entirely employed the former, and the southern areas relatively more greatly the latter. These data Suggest that acquiring the small town community hOSpital has as its central base of Operation the town itself, rather than the entire service amea which has been throughout designated as the relevant hospital com- munity. In none of the five projects studied intensively was it found that ‘a.previously organized citizens group, such as the health council, played Ean.important part in initiating or Sponsoring the community organizational Illan. The evidence from the case studies suggests that the device of the citizens council is related to community activities of a mOre short I‘ange nature and of less magnitude than the hospital.7 \1 7The evidence suggests that the health council, beyond its defined 1function of coordination, has been related to public health programs 98 Secondary sponsorship. Sponsorship usually involves more than the single and centrally important Sponsoring group. Although such a group has been necessary a variety of others has actively participated. Such participation has had to do with giving approval to the primary Sponsor- ing body and of providing participants and other resources for the active work of the project. Various civic and service clubs have been important to the reporting hospital projects. In Table 11 it will be found that local Chambers of Commerce, Lions, Kiwanis, Rotary Clubs, the American Legion, and Veterans of Foreign wars, and the Farm Bureau-—have all been cited for active participation. Attention to the rank order of these associations by the prOportion of hospital projects reporting their activity will again demonstrate that business and professional classes in the community would, by inference, be more closely associated with the hOSpital project, and indicates that the town as the site Of the hOSpital must be considered a disproportionately important subgrouping of the community in a decision- making sense. Reference to Table 11 will indicate that the service clubs, in total, were reported as active participants more commonly in the Southeast, ____- ¥ (Cont'd) within the community rather than hOSpital develOpments. A report ‘by'the National Health.Council on selected characteristics of local health Councils indicates that community needs frequently related to the functions ids later amputation." (p. 113); "A word Of warning needs repeating; 3}1T the desire of a worker to set up a new organization . . . makes him iLgunore the existence Of a well-established group already associated in ‘trhe public mind with the kind of a job to be done, by-passing it purposely Tnaqy prove a Serious blunder as well as a waste of available social re- SO‘urces." ‘(p. h8); although concerned with the larger urban community, CfT. the article by'W} H. Form, "Mooilizing Urban Community Resources," 111 I. T. Sanders, Ibid.,;pp. 133-139. For example: "The larger the city grows the greater is the need for its sub-areas to COOperate in attaining Common services and goals. Since size itself'makes personal and Spon- taneous cOOperation on a continuous basis almost impossible, Special associations are created to meet Special needs. Thus, in a real sense, organizations and institutions, not personalities, run the life Of the city." (p. 133); "The first job Of urban action-minded peOple, then, is to decide: (1) whether their problems are citybwide or local in character; (2) what organizations already exist on a city-wide or local basis." (p. 133). 111 this individual made mistakes in approaching rural peOple regarding cer- tain financial matters of the campaign, but that other members of the Sponsoring group were able to reduce the effects of the errors. Reference was made in Chapter Two to the written reports of 33 com- munity organization specialists. Some of their comments dealt with the function of Sponsorship. One such question was: "What Sponsoring groups in rural communities do you find most successful to work with?" A variety of comments included the following. One rural sociologist in a south- eastern state emphasized I'that they (sponsoring groups) should not be too closely tied to one institution or clique within the community. It is :bmportant that they have both lay and professional leadership; and that tfliey reach the masses as well as the privileged few." The inability to dfincide on the one group to employ is referred to by another sociolOgist ir1 a southeastern state, who pointed out that "the use of groups will <3813end upon the project to be done." Then, he added, "we often find that a. Egroup is zealous but with very little influence in terms of the power S1axructure. After they have done the Spade work it is frequently helpful 'tC> get an established influential organization actively engaged.6 Selected Community'Methods Employed Earlier treatment has been given to the patterns and forms of Spon- Sormfidp that have been associated with 218 reporting Hill-Burton hospital 'prOjects. In addition, some predominant problems were described as they apply to the role of the Sponsoring group of the community action plan. These problems have to do both with subgroups within the service community, and those growing out of resistances from local organizations and ll2 influential persons. This chapter will now turn to certain selected methods, in a community organizational sense, employed by centrally im- portant Sponsoring groups. It is assumed that the selection of methods by which individuals and groups are encouraged to participate, by which finances are collected, and by which legal and political regulations are met and resolved-—all have a direct effect upon the successful out- come of the project. They, in fact, represent the way in.which the means in the decision-making process are organized, The method evoking problem. Before an elaboration of the selected community organizational methods is presented, it should be repeated that .for'such.major health goals as the hOSpital the almost always predictable ruesistance of local citizens has had to do with present or potential iiirencial investments. There is little doubt that for the hOSpital projects Orne of the predominant problems to be overcome is that of the resistance ‘tfrrough both explicit and implicit fears of higher taxes. Reference to Table 18 will demonstrate the importance of Opposition through threat ‘3f7 higher taxation as compared with other types of Opposition. Continued reference to Table 18 also will provide regional differ- 911C£S. The threat of higher taxes apparently was more greatly felt in 'tfme Far West, the Middle States, the Southeast, and the Southwest. It is Sixriking that only one in five of the Northeast projects reported such C>pposition. The Opposition of professional persons (probably due to their feeling of interests not served) was greater in the Far West, least great in the Southeast and Northeast. 113 TABLE 18 TYPES OF OPPOSITION Region Opposition South- South- Far Middle North- North— Type east west west States west east Total Percent Percent Percent Percent Percent Percent Percent Threatened high taxes Sh 60 72 6h h2 21 53 Professional in- terest not served h 12 28 7 13 h 9 (non-M.D.'s) Interest or Medical Practice not served l7 12 00 7 13 17 11 Other (miscel- - . laneous) h 12 28 12 2o 29 15 bio reply 2 00 OO 2 2 OO 1 Iqo important Opposition 29 16 11 21 2O 38 23 3?Otal percent 110 112 139 113 110 109 112 3?otal number 52 25 19 58 hO 2b 218 Individual and organization focus. Remembering that the 218 report- irug hospital projects were examples of successful attempts, the informants, tJurough both questionnaire reports and case studies, insist that it was necessary to appeal not only to organized groups in the community but independently to influential persons. A small minority Of projects re- ported that appeals had been made only to organized groups or only to 111; individuals for support. In this way organizational plans, and associ- ated skills, had to be focused in teens of both organizations and individuals. Long and short range plans. The evidence suggests repeatedly that obtaining a hospital requires the transference of this concrete goal into Specific goals as I'raisingmoney through a campaign," "develOping a pro- motional program for the community," "negotiating with local government bodies." One of the skills in hospital project decision-making would appear to be the ability to re-define the long range and generalized ,problem, such as the hospital, into the more short range and specific goals of campaigns, raising money, hiring a contractor, hiring an architect , etc . Fund raising devices. Perhaps the most important choice of the Spon- scxring group of a hospital project is that of selecting the method by ‘thich the local share Of construction costs may be obtained. more than Ibexlf Of the hOSpital projects employed voluntary gift campaigns under the :Lezadership of local individuals. Ranking next in importance as a fund- iralisingzmethod was that of voting a county bond issue to supply the funds rSequired by the community under Hill-Burton legislation. Forty-two per CEBnt Of the hospital projects reported the use Of this fund-raising “method. Ranked third was the voluntary gift canpaign under the leadership (Jf a professional fund-raiser from without the community under considera- tion. ther less freguently employed fund-raising methods were those of the bond issue limited to the municipality of the relevant town, securing memberships in a cooperative hospital (Southwest and horthwest), and the 115 TABLE 19 METHODS OF FUKD RAISING EMPLOYbD hegion South— South~ Far Middle North- North- east west ‘West States west east Total Method Percent Percent Percent Percent Percent Percent Percent Locally led pub- ~ lic subscription 5h hh 39 71 80 29 58 County bond issue L8 56 22 h8 h0 13 D2 Professional led public subscrip- tion 10 OO 6 15 15 71 17 biunicipal bond issue 10 12 6 19 13 00 11 Co Operative member- ship 00 12 OO oo 8 00 h iic>3pital district bond issue 2 OO 33 OO 00 OO 3 (313her (miscel- laneous) 2 oo oo 3 2 oo 2 NO reply 2 h 00 00 OO 00 1 Total percent 128 128 106 156 158 113 138 Total number 52 25 19 58 hO 2b 218 ‘ Enaecialized hospital district bond issue currently being developed in the Far West. The comparison of regional differences in fund raising methods is significant. The voluntary gift campaign under local leadership, al- though relatively important in all regions, has been employed almost 116 entirely in the Northwest projects, although in combination with the county bond issue, in that hO per cent of the Northwest projects report its use. The voluntary gift campaign under the leadership of a profes- sional fund raiser was employed in more than seven of ten hOSpital projects in the Northeast, with all other regions showing a relatively minor use Of this professionalized device. Voting a county bond issue was an important method in the Middle States, the Southwest, and the Southeast. It is important to note that the projects of these three regions, in addition to the Northwest, also joined the locally led volun- tary gift campaign with the county bond issue. Selling memberships in El COOperative hospital to raise the community's share of construction CKDStS showed the greatest incidence in the Southwest and the Northwest. Chne in three of the hospital projects in the Far West region had utilized ‘tlie hOSpital district as a device in that it provides the mechanism for leevying sufficient district bond issues to provide the necessary pro- Iscyrtion of construction costs.9 Two factors would appear to be related at this juncture, to an Eisqplanation of regional differences. One is the type of community 9For the details on the Special hOSpital district, see Laws Relating 351 Hospital Districts, fig Excerpt from the California Health and Safety CD'Ode, San Francisco, Department of Public Health, 1950P(Division 23: ERDSpital Districts, added by Statutes, l9h5, ch. 932). Cf. par. 32001: YA.1oca1 hospital may be organized, incorporated, and managed as provided iLn this division and may exercise the powers herein granted or necessarily implied. Such a district may include incorporated or unincorporated terrii tory, or both, or territory in any one or more counties. The territory comprising this district need not be contiguous but the territory of a municipal corporation shall not be divided." 117 participant for the hospital projects, the other is the past experience ‘ of communities with the use Of political machinery to solve local problems. For instance, it might be assumed that the incidence of em- ployed executives in the Northeast as hospital project "leaders," and their attending beliefs in specialization, was a factor in the employment of professional fund raisers. It was found in the intensive study made in the Northeast that there ans 3 stated lack of confidence on the part of the leaders in their own local administration Of Specialized campaigns for raising money and that professional skill was necessary. In the Northwest case local leaders believed that they possessed the necessary skills not only to initiate and organize the program but to remain .actively in charge of the fund raising activities. It should be remembered, ‘too, that employed executives were highly associated in the Northeast, self employed businessmen in the Northwest. The incidence of professional fund raising in the Northeast would :seem to coincide with the fact that the existence Of previously estab- Ilished small hospitals is perhaps greatest in this region, leading to a égreater exposure of Northeast communities to the skills of the professional :fund.raiser.10 IMoreover, since the locations of professional fund raising ‘ 10For regional diSparities in hospital facilities, see the follow- ;‘Lng: F. M. Mott and M. I. Roemer, Rural Health and Medical Care, McGraw- dill, New York, 19b8, pp. 226-227, for a state by state tabulation of hcJSpital beds available per one thousand population. New York state has, SKIP example, h.9 beds per 1000; and Alabama has 1.8 beds per 1000; and ”ONJming, 3.6 beds per 1000; see also J. W. Mountin, E. H. Pennell, and -IM. HOge, Health Service Areas: Requirements for General Hospitals and .Healtn Centers, U. 3. Public Health Service Bulletin 292, Gov't Printing Orifice Washington 19h5- American Medical Association Council on.Medi- 3 .3 3 ’ ’ CECL Education and HOSpitalS, "Hospital Service in the United States," Journal of the American Medical Association, Vol. 121, p. 1010 ff., March 27 , 197137“ /I 118 organizations are now largely in the metrOpolitan areas of the country, it would seem that the Northeast enjoyed greater access to such groups than did, for instance, the Northwest and Southeast regions. Campaigns. The community organizational activities of the hOSpital project focused in an intensive campaign to raise the local share of construction costs. Four out of ten of the reporting 218 hOSpital projects gave evidence of campaigns of not more than two months in dura— tion. Less than one in ten carried on a campaign for a longer period than one year, and more than two in ten performed the campaign in a period of from two weeks to two months. Moreover, when asked to recom- mend the length of campaign most desirable for fund raising in a hOSpital project, the reports indicated a general recommendation of spending from approximately one month to three months of intensive community work. 'des, of course, does not include the early discussions, organization cievelOpment, conducting community surveys, and gaining technical assist- ance . The task of raising sufficient funds for hospital construction was Snot.a1ways solved by a single campaign" In a few instances as many as fknxr campaigns were required. Reference to Table 20 will give a summary °I7 such experiences. Note should be taken of certain regional differences in this regard. By far the majority of the Southeast, Southwest, and IE‘Eilt‘West projects accomplished the task in one effort; while the Middle Stdates, Northeast, and Northwest projects were more frequently confronted "53th two or more campaigns. It remains to be emphasized that the former Elfiaups of projects had most frequently employed the county or town bond iSsue as a fund raising method and the latter groups voluntary public Subscription. 119 TABLE 20 NUMBER OF CAMPAIGNS EMPLOYLD Region Number South- South- Far Middle North— North- of east west west States west east Total Campaigns Percent Percent Percent Percent Percent Eercent Percent One 60 72 78 SS 35 SO 56 Two 19 16 ll 26 3o 38 2h Three h h 6 9 22 12 10 Four or more 2 00 00 S 13 00 h No reply 15 8 S S 00 00 6 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 hO 2b 218 Community gppeals. A necessity for the develOpment of a hOSpital jproject has been that of the Selection of appeals or slogans to the com- Inunity in order to encourage interest, loyalties, and the participation be somewhat intermediate in this regard.ll \ 11See I. T. Sanders, _p, cit., pp. h9- SC, for this statement: "In SCHne communities I would rather have two loquacious barbers reciting the VJJPtueS of my program for two or three days to all the customers who sat ifl their chairs than to have two or three high-sounding editorials in t be local press. This is not to deny the power of the press and the 123 Preferred communication media. In addition to reporting actual communication media, the reports from the 218 projects included recom- mendations as to superior effectiveness of particular media. Although personal contact was stressed, as Well as news articles and Speeches to organized groups, reference to Table 23 will demonstrate that the TABLE 23 PREFERRED COMMUNICATION MEDIA FOR PUBLICITY CAMPAIGNS 1h HOSPITAL PROJECTS Region South- South— Far Riddle North— North- Communication east west 'West States west east Total __ Media Percent Percent Percent Percent Percent Percent Percent Personal contact 38 hh hh h? 58 58 h8 News articles 10 16 33 2h 30 17 21 Speeches to organ- ized groups 15 8 39 22 28 50 23 IJirect mail h h 11 12 5 OO 6 Hand bills 2 00 OO 2 5 OO 2 General meetings h 00 OO 2 00 h 2 No reply h8 LO 33 26 25 21 33 Total percent 121 112 16O 135 151 150 135 Trotal number 52 25 19 58 hO 2b 218 (chnt'd) tremendous role it can wield in the formation of public Opinion. It. just so happens that getting the program favorably accepted in some 9f? the community's gossip chains will aid greatly in the launching . . hh'ery community has its loafing spots, such as the feed store, the court hQuse, a fire station, or a bowling alley. Competent supporters in any (*5 these places at the right times can be real assets." 12h recommendations of reSpective regions approximate the evidence on media actually employed. The Northeast, Far West, and.Middle States projects stressed personal contact and presentations to organized groups, with a less felt awareness of their importance by the Southwest and Southeast projects. Note also from Table 23 that the prOportion of projects in each region that failed to indicate a preference at all provides an in- direct way to measure the relatively less concern of the Southeast and Southwest projects with communication media. Extent 3£_personne1. Since the develOpment of the community organi- zational plan, and Specifically the fund raising plan, required the activation of individuals to assist With the Operations, it should be noted that a range in the number of participating persons was reported. .Attention to Table 2b which represents the reSponses regarding the :number of persons participating in the most recent campaign, will indi- cate this range and some regional variations. Almost two in ten of ‘the projects indicated that more than 100 persons assisted in the most Irecent campaign; slightly more than one in ten reported less than ten assisting persons; and also more than one in ten reported that between .30 and 50 persons assisted. The Southeast and Southwest projects tended t0 fall into two groups, those that indicated less than ten persons associated with the campaign and those with more than 100 persons assist- 111g. It is striking that nearly half of the Northeast projects reported "Nbre than 100 persons so participating. Although the Far'West projects tEEnded to agree with the Southeast and Southwest on the nwmbers of partici- Efiating persons, their reports indicate that numbers of participating IDersons fell in the middle range. TABLE 2h EXTENT OF PARTICIPATING PERSONNEL IN CAMPAIGNS FOR HOSPITAL PROJECTS Region South— South- Far Middle North— North- Number east west ‘West States west east Total Individuals Percent Percent Percent Percent Percent Percent Percent 10 or less 17 2h 11 12 13 h 1h 15 u 00 co 3 3 h 3 20 5 12 OO 3 10 OO 6 25 8 b 12 5 t 5 oo 6 30 2 b 17 2 7 00 h 31-50 10 8 5 12 27 17 1h 51-75 00 h S 5 3 ' oo 2 76-100 14 oo oo 18 15 8 9 (Dver 100 19 16 . 5 20 12 h2 19 No reply 31 28 us 20 5 25 23 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 to 2b 218 ‘.~ Miscellaneous methods. Throughout the develOpment of the hOSpital Lprwoject various Specific methods were employed to provide an orientation kar the local project. For example, more than one in three of the hos- pjstal projects reported that "leaders" had traveled to other communities ‘tC> learn about the experiences of others. More than one in three projects hFidemployed some sort of community survey to learn the extent of need for hospital facilities.l2 More than Six out of ten projects have asked for and received technical assistance from various professional agencies. But five per cent of the projects reported assistance rendered by college Specialists, indicating that hospital programs in small communities have not yet seen in the colleges a major source of assistance in the educa- tional and organizational functions. The hOSpital projects reported a recommendation, nine to one, that the careful employment of community surveys and the wise use of extra-community technical help are worthy devices. Reference to Table 25 will demonstrate the uniformity of use made of such devices by the regional groupings of hospital projects. It Should be noted that the Far West, the Middle States, and the Northwest projects have tended to use them more, and the Southeast and Northeast less, eSpecially in regard to the assistance of state hOSpital agencies and associations. The predominance of hospital boards as Sponsors, and the experience with already deve10ped facilities in the Northeast may account for this. The Northwest and Far west communities represent areas 12The community survey, and Specifically the self-survey, is of growing importance in the health field. See, for example, K. M. Pray, "Quantitative Measurement of the Community's Needs and Services, " Proceedingg of the National Conference of Social‘Work, Columbia Univer- sity Press, New York, 1930, pp. L334LHeT S. A. Rice, "The Factual Basis 0f Community Planning," Proceedings of the National Conference of Social Work, New York, 1939, pp. 512-:21; Journal of Social Issues, Vol. no. 2, 19h9 (entirely given to community self-surveys); W. S. Ryden and E. C. Chenoweth, "Community Discovery Through Survey and Discussion, " Journal of Educational Sociology, Vol. 19, l9ho, pp. h36-hhh; and for two lmalth surveys conducted by entire counties, see the following: Ohio State University, You and Your Deighoor, Columbiana County Rural Health Survey, Cooperative.Agricultura1 Extension Service Bulletin 307, Ohio State University, Columbus, April, 19u9; The Clinton County (Chic) Health Council, Clinton Connty Health Survey, a bulletin summarizing the Clinton County, Ohio, self-survey of county health needs, 1950. l2? TABLE 25 SPECIAL COMMUNITY ORGANIZATIONAL SERVICES EMPLOYED BY HOSPITAL PROJECTS Region Community South— South- Far Middle North- North- Organizational east west west States west east Total — Device Percent Percent Percent Percent Percent Percent Perceht Community survey of health needs hO to 67 38 LS 33 hz Community survey of financial data 33 36 S? 33 L; 33 37 Visited other communities 31 36 Lb bl 35 33 37 Consulted profes- sional consult- ants 17 so 72 7b 75 L2 68 Consulted college Specialists 2 00 OO 16 7 h 5 Other (miscel- laneous) 11 8 28 10 7 u2 15 No reply 13 12 11 19 5 21 1h Total percent 1&7 192 279 231 219 208 218 Total number 52 25 19 58 DO 2h 218 of the country that have had a retarded growth of small hospital facili- ties, which may explain the greater use of devices to provide facts and orientation of the particular local project. Ownership. The completion of the community organizational phases of the hOSpital project and the technical aSpects of hospital construction result in a final decision regarding ownership of the hospital. Attention to Table 26 will show that the favored ownerShip of hospitals for the 218 reporting projects is that of county ownership, non-profit hospital associations, and city ownership. Note that more than 60 per cent of the hospitals in the Southeast resulted in county or city ownership, and in the Southwest more than 70 per cent came under the ownership of county or city. This should be contrasted with the Northeast hospitals, of which almost 90 per cent have resulted in owner- ship by noneprofit hospital associations. The hospitals of the Middle States, the Northwest, and the Far west are to be owned to some extent by county or city governments (as per cent, 52 per cent, and £3 per cent reSpectively). In both the Northwest and Middle States hOSpitals another important method of ownership is that of the non-profit associ- ation (or h? per cent and 33 per cent, respectively). It should be ob- served that in one-third of the Far'West hospitals, ownership is assumed \ by the Specialized hospital district. Summary of Descriptive Comments This chapter has stressed certain features of the community organi- zation setting within which occurs the decision-making process toward kmspital construction; and emphasized the broad limitations and institu- tional patterns associated with the planning and carrying out of hOSpital prOjects in regional areas of the United States. -Community situation. Some aSpects of the community organizational Setting for hOSpital projects encourage a brief summary statement. First Of all, a wide range of informal discussion occurred in the early 129 TABLE 26 FINSL OflNERSHIP OF HOSPITALS Region South- South— Far Middle horth- horth- . . east west West States west east Total Ownersh1p Type Percent Percent Percent Percent Percent Percent Percent County 51 hh 50 L3 DO 12 E2 City 10 28 oo 22 12 00 1h County-City 00 h 00 2 oo oo 1 Non-Profit Ass'n 39 2h 17 33 h8 68 hO Special Hospital District 00 OO 33 OO 00 OO 3 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 hO 2h 218 community situation prior to the formal initiation of action. The delays throughout the discussion period were related to the events and circum- stances regarding hOSpital facilities in the community and the attitudes of people as to hospital need. The delay of community activity has, in most instances, resulted from inadequate financial resources to provide the local share of construction costs under Hill-Burton legislation. The execution aSpects of the decision-making process relates to the allo- cation and/or manipulation of the means at the disposal of the decision- makers. The delays to active planning for hospitals in small town and rural areas seem to be provoked by insufficient financial means or their expected insufficiency on the part of the decision-makers. 