EMERGENCE 0F HOSPITAL PERSONNEL ADMINISTRATION: AN EXPLORATORY STUDY OF HOSPITALS IN A LARGE METROPOLITAN AREA Thesis for the Degree of Ph. D. MICHIGAN STATE UNIVERSITY VICTOR C. DDHERTY 1967 LIBR A R Y I“ MlCl‘tTgxn State University IIIIIIIIIIIIIZIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I 310474 7641 This is to certify that the thesis entitled EMERGENCE 0F HOSPITAL PERSONNEL ADMINISTRATION: AN EXPLORATORY STUDY OF HOSPITALS IN A LARGE METROPOLITAN AREA presented by Victor C. Doherty has been accepted towards fulfillment _ of the requirements for __Ph.._Q..__ degree in Management T‘mfiiw by ' Ma'jor professor Date November 15, 1967 0-169 ,5” I I rum; y BINDING av T" " IIIIAII 8: SIIIIS' 300K BINUERT INC. usamv stanzas 1249—2—92 W5. - @ VICTOR CHARLES DOHERTY III 1968 ALL RIGHTS RESERVED ABSTRACT EMERGENCE OF HOSPITAL PERSONNEL ADMINISTRATION: AN EXPLORATORY STUDY OF HOSPITALS IN A LARGE METROPOLITAN AREA by Victor C. Doherty The recency of the emergence of hospital personnel administration as a departmentalized activity attracts scholarly inquiry into the behavior of personnel special— ists in this "new" industrial environment. To develop a framework for understanding personnel director behavior the following hypothesis was derived from the body of organization research knowledge: The behavior of hospital personnel directors is a function of the organization environment within the hospital, and the director's occu- pational orientation. Lengthy, tape-recorded interviews were conducted in the offices of seventeen personnel directors. The directors selected worked in voluntary, non-profit, gen- eral hospitals which faced a common labor market and a common socio-political environment. The hospitals studied employed approximately fifty percent of all hospital em- ployees in the metropolitan area. Hospitals, in communicating their structures and purposes through organization charts and annual reports, appear to work similarly in the organization and administra- tion of their resources. The reliability of these formal presentations was examined. The study demonstrates, through a dimensional examination of the centralized Victor C. Doherty personnel administration function, that hospital organi- zations vary along bureaucratic dimensions, and further demonstrates that a major factor influencing this develop- ment could be traced to the evolved power centers within the socio-economic and organic complex of a hospital. The evidence reveals that the authority system in some hosp- itals is of the non-administrator dominated type, while in other hospitals it is of the administrator dominated type. It was found that the personnel departments' func- tional activities and purposes were significantly different in these two classes of hospitals. The occupational orientation of the personnel di- rectors was examined. The study demonstrates through a study of reference group selection choices, that some personnel directors have a relatively strong sensitivity to their occupation, and that other directors have a stronger sensitivity to groups within the hospital organi- zation than to occupationally located groups. The attitudes of the personnel directors when examined by selected bureaucratic factors, further supported orienta- tion characterizations based on reference group selection. The attitudes of the "occupationally oriented" directors differed significantly from those of the "organizationally oriented" directors. Victor C. Doherty The hypothesis was affirmed. The thesis demon- strates, through an examination of four work—related fac- tors, that personnel directors with similar occupation orientations and attitudes exhibit differences in behavior in hospitals of differing authority environments. The report further demonstrates that personnel directors with differing occupational orientations and attitudes exhibit differences in behavior within hospitals of similar authority environments. Finally, the thesis demonstrates that personnel directors in similar authority environments and with similar occupational orientations and attitudes exhibit similar role-behavior patterns. The evidence reveals that among the seventeen personnel directors studied, four role-behavior patterns exist. The most frequently exhibited pattern (seven cases) can be best characterized as "administrative task specialist-personnel." These directors are in administra- tor dominated hospitals, and are organizationally oriented. Another role-behavior pattern (four cases) is that of oc- cupationally oriented directors in administrator dominated hospitals. This pattern can be best characterized as "personnel functional specialist." A third pattern (four cases) is best characterized as "administrative assistants- personnel." These directors are in hospitals not dominated by the administrator, and the personnel directors are organizationally oriented. The least frequently exhibited Victor C. Doherty pattern (two cases) can best be characterized as "resident personnel specialist." These directors are occupationally oriented and work in hospitals not dominated by the hosp- ital administrator. Though the behavior of the directors differs for each role-behavior pattern, meaningful per— sonnel activities and functions are performed by the di- rectors and their departments in three of the four patterns. The directors, characterized as "administrative assistants-personnel," appear unable to centralize, either in their offices or their departments, any meaningful personnel functions and activities. EMERGENCE OF HOSPITAL PERSONNEL ADMINISTRATION: AN EXPLORATORY STUDY OF HOSPITALS IN A LARGE METROPOLITAN AREA by .< \C’ \' Doherty fll 'I Victor CIT A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Management 1967 COpyright by VICTOR C. DOHERTY N‘ 1967 N ACKNOWLEDGMENT I thank the members of my committee for their guidance of this dissertation: Professor Darab B. Unwalla, Chairman; Professor Dalton E. McFarland; and Professor Stanley E. Bryan. In addition to the members of my dissertation committee, I am indebted to Professor Rollin H. Simonds, Guidance Committee Chairman; and to Dr. David G. Moore and Dr. John H. Hoagland for stimulating my interest in exploratory research. I am indebted to Dean John Cadarat and Professor Edward Raney of Wayne State University for their under- standing and support; to Dr. Thomas R. O'Donovan for his encouragement and favors; to Mr. James A. Bechtel for his assistance; to Mrs. Peg McAllan for coordinating communi- cations and her generous secretarial assistance; and to Mrs. Connie Lockett for her secretarial services. I dedicate this work to Kathleen, my wife, and to Mary Kathleen and Victor Charles, my.children, whose love, encouragement and understanding made this work both pleasant and possible. 11 TABLE OF CONTENTS ACKNOWLEDGMENTS. LIST OF TABLES CHAPTER I. RESEARCH DESIGN FOR THE STUDY OF HOSPITAL PERSONNEL ADMINISTRATION . . . . . . . Hypothesis . . . Sample Selection . . Research Method. . . . . . . . . . Significance of the Study. . . . . . . . II. ENVIRONMENTAL SETTING FOR THE STUDY OF , HOSPITAL PERSONNEL ADMINISTRATION. . . . Introduction . . . The Evolution of the Modern Hospital . Hostels of Death . . . . . . . Hospitals of Medical Science . Medical Center . . . . . . . . . . . Hospital Administration. Personnel Administration . . III. THE FUNCTION OF. PERSONNEL ADMINISTRATION IN HOSPITAL ORGANIZATIONS. . . . The Professional Hospital. . . . . A Division of Work Based Upon Functional Specialization. A Well Defined Hierarchy of Authority . . A System of Rules CoVering the Rights and Duties of Positional Incumbents. A System of Procedures for Dealing with Work Situations . . . . . . Impersonality of Interpersonal Relationships. . . . . . .-. . Promotion and Selection for Employment Based Upon Technical Competency. I 111 Page ii WWNQ I-’ 15 2A 25 27 29 32 40 L19 A9 52 5A 58 60 62 CHAPTER IV. THE FUNCTION OF PERSONNEL ADMINISTRATION IN HOSPITAL ORGANIZATIONS: THE ADMIN- ISTRATIVE HOSPITAL. . . . . . . . . . . A Division of Work Based Upon Functional Specialization . A Well Defined Hierarchy of Authority . . A System of Rules Covering the Rights and Duties of PoSitional Incumbents. . A System of Procedures fOr Dealing with Work Situations. . . Impersonality of Interpersonal Relations Promotion and Selection for Employment is Based Upon Technical Competency. V. OCCUPATIONAL ORIENTATIONS OF HOSPITAL PERSONNEL DIRECTORS . . . . Consequences of Occupational Orientation VI. THE DI on Work-Related Attitudes Expectations of Supervision Legitimacy of Rules Sources of Authority. Nature of Service Profile of an Occupationally Oriented Director . . . Profile of an Organizationally . Oriented DirectOr . . BEHAVIOR OF HOSPITAL PERSONNEL RECTORS . .' . . . . . . . . Behavior and Change Be Be Be havior and Competition. havior and Authority. havior and Service. Behavior and Directors. BIBLIOGRAPHY. iv Page 68 69 71 75 78 80 82 88 96 106 116 125 13” 135 137 139 1A5 154 161 169 172 TABLE LIST OF TABLES Page Selected Characteristics of General Hospitals in MetrOpolitan City by Ownership Control 6 Selected Characteristics of Voluntary, Non- profit General Hospitals in Metropolitan City by Study Criteria. . . . . . 9 Influence of Background Characteristics on Orientation Characterizations . . . . . . . 92 Location of Personnel Directors by Orientation Characterizations . . . . . . . 169 CHAPTER I RESEARCH DESIGN FOR THE STUDY OF HOSPITAL PERSONNEL ADMINISTRATION It is the purpose of this study to develop an understanding of personnel administration as a centralized function in hospital organizations. Because of the evo- lutionary development of hospital organizations, this study will investigate the organizational environment and its effect on personnel administration activities. The recency of the development of personnel administration functions in hospitals has caused hospitals to place people of varying education and experience into personnel directors positions and, therefore, this study will in- vestigate the orientations of these directors to personnel work. It is expected that an understanding of the hospital organization climate and an understanding of the directors orientations will enable us to understand the behavior of personnel directors during this period of development and expansion of the personnel function in hospital organiza- tions. The conceptual framework for this study stems from an observation made by Talcott Parsons and noted in his introduction to the translation of Max Weber by A. M. Henderson and Talcott Parsons.l Parsons reasoned that Weber had "thrown together" two essentially different types of authority. Weber based authority on technical competency and knowledge of an individual holding an office, but he also suggested that authority is dependent on the occupancy of an office. Therefore, authority in one instance rests on the individual and in another it rests in the office that the individual occupies. Parsons contends that these two forms of authority are often com- bined in a single office, but that they should remain analytically distinct. In the decade of the 1950's three major pieces of research were performed that shed additional light on Parson's observations. Alvin Gouldner in a study of a gypsum plant sought to clarify some of the social processes leading to different degrees of bueaucratization.2 Gouldner uses Parson's observation to distinguish between "representative" and "punishment centered" forms of bureaucratic organization. The "representative" form favors authority resting with the individual holding an 1Max Weber, The Theory of Social and Economic Organizatign, Trans., A. M. Henderson and Talcot Parsons (Glencoe, Ill.: Free Press, 19A7), pp. 58—60, n. A. 2Alvin W. Gouldner, Patterns of IndustriallBureau- cracy (Glencoe, Ill.: Free Press, 1955), pp. 22-27. I‘ 'r ‘r office, while the "punishment centered" form favors authority being dependent on the occupancy of an office. Gouldner, as Parsons had contended, found both forms of authority within the gypsum plant. Stanley Udy, in a study using data largely from the Human Relations Area Files at Yale University, tested seven of Weber's ideal-typical specifications for bureau— cracy in a comparative analysis of 150 formal organizations in 150 non-industrial societies.3 Udy found that the seven specifications were a system of three "bureaucratic" variables and another system of four "rational" variables, and that these two systems were not positively associated. Udy, therefore, in addition to supporting Parson's obser- vations, demonstrates that the bureaucratic specifications 013' Weber are not totally interdependent and that they have enough dimensional freedom to be subject to patterning. Arthur Stinchcombe in a comparative study of mass production and construction industries demonstrates that only some of Weber's bureaucratic specifications are peculiar to bureaucracies, while others appear to be a part of "rational" organization.Ll Stinchcombe, as did \ it 3Stanley H. Udy,.Jr., "Bureaucracy' and 'Rational— y' in Weber's Theory," American Sociological Review, XxIV (December, 1959), pp. 791-795. Ad “Arthur L. Stinchcombe, "Bureaucratic and Craft Q ministration of Production," Administrative Science uaI’terly, IV (September, 1959), pp. 168-187. Udy, supports Parsons' observation and he further demon- strates the dimensional qualities of Weber's specifications. These three studies made available to research interest two alternative paths to follow. One path cen- ters its course on the demonstrated availability of alternative authority bases within formal organizations. Authority can be based on the technical competency and knowledge of an individual holding an office that was ob- served by Parsons, the "representative" form of organiza- tion indicated in Gouldner's work, Udy's "rational" system and Stinchcombe's "rational" specifications' or authority can be based on the occupancy of an office as indicated by Parsons, Gouldner's "punishment centered" organization form, Udy's "bureaucratic" system and the "bureaucratic" Specifications identified by Stinchcombe. The alternative path centers its course on the demonstrated dimensional qualities of Weber's Specifications as indicated in each of the above research studies. The first of these research avenues was eXplored in a dissertation by William Richard Scott at the University of Chicago.5 Scott, in a case study of social workers, demonstrated four bureaucratic factors derived from his 5William R. Scott, A Case Study of Professional Workers in aiBureaucratic SettingITunpublished dissertation, University of Chicago, September, 1961) analysis of the three research studies just discovered that successfully differentiated the attitudes and behavior of externally oriented workers (Parsons' authority based on the individual holding the office) from the internally oriented workers (Parsons' authority resting on the occu- pancy of an office).6 Scott's demonstration of a means to differentiate the authority orientations of members of an occupation and his demonstration of a means of illu- strating the affects of these orientation differences affords us, for our study, a means of occupationally in- vestigating hospital personnel directors. These four differentiating factors that were operationally defined by Scott are: l. EXpectations of Supervision 2. Legitimacy of Rules 3. Sources of Authority 4. Nature of Service7 The second of the research avenues was eXplored' in a dissertation by Richard H. Hall at Ohio State Uni- versity.8 Hall used the three previously cited studies in the 1950's to conceptually support an investigation of 61bid., pp. 110-139. 71b1d., pp. 13-1A and pp. 78-91. 8Richard H. Hall, An Empirical Study of Bureau- cratic Dimensions and Their Relationship to Other Organi- zational Characteristics (unpublished dissertation, Ohio State University, 1961). Weber's specifications as independent bureaucratic dimen- sions and that these dimensions exist in the form of continua. Hall successfully demonstrated that the dimen- sions studied tended to act independently, and were, in fact, in the form of continua, and that they could be used as a basis for describing an organization.9 Hall's re- search affords us, for our study, a means of describing the organizational environment of hospital personnel de- partments. defined by l. The The six dimensions that were operationally Hall are: A division of labor based upon functional specialization. A well-defined hierarchy of authority. A system of rules covering the rights and duties of positional incumbents. A system of procedures for dealing with work situations. Impersonality of interpersonal relations. Promotion and selection for employment based upon technical competency.lo Hypothesis hypothesis for this study is: The behavior of hospital personnel directors is a function of the organization's environment within the hospital and the director's occu— pational orientation. 9Richard H. Hall, "The Concept of Bureaucracy: An Empirical Assessment," The American Journal of Sociology, Lxx (July, 1963), pp. 32—uo. lO Ibid., p. 33. h\' t fl! ,: a. we 1 F I This hypothesis is a logical extension of the evolving body of research knowledge stemming from Parsons and ex- tending to the study by Hall and the study by Scott. The research of Richard Hall demonstrated the continua characteristics and independence of bureaucratic dimensions. It is reasonable to hypothesize that hospital organizations will differ in their degree of bureaucratic development as observed along bureaucratic continua, and therefore, will differ in their organizational environment. The research of William Scott demonstrated the differences in authority orientations among members of an occupation. It is reasonable to hypothesize that hospital personnel directors will differ in their authority orien- tations, and therefore will differ in their occupational orientation. It is reasonable to relate the differences ob- served in the two variables, for the theory underlying both variables stems from a common source, and therefore it is reasonable to hypothesize that the behavior of hospital personnel directors is a function of the organi- zation environment within the hospital and the director's occupational orientation. Sample Selection In order to test our hypothesis and to enhance the significance of the findings, it was decided that the personnel departments to be examined should be managed by a full-time personnel director and should reside in hos- pitals meeting the same legal standards in their formation and operation. The legal form selected is that of the voluntary, non-profit, general hospital type. It was further decided that these hospitals should face a common labor market and a common socio-political environment. The geographic area selected is a large metropolitan area in a mid-western state. This area will be called "Metro- politan City" in the reporting of this research. The significance of the voluntary, non-profit .hospital among all classes of general hospitals in Metro- politan City is evident in the data presented in Table 1. ’The voluntary hospitals account for over two-thirds of the number of hospitals, beds, admissions and employees among Metropolitan City's general hospitals. TABLE 1.--Selected characteristics of general hospitals in Metropolitan City by ownership controlll Ownership Number Beds Admissions Employees Voluntary, Non-Profit A7 9,220 388,215 20,591 Proprietary 1 55 ' 918 36 Gov't. (Non-Federal) 9 3,008 95,341 6,682 Gov't. (Federal) 3 1,559 15,865 * 2,106 63 13,842 500,339 30:"15 llHospitals, Guide Issue, Hospitals, 39: Part Two (August, 1965), pp. 119-127. The significance_of the voluntary, non—profit hOSpitals meeting our study criteria, among the city's voluntary, nOn-profit hospitals, is evident in the data presented in Table 2.' The hospitals within our sample account for over two-thirds of the number of beds, ad-' . missions and employees among MetrOpolitan City's voluntary ' hospitals. TABLE 2.--Se1ected characteristics of voluntary, non-profit general hospitals in Metropolitan City by study criteria.12 . Criteria Number Beds AdmissionS‘ Employees In study sample. 17 6,171 281,98u' 15,060 'Not in study sample. 30 3,0u9 4 106,231 ’5,531 Research Method _ The-research was conducted by means of lengthy-in-g terviews in the offices of the selected personnel directOrs. The initial interviews which lasted three to four hours were of the variety termed "semi-structured." .In these in- terviews the interviewer did not approaCh the directors [with formulated questiOns, but rather with broad general tOpics for discussion. CSubsequent interviews with a director were of the"focus" type. In order to provide for l2Ibld. 10 maximum interaction between the interviewer and the in- terviewee, and to provide an accurate source of recall for the interviewer, the interviews were tape recorded. The interview period extended from December, 1965 to September, 1966. The period from December, 1965 to February, 1966 was devoted to investigating the broad hospital personnel environment in the city. During this period the author identified and became known to the various personnel and hospital associations that hospital personnel directors tended to attend. The author also interviewed two hosp- ital administrators in order to obtain greater familiarity with the personnel environment in hospitals. A major objective during this period was to identify opinion leaders among the personnel directors, and to identify a cross-section of directors for a future pre-test of the methodology. In February the author conducted four lengthy interviews with selected personnel directors. The purpose of these interviews was. twofold. First, the author wanted to learn of the personnel environment directly from the directors and also to learn the range of topics of interest to them, and second, he wanted to develop rapport with opinion leaders. In March the author reinterviewed one of the Opin- ion leaders and in the process of the interview the ll interviewee suggested that he would be willing to assist the author in setting initial interview dates with the remaining members of the sample. This was accomplished by phone with initial interviews being scheduled for the April through June period. In requesting interview ap- pointments for the author the sponsoring director eXplained to each subject that the research was an exploratory study in hospital personnel administration, reminded them of the need for research, and eXplained to them that the initial two to three hours requested was really a short time period in which to discuss the "personnel picture" in hospitals. In the summer months return interviews were con- ducted. The average number of interview hours with each interviewee was 6.5 and the medium number of interviews was two per sample subject. The use of the tape recorder proved to be a source of distraction and caution in the four pre-test interviews. A major contributing factor to this was the frequent need to replace tapes and to change the recording tracts on the tapes. The use of a three hour per tract tape remedied this situation. A few directors appeared to be guarded in their remarks when the recorder was on, and with these directors it was necessary to first discuss forms, proce- dures, and factual materials until they gained confidence in the interviewer and tended to forget about the recorder. An interesting sidelight of these directors was that once 12 they started seriously discussing their work the openness of their discussion prevented the author from playing back these tapes in his office because of their disclosure of internal political data that would prove to have un- fortunate ramifications if, by chance, it became public knowledge. Some directors appeared to look forward to the interview as an opportunity to safely display their strategy, plans, and political accomplishments within the hospital. With these directors the interviewer has to ex- pend some energy in assisting these directors in offering concrete examples of their behavior, and the interviewer also, in these cases, suggested that they go to the scene of some of these changes so that he could observe and discuss the topic area with those most directly involved. These two behavioral activities on the part of the inter- viewer had two interesting effects. First, the inter- viewee tended to confine his discussion to specific issues and, second, the interviewee tended to view the inter- viewer in a new light that was eXpressed by one of these directors after four hours of interview as "its great to have a visiting 'fireman' come in, and I hope you find an opportunity to return-~you know you just can't discuss these things with peOple here and at meetings." Other directors appeared to consider the inter— view as an obligation to recite an extensive list of tasks 13 that they and their peOple perform. With these directors the interviewer suggested, early in the interview that they take a tour of the hospital. On the tour the inter- viewer would observe conditions and ask the director how they might apply to personnel. Usually the interviewee would catch the spirit of the conversation, and would in- corporate into his task descriptions the ramifications of this work within the hospital. This behavior activity on the part of the interviewer had one interesting effect. The interviewee, in discussing ramifications with tasks, would pose aloud many questions in his mind and by the end of the interview would be attempting to obtain task reference sources from the interviewer. The data collected was reduced to notes that were analyzed and are reported in Chapters III, IV, V and VI of this report. Significance of the Study In addition to extending and demonstrating the concepts of Hall and Scott, the research provides a basis for reintegrating these two alternative research paths for future conceptual tasks. The research provides an Opportunity for a student of business to eXplore the usefulness of two conceptual tools in Operationally investigating organizations and occupations. 14 The research provides the business scholar with an Opportunity to observe an important functional activity, personnel administration, in its early development stage within an industry. The shedding of additional light on the problems and processes in the development of occupa- tional activities within an industry is particularly significant in this era of renewed occupation and work specialization in the middle management levels of American industry. The research provides an opportunity for indus- trially rooted personnel scholars to eXplore the poss- ibilities of contributing from their vast fund of knowledge to the needs of an important service industry. Finally, the research provides hospital administrators insight into an important management functional specialization. CHAPTER II ENVIRONMENTAL SETTING FOR THE STUDY OF HOSPITAL PERSONNEL ADMINISTRATION Introduction The hospital is one of this country's most vital institutions. The public is dependent upon the hospital in its community to localize the research discoveries, specialized equipment, and professional skills that are generated by medical sciences. The citizen relies on the hospital to provide professional patient care at the time of major sickness or injury, so that he might return to his home to lead as full and as normal a life as physically possible. Community leaders look to the hospital for available facilities, services, and the special knowledge necessary to COpe with the local disasters, tragedies and emergencies. Patients of private physicians depend upon the hospital to provide alternative types and qual- ities of service from which their doctor may select, and to provide the professional environment necessary to assist him in keeping abreast of his field. The product of few other industries can match the reliance that society places on the hospital's product, patient care. 15 16 The modern hospital has become an important part of the life style of most Americans. Over 95 percent of the babies born in this country are delivered in hospitals, and approximately 50 percent of the population will spend their final hours in a hospital. The average American now spends one day for each year of his life in the hospital.1 Last year hospitals admitted 1A8.7 patients per 1,000 pOpulation. The vast majority of admissions, which have increased 7 percent (15 percent in number of admissions) during the past six years,2 are for diagnostic, preventive, curative and corrective services that modern medical science has developed. The hospital today has become an important medical center in contemporary American society. The general society's recognition and acceptance of hospitals have made it one of the country's largest in- dustries. These Organizations have aggregate assets of about $2A.5 billion, annual eXpenses of approximately $13 billion, and employ almost 2 million full-time people.3 Though these industry statistics are impressive and indicate the economic significance of institutionalized professional l"Curfew," New England Journal of Medicine, 26A (April, 1961), pp. 773-774. 