130 Initiation. The reports of the 218 hospital projects indicate that shifting from the early community situation to purposeful activity is related to the efforts of individual persons or informal groups of in— dividuals. The identity of the initiators is in the direction of persons rather than organized groups. .Also, the initiation of community activity appeared to Spring from the municipal or town sites for the hOSpital, with male persons playing the initiating roles. In addition, two out of three of the most active initiators and leaders in the development were either self employed business men, professionals, or employed executives. Empha- sizing that the hOSpital is a project of great financial stress for the small community and that its physical site is usually a relevant munici- pality or town, it would seem that decision-makers have been drawn from the business and professional classes of the relevant municipality or town. Sponsorship, Following the initiation of action, hOSpital projects were characterized by centrally important sponsoring bodies that were generally organizationally Specific. Such sponsoring groups were organ- ized Specifically for the hospital project task, and were not subgroups of, or extensions of, other persistent arrangements for community action, such as the formal political system, and particular associations or councils, although to a less extent, local political governing bodies were active in the Sponsoring role and were aSSOCiated with certain regional areas of the country, eSpecially the Southwest, the Southeast, and the Far West. 131 Methods. .The crucial event in the hospital project has been that of the fund raising campaign. The devices employed here have been voluntary public subscription under local leadership; the voluntary public subscription under extra-community'professional leadership; the bond issue; and certain limited devices such as the cooperative membership plan of some Southwest projects, and the hospital district bond issue of the Far West. It is the planning and organization of the campaign that appears as the major nexus of the decision-making process. Problems. Attention to the problems encountered in such hospital projects and the communication media, community appeals and methods--all indirectly define the required proficiencies for the decision-making function. The hOSpital is a highly Specialized and technical institution, requiring the proficiency of adequate subject matter knowledge, either by intra-community "leaders" or extra-community consultants. The majority of hospital projects indicated a variety of problems such as deficiencies in community "leadership" and experience, the resistances and Oppositions of subgroups within the community, and from community influentials and associations. Since the hospital project was constantly confronted with felt financial threats upon advent of the hOSpital, a body of Skill was required that had to do with a knowledge of legal arrangements within the community, and negotiations with the functionaries of hOSpital agencies external to the community. The very fact that consensus on the part of the total community had to be gained, eSpecially in regard to successful fund raising, required the exercise of ideological Skill. Although this was apparently supplied in some areas, particularly the Northeast, by 132 the professional fund raiser, the majority of the projects raised suffi- cient funds largely through indigenous proficiencies of organizational and ideological skill. So we find that the hOSpital project called forth the activity of local peOple and simultaneously rested in the midst of a larger frame- work of a federal and state prOgram. Although the pattern of local political organization had to be reckened with, no less important was the contractual relations with federal and state agencies, the mobiliza- tion of sub-groups within the total community, the recruitment of in- fluentials and associations, and the Specialized negotiations with archi- tects, physicians, and hOSpital planning agencies. The panorama of the hospital project is at once community, state, and federal; and is revealed in a veritable host of cues-~"the court of commissioners," "the bond issue," "the professional fund raiser," "architects," "Hill-Burton legis- lation," "the hospital board," "regional hospital council," "doctors," "hOSpital administrator," "taxes," "the health council," "chamber of commerce and businessmen," "probate judge," "Farm Bureau," "the health survey," "the state college," "Lions and Rotary," "local weekly newspaper," "street corner discussion," "Speakers bureau," "the campaign banquet," "hOSpital districts," "000perative memberships," "influentials," "dis- agreement," "competition," "official appointments," "elections," "Memorials," . . . ." ‘ Summary of Interpretative Comments The concluding comments of this chapter will refer to selected simi- larities and dissimilarities of the hOSpital projects based on regional 133 groupings. ‘The purpose here will be that of collapsing the data on the regional tabulations in an attempt to suggest certain guiding comparisons between regional hospital projects. Such comparisons may then be checked in greater detail as the five case studies are treated. Since the over- all purpose of this chapter has been to describe the community organiza- tional setting for the decision-making process in hOSpital projects, the drawing of such comparisons, although crude, will tend to extend the over-all purpose in the direction of the theoretical interests of the study and preparation for case study analysis. In order to collapse the material presented heretofore the method of rank order comparisons will be utilized. This method is not employed as a measure of statistical significance, but more largely as a mechanical device to regroup and reclassify the data into rubrics which will be assumed to be both relevant and meaningful in terms of the theoretical scheme. Classificatory assumptions. Before proceeding with the analysis certain assumptions must be made explicit in that they deal with the subsequent reclassification of the data. These assumptions follow. 1. Since authority is a major capacity for decision—making, certain items in the community organizational process are combined with the assumption that the most direct eXpression of authority in the decisionamaking process for these projects is in terms of formal political or civil components. Six items have been construed to have the following lOgical relationship. If a county or municipal local governing body serves as the official Sponsoring agent of the hospital project, it would be expected that the 13h representatives of promotional and operating hospital groups would be appointed by local officials; civil or political officials would be active participants in the decision-making process; political instru- mentalities such as the bond issue would be used for fund raising; and the hOSpital would result in ownership under the jurisdiction of a governing body with civil mandate. Finally, with these assumptions operating toward the definition of a decision-making process functioning by authority as a major capacity, it would be further assumed that it would follow that the total number of active participants (decision- makers) would be relatively small. 2. Since hOSpital development is a Specialized activity, and has re- quired official Sponsorship, it would be assumed that if formal political governing bodies are not Sponsors, then an organizationally Specific group must be; and this is construed here as the specialized hOSpital board or association, a functionally Specific group that has no authority in the continuing and formal sense, but only in regard to the limited and Specialized details of hOSpitals. It would then be assumed that non- political or civil or otherwise governing officials would not be the active participants, but others selected for resources and proficiencies peculiar to the Specific task, and that these selections would be made through non-political methods related diffusely to the community. Further, it would seem to follow that certain methods, i.e., fund rais- ing, would not be political instrumentalities but devices resulting from the resources and proficiencies of the active participants; and that ownership of the hospital would be not under the jurisdiction of formal political officials but in Specialized arrangements having their loci in 133 the before mentioned Sponsoring group. Finally, with these assumptions operating toward the definition of a decision-making process thriving on influence as a major capacity, it would be further assumed that it would follow that the subsequent community orientation would provoke a relatively large number of active participants (decision-makers). 3. Since the decision-making process that functions on authority, and assumed here as the formal political and legislative type, is character- ized by generalized rights of political office, it would seem to follow that the possibilities of recourse to decisions by those Which they affect would be somewhat less and, hence, less resistance and Opposition would be expected to follow. Likewise, with this type of process it would be assumed that there would be less need to communicate and appeal to the community in order to gain consensus and support. For the process thriving on non-political components, i.e., the capacity of influence, the opposite would be assumed, namely, that without institutionalized offices and rights associated with the decision-making process but only narrow limits of jurisdiction one would expect to follow a relatively greater content of resistance and Opposition. Also, would follow rela— tively greater communication and appeal to the community in order to gain consensus and support. Analysis. Attention to Table 27 will provide comparisons on five items dealing with various components of formal political authority grouped on the basis of the assumptions noted above. Summarized, this grouping indicates a continuum of identifiable formal political components in the various regional categories of hOSpital projects. The Southeast 136 sash cmoz mxcwp mo sow o.s mm.s m©.N om.m oo.N mm.N on oN NH HN NH 3H 0 a m m H N o a m H N m e m N m H a e m N m a H o m a m N H e m m a N H ameto acme ammo 1lwmm: mopwpm pmmz pmoa pmwm -eppoz -epeoz mHeeHa tam -assom -asaom coamom aapnoa nepeoa mHeeHz tam napaom nepsom : ma NH Ha 4m NH wmoa no OH poonopm cw qucompom NH Nm as om ea He aHem upoaao Hmmfloflqse Lo hpqsoo MH mm ab Ho as oo eozpoe mcfimamw scam mm mammfl ozom m m OH 0 Q OH mcompon o>flpod mm mHmHonmo HH>H0 m wH Om mm om om meHOHmmo Hmooa hp . oopcwomdw pcomm mafinomcomm 00 OH mH HH on mm gamma mcflmomcomm mm hoon HmoHpHHom Ili pamopom pGoComEoo Hmoflpflaom pmmo pmo: mopmpm pwmz pom: poem maemzomzoo qaoHquom Mm meoaeoma gagHamom qaonoam mo mzomHmamzoo emcee maax N N 343.98 137 and Southwest projects exhibit a high incidence of political bodies as sponsoring groups, the Northeast and Northwest projects a low incidence. The same relationship is true on the matter of the Sponsoring and operat- ing groups for the hOSpital having been appointed by local political officials. Some variation occurs relative to officials as most active participants, but the Southeast is ranked high, and the Northeast low. Even more variation occurs with such items as employment of the bond issue as a fund raising method, county or municipal ownership, and low participating personnel, but the Southwest and Northeast projects remain high and low, reSpectively. Attention to the rank order, sum of ranks, and the mean rank of the regional categories of projects in terms of the six identifiable politi- cal components reveals that the Southwest and Southeast projects are relatively high, the Middle States and Far west projects fall in the middle, or moderate range, and the Northeast and Northwest projects re— sult in the relatively low ranking.13 13Nany students admit of the high political content of the southern regions Of the United States. See, for example, C. C. Zimmerman, Outline of Regional Sociology, Phillips Book Store, Cambridge, Mass., 19u7, pp. 39-58; H. W. Odum, Southern Regions of the United States, University of North Carolina Press, Chapel hill, 1936, Speaks Of the southern regions as ". . . this all powerful political culture which is inextricably inter- related with the religious and moral culture of the peOple," (p. 525); and: "The folkways of southern politics may be set up as perhaps the most powerful of all the culture retionalizations which serve to satisfy the peOple and 'solve' their problems . . ." (p. 525); C. P. Loomis and J. A. Beegle, Op. cit., p. 30h, ". . . the plantation system for generations has permitted only a relatively few to initiate action, to make important decisions, or to engage in concerted community action;" and: "With the exception of Vermont and Oregon, all judicial-type governing bodies are found in southern states. Also, the single non—judicial-tvne Officer is a southern product." (p. 578); see A. F. Rape-3r in C. C. Taylor, 319 EL, In Table 28 an attempt is made to classify certain items that re- flect non-political (in the formal sense) components but a functionally and organizationally Specific content with a narrowly circumscribed area in which decisions may be made with authority. Although this classification is to represent the ranking of regional categories on non- political components, the converse of the former Table (27), it will be found that greater variation occurs. Nevertheless, the computation of the sum of ranks and the mean ranks for Table 28 demonstrates that some correSpondence is present, the Northeast and Northwest projects exhibit- ing in this case a high non—political component; and the Southeast and Southwest a relatively lower non-political component, with the Far West moving into the lowest ranking for the non-political component. Reference to Table 29 will demonstrate an attempt to classify the various problems met through the develOpment of a hospital project, and to compare the incidence of these problems in the six regional categories of projects. Although considerable variation occurs when the ranking device is employed, as evidenced by the relatively small difference between the high and low'mean ranks, attention to the mean ranks of the regional project categories indicates that the Far West projects tended Cont'd) op, cit., p. 355: "Throughout the cotton belt the county is the most important local governmental unit (in Louisiana it is the parish). The peOple of all groups are county-conscious, as shown by their customary way of identifying themselves as residents of a particular county; by the fact that the courthouse, which is Often the most imposing building in the county, occupies the central position in the county-seat tOWn; and by the public esteem in which county Officials are held in most cotton-belt communities." See also L. W} Lancaster, Government in Rural America, D. Vanhostrand Co., New York, 1937; and D. G. blShOp and d. E. Starratt, The Structure pf Local Government, The National Council for Social Studies, Bulletin 19, Washington, 1935. 139 3H 09m oo.m mm.m mmi 0H3 xcmc 983 N wH ma mm om mm mxsmp mo sum H m N o m 2 cm aN mm m 0H MN Hates no way pomnomm no qucompmd cmHm H N N a m m Na a: mm NH qN am aHamamczo defipmfloommm pfiwopulcoz H N m a m o No em on as Nm ms mcomtma m>Hpom mm mammmcms bemoadsm cam GmEmmechdQ cohoadsm mamm H m N a e m mm 00 me Ho 00 No Aapa>Hpow psmmmpa pan UmpomQOQm duopw mcfipomQOva oflwflomdm mHHNQOHpmNchmpO N H m b a m mm 04 SN 0 oN HH mNQHpmme apHcassoo pm Umpcfiomdm Amvpcmmw weapomcomm H m m m m a me am me an so am ncmmm weapochdm mm cowpmfloommm no Upmop Hmpfldmom Macho acmm psmopmm pamcomsoo pmmm pmmz mmpmpm pmmE pmmz pmww pmmm ewe: mmpmpm paw: ewes. pmme HonpHHoaucoz -apaoz -eptoz mHeeHa ham uspsom Izpdom Izphoz ISpLOA mHUUHE Mam Igpdom Igpdom :oamom mHZHZOMEOO AdOHHHQOLIZQZ Mm mBOfldoxm AfiBHmmom AHpomsH m>Hpom m>HpomcH m>Hpo¢ m>HSomsH m>Hpo¢ m>HpomcH m>Hpo¢ mnemSUsH ho meow mo mocobHocH mmbze mo mesmpHocH bee mo mommpHoSH moo no mocmbHocH mmochdm wqupommx pcmopmm maHpaOQmm pcmopmm mchhoamm paeopmm mchhoamx pcmonmm mo muHm meoflwOMA HdBHmmom 2H muHmenznaH Qz¢ mammMZHmDm mmamomuz mo DZOHB¢OHMHWmHAo m>HBonZH Qz<.m>HBo¢ H4 mqmerimental Designs 39 Sociological Research, Harper and Bros., haw York, l9h7. I“) 0 \J1 then more significant variations might be expected to occur. The remain- der of this summary statement will be given to an elaboration of these three statements. Area of use. The situation of develOping a project in a single administrative unit as compared with multiple units relates to some aspects of Sponsorship. With both municipalities and counties, the net effect of having a multiple unit project is to increase the odds that the Sponsoring group will be an organizationally Specific assobiation or board. In addition, the limitation of the project to the county unit results in a greater incidence of local governing bodies as the Sponsor- ing agent. Single or multiple village and town projects consistently report more formality as compared with the single or multiple county projects. Although not in a Significant way, it is interesting to observe that the occurrence of a multiple unit project tends consistently to increase the extent of formality in the organization of the sponsoring body. Also, the selection of Sponsoring group members through official appointment is considerably more employed in the Single county projects, while other types tend to more largely employ various community oriented methods. This evidence, although not conclusive, suggests that local governing bodies tend to be associated with county projects, but multiple county projects do not find two or more political governing bodies joining as the Sponsoring group. When administrative units are combined, the reported problems with influential persons tend to be more extensive than when projects are limited to single administrative units. The Opposite is true for prob- lems of insufficient feelings of need for the hospital, for single unit projects tend to be more confronted with this problem. The explanation for this finding may be that the combination of units into a single project is characterized by influential persons who represent somewhat autonomous systems of community influence, planning, and action, whereas the single community provides greater Opportunity for prevailing authority and influence systems to operate exclusive of others. This, then, should reduce the incidence of unintended reSponses from influential persons that Operate in other influence or authority systems. Moreover, the multiple or combined projects rests on a wider economic and service base, which may tend to reduce the usual Oppositions of a financial content and beliefs that the hOSpital is unnecessary. Varying area of use structures did not relate in an observable way to the history of previous activity of the Sponsoring body, community wide lack of "leadership," and the incidence of difficulty over threatened high taxation. Extent 2f hospital need. Projects with a relatively low need for a hospital tended to employ more frequently the hOSpital association or board as the Sponsoring body, although extent of need did not seem to influence the presence of local governing bodies as Sponsors. Extent of need was not related consistently to such characteristics of sponsoring groups as formality, the methods of member selection, and the history of other activity. Problems of recruiting "leadership" were more largely felt in the high need projects, as well as the resistance over threatened high taxes . Extent pf rurality. hodcrately rural communities tended to be more frequently Sponsored by hOSpital boards and associations than either the most or least rural projects. however, political Sponsorship occurs more greatly in the most rural projects, as well as the Sponsorship of community councils. Rurality has little effect on the formality of the Sponsoring boCy and the methods of member selection. The most rural projects tended to have worked more on previous community projects. Very rural projects reported more extensive problems of the lack of "leadership," with influential persons, and with medical doctors. Rurality did not materially influence the problems over threat of high taxation, but the least rural projects did report a higher incidence of prevailing beliefs that the hOSpital was unnecessary. Per capita income base. This situational factor was related to a number of the phases of Sponsorship. It was the high per capita income projects that were Sponsored by Specific hOSpital boards and associations, while the economically disadvantaged projects tended to be more greatly Sponsored by local governing bodies. In addition, the Sponsoring and Operating hospital groups were more formally organized in the more wealthy communities. High income projects used community oriented methods to select members to Sponsoring bodies, while the low income projects tended to employ appointments by local officials. Little difference occurred with this factor as to the history of Sponsoring group activity on other projects. m O 0“ High income projects had more difficulty with beliefs about the hOSpital being unnecessary, and with resistance from outlying areas. Financial problems were greater in the low income projects, as might be expected. Total pppulation. Of the five Situational factors the extent Of total pOpulation in the service area seemed to have less effect than any other factor. In several instances it seemed to be linked with the income Situation, but did not produce as great variation. Since the hospital project is, in sum, a financial problem, it may be that extent Of total pOpulation is one kind of economic factor. Patterns. Although the five Situational factors demonstrate vary- ing relationships to some aSpects of Sponsorship for hospital projects, in many instances inconclusive, the following two patterns seem to be suggested. The first pattern is that of the economically more wealthy Situations, the projects of which were more largely Sponsored by associ- ations or boards; oriented to municipalities as units in the service area; relatively low in rurality and extent of hOSpital need, encounter the usual problems, but with a somewhat greater problem of beliefs that the hOSpital is unnecessary. The second pattern is that of the more economically disadvantaged situations, the projects of which were Sponsored more largely by local governing bodies; oriented to counties as units in the service area; relatively more rural and with greater need for a hospital; encounter the usual problems, but with relatively greater problems of lack of local "leadership," difficulties over threatened high taxes, and with pro— fessionals, eSpecially medical doctors. Throughout the analysis of this and the previous two chapters, ordering the data has followed from the assumption that the political content of Sponsorship provides an initial starting point. hence, the dichotomy was employed Of the projects sponsored by formal and political local governing bodies, and those Sponsored by organizationally Specific hOSpital boards and associations. Earlier treatment has demonstrated that other aSpects of the community organizational process were linked in particular ways to these two groups of projects. Analysis was then continued in terms of regional groupings of projects, with the assumption that if political and non-political projects were dichotomous groupings then their respective incidence in regional groupings would be followed with differing community organizational profiles for the regions. Regional differences in community organizational profiles refer to possible explanations which are, in effect, hypotheses. The first is that historical and cultural orientations of different geOgraphical areas of the United States have produced varying normative arrangements for the solution of community problems. The second is that because different geographical areas of the United States feature community settings that vary in certain situational characteristics, it would be here that one might expect variations in community organizational procedures. Before this could be true, however, some general relationship must exist between particular community situational features and community organization, eSpecially Sponsorship. Community Situation preponderances. Reference to Table L3 will in- dicate that considerable variation occurs in the relative economic bases 210 TABLE t3 PER CAPITA INCOME 0F SthICE.AhnAS FOR 215 HOSPITAL PROJECTS DY RLGIQN M Region (dgllggg) Percent Percent Percent Percent Percent Percent Percent 000-399 35 8 00 2 00 00 10 too-599 Lb to oo 20 10 oo 22 {£0-799 lb, 16 ll 37 28 25 2h 500-999 5 32 33 27 37 29 25 1000-1199 00 h 33 12 2o 21 12 Over 1200 00 00 23 00 5 25 6 No reply 2 00 00 2 00 00 1 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 hO 2b 218 of regional groupings of projects. The Southeast and Southwest regions have relatively less wealthy situations for the hOSpital projects. The most sharply contrasted difference is that between the Southeast and the Northeast, for the former is characterized by 79 per cent of the situations with less than $599 per capita income, and the latter, with no projects this low, but be per cent above $1,000 per capita income. The Far west projects do not, on the basis of this factor, follow earlier comparisons in that they compare most closely with the Northeast projects, with 56 per cent above $1,000 per capita income. 