2Hospitals. Guide Issue. Hospitals, A0: Part Two (August, 1966), pp. A27—Au1. 3Ibid. 17 medical services, they should not imply that the nation's hospitals are a homogeneous group of organizations. The 7,123 hospitals in the United States can be subdivided and classified according to their ownership- control and the average number of days the patient stays in the hospital. The federal government operates AA3 hospitals for armed services, veterans administration and public health purposes. There are 9““ hospitals devoted to psychiatric, tuberculous and long term (average stay is over 30 days) illnesses. These hospitals have approx- imately 50 percent of the nation's average daily hospital census, but account for less than 3 percent of yearly hospital admissions. Of the 5,736 non-federal, short- stay, general hospitals 1,A53 are controlled by state and local governments. The country has 857 privately owned proprietary hospitals. These hospitals are usually very small, quite limited in their services, and often supple- ment the practice of a single physician.Ll The remaining 3,426 hospitals are voluntary, non-profit, short-term, general hospitals. The voluntary hospital is the insti- tution with which most citizens come in contact. Volun- tary, non—profit hospitals care for approximately two-thirds “Walter J. McNerney, Hospital and Medical Economics, Volume 2 (Chicago: Hospital Research and Educational Trust, 1962), pp. 729-733. 18 of all hospital admissions, or about 10 admissions per 100 pOpulation per year, and have an average daily hosp- ital census of u01,000 patients.5 Of all the hospital classifications, the voluntary, non-profit, short-term, general hospital most closely resembles "big business" in the United States. These hospitals are corporations that were organized and are operated by private citizens. As a corporation the hosp- ital has institutional functions similar to those of organizations in other industries. The hospital's capital funds primarily are derived from donations from local peo- ple interested in developing a medical services institution in their area. Hospitals have a product line of profes- sional services which is generated through the organization of activities and facilities. The customer, the patient, does not personally select the services he is to receive, but normally assigns this authority to his agent, the physician.6 In marketing its product through the private physician, the hOSpital'S marketing strategy is aimed at attracting doctors through modern facilities and services 5The statistics in this paragraph were taken from: Hospitals, op. cit., pp. A27-AA3. 6Charles U. Letourneau, "New Look in Hospital Organization," Hospital Management (September, 1965), p. 53. 19 which their patients can use, research assistance, provi- sion of meeting rooms where relaxation and consultation with other physicians are possible, and hospital supported lectures and discussions on current medical tOpics.7 In a large metropolitan zone, hospital locations give an appearance of having been selected at random. The factors that influence the selection of a site for the construction of a new hospital are the interest of donors willing to contribute capital funds, the willingness of doctors to use it in their private practice, and the readiness of citizens to go to this particular place for patient care. Consequently, hospitals tend to be built to serve a limited geographic area, specific doctors, and a particular segment of the local population. This local orientation, particularly in voluntary, non-profit hosp- itals, tends to influence the hospital's board of directors and administrator to operate the hospital as a unique unit and have little industry orientation or economic activity.8 However, this local commitment by administrators, donors, doctors, and citizens does not mean that the hospital, once 7Temple Burling, Edith Lentz and Robert Wilson, The Give and Take in Hospitals (New York: G. P. Putnam's Sons, 1956), pp. 5-6. 8Edith M. Lentz, "Hospital Administration - One of a Species," Administrative Science Quarterly, Vol. 1, No. A (March, 19577, pp. uu9-u50. 2O established, is not subject to a competitive environment. The size of its service area and the security of its mar- kets are dependent upon its ability to best serve the present and future needs of its prospective patients. To meet its competitive objectives and to provide funds for times of general economic recessions, the voluntary, non- profit hospital must internally generate "profits" from the sale of its professional services.9 A hospital carries out its purpose as an organiza- tion in what a hospital historian has termed a "medical factory."10 The organization of the physical facilities is based on economic and functional factors of cost per square foot, traffic, noise and the minimizing of vertical and horizontal transportation of patients receiving care.11 The administrative activities of the hospital are usually located on the main floor, with the cashier and admitting offices adjacent to the lobby. These business offices are a major nerve center in the hospital, for it 9Ibid., p. 449. 10George Rosen, "The Hospital: Historical Sociology of a Community Institution," Reported in: Eliot Freidson (ed.), The Hospital in Modern Society (Glencoe: The Free Press, 1963), p. 32. 11John L. Brown, "Planning and Organizing the Hospital," Reported in: Joseph K. Owen (ed.), Modern Concepts of Hospital Administration (Philadelphia: W. B. Saunders Co., 1962), p. 62. 21 is here that patients are admitted, assigned rooms and discharged. The patients stay can be followed through services rendered and charges recorded here. The admin- istrative functional activities of accounting, finance, personnel, legal and data processing are normally located near the business offices, but away from the lobby. This area appears like most management office areas with white- collar workers performing their functions and executives meeting, planning and reading the pulse of their business. The floors above the main level are normally patient floors and they represent the organization's "plant." Each floor of patients is divided into units of approximately 30 to 60 beds, with the activities in each unit being directed from the unit's control desk, which is called a nursing station. The unit supervisor, the head nurse, assigns to her subordinates the authority to carry out the professional services which have been ordered for each patient by his agent, the physician. The role that each worker has in the care of patients is designated by the color of his clothes, pins, caps, and badges that he wears. The hospital "plant" also has technical and pro- fessional service departments. These departments have functional authority in their area of specialization. The impression one receives upon entering one of these depart- ments is similar to that impression received upon entering an industrial plant. The work appears to be processed 22 through various stages, using highly complex equipment, by workers using a very specialized language. The ground floor of the hospital is usually de- voted to institutional services, and bears a strong re- semblance to the ground floor of the large hotels. The visitor observes large central kitchens, linen rooms, a large laundry and building engineering facilities. The workers uniforms identify their department and are quite similar to those worn by workers, in comparable depart- ments, in other industries. Hospital administrators and directors have been slow to recognize any similarity between their hospitals and business enterprise. The humanitarian objectives of the hospital have, in the past, precluded, in the minds of many hospital people, the economic problems of competi- tion and productive efficiency. The resistance and re- sentment of the application of the term "business" to the hospital institution is diminishing under the current socio-economic conditions that the hospital must face.12 One researcher summed up the current feeling among hosp- ital planners by quoting one planner's remark that "the business point of view has to predominate in hospitals. 12Letourneau, op. cit., p. 53. 23 Tradition and patient care and all are fine, but the business sense has to be applied."13 Since the hospital is so important for community welfare and becoming such an integral part of contemporary life, it is increasingly more important for business scholars to focus their knowledge and skills on the management problems of this large service industry. An area of interest for both scholars and administrators is the emerging hospital management function of personnel administration. The hospital industry employs one of every forty working Americans. Within a hospital the work performed by its personnel is the hospital's principle product, and hospital payroll costs represent about two- thirds of the total Operating costs.1u In order to pro- vide the environmental framework necessary for a study of of hospital personnel administration we will now, briefly, discuss the evolution of the voluntary, non-profit hosp- ital and the recent emergence of hospital personnel administration. 13Roy H. Elling, "The Hospital - Support Game in Urban Center," Reported in: Eliot Freidson (ed.), The Hospital in Modern Society (Glencoe: The Free Press, 1963), P. 76. 1“U. S. Department of Health, Education and Welfare, Hospital Personnel, Public Health Service Publi- cation (Research Report), No. 930 - c - 9 (October, 196A), p. iii. 2A The Evolution of the Modern Hospital Voluntarism is an American cultural tradition. Citizens in many suburbs and small towns eXpress it by maintaining voluntary fire departments, and it is demon- strated in large metropolitan areas by people contributing both time and money to United Charities and United Founda- tion activities. Some Americans acting in small groups or as individuals express the tradition of voluntarism by keeping in private hands many of our universities, museums and symphony orchestras. The majority of our general Short-stay hospitals are a product of this tradition, and are Operated as non-profit institutions by civic-minded groups. It is necessary to review the historical deveIOp- ment of voluntary hospitals in order to fully understand its objectives and functions. Hostels of Death From the colonial period to the latter part of the nineteenth century, the primary purpose of most hospitals was to provide custodial care to the dying poor. For the average citizen the home was the center of medical practice. It was here that the doctor found the resources which he needed for his patients, relatives providing nursing care, food and shelter.15 Voluntary hospitals were organized by 15Burling, Op. cit., p. A. 25 members of the community to provide these basic patient requirements for less fortunate fellow citizens. The financial contributor's interest in these charity cases was for humanitarian reasons, and consequently, hospital activities were directed toward their principle objective l6 and product, patient care. Hospitals of Medical Science Two nineteenth century discoveries prepared the way for the hospital to be transformed from a hostel for the dying to an institution for medical practice and science. First, was the discovery of anesthesia, which widened the scope of surgery; and second, was the develop- ment of the science of bacteriology, which enabled hosp- itals to control many infectious diseases.17 As hospitals developed aseptic facilities, programs and methods, the risk of infection resulting from surgery was reduced, and there was rapid increase in the number and complexity of Operations. To provide pre-operative and post-operative patient care, hospitals undertook educational programs to l6Lentz, Op. cit., p. AAS. 17Michael M. Davis, "The Hospital's Position In American Society," Reported in: Joseph K. Owen (ed.), Modern Concepts of Hospital Administration (Philadelphia: W. B. Saunders Co., 1962), pp. 7L8. 26 develop the trained personnel that the new, curatively oriented nursing required.18 The rapid growth of medical sciences during the ensuing decades was aided by research discoveries, such as x-ray, the measurement of basal metabolism, and the electrocardiograph..l9 The transferring of research dis- coveries into useful tools of medical practice required space for the equipment, funds, and special training for those who were to do new work. The hospital posed many advantages as a center for the application of research, for it could provide space, funds from their supporters, controlled environmental conditions, and could reduce unit Operating costs by serving the patients of many doctors. As research discoveries advanced the curative case activities and potential, hospitals developed add- itional technical and professional services to meet the changing needs of patients and doctors. The develOpment of the hospital presented to the doctor a logical place to send his patients requiring special treatment or more intensive care than could be provided in the home. The physician, in using the hospital for his private patients, incurred no administrative or financial responsibility to the hospital, but was becoming essential for its Operation, 18Burling, Op. cit., p. 5. l9 Burling, op. cit., pp. A-7. 27 while the institution became more and more indispensable for the practice of good medicine.20 The hospital also provided the medical profession with a natural meeting place for their lectures and symposiums. The hospital in time became a logical place to train medical students and to carry out medical research studies, for hospitals had practitioners to lend guidance, available patients, and the necessary facilities and professional skills. The spirit of voluntarism remained unchanged, for the voluntary hospital was still providing facilities and services that citizens normally could not provide for them- selves. By the end of World War II the hospital's original humanitarian image had grown to include technological and scientific values, and the hospital's original community role of assisting man in the time of great need had matured to one of assisting the citizen in retaining his position in society through medical services. Medical Center During the past World War II period, hospitals be- gan to feel some secondary effects from the prepaid hosp- ital insurance programs they helped sponsor in the depres- sion period of the 1930's. These prepayment plans became quite popular with the general public, and many employers v 20Rosen, Op. cit., p. 31. 28 began assisting their employees in insurance premium pay— ments. One plan, Michigan Hospital Service, grew from 175,000 subscribers in 1939 to 3.5 million subscribers in 1959. With well over one-half the pOpulation enrolled in various prepaid programs,21 doctors felt freer to recom- ment hospital stays for their patients, and the patient was more willing to go, realizing that he had already paid for this privilege. Hospitals soon realized that the pre- paid customer insisted on having his needs considered and met, and that marketing strategy must include patient and public relations activities.22 At the same time the financial supporters Of hospitals became reluctant to contribute to hospital operating expenses, when these funds could be internally generated from patient fees largely covered by insurance policies.23 The modern hospital is emerging as a self sufficient, voluntary or- ganization that acts as a medical center for professional patient care, the support of which requires educational activities, research and good business management. 21McNerney, op. cit., p. 129A. 22Oswald Hall, "The Changing Public Image of the Changing Hospital," Hospital Administration, 9:A (Fall, 196A), pp. 8-12. 23A. W. Brewster, "Financing Hospital Care Ser- vices," Reported in: Joseph K. Owen (ed.) Modern Concepts of Hospital Administration (Philadelphia: W. B. Saunders Co., 1962), pp. 6A6-661. 29 Hospital Administration The administrative typology of hospitals can be centered on a triangle of administrative relationships that have emerged from the hospital industry's evolutionary process. The members of the triangle are the board of directors, the medical staff and the hospital administra- tors. The boards of directors of early voluntary, non- profit hospitals tended to be wealthy people who had donated money to the hospital as a demonstration of their position in the society.2u The role of director in these early hospitals Was to secure donations and to legitimize the hospital in the community. The hospital directors, at later dates, usually represented social, economic and professional prominence and Status. In recent years many voluntary hospitals have Selected people from business, public relations, law, finance, engineering and other occupations that can assist the hospital administrator and the board in meeting current hOSpital problems.25 The board of directors has the over-all respons- ibility for the operation of the hospital.; The board 2“Lentz, loc. cit. 25Paul J. Gordon, "The Top Management Triangle In The Voluntary Hospital," Hospital Administration, 9, No. 2 (Spring, 196A), p. 61. 30 selects the administrator who is the chief executive officer and it selects the medical staff, who are usually private physicians that have the privilege of practicing in the hospital. The relationship between hospital pol- icies and Operations and the community's current and future needs is also a board responsibility. The board must provide the equipment, facilities and personnel the hospital requires and it must insure that the hospital finances are handled in a businesslike way, but not at the eXpense of patient care.26 Hospitals are not normally licensed to engage in the practice of any of the healing arts. The hospital, therefore, relies on private physicians to use their fac- ilities and services in the care of patients. The only real authority that the hospital has over the doctor is the right to grant him hospital privileges.27 The doctors privileged to practice in the hospital usually form an organization of their own, "the medical staff." The medical staff renders direct medical care, accepts direct responsibility for the quality of that care and advises the board on its evaluation of the clinical 26American College of Hospital Administrators and American Hospital Association, Code of Ethics (Chicago: American Hospital Association, 19577, p. A. 27 Gordon, Op. cit., pp. A5-72. 31 services of the hospital. The medical staff usually re- views and recommends additions and changes in the medical staff to the hospital board.28 The medical staff, in a typical hospital, forms departments or committees such as; surgery, internal med- icine, obstetrics, pediatrics, laboratory, radiology and general practice. It is through these internal committees that the medical staff meets its obligations to the hosp- ital, patient and general public. The administrator's role in the hospital has changed greatly since early hospital history. The changes in his position can be seen through the terms used to iden- tify him. The term "custodian" gave way to the term "superintendent," which gave way to the term "administra- tor," which is now giving way to the term "executive director."29 The administrator's duty is to ensure that all policies of the board are carried out, and to recommend changes in policy when they are needed. The administrator also is the primary liaison man between the board and the medical staff. As the chief executive Officer it is his responsibility to see that the hospital is managed prOperly 28Gordon, loc. cit. 29Letourneau, op. cit., pp. 53-5A. 32 and that the medical staffs' activities are coordinated with those of the hospital's personnel.3O Personnel Administration Personnel administration, as a recognized func- tional activity in hospital organizations, is a recent development in the evolution of the modern hospital. The recency of this development is particularly evident in the absence Of reports on personnel department activities in the major hospital research studies undertaken during the preceding decade. Four of these studies eXplored issues and circumstances that, if they were conducted to- day, would necessitate the inclusion of personnel depart- lkment activities in the analysis of their data. The firSt of these was a study of "human organization" in hospitals.31 The researchers in drawing their sample selected a cross— section of hospitals representing the socio-economic and geographic spectrum of American voluntary, non-profit hospitals. In their analysis of personnel practices and relationships no evidence was reported of the existence or activities of a personnel department. In a second study Chris Argyris investigated "human relations" in a hospital organization. A major focus in this study was the problem 30 31 Gordon, loc. cit. Burling, Op. cit. 33 of high labor turnover in the hospital.32 Argyris, in his analysis of the problem and in his recommendations to the hospital "management team," did not indicate the ex- istence of a personnel department, nor did he consider the use of a personnel department in satisfying this problem. A third study was undertaken on the recommenda- tion of a Governor's Study Commission to investigate hospital costs and to make constructive recommendations.33 Even though personnel costs are approximately two-thirds of hospital total costs, the study team, in their two volume report, did not report on the existence or activ- ities of central personnel departments, nor did they con- sider such departments in their recommendations. The last of these studies was an in depth investigation of ten community general hospitals.34 Again, in this study there isn't any evidence that the researchers Observed a central personnel department in the hospitals studied. The significance of these early studies on our research is enhanced by the fact that the geographic lo- cation Of our sample is within the geographic sample area 32Chris Argyris, Diagnosinnguman Relations in Organizations, Labor and Management Center (New Haven, Connecticut: Yale University, 1956). 33McNerney, Op. cit. 3LIGeorgopoulas, op. cit. 3A used in the study led by McNerney and in the study con- ducted by GeorgOpoulas and Mann. The recent development of personnel departments in many hospitals can be traced to pressures and changes in the general hospital environment. A major factor in this environment has been the government. The government first influenced hospitals to initiate personnel depart- ment activities when the social security system was amended to include hospital workers. The effect of this on hospitals was revealed in a statement made to the re- searcher by a personnel director who was first employed by a hospital at this time. She stated: At that time there wasn't a personnel department. There was a bookkeeping department—-it wasn't even called accounting at that date (l950)--and they had what records that existed. When I came to the hosp- ital I tried to organize the records, so I dug through old file boxes and it's mighty dirty work trying to get records on all the employees presently with the organization. In setting up files on each employee we didn't have birth records and dates of hire on many employees and this meant individual in— terviews. Some of our people still have approximate dates of hire now. It took over a year to assemble the records for A00 employees, and the administrator felt that this was poor, and that we needed a person- nel department. Another government based influence was the legal trend that hospitals were increasingly being found by courts to be liable for the acts of their employees. One hospital legal advisor eXpressed the current attitude of the courts as: 35 It is almost contradictory to hold that an institution organized to dispense charity shall be charitable and extend aid to others but shall not compensate or aid those injured by it in carrying on its activities. 35 The effect of this legal trend has caused influ- ential hospital people, like the Commissioner New York City Department of Hospitals, to strongly recommend im- proved personnel selection techniques and the "exercising 36 of due care" in hospital employment practices. The most recent government pressure on the hospital personnel sett- ing is the inclusion of hospitals under federal wage and hour standards. A hospital consultant revealed in a state- ment made to the researcher the personnel ramifications that he foresaw caused by this change in government policy. He stated: The professional departments have been able to retain control over personnel activities in many hospitals, because they could take their sweet time to find re- placements by working everybody overtime. Now that this is going to be charged at time and a half, they are going to have to rely on somebody to work fulltime on their employment problems or their costs are going to go out of sight. This is the first break that the personnel man has gotten--he now has leverage on the departments--now is his chance to prove how effective he can be. 35Emanuel Hoyt, "Legal Trends Affecting Hospitals," Hospital Administration, Vol. 8, No. 2 (Spring, 1968), p. 27. 36Joseph V. Terengio, "Hospitals and the Changing Legal Climate," Hospitals, Vol. A0, No. 23 (December 1, 1966), p 50 36 A second major environmental factor influencing the growth of personnel departments is the threat that raising personnel costs pose to hospital administrators. One administrator in an interview with the researcher ex- pressed a fear that appears to be growing among voluntary hospital peOple. He stated: Approximately 65 per cent of the total budget of the modern hospital today is made up in labor costs. Un- less costs in general, including labor, are controlled, the hospital of today will not be able to maintain its private control. The alternative would be government takeover. What management needs from the personnel department is control of labor costs. Third and last major environmental factor influ- encing the development of hospital personnel administra- tion is the change that is taking place in the hospital labor force. A hospital personnel director expressed to the researcher the change he has observed in the up-grading of hospital work in recent years. He stated: The hospital field, now, is getting to require more and more professional and degree peOple. A few years back, I can recall, it was pretty well known that if you wanted a job--I mean the housewife type who had never worked in all her married life--apply at a hosp- ital, they will train you, and you will do work that's the same as you do at home. We're getting away from this. It is necessary now to have extensive in- service training even for our lowest type of positions. I send these housewifes who inquire to nursing homes for jobs now. The rapid growth in the technical capacity of the hospital labor force has been cause for concern, and was 37 the subject Of an award-winning article in 196A.37 In the article, Donald Cordes stresses the need to centrally control many personnel activities that no longer can be left solely to the professions because of the prolifera- tion of specialism among health personnel. The importance of personnel administration and its newness to the hospital industry have caused the American Hospital Association to make a special statement to en— 38 courage research in personnel administration. They stated, in part, that: The success of the individual personnel program, as well as progress and develOpment of the broad hospital personnel field, depends upon a variety of approaches. Hospitals should renew their efforts to participate individually and cooperatively in personnel research. The gains recorded by medical science through wise in- vestment of both human and technical resources are well known. It would be a paradox if hospitals were less concerned with the conservation and utilization of their own human resources.39 The change in the role of the hospital personnel directors in recent years has been noted by many authors and was summarized well by a leading hospital industrial 37Donald W. Cordes, "Proliferation of Hospital Professions Is New Challenge to Management," The Modern Hospital, Vol. 36, No. 6 (June, 196A; and Hospital Admin- istration, Vol. 10, No. 2 (Spring, 1965), p. 6. 