211 Reference to Table hh will Show somewhat similar variations in the extent of rural pOpulation Of proposed service areas. Seventy-five per cent of the Southeast projects and 60 per cent of the Southwest projects had service areas of more than 60 per cent rural population. The North- east projects are different in that 5h per cent are below O9 per cent rural pOpulation. The other three regional groupings vary from previous patterns, the Far west being relatively less rural, the Northwest and Middle States relatively more rural. TABLE bu PEhCENT 0F RURAL POPULATION Ih 216 HOSPITAL SERVICE ARLhS bY REGION Region Percent Of South- South- Far Middle North- North— All Seizigitiiea east west west States west east Projects Rural Percent Percent Percent Percent Percent Percent Percent 00-29 00 OO _ 00 00 5 00 l 30-h? .u 16 00 7 5 9 6 50-69 8 8 l7 l7 lO h5 16 70-79 11 16 50 3h 10 25 23 80-89 26 12 6 23 23 I 17 20 90 and over b9 us 27 17 t7 t 33 No reply ' 2 oo oo 2 oo oo 1 Total percent 100 100 100 ’100 100 100 100 Total number 52 25 19 58 LC 2b 218 Attention to Table h5 will provide some comparisons Of the adminis- trative structure of the service areas. Although the county as the unit is important to all the regional groupings, the Southeast and Southwest reported this most extensively, the Northeast and Northwest least fre- quently. The Southeast and hortheast projects vary greatly as to the incidence of multiple county projects. TABLE hS ADMIE STRATIVE STRUCTUnE 0F THL.ARSA OF USE FOR 216 hOSPITAL PROJLCTS DY REGION . Region Type Of SerV1ce D (Admihi::rative South— South- Far Middle horth- North— All Units) east west ‘West States west east Projects Percent Percent Percent Percent Percent Percent Percent Single village, town, or city (with trade area) 6 8 23 13 2o 9 12 Multiple villages, towns, or cities h 8 16 22 22 5O 20 A single county 55 71 hé hS 31 32 ht Multiple counties 35 13 15 2O 27 9 20 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 to 2h 218 The above three community situational factors have demonstrated the greatest differences as related to Sponsorship of hospital projects. It will be seen from this brief summary that the Southeast and Southwest projects are those with the highest rurality, the lOWest economic base, (\3 H bu and the greatest use of the county as the principal administrative unit in the service area. It will be also seen that the Northeast, and to a less extent the Northwest, have been characterized by service communities that are of lowest rurality, the highest economic base, and the greatest use of the single or multiple municipality as the principal administrative unit in the service area. TABLE us PEECENT OF hOSPITAL NaED uLT FOR 218 HOSPITAL PROJECTS CY REGION Region Percent South- South- Far Middle horth- horth- All of Need het east west 'West States west east Projects Percent Percent Percent Percent Percent Percent Percent 00-19 51 52 SO 67 62 17 53 20-29 8 16 6 8 16 u 10 30-39 6 12 00 10 10 25 10 hO-h? 10 12 6 S 2 33 10 50-59 6 00 11 2 3 13 S 60 and over 17 8 27 6 7 8 11 No reply 2 00 OO 2 00 OO 1 Total percent 100 100 100 100 100 100 100 Total number 52 25 19 58 b0 2h 216 2111 Tables he and h? deal with the remaining two situational factors, both of which were neither significantly nor consistently related to variations in Sponsorship. Part of this may be due to the fluctuations, and lack of pattern, in the extent of need and total pOpulation for the service areas. In Table L6 rather comparable need patterns have char- acterized the various regional groupings, with the exception of the Northeast with projects of relatively less need. (note that Table hé is organized in terms of percent of need met.) In Table h? a tendency appears for some patterning of regional service area pOpulationS, with the Southeast and Southwest projects representing relatively smaller total populations, and the Northeast with service areas of relatively high pOpulations. Finally, Table h8 summarizes the comparisons treated in more detail earlier, namely, the relationship between the five situational factors and the nature of the official Sponsoring group. Reference to this sum- mary will indicate that the economic base of the service area, and its rurality, are related to the type of Sponsoring group. High rurality and low economic base are linked to political Sponsorship. Moderate rurality and high economic base are related to associations and boards. Further, both low need and municipalities as units of the service area appear related to Sponsorship by boards and associations. Summary comments. The foregoing analysis has explored the relation- ships between five situational factors and Sponsorship in hOSpital pro- jects, and has summarized regional characteristics in terms of these Situational factors. The question to be answered deals with the extent 215 TABLE h? TOTAL POPULATION OF SERVICE AREAS FOR 218 HOSPITAL PROJECTS BY REGION hegion South- South- Far Middle North- horth— Total POpulation east ‘ west ‘West States west east Total in thousands _ . . . . , - ( ) Percent Percent Percent Percent Percent Percent Percent 00-09 9 28 3h 2 22 5 13 10-19 27 56 22 36 32 OO 30 20-29 27 l2 17 35 13 12 22 30-39 15 OO 5 13 2O 21 1h hO-h9 S 00 S S 3 00 b 50-59 h 00 6 2 00 h 2 Over 60 11 h 11 5 10 58 lh No reply 2 00 oo 2 00 oo 1 Total precent 100 100 100 100 100 100 100 Total number 52 25 19 58 hO 2h 218 to which preponderant Situational factors in certain regions are congruous with the political and non-political content of hospital projects. For instance, an incongruous condition would be present if rurality were in- versely related to political Sponsorship, after one would determine the heavily rural nature of hOSpital projects in the Southeast and Southwest and their greater incidence of political Sponsorship. An incongruous condition would result if income base of the service area were directly related to political Sponsorship, after one would determine: the low 216 ea mm Ha Ha mm aa mm ea am Ha mm mm mm mm Ha ma aaaea ea Hm nH mm Hm mH Hm JH NH mm :m 3H Om Om mH mm mH mHHosdoo :pHmm; paw thfiSEEoo mm ,ea Hm am am OH OH am pm mm ea mm am pm N am paaeee Heeaaaaoa HmQHoHCdE to hpCSOU op pm pp am am ca am at pm we ma am 00 mm cw pa meeaeeaeemae bum mbpmoo Hmpfiamom 30H .poz :me 304 .Uoz_:mH: 30H .eoz zmwm 30A .boz_JMHm mmeQSOD handoo mazey fizoe macho mQHmomcoam nOHPdedom fleece mm mm OHEocOom aeaaeaae .8 seesaw eeea we esteem aaaaaaae maeeam aaaaeaaa aaaeam mm: «0 mmh4 mo each popowm HmCOHpmSpHm mpHQSEEoo mmoeomm HAZOHedpaHm NBHZDEEOQ M>Hm Mm mmzomw UZonmzomm LO mzmom mo_MMdflaDm mg flqmital predect demon- stra 1380 such conments to have validity. iciations. As was the case in horwest, the ‘CI LJV Integration through as " ”sociational life of I‘loreast constitutes an important dimension of the 33tting in which decision-making occurs. Significant here is that the city of Koreast is a relatively autonomous associational complex. Although City-centered associations link with a few countg-aige organi— zations and some rural representatives par icipate fully in Loreast, nevertheless the relation of city to county appears Quite nebulous, horeast relates to a somewhat discreet social organization are community treblems are large y city problems, Three associations, largely composed of Koreast business and professional representatives, stand out as particularly relevant to con- tinuing problem-solving activities. These three Were ranked by horeast informants as notary, Lions, and the horeast Xoung Woucn's Service Cluo. ’znization that could E: .s the or L—t'o Informants agreed that the Rotarv Club most successfully initiate major community and civic projects, Rotary differs from Lions, in the composition of membership, by repreSenting ‘more of the businessmen and prosperous commercial farmer , with the Lions Club somewhat more oriented toward the professions. Informants conveyed the general impression that the notary Club was viewed as a higher prestige group than the Lions. Significantly enough, not one informant spoke of a county-wide organization, such as Farm Bureau anu Grange, that might initiate projects in the "community" of Noreas , Located in one of the business buildings of Noreast is the Aoreast Club, an exclusive male club devoted to informal recreational functions for its some 60 members. Organized about 20 years ago as an athletic club, the Koreast Club nOW'prevails as a dining and recreational center for its members, Due to the selective prOCesses involved in recruiting members, the horeast Club obtains in its somewhat informal arrangement ' I those representatives of the business and professional life 01 the com- munity who constitute keys to the influence structu~e of the community. Since the Noreast Club is so exnressive of the middle class business and professional group along Rain and hill Streets, it is viewed with some suSpicion by the "peOple across the canal." Some of the recrea- tional pastimes of the Noreast Club are considered "too liberal" by more orthodox groups in the community and, even among the members, some differences of Opinion prevail as to the rules of conduct, involving "drinking," and "card—playing." Since the objectives of the horeast 3 ub exclude the formal Sponsorship of civic projects, together with the images mentioned above, it was not viewed by local informants as an in- portant group for Sponsoring projects, The function of the Noreast Club is to bring the influentials of horeast into a recurrent series of in- formal relationships. Another important component of the organization of horeast is its churches. The Italian and Polish population provides strong Catholic denominations, and the business and professional influentials generally are active in the usual Protestant denominations. An important denomi- nation is the Presbyterian and a number of civic influentials hold active offices within this denomination. The religious organization of horeast is to be mentioned in a pointed way in that local informants indicated in a may not previously encountered that the churches here im- portant in "putting things across in Noreast," Their particular relevance to the hOSpital project will be examined in a later analysis, Finally, horeast presents a Specialized orsanizational arrangement not heretofore encountered, due perhaps to the already existing hOSpital 29b in the community at the time the present hOSpital project was initiated. Present was a hospital board, charged with administering the old hOSpital. Three members of this board had assumed these offices held before by their parents. To this extent interest in local hospital facilities tends to have a family history. Assisting the duties of the hOSpital board are the "Twigs." ‘he Twigs are a series of 28 women's groups which, together with regular pregrams of interest to the members, maintain club projects that Specificallr render financial or material assistance to the hOSpital. That they have a tradition in Noreast is evidenced by the year of organization, l9lh. The Twigs are composed of the wives of horeast business and professional men and encourage the introduction of hospital concern and duty from mother to daughter. In addition, the Twigs constitute one visible expression of the infonnal social arrange- ments of the women in Noreast, Although the manifest function of the Specialized hOSpital organizational structure is devoted to the mainte- nance of a hOSpital in the community, its latent function is that of bringing into an informal focus many of the associational and religious aspects of the city of Noreast, The behavioral Set. As the "factions" of Southeast county were known to its residents, the people of Loreast seem immediately aware, as they reported, of certain "teams" composed of persons With a long history of informal and friendship relationships, and with a record of participat- ing together in the initiating and the carrying out of civic projects. Informants quickly reported that certain persons in horeast "went together," and that one could always predict this relationship in community affairs. 295 These "teams," termed here a behavioral set, have developed from particular histories of reciprocal obligations. Later analysis Will demonstrate their relevance to the Noreast hospital project. C. Empirical Decisionaiaking System ”he available evidence for the social arrangements within which decision-making for major projects occurs in horeast suggests two over- all conclusions: (I) that Noreast, for the decision—making context, con- sists of two segments, the city and its business and professional organi- zation and the immediate hinterland of a rural trading area. Different from Southeast the locus of decision-making moves from an out-county social organization to the main street of the city. The rural hinterland is relevant only to the extent that a few commercial farmers have ready and fluid access into participation in the associational and religious life of Noreast, (2) The organization of Noreast for purposes of com- munity problem-solving is, as it were, multidimensional. by this is meant that differing community issues will tend to call forth differing segments of the community. Life would seem to be extremely Specialized in horeast, and the way that the resources of the community articulate to bear on a particular problem would seem to depend on the manner in which associations view the problem as a part of their social domain. In this way the domains of decisionrnaking would seem to be many and varied. Political organization. Although Noreast serves as the county seat for Mary county, no references could be drawn of county political organi- zation having any relevance at all to the civic affairs of Noreast, The 29:3 demands of operating county government appear similar in Mary county to those of the previous cases. but municipal concerns of Civic signifi— cance to horeast apparently are resolved through the autonomous arrange- ments posited in Noreast, Even the city council of horeast would appear to have a limited domain regarding public projects, eSpecially in initiation. here the projects tend to be limited to the improvement and maintenance of the city physical plant, tranSportation, and communication. Much of the civic activity in noreast revolves around plans and pro- Cedures to assist certain service prOgrams, such as the Boy and Girl Scouts, Red Cross, volunteer health agencies, recreation for youth, church "benefits," and supporting the extra-curricular events of the schools. Such civic affairs fall outside of the domain, apparently, of the city's governing body. In the previous case studies one could not possibly attempt to re- construct the sequence of events in the hOSpital-getting process without eventually casting it into the midst of larger and generally applicable settings for decision-making; hence, the varying relevance of county and out-county political organization and the relation of county associ- ations to the articulation of authority and influence structures. But the Noreast case must be viewed in another way. First of all, it is an autonomous grouping that the present research does not reveal was clearly linked to larger arrangements, except in the Specializations in extra- community affairs that result from Special interests. Secondly, horeast aresents a series of social zones, which have domains and "rights" in certain problem areas. Hence, the earlier theoretical treatment would 297 suggest the explanation that Noreast's decision—making setting fines its locus in an influence structure, expressed through the associational complex of the city of Noreast, and that the articulation of an authority structure, i.e., formal political offices, is not necessarily required for the functional operation of decision-making processes. This, of course, does not mean that decision—making involving financial civic projects is wholly self-contained in hereast. The hOSpital project was related to the Gately Hospital Council, which is concerned with several counties, as well as officials of the dill-Burton program of federal assistance. hevertheless, the relationship from the standpoint of noreast was carried out through the presently defined capacities of influence, and did not proceed through an intermediate process of formal political legitimacy. Although in previous case studies county governing bodies played varying roles, no such process stage was evident in h reast. These conclusions must recognize that the Noreast project did not employ political instrumentalities, i. e., bond issues, to provide for the local share of hOSpital construction costs, but rather a voluntary public subscription of funds. An Operating hospital was already present with a Specialized supporting organization. These two characteristics may explain the Specificity and the predominant influence content of the horeast project, or, the Noreast project initiated from a community situation differently organized from the standpoint of a hOSpital. An earlier cited analysis, however, revealed that eight in ten of the north- east projects employed the voluntary subscription device, which undoubt- edly relates to the analysis above regarding the separation of authority and influence structures. {\D \O Of‘ Associations and influence. An earlier cited statement provides a cue for the present analysis: “If you want to understand Noreast you have to know what happens at the corner of Main and hill Streets." The leading question becomes, “What does happen there?" The main corner of horeast appears no different, physically, from that of the usual city with a pOpulation of 5,000. The corner building is the local bank, a branch of a chain headquartered at Oakton. On the second floor of the bank building are the club rooms of the horwast Club. Each week finds some 50 members of the Noreast Club coming and going from the bank building and the club rooms, for purposes of dining, a game of billiards or cards, and the frequent Saturd y evening party to which Wives are invited. Each week will also find five men meeting in the di- rectors' room of the bank, to retire upstairs to the Noreast Club for lunch; for the five men are not only members of the Club but two of them are it organizers twenty years previously, a third is its business manager, and the fourth is one of the popular members. The horeast Club first began as an interest of two man. One was the son of a wealthy landowner and investor, newly out of a prominent Eastern university; the other was the son of the owner of a well—known printing company in Noreast, The two sons had traveled tOgether to Latin America on an extensive trip, met regularly with others for recreational activities. Today the first has succeeded his father, is a wealthy gentleman farmer and investor, Spending time in Oakton on business affairs and in Noreast as a member of the bank directors and the only president of the horeast Club. The second has taken over the printing company, is 299 a member of the bank directors, and continues as a prominent member of the horeast Club. The president of the bank, new to the community by some fifteen years of residence, serves as business manager for the Club. The fourth director, a wealthy vegetable produce broker, is the chief link between the bank and the credit arrangements of the rural peOple in the entire county, This group is a crucial "behavioral set" in horeast as it concerns the initiation and completion of larger civic enterprises. The public images of these men might be summed as follows: For the printing company owner: "The personification of Noreast;" for the wealthy gentleman farmer and financier: "Money and vitality, what else do you need?" For the vegetable broker: "Knows everyone in the county;" and for the bank president: "No influence outside of Noreast, but a smooth Operator when it comes to organizing," The informal proceedings that take place daily at the Noreast Club do not overlook much, for discussion purposes, that concerns the life and times of Noreast, Although the horeast Club does not declare formal— ly the sponsorship of particular‘civic enterprises, it does consoitute an arena in which strategies are deve10ped involving both the community and.recalcitrant members of the Club, .As one hOSpital official sta ed in Catelj, "When you go to Noreast to consult about the hOSpital, you will eventually end up at the Noreast Club where the business will con- tinue from there." fieciprocal oeligations renarding civic activities are displayed and tested in the informality of the Noreast Club. For example, A one of the almost legend pastimes of the Club is a veritable potletch. \1) O C) It may be depicted by some such conversation as follows, flowing from a group of the Club members gathered informally for a "game." First member: "I just happen to have some tickets for the church supper next week. I think each of you will have a hard time get- ting out of here without buying one." Second member: "The church supper is fine, but the Boy Scouts are in need of a donation right now. I'll pay double for your church ticket if each of you will throw in e to the Scouts." Third member: "But the hOSpital needs a new . I would buy three tickets for the churcn supper in trade for d to the hOSpital." Other members: Etc. The present elucidation in regard to the Noreast Club has been made in order to accent the point that the some 60 members of the Club not only repreSent the associational life of Noreas , but in its memoers is posited the official associational leadership, Although the association- al structure is multi-dimensional, or having prescribed domains of reSponsibility.and decision-making rights, its complexity is in part articulated and resolved by the events of the horeast Club. The functional contribution of the horeast Club, however, is related to, and supported by, certain high ranked associations. Three prominent associations in horeast were continually cited by informants as the "kind of groups that usually get things started." Informants ranked them on the basis of usual initiating reSponsibilities as the Rotary, Lions, and Women's Service Club. Three of the four men noted above are members, and former officers, of the Rotary Club, and the fourth a standing prominent member of the Lions. If one were to 30l conceptually view the social arrangements within which decision-making .is carried out, from the vantage point of the horeast Clue, both the Rotary and Lions Clubs Would have to be two of the important terminal points. both of these associations serve to incorporate the capacities of some rural influentials, and the city prcfessionals. To this point, and inclubiné tie previous case studies, the presenta- tion has excluded women in either roles of authority and influence in projects of the magnitude of a hospital. Indeed, the hOSpital-petting process has been an essentially male activity. For the must part this has been true of horeast. nevertheless, the associational complex that involves women in Noreast is important in civic enterprise, but it is contained distinctly from the one involving men. Depending upon the project studied in the