38American Hospital Association, Statement to Encourage Research in Personnel Administration (Chicago: American Hospital Association, May 6-7, 1965): pp. 5-2A. 39Ibid. 38 relations counselor, who statedzuO The role of personnel administrator in the modern hospital is at present in a process of profound change. The personnel administrator, who until recent years was merely a combination of disciplinarian, security Officer and organizer of picnics is now being entrusted with work of an increasing specialized nature and which is increasingly essential to the efficient running of the hospital. To an increasing extent, he's being called upon to take an active part in determining the hospital's objectives, and in the assessment of factors which enable these Objectives to be obtained in setting up the administrative machinery which will enable these factors to operate effectively. This increase in the complexity of the personnel directors' position has placed many hospitals in a diffi- cult position in attempting to establish their departments because of the shortage of trained and experienced people. This situation was noted by a leading hospital administra- tor who saidzu2 The demand for qualified, eXperienced personnel di- rectors in hospitals today far exceeds the supply. Job Opportunities have increased so rapidly in the past 10 years that inadequately prepared persons lacking formal education and hospital experience are thrust into positions where they are eXpected to solve the total personnel problems. uoDeO Ledoux, "The Role of Personnel Administrator," C.H.A.C. Bulletin, Vol. 9,.No. 5 (May, 1967), p. 5. A1 “2Miriam Eveline and Edith Belsjoe, "What the Administrator EXpects of the Personnel Director," Hospital Progress (March, 1966), p. 70. Ibid. Ll31bid. 39 What do the administrators of hospitals in the proposed sample expect and hOpe for from their personnel directors? The following two statements were taken from the researcher's interview data collected during the early eXploratory phase of this study. One administrator stated: I would like to see the personnel function take on a more strategic view of its role in the hospital. By this I mean that I would like to see the personnel director make himself more indispensable to the orga- nization by being tactful in finding those areas which will be of greater service to the hospital. Another director stated: There are many areas in which personnel can be very critical to the organization--all Of the functions that relate to employee discipline, human relations, development of people, attempting to get willfull co- Operation from peOple, training, overall direction of goals. It would be very helpful to have the personnel director as an integral part of the top management of the organization. In both instances the administrators eXpress more of a hOpe than an eXpectation. It was apparent in the researcher's interviews that the administrators did not fully understand the personnel director and his problems, nor did they feel prepared to direct his develOpment so that he might meet their expectations. It is in response to the apparent needs of the ad- ministrators, the expressed need for research by the American Hospital Association, and the personal interest of the researcher in personnel and evolving structures that this study was undertaken. CHAPTER III THE FUNCTION OF PERSONNEL ADMINISTRATION IN HOSPITAL ORGANIZATIONS Personnel administration activities occur in all organizations. Organizations must be staffed. Policies governing the rights and duties Of the members and proce- dures for processing personnel actions will either be designated by persons in authority within the organization or will emerge as operating practices. The wages and fringe benefits to be paid, the criteria for evaluating performance, and the basis for membership interaction are subjects of interest and issue within many organizations. Most large organizations and many hospitals have estab- lished specialized departments to assist, service, and advise management personnel in the administration of these and other personnel practices. In this chapter we will study personnel administration as a departmentalized func- tion in hospital organizations. Voluntary, non-profit, general hospitals, in communicating their structures and purposes through organization charts and annual reports, appear to be quite similar in the organization and administration of their resources. Limitations on the reliability of these AO Al presentations as a true portrayal of the hospital organ- ization were demonstrated in the research findings of Temple Burling, Edith Lentz, and Robert Wilson.1 Their research indicated that in the evolution of the modern hospital a unique distribution of authority was estab- lished. The power of the governing board to appoint the administrator and the medical staff does not necessarily mean that these people become creatures of the board. The members of the medical staff derive their power from their professional training and competence, and when they speak on hospital problems, they speak not as creatures of the board, but as members of the medical profession. The administrator, being more fully aware of the day-to- day changing problems of the hospital and having more de- Itailed knowledge, is able to use this information as leverage in influencing board decisions. The conclusion for this aspect of the study was that in the hospitals they examined these three centers Of power existed, and that the effective authority within a hospital was the result of the interactions Of these three groups. Basil Georgopoulos and Floyd Mann in their study of community general hospitals2 observed these three lTemple Burling, Edith Lentz and Robert Wilson, op. cit., pp. 35-36. 2Basil S. Georgopoulos and Floyd C. Mann, The Community General Hospital (New York: The Macmillan Company, 1962), p. 569. A2 centers of power, and concluded that for the ten hospitals they Observed, these centers were not in conflict but rather acted as checks and balance. They found that the three power centers expressed a good deal of consensus as to hospital Objectives, and they cooperated to a substan- tial degree. In an effort to obtain a more comprehensive under- standing of the authority system within a hospital, Charles Perrow researched the goals and power structure of a hospital as an historical case study.3 The more in- tensive investigation afforded by a case study revealed that though the power centers have existed through time, the hospital tended toward domination by a single power center at a moment in time. The selection of a dominating center tends to be based on who is to perform the most difficult and critical tasks to meet the major problems and issues confronting the hospital at a given time. The identification and selection of problems and issues seem to be influenced and directed by a wide range of sources and eXperiences, and as a consequence, tends to be some- what unique for each hospital. The authority structure may stem from the administrator to other members of the 3Charles Perrow, "Goals and Power Structure - A Historical Case Study," Reported in The Hospital in Modern Society, Eliot Freedson (ed.) (The Free Press of Glencoe, London: Collier-Macmillan Limited, 1963), pp. 112-115. A3 hospital organization or it may be rooted outside the ex- pressed formal organization and therefore restrict the effectiveness of the administrative hierarchy of authority to those areas not directly influenced by the dominating power. Mr. Perrow's findings demonstrate that an adminis- trative centered hospital is a special case, and is probably the emerging stage in the evolutionary develop- ment Of the hospital. For the purpose of examining the personnel depart- ment in hospital organizations, it is necessary to recog- nize that hospital organizations in Metropolitan City may not all be established on the same authority bases even if their stated formal organizations and objectives are similar. To advance a framework for our examination, we will briefly review the more relevant hospital literature to more firmly establish the non-administrator dominated and administrator dominated authority systems, as reported by Charles Perrow, as types Of hospital organization. Harvey Smith, as a member Of the Institute for Research in Social Science at the University of North Carolina, wrote one of the most widely cited articles on the nature of hospital organization.“ Hospitals, as Mr. Smith reasons and illustrates, have not one, but two ”Harvey L. Smith, "Two Lines of Authority Are One Too Many," The Modern Hospital, Vol. 8A, NO. 3 (March, 1955), P- 59. AA lines of authority within the operating organization and, therefore, the formal organization charts are not an accurate portrayal of the hospital organization. The un- planned line of authority stems from the professional person, especially the physician and those who can act in his name, who can abrogate or countermand almost any ad- ministrative routine in the hospital by claiming medical emergency. Although the medical staff is conventionally located outside of the hospital's line of authority, it is able to exert power at all levels of the organization and thus two lines of authority--lay and professional-- exist in the hospital. Edith Lentz, in a case study of a voluntary hospital, concluded as did Smith, that there were two lines of authority in the hospital.5 In this hospital the major factor supporting the unplanned line of authority was the administrator's financial inability to meet the social level of activities experienced by the trustees and the doctors. Lentz in reporting the effect of this social differentiation stated: The Opportunity for informal contacts shared by doc— tors and trustees gave them an ease of communication which was not lost on the employees in the hospital. 5Edith Margaret Lentz, "The American Voluntary Hospital as an Example of Institutional Change" (unpub- lished Doctoral dissertation, Cornell University, February, 1956). A5 There was ample evidence. . .that in a crisis the older employees turned to the doctors for assistance in overruling the administrator. This is one of the reasons why the nurses deferred to the doctors. They knew where power lay. The doctors could, and did upon occasion, stand up to the trustees whereas no- body else had the necessary independence or fortitude. In contrast, the superintendent's role was strictly one of subordination. In these non-administrator dominated type hosp— itals the lines of authority are confused, and a question naturally arises as to how these organizations are bound together. In another study involving hospitals of this type, the researchers made the following conclusion as to how the hospital organization was bound together. They stated: The goal (vaguely ambiguous) is to return patients to the outside world in better shape. The goal is the symbolic cement that, metaphorically speaking, holds the organization together--the symbol to which all personnel can comfortably and frequently point--with the assurance that at least about this matter every— one can agree! This research team also provides us with an adequate brief description of this type of hospital. They stated: .hospital can be visualized as a professional locale--a geographical site where persons drawn from different professions come together to carry out their respective purposes. 6Ibid., pp. 50-51. 7Anselm Strauss, Leonard Schotzman, Danrita Ehrlich, Roe Bucher and Melvin Sabshin, "The Hospital and Its Nego- tiated Order," Reported in: The Hospital in Modern Society, Eliot Freidson (ed.) (The Free Press of Glencoe, London: Collier-Macmillan Limited, 1963), p. 15A. 8Ibid., p. 150. A6 In order to simplify the designation and to bring forward one of its major power factors, we will refer for the pur— poses Of this study to the non-administrative dominated type hospital as a "professional hospital." The administrator dominated type hospital, as was evidenced in the research findings of Perrow,9 is charac- terized as having an Operative hierarchy of authority ex- tending from the administrator to all members of the organization. This condition of an operative administra- tor centered hierarchy does not exclude the present or possible influence of other power center members from the hospital, but it does require that the administrator's hierarchy of authority take precedence over other direc- tional and control systems that might be present within the hospital. In order to simplify the designation_and to bring forward its major power factor, we will refer for the purposes Of this study to the administrator dominated type hospital as an "administrative hospital." In the administrative hospital the implementation of the formal hierarchy of authority will tend to give the administrator and other management personnel greater in— fluence over the direction and control of work performed in the hospital. A significant effect of this management influence will be a reduction in the hospital's reliance 9Perrow, loc. cit. A7 on social specialization (work activity interpreted and guided by forces located outside the hospital—-occupations, professions, ect.) and an increase in task specialization (work activities interpreted and guided by forces located inside the hospital-—managers, administrators, ect.) of activities within the hospital. Therefore, it is eXpected that administrative hospitals will have some evidence of organizational development along bureaucratic dimensions.lo From the evidence available in hospital research and literature, it appears that hOSpital organizations tend to be of two distinct types, professional and admin- istrative. In the professional hospital the role of the administrator appears to be that of a functional special- ist with a limited scope of effective authority. The ad- ministrator's role in the administrative hospital appears to be that of the chief executive Officer and the focal point of an organizationally Operative hierarchy of au- thority. A consequence of this differentiation in the administrator's role is that the professional hospitals are expected to exhibit a relatively low degree of organ- izational development along bureaucratic dimensions, and 10For a more detailed explanation of this bureau- cratic process, see Victor A. Thompson, Modern Organiza- tion (New York: Alfred A. Knopf, 1961), pp. 25-57. A8 that the administrative hospitals are eXpected to exhibit a relatively high degree of development along these dimen- sions. Since the personnel department is a staff function in the administrator's hierarchy of authority within the hospital, it is eXpected that in administrative hospitals there will be a relatively high degree of personnel func- tional development to meet bureaucratic Objectives; and it is further eXpected that in professional hospitals the functional development of the personnel department will be relatively limited when examined along bureaucratic dimensions. In order to provide a bureaucratic framework for the testing of the empirical evidence, we used the six bureaucratic dimensions that were Operationally stated and tested by Richard Hall.ll These dimensions are: (1) A division of labor based upon functional specializa- tion; (2) A well defined hierarchy of authority; (3) A system of rules covering the rights and duties of posi— tional incumbents; (A) A system Of procedures for dealing with work situations; (5) Impersonality of interpersonal relations; and (6) Promotion and selection for employment based upon technical competency.12 11Richard H. Hall, "The Concept of Bureaucracy: An Empirical Assessment," The American Journal of Sociology, LXIX (July, 1963). pp. 32-A0. 12Ibid., p. 33. A9 The study now focuses on the empirical evidence. It will examine in this chapter the personnel function in professional hospitals, that is, those hospitals exhibiting relatively low degrees of bureaucratic utilization of the personnel department, and then it will examine in Chapter IV the function in administrative hospitals--those hosp- itals exhibiting a relatively high degree of bureaucratic utilization of the personnel department. The Professional Hospital Of the seventeen personnel departments studied, six departments exhibited a significantly‘lower degree of functional development along bureaucratic dimensions, and were classified as residing in professional hospital or- ganizations. The placement of these departments was based, not only on their limited functional development, but also on the evidence, as supplied by the personnel directors that these organizations, in fact, met the criteria for a professional hospital. Attention will now turn to the statements made by these directors in describing the per- sonnel function in their hospital organizations. A Division of Work Based Upon Functional Specialization In each of the six professional hospitals, as in all hOSpitals in this study, a member of the organization has been designated "personnel director," and the authority 50 to perform and supervise personnel department activities has been assigned to him. This designation and assignment of personnel activities to the personnel director does not represent the centralization Of a functional specializa- tion within the hospital, but rather a division of work of a hospital administrator. The supportive character of .this position is illustrated in the following director's statement. Other than directing the work in my department, my job is to research the personnel authorities on ques- tions and problems of interest to my boss. I present him with the evidence, defend it, and then we talk about programs that might evolve. The personnel director's position tends tOward assisting the administrator in his tasks, rather than acting as a functional specialist advising the administrator. The administrator's eXpectations toward the personnel director are demonstrated in a recent eXperience related by one Of the directors. He stated: The hospital had a full time girl to set up annual physicals (for employees) and she never did get any- thing done on it. Well, I'm supposed to go to a hosp- ital personnel convention next week. It's in Chicago, but the administrator told me I couldn't because he thinks it's about time that we got this annual phys- ical examination program designed. The meeting is going to be on personnel utilization, which I think is basic, but hospitals on this particular thing are working more or less in the dark. The administrator has indicated to me that he has been unhappy with the way departments in this hospital have grown. They've been adding two or three people a year. It would be helpful to hear the speakers and get some ideas, but it's not in the cards this year. 51 Personnel administration is not only an element of an administrator's position, but is also a division of administrative work. The personnel department directs the broad public recruiting activities of the hospital and is assigned the authority to control newspaper adver- tising and the contacting of both public and private em- ployment agencies. The department collects and maintains basic employment records that are used for various admin- istrative purposes and acts as a central source for em- ployee reference services to other hospitals. The department also provides personnel services upon request from a department head, and is a receiving and referring area for those who enter the hospital seeking employment. The activities of the personnel department in a profes— sional hospital were typically described by one director, who stated: The most easily identified personnel function is that of employment. I think most people in the hospital associate personnel with hiring and terminating em- ployees. In our larger departments the department director makes the contacts and actively recruits, so, as a result, what personnel is really doing is talking to the employee, filling out forms, setting up personnel records and having them available. Now, we control the advertising. We do the calling to employment agencies. We generally have people call in to the personnel department to make arrangements for appointments and so on. The mechanical part of it. Supervisors in smaller departments and in less technical departments come to us more or less in terms of screening, giving tests to the employee like typing tests, spelling tests and arithmetic tests. We help them narrow the field down and give them some judgments as to whether this employee would be satis- factory Or not. 52 A Well Defined Hierarchy of Authority The personnel departments in the six professional hospitals participating in this study are treated in the description of their formal organizations as distinct de- partments reporting to a formally designated central authority in the hospital. The reality of their position in the hierarchy of authority in the hospital can be seen in the handling of personnel records. The maintenance and control of files have long been considered organiza- tionally meaningful and important. The common situation in these hospitals is illustrated in the following direc- tor's statement: All personnel records are to be kept in the personnel office. NO duplicate records are to be maintained. Any action taken by a department manager is to be sent here and we keep it on file. This is the policy. Now some supervisors probably maintain some personnel records that we have, which is a duplication. They really don't need them, but again this kind of en- hances their own feeling about themselves and, as I say, they like the idea that they have a certain amount of authority and anything that detracts from it, they resist. We ask these peOple to please come in periodically and check with ours and make sure that theirs are correct. In other words, ours are the final authority as far as we are concerned. Now if you challenge ours we will be glad to try and sub- stantiate them, but we aren't going to take your records in precedence to ours. If you want to main- tain them, that's up to you. The personnel director's recognition of the Operating limits of formal authority and the need to respect pro- fessional practices are most apparent in their work with departments that are under a doctor's supervision. In 53 one of the interviews a director expressed the Opinion generally held by personnel directors in professional hospitals. He stated: Let me point out one thing that is very true here, that you must be very much aware of in a hospital situation. Those departments that are headed by a doctor--you have to be very, very careful in terms of how you approach them in handling any problem, because they want to make the decision, you know. . .When you have doctors involved, as I said, there I'm very care- ful to make sure that I'm going through their channels. In many hospitals the administrators use meetings with department heads to discuss possible changes in the hospital's general administrative policies, rules and procedures, and to reinforce the acceptance of current administrative practices. The interviewer asked the director of one hospital if it had regular meetings of department heads. He said: Our hospital is twenty years behind in that we don't have department head meetings on a regular basis. The real reason here is that there is no common ground on which people could meet. I'm afraid that the ad- ministrator feels that to hold department head meetings may only bring out dirty linen, that he could not con- trol the department heads--he could not get an intell- igent discussion of a problem. Only one of the professional hospitals in this study has regularly scheduled department head meetings. In the di— rector's description of these meetings, the weakness of the defined hierarchy of authority is again in evidence. He stated: Well, primarily my department heads actually attend the meetings. We discuss problems—-usually everything gets pretty bitter. Well, you see it's kind of small 5A stuff which is important to department heads--like the elevator breaking down during meal time and people laughing at the food service people carrying trays up, instead of helping them. Little things like that-- the garbage isn't being picked up on station four-- you know, little things like that. A System of Rules Covering the Rights and Duties of Positional Incumbents Hospitals, as do most large business organizations, provide their employees with a handbook containing state- ments of hospital personnel policy and descriptions of various rights and duties that the employee has as a mem- ber of the organization. In the professional hospital these handbooks are usually designed and written by an executive committee, and their contents are primarily based on observed practices both within the hospital and in the local hospital industry. In most instances the personnel director acts as a resource person for these ad hoc committees. The origin of a handbook can be seen in the case of one hospital as it was described by its director. He stated: The handbook was first printed in 1960. Work was started on it in 1956, and at that time we had no written policy to go by. By that I mean fringe bene- fit policies, holiday policy, vacation policy, sick- leave policies. There were practices, yes, but there was nothing in writing to substantiate why certain things were being done. We had to get everything down in writing--written for consistency of action and for application throughout the house. Certain people were doing certain things their own way. Now in 1956 the administrator set up a committee of himself, the doctor who works with the medical staff, the doctor 55 who directs our medical services, the lay administra- tor (assistant administrator in charge of dietary, housekeeping, laundry, and maintenance) and the pay- roll director and myself as resource men. The com- mittee met regularly and I furnished the policies of other hospitals. I suggested and then later the ad— ministrator suggested that we hold meetings with our employees (1959). I programmed them. I sat in on every one of them, with the doctors and the lay ad- ministrator. I acted as a resource person. The employees expressed their grievances. We looked at these grievances and decided that there were certain areas in our policy that needed revision. That's how it was done. Once the employee handbook is published, the committee disbands without apparent provision for future review and updating of the printed policy. In each of the hospitals personnel policy practices have changed without corre- sponding changes in the handbook. Most of these changes have been either to liberalize the policy or to clarify the application of the policy for specific groups within the hospital. One personnel director has resolved this situation for himself by cutting out each paragraph in the handbook and gluing them at the tOp of pieces of paper. When asked about this, he replied: This is my handbook. I've been chopping it all up because we have made concessions, and I want to keep up with them. This is the handbook (uncut copy). Well, it's printed--the policy--essentially it's got structure. Matter Of fact, not too long ago they decided that they would reprint the handbook. This guy (picture and welcoming statement on the first two pages of the book) isn't the executive director. Whoever reprinted it is still perpetuating this guy's name. The establishing of rules covering the rights and duties of employees in the work setting is treated in the 56 professional hospital as a personnel manageMent activity of each department head. Each department head designs, interprets, and enforces rules for his own department. This is illustrated in a case reported by a director. He stated: Some department heads are chasing them out the front door faster than I can bring them in. Here's a case --a lady is fired. It was near the holidays--day be- fore New Year's, I think. She was supposed to have Friday Off. She had asked earlier, "Can I plan on having Friday off?" The answer was yes. She wanted to give her housekeeper the day Off, and she wanted to have her hair done. She made these arrangements. Come Monday she (department head) said: "I'm chang- ing your day off." She (employee) said: "You can't! You know how hard it is to get your hair done on the day before New Year's-—you can't." If you want to keep your housekeeper you have to have a pretty steady schedule. So she said, "I'm sorry, I just can't change all of that." Well, She had a one-day illness in between, which was documented by a doctor. She fired her on Thursday, and gave her one week's pay on top of it. I've talked with some people who have con— tact with that department and they all said that her boss thought she was pretty and that's why people were hanging around her. That wasn't it at all. It was the first time they had somebody civil who also got her work out. This is how I learn. It just keeps coming to you and you start to get a feel for what's going on. The scope Of the personnel department is quite limited in influencing personnel management activities of supervisors within their departments. The personnel director has the authority to require records of personnel actions taken by a supervisor, and the right to report to the administra- tor actions which he feels are unfair. The major contri- bution of the personnel department appears to be that of providing an office where the employee can come and 57 verbalize his problems and seek advice. The personnel department's relationship with other departments for this policy area can be observed through the report of a recent incident by one of the directors. Director: Generally I have no objection to employees coming to my office. I always leave my door open. A person doesn't have to have an appointment to see me. Now some people feel that this is wrong. Here I think you run into an area in the hospital field where some department heads are very unhappy if an employee comes to the personnel department. You're accused of under- mining them, so you have to be very careful there. I think I might illustrate the relationship. We've been having some problems between one of the employees and a supervisor. . . .She called the personnel department and asked if she could see me yesterday. The depart- ment head called later in the day and said: "I under- stand you've had some problems. Well, I wish you would let me know if any problem occurs in my depart— ment." I_was then very much aware that if anything was going to happen, it was going to be in the frame- work Of his judgment. So when the employee came in yesterday to talk to me, I said, "You be sure and talk with the department head who is in charge of that de- partment." Now he is aware of the fact that the employee is going outside of his area to discuss this and while he might not be happy about it, at least he is accepting it. Now I would prefer that it be handled in the depart— ment, because she's going to have to live with the conditions as they are there. We're acting as a safety valve. That's great! But I can't make a de- cision as long as I'm convinced that a department head is treating an employee fairly. Interviewer: Fair treatment? Director: By the number of complaints. This one thing I tried to point out to the employee, that other employees don't seem to be having problems. If there were a number of complaints I would advise the admin- istrator, who would decide on what the next step would be. 58 A System of Procedures for Dealing with Work Situations The professional hospital does not have a complex procedural system to govern the work-flow between the cen- tral administrative offices and the Operating departments. This is evident in the affairs of the personnel department. The department's rights on most personnel aCtions is one of record, and consequently, it is incorporated into the procedural system at the convenience of the operating de- partment. One director demonstrates this in his remarks about the hiring procedure in his hospital. He stated: People are sometimes hired before we even know they've been interviewed. Sometimes department heads don't use our services (employment), and sometimes they pro- cess their own paperwork. The paperwork is drawn up. The tax deduction forms are completed. They are for- warded to the payroll Office. The payroll department checks the rates of pay and forms for accuracy. They then get an authorization form from the administrator to hire this person. The authorization once received is noted. Then the application is forwarded to us for the establishment of a record. The contribution Of the personnel department as a part of the procedure system of the hospital is illustrated by a director whose hospital appears the most advanced in this dimension. He stated: There's the matter of reality. Once the budget is set and approved (number of authorized positions), we see that nobody cheats the budget. So we're constantly challenging the department head, "Well, you don't have an approved position for this." It's not that we have the authority to say, "You can't hire them." But they must prove it before we will actually record a new hire. Then, of course, there's the matter of rate changes and so on. Again, we would see that someone 59 doesn't get an increase before he is entitled to it. So we try to do as much as possible to involve the department head. On the other hand, paperwork seems to frighten a lot of department heads. They do their job very well, but this matter of paperwork, "Oh, I don't want to be bothered by it," or "I don't under- stand it." We should try to give them as much assis- tance as possible so that, although it's really part of their function, people will still get their in- creases at the proper time-—that the budget is adhered to. None of the personnel departments in this group of hospitals has standard procedures or practices to use in performing personnel administrative activities not di— rectly related to their employment function. A director expressed the feeling of his fellow personnel directors when he said: The hospital has never had any particular procedure to follow. It's a gamble, and it leaves a lot to the imagination. The procedure used by the directors varies from problem to problem, with the most typical one used being that of Simply talking with the parties involved. This is demon- strated in a case reported by one director, who said: A few weeks ago a girl came in and talked about her pay and her title. She feels she is not being paid for what she is doing. She is a stock clerk, and she says she is not just a stock clerk. She orders, she does stock control, and she keeps the cards for spe- cial inventory. Well, I did talk to her boss. I‘ said, "Miss So and SO was up to see me," and I put this right on the line. I said, "It's about her pay. She would like a little more money, possibly. It's up to you." He said, "I'll have to take a look at it, talk to her." Well, a week later she called and said nothing had happened. I said, "I'll tell you what. I can't tell him to give you a raise. I can mention it to him again." I did-—and nothing came of it. 6O Impersonality of Interpsrsonal Relationships The interactions among department heads and be- tween department heads and the administrator tend to be based on a personal rather than positional norm. The personnel director in carrying out the duties of his of- fice, cannot rely on the rights of his office but must project himself as a person or involve the administrator, or both, in seeking his objectives. A director expressed his position, which is similar to that of other personnel directors in professional hospitals, when he discussed what would happen if his judgment differed from that of a department head on a personnel problem. He stated: Well, you try and sit down and iron it out between the two of you. If you don't--and I say this again is something you don't learn in school--you have to figure out what allies you could round up. The ally most Often selected is the administrator, who is limited in his use of his position, and he too, tends to rely on a personal rather than a positional basis for interaction. This is illustrated by a director in re— lating an experience at his hospital: She isn't here now, but we had one superVisor who had a turnover in her department of about 25% every month. Somebody would do something that she didn't like and she would just fire her--just like that. What could I do? Well, the administrator and I talked to her and tried to point out that this isn't the way things are done. After so much talking to her, she finally re- alized the truth of what we had been telling her--that she wasn't emotionally stable enough to be in a job of handling people. She went into a teaching job. She seems to get along very well there. 61 The personnel director, if he wishes to influence a change in departmental personnel practices, finds that he must bargain directly and personally with the department head involved. In instances of this nature he does not act as the hospital's personnel director, but as a man interested in improved personnel conditions within a department. This is illustrated in a case reported by one of the di- rectors: Here's a problem for you--call-in pay. You can see how much carpeting we have. All over the place. Why, hell! You can't come in here and clean carpeting with peOple walking all over it. So Saturday they'll come in at 3:00 in the morning and scrub until 9:00, and then maybe on Tuesday they'll do the same thing. Or it will snow during the night and they'll call the guys up and say, "Can you be here by 5:00?" Some of the guys came in and said they would like to get something for it. SO I started a survey around town to see what other people were doing. Now, we used to contract for this. So I asked the superintendent of the department about it. I said, "A few of the guys are yakking. They'll come in, but they think it's unfair that they don't get a little something." He answered, "We give them a ham sandwich--we give them coffee." I said, "I'll be truthful with you--there are some mornings I wake up around 3:00 and have to go to the bathroom. You know, I don't even want to get up for that--for my own comfort--and I sure as hell wouldn't come down here for a ham sandwich." "Truthfully, Jim, do you really save money having the boys do it?" He just kind of smiled. "Jim, do you save a lot of money? It just seems to me, based on the Opinion of a lot of people, that for the incon- venience of getting out of bed at 3:00 in the morning to come down here and do your work, you could do something for these guys." He said, "Yeah, they get off at 2 O'clock." iI said, "you know what happens to a guy who gets off at 2:00 and is not used to getting off at 2:00? Probably the first thing, his Old lady hauls him down to the shopping center. First of all he doesn't get a payment from you, but he's out five 62 or ten bucks because he went to the store with her, and by seven he's fallen asleep because he got up four hours early in the morning. So it's really a big nothing." Jim's still working on it. Promotion and Selection for Employment Based Upon Technical Competensy In the professional hospital the personnel depart- ment does not have a voice in the selection and promotion of employees. It is given to the departments to judge the technical competency of their people. The attitude of the departments toward the central administrative of- fice's involvement in competency matters is reflected in their attitude toward employee evaluations requested by the personnel office. The evaluations are used to just- ify step increases. A director reports the attitude in his hospital, which is not uncommon among the professional hospitals. He stated: Our associate director (doctor who oversees medical and patient care departments) does not believe in em- ployee evaluations. He thinks it's a waste of time. SO for step increases, I send out slips requesting the department head to consider the person or persons who are eligible. If the person happens to say some— thing wrong to the department head the day before he receives the pink slip, he's in trouble, and I have nothing to go back to the department head with. In instances where the administrator or the per- sonnel director are involved in competency questions, the hospital norm tends toward sentiment rather than perfor- mance. A director illustrates this in a case at his hospital. He stated: 63 We have a girl who is performing extra duties in con- nection with helping the department head. The admin- istrator saw the reliance being placed on the girl and we worked it out so she would get some extra money. We don't like to take advantage of somebody like that. So, out of consideration for her extra work, we just put a little extra in her pay, but it was apart from the base salary, and we called it a reward for work performed outside her usual line of duties. The ad- ministrator did this. I suppose the department head didn't like to admit that She needed help, or was getting help. Another case cited by this director: Kaye came in and said, "You know what my eXperience has been with orderlies! Here we have a really good one. A very reliable boy who is liked by everybody, and we've got to do something for somebody like that." Rather than go overboard on his classification as an orderly, we changed his classification in order to give him more money. We made a surgical technician out of the boy. What is a surgical technician? He's someone who helps out around surgery—-well, he wheels patients to and from! This brief examination of the personnel function in professional hospital organizations reveals that the administrator's authority position meets our criteria for the non-administrator dominated authority system. Evidence of this is reflected in the affairs of the personnel de- partment. One non-administrator dominated type organiza- tion criteria area surrounded the reliability of the formal organization chart as an expression of Operating authority relationships. In the professional hospitals the personnel department is designated formally as a cen- tral staff department serving the hospital. In practice the department is not a division of hospital work, but is a division of the administrator's task assignment, that 6A is, it is part of the administrator's general office re- sponsibilities. The test of this finding is in the efforts to centralize employment records. Though policy exists stating that personnel is the seat of all employment re- cords, they are in fact duplicated and decentralized among the departments. The only personnel activities that have been successfully centralized are the coordination of employment advertising and the contacting of employment agencies. The operating departments have not, apparently, questioned the right of personnel to possess records, but through their actions in maintaining their own records, even against administrative policy, have challenged the central authority's right to control records. The administrator's true position in the organi- zation was brought into sharp focus when we observed the procedure for instigating new formal employee policy. The administrator's role in these activities was that of an Operating committee chairman. His "peers" on the committee were representatives of the major professional and occupational areas in the hospital. The administra- tor's two most interested subordinates, the personnel and finance representatives, did not have committee member- ship status, but were treated as resource peOple for the committee. As is true in these hospitals, the policy agreed upon by the committee was not enforceable once enacted. The status of central policy was clearly 65 indicated by the director who used loose-leaf notebooks to keep track Of current Operating practices, so that he might be familiar with the status of policy at the Oper- ating level. The last major evidence of a duality of authority within the hospital is revealed in the administrator's involvement in the personnel affairs of operating depart- ments. In these instances reported, the administrator did not Operate from his formal position, nor did he judge performance with policy criteria but rather he acted personally and, when necessary, substituted sentiment for hospital performance criteria in order to meet operating department's eXpectations. One case clearly demonstrated that the administrator recognized the limits of his office in dealing with operating departments. In this instance a department head was eXperiencing 25 percent turnover per month, and the administrator's approach was that of convincing the offending department head that she wasn't suited for the job. He didn't discharge her or threaten her--he personally interacted with her in hopes of solving the problem. It is felt that the evidence is sufficiently strong to identify the hospitals as professional and to account for the formal posture of the personnel departments as a product of organizational conditions. This evidence is not to imply that the administrators of these hospitals 66 are necessarily frustrated people, for they are, in reality, functional specialists within the hospital, and may view their work from this foundation rather than that of the formal structure as it is communicated. The posture of the personnel department in pro- fessional hospital organization is that it is a department and it is involved in the hospital's procedure system. The department has the right to possess records, offer services, and is responsible for the coordination of em- ployment advertising and contact with employment agencies. The personnel office can act as a referral center for applicants, an office where employees can come and talk, and a record center for employment data. The personnel director can act as a resource person for the administra- tor in addition to managing the personnel department. In attempting to account for the occurrence of professional type hospitals, the only characteristic that offered a plausible reason was the interest of special interest groups in the larger community. One hoSpital was sponsored by a large manufacturer who took pride in its medical excellence. This hospital is presently dominated by medically oriented research doctors. Another hospital was sponsored by a union movement and this hosp- ital too, has a strong medical influence, as the sponsor- ing group has not ventured deeply into its Operating structure. A third hospital for much of its history was 67 oriented by charter to be administered by women for women, and this hospital tends to be both medical and board dominated. A fourth hospital is limited by charter to having a doctor in its chief administrative position and appears to be medically dominated. A fifth hospital is affiliated with a church group whose board takes an active interest in the internal affairs of the hospital, and it has charter limitation designating that a minister must be the administrator. The sixth professional hospital was started by a doctor whose interest presently dominates the hospital. This hospital has a medical dominance in favor of the practicing doctor. fin! I ‘q. I. 2, H” I CHAPTER IV THE FUNCTION OF PERSONNEL ADMINISTRATION IN HOSPITAL ORGANIZATIONS: THE ADMINISTRATIVE HOSPITAL Of the seventeen personnel departments studied, eleven departments exhibited a relatively high degree of functional develOpment along bureaucratic dimensions, and these departments were classified as residing in admin- istrative hospital organizations. The placement of these departments was based not only on their functional develop- ment but also on the evidence, as supplied by the personnel directors, that these organizations, in fact, met our criteria of an administrative hospital. Along some of the bureaucratic continua some of the hospitals appeared to be further advanced than others. In the reporting of the data, when significant dimensional development was evident, the departments were classified into representative groups within the dimension. We will now turn to the statements made by the directors in describing the personnel function in their hospital organizations. 68 69 A Division of Work Based Upon Functional Specialization In the administrative hospital the personnel de- partment is a functional division of hospital work spe- cializing in the development, administration, and maintenance of the hospital's personnel services and pro- grams. A director, in describing the role of the personnel department in his hospital, outlined what is typical of personnel department activities in this class of hospital. He stated: Of course we have employment responsibility, we re- cruit, screen, and process all non-contractual em- ployees. We keep a full set of employee records, and we determine employee eligibility for the various fringe benefits. We review and process all employees request and all department personnel actions to see that they meet hospital standards. I would say that an important part of our work is to see that depart- ments know and honor our policies and procedures. We advise supervisors. We handle grievances. We regu- larly review wages, benefits, and policies. We send out employee evaluations and we review merit raises. In short we handle all personnel matters. A director in discussing her department's employ— ment and employee benefit activities again illustrates this centralization of hospital work. She stated: We handle all employment activities in the hospital. I don't handle interns and residents. They are screened and supervised by the medical staff. Also I don't handle our medical specialists--pathologists, radio- logists--who have contracts with the hospital. Other than doctors, all personnel is recruited and screened by the personnel department. Later in the interview she stated: 70 In our benefit programs basically our function is record keeping. We keep all the employees records, and we keep them all up to date. If a question should arise as to it an employee is eligible for a benefit. It is not a matter of Opinion. It is simply a ques- tion of whether the employee has or has not met the conditions set in the policy. The coordination of personnel activities by mem- bers of the organization is further illustrated by another director. the her the Personnel also includes personnel policies, practices, and induces-—reviewing them to make sure that they are current and are prOperly being practical uniformly throughout the organization. If there are any excep- tions, that the exceptions are known, and that the exceptions follow through the department that they happen in. Personnel must make sure that the employee no matter where he is in the organization receives the same treatment and has the same benefits as they are appropriate. In an interview with another director she expressed need and purpose of these coordinative activities in hospital. She stated: Personnel makes sure what was said would be done is done. If personnel was not necessarily involved, the hospital would have inequitable wages, salaries and benefits. There would be a loss of Objectivity in hiring and discipline, and there would not be uniform policies. A major personnel responsibility is to see that personnel activities in the hospital are equit— able, objective, and uniform. The last area of personnel activity deals with department's efforts to keep the hospital abreast of industry changes that have a bearing on the hospital's personnel programs. One director eXpressed it this way: The personnel director at all times will try to keep the wages and fringe benefits of the employees in line with the area, and make suggestions to management 71 Of any that he might find that are below standards in the area. It is quite important, if a hospital is to get the type of employee that they want, that they at least meet the wages and fringe benefits offered by other hospitals. The personnel department in each of the eleven administrative hospitals is a functionally specialized division of hospital work. The activities of these de- partments vary with organizational size and with the spe- cial circumstances that surround the activities Of each organization. In each of these hospitals the supervision of personnel administration activities within the organ- ization has been centralized and departmentalized within the personnel department. Each of these personnel de- partments perform employment, employee maintenance, co- ordinative, and personnel specialist activities as they are appropriate for this organization. There does not appear to be any significant differences among these hosp-p itals in the develOpment of personnel administration along this bureaucratic dimension of organization. A Well Defined Hierarchy of Authority The direction and coordination of work in the administrative hospital is achieved through the hospital's hierarchy of authority. To facilitate their direction and coordination activities administrators make extensive use of meetings with their managerial personnel. A hierarchy of authority typical Of these hospitals was illustrated by one of the directors. He stated: 72 Let me describe our organization. Our chief executive is the administrator. The next status level is the assistant administrator level. We have four people here. I should indicate that these four with the ad- ministrator are considered top management, and that our assistant administrators have both technical and non-technical type of operations reporting to them-- they have M.D.s reporting to them. The next level of management is composed of our department heads. The nurses, technicians, housekeepers--the employees-- are on the fourth status level. Later in the interview this director discussed the admin- istrator's use of meetings to direct and coordinate the work in the hospital toward hospital Objectives and goals. He stated: The administrator meets with the four administrators—- his executives--once a week. All pertinent things for the hospital are decided at these meetings. Now we also have a department head meeting each week which is usually conducted by one of the executives. The admin- istrator sometimes attends these meetings to tell the department heads directly what has been decided, and . the need for them to work together to advance the hospital's goal. The administrator's use of meetings is again il- lustrated by another director. He stated: The administrator meets each assistant administrator once a week and they report the problems and questions that have arisen in their area. The administrator makes his decisions, and on problems and questions that affect other areas or appear in other areas he will bring them up at the monthly department head meetings-~he will review policy so that all depart- ment heads will understand it and administer it the same way. Another director states in still another way the purpose of these meetings and the position of the administrator in the hospital's hierarchy Of authority. She stated: 73 The meetings are where the problems come out. Every department head hears the same thing, and nobody has been told something that the rest didn't know about. What Mr. has told us seeps down through each department. Mr. is a strong administrator and these are not social meetings. The position of the personnel department in the hierarchy of authority was best described by one director, who stated: Personnel is a staff department and in our new organ- ization we are under Mr. who is an assistant administrator. In some hospitals the personnel di- rector is an assistant administrator-—here with our new PBX department we are under the assistant admin- istrator who will work with accounting and personnel in establishing our records for PBX. Now as personnel director, I would participate in any personnel deci- sion that the administrator was planning and I work directly with all the department heads and assistant administrators in the hospital on personnel problems. If I had any recommendations--wages, a change in pol- icy--I would take these to the assistant administrator and he would take them to the administrator. The administrative hospitals, which are not as fully developed along this dimension of organization, have hierarchies of authority that can but be described as simple and flat. The administrator has a large span of control consisting of department heads who represent the various functional specializations in the hospital. One of the directors described the typical organization struc- ture of these hospitals. He stated: There is the administrator. There is the executive committee which meets each week with the administrator, and is made up of the hospital's eighteen department heads, and then there are the employees. 