Koreast community, One would find himself viewing the organized women's associations as almost a "different world" from that of the men. r‘hcre is, indeed, a counterpart of the Noreast Club for the women, the Silver Club, with club rooms in the same sank build- ing, and from it the ties lead to the Women‘s Service Club, the "Twigs," and the church groups. Women make themselves felt in the civic affairs of Noreast but they are subordinate to men in projects of financial 1tagnitude. The churches of Noreast participate as groups in the general conduct of‘civic enterprises, although they do not Serve as the sponsoring agents. QForemost is the Presbyterian church, in which two of the four men cited above hold active memberships, and one is the presiCing official in the church governing body. This latter official contributed a statement which inoicates the manner in w} ion the Church mayo co ..stitnte a "plat- ‘re cefinen as "COmnuthj C' O C“ b P (r (0 (,n ct :3 C‘ p) form" for Springing in improvement." "If you are going to he active in the community, you have to have sore "roup that Jou can depend on--that will tack you every time. In my case, I feel tha't serving t1;e cowmunityi one way of being a good Christian, 50. etimcs I'm rot “vais sure that all the groups I belong to will each ne up in a pinch, out I know the church will." ‘0 In addition to these core groLps are many Lore, an understandin of I) which could be yielCed by only a conylete stuev, .A great nanoer of fraternal 100 chs, professional societies, a r~porte C 22k Glitter of Commerce, veterans organizations, and wome1‘s clubs--nould fill the clan roster Of horeast, The above analysis has viewed the organizational setting for Cecision— making as it related to the largely micele class, olC American segment of the pOpulation. The associational life of the Italian ans Polisl centers "on the other side of the canal," ano corsisis of a number of J c' 1" , L.) O, et :Lnic oritnte L clubs. The community activi these groans is focuseo in tle ir Catlolic denominations A recent priest nelonned to the horeast Club, which proviocd some linha5e. In the rur;'1l are as one finos the usaal associations, such as the Farm Bureau, home eitension clubs, ans certain county—wi iie Special interest groups devoted to the horticultural enterprises of the area. They, however, follow their mani I st furictions and do not provide a mechanism of articulation. In the hOSpital pro eat, the county-wide organizations assisted wit} certain organizational and financial details of fund raising, out it was imcossible to ascertain 303 their relevanCy to the arrangements centereo in Loreast that mace, legitimized, and carrieu out the decisions resulting in a hOSpital. Sum 9F . In some respects tne striking cOnclusicn of the horo-st decision-making System of relationShips related to major civic progects is that it presents no authority arcncy in the form of a local governing C) .1 body, but the the organization of the capacities of influence is pre- dominant. The problem here, as it was in southeast, hid-State, and Ear- west counties, is £93 the articulation of influence and authority agencies and structures. Insteac, it is to gain coherency in a se mentaliZeu associational structure, in which the capacities of influence are diffused. In this way the associations of Noreas are truly Special interest and they would appear to have relatively well cefines ocmains of responsibility for decision-making in differing orders of civic issues. In a maJor project, reQuiring the mobilization of rather complete consensus and finances, the oomains of the associational structure must be collapsed in favor of a common an and a Joint employment of means. In horeast this proceuure becomes possible through a pyramioing of both associations and influence, to the point where a few persons have control of the total influence capacities (resources and proficiencies) that are present. D. Important events in the fioreast Hostital Project The horeast community enjoyed a small hospital for some LHUUtJ years previous to the initiation of the present project in IQLh. The old facility was a converted dwelling. Community informants provioed numerous reports that the old hoseital had been decreasing in desirability. One person said, "The old hOSpital had become so crowded tha* (r H (h (I) H (‘4 they were using bathtubs for beds." Another stated, "The bis worry of mine was that newborn babies had to be carried up two flights of drafty stairs from the delivery room." It was reported that local discussion had been provoked over a local man having been injured, then refused admittance to the horeast hOSpital due to lack of room, and had later died in a neighboring hospital. The informants agreed that they believed, in l9LO, that a new hospital was needed and felt that this to be a general attitude in the community. In the two-year period following lihO, hospital board minutes indi- cated that freQuent mention had been made of the possibil'ty of a new hOSpital. From l9h0 to l9hh the president of the hOSpital board had I stated to many "his dream" of a new hoSpital in Noreast, and the board's tribute to him on the event of his death included a statement about this "dream being realized." The central figure on the board in l9LO was the owner of a local printing company, whose father had preceded him on the hOSpital board. In this same year, this person invited a wealthy land— owner and financier, his lifetime friend, to become a member of the board. These two men began to function together in matters pertaining to the hOSpital and on the death of the board chairman the wealthy landowner became president, the printing company owner the vice-president. flith this event, the administration of hOSpital affairs was reported to nave taken on a new vitality. A new fire escape System was installed, a new hOSpital supervisor was employed; and negotiations Opened with the bately Regional hospital Council. The latter negotiation was to secure the services which the Council provided for small hospitals in the area, In September of l9hb the vice-president of the hoSpital board, the printing company owner, read of the successful attempt of a nearby com- munity in raising funds for a new hOSpital through the employment of a professional fund raiser. He contacted the president of the board and the two of them investigated the merits of the particular fund raiser employed in the other community. Satisfied with the results of this investigation the two men discussed with the fund raiser the possibili- ties of a similar venture in Noreast, The professional fund raiser agreed to Spend two weeks in Noreast in an attempt to ascertain the feasibility of fund raising for a new hOSpital. This was done under a pact of secrecy between the three men, with the expectation that the fund raiser would report to the board if the venture was deemed possinle. During the intervening two weeks the two officials of the hOSpital board contacted the local bank president in order to obtain his coOpera- tion if the report came back as favorable. The bank president abruptly refused his COOperation on the grounds that the proposed amount, plZS,OOC, could never be raised in Noreast, for as he stated: "This is a $.25 and $1.00 community." The two hOSpital board officials prevailed, however, when they indicated the extent to which they would support their inter- est by personal contributions. One other person was informally contacted and presented with the plan. This was a wealthy vegetable broker, who joined with the previous three as a director of the local bank. In addition, he was reputed to "know the rural peOple better than anyone else in the county," and had long been prominent in the horeast Lions Club. This person approved the plan, as reported, on the grounds that (l) the bank president be- lieved it to be feasible, and (2) of his history of COOperating with the three men on other community projects. After the completion of the two-Week investigation by the profes- sional fund raiser, he appeared before the hOSpital board and presented a favorable analysis, According to the board minutes, he made an "excellent impression." The board members indicated that at the time of the meeting they felt some reluctance because of the possible "public attitude toward an expert coming into the community and taking money away with him." The two officials of the board who had earlier initiated the idea observed that the "board was worried about the expert and the bigness of the job. Yet, the fund raiser had all the answers that night, said the cost would be less than five per cent, which is as low as anyone could do the job, a local person or anyone else " Informants generally indicated that the community at large supported the hospital board in its approval of the new hOSpital project by means of a subscription of funds with the services of a prefessional fund raiser. The majority believed that the board had the right to do this, that it represented the community, and that "no other group could have done it." But five of the L2 informants believed that the board should have communicated more with the community. The informants generally agreed that the professional fund.raiser was necessary because of the efficiency and competence which he would provide. Following approval of the professional fund raising plan by the hOSpital board there followed a series of informal discussions, largely 307 centered in the horeast Club. Presentations were also m de at other horeast associations, particularly the Rotary and Lions Club, and an extensive newspaper publicity campaign initiated, Almost immediately the professional fund raiser arrived in the community to initiate the fund raising campaign. The campaign phase of the horeast project brought to the community a complicated finance campaign. This was, in effect, a short-run bureau- cracy. The four men cited above were placed in functionary roles in an organization of the community that put some COO persons to work. Each worker occupied a role with a title, answered for others below him, to others above him. The goal was no longer the more general idea of a new hOSpital but had become Specifically defined as a sum of money, or el25,000. The professional fund raiser became, by contract and public announcement, the director of the campaign. For the short—run period of the campaign the fund raiser brought to the community a new set of norms and at least a Short course in the develOpment of bureaucracy. werkers in the campaign were trained in the tactics of gaining money pledges from friends; for, in fact, one of the basic rules was that of seeking out a relationship of friendship and of obligation. Each worker was given maximum reSponsibility to select his subordinates and to proceed to obtain a pledge from them. It was argued that this would encourage the sub- (D ordinat in turn, to aggressively get pledges from his acquaintances. 3 At this stage it was no longer a question of whether the hOSpital idea was legitimate or not but "how fast can the goal be reached." hote the , - following statement included in a written report submitted by the fund K») C‘) (‘r‘ raiser to the hOSpital board in securing the contract. From our knowledge of your community and its peOple, we believe that at this time we could recommend the well known short term campaign, in which the preparations are begun and the campaign runs its full course over the Space of a com— paratively few weeks._ This short term campaign involves the rapid concent‘ation of all the forces allied to the institu- tion, and the application of this power over a very limited period. It can be used in your case because we believe sufficient power exists, because the appeal which you can make is now sufficiently clear in the minds of the public . . . As important as is the develOpment of man-power, it is also essential that the mechanics of the campaign be thoroughly organized; the endless detail of office routine; the proper de- velOpment and checking of prOSpects to the best advantage for solicitation; the secretarial work of the committees, team members, and the thousand and one other things essential to a campaign. For those individuals who played official roles in the campaign organization, Speeches to committee and other group sessions were pre- pared and standardized by the professional fund raiser. In addition, 6h different printed or mimeographed forms, letterheads, and publica- tions were counted as a portion of the campaign materials. At least 30 different letters were prepared and sent to the some oOO workers in the organization. A great variety of Operations were deve10ped that in- cluded teas for the women, appointment of a great number of committees (building, Finance, Rating, Special gifts, Etc.), and planning and action meetings on the various levels of the campaign organization. With the intensive portion of the campaign occurring in the last two months of l9ht, by February of l9h5 the original amount of funds (d125,00C) was over-subscribed, or elSE,OOO. By this time the problem of certain of the previous case studies became apparent, namely, that the amount on hand would not be sufficient at current building costs, iiiil Illlll ‘1‘ [III III‘ 11 309 The evidence does not suggest that the alternative plan of a bond issue was conside ed. Instead, the available funds Were convertec into treasury bonds and the board decided to withhold construction until a more advantageous construction period would arrive. No important events occurred until l9ht, although during the intervening period encourage- ment was derived from the passage of Hill-surton legislation. In the fall of l9h8 Noreast was given a high priority to receive a federal grant to assist in defraying hospital construction costs. The details of this event were handled through the offices of the Gately HOSpital Council, with the president and vice-president of the Noreast hOSpital board representing the local project in the negotiations. By this time the proposed hOSpital was defined as a 50—bed facility, with an estimated cost of dht0,000. During the inactive period from early 19h; to l9h8, additional pledges in the Noreast community increased the earlier subscribed amount to approximately $200,000. Since hill-burton funds were to provide one-third of the costs, additional funds were re- quired. These were secured by a grant from a foundation, negotiated under the auSpices of the dately HOSpital Council. The amount obtained was $92,000, which made it possible to initiate hOSpital construction. It should be noted that at no time was there a consideration of returning to the community for additional subscriptions or legal measures. In fact, as it was reported, the original four initiators considered taking a personal reSponsibility for obtaining the needed deficit. With the de- tails for construction being handled largely through the arrangements of the Gately Council, ground was broken for the horeast hospital in march 1950. 310 -v~ Koreast Summaig. The important comparative feature of this case study is the absence of reguirec articulation of authority and influence agencies. The only approximation of an authority structure was the con- tinuing hOSpital board with publicly approved rights within a restricted jurisdiction. The methods selected and the subsequent events in the mobilization of consensus and resources in horeast would seem to con- sistently indicate that this hOSpital project was related to decision— making systems and processes functioning through the capacity of influ- ence. Although a portion of the legitimizing function for decisions made was posited in the hOSpital board, legitimacy appeared to be expressed through a few community roles of public responsibilitj. hence, legiti- macy was built into the roles played Ly a few men, and the hoSpital board, as an authority agency, became a sounding board of approval. Thus, the condition that only began to be evident in horwest county, namely, decision-making geared to influence and a resulting high partici— pation of local peOple, found its real extension in Noreast, Important at this point is that in the previous four studies the authority agencies were generalized structures for decision-making, i.e., the county govern— ing bodies; while in horeast the related authority agency was specialized and the various roles of influence in the community were generalized. This reversal means that the real proolem was not one of articulating authority and influence structures but one of articulating diffused in- fluence and collapsing it to a common Set of means and ends. To under- stand how this was done in Noreast is to understand how the community obtained a hOSpital. 311 The arena for deCision-mz' n. was a series of settings permitting well-cef ned informal sets of relationships. Impressive throughout was the "symbolic behavioral set" of four men with a long his tory of re- ciprocal Obligation and joint community participation. hot only did the initiation of a new hospital flow from this relationship, but dependent on it was the develOpment and Operation of a short—run campaign bureau- cracy. This relationship set_enjo3ed a permissive public image as well as important accesses into the associational structure of Noreast. In fact, tie four men controlled not only the a5 ency' of approval, the hospital board, but the important or_anizational loci of infllence in the community, i. e., the Noreast tCluh, the hlotaly Cl 0, and the Lions Club. In these ways what happened in horeast was a deployment of in- fluence rather than a deployment of both influence and authority. Without the presence of formal political authority and the use of politics al instruxm talities for fund raisin5, such a singular deployment of influence resulted in a brief stage in which a bureaucratized finance campaign de v loped throW ;h the or5‘ anizational and ideological skill of an extra-community professional fund raiSer. Althou5h this snort-run organization recruited the influential OUTSOfiS of the community, it functioned rationally in terms of the specific goal of a sum of money. The fact that its structure developed around a 5reat number of temporary offices leads to the conclusion that the campaign organization constituted a simulated authority agencv constructzd on the influence base of the com- munity and serving to collapse andt annelize the attending social 'ro erties in the communit". P P J w }-J l\) Finally, horeast presents an entirely different administrative unit in so far as the service area of the hospital is conceried. In horwest county, the appropriate antihistrative unit was the county, but decision-making was largely centered in horwcstville. In horeast, decision-making was not only an activity of flain Street, but expectations for areas outside the immediate city, itself, were indeed inconsequential. .yxfirt- " , ,. CluiLL; or Diffuht‘r‘z The present chapter has oeen devoted to an explanation of how the capacities for decision-making were organiZed in five selected hospital projects. The major hypothesis upon which the description and analysis was made is that authority and influence, as the capacities of decision- making, are differentially distributed through the roles in the community, and hence concentrated about certain pivotal axes of the social organi- zation. If it is given that the hOSpital project is, by definition, a relevant task for either or both authority and/or influence, then the theoretical problem becomes that of not only delineating the agencies of both, but understanding the manner in which they become articulated. Authority agencies. In four of the five projects, the county was 1 the administrative unit involved anc the county 5overnin5 body was the centrally important agency of authority. In Noreast, neither the county nor its governing body was of apparent relevance to the community hOSpital. Instead, an already existing hOSpital hoard, supported o" a positive and permissive public image, represented the only agency of authority, and that within narrowly circumscribed limits. In this latter case , the members of the board were also Influential persons in the 3.13 communitV. The body of rights which they exercised in decision—making was extended beyond those constituted within the hOSpital hoard, which is one exylanation of the loose connections of the hoard as a unit to 1. .. .. the hospital project. nether than hein constituted as an aguncy of authority in Noreast, the hoscital board was largely another pivotal point of the organization of influence in the community; That it func- tioned as a source of approval for the decisions made by its officials was due to its existence at the time of initiation and its oovious relevancy to considerations of hospital construction, That the hospital 'etting process is indicated "‘ V hoard was hardly necessary to the hoSpital by the fact that it never served as an arena for decision-making. Decisions were made through other arrangements and both decisions and arrangements were frequently unknown to the bulk of the board members. hevertheless, the decisions were approved by the board in a perfunctory manner, 'Whatever legitimacy was posited in the constituted hOSpital board, it was controlled oy the two presiding officials. The crucial decision of inviting a professional fund raiser to the community did not come from the context of the board but independent of it. The initiatory negotiations were with persons who Were not members of the board, and these negotiations and persons were held in secrecy from the board until others of community influence were committed to the project. The structure of authority agencies related to the five projects varied. In Southeast county the County Commissioners Court was not greatly concerned as a total group, and in this reSpect was similar to the hoSpital board of koreast. For the Southeast county project the important office for authority was the probate judge, and it was this role that expressed active decision-making and the legitimizing function. It was only Southeast county that exhibited a formal political office role and involved throughout the entire decision-making process. In Mid-State and Farwest counties, county governing bodies were less central in either initial or continuing decision-making, nor were particular political roles differentiated. In both of these instances there were salient political roles, the Circuit Judge ("the source of legal knowledge") in the former, and the State Senator (the "go-between") of the latter. In hid-State and Farwest counties the county governing bodies Were both loci of the legitimate order, but there was no evidence of differential strategies with political offices contained within them. In Mid—State county the problem of the decision-making process was that of "capturing" the legitimate order, i.e., the county governing body; and in Farwest county the c00peration and participation of the county governing body had to be insured with the advent of a parallel authority agency, the hOSpital district governing board. In effect, this was accomplished by a kind of co—Sponsorship by the two authority agencies. In Norwest county the county governing body was necessary to the \ initiation of the project, as defined by state law if a bond issue was to be employed in hOSpital construction, but it was in this case that the focused legitimate order moves from a central importance. This was in- dicated by the differential behavior of non-political participants toward differing members of the body, and that he bulk of the decisions were approved through other devices than the county political group. Initial 315 overtures were made to members of the county governing body as individ- uals, and the same was true in regard to such matters as the appointment of a hospital board. From this point onward the county governing body was so loosely related to the completion of the project that decision- making, legitimizing, and execution functions ware carried by non- political participants and the associations which organized the influ- cntials. Throughout the analysis of this report the major agencies of author- ity have been found to be formal political governing bodies. Yet, other agencies have appeared in the case studies that are non-political in the formal sense but exhibit the attributes of the authority agency. Although it is striking that the hospital, being located in a municipal site, has not been Sponsored by a municipal governing group, it should be pointed out that in Southeast county the Carlin town council was involved as a total agency in the later stages of the project. Only Southeast county and its hospital project provided any evidence that municipal political groups were related to the decision-making process. In Farwest and.Hid- State counties medical societies Were relevantly included. There was no medical society organiZed in Southeast county and Norwest county. In Noreast the organized medical society for the county must be con- sidered only another association in support of the project. ho physician was active in the "inner circles" of decision-making as was the case in hid-State and Farwest. The foregoing evidence suggests that the hOSpital-getting process for small communities is carried out by decision-making which functions on the capacity of influence more largely than authority, with the ex- ception of Southeast county. In Koreast there was no problem of the OVertures were legitimate order at all. In the remaining three cases, made to the apprOpriate county governing body. This should be con- 1 treated with Southeast county WL’PG the problem was one of securing the commitment of the large landowner influentials. This reversal should demonstrate, in part, that in Southeast county the preponderant capacity for decision-making is that of authority concentrated in the role of the probate judge, and extended through the elaborate political machinery of the county. Accordingly, only in Southeast county were members of the county governing body active in the making of decisions as well as providing the legitimizing and execution functions. In Mid-State, Far- west, and horwest counties members of county governing boeies were not active in the decisionemaking, per_§eJ but Were restricted to the casting of approval for legal requirements of the project. The distinction, analytically, would seem to be that then governing groups hold the public image of functioning in the totality "to get something done for the county," their members do not hold sharply defined offices of authority and tend not to Operate in the initial process of making decisions; but where certain roles have superordinate rights of office, such as the probate judge, this office may include the making of decisions as well as giving approval and assisting with the administration of decisions. This, then, is the degree to which the governing group has a heirarchical arrangement of roles. One last observation from the foregoing presentation should be made. i This has to do with the tendency of the hOSpital project, although it 317 may spring from the influentials of the community, to work toward in- creasing specialized forms of legality, Hence, in Southeast county a formal hOSpital committee was appointed and later re-formeo into a hOSpital board. Iniiid—State, Farwest, and Lorwest counties an initial step was to form a hOSpital board, in these cases prior to the details of hOSpital construction. The hospital is a specialized institution, and it would seem to require a Specialized administration. Although influential persons active in the hOSpital-getting process have found their way into membership on the hOSpital board, the magnitude of the hospital project to the small community apparently forces the develOp- ment of formal and constituted, but Specialized, authority for purposes of administration. It is inceed noteworthy to mention that the initial decisions to embark on a new hospital project were made without benefit of a Specialized agency such as a board, but the carrying out of the decisions had largely taken place unoer the auSpices of such a newly created structure. Influence agencies, ilthough later treatment will give in more detail an analysis of the ingredients of influence, it Should be mentioned that the exercise of influence in the foregoing case stucies appears organized in certain consistent ways. With the possible exception of Southeast county, the civic and service oriented associations would seem to provide the organizing principle for community influentials, and to provide the arenas for both their participation in public affairs and the maintenance of reciprocal and infomial sets of relationships. Even the influential person must have, or obtain, Operational access into decision- f making domains of the community. fhe association would seem to provite the most readily available mechanism, County-wide associations Were important in Southeast and Farwest counties, the Farm bureau for the former and the Grange for the latter. In both of these instances, in- fluentials tended to cluster, in a social organizational sense, in these prominent county-wide organizations. n hid-State, Farwest, horwest, and horeast, the organized male civic clubs could not be overlooked as greatly relevant in the reSpective projects. The two autonomous subgrOVpings of hid-State county, Larch and Westville, each had an organization of influentials constructed around such service clubs. In Larch it was the notary Club, and in West- ville it was the Chamber of Commerce. In Farwest county the two towns of Champ and Merino had each a similar sort of association, and they were active as groups in the hOSpital projects. In norwest the associational structure was pyramided, with informants agreeing that the Lions Club of horwestville was the centrally important group for the initiation of civic projects. This appeared to be so true in regard to the hOSpital project that some of the legitimizing function for decision-making was assumed by the Norwestville Lions Cluo. It was in horeast that the fullest expression of the organization of influence in associations was found. Again, informants attributed male civic clubs as central groups in the initiation of larger community projects. Too, further pyramiding was present, with the male horeast Club serving to bring tOgether the influentials of the community as Well as associational leadership. A great variety of associations have been related to the dovelormant of hospital projects. Earlier chapters have pointed out the incidence of fraternal lodges, churches, veterans organizations, women's clues, and Special interest groups. In the five projects studied intensively many kinds of associations took part in the task in many ways, howeVer, the develOpment of new hospitals for shall communities has been diSpropor— tionatcly the activity of businessmen. Loticcacly lackinq are employed prcfessionals, i. e., officials of welfare organizations, and the prOiessional directors of various rural programs such as the Cooperative Extension Service. When one focused on the decision-making process, the manner in which community business-oriented influentials employed certain favored associations can not be overlooked. ’rticulation of authority and influence. One assumption drawn from tne theoretical formulation of the problem for this study is that the capacities for decision-making within the community organization context may be oryanized in terms of authority and influence. den“e, Social properties and proficiencies may oe diffused throughout the structure of the community, although consentrated around certain organizational nodes. The decision—making function, conserned with the deployment of authority and influence in social situations of goal-oriented behavior, reckons ‘ with the neutralization of or Securing of the prOperties and proficiencies vested in actors and arrangements not fully owned or controlled by the incumbent decision-makers. This problem may be accomplished by strategies and tactics, by the jurisdictions and mandates of constituted offices of authority, and by built-in patterns of social erranization, which permits, b) {\J C) in either manifest or latent ways, the articulation of the capacities. The previous case studies demonst- at: in par a v ricl3 of diifer- ences in the way that authority and influence may be Joined for a particu- lar problem-solving task. The articulation of auth)rity and influence aoulc Mean to occenn on the extent to which t.e relevant resources and proficiencies Vested in tile community are organized in terms of active or potentially active oecision—makers, Authority is an explicit capacity to the conninity. IT i‘he FL sources and proi liCl er icies of influence, on tn: other Lane, are not so "eneralinx4 N Fio. IV Possession of Capacities By High Ranked Decision-makers. t) 111-3 decision-makers. A few obvious patterns immediately may be distinguished, eSpecially the consistent possession of intra-community access, the ex- penditures of considerable time on the project, and the differential ex- tent of reciprocal obligations among the decision-makers of the inner circle, the latter occurring only in the Norwest and Noreast projects. Also to be noted is the scepe of the resources possessed by decision- makers in the Norwest and Noreast projects. 8. Finally, it should be pointed out that in both Norwest and horeast the relatively higher incidence of resources possessed by the decision- makers was related to extensive organizational plans in the reSpective hOSpital service area communities. In both instances, at certain stages in the project, associations and included influential persons were uni- formly mobilized, This is suggestive that when the decision-making process includes an inner circle with no political or jurisdictional mandates, the applicable strategy to gain consensus must include the involvement, and subsequent approval, of a dispersed and diffused influence. Conversely, the inclusion of decision-makers in constituted offices of authority organizes the "rightfulness" to make decisions into explicit and concen- trated centers of decision-making, This may be one.explanation for the greater decisiveness of politically Sponsored projects, as measured by the success after but one campaign. CHI; PT ER EI GHT GENEREUET MAKING DECISIONS AND GAINIthAPPROVAL Previous chapters have treated two aSpects of the decision-making process: (1) the empirical outlines within which the process occurs; and (2) the capacities for decision-making, authority and influence, by- which the process functions. A third aSpect must be considered. This deals with those Operations which actively deploy the capacities in decision-making. To understand the functioning of decisionemaking is to understand the forms of decisions made, the strategies and tactics for gaining legitimacy and/or approval, the negotiations by which strategies are exercised, and the consequences. The assumptions for the present analysis are to be found in a more definitive form in the first chapter. Nevertheless, a cursory comment, at this point, should indicate (1) that if a decision reduces the alterna- tive courses of action for those to whom they apply in the community organizational context, the reSponse of the publics may result in either or both of intended or unintended consequences; and (2) unless the capacities of authority and influence are completely controlled by the incumbent decisionemakers, both must be gained or neutralized through negotiation and strategy. The present chapter fosters an attempt to ascertain the major forms of decisions made in the five hOSpital projects, and the attending hlS strategies, negotiations, and conseguences. Wherever possible, the com- parative treatment of the five cases will be continued. The major organi- zation of the chapter will relate to the four forms of decisions in hOSpital construction derived from the previous analysis: (I) decisions to initiate the hOSpital project; (2) decisions as to method of financ- ing local shares of construction costs; (3) decisions as to the composi- tion of sponsoring and operating groups; (b) decisions concerned with a major problem of hospital projects, the resolving of unanticipated rising building costs through external factors. Decisions: Initiation of the Project A. Southeast The decision to initiate the hOSpital project in Southeast County occurred at the convergence of three circumstances and/or events: (1) a rapid expansion of the Southeast Farm Bureau and a subsequent attention to the develOpment of hOSpitalization insurance; (2) the early acquaintance- ship with impending federal legislation to assist local hospital construc— tion; (3) the increasing recognition of need brought into focus by the acceptance of hOSpitalization insurance by Southeast peOple, but with no hOSpital to freely extend hOSpital services. Initiation of the hOSpital project involved a decision that would limit the expenditures of public funds on a favored Southeast interest, the maintenance of rural roads, and would place a burden on the chief tax— payers of the county, he 30 or more large landowners in the Black Belt. With such limitations in the alternatives to relevant publics, the de- cision to attempt a new hospital was made. hlo The making of this original decision involved at least three elements: (1) the Farm Bureau directors, and their president, who posed the decision; (2) the Court of County Commissioners, and the probate judge, which could legitimately make the decision; and (3) the large landowners who, by recog- nizing the consequences that would diSprOportionately fall to them, could, with a positional and influential control of the out-county political sys- tem, approve or disapprove the original decision. This organization of the capacities for decision-making rendered a two-fold strategy, that deal- ing with the initiation to the County Commissioners, and that dealing with the involvement of the large landowners or, at least, a neutralization of their influence. Tactics and strategies. In Southeast County, the original negotiation was that of the initiation of the president of the Farm Bureau, in company with the directors, to the members of the County Commissioners Court and the probate judge. The physicians of the County were invited to this origin~ al parley. Previous to this direct negotiation, however, the executive directors of the Farm Bureau had both informally and formally discussed the manner in which to approach the Court. Case study comment. At the first meeting of the Court, the Farm Bureau directors, and the physicians, mention was not made of the possibility of a voted bond issue to provide Southeast's share of construction costs. The tactic employed by the Farm Bureau directors, in their strategy to carry the Court was that of explaining that the Farm Bureau would underwrite the local costs, variously estimated from $25,000 to Sh0,000, with the exe pectation that federal funds would provide two-thirds of the total costs. The consequence of the first meeting was that the Court suggested a public hearing on the matter of a hOSpital. The interest of the Court, as reported by a former Court Com- missioner (incumbent at the time), was not so much on the finan— cial aspects of the project as with the need to "bring into the Open" the big landowners, and representatives of various hi? political factions, in order to ascertain the potential conflict to the project, and to determine if the big landowners would sup— port the hOSpital "as individuals and outside the Farm Bureau." The foregoing comment illustrates that the directors of the Farm Bureau, through a willingness to financially underwrite the project, de- sired to carry the Court toward official Sponsorship; and the Court felt unable to do so without a Open endorsement of influentials, to be found among the large landowners and the professional and civic representatives Of Carlin and Farmville. This endorsement was gained at a public meeting, held in Carlin, the county seat, characterized by the attendance of mem- bers of the Court, Farm Bureau directors, several landowners, physicians, and representatives of health, educational, and welfare agencies. The issue of this meeting, apart from support of the project, was that of forming an official planning and Operating body for the hospital, as prescribed by federal legislation for cOmpliance in the receipt of federal funds. Case study comment. By the event of the public hearing both the Court and the Farm Bureau directors were preoccupied with the strategem of officially committing the large landowners and store- keepers to the project. The notion of the Official hospital association was, of course, a legal.requirement, but it Offered the decision-makers (the Court and the probate judge and the Farm Bureau directors) the Opportunity for two tactics to accomplish the mutual purpose: (1) the appointment by the probate judge of 16 hOSpital association directors from a list of names provided by the Farm Bureau directors that included the approximate 30 large landowners. Since the probate judge was also determined in committing the landowners, it is perhaps not surprising that the hOSpital association directors included the influential land- owners of the Black Belt; (2) the publication of the names of the association directors in the Southeast County weekly newspaper, which circumstance identified the Black Belt influentials with the hOSpital project. 0 L2 The reaction of the landowners to these tactics apparently varied. Several of them admitted, and were reported by others, to have been individually Opposed to the project, but that the previous tactics had successfully forced them to "go along with the project in the face of threat to reputa— tions in the Black Belt of being "refined and educated." In addition, few of them believed that anything concrete would result in the activity, so nothing would be lost. At least a few of the landowners believed that the Court had gone through the ritual of listening to public interest but that, through insufficient concern, the Court would find a way to delay fur- ther action toward a new hospital. Thus, in Southeast County the initiating decision for the hOSpital project occurred amidst a structural rigidity of the decision-making sys- tem of relationships, the initiating Farm Bureau, the legitimate and authoritative structure for decision-making, the Court, and the possessors of both influence and position, the large landowners. Thus, excepting the Farm Bureau directors, other decision-makers were involved in the process although individual orientations may have restricted their entrance. That this was possible is to be explained by the rigidities of the setting for decisionemaking in Southeast County, and the predictive knowledge of the decision-makers regarding the forms of expectations which obligate others. B. Mid-State The agreement of informants in.Mid-State County, and other available evidence, regarding the initiation of the Mid-State project indicates that the crucial initiating event was an extensive campaign by the publisher and editor of the weekly paper, the Larch Republican. The editor, new to Mid-State County, was aware of impending federal legislation and the successes of other localities with voluntary public subscriptions of funds hl9 for the improvement of hOSpital facilities. The functions of the news— paper editorials were undoubtedly varied, but included: (1) the elicita- tion of letters and testimonials from Mid-State County citizens which served to cast the possibility of a hOSpital.in terms Of a public issue. Letters of recommendation were encouraged from men in military service, and these were reported to have suggested a "memorial" hospital. One editorial dealt with a count of recent deaths of mothers during child- birth. Even the Board of County Commissioners took cognizance, with financial recommendations for the improvement of medical facilities at the Mid-State County Home. This event encouraged the editor (H81) to make the initiating decision, manifested in the arrangement of what locally was called, "The Sunday morning breakfast." To this meeting were invited the physicians of the county, the cir- cuit judge, a few businessmen and association officials from Larch (the county-seat town), two industrialists-u-one from Westville--and the editor of the Democratic weekly paper in Larch frequently Spoken of as the "wheelhorse" for the Democratic Party in the County. The avowed purpose of "The Sunday morning breakfast" was that of informally discussing the possibility of a new hospital and to explore methods of local financing. Case study comment. Those informants who were present at the initial meeting believed that the major strategy involved was that planned by-MSI, the editor, in order to gain approval for an attempt, to be led through the newSpaper by the editor, at a voluntary public subscription Of funds. If this was the in- tended strategy, it completely failed, for a major devisiveness occurred that was to carry throughout the project and to explain much of the difficulty and delay which the Mid-State project was to incur. The disagreement was based on, not the feasibility of building a new hOSpital, but the possibilities of the voluntary subscription. The two industrialists joined with the editor in believing that this was the correct method, and one stated, "that he would tOp the highest contribution made." The other representatives at the initial meeting believed that a legal instrumentality should be employed. This view was Sponsored by the circuit judge (RSB), reportedly on the grounds that it would be well for the incumbent Republican administration to be associated with the hOSpital, and the Democratic Party leader, reportedly on the grounds of rivalry withhsl as the editor of the Democratic paper and his desire to force the Republican ad- ministration of the county into Sponsoring additional taxes. Physicians present at the meeting reported that they preferred the voluntary subscription, but agreed with the prOponents of legal instrumentalities, because this would insure from their point of view a EEEEEZ hOSpital, more feasible to them than one based exclusively on the service area of Larch. The editor (M81) actually withdrew following the first meeting. Two committees were formed at the meeting, one called a "survey committee," composed of physicians, and a "finance committee." That the "Sunder morning breakfast" was, in part, divisive is suggested by (13 the Westville industrialist refused appointment to the finance committee, which later encouraged influentials in westville to believe that the "west side" of Mid—State County had been excluded in the early decision-making processes; (2) although the majority sentiment at the meeting was against public subscrip- tion, a brief attempt was made for voluntary pledges but with no avail. Hence, the hid-State project found itself without a de- fined Sponsoring body and no approved method to raise funds. As compared with Southeast County, the project in Mid+State differed in those decisions for initiating the project: (1) the decision-maker who made the initiating decision did not, by the present evidence, informally discuss the possibility outside the context of the newSpaper, or consider the structure of the needed Sponsoring group; (2) the original negotiations, by-passed the issues of feasibility and Sponsorship, and engaged on the tOpic of finance. 5y this procedure, decision-makers were not able to organize the capacities of decision-making sufficiently to forestall the unintended consequences to follow; (3) the loci of competing decision- making centers (Westville, Board of County Commissioners, the town councils of Larch and Westville) were not directly involved, since the intent of L21 the "Sunday morning breakfast" was, within the designs of M31, anything but that of involving the municipal and county political instrumentali- ties. Tactics and strategies. The Mid—State project is an example of a civic project of considerable magnitude in which a decision-maker without either authority or influence attempted to "gamble" for approval without negotiating with the centers of authority and influence. The strategy was that of gaining quick approval, not for a hospital or for the structure of Sponsorship, but for a fund raising method in which the initiator would play a central role. When the strategy failed, all of the decision-makers involved were alienated in one way or the other,-and the reSponsibility moved away from the intiating actor to an indefinite, if not void, set of alternatives. Hence, strategy was devised, but without supporting tactics and negotiations. C. Farwest In some respects, the setting for decision-making in Farwest County was similar to that in.Mid-State, eSpecially in regard to the importance of the county as an administrative unit in the develOpment of public pro- jects, and the existence of two towns as major service centers. One exception seems to reveal itself, namely, the uniformly distributed feel- ing of need for a new hOSpital throughout Farwest County. The initiating decision in Farwest was, in a specific sense, provoked by the formal unterest of one small community, Crossroads, to obtain mini- mum "health center" facilities and a recreation hall--both to be planned under one roof. At this point, the convergence of a variety of situational factors occurred, among which were: (1) the presence of state medical standards, making the Crossroads activity appear hOpeless; (2) the develOpment of state and federal legislation to assist with the financing of small hOSpitalS; (3) the permissive legislation for hOSpital districts, a device to rest the legal responsibility of hOSpital construc- tion and maintenance with the peOple; and (h) the proximity of one resi- dent of Farwest County to such events, a state senator, with an interest in introducing social legislation and possessing the resources and pro- ficiencies of influence in Farwest political and associational circles.’ Hence, the decision of initiation became visible when the State Senator, le, appeared, by invitation, at Crossroads and recommended support to the formation of a county hOSpital district. From this point, FW1 negotiated as follows: (1) with the Sponsoring committee at Crossroads in order to secure its c00peration in the deve10p- ment of a hOSpital district; (2) the civic and service organizations of the two major towns, Champ and Merino; (L) consultation with the Farwest Grand Jury, which, in turn, investigated the alternatives to building an entirely new hospital; (5) the initiation of newSpaper articles on hos- pital facilities, the newSpaper being owned and edited by le. Such negotiations of FM; encouraged a simultaneous activity on the part of various agencies in Farwest County, which was directed at two targets, namely, a new hOSpital but, more importantly, the formation of a Specia- lized hOSpital district to deal with hospital affairs. The result of this activity was the completion of a county—wide petition to make it mandatory on the County Board of Supervisors to call an election for the hOSpital district issue. L23 Certain differences occur between the initiating decisions of Mid- State and Farwest, although, in each instance, the initiating decision was made by a neWSpaper editor and publisher: (1) the Farwest decision- maker, FWl, had the authority of constituted office as State Senator and the resources of influence which this office rendered, i. e., access to intra-and extra—community political and administrative agencies; (2) the immediate concern of le was neither the hOSpital nor methods of finance, as was the case in Mid-State, but to develOp a legal instrumentality for the articulation of influence agencies and authority agencies.toward a common end; (3) although the notion of the hospital commenced in a re- stricted segment of the county, le immediately cast it into the larger framework of the county; and (L) finally,.wioe3pread community activities culminated in placing the burden for subsequent decisionemaking on the important structure for legitimized and political decision-making, the Board of County Supervisors. D. Norwest Initiating the hospital in Norwest was comparable to the Farwest instance in regard to the extensive feeling of need for the hOSpital and the extensive period of negotiations conducted informally by the initiat- ing decision-makers. Perhaps an added advantage was the concentration of county pOpulation in the county seat of Norwestville and the pyramided associational Structure. In Norwest, the initiating decision was that of having the hospital construed as county and to involve the County Board of Commissioners, long considered by influentials as conservative in the h2h initiation of public projects. How this occurred may be explained by the explicit tactics of the initiating decision—makers, hwl and hwg. Case study comment. NW1 explained, in his review of the ini- tiating decision, that the strategy involved was that of obtaining the approval of the Lions Club to publicly support the project, but to move the Sponsorship to a county—wide basis by the locus of decision-making shifting from the Lions Club to the Board of Commissioners. The following tactics were employed: (1) xwl, then mayor of Norwestville, began, as he said, "to Operate on the street corners." This "Operation" included discussions with the president of the Lions Club and the chairman of the County Republican Committee and termed the "best organizer“ member of the Lions Club, as well as other in- dividual members of the Lions Club. hwl reported that these informal sessions were held in order that he "could get an idea of who would support a new hOSpital if I started to talk about it formally." Another person contacted informally was an in- dividual member of the Board of Commissioners, recognized by hwl, as he reported, to be the one Commissioner "who would be likely to question the idea of building a county hospital." NW1 reported that he had been entirely selective about the first informal contacts, i. e., he was mindful of the fact that the current president of the Lions Club had previously been in touch with a friend, a physician, who was interested in practic— ing in horwestville, "if the facilities situation could be improved." The second tactic employed by NW1, and by this time supported by NW2, was a formal presentation of the possibilities of construct- ing a county hospital to a meeting of the Norwestville Lions Club. That the earlier informal contacts were successful is evidenced by the verbal support which the contacted persons gave to the hOSpital idea, and the subsequent unanimously rendered vote of approval by the Lions Club. The endorsement of the Lions Club was followed by an appointment of a committee, consisting of the initiator, le, two Lions members earlier contacted informally, charged with the investigation of "ways and means" to develOp a county project. The foregoing comments indicate the extent and quality of the indirect and direct negotiations that steered the hOSpital project through to an endorsement of the Norwestville Lions Club. Immediately following, a pub- ' lic mass meeting was Sponsored by the committee as an attempt to move the L25 project out of the Lions Club into a decisionpmaking domain oriented to the county. In order to document the mass meeting, a petition was cir- culated which, in turn, became a device to formally approach the Board of Commissioners. Members of the three-man Lions Committee reported that, although the petition was not legally required, it was conceived in order to demonstrate that the hospital project was intended as "truly a county project," and thus would secure the active entrance of the Commissioners into the decision—making process. E. Noreast The initiation of the hOSpital project in Noreast actually occurred three years prior to the date of its formal introduction in the community. This circumstance was: the decease of the incumbent president of the existing hospital board made it possible for NEl, the vice-president of the board, to secure the appointment of NEz as the new president. The ex-. planation here was that a new set of plans and activities in hospital services was forthcoming, and NE1 wanted, and needed, the official support of a member of the "natural symbolic set" previously active in community affairs. Added to this circumstance was the organization of the Gately Hospital Council to promote hospital service improvement in the Noreast area, and the increasing sensitivity to need in horeast stimulated by hospital construction in adjoining communities. The evidence suggests that the initiation of the project in an explicit sense began with the observations of NE1 and hEz of the successful con— clusion of a fund raising campaign in a nearby city, which was assisted by L26 a professional fund raiser. The following events describe both the negotiations and strategy involved in the initiating decision. Case study comment. The immediate reactions of NEI and NEz to their observations of professional fund raiser periarmances not only initiated the decision to declare the hOSpital project in process but, simultaneously, that a professional fund raiser should be the modus Operanci for collecting local funds for con- struction purposes. The two initiating decision-makers not only contacted the professional fund raiser active in the nearby com- munity, but proceeded to employ their resources of access to this community in order to determine the sentiments of the people re- garding the conduct and the methods of the fund raiser. Assured on these points, the two (NE1 and NEE) proceeded to invite the professional fund raiser to the Noreast community "to Spend a few days in measuring the ability to provide the money" for a new hospital. To this no evidence was gained that other representa- tives of the community, including the hospital board, were at all aware of these events. Just prior to the arrival of the profes- sional fund raiser, who had been pledged to secrecy as to the _import of his inspection trip, hEl and hEg made two other in— formal negotiations. One was with the bank president, hE4, and the other with NEB, the vegetable broker, and a member of the "behavioral set" earlier cited. When NE4, the bank president, was informed of the events under way, his immediate reSponse was that the prOposed task was an impossible one, premised on the belief that "the cost of a hos- pital was too much for a $.25 and $1.00 community." Reported by each of the three negotiators in this instance was that the turning point to gain the approval and the participation of hE4 was when the latter asked, "What would each of you personally give to the building fund?" The reSponse of each came, as re- ported, as a surprise to NE4. (Other explanations of the ap- proval secured by this negotiation may be gained from the analy- sis of the preceding chapter.) The involvement of NEa in the proposed project, yet held in secrecy from all except those concerned in the informal negotia- tions, was simply secured by his knowledge that the bank president was, as one of the initiating two put¢it, "on the band wagon." (To be stressed is the not perhaps incidental order in which hE4 and Nha were contacted in the negotiations.) Following the previous interlude of events and the inspection of the professional fund raiser, the project was launched formally with the appearance of the fund raiser at a meeting of the hOSpital board. Two events occurred there that were climaxed by the formal approval of the board that the fund raiser should be employed and an on-going project initiated. One was the favorable report of the fund raiser, the other was the announcement of the president and vice-president (KB2 and N31) that the bank president and hhs "would go along with the project" in terms of their "organizational abilities" and personal contributions. To be noted, also, is that the professional fund raiser appeared at the meeting with a contract prepared for signing. In effect, the hOSpital board, by signing the contract, had committed themselves to a project and, simultaneously, legitimized the fund raiser's entrance into the community. F. Summary: Initiating Decisions Reference to Figure (V) will demonstrate the patterns of negotiation related to the initiating decisions in the five projects. Certain differ- ences reveal themselves. In three of the projects, Southeast, Norwest, and Noreast, the initiating decision first became visible within the arrangements of relevance to hOSpital services found in formal structures. Hence, in Southeast, the initiating decision and decision-maker came from the "platform" of the Farm Bureau; in Norwest, from the municipality (as Mayor) of Norwestville and its Lions Club; and in Noreast, from the al- ready existing hospital board. In Farwest, initiatory decision-making was, through the intervention of FWl, extended and enlarged into the decision-making domain of the County. It is only in Mid-State that an al- most complete lack of direct or indirect negotiation was found, and with 7., mile: L‘ JAM nur'ddti 04:4 err _ ‘42-: beam i o- f our )3?— ~ r “‘50.- ,3) i o’ 'w r . L- bunt, Boar (7 - ,- k1" 111mb?" .uuulu" ice see deer“ U\_/ \V/ r of County Commissioner” {hie (Jenflie IiOS'pi‘ba Hoopital Boar” Board v. \ vvy a»... V) Battains c" Initiatory degot L29 initiatory decision-making evoked by one lacking the capacities of authority and influence. While the initiating decisions of Southeast, Farwest, and Norwest intended for the locus of decision—making to pass through the reSpective county governing body (at least), in Mid-State County an unintended consequence, from the vantage point of M31, was the somewhat inadvertent (via M83) movement toward the Board of Supervisors. Thus, the legitimate rights of initiating decision-makers were ap- parently not sufficient to launch a project of the financial magnitude of the hospital without the additional pronouncements of county governing bodies. Although negotiations were involved with strategies to gain ap- proval and Sponsorship in initiation by influentials and associations outside the context of such governing bodies, nevertheless, they worked in the direction of apprOpriate governing bodies. It should be noted, too, that precise "stages" of informal negotiations did not occur in the Southeast and Mid-State projects, but_did in the other three. Finally, initiatory decisions in horeast sprung from the hOSpital board already in existence, but the negotiations were involVed with in- fluential persons outside its formal context. Thus, the negotiations carried on £32m the hospital board, through external contexts, but served to gain the official approval of the same hOSpital board. Decisions: Methods of Financing Throughout this report, references have been made to the centrally important requirement of sufficient local funds for hospital construction. In instanccswhere state or federal assistance was expected, a guarantee of locally held funds was a legal requisite. Hence, those decisions affecting b30 the method of fund collection not only followed on the initiatory form, but were crucial to project completion. A. Southeast For the Southeast project, the rigidities of the structural setting for decision—making process provided no alternative to moving the locus of the process into the principal authority agency, the Court of County Commissioners. This circumstance, of course, gave every expectation to the initiating decision-makers that the method of fund raising would be that of the bond issue. However, the preoccupations of the initiatory decisions, and related strategies and negotiations, were with gaining access to, and the approval of, both the Court and the influence system of the large landowners. The question of funds was apparently contingent on these exigencies. Nevertheless, the fund raising method still remained as a weapon of the Court if, as several of the landowners reported, it were intent on delaying the project. ‘ The organization of the hospital association, and its executive com- mittee, gave both the officials of the Farm Bureau and the large land- owners the preponderance of weight in suggesting action to the Court for the continuation of the project. The Court, however, was still the offici— al Sponsor in that the hOSpital was to be a county hOSpital. The probate judge, and the Court, although remembering the promise of the Farm Bureau to "underwrite" the local costs, were eventually placed in position of approving or disapproving a bond issue of $60,000. Case study comment. Several events had occurred to obscure the original promise*3f the Farm Bureau to "underwrite" the local share of funds: (1) a new probate judge, in sympathy with the 1131 state administration held in disfavor by the Black belt; (2) the passage Of federal legislation to assist with local hOSpitals, which created for the Southeast decision—makers the erroneous expectation that federal sources would supply two-thirds of the cost; and (3) the develOpment of resistance to the hOSpital project from a political faction strongly Opposed to the incumbent state administration and the probate judge. ' The bond issue, rather than the promise of the Farm Bureau, did, for the probate judge, suggest the possibility of strengthening his administration, eSpecially in the "hill country", where the Opposing political faction was entrenched and, for the representatives of the hospital association (Shl, etc), to be more certain of remaining free from publicly construed "deals" with the Court. Although the probate judge favored the hOSpital project, the evidence suggests that other members of the Commissioners Court did not. ReCOgnizing this, SE1, with the assistance of functionaries of the Farm Bureau, circulated a petition to gain support from the peOple, and sub- sequently provided between h,OOO and 5,000 names of taxpayers to the probate judge. Such a testimonial led the Court to approve a bond issue to the extent of $60,000. Later, the bond issue was passed by public vote by a two-thirds majority. The foregoing comments depict the manner in which public consensus may be employed in the decision-making process. In this instance the probate judge and the hOSpital association officials had something to gain from a bond issue; but, also something to lose if the political resistances or the strength of the Court in Opposition to the judge became severe. Thus, to decide the bond issue as a feasible way to collect funds, the decision—makers used the device of the petition to channelize and utilize public support as an item of legitimacy. In this sense, the frequency of use of the legally unrequired petition indicates that it is one "social gadget" of importance to decision-making. B. Mid-°tate An earlier analysis pointed out that the initiating decisions in hid-State were primarily concerned with the method of fund raising rather A. L32 than, as occurred in the other instances, with gaining approval by either a general consensus or by the dictum of authority agencies. The result was a disintegration of the strategies of M81, the newSpaper editor, and the "picking up" of decision-making by the incumbent circuit judge. This activity included (1) the calling of a public hearing, (2) the completion of legally necessary petition to show cause for a bond issue election, and (3) the election itself (which passed by a two—thirds majority). At this juncture, although a hOSpital committee had been formed at a public hearing, an unknown delay occurred in the issuance of the bonds. The Larch editor (Lasl) began to editorially raise questions "eneral unawareness of the public as to what L' k} about the delay, and the constituted the delay provided the mechanism for the resistance fOcused in Westville. . The explanation of the bond issuance delay occurred at the juncture of a disagreement of the apprOpriations committee for the Board of Com- missioners (the county council) over the manner in which the hOSpital project had inadvertently moved,through M83, the circuit judge, to the reSponsibility of the Board of Commissioners. The chairman of the appro— priations committee was a Larch dentiSt, noted for his knowledge of county finances and bearing a reputation of "the watchdog of the county treasury." Believing that the physicians had initiated the project and that the county had then been given the reSponsibility, the apprOpriations chairman reported the petition to have been the mandatory cause to conduct the bond issue election. Otherwise, the evidence suggests that the apprOpriations committee would have resisted and delayed, even though the 1433 Board of Commissioners had entered the arena of decision-making and Sponsorship for the hOSpital. But the delay occurred, nevertheless, and it was due to both the legal and financial acuteness of the appro- priations committee chairman. Through a political contact in the Court House, the county attorney, the apprOpriations chairman learned that the public petition did not Specifically state that it was mandatory on the Board of Commissioners to issue bonds. Then, by the rights of the office of apprOpriations chairman, he was able to forestall continued action on the bond issue. That the hOSpital committee, described heretofore, did not immediately attack the delay was due, in part, to the difficulties of personnel mobility within the committee, the mounting resistance of westville influentials to the entire project, and the constant editorial annoyance of the Larch editor who had been "jilted" in earlier decision— making initiations. The chairman of the apprOpriations committee was eventually con- fronted with another petition which, in effect, demanded that bonds be issued and sold to the extent of $200,000. This petition resulted as the activity of a reappointed hOSpital board, which brought in men who, as one informant put it, "were very friendly with the doctors." Although the physicians had apparently withdrawn following the "Sunday morning breakfast," internal personnel difficulties on the board and mounting Opposition led to a resumption of activity in the prOgram through a hospital board that was close enough to the physicians that "it met fre- quently in joint session with the county medical society." Mb The strategy which the apprOpriations chairman devised in view of the new petition, and the tactics applied, provides one of the lucid examples of what is meant by strategy and tactics in this report. Case stucy comment. 'lhe appropriations chairman was, of course, well aware of the major center of Opposition and resistance to the hospital project, namely, ”mestville. .The Opposition there had been carried on largely by one of the town's influentials, a mortician, and supported by the weekly newSpaper editor in westville. The strategy of delay devised by the chairman of the apprOpriations committee was that of develOping a "remonstrance, or a petition which, if gaining more signatures than the original petition to show cause for a bond issue election, would halt the issuance and sal eof bonds pending an investigation of legality. It was possible to devise the tactic of the remonstrance beca .use of the fault by wording of the original petition, which did not Specifically make mandatory the issuance of bonds by the Board of Commissioners. The tactics of the remonstrance develOpment were constructed on the resistances of Westville, for the apprOpriations chairman negotiated with the mortician of Westville, devised the remon- strance, and arranged for a Westville attorney to circulate the petition, largely in the town and surrounding environs of West- ville. After the remonstrance petition was filed and substantiated by the appropriate state tax authorities, a delay followed in the further action necessary to issuance of bonds by the board of Commissioners. During the intervening period, the size of the board for the proposed hospital was enlarged, with three of the seven members as physicians from Larch. Dur— ing the delay period as well, federal legislation and the assignment of construction priorities provided Mid-State with an Opportunity for assist- ance, which encouraged the enlarged hospital board to remove the delaying 1An interview with the apprOpriations chairman found him Opposed to the hospital project on the grounds that "it was not logical public action--the doctors are willing to take money from the Government for the hOSpital, but fight 'socialized medicine' at the same time." DBS action of the remonstrance. Case study comment. The tactics applied by the hOSpital board were largely person-to-person contact, appearance at county and community meetings——such activity directed toward a flood of resolutions and petitions from groups and organizations that had approved the hOSpital throughout the events of the Mid-State process. The resolutions and petitions requested the Board of Commissioners and other related authorities, i. e., state tax commission, to conduct a hearing in order to attempt a decision on he remonstrance. This intended consequence materialized, and an outside judge (not hSB) presided at the hearing which declared the remonstrance "unverified", and thus removing the delaying action. It should be pointed out that the hospital board could have nullified the remonstranoe, not by court action, but by simply executing another petition to request bond issuance, out With legally correct wording and with more signatures than the remonstrance. That the hOSpital board elected to contest the remonstrance rather than circumvent it is to be explained, in part, by the uncertain history of the development of the board, the public criticism received for ineffectiveness, and the rapid turnover of board members. Confronting the remonstrance, the evidence suggests, was one way to publicly demonstrate that the board had arrived DC) at operational maturity; in effect, a "face~saving" measure. C. Farwest The decision area dealing with the method of financing local shares of construction costs was simply handled in Farwest County, due to the administrative permissability of the hOSpital District. The task of ini- tiating decision-makers in Farwest was the legal develOpment of the hOSpital district, for this solved automatically the method of gaining funds through the voted jurisdiction of the hoSpital district board. £36 The problems of Farwest County were apparently encountered and solved in the extensive negotiations and arrangements of the initiation of the project, and described heretofore--and carried out under the supervision of FWl, the state senator. Beyond the activities of initiation, the physicians ssumed the task of circulating a petition (gaining 1,200 sigratnres) to encourage the election dealing with the hOSpital district. One distinctive feature of the Farwest instance is that the decision to issue bonds per an election on the bond issue fellowed after more than a year of planning with hOSpital architects. deported throughout was the circumstance of visiting hOSpital architects having appeared before county organizations, eSpecially the service clubs of Champ and Marine. No evidence suggests anything but that the hOSpital district board Simply, after construction costs were determined, gave notice of a county election to approve the issuance of bonds. D . L. err-3c st Deciding on the method of raising local funds in Norwest County was, like Farwest and the other cases, somewhat automatic by the attempt of the initiating decision—make‘s to move the locus of decision-making into the Board of County Commissioners. Accordingly, a county bond issue was envisioned by the initiating decision-makers from the outset. Lever- theless, a variation in procedure occurred in the Norwest instance not previously encountered. In Southeast, Lid-State, and Farwest, petitions were employed to make mandatory a county vote on either a bond issue or a hOSpital district. For Norwest County, the petition became a device 1137 to document the approval engendered by-a county mass meeting and to demonstrate county interest to the Board of Commissioners. It was