7A The administrator's position in the hospital's hierarchy of authority is that Of chief executive Officer. He went on to say: If there were any changes to be made the administrator would announce them at these meetings. Of course if the changes required approval by the board of trustees that would be done prior to bringing them up at the executive meeting. The department head meetings are used by the ad- ministrator to coordinate the work of the various func- tional specializations in the hospital. With a large span of control, and with the need to direct activities toward hospital Objectives and quotas, the administrators tend to develOp these coordinative efforts around agreement by the department heads on practices. Consequently, if a department head has a problem or a suggestion that affects other departments, he would introduce it at these meetings. One of the directors illustrates the process typically followed in these hospitals. He stated: Well, the administrator goes right around the table and asks each department head if he has something he would like to bring up at the meeting. The nursing director might bring up problems concerning his part- icular job--about the way department heads are ordering certain things, and he would suggest a way that would be helpful to him. The dietician at the meeting this morning said that she felt that the lunch line is too long during certain periods of the lunch hour. We discuss these problems and see what could be done about them. Another director illustrates a case not typical of these hospitals, where the administrator wishes to Obtain agree- ment through participation on a Ixnudimechange. She stated: 75 We are considering putting vending machines in our cafeteria. At the last meeting the administrator in- troduced this, and they just sat there so he coached them a little bit and said "let's hash it out." Let's talk about it, and find out just what the problems might be. Well, we discussed should we stagger the coffee breaks and would people take food out of the cafeteria. What are we getting into with vending machines, and what the personnel problems might be with this as to enforcing policy. This is the type of questions that come out of it. We haven't written anything down as of this date, as of how we are going to handle vending machines, but out of these conver— sations there will be policy agreed on and it will have the administrator's approval. The position of the personnel department in the hierarchy of authority within these hospitals was best described by a director, who said: I am a department head, and at the department head meetings I represent this office. All personnel ac- tions and problems must be reviewed by this office. In addition, we administer all personnel programs-- employment, benefits, etc. A System of Rules Covering The Rights and Duties of Positional Incumbents Each of the administrative hospitals has a pub— lished system of rules covering the rights and duties that are applicable to all hospital employees. These rules are contained in the employees handbook. The significance of these handbooks was best expressed by a director, who said: The manual (employee handbook) is substantially an agreement or contract between the hospital and the employees. Another director expresses the same sentiment in comment- ing on the flexibility of policy. He stated: 76 I think it's fair to say that just as laws are inter- preted, the interpretation of policy is always--just like a labor contract. You think it's spelled out one way, but two years later the union, here the em- ployees, convinces you that it's really interpreted this way. In answer to your question, we have flex- ibility if things are justifiable. The tightness of policy enforcement is illustrated by another director. He stated: There are times, yes, when they might want to make some exception to standard policy and might have pretty good arguments for it, but I would say that up to the present time I've had no trouble keeping them from making exceptions. If I feel a change should be made, I would do this through the administrator. When policy is changed or an exception is made, notice is commonly given to all department heads in the hospital. This was illustrated by one Of the directors. She stated: We don't make exceptions without administrative ap- proval. If we make an exception, I send a memo to all department heads, so that they are aware of this change. To reinforce the published system of rules at the personnel management level, many hospitals have instituted a session dealing with the rights and duties of employees in their orientation programs. This was best illustrated by a director, who said: One aspect of our orientation meetings is to develop a two-way street. The employee knows what to eXpect from the hospital and the employers know what the hospital eXpects from them. It's in the form of an informal get-together with the exchange of questions and answers. . . Another method of reinforcing the rule system is to publish a supervisor's policy book that covers each rule in detail. The purpose of these books was explained by one director who said: 77 The supervisor has a copy of the employee policy manual and a COpy of the supervisor's manual. He has no ex- cuse if he doesn't interpret policy prOperly. Hospitals that are not as well developed along this dimension of organization tend to have frequent policy changes, e.g. changes in the system of rules covering the rights and duties of employees. The flexibility of per- sonnel policy was best illustrated by a director who stated: When our policies become Obsolete, I take them to the administrator. Last year we received our policy hand- book. . . .Our manual is not even a permanent manual now. We just mimeographed it because we wanted to wait a complete year-—find out just what's going on. It isn't a year old and it is already out of date. A major factor in causing the flexibility of pol— icy in these hospitals appears to stem from the basic premise upon which they are written. Employee rights and duties are based primarily on what other hospitals have in their manuals and upon the eXpectations of their own employees as to what they expect to find in the policy. The policy is not treated as a contract but more as an agreement outlining maximum duties and minimum rights that an employee can expect in the hospital. One director il— lustrates what is a common practice among these hospitals. She stated: We are in the process of rewriting our policy. There again it's a study of what other hospitals are doing, what the country is doing. You ask yourself a million questions, and say how would Suzie generally react to this and what happened the last time this came up. 78 And pretty soon you work it out and hOpe that this is the best. Policies are forever changing they aren't going to hold forever and a day. A System of Procedures for Dealing with Work Situations The work performed by the personnel departments in administrative hospitals is organized and directed by a well develOped system Of procedures. The procedure for handling routine personnel activities is controlled either through procedure manuals or forms. The use of procedure manuals was illustrated by a director. She stated: We produce books. Every department has a procedure book, and every time a new procedure is written, it goes to the departments that are affected. We have a procedure book in personnel, and every department has in their procedure book the information on how to process every type of personnel action. Another director illustrates the use of forms as a pro- cedural device. He stated: We use personnel action forms. These forms cover all possible personnel actions. The forms are in the hands of the department heads, and it's initiated there. We probably handle 3 to A hundred a month for A0 to 50 different purposes and reasons. The procedures for handling non-routine activities appears to be equally developed in these hospitals. The routine of these "non-routine" activities is demonstrated in the remarks of another director: She stated: If an employee comes here with a problem, I contact first their supervisors. I tell the employee that I must do this, and the supervisor and the employee may settle the problem between them, and that is the end of it. If they can't settle it then it is taken 79 to the department head or the assistant administrator in that area. Now if the problem were a question of policy, I would have advised the employee to go back to his department and file a grievance. A major objective of personnel administration is to set procedural guides for personnel management activities of supervisors in the work setting. Hospitals have training programs for their supervisors and department heads which are usually conducted as part of the program at department head meetings. The need for training was discussed by one of the directors. He stated: I'd say that over half of the supervisors say that they don't care what effect their actions might have elsewhere in the hospital. This is why we have started training. The need for training is again illustrated by another director. She stated: On the department head level, our training purpose is to train them in supervisory responsibility. I think department heads get bogged down in their daily rou- tine. Then, perhaps somebody doesn't report for work and they want to fire them. I think we have to bring awareness to them, so that they don't think this is my laboratory and this is my problem. The laboratory has to mesh with every other department. The use of management meetings for training purposes was illustrated by still another director. She stated: Our management meetings are frequently program type meetings where we learn new management ideas. The use of meetings is again illustrated by another di— rector. He stated: Of our A0 to 50 department head meetings each year, I would say 80 per cent of them are devoted to super- visory development and bringing awareness of how to manage peOple. 80 In the hospitals that do not appear to be as far developed along this dimension, the procedural development, insofar as the personnel department activities are con— cerned, appears developed, but these hospitals are not involved in training activities to any large degree. Impersonality of Interpersonal Relations The interpersonal relationships between the mem- bers of the hospital's administrative hierarchy tend to be carried out on a business-like basis. In the course of the interviews the interviewer noted that the rela- tionship between the personnel director and other depart— ment heads appeared to have a matter-of-fact, if not a quiet professional basis. During the interviews with one director, the relationship between the director and other people who entered her office that morning seemed to be quite formal, and when the interviewee touched upon this subject, she commented. Everyone here is on a Mr. and Mrs. basis. If I meet an orderly in the hall or in the elevator I address him as Mr. The administrator has suggested this and has tried to instill it in others. Now the jargon of nurses is to say "Hey, Smith what are you doing?" A major factor in the growth of impersonality of inter- personal relations at all levels of the hierarchy has been the emphasis in many hospitals of identifying positions in the organization rather than individuals. Through the 81 control of job descriptions by the personnel department, the department heads have been restricted from completely personalizing the work and the relationships within their department. A director illustrates how job descriptions are converted into job classification. He stated: We have family groupings of jobs wherever we can use them. SO we could have a purchasing clerk who is a clerk 3 and a personnel clerk who is a clerk 3. So there's a functional title, but one job description would show clerk 3. With positions identified into family groupings, it is possible to consider transferring employees from one de- partment to another in times of personnel shortage. A director illustrates a case where nurses aides were given in-service training to insure that they met the hospital's classification in addition to that of their department. She stated: Our nurses aides were trained by their head nurse. If there was a shortage in another department you couldn't put an aid on another floor because they did things differently. This was our first reason for putting in in—service training. We insisted that every nurses aid attend these classes. Now, we had some problemS--they would come in and say "I knew how to make beds 20 years ago, why should I go to school now." I had to explain to them the purpose of the program. A secondary effect of this program was that the nurses aides were learning how to perform their jobs by hospital standards, and that the basis for interaction between her- self and her department head was shifting from personal direction to one of positional expectation. 82 The hospitals that are not as far developed along this dimension have about the same degree of impersonality of interpersonal relations development at the administra- tive levels, but they have not advanced personnel activ- ities that would give the hospital administrator some influence over the organization and direction of work within the departments. Promotion and Selection for Employment is Based Upon Technical Competency The employment function is centralized in the personnel Office in administrative hospitals. In the screening of technical and professional employees the personnel department relies on the employing department to judge the technical competency of the employee. The department heads normally use in—service training programs to assist them in this technical competency judgment. A director illustrates one of the purposes of this week long orientation program for professional and technical people. He stated: A more pragmatic reason is that any job has certain life sustaining qualities to patients involved—-we would be very foolish to have someone come in and run off a batch of lab tests saying that every married woman has syphilis. . . . We've got to know she can give shots, perform lab tests. We can't assume it . . . The only way you can do that is to watch her do it. 83 Another director again illustrates the reliance placed on in-service training. She stated: For example--we will still take a trained practical nurse and give her in-service training after we hire her. Even if she has just gone through her training, received her registration--takes her boards, we will still put her into in-service training to acquaint her with our hospital and to observe her before we will put her on the floor here. The personnel department has another aspect of this dimension and that is to see that performance, and not sentiment, govern personnel activities of department heads. The personnel departments in these hospitals make extensive use of employee evaluation reports in reviewing personnel actions taken by supervisors. The most common use of these records is in the review of merit pay increases. One director illustrates a case where the employee initi- ated the review. She stated: Let's say an employee comes in and says, "I haven't had a raise in a year," and after reviewing her eval- uations in the file I feel she has earned her merit raise. I would call the department head and talk with him. If he wasn't responding too well, I would point out to him--"You signed a good evaluation--you signed it, so you can live with it." If he didn't respond, I would take the case to the administrator who could do nothing but order the department head to give the raise. Another director again illustrates the significance of the evaluation. He stated: The department head must include remarks for any low marks. If a department head doesn't make a recommen- dation for a merit raise, and there is no justifica- tion for it on the form, the personnel department would call him in. The evaluation puts the supervisor 8A on the spot. If he wants evidence for discipline, he must put it on the evaluation form--if he does, he can't justify a merit raise. If he wants to give the raise or he doesn't want the employee mad at him for a poor evaluation, he must live with it. The super- visor is forced to judge performance regularly. The best evolution in the review of a disciplinary action by a department head was best illustrated by a director, who said: We have an orderly who has been with the hospital for some time. He has been known to make candid remarks to other employees and so forth, but nothing has ever been recorded. If an outsider were to look at his file, he would say that he was an ideal employee. Yet here is someone who would sit on stretchers in the halls, would wheel himself down the hall in a wheelchair—-you name it--but no one had ever bothered to put it down on paper. The nursing director came and said that this was it. They had tolerated as much as they could with him, and they were going to term- inate him. I couldn't approve it, not with his file as it is, and the administrator, I am sure, wouldn't approve it either. They kept the employee, but gave him a warning. I am sure that the evaluation from that department will be better in the future. In two of the three hospitals not as far developed along this dimension, the personnel department does not perform employment services in the recruiting and screening of registered nurses. These departments maintain complete files on nurses and they administer all other personnel programs in their hospitals. In all three of these hosp- itals, the use of evaluations is not nearly as extensive as it is in the other administrative hospitals. This brief examination of the personnel function in administrative hospital organizations reveals that the hospital's authority systems meet our criteria for 85 administrator dominated type hospitals. Evidence of this is reflected in the affairs of the personnel department. The personnel departments in these organizations, as rep- resentatives Of the central authority, are able to perform activities throughout the organization. The major func- tions of the department--employment, records, and policy enforcement--are not seriously duplicated elsewhere in the organization and as a consequence of this, the operat— ing departments are dependent on a central office for some critical activities. This evidence indicates that the central authority, the administrator, is able to exercise that authority in all sectors of the organization. The exercise of this authority is demonstrated in the ability of the administrator to use the formal organization as an Operating structure, and to reinforce his position through management meetings where policy is communicated and prob- lems solved. This use of the hierarchy of authority is present even in those hospitals which are not as far ad- vanced along this bureaucratic dimension. The hospital's policy interpretation is in the hands of the administra- tor and this further reinforces our contention that these hospitals are of the administrator dominated type. Evidence of strength in the administrator's posi- tion is visible in his ability to support personnel de- partment programs that directly influence personnel management activities at the department head level. The 86 development of supervisors' policy books, orientation programs for employees, and management training are ex- amples of this. The administrator himself tends to be able to make effective use of management meetings as training occasions. These activities indicate that ad- ministrative influence is able to penetrate all levels of the hospital. The personnel department's use of job descriptions and employee evaluation furnish convincing proof that the central authority is recognized in the Operating depart- ments. The use of job descriptions as a means of limiting the Operating supervisor's interpretations of tasks, and as a means of establishing in the employee an identifica- tion with his position rather than his department as supervisor, is a serious invasion of professional and occupational prerogatives that have so long dominated hospitals. The use of job evaluations as a means of committing supervisors to the making of employee related decisions that affect not only wages, but any future em- ployee action the supervisor may wish to take, tends to remove from operating department heads the arbitrary power that is all too frequently associated with hospital work. It is our Opinion that the evidence is sufficiently strong to justify our designation of hospital dominance type, and that the formal posture of the personnel depart- ments examined can be attributed to organizational sources. 87 The attitude of the personnel department is that they are a centralized departmentalization of personnel administration activities of employment, records, and personnel policy maintenance. The departments can commun- icate formally with employees and managers, and are a necessary step in any employee action instigated by a de- partment. The departments can extend their activities to review and challenge management personnel actions within a department. The personnel departments appear at this time to be in a process of extending their zone of influ- ence, rather than SOphisticating their contribution to the hospital. This may be a sign that the administrative hosp- ital basis is fairly new in these organizations. The findings illustrated in Chapters III and IV confirm the hypothesis stated in Chapter I that hospital organizations differ in their organizational environment. It was demonstrated that the voluntary, non-profit, general hospitals in Metropolitan City, that have full-time per- sonnel directors, are of two general types--administrative and professional. CHAPTER V OCCUPATIONAL ORIENTATIONS OF HOSPITAL PERSONNEL DIRECTORS The departmentalization of personnel administraa tion activities makes available to the hospital not only a Specialized administrative function, but also an occu— pation supported by academic programs, research, and writings, and endowed with rich experiences and wide acceptance in American industry. The personnel director is the personnel occupation's principal repreSentative in the hospital, and he is the hospital's primary channel for the reception of advancements in personnel technology, practices, and knowledge. With memberships in both the personnel occupation and the hospital's formal organiza- tion, the personnel director is confronted with a dual authority system.‘ If he is highly sensitive to his oc- cupation, he will tend to accept the research, writings, experiences, judgments, and decisions of his broad occu— pational colleague group as the ultimate authority on personnel questions. On the other hand, if he is highly sensitive to the formal organization, he will tend to accept the hospital's hierarchy of authority and its sup- porting sub-system as the ultimate authority on personnel 88 89 questions within the hospital. In this chapter we will first characterize the directors by their sensitivity to their occupation, and then we will examine the effects of their orientation on their work related attitudes. As a basis for this examination we will use the four bureau- cratic factors, noted in Chapter I, that were identified and Operationally stated and demonstrated by William R. Scott as being locations of attitudinal differentiation between occupationally and organizationally sensitive people. The personnel occupation's Opportunity to attract and influence its members is not equal to that of the formal organization which employs them. As an employed member Of the hospital organization, the personnel direc- tor is subject to its authority system and he may, but need not, be sensitive to the demands of his occupation. Our first task is to identify those directors who are sensitive to their occupation, as is evidenced by their selection Of the personnel occupation as a positive re- ference group. Each of the directors was asked to ident- ify the source from whom he obtained the greater part of his intellectual and occupational stimulation in connec— tion with his work. The directors were asked to make three selections from the following list: a. My immediate supervisor b. The hospital administrator C. The assistant administrators 90 The department heads and supervisors The employees Hospital Personnel Directors Association (members, speakers, etc.) g. Personnel books and journals (authors, contribu- tors, etc.) h. Personnel people outside the hospital industry (teachers, conference leaders, etc.) 1. Other. H)(DQ.. In analyzing the responses, choices "a" through "b" are considered hospital organization choices "f" through "h" are considered personnel occupation choices, and choice "1" answers are treated as either organization or occupa- tion choices as indicated by the location of the group cited. The directors who selected two or more occupation choices are considered to have relatively strong sensit- ivity to their occupation and are characterized as being occupationally oriented. The personnel directors who selected less than two occupation choices are considered to have relatively weak sensitivity to their Occupation and are characterized as being organizationally oriented. In responding to the above question, two personnel direc- tors made no occupation choices, ten personnel directors made one occupation choice, one personnel director made two occupation choices, and four personnel directors made three occupation choices. Therefore, for the purposes of this study, five of the seventeen personnel directors in Metropolitan City's voluntary, non-profit, general hosp- itals are characterized as being occupationally oriented, 91 and twelve directors are characterized as being organiza- tionally oriented. The background characteristics of the personnel directors were studied to determine the extent of their influence on the orientation characterizations. Particu- lar emphasis was given to the career and education ex- periences of the directors. Certain selective factors were identified, and these data appear in Table 3. These data suggest that the orientation charac- terizations are related to career patterns and to exposure to graduate school courses in personnel administration, and that they cannot be directly related to age, sex, and seniority in office. Taking the last point first, all five of the occupationally oriented directors are male, but six of the eleven male directors are organizationally oriented. The age distribution of both classes of direc- tors, when considered relatively, is approximately the same throughout the age range. All of the occupationally oriented directors have less than six years seniority, but seven of the twelve directors with less than six years seniority are organizationally oriented. These data ind- icate that the orientation characterizations are more deeply rooted than those which can be identified by sex, age, and tenure in Office. 