not an Open declaration for a bond issue. Instead, state laws prQS‘FiDBd that if olS,OOO was raised by citizens of a county for the intent of hOSpital construction, the Board of Commissioners would be therein authorizes to call for election on a bond issue. \ The efiicacy of the unrequired petition, as a documentation of county interest, was that it enabled NW1 and other members of the Lions Club committee to negotiate with the Commissioners in having a finance com- mittee appointed with the recommendations of the Lions Club committee, eSpecially xvi. Appointments to the finance committee aimed to further guarantee that the project had moved from the Lions Club to the County. As mentioned heretofore (Chapter Six), the finance committee deve10ped an extensive organizational machinery throughout the county and, per public subscription, gained an over-subscription, or $19,000. The Board of Commissioners, with this evidence, appointed the Hospital Trustees to further investigate hospital construction and to subsequently recom- mend the amount of bonds to be issued. With the history of attempts, and events, to legitimately secure the Norwest project as a county pro- ject, the recommendation of the Trustees to the Commissioners appeared as an administrative exercise. E. Noreast As numerous references had depicted, the initiating decisions of the Noreast project were actually made within the context of the fund raising 1436 method. It should be noted that, since the Noreast project had no re- lationship with either municipal or county governing bodies, fund rais- ing was apparently never considered as anything but an appeal to the people at large to voluntarily subscribe the required funds. For horeast, the decision to employ a professional fund raiser committed the Sponsor- ing group, the existing hOSpital board, to a hOSpital project. That the method of fund raising was taken as the initial decision, and not the legitimation of the hospital idea, was explained by the apparent con- stituted authority of the already organized hoSpital board, and its ap- parent, but gradual, plans that a new hOSpital was a necessity. Contribut— ing to this point, too, was the deve10ped expression of hOSpital need in the community, and the increased attention to hospital facilities en- gendered by the prOEram of the Gately Regional Hospital Council. In passing, it should be mentioned that the fund raising campaign in horeast led to extensive diSplays of strategy and tactics, largely sug- gested and directed by the employed professional fund raiser. Although a variety of references have been made to the short-run bureaucratic char- acteristics of the campaign, the following comment may indicate the manner in which tactics were devised and executed. Case study comment, After the fund raising campaign was well along toward completion, the point was reached where the originally set goal was accomplished. The professional fund raiser independently sent a telegram to the various functionaries in the campaign organization, calling an emergency "breakfast" meeting for the following morning, At the meeting, the campaign workers were told that they were in danger of not reaching the intended goal, but that a day or so of intensive activity on their part would accomplish the desired end. In this way, it is not surprising that an over-subscription occurred when the final tally was made, L39 F . S zmrmarz The foregoing section indicates the manner in which the initiating decisions for hOSpital projects were frequently indistinguishable from those decisions made to choose the method of fund raising. Southeast County separated the two forms of decisions, concentrating on first the approval of the hOSpital project, secondly, the method of fund raising. The same circumstance was true Of Farwest and Norwest. In Hid—State County, the entire decision-making process initiated with a debate over the method of fund raising to be employed, while in noreast, deciding on the fund raising method concurrently committed the community to a project. In four Of the five projects, a general movement of the decision- making process occurred toward the locus of county governing authority. In each instance, the method of fund raising, and related devices such as the petition, served either to encourage the involvement of political governing bodies, or to further secure the involvement. Important, also, is the extent to which the petition in various forms has functioned to channelize public support or Opposition and, hence, to gain a concrete lever for purposes of negotiation and transaction. As was illustrated by Mid-State County, the petition.made it possible to not only devise the strategy Of Opposition, but tne means to finally immobilize the Opposition. In Norwest County, the petition, while not legally called for, served to express the determination of the Lions Club to shift the burden Of decision—making from the locus of restricted Norwestville to that Of the county governing body. 14' 11.0 Decisions: Composition Of Sponsoring Groups A, Southeast The Southeast County project demonstrated that, although the recorde ed official sponsorship for the project rested in the County Commissioners Court, the process of Sponsorship was extended to form another group, which, in the details of the project develOpment, became representative of the Sponsoring function. But, more important, is the way in which Sponsorship contributed to the exercise of strategy. Although treated in detail in earlier sections of this chapter, it should be pointed out that the device of the hospital association, and its executive committee, served to identify the influentials Of the County as official proponents of the hospital project. Here was a case in which the initiating de- cisions were made by decision-makers possessing authority through con- stituted Offices; but they recognized that one of the major capacitie for both legitimizing and executing decisions rested with the influential big landowners, and that the resources possessed by the landowners (wealth, reSpect, access, etc.) were felt necessary for the pursuit of the project. Hence, since strategy is the attempt to gain or to neutralize the re- sources and proficiencies not possessed by a particular decision-maker, mere attendance at public hearings was not enough to insure the formal commitment Of the landowners amidst the subtleties Of the out-county political network Of relationships in Southeast County. The resources and proficiencies Of the landowners had "to be moved over" from their perhaps diffuse deployment in the out-county system to a firmly aligned relation- ship to the nexus of Sponsorship, the Court and the Farm Bureau directors. Mu It is significant that after the appointment of the hOSpital association directors, the total group became inactive, and its executive committee assumed the details Of Operations. hot to be overlooked is the manner in which the executive committee enabled the initiating decision—makers from the Farm Bureau to become officially and legitimately incorporated, not as representatives of the Farm Bureau, into the sponsoring function. As previously mentioned, the procate judge made the selection of hOSpital association directors, but the initiating decision—makers from the Farm Bureau provided the alternatives for the selection. Whereas the petition was a device to construct strategies and tactics pertain- ing to the fund-raising method, the appointments of sponsorship were the devices for moving the locus of legitimacy EB and through constituted agencies of authority, and permitting initiating decision~makers to be released from initiating roles and placed within the context of Sponsor- ship, approved and legitimized by the authority agency. B. hid—State Previous analysis has demonstrated that neither the feasibility of. the hospital project nor the exigencies of Sponsorship were explicitly met in the initiating decision area. Indeed, the Mid-State project was initiated outside the domains of formal structures, either associations or political bodies of authority. In some ways the most inadvertent process in.Mid-State County was that of sponsorship. hot only did this, in itself, condition a series of unintended consequences, but, as well, the presence Of competing centers of decision-making resulted in the we almost aimless passage of sponsorship from one competing center to the other. The assumption of sponsorship by either existing or newly formed groups came frequently so inadvertently, that devisiveness would occur within the respective groups which held Sponsorship at a particular moment in time. Thus, the appropriations committee within the county governing body aligned itself against the parent group on the premise that the county was taking over the responsibilities decided by those of vested interest (i. e., the physicians). Similarly, the internal changes within the hOSpital committee resulted in an indefinite Operat- ing group, serving to finally bring organized medicine back into the decision-making arena. Case study comment. The end—point of the inadvertent forming of Sponsorsnip was a kind of competing bi-lateral structural arrangement. On the one hand, the medical society stood back of, and frequently directed, the Operations Of the hOSpital board, which the Board 9f Commissioners had appointed; and on the other hand, the appropriations committee, althougn Opposed, was linked to the authority Agency of the board of Commissioners. All the while, the influentials of Westville provided the Oppor- tunity for strategies of Opposition to be initiated, or the im4 mobilization of Opposition. That such a circumstance could result is, in part, explained by the inability to explicitly place or settle Sponsorship in either a structure that could legitimately exercise it, or a nexus of Sponsorship that would articulate authority and influence agencies, i. e., Farwest C ounty . 5 These references to Mid-State County suggest the conclusion that the decisions of Sponsorship were not concretely considered as necessary decisions at all. The result, of course, was that the participating decision-makers never quite knew, at any particular point, just what constituted the lOCus of Sponsorship. hb3 C. Farwest Previous analysis has attempted to Show that the initiating decision in Farwest County directly included the formation Of Sponsorship. The period Of informal and formal negotiation instituted by le increasingly spread the circles of involvement to an ever-enlarged assembly of associations, and hence organized influence in the County. But the real purpose Of these negotiations was tO move, through the Grand Jury, in the direction of the Board of Supervisors in order to gain a legiti— mate decision that a hOSpital district be formed. As pointed out earlier, the hOSpital district decision was to result in a second authority agency staffed by influentials. Not only did this mechanism provide the pos- sibility to formally articulate authority and influence toward a common end, but, conversely, provided for the possible consequence of two competing authority structures in the decision-making process. This, however, was destined not to occur, in that the bi-lateral authority structure resolved itself into a form Of co-Sponsorship. How this was effected is explained by the interlocking arrangement of Ffi4 serving on both, the joint sessions given to the details of decision-execution, and the circumstance of FWl, while literally holding no Office in either authority agency, through both tangential authority positions and in- fluence, assuming a continuing interlocking role. In effect, the de- cision-making process appeared to be centrally devoted to (l) explicitly pyramiding influence and authority, and then (2) interlocking the two in co-sponsorship. To be pointed out is the similarity with Southeast County, namely, that initiating decision—makers (in this instance, FWl), although huh Shifting the locus for decision-making to an authorityoagency, determined the appointments to the Sponsoring group. A dissimilarity was the latent function of the appointments. For Southeast County, they provided the immobilization of influence that could be deployed against the project, and in Farwest, the mobilization of proficiencies construed to be rele- vant and essential. U. norwest Although the horwest instance compares similarly with the decisions of Farwest in affecting the form of Sponsorship, one exception, at least, prevailed. AS commented before, initiating decision-makers preferred to move the Sponsoring function from the initiating nexus, the horwest- ville Lions Clue, to the County Board of Commissioners. In this movement, the elicitation of general and public approval (per mass meetings and the documentation by petition) served to legitimize the decision and provide the arrangements of decision-axecution-—various committees selected at mass meetings to represent subgroupings of Norwest County. Again, initiat- ing decision-makers (eSpecially th) provided the alternatives for choices to be made by the county governing body on the extension of Sponsorship, the hOSpital board. hence, the transfer of the Sponsorship function must be held as moving through constituted bodies of authority, rather than moving :2 the authority agency and remaining. The distinction of the Norwest case is that the eventual Sponsoring group, the hOSpital board, proceeded to an alignment with the initiating decision-makers and the most relevant agency of influence, the LLB Norwestville Lions Club. Conversely, in both Southeast and Farwest, eventual extensions of Sponsoring arrangements continued in either a subordinate or bi-lateral relationship to the county governing body. For Norwest, the beginning and the end of the Sponsorship arrangement was, in most reSpects, identical. hence, tranferral of Sponsorship was circuitous, but in the process added the legitimizing sanctions of both the public and the centrally important agency of authority, As several references have demonstrated heretofore, once the circuitous transferral was completed, the board of Supervisors appeared to have but a perfunc- tory relationship. Subsequent decisions, for example, as to details of finance and technical construction matters were directed for discussion and implementation to the Norwestville Lions Club, to the almost total exclusion of the Board of Supervisors. e. horeast For the horeast instance, the structure of Sponsorship would appear to be a relatively less complex decision confronted by the initiating decision-makers. Throughout the project, the hospital board for the already existing hOSpital served as the Sponsoring agency. however, more detailed consideration reveals certain distinctions not encountered in the previous cases. First of all, no constituted authority agency of municipal or county jurisdictions was relevant. Instead, the hOSpital board sufficed as an authority agency with narrow limits of jurisdiction, but also was another focal point of the organization of influence in the community. As referred to previously, the decision-making function was has carried out largely in contexts (arenas and domains of decision-making) Other than the hOSpital board. The study of the evidence pursuant to Specific decisions reveals that the Noreast hospital board was recur- rently confronted, for approval, with decisions made by its presiding officials, dbl and hbz. Such recurrent deferences to the total board were not necessary for the requisite legitimizing of the decisions, but served to continue the mandates of the offices which NEl and NEE held. Functionally, the hoSpital board was an authoritative expression of a "vote of confidence." Since the Noreast case is an example of a wide mobilization of the influentials of one community, the access which the initiating decision-makers possessed into the associational life of the city secured the major locus of the legitimizing function, the influence structure. A second distinction of the Noreast instance is that the campaign organization functionally structured the entire community into sharing the responsibilities of Sponsorship. Since the Operational goal became defined, not as the hospital, but a Specific sum of money, the organiza— tion of a multitude of committees and other work groups served to diffuse the Sponsoring obligation throughout the community. In one sense, this step was necessary in that the hospital board actually had no mandate to assume official Sponsorship for a new hOSpital, but only to manage the affairs of the hospital already operating. Moreover, with a fund-rais- ing method based on voluntary contributions, the hOSpital board could not exercise authoritative instrumentalities to insure that funds would be forthcoming, as contrary to the county governing body's rights to issue bonds. neither was the hospital board in hore st an extension of a political agency for sponsorship functions, as was, conVersely, the circumstance of Southeast County. Thus, the character of the fund- raising method entailed not only the maintenance of the hospital board for mandating the only vestige of authority of office (its presidency and vice-presidency) but the diffuse involvement of the influentials of the community into a short-range bureaucratic structuring of the Sponsorship function. The question could be asked, however, as to the need for the cam- paign structure, since the initiating decisions for the hOSpital had been effectively approved by the hOSpital board. One explanation would be that the advent of the professional fund-raiser produced a host of tactics in fund—raising that called for atypical interpersonal behavior. The bureaucratic structure of the campaign organization instituted, for a brief period, the impersonal order. Thus, when one became "chairman of the Special Gifts Committee," both title and office affected a form of impersonal behavior probably not possible, nor customary, in a decision-making system of relationships functioning more largely through influence than authority. F. Summary The comparative comments of the manner in which the structure of Sponsorship for hOSpital projects was decided indicate (1) that in four of the five cases (except Noreast), the Sponsorship function was trans- ferred from the structural nexus of the initiating decision-makers to or through the reSpective county governing bodies; (2) in Southeast, Farwest, and Lorwest, the transferral was advertently performed, while in hid-State the transferral, from the vantage point of the initiating decision-makers, inadvertent; (3) in both Farwest and Norwest, the transferrai was legitimized and facilitated by public expressions of con- sensus; (L) in Norwest, the transferral started and finished with identi— cal structural alignments, while in Farwest, the transferral produced a bi-laterel structure of authority, effecting a co-Sponsorship of the project; (5) in horeast the sponsoring function was, for a brief period, diffused throughout the influence structure of the community by means of an impersonal bureaucratic campaign organization. Decisions: Countering Unanticipated Building Costs The develOpment of small hOSpitals after world War II encountered the difficulties of an inflationary period. hOSpital construction, operationally equated with relatively large sums of money, increasingly became a more expensive prOposition--both to participating decision— makers and the public at large. Two over-all aspects of the problem, largely unanticipated at the point of project initiaion, need to be set forth: (I) the expressions of Opposition to the project were destined to be based on themes of financial difficulty (reviewed in Chapter V); (2) since fund-raising required a period of time, original estimates of construction costs were found wanting at the close of the fund-raising period, due to the interim effects of increased building costs. Resolv- ing this problem formed a class of decisions rendered in the majority of the hOSpital projects deve10ped sinde'World'War II. Lt? A. Southeast barlier presentation has included the references to a mistaken assumption of Southeast decision—makers, namely, that federal as istance would be forthcoming to the extent of two-thirds of the total construc- tion costs. The eventual ratio of federal assistance was one-third of the construction costs. In the midst of the incorrect expectation, the original bond issue of $00,000 had passed by'a public vote. ‘Two decisions were made in order to offset the damage to original plans when knowledge made it clear that original expectations of federal assistance would not be received: (1) the original construction plans (a SO-bed facility at the county-seat town of Carlin and a small health center in Farmville) were reduced. The Farmville health center was eliminated from the project, and the size of the Carlin facility was reduced from 50 to 20 beds; (2) negotiations were Opened with the state building commission in order to obtain assistance from the state monies. Case study comment. Deciding to eliminate the Farmville facility would appear to run counter to the earlier efforts to secure the large landowners of the Black Belt area on the Sponsoring and Operating group. It will be recalled that the village of Farm- ville, placed in the midst of the Black belt, actually served as the residence of many of the larger landowners. One might expect that, with an intent to eliminate the Farmville facility, resist- ance would be encountered from the large landowner influentials. In addition to the fact that Farmville was proximate to a larger city hOSpital, the approval of the landowner members of the hos- pital committee to eliminate the Farmville facility was secured without difficulty. The explanation is that the landowners, as individuals, believed that the hOSpital would not materialize, and that the present elimination was actually the start toward the complete defeat of the project for the entire county. Active resistance to the Farmville elimination could have, due to the financial impossibilities involved, perhaps indefinitely delayed the project, but the fact that the landowners did not resist is evidence, again, that the expectations of the Black Belt tradition could not permit the explicit Opposition to the "worth-while" hOSpital project. In regard to negotiations with the state building commission, the politi- cal identification of the incumbent probate judge with the generally Opposed state administration provided the needed access to negotiate two contributions from state sources. The third and final alternative to completing the Southeast project was to place before the public a two-mill sales tax for the purpose of not only completing hOSpital construction but, for a brief period, to provide public support to the Operation of the hOSpital. That this was accomplished is explained by its introduction after the construction had begun. Rather than being confronted by an unfinished project (also a skeptical procedure for large landowners with a public image of "success") there was no alternative to voting the sales tax through successfully. For the large landowners on the Sponsoring body, and the organizers of the resistance to the project (centered in the "hill country"), actual construction was both unintended and unexpected. It is here that the relevance of extra-community agencies became paramount. Visiting govern- ment architects, negotiations and closing of contracts with state and federal agencies, all worked toward an increasing burden of obligation for the Southeast sponsoring body. Although these were carried out and secured largely through the negotiations of SB1 (Chairman of the Sponsor- ing group), nevertheless, there were the previous sanctions of probate judge, the Commissioners Court, and the large land owners-~all incorpor— ated into the Sponsoring and Operating group for the project. The Southeast instance is, therefore, characterized by three pro- cedures in countering increasing costs of construction, namely, employing ngir.‘fi4.flau 0‘! , E. rd. riég access to state agencies for aid, reducing the extent of facilities planned, and negotiating a form of taxation when no alternative was present. The original method of raising funds, the bond issue, was not employed again, similar to the other cases that encountered increased construction costs. 