92 TABLE 3.-—Influence of background characteristics on orientation characterizations Orientation Occupation Organization Sex Male 5 6 Female 0 6 Age 20 - 29 years 0 1 3O - 39 years 2 A A0 - A9 years 1 2 50 years and over 2 5 Seniority 0.0 - 2.9 years 3 A 3.0 - 5.9 years 2 3 6.0 - 8.9 years 0 l 9.0 years and over 0 A Decided to enter personnel work before age 30 5 6 Age when entered hospital personnel work 20 - 29 years 1 A 30 - 39 years 2 1 A0 - A9 years 1 O 50 years and over 1 I Decided to enter personnel work after age 30 O 6 Age when entered hospital personnel work 30 - 39 years 0 A A0 - A9 years 0 2 50 years and over 0 0 Graduate school work in personnel 5 l 93 The career patterns of the directors reveal that those who started their careers in personnel at a rela- tively early age, but did not enter hospital personnel administration until relatively late in their careers, were more likely to be occupationally oriented than those who started their personnel careers at a relatively late age, and those who entered hospital personnel administra- tion relatively early in their careers. This finding is consistent with our orientation concepts, for it is rea- sonable to assume that those directors whose early per- sonnel experience was in a foreign industry, have had an opportunity through cross-industrial comparison to deepen their understanding of personnel concepts and, therefore, have had an additional stimulant to develop sensitivity to their occupation. It is also reasonable to assume that those directors, whose early work experience was in a foreign occupation, have had an opportunity through cross-occupational comparison to deepen their understanding of administrative concepts and therefore have had an add- itional stimulant to develop sensitivity to the organiza- tion. These findings, that cross-industrial exposure (late entry into hospital personnel administration) is positively related to occupational orientation, and that cross-occupational eXposure (late entry into personnel work) is negatively related to occupational orientation, give further support to our treatment of the characteriza- tions as two distinct categories of directors. 9A The examination of the directors' educational ex- periences reveals one discriminating characteristic. All five of the occupationally oriented directors have at least some advanced formal education in the field of per- sonnel administration, and only one of the twelve organi- zationally oriented directors has such eXperience. This finding is consistent with our concepts of occupation orientation and organization orientation. It is expected that the occupationally oriented director would be attracted to advanced courses in personnel administration because they provide a means for reinforcing occupational creden- tials, a means for keeping abreast of current occupational issues, and a means of enlarging his reference group through eXposure to teachers, authors, students. It is further expected that those directors who do not seek the major portion of their work related intellectual and occu- pational stimulation from occupational sources would tend to restrict their use Of intra-organizational sources to the receiving of technical and task information. There- fore, since advanced university courses in personnel tend to emphasize research and theory, and tend to minimize technical information and task training, these findings provide an additional source of confidence in our typology. The specific "stimulant-choices" of the directors were compared with their background characteristics. Though this investigation did not prove fruitful, it did 95 uncover an additional discriminating dimension in support of the orientation characterizations. The Hospital Per- sonnel Directors Association (choice "f") was selected by eight of the ten organizationally oriented directors who made one occupational choice, and it was not selected by any of the occupationally oriented directors. A review of the comments made by the directors about the associa- tion reveals that the organizationally oriented directors consider the association a source of valuable information, and that the occupationally oriented directors consider their attendance at association meetings as a social and political obligation. One occupationally oriented direc- tor expressed the following Opinion about those who attend these meetings. He stated: Bunch of old clerks--there are some good ones. All most of them want to do is talk about things. They want to know the vernacular. If some of them want to know something about job descriptions or job evalua- tion, they learn to define it so they can talk about it, but that's it. They don't use references and authorities that represent different views. My refer- ences come from the whole personnel area. This finding tends to support our concept that occupational orientation is an intellectual identification with the occupation. The support of these three behavioral dimensions strengthens our confidence in the success of our attempt to differentiate between directors on the basis of their sensitivity to their occupation. Using these characteriza- tions, we will next examine the work-related attitudes of the directors. 96 Conssquences of Occupational Orientation on Work-Related Attitudes Our bases for examining the consequences of the orientation characterizations on work-related attitudes are the four bureaucratic factors noted in Chapter I that were identified and opperationally stated by William R. Scott. These four factors are: (1) expectations Of supervision, (2) legitimacy of rules, (3) sources Of authority, and (A) nature of service. Expectations Of Supervision What are the expectations of the personnel direc- tors toward the direction and control of personnel activ- ities within the hospital? The occupationally oriented director, who has a relatively strong sensitivity to his occupation, is expected to rely on his knowledge of the occupation's standards and practices and on personnel authorities for the direction and control of his activities. The organizationally oriented director, who does not have a close personal identification with his occupation, is expected to rely on the hospital's hierarchy of authority for the direction and control of his activities. In order to test and demonstrate these differing eXpectations the directors were encouraged in the interview to discuss recent and proposed changes in personnel act- ivities within the hospital. This tOpic was selected be- cause many hospitals only recently have taken under 97 consideration or have inaugurated such personnel practices as written job descriptions, wage and salary administra— tion, written policy manuals, orientation programs, employee benefit programs, and manpower budgets. In discussing the the change process within the hospital, the director's ex- pectations of supervisors should emerge. The organiza- tionally oriented directors should eXpect a relatively high involvement by their superiors in the change process, for they are dependent upon the hierarchy of authority for the direction and control of their activities. The occu— pationally oriented directors should consider themselves qualified to function independently and responsibly in their positions, and therefore, anticipate a relatively low involvement by their superiors in the change process. We will now examine the empirical evidence for this factor. The occupationally oriented director's thoughts, when he was asked to identify the activities that should be performed by his department, tended toward his occupa— tional territory rather than specific tasks or current hospital personnel practices. The attitude commonly ex— pressed by these directors was simply summarized by one director who said, "Personnel should have everything in the textbook listed under personnel and labor relations." The attitude of the occupationally oriented director is that his jurisdictional rights, privileges, and 98 responsibilities are based on occupational standards, and that these standards constitute the minimum scope of his activities. It is one thing to define one's jurisdiction and another to implement the changes necessary to exercise one's rights, privileges, and responsibilities. The occu— pationally oriented director tended to view changes in personnel activities as a responsibility that he assumes upon accepting his position. Evidence of this can be seen in the following statement: You just see what you feel should be done and start right in. How do I know what changes will take place? I create them. Nothing ventured, nothing gained. When you are new you're not swamped because you don't know what there is. You don't realize, you know, what is there--what has to be done. You just do the routine, then when you start venturing that's when you start realizing how much has to be done. There is a constant need to study, to improve, and I would say that any personnel director that feels he knows personnel and doesn't need to study and improve, shouldn't be a personnel director. The occupationally oriented personnel director's attitude toward change is that it is an important part of his job, and that it is his personal responsibility to study, to eXplore the needs for change, and to initiate changes in the hospital. Since personnel administration is in an emerging stage in the hospital industry, it is hypothesized that the occupationally oriented personnel director would recog- nize or feel a need for a great number of changes in 99 current personnel activities. This attitude would be best reflected in his attitude toward the pace at which he hopes to accomplish change. The attitude of the occupationally oriented director toward the pace of change can be seen in the following statements: In starting so many things my situation now is that there is more work coming in and nothing going out. My biggest problem is that my deeds have not been coming out as fast as my thoughts. I am trying to establish priority order over the cir— cumstances, but the basic concept is like a juggler. I hOpe not to drop too many balls at one time. Now you start a number of things based on the fact that it takes a longer time to develop certain things-- you've got to have more than one thing going at a time or you're not going to get anything done. The basic attitudes of these directors are that they con- trol the pace of change, that their thoughts and desire for change exceed the rate at which they can be brought about, and consequently they recognize that personally they must establish priorities to make efficient use of the time available. The occupationally oriented director's attitude toward the current changes in personnel is not one of random selection or a result of a specific pressure, but tends to View these changes as necessary parts in the long run development of his department. The following statements give evidence of this attitude. Some days you really feel tremendous--that three to five years from now a lot of this will be running smoother. 100 The picture Of a hospital personnel department today is like an amoeba, it constantly changes. Hopefully, I know what shape it will end up in, but in the inter- mediate process it takes on many shapes. The occupationally oriented director's attitude is that he is the designer and programmer for his depart- ment in both the short and long run. The occupationally oriented director tended to View the hospital administrator as just another person in the organization. One director in attempting to describe the degree Of the administrator's involvement in the act- ivities of his department said: The administrator can't understand--doesn't always understand. I have had quite a bit of success with the department heads. Another director stated what possibly reflects the consen- sus attitude of this group. He said: The administratos is very nice--we see each other about once a week to get the various forms signed and to get the administrator's signature Of approval for the various things that we're going to do. These directors tend to recognize the position of the ad— ministrator and the right of the administrator to review and approve department activities, but they did not see the administrator as being responsible for or involved in the affairs of their department. This attitude is evident in how they wish to be evaluated. One director briefly stated the thought of this group. He said: You can measure my success and my department's success by how well we implement things and get other peOple to support that implementation. 101 The attitude of the occupationally oriented direc- tors toward their expectations Of supervision is that they are able to supervise themselves, and that it is their responsibility to see that the hospital personnel depart- ment meets occupational standards. These directors View change as something they develop, control the pace of, and incorporate into the long run objectives of their depart— ment. The directors wish to be evaluated on their success in implementing things; that is to say, their ability to perform within the hospital environment. With the occu- pationally oriented directors' attitude toward supervision identified, we will now turn our attention to the att- itudes of the organizationally oriented. The organizationally oriented director's thoughts, when he was asked to identify the objectives that he felt the personnel department should achieve, tended toward his relationship with his superior rather than a specific list of objectives. The general attitude of these direc- tors is that the personnel department activities are a division of a total management effort, and therefore, it is the responsibility of those who direct this effort to inform the personnel director of the contribution to the management of the hospital that is eXpected from him and his department. Evidence of this attitude can be seen in the following statements made by directors whose eXpecta— tions of supervisory direction have not been fulfilled. They stated: 102 The administrator should designate the objectives for this department. The administrator may have objec- tives for this department that I may not be aware of—- the administrator has to come across and inform me. The administrator hasn't eXpressed to me what he ex- pects of my department or me. I don't think he knows. I don't think he realizes what potential personnel can be to the organization. I need more flesh and blood contact. I would rather have the administrator tell me to go to hell rather than ignore me. I need more direction. I don't mean by that, that I like to be bossed all the time, but I would like to know what is eXpected. This attitude of relying on the hierarchy of authority for the selection and direction of personnel activities is held by all of the organizationally oriented directors. Most directors tend to express this dependency in a more subtle fashion. The following two statements (not nec- essarily the most subtle) typically represent the attitude of the directors toward supervision: I like periodic reviews of my performance. I like to work with the administrator in defining how we can obtain our goals rather than being independent. There are too many areas where I am not fully knowledgeable and he might have greater knowledge. I certainly like a good argument now and then, and I want someone to challenge me, because I don't claim to know everything and the administrator's opinions are of value to me. These attitudes of desiring direct administrative involve- ment in the review of their work and of deferring to the administrator's knowledge and opinions stem from a common source. This group of directors, in assuming that their objectives are designed, set, and can be changed by the 103 administrator, are dependent on the administrator to in- trepert that which he has designed. A consequence of this is, as one director stated, "the administrator is the per- son who can best measure my performance as a personnel director." Another director expressed a similar thought and the one most frequently expressed by these directors. He stated: This is our aim, you see—-to please the administrator. It is to supply what he expects of us. The general attitude of these directors toward their pur- pose in the hospital was best expressed by one director who said: I want to improve in this position. I want my depart— ment to improve. I want to be a better personnel director, so that I can help the administrator run this hospital better. The organizationally oriented directors do rely on the hierarchy of authority for the direction and control of their activities, and they do have attitudes supporting relatively high superior involvement in the planning and review of department activities. Our next responsibility is to examine the consequences of these expectations on the directors' attitudes toward change. The organizationally oriented director, in relying on the hierarchy of authority for the direction and control of his activities, tends to assimilate the activities that have been assigned, and to stabilize them through the assignment of tasks to members of his department. The 10A effect of this process on the directors' attitude toward change is that they tend to view most changes as project additions to an already established work load. An example of this attitude can be seen in the statement of one di- rector who said: These new programs--setting up in-service training, orientation programs, and so forth. An awful lot of this falls on the personnel department to do. We must stand the cost of it in time and people. The general attitude of the directors toward change is illustrated by another director who said: Three years ago I don't believe we were thinking of having everything in writing—-policies, job descrip- tions. These are things that are being forced on us, and they are not projects we just want to do. In considering change as additional work, many of the di- rectors feel that these changes represent a serious strain on their personal resources. The attitude was expressed by one director who said: I don't feel I am doing my best when I have so many extra things to do. I do try to accomplish one new project per year. Attitudes of the directors were best summarized by one director who said: The objectives should be to be doing a better job on what we're supposed to be doing now, rather than try- ing to do new things. The organizationally oriented directors recognize that there are hospital personnel directors in Metropolitan City who seem to favor change and be change-makers. The attitude toward these directors tends for the most part 105 to be neutral, but there are a few directors, particularly in hospitals which have major changes under consideration, who question the motives Of these more dynamic directors. The following statements illustrate their attitude: In the personnel field, if a person wanted to build an empire or augment personal esteem, it wouldn't be too hard. I think that some personnel departments do a lot of work that doesn't mean much to them, but it keeps them busy, and enables them to have a pretty good-sized de- partment. You can go into some hospitals and the man can tell you what the median wage is for some group, and things like that. Well, that's fine, but to me it doesn't mean much. These protests reflect the general attitude of the organi- zationally oriented, that as personnel directors they are members of an administrative team and that their primary responsibility is to contribute to the team's objectives. Though these directors are not positively oriented toward change, they are receptive to suggestions from their superiors. One director expressed the general feeling quite nicely when she said "Well, I'm willing to be sold on it." Another director stated the general feeling of this group toward changes that have been assigned when she said, "We don't need probing—-we just need the time in which to do it all." The attitude of the organizationally oriented di— rectors toward their eXpectations of supervision is that of dependency on their superiors for the selection, direc- tion, and review of personnel activities. The directors' 106 attitudes toward change reveal that they evaluate change in terms Of departmental effort rather than occupational standards. There are a number of interesting contrasts be- tween the occupationally oriented and the organizationally oriented. The occupationally oriented express indepen— dence of supervision and the organizationally oriented express dependence on supervision. The occupationally oriented are change-makers, and the organizationally oriented are change-takers. The occupationally oriented indicate temporal planning, and the organizationally ori- ented tend to be atempora1--the occupationally oriented want to be measured on their ability to perform in the hospital, and the organizationally oriented want to be measured on their ability to perform in their departments. Legitimacy of Rules What are the attitudes Of the personnel directors toward personnel norms and values? The occupationally oriented directors, who tend to be socialized to personnel work by their occupation reference group, should reflect their internalization of occupation norms and values in interpreting and evaluating the hospital personnel environ- ment. The organizationally oriented directors, whose socialization to personnel work tends to be organizationally derived, should reflect their internalization of hospital 107 and hospital industry personnel norms and values in inter- preting and evaluating the hospital personnel environment. To test and demonstrate these differing attitudes, the directors were encouraged in the interviews to discuss competition. This topic was selected because it was rea- sonable to assume that the industry's rich humanitarian heritage, community dependence, and the voluntary, non- profit dimensions Of hospital corporate charters would tend to produce industry norms unfavorable to inter- hospital and inter-industry competition. With hospital personnel directors facing a tight-labor market, the di- rector's attitudes toward the legitimacy of the industry's interpretation of its competitive position should emerge. The organizationally oriented directors, who tend not to internalize occupational norms and values, will tend to accept the legitimacy of the industry's position on its inter-industry uniqueness and its intra-industry community of purpose. The occupationally oriented directors are ex- pected to question the legitimacy of industry rules, codes, and beliefs that cannot meet occupational tests. The occupationally oriented directors do not per— ceive hospital personnel administration as being signif- icantly different from personnel administration in any other industry. This attitude was typically expressed as follows: 108 I find that generally speaking the problems of per- sonnel in hospitals are not dissimilar from those in industry. I don't think that a person experienced in personnel will find it an awful lot different in a hospital. One effect of the occupation socialization of the direc- tors appears to be their tendency to compare and evaluate their situation in the hospital on occupational bases. This Observation is reinforced by the attitudes of the directors toward competition in the labor market. The following statements demonstrate the tendency of these directors to interpret the labor market with occupational norms that they have internalized. The vieWpOint of many hospitals is that they're apart from the outside community. I disagree with this. All our people can work in other industries--the lab people can work in pharmaceutical houses, clerks can work in commercial or industrial establishments, nurses can work in industry and work regular hours and none of this twelve-hours-a-day because somebody didn't show up. Our office people are interchangeable with industry, our x—ray people can work in clinics, and so forth. I'm a minority opinion in this industry. The labor market should be seen as people who are willing to work in hospitals because hospitals are a good place to work, as good a place as any other place in town for comparable skills and effort. Our main competition is with industry. With wages as they are we employ moonlighters and people who need the permissive atmosphere and the security of no lay- Offs. The general attitude Of these directors is that they are competing with non-hospital employers for labor, and that the hospitals do not have a captive labor market for any large group of employees. As a result of this attitude, 109 the directors tend to feel that the hospital wage struc- ture has made them a secondary employer, and that in order to compete they must meet competition for employees at the levels of skill and effort they they desire. The occupationally oriented directors recognize that in addition to non-hospital industries they do com— pete with other hospitals. The attitude of these direc- tors toward the general competitive climate within the hospital industry is illustrated in the following statement: One thing about hospitals in general, they are more cooperative in exchanging information than industry is by any means. You can account for this because you can't fill hospitals any more than they are right now. In other words, we have automatic capacity so we aren't competing for business. My thought is, in that we compete for labor, we might try to compete on some other basis than salary, and hopefully, slow down the wage spiral and have some standardized wages in the area. This group of directors interprets the industry's cooper- ative climate as an effect of the industry's capacity limitations, which insures the maximum utilization of each hospital's assets. The directors interpret conditions in the labor market within the hospital industry as being highly competitive and unstable, due to the inadequate supply of labor, and due to spiraling wages causing intra— industry movement of labor. This interpretation of the competitive situation places the attitudes of the occupa— tionally oriented directors toward personnel policy in contrast with the industry's position. r”‘ 110 The occupationally oriented directors feel that the industry's personnel norms and values are not realistic in today's labor market. The general attitude was stated by one director, who said: The day is past when hospital workers would subsidize the patients by accepting low wages. In rejecting the legitimacy of the industry's position, the directors' attitudes tend to conflict with those of hospital administrators. This conflict tends to center on hospital and industry wage policies. The following two statements best illustrate the dimensions of this con— flict: .people who have been in the hospital business for any length of time have just grown accustomed to these sub-standard wages and can't imagine that people aren't pounding the door down to get a job for $1.15 per hour. They see wages as secondary because the hospital pro- vides a humanitarian, community service--hospital people don't work for wages. This just isn't realistic today. The hospital industry's attitude toward wages is asinine. Let's say we're paying $500. per month and other hospitals are offering $515. per month. The typical administrator would refuse to give a wage in- crease, so our people quit and we replace them at $515. per month. This is asinine. This just keeps wages spiraling up-—keeps turnover high. The employee shouldn't have to quit to get market wages. Administra- tors just don't understand that there is wage competi- tion-~skill competition. The occupationally oriented director's attitudes toward the effect of industry norms and values are that they pro- vide a rationalization for an unrealistically low level of wages, and that, for those who hold them, they interfere 111 with their ability to comprehend and deal with the existing wage competition. The directors also feel that the indus- try's inability to recognize and deal with wage competition might lead to unionization of some groups within the hosp- ital. The basic argument of these directors is demon— strated in the remarks of a very concerned director. He stated: It's by market pressure that things are given to em— ployees in the hospital. For the unskilled group the only pressure they can get is through a union. This is the only way they can get fairness in the future. This is wrong, stupid--hospitals are going to have to wake up. The occupationally oriented directors in reflect- ing occupational norms and values tend to define the per- sonnel situation in the hospital industry differently than those who reflect industry norms and values. The attitudes of these directors are that hospital personnel administra- tion is similar to personnel administration in other in— dustries, that the labor market is geographic in dimension, that the application of some industry norms and values, particularly in the area of wages, is unrealistic, and that the continued application of these norms and values poses both present and future personnel administration difficulties. The organizationally oriented directors tend to View the hospital industry as essentially different than other industries. These directors in reflecting their ap- parent socialization and internalization Of hospital and 112 industry norms and values tend to consider that their personnel problems and issues are not comparable to those in other industries. This general attitude is illustrated in the following directors' statements: Manufacturing is entirely different than a hospital. There just isn't any comparison. Personnel termin— ology was the only useful thing I learned in industry. I went to a couple of their meetings (general business personnel group) and it was so far removed--their con- versation—-from the hospital business, that I just didn't go after that. I don't think our problems in the hospital are the same as theirs (non-hospital industries). To answer your question, I don't look to industry for help. The attitude revealed in these statements identifies an effect of the directors' organizationally oriented sociali- zation process on their work-related attitudes. The di— rectors tend not to compare personnel functions among organizations and industries, but to compare the organi- zations and the industries themselves. This strong identification with the hospital and hospital industry is a common attitude among these directors, and one director Verbalized the common feeling of this group when he said: I am very proud to be associated with this organization and with hospital work. A director in attempting to eXplain why hospitals and hosp- ital personnel were essentially different from other in- dustries stated: Hospitals are different from other industries. Hosp- itals have responsibilities to the community, and must 113 always be aware of the community--not that we have to cater to the community. This is important. This af- fects how you are to do things. This vague attitude of community responsibility appears to be the basic supporting rationale for the attitudes of these directors toward hospital personnel administration. The general feeling of community responsibility, coupled with a strong identification with the hospital and the hospital industry, tend to support an attitude among the directors of a mutuality of problems and purposes. Evidence of this attitude can be seen in the following statements: I think my problems are identical to those in other hospitals. We can call any director in town and find out what they are paying. This is because of community inter- est. Now industry doesn't do this, but we are respon— sible to the community-—in serving them. We know each other and we trade information. I go to other personnel directors for technical in— formation--wages, benefits, etc. The directors do not View each other as competitors, but as friendly peers, who have similar Objectives and prob- lems, in parallel organizations. There is some evidence that this attitude is a demonstration of internalized in- dustry norms and values. An illustration of this can be observed in a statement made by a director who was de— scribing the purpose Of the training programs carried on by her department. She stated: 11A We train them in the same vein, so that they could work in any hospital. Because of the shortage, we train them specifically for our hospital, but normally we train them so that they could work in any hospital. This general attitude Of industry orientation and recog- nition of a mutuality of interest, Objectives and problems was demonstrated by a director, who said: I see every time another hospital expands it's staffed with people who were working someplace else. I talked with a personnel director, who is a friendly personnel director, and a friend, at one hOSpital who said to me the other day—-"Thanks a lot," he said, "for taking half my staff when you expanded." I reminded him that we didn't run an ad for these peOple that he was losing, and when they opened their addition, where did he think he got his people? The organizationally oriented directors accept the indus- try's definition of the situation; i.e., community re- sponsibility and interest prevent competition between hospitals, and they have built attitudes and relationships that reinforce this rule. The consequence of the acceptance of the industry position on their attitudes toward hospital wages can be seen in the following statements: We can't pay our porters less than what other hospitals 93Y- We are not paying the salaries that industry is paying, and we can't pay a porter what industry pays a porter. When industry starts up again--like they did last year--they take some of our good peOple. We can't com- pete with them. Today you think we're paying near the highest for a job and tomorrow you may be halfway down the stairs. 115 The directors do not appear to eXpress a significant in- terest in salaries or wage competition. They recognize that competition exists for they lose people, and wage rates in the community are changing, but their attitude is basically reflected in the first of these statements, where the director in losing his porters to non—hospital industries, recognizes only that he can't pay less than other hospitals pay. Non-hospital wage rates are not treated as relevant data by these directors. The organizationally oriented director reflects his organizational socialization by his internalization of hospital and hospital industry norms and values. The attitudes of these directors are that hospital and hosp- ital personnel administration are significantly different than that which may be found in other industries; that there is a mutuality of interests, problems, and objectives among hospital personnel departments, and that, conse- quently, they are not in competition with one another. There are a number of interesting contrasts that appear to be products of these differing socialization processes. The occupationally oriented directors, who have external reference groups, view the hospital as a member firm in an OligOpOlistic competitive industry, and the organizationally oriented directors, who tend to have internal reference groups, view the hospital as a sovereign member of a non-competitive confederation of 116 hospitals charged with the responsibility of meeting and serving community medical needs. The occupationally ori— ented directors Share information because hospitals have automatic business capacity, and organizationally oriented directors share because there is a mutuality of interests; the occupationally oriented directors see their major problems as being derived from competition, while the organizationally oriented directors see them as being derived from recent hospital expansion programs and a major upswing in non-hospital industries. From this evidence it is apparent that there are two groups of di- rectors and that their attitudes toward the legitimacy of rules affects their definition of the situation before them. Sources of Authority What are the attitudes of the personnel directors toward the source of their authority? The occupationally oriented directors hypothetically, would interpret their functional specialization in the hospital organization as an occupational specialization and therefore they would consider the source of their authority to be based on their occupational competency. The organizationally oriented directors hypothetically, would consider the source of their authority to be based in the position they occupy in the hospital organization. 117 In order to test and demonstrate these differing expectations, the directors were encouraged in the inter- views to discuss the administration of their offices. It is eXpected that the occupationally oriented director will tend to have his Office be identified with him, and that the organizationally oriented director will tend to ident- ify with his office. The occupationally oriented director's thoughts, when he discusses the personnel function in the hospital, tend to be centered on his contribution to the hospital. The typical attitude of these directors, as eXpressed by one Of them, is, "I and my office perform a special ser- vice for the hospital." This special service tends to be centered in the performance of the director within the hospital rather than his performance within his depart- ment. Evidence of the director's personal involvement within the organization can be seen in the attitudes ex— pressed in these two typical statements: Any personnel director who sits in his office all day is wasting his time. I don't think you can sit here and write a lot of memos and wait until they come back. The general attitude of these directors was briefly stated by one director. He said: To deliver the goods--that's what I am here to do. If they like it, good. If they don't, that's some- thing else, but that's the way it is. 118 These directors tend to view their Offices as part of their contribution, which is to perform as competently as they can. The orientation of these occupationally sensitive directors tends to influence their attitudes toward the employment activities and problems Of their departments. The role that employment activities have in their thinking was illustrated by one director, who said: Employment is one aspect of personnel. It shouldn't be the top priority one by any means. The employment Office should be considered the first place the em- ployees come to when they enter the organization, and the treatment they receive here affects their opinions when they start to work in the hospital. The attitude Of these directors is that employment activ- ities are a part of the Office routine, and that these activities are Of concern only to the degree that they influence the employee's orientation to the hospital. This attitude is again demonstrated in the director's appraisal of a tight labor market situation. One director stated: We have quite a few vacancies right now--it's just the way things are now and you have to live with it. When things really get bad, we'll have to do something. Maybe then we can get into conducting studies to see how many peOple we really need-—maybe then administra- tion will buy the idea. The problems of a tight labor market do not appear to in- fluence the directors' evaluation of their efforts, and they do appear to Offer hope to these directors of possible future improvements in hospital personnel administration. 119 The source of authority for the occupationally oriented directors, as is implied by their attitudes toward their office, appears to stem from their attitudes toward their occupational competency. Typical statements made by the directors regarding their authority were: I believe that the peOple here realize that they can rely on my years of eXperience in industry and in the hospital. LOOk,I[know more about personnel than anyone else here--they need me; personnel is really just starting to develOp in hospitals. I am the only qualified to advise them on human re— source management, and therefore I am the one respons— ible for human resource problems. I earn my respect by giving service. Don't forget that. You earn it. You serve your client. The occupationally oriented directors simply feel compe- tent and responsible, and eXpect others to recognize this quality in them. These directors identify with their role and purpose and as a consequence of this, they tend not to test their esteem in the routine of their Office, as was demonstrated in their attitudes toward employment activities. The organizationally oriented directors tend to have a strong identification with their office and with Office work. This orientation toward the work of the of- fice, rather than the function Of the Office within the organization, can be Observed in the attitudes that they expressed: 120 I would like to be considered an administrator. I want to do administrative work. Personnel is important administrative work. I'm very much a part of Office administration. Personnel is a desk job. I think that paper work to me-—from the very beginning, almost my very first position--was one of the most im- portant phases of my work. The importance of paper work. These directors tend to View their positions as administra- tive department chairmen, whose major contribution is office management. This observation is reinforced by the directors' attitudes toward their own skills within the Office. The following statements typically illustrate the attitudes of this group of directors: The personnel director should have extensive back- ground in administrative skills and he needs an over- all picture of the organization. I think that the personnel director should have the same kind of skills that a nurse has, only his would be in recruiting, training, or in the ability to speak before people. I would like to be able to go into the record room and see someone doing his work, and be able to know if he is doing it right or wrong. This is an important part of being a director. You have got to know it yourself. You have to know how to do each job in personnel. The attitude generally eXpressed was the need to know each job within their department and either pride in, or a de- sire to have extensive knowledge of, one Of the department's task areas. The principle interest that these directors found in their positions was based on the variety of work that they performed, as is demonstrated in this statement made by a director: 121 Personnel work isn't dull. Every time we sit down to figure out a vactaion it's different because of the hours worked and the length of time. The orientation of these organizationally sensitive direc- tors is toward Office work, with the directors tending to identify with their Office. The organizationally oriented director tends to base the testing of his self-esteem on the role and status Of his department. The attitudes of these directors to- ward the role and status of their department within the organization are well illustrated in the remarks of two of the directors. They said: The personnel department is perhaps a notch above other departments in the hospital--not because of the direc- tor, but because we know a little bit about everyone's business and they don't. I sort of feel that personnel is an arm of administra- tion--not above the other departments--but as a tool of administration to carry out the policies of the hospital and to keep the records. We have the first and last contact with the people and we have to ind- icate to the individual how the administrator feels-- by saying we give such and such benefits, salary, for this position. The department's proximity to records and the administra- tor tend to be the major sources of departmental influence. The directors tend to View their departments as having an administrative role and a functional role. The directors' attitudes toward their administrative tasks are evidenced in the following statements: Personnel is a control function--to see that what was said would be done, is done. 122 Our basic function is record keeping. My major effort is to see that our policies are carried out uniformly, and information is a close second. We screen and keep records. My greatest problems are in the Office--getting bet- ter records and improving my procedures. As these brief statements reveal, the directors have a clerical orientation to their responsibilities as an "arm of administration." These clerical and administrative responsibilities of their department can, under stress, be a threat to the director's own self-esteem. Evidence of this can be seen in the statements of two directors whose feelings were not uncommon among this group of directors. They stated: You can't do this job in eight hours. Maybe I take this job too seriously at times. There must be an easier way of doing things. I wish I could find one. I would sleep better if I could; I'm getting sick of Johnny Carson. I don't feel like I'm the personnel director. I'm doing too much work. With all this paperwork I've Spread myself too thin. The administrative tasks appear to represent influence ("we know a little bit more") and "risk" to these directors. Another area of influence and "risk" is the department's functional roles, particularly that of employment. One director briefly summarized the general attitude of this group Of directors when he said: 123 The primary Objective of the personnel department is to provide people. Once we have the person we have to communicate policy. With a tight labor market in Metropolitan City employment activities are a major area of concern for all of the organizationally oriented directors. The most common feeling among these directors was eXpressed by one direc- tor, who said: Most personnel directors feel inadequate in recruiting the peOple that are needed. It bothers me, because I am not doing the job I'm hired to do. These directors tend to test the value of their contribu- tion and their personal worth to the hospital by the ability of their departments to perform and meet objectives. As the above attitudes suggest, the attitude of the organizationally oriented director toward the sources of his authority tends to stem from his position in the organization and from his personal involvement with his work. Taking the latter point first, many Of the direc- tors feel that a major factor in the respect given a di- rector, and in the authority that he is able to exercise, is his personal code Of conduct and feeling of respons- ibility. Evidence of this attitude can be seen in the following statements: The old fashioned words that we used to use—-that I have prized all my life—-are square-shooter, trust, honesty in my day-to-day contacts. These words are my personal source of strength, and the reason why people respect what I say and what I do. 12A I think it's just by integrity and trying to give the people straight information and not misinformation. Trying to be helpful. People respect this. I am respected because I am here to help them. It is the consensus of this group that authority stems from the man and from his position. Though they View the director's character as important, they tend to rely on their positions within the organization for securing the authority that they possess. The attitude is demonstrated in the following directors' statements: I think that the most important thing in my job is quite intangible. The employees have come to learn that I have direct communication with the top. I tell them this, so that when I interpret policy--in— stead Of laughing me out the room saying I'm in the dark ages-—they listen and comment, knowing I can take it to the top. People know that the administrator and I talk fre- quently. I think that people respect my authority because they know that a hospital is a necessary function in the community, and that I administer policy that has been approved and is for the benefit Of the hospital. The source Of authority for these directors seems to re- side mainly in their Office and in their proximity to the administrator, as well as their attitude toward integrity, and service tending to support the stabilization of the authority once it is received. The directors are inclined to measure their performance on the basis of their depart- ment's performance in meeting its Objectives, for the directors tend to identify with administrative work and Office routines. 125 There are some interesting contrasts that appear to be products of differing attitudes toward the source of their authority. The occupationally oriented director interprets his position as an occupational specialization, and the organizationally oriented director interprets his position as an administrative specialization. The conse— quence of these interpretations is that the occupationally oriented view the source of their authority as their oc- cupational competency, and the organizationally oriented directors View the source of theirs as residing in their positions. The effect Of this is that occupationally oriented feel that their major responsibilities reside away from the routine Of their offices, and that their employment activities are only one routine aspect of their departments. The organizationally oriented directors feel that their major responsibilities reside or are incorpo— rated into the routine of their Offices, and that their employment activities are an important and major aspect of their jobs. Nature of Service What are the attitudes of the directors toward the nature of the service they Offer the hospital? The occupationally oriented director, whose reference groups reside outside of the hospital, will tend to View members of the hospital organization as clients, and his attitude 126 toward service will be to assist his clients in meeting their personnel responsibilities. The organizationally oriented director's attitude toward service will be to perform services necessary to meet the personnel depart- ment's obligations within the hospital. In order to test and demonstrate these differing attitudes, the directors were encouraged in the interviews to discuss the personnel climate within the hospital. The occupationally oriented director's attitudes are to support an equitable climate for his clients to operate within, and, hypothetically, that the organizationally oriented director, whose client is his department, has attitudes reflecting his interpretation of his department's direct responsibilities in this area. The occupationally oriented directors' attitudes, when they discuss the personnel department's role in setting and maintaining the general personnel climate within the hospital, were succinctly stated by a director who said "personnel gets this work done through other people." The attitude of these directors is that the primary responsibility for this climate rests with the Operating supervisors and department heads who have im- mediate contact with the employees, and that the personnel director's chief responsibility is to ensure that these relationships are conducted equitably on matters relating 127 to personnel. The general attitude of these directors is demonstrated in the following statements: When I first came here I told them (department heads and the administrator) at the weekly meeting that I represented the administration of the hospital in dealing with the employees, and I also represented the employees of the hospital in dealing with the admini- stration. I wanted it understood that I stand for sound personnel policy, and that I felt free to support and represent any person whose case merited it. I don't feel that I want anything from them (other members of the hospital organization), and I don't want them to feel that they can use me. I'll do what is right. This is really what I am trying to do. This equity attitude on the part of the directors stems, at least in part, from their interpretation of the per- sonnel situation within the Operating departments, as is evidenced in the following director's statement: At this time I find that I must Operate in such a way as to get others to treat the employees fairly, with equity, and as co-members Of the hospital organization. Another director, in expressing this sentiment, reveals what appears to be the general objective of these directors. He stated: I think that today one of the biggest things the per— sonnel department should do is act like a balancer between management and the employees. The directors' attitude, Of balancing the employee- supervisor relationships on equity principles, raises two points of conflict within the hospital setting. The first of these is that most hospitals have had a paternalistic attitude toward the employees, and the employees have de- veloped eXpectations of treatment based on personal and 128 sentimental grounds. The occupationally oriented direc- tors' attitude toward these expectations is illustrated in the following statements: The conversations around here remind me Of a large family--it makes you sick when you hear them. The employees are welcome to come here and discuss personnel problems, but we don't encourage them to come in with personal problems--we're not equipped to handle them. These directors tend to View equity in terms of positional rights and performance criteria, and consequently, reject the paternalistic eXpectations that sometimes exist in hospitals. The second area of conflict centers around many supervisor's difficulty in accepting the personnel department's role in employee-supervisor relationships. The attitude of the directors toward these conflicts is evidenced in the following director's statement. He said: I feel that there are some department heads who don't particularly like me and the work I am doing. I can't let this interfere with my job. I try to handle each situation separately and not be influenced by these peOple. The directors tend to View these conflicts as unfortunate, but they tend not to permit them to interfere with the exercising of their duties, and their attitude is, as one director stated: "this is what a staff personnel man is supposed to do--he gives a service." The occupationally Oriented directors' attitude toward the nature of the service that they Offer is that they ensure equity in personnel practices throughout the 129 organization. The director Views all members of the or— ganization as clients and he serves his clients not by meeting their eXpectations, but by acting in their best interests. The attitudes of the organizationally oriented directors toward the setting and maintaining of a personnel climate within the hospital tended to be confined to those aspects of the climate directly chargeable to their de- partment's performance. In considering the scope of their responsibility, the directors tended to accept the trad- itional personnel climate norms of the hospital industry. Evidence of this can be observed in the following directors' statements: TO me we have one big Objective and that's to keep the family happy. Our organization hasn't changed so much that we can't keep the closeknit family idea that we have always had, fortunately, and