5. hid-State h'd-State County was the only case of the five projects intensively studied in which adjustments of estimating building costs were unnecessary. Actually, the latent function of the extensive delays in.Mid-State County was that Of permitting the project to await the clarification of federal assistance. This circumstance contrasts with Southeast County project, which was initiated and bond issues committed in the midst of ill-defined state and federal assistance. The first estimate of a bond issue in Mid-State County was that of $200,000. During the delay brought on by internal variability in the Sponsoring committee, and the remonstrance of Opposition to bond issuance, Hill-Burton legislation was defined. Accordingly, in hid-State County, the original support assurred was that of one-third the total cost ($100,000). Finally, one-half of the total cost was assurred (u200,000). Hence, the delay inadvertently solved the problem of increasing building costs. Also, the turn of events with federal assistance was one factor in encouraging the Sponsoring hospital committee to hasten to remove the delaying action of the remonstrance and to arrange for a deluge of petitions and resolutions from individuals and organizations in hid-State County. C. Farwest Earlier references have indicated that in Farwest County the esti— mation Of local shares of construction costs occurred after the details of sponsorship and negotiations with architects had been completed. Upon receipt of bids from construction firms, the low bid, or $900,000, was believed by the hospital board to be in need of reduction to $750,000. Throughout the early negotiations of the board, and the progressive develOpment Of federal legislation to provide one-half of the cost, it was planned that the Farwest County bond issue should not exceed 9330,000. The alternative solution taken was that of arranging for certain archi- tectural changes, and the calling for a new set of bids. The discontinuance of the received bids presented a problem to the Farwest decision-makers. The architectural plans and the bids had been approved by state and federal agencies. Consequently, Farwest decision makers were forced to choose betWeen two alternatives: (1) re-formulat- ing the plans and calling for new bids in order to keep local costs at expectations; or (2) accede to the approvals rendered by extra-community agencies and increase the size of a local bond issue. It is at this juncture that the possession and exercise of proficiencies may be viewed. A single decision-maker (FWZ, the legal consultant) was authorized by the hospital district board to attempt negotiations with state officials in order to gain and "null and void" on the plans and bids already re- ceived. sz, with extensive access to state administrative agencies and architectural firms, was able to bring about the "null and void" condi— tion. Both state agencies and architectural firms agreed to a re-formula- -. r tion of hOSpital design, and a subsequent reduction in total cost of $150,000. 4:..- \JT b.) D. Norwest For the Norwest instance, considerable difficulty was manifested due to the initiation of the project prior to federal legislation to authorize assistance. Three steps were taken by Norwest decision—makers to meet the alterations in building costs. The first was to gain, per a county mass meeting, approval to use the original $19,000 raised volun- tarily to show cause for a bond issue election; the second, to follow the first bond issue of $130,000 with another of $25,000, which was duly approved by public vote. In this instance, construction was already underway and still prior to the opportunity for federal assistance. The third Conrse of action, after federal funds were made available and $21,000 was still needed for matching purposes, was that of Securing one thousand dollar pledges from businessmen, almost altogether in residence in horwestville. As earlier cited, the decision made was that of sup- planting another bond issue with a challenge to the Norwestville Lions Club to provide the solution. The distinctive note about the Norwest case is that the same fund— raising method, the bond issue, was employed successively. In no other Of the five projects did this occur. however, when the final sum ($21,000) was required, the decision-makers sought another alternative. E. Noreast The distinction of the Noreast instance, beyond its employment of the voluntary subscription method with professional assistance, was the apparent intent to raise a sum of money, but not to continue immediately L614 with construction. In Southeast and Farwest, the financial decisions ran concurrently with those of construction and design planning. In ~l Norwest, details of construction planning were accomplished prior to decisions of finance. In Noreast, however, the decision process did not include an initial attention to estimated costs based on architectural designs. Informants reported that the technical details for which funds would be expended was the problem of the existing hospital board, in that "it had been looking over hospitals for several years." Indeed, the presiding officials of theboard(;;h‘l and N32) had become familiar with the requirements of hOSpital planning and design. In any event, the Noreast case provides an example of how public images of competence vested in decision—makers permits atypical alterations in the sequence Of events within the decision—making process. Since hOSpital building is a financial consideration, it would be expected that the requirements upon which costs are based would be placed rather uniformly in the de- cision sequence. The alteration in the decision sequence in Noreast is to be eXplained, in part, by the positive public image Of subject matter competence leveled at the participating decision—makers. In Noreast $152,000 was raised through the voluntary public sub- scription. .The horeast hospital board, with the explanation that build- ing costs would not permit immediate construction, converted the funds into treasury bonds with the intent to await a more favored period for construction. Case study comment. Although no evidence is available that directly relates, nevertheless, there is some reason to believe that the initiating decision-makers did not see the construction , v ._ f .1 v. . . y . 50 ,....<..4J’.......bm.fl(1m,n. - .. .. ...: . ..-mmlghmflu, ‘lggzm‘. In; ND. 3!. 4. ... J:......;...PI....\1..6‘I\. 1a: . at. . that. l. .1». l n . . , v .v 2.1. .00.: ..A i,‘ filial-... 1“, Mgflgl I. ._n_u_ .- = _- -— II It IchiI .rr . .l ... i ‘ 4‘3“! ... I IYL . fa! i . .l! '2 . . . . ... :1». .6. 1.3 L. at: l. n. . . u . . .lv 1 n . ‘ DES details as an immediate problem, and were expecting that a con- siderable delay would result, even though the voluntary sub- scription would be successful. In addition, the initiating decision-makers (nEl and hbg) had become involved in the increas- ing relevance of the Cately Hospital Council to hOSpital develop- ment in the Noreast area. Knowledge was also available that the Cately Council was supported by a major health foundation. Since Eill-burton legislation was not yet known to be forthcoming, it is entirely possible that the alignment made with the Uately Council was viewed as an agency that would, if the Noreast com- munity could demonstrate its interest by a collected sum of money, be depended upon for construction assistance. During the intervening period of inactivity (l9h5-19ht) federal assistance became available to the extent of one-third of total cost; and detailed planning commenced. The resulting total cost was estimated at §h60,000, the federal grant to be dl00,000, the Noreast contribution, 1*: $200,000. The remaining amount was negotiated by hhl and hEz through their established relationships with the Cately Council, and a grant was obtained from a major health foundation. Case study comment. The horeast hOSpital board, through Nil and she, had become reciprocally related to the dately Council, particularly in an obligatory way. The Cately Council had as one objective the improvement of hospital administration in the mem- ber-hOSpitals. Accordingly, the Council had supplied an adminis- trator for the old Noreast hospital, but who met with early difficulty in role definition from the medical staff of the hOSpital. It was hEl and LE3 who met with the medical staff and insisted on the reSponsibilities of the administrator. In this way the aims of the Gately Council were being extended. This and other COOperative acts of hi1 and nhg had made the Noreast hos— pital one of the more resnonsible members of the dately Council, and was viewed, by Council officials, as one of the progressive members. Such events, of course, provided the access to the Council when additional funds were required. F. Summary J Four of the five selected projects experienced difficulty due b0 successive upward alterations of construction costs. A variety of alter- native courses of action were taken to counter this difficulty, namely, \ (MI {1"}... afield. fl..r-. . n . . I l L PEANIH: . . t. t .-..v i it ..Ii.«. ._ Ru 1... .ruflWitw. ELM. W ugh): .i‘dtr 25!! I .. :tbkgr‘ut I." .v p. x .1; . u ... . . a . twin???» iii $. 1.1.ilii‘O1EIIIJH'IW'lI. .I'III'! I, ‘vivt [lilti‘v’kr .tQ‘l... , application for state monies, reducing earlier Specifications in archi- tectural design, and returning to the community for additional contribu- tions. The important summary statement, however, is that participating decision-makers did not geierally return to the community with the identical fund-raising device. In the two instances where this did occur, hOSpital construction was underway; hence, the tactic was one of appeal- ing for completion of a task already initiated. In those instances where construction was not initiated, securing additional funds was accomplished V through the access possessed by decision-makers to extra-community aIERCleS. ""1 Unanticipated increases in construction costs brought into relief the manner in which extra—community access may be employed in decision- making. The concern with such agencies was focused in the inter—play between construction details and resolving rising building costs. At this juncture of the decision-maxing proceSS negotiations tended to be taken by a restricted number of decision-makers, in some cases out one, who possessed Operational access into extra-community agencies and enjoyed the proficiency of legal knowledge and Skill. Chapter Summarv ...—Jr'— Forms of decisions. Four major forms of decisions have been made in the task of acquiring hOSpitals. The first Was that of decisions to initiate the project; the second, the selection of the fund-raisins method; the third, composition of Sponsoring and operating ,roups; and fourth, resolving unanticipated construction costs in an inflationary period. {‘7‘ \F. \J This chapter has indicated that the four major decisions usually occurred in a Sequential pattern. ‘When the initiating decision occurred within an inter—play of authority agencies, the decisions of Sponsorirg structure were, in effect, made simultaneously. When the interplay was between authority and influence agencies, an initial concern with Spon- sorship did not necessarily esult. For instance, the Southeast case reflected an initial interplay between authority acehciss, with a weighted and initial attention to the necessary involvements for sponsor— ship. The initiatory negotiations were direct and explicit, and early decision-makers were not involved through indirect and informal negotia- tions. This initiatory profile would surgest that in Southeast (and to some extent in Farwest and horwest) decision-making was confronted with rigid structural limitations, which mandated the first consideration as that of Sponsorship. Conversely, in Noreast the decision sequence was altered. The fund- raising method was decided prior to Sponsorship. Although Sponsorship was immediately construed within the context of a Specific authority agency, the hOSpital board, the negotiations to affect the Operational group resulted from indirect and informal negotiations outside the con- text of the board. Hence, in Noreast initiatory interplay was not between authority agencies, but within limited networks of relationships con- trolled by influentials. In this way, no direct and immediate concern with the structure of Sponsorship preceded the decision as to fund- raisinc method. One explanation here is that in Noreast the initiating relationship set controlled the resources and proficiencies necessary 1.13:0!" “0 1”" \Ol .. . _P...IL~ O . l. 1.1"} 1%,. I I 1111i 6.... £31.] <- L . ‘ to enter the decision-making arena; whereas, in Southeast a portion of these capacities were controlled by the larre landowners, but one of whom was in the initiating set. These uncontrolled capacities had to be gained or neutralized, with a resulting initial attention to Sponsor- shi). Technical hOSpital planning was altered in much the same way. In Southeast and Farwest technical planntng occurred simultaneously with the selection of fund-raising method and the collection of local funds. In horwest and Noreast, technical planning followeo the selection and execu- tion of the fund-raising method. Again, decision-makinq within the con- text of authority tends not to permit alterations from an expected decision seguence; whereas, the process functioning more largely on the basis of influence and influence agencies does permit such alterations. Strategies and tactics. Initial strategies and tactics tended to move the decision-making process in the direction of the legitimate order, namely, the apprOpriate county governing body. This movement was ad- vertent in Southeast, Farwest, and Lorwest; inadvertent, from the vantafie point of the initiating decision-maker, in.Mid-State. The initial strategies in horeast tended, not to move toward the legitimate order, but to expand tne involvements of influential persons in the community. Summarily, in four of the five projects, strategy moved the process ini- tially always in the direction of the legitimate order; only in horeast was the movement away from the only visible vestige of the legitimate order, the hOSpital board. ‘1 9‘7 ‘;¥’ ’l‘lv .5 ’1 1 u' For three of the five projects (Southeast, hid—State, and Farwest) the movement of the decision-making process resulted, as it were, in its being lodged with the reSpective county governing bodies. By this is meant that incumbents of such bodies played participating roles in decision-making from that point. In Southeast County, the probate judge continued to be an actively participating decision-maker. For Mid-State County, the interplay between the appropriations committee of the county governing body and the hOSpital committee proved to be the crucial structural arrangement. The resulting co-Sponsoring function of the Farwest instance between the county supervisors and the hospital dist- rict board is also indicative of the manner in which decision-making may 0 lodge with the legitimate order. In Norwest County the process moved to and through the county governing body. Subsequent decisions of fund- raising and legality did not find incumbents of formal political o‘fice in participating roles. One must therefore assume that passage through the legitimate order was to legitimize decisions of initiation and spon- sorship, but not to introduce political officials as active participants. Finally, in Noreast no movement or passage relevant to the legitimate order occurred. As previously stated, the Noreast board was a constant sounding board of approval and served to voice a vote of confidence to its two major officials who almost entirely negotiated outside the con- text of the board. Accordingly, the conclusion is tentatively rendered that the decision-making process initiated in the midst of a rigidly structured interplay of authority agencies will be more likely to lodge with the legitimate order than when the interplay involves influentials and influence agencies. )4 CO The strategies of the five projects reveal periodic attempts to channelize public support and consensus, eSpecially preceding public voting. For this purpose the device of the petition was widely employed. For Southeast the petition served to mobilize consensus prior to a bond issue vote; in.Mid-State to make mandatory a bond issue vote and to later mobilize Opposition to the project. In Farwest the petition again mobilized public support prior to the vote for a hOSpital district. The petition in Norwest enabled a documentation of public support in shift- ing the locus of decision-making temporarily to the county governing body. he petition was employed in Noreast at any point. Mobilizing public consensus was achieved by a short-run campaign structure. he For the decisions of sponsorship, initiation, and selection of t fund-raising method, strategies, tactics, and related negotiations were, for the most part, confined to the relevant jurisdictions for the projects. Intra-community access was a needed resource. however, the unexpected decision of resolving rising building costs brought the need for extra- community access. It was at this point that a shift frequently occurred in the operations of the decision-makers, resulting in intensive negotia- tions by but one with this resource. hence, in Southeast the probate judge (831) possessed the needed resource; in hid-State, the druggist (MSQ) with state connections; in Farwest, the legal consultant (Ffll); in NOFWGSt, the oil company executive (AWE); and in Loreast, the financier- wealthy gentleman farmer (1132). Consequences. The fourth major form of decisions was, from the vantage point of the initiating decision-makers, actually an unintended hol consequence, namely, constantly rising construction costs. Although each project commenced with the a351iption that initiation, Sponsorship, and fund-raising constituted the integral decisions, the national econo- mic setting forced another. This circumstance demonstrates why community organization projects may never be defined as distinctly local or auto- nomous. Yet, in at least two of the cases (Mid-State and Noreast) the delay which economic forces engendered also had the latent function of casting the projects into favorable Opportunities for feieral assistance. Hence, in.hid-State, where the greatest delay occurred, the least con- cern was had with the consequence of rising costs. not to be over-looked is the selection of decision—makers between three alternatives: return- ing to the community for additional funds, deciding to await a more favorable construction period, and negotiating with extra-community agencies for financial support. In Southeast, for example, the selected alternative was to follow defined channels to state agencies; while in horeast, with decision-making initially functioning apart from structural arrangements with state'agencies, a construction delay seemed most feasé ible. This chapter has revealed the manner in which two projects, hid—State and Noreast, failed to initially make the decisions to form the structure of Sponsorship. The consequence for hid-State was two competing centers of influence with loci in two autonomous subgroupings of the County, and both attempting to control the legitimate order, the county governing body. The consequence for Noreast was the impersonal structuring of the resources and proficiencies in the community by a bureaucratized campaign organization. This, in effect, expanded the reSponsibilities of Sponsorship to Operationally include the entire resources and pro- ficiencies of the community. Thus, one may obtain a final glimpse of the flexibility which accrues to the decisionrmaking process functioning on the basis of influence, rather than.'amiest the rigidities of con- stituted and jurisdictional authority. CHAPI‘ hilt hfliifi CHL'r‘Th‘R 1mm A ThEOhETICAL.AND.hdlhODOLOdlCAL RU“E The problem re-stated. The foregoing presentation is primarily a comparative treatment. Its premise, postulated in the initial chapter, is that research in community studies has been characterized by an in- sufficient concern with comparative materials, and a subsequent failure to explicitly relate community processes to larger sociocultural sys- tems. This study has attempted, in a theoretical and methodolOgical sense, to build on these needed research areas. Accordingly, a research 'design was formulated in order that both quantitative and qualitative materials might be scrutinized, and that the traditionally employed time-sequential patterns of community organizational studies might be combined with a non-sequential analysis of community organizational process. The theoretical problem was one of introducing into a community organizational context the perSpective of the political process, Specific- ally defined and deve10ped herein as the decision-making process. The analysis has attempted an attention to the major problem: that "within one general class of communities in which community organization and action toward an identical and concrete action goal have occurred, varied community situations subsumed under the integrating concept of region will exhibit differences in the decision-making function." With lion greater precision the hypothesis was that "some decision—making pro— cesses function on the basis of authority, and that others function on the basis of iLfluence, and that community situation tOgether with an understanding of higher levels of integration such as the region will be among the determinant factors." This dissertation, therefore, has viewed the applicability of two major concepts, authority and influence, to an understanding of comparative differences in the decision-making process. Summary conclusions.1 The most recurrent conclusion is the relevancy of the legitimate order to four of the five Selected case studies, and the collated indications of relevancy in regional groupings of hOSpital projects. For hOSpital construction projects the legitimate order must be construed as the respective county governing bodies. Although hos- pitals are normally constructed on physical sites within the jurisdictions of municipal governing bodies, the major jurisdictional unit is, for the most part, the county. Since analyses of community organizational settings (Chapters Two, Four) conclusively demonstrate variations in the incidence and function of county governing bodies in regions of the United States, and their almost total exclusion in the horeast, one must 1The comparative interests of this study, and the determined atten- tion to the meticulous handling of qualitative evidence, have both en- couraged extensive summaries of each chapter, organized to deal with a basic aspect of decision—making. For this reason, little, except redund- ancy, would be added to attempt here an extensive summary of the summaries. Instead, certain central tendencies will be noted in order to aid the reader in recalling more detailed sets of conclusions. has conclude that the capacity of authority in decision-making for hospital construction does indeed vary. Both the quantitative and qualitative evidence provides the conclu- sion that the relationship of county governing bodies will frequently explain the manner in which the capacities for decision-making are structured, the forms and content of negotiations in initiation, sponsor- ship, administration, and organization, and the way in which decisions making may move toward, lodge with, or pass through the legitimate order. Once, however, the county governing body has been delimited, it is the internal structure of this authority agency which determines the movement of the decision-making process in relation to it, and determines the extent to which local political officials may assume active roles in decision-making. Thus, to find a community situation, as evidenced in the Southeast, which exhibits superordinate and subordinate roles of authority within the county governing body, incumbents in the superordi- nate roles will tend to make an active entry into, and continue in, decision-making initiated outside the context of the legitimate order. Conversely, where county governing bodies have no inner hierarchical arrangements, the decision~making process may move in the direction of the legitimate order in order to legitimize decisions of initiation and the forming of Sponsorship, but fails to lodge there, in the sense of an active entry of particular officials into the decision-making process (as in Farwest and Noreast).2 2Several students of local government in relatively rural counties have pointed out the inadequacies of many forms of county government in E65 When incumbents of superordinate offices within the legitimate order enter decision-making and continue in actively participating roles (as in Soutteast and hid-State), evidence of this study sugges sts that certain consequences follow: decision-making becomes more decisive as measured by Operational efficacy of first attempts; the role of the inner-circle of decision-making is restricted, with less gradation between the highly active decision-makers and others who may share in the decision-making function, and hence a reduced number of participants in the process; legal instrumentalities to solve problems which, in other situations, would encouragee extensive organization apparatus to gain consensus (i. e., fund raising); and less attention to communicating, and employing com— munication media, to the publics to which the decisions apply. As the present study indicates, this type of setting (decision-making lod ing with the legitimate order) may be confronted with the need to devise strategies and tactics to secure the involvement and commitment of in- fluential persons who may control major and required resources and pro- ficiencies, eSpecially wealth, access, and reSpect. Although the process may move in the direction of the legitimate order, it may move through and back to the sharing of the function by 2(Cont.) effectively dealing with legislative and administrative duties. The reason frequently cited is the lack of central positions or offices of authority in these groups. These iindin 8 suggest that the tendency for members of county governing groups to directly participate in commun- ity decision-making apart from the usual judicial duties is also reduced by the lack of such offices. For example, see D. G. BishOp and h. E. Starratt, Tie Structure of Local Gov