I hope that we'll never outgrow this. The personnel director has a tremendous Obligation toward morale. We have to take care of things in our family here. These directors feel that their departments are directly responsible for maintaining morale that is generated by be— longing to the hospital "family." The consequence of this interpretation is reflected in the attitudes of the di- rectors toward the nature Of the service that they and their departments are to perform. The general attitude 130 of the directors is that they are to provide empathy and assistance to organizationally allied members with prob- lems. The attitude is illustrated by the following statements made by the directors. They said: My job is to listen to people's problems--employees, supervisors, and even doctors and volunteers at times --requests for transfer, interpretation of benefits, and just generally listen. I think much of personnel is simple courtesy and a feeling of sensitivity to peOple. Mostly being a person having the ability to listen and suggest—-human relations. I think part of my job is to try and help the employee with any kind of problem. The directors tend to View these personal and personnel aspects of personnel work as means Of meeting the morale Objectives of their departments. The directors' attitudes are that these activities will increase their influence within the hospital and thereby give them greater influ- ence over morale, or at least the effects of morale, within the hospital. The following are typical statements of these directors: I hOpe to have a strong voice in the hospital and to be a person, an office, that anyone can come to with any type of problem. I think and feel that I personally have a lot of in- fluence with hundreds of the employees at the hospital --more so than anyone else. 131 The attitude of these directors is personally and depart— mentally centered, exemplifying a desire to provide services that will enhance their direct control over the morale aspects of the personnel climate. The organizationally oriented directors' inter- pretation of the current morale needs within the hospital are demonstrated in the following two statements: Now generally it seems that the personnel director has to align himself with the management function in the organization, but somebody has to interpret the em- ployees to see that they are getting a fair shake. Employees need someone to identify with and the per- sonnel director should help here and give personal identity. The directors feel that there is an imbalance in the supervisor-employee relationships, and that at this time the employee needs someone to identify with him in order to achieve a reasonable equilibrium. Support for this finding can be Observed in the directors' attitudes to- ward the employees. Attitudes frequently expressed were: I know the peOple in the hospital. Usually I can call them by name. This has helped me greatly, for the em— ployees feel free to come in anytime. I would like to know the employees by name. It's physically impossible, but I would like to know as many as I can. I like to think that I know most of the employees. I regret not knowing all the employees by name. I think friendliness, trust, and interest in them and their personal problems is a very important part of personnel work. 132 The directors' attitudes are to substitute their identi- fication and interest for that which is missing in the normal supervisor-employee relationship, in order to im- prove the balance between administration and workers. These attitudes supporting direct action to meet morale needs at the supervisor-employee level reveal not only that these responsibilities are considered depart— mental tasks, but also that the personnel directors do not consider it their responsibility to ensure that these relationships meet a behavioral code other than that established by policy. The directors' attitudes toward their involvement with supervisors in this interest area are illustrated by such statements as: Many times I feel like an outsider. You're all alone --department heads are a funny group. I'm in limbo. We are the middlemen——the persons who report. It is evident that these directors wish to avoid involve- ment with the supervisors on general morale matters. This desire can be seen in these two typical statements: We have got to live together. We'll be here tomorrow, and the day after. I always feel that no one is so big that he can't ad- mit he made a mistake. It annoys me when peOple will not do this. Yes, we do have a few supervisors who will not--and to keep peace in the family, we might back down on a particular thing that we feel we may be right about. 133 The directors appear to feel satisfied when their depart— ments have fulfilled their identified service tasks, and they appear to leave to higher superiors the responsibility of ensuring the Overall personnel climate within the de— partment and within the hospital. There are some interesting contrasts that appear to be related to these differences in attitude. The oc— cupationally oriented director tends to View all hospital employees as his clients, and the organizationally oriented director tends to View his department as his primary cli- ent. The occupationally oriented tend to work through others to give the employees equity, and the organiza- tionally oriented tend to give the employees identifica- tion through direct efforts. Both types of directors recognize an imbalance in supervisor-employee relationships, but the occupationally oriented directors' attitude is to improve the balance, while the organizationally oriented directors' attitude is to substitute for the absent bal- ancing item. The occupationally oriented directors' at— titude is to serve the hospital's best interest, while the organizationally oriented director's attitude is to serve his department's best interest. 13A Profile of an Occupationally Oriented Director The occupationally oriented directors were so characterized because they selected their occupation as a positive reference group. This selection appears to have been positively influenced by inter-industry career experiences and graduate education in personnel admini— stration. Confidence in the Characterization as a mean- infgul occupational identification has been established by the directors' work—related attitudes meeting occupational expectations. The directors relying on occupational sources, knowledge, and eXperience feel competent and responsible for the direction and control of their activities and those of their departments. These directors tend to be Change-makers, to perform temporal planning, and to use occupational standards for determining the minimum scope of their activities. The directors reflecting their socialization to the occupation and the internalization of its norms and values reject the hospital and hospital industry norm of mutuality Of interest among community hospitals, and instead consider hospitals to be in a business type Oligopoly currently facing a highly competi- tive labor market. These directors consider their occu- pational specialization as the basis for their authority in the hospital, and a consequence of this is that they 135 do not identify their contribution to the hospital as being a product of their department's routine. These directors View members of the hOSpital organization as clients and consequently seek to serve their best interest rather than solely meeting their expectations. Profile of an Organizationally Oriented Director The organizationally oriented directors were so Characterized because they selected organizational refer- ence sources over occupational reference sources when questioned. This selection appears to have been influenced by mono-industry experience and by inter-occupational ex- periences. Confidence in the characterization as a meaningful occupational identification has been established by the directors' work-related attitudes meeting organi- zational expectations. The directors rely on the hierarchy of authority for the direction of their activities and those of their department, and they are dependent on superiors for the review and evaluation of their activities. The directors tend to be change-takers, to be department guardians, and to have an atemporal approach to planning. The directors reflecting their socialization to the organization and the internalization of its norms and values, believe that the hospital industry is unique, unlike business, non— competitive, and bound together by a mutuality of interest 136 based on community needs and eXpectations. The directors consider themselves administrative specialists, with their authority stemming from their formal position, and they tend to measure their performance by the success of their office activities in meeting department Objectives. The directors consider their client to be their department and consequently seek to serve the personnel department's best interest. In this chapter we have demonstrated that there is a continuum of occupation orientations as measured by reference group selection. We have demonstrated, for this sample, that there are two identifiable types of orientation as indicated by reference group choices and confirmed by work-related attitudes. And, we have demon— strated that these two characterizations are meaningful occupational identifications. CHAPTER VI THE BEHAVIOR OF HOSPITAL PERSONNEL DIRECTORS Chapter I presented the hypothesis that the be- havior of hospital personnel directors is a function of, the organization environment within the hospital and the director's occupational orientation. Chapters III and IV demonstrated through a dimensional examination of the centralized personnel administration function that hospi- tal organizations varied in their develOpment along bureaucratic dimensions, and further demonstrated that a major factor influencing this development could be traced to the evolved power centers within the socio-economic and organic complex of a hospital. The evidence sup- ported the hypothesis that the authority system in some hospitals was of the non-administrator dominated type (characterized as "professional hospitals"), and that in other hospitals it was of the administrator dominated type (characterized as "administrative hospitals"). It was found that the personnel departments' functional activities and purposes were significantly different be- tween these two classes of hospitals. The fifth chapter demonstrated, through a study of reference group selection 137 138 choices, that some personnel directors have a relatively strong sensitivity to their occupation (characterized as "occupationally oriented"), and that other personnel di- rectors have a relatively stronger sensitivity to groups within the hospital organization than they do to occu— pationally located groups (characterized as organization- ally oriented"). The attitudes Of the personnel di- rectors further supported our orientation characteriza- tions, when they met our expectations for the selected bureaucratic factors. The attitudes of the occupationally oriented directors differed significantly with those of the organizationally oriented directors. With the above data in hand attention will now turn to testing and demonstrating the hypothesis. It is expected that:. l. The behavior of in professional the behavior of occupationally oriented directors hospitals will be different than occupationally oriented directors in administrative hospitals. 2. The behavior of in professional the behavior of in professional 3. The behavior of in professional the behavior of occupationally oriented directors hospitals will be different than organizationally oriented directors hospitals. organizationally oriented directors hospitals will be different than organizationally oriented directors in administrative hospitals. A. The behavior of occupationally oriented directors in administrative hospitals will be different than the behavior of organizationally oriented directors in administrative hospitals. In testing and demonstrating these expectations, the work-related factors used in the examination of di- rector attitudes will be employed. 139 Behavior and Change The first set Of Observations is the behavior of occupationally oriented directors in professional hospi- tals. These directors tend to accomplish changes in personnel activities by gradually and informally intro- ducing the changes into the hospital routine and by raising questions based on evidence collected by their department that tend to force a behavioral response from others in the organization. These directors appear to be well aware Of the weaknesses in the hospital's formal hierarchy of authority and tend to compensate for this by maintaining extensive personnel files. This strategy is briefly illustrated in the following director's statement: Ever since I came here I've been building my files. We have files on grievances, turnover, wage requests --files on everything we can get information on. If I want to do something I can lay out my idea in dollars and cents and in good personnel practices-- I can raise a lot of personnel questions that de- partments may find hard to answer. The success of the basic strategy of gradually and in- formally introducing personnel changes into the larger hospital environment can be observed in another director's statement: I have started an increment plan, man—power budgets and periodic wage and salary studies in the last year. I quietly do them and gradually change procedures, and once it is operating I will get approval when it's required or a change in wages when they are called for. I have just started exit interviews. You just do it. You collect your evidence. You decide what should be done, and then do it. 1A0 These directors implement changes directly and personally, rather than implementing them from their position and through the formal hierarchy of authority. The second set of Observations is the behavior of occupationally oriented directors in administrative hospi- tals. These directors respect the formal hierarchy of authority within the hospital, and they initiate and accomplish changes in personnel practices through the formal system. The change process was typically stated by one director who said: The growth of personnel work has been tremendous. I have been able to do this because top management has done their part in directing the departments to accept and assist us in making these changes successful. Once a change that we prOpose has been accepted my responsibilities are essentially edu- cational and, of course, we make it part of our own routine here in the office. I am forwarding im- provements and additions to present programs to tOp management regularly--I think that personnel changes here are now accepted as part of the normal routine. Though changes in personnel practices and ac- tivities are processed through the hospital's central authority system, these directors attempt to influence the circumstances within that system in order to improve the sales of their ideas and to accomplish their ob- jectives. This is evidenced in the following case: For example policy revision. The administrator and department heads are reluctant to change policy be- cause it meant reconsidering the entire employee manual, and some policies only really affect certain employees and it's hard to develop an interest in changing the manual for them. SO in redesigning the orientation kit I broke up the policy manual lAl into a number of little books explaining the hospital, department, and employee rights and duties for vari- ous things. This was approved because it helps us get our message over better, and it does, but it also lets me now limit policy revision to one of these little books at a time and this is much easier to sell. The occupationally oriented directors in these hospitals accomplish their occupational Objectives through positive behavior within the established authority system. The first expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different than that of their counterparts in administrative hospitals. The directors in profession- al hospitals implement change informally, and by pressure generated through informally collected evidence. The directors in administrative hospitals, on the other hand, implement change formally and by "sales" made possible by other formal activities. Therefore, these behavior differences meet the expectations for this work-related factor. A third set of Observations is the behavior of organizationally oriented directors in professional hospi- tals. These directors appear to have difficulty meeting the demands of personnel changes within the hospital. When personnel changes are imposed on the director and his department, they tend to increase the director's feelings of ambiguity and confusion. These directors, who are dependent on the hierarchy of authority for 1A2 directions, are unable to use the authority hierarchy to implement change, because of the duality of authority systems in the hospital. One director, who has recently experienced a number of minor changes, reveals his frus- trations as caused by a lack of accord between his su- perior, the administrator, and the head of a major medi- cal department. In referring to this department head, he said: He wants me to be so subordinate that I'm nothing more than a pawn in his hands. This is fine. They must specify where this is. Another director explained what is commonly felt by these directors to be the source of their ambiguity and confusion, particularly under changing conditions. He stated: A major problem I have is a specific place outlined by the administrator of what my duties and re- sponsibilities are and communicating this to all re- sponsible peOple. I think before I can do anything new there has to be an understanding relative to where I fit into the administrative picture. The behavior of these directors for this work— related factor can best be described as non-behavior or avoidance behavior through inactivity. Evidence of this can be observed in the following brief case: The administrator suggested that we should have an employee handbook over a year ago. Well the ad- ministrator hasn't really taken a serious interest in it and nothing has been done so far. 1A3 These directors, even under suggestion from their superior, do not initiate change or initiate activities to prepare for change. The second expectation was that the behavior of organizationally oriented directors in professional hospi- tals would be different than the behavior of occupationally oriented directors in these hospitals. These occupation- ally oriented directors compensate for weaknesses in the formal hierarchy of authority by personally and informally implementing the changes that they feel are necessary for their personnel program. The organizationally oriented directors, on the other hand, are unable to undertake new activities without an accepted designation of their po- sition within the hierarchy of authority. Therefore, these behavior differences meet the expectations for this work-related factor. The final set of Observations is the behavior of organizationally oriented directors in administrative hospitals. These directors, who tend to be receivers Of change suggestions rather than change-agents, accept and implement change suggestions submitted to them by their superior, but tend to resist suggestions stemming from management peers. The following case illustrates this point: When I was on vacation, the department heads got together and agreed that we should have a newspaper in the hospital. . . . Well one was started and from 1AA the very beginning I told them that I didn't want this responsibility. Well you know who finally had to get the paper out--I did. We've had three editions and they were very well received. We had a name contest for the paper and the employees got very excited about it. --Now I haven't had time to get a paper out in the last three months. There has just been too much work to do and my girls have been very busy. I hear that the employees have been asking about it and miss it. I feel bad about that but my department's work just has to come first. In the beginning I told the department heads that I was not going to assume re- sponsibility for it, and I can't. They are just going to have to make some other provisions for it if they want a paper. This case points out the strong task identifi- cation exhibited in the behavior of these directors. The directors tend to protect their current activities and under work pressure will drop activities that are not part of the procedural system of the hospital. The secondary effects of their behavior, such as the effects on employee morale and personnel management in the hospi- tal, are not given serious consideration in the decision process of these directors. Change tends to be viewed by these directors in terms of its effects on work tasks, and the acceptance Of task assignments tend to be re- stricted by these directors to those that haVe been as- signed by their superiors. The third expectation that the behavior of organi- zationally oriented directors in professional hospitals is different than the behavior of their counterparts in administrative hospitals. The directors in professional hospitals tend to avoid changes in activities and 1A5 practices, while those in administrative hospitals accept Changes stemming from the hierarchy of authority and in- corporate them into their task procedures. Therefore, these behavior differences meet the expectations for this work-related factor. A fourth and final expectation is that the be- havior of occupationally oriented directors in adminis- trative hospitals is different than the behavior of organizationally oriented directors in these hospitals. The occupationally oriented directors use the hospital's authority system a means of introducing and implementing personnel Changes of their own design, while the organi— zationally oriented directors use the authority system as a means of filtering changes designed by others. There- fore, these behavior differences meet the expectations for this work-related factor. Behavior and Competition The first set of observations is the behavior of occupationally oriented directors in professional hospi- tals. The response of these directors to employment strategy and to the tight labor market in a Metropolitan City has been to reduce the hospital's demand for labor by reducing its labor turnover. Evidence of this approach can be Observed in the following director's statement: 1A6 In today's market we can't afford the high turnover that the hospital has grown accustomed to. We can fill a lot of jobs from within--with people who normally would have quit. I have a girl with a health problem. The doctor says she's subject to tension and feels closeness working in the elevators. We heard about her and now have her up for considera- tion in another department. You know if you don't pay close attention you can lose a lot of people. Another case reported by one of these directors illustrates the general feeling of independence and the general disregard for existing hospital norms and practices by these directors. He stated: I have been doing some exit interviews and reviewing discharges. This has turned out to be a good source of labor for me. I've rehired some people for other departments. I got yakked at this morning, because I rehired a girl the other day. I didn't hire her-- I merely coordinated her referral. The other person did the hiring. She's very presentable, she talked with good logic, and her department had given her a wage increase not too long ago, which white papers her discharge. The department that hired her was short staffed and I explained the situation to the department head and asked if he would like to speak with her in my Office. He said, "yes," so I left the office and about 15 minutes later he said, "I'll take her." These directors again reflect their direct, personal approach to personnel activities. When their behavior under competitive situations is compared with their behavior under change conditions we can Observe a behavior pattern starting that indicates that these di- rectors consider their departments as quasi-independent departments in a loose confederation of occupational specializations, and that their jurisdictional boundaries are considered to be occupationally derived. 1A7 A second set of Observations is the behavior of occupationally oriented directors in administrative hospi- tals. The response of these directors to the competitive climate in the hospital's labor market has been to pre- pare the hospital tO compete with all other potential employers. These directors hOpe to improve their competi- tive positions by improving the working conditions within the hospital as well as the wages and employee benefits the hospital can provide. These activities of designing and implementing a superior "personnel package" for the employee were illustrated by a director, who stated: I have worked hard with the administrator and the department heads explaining to them the need for improved personnel management efforts as their part so that we might compete better as a hospital. I have spent hours explaining to them that every hospital can offer wages and benefits, but only well managed departments can offer superior working re- lationships-—that we can best compete by Offering a superior personnel package. One of the directors initiated a wage information sharing plan, which a number of hospitals have agreed to participate in, as a means of reducing the emphasis on wages in the labor market. He stated: This wage survey is perpetual among the participating hospitals. What I hope will happen is that with full knowledge of wages there will be a greater tendency to standardize them and to have fewer arbitrary in- creases that have been so frequent lately. This survey can only help the participating hospitals-- spiraling wages hurt everyone. 1A8 Another director illustrates a second activity area of these directors in preparing their hospitals to meet the current competitive situation. 'He stated: That's a nice word. Men. Why do you have men? Oh, janitor, eh. Everytime I see an old movie it seems to me that, who do I see scrubbing the floors--two Old scrub women. I've never seen a man scrub a floor in the movies. I wonder is it possible that we could use women. I could get women—-so we are now using women. This is what we are doing, men, throw them out. We don't need men. The law says that women can't lift over 35 pounds. Fine, we'll break the job down so that she'll never lift more than 35 pounds. Industry doesn't take women and there are a lot more women available at the lower strata. --We employ them. You see, I have to educate the supervisors to think of objectives and resources and not of jobs and people they're used to having. Personnel adminis- tration is really an educational program. These directors tend to View requests for labor as Opportunities to explore labor alternatives and alternative labor costs within the hospital. These di— rectors tend to direct the employing supervisors toward the available labor supply and toward lower labor costs. The directors accept and act within the formal authority system within the hospital. When the director's behavior in the competitive situation is compared with his behavior under change conditions, we can see a behavior pattern emerging. These directors, rather than being responsive to the authority system, tend to employ the system in seeking occupational objectives, and they tend, by posing personnel suggestions, questions and problems to members of the authority system, to expand their jurisdictional boundaries to cover all areas of interest to them. 1A9 The first expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different than that of their counterparts in administrative hospitals. The directors in the pro- fessional hospitals reflect in their behavior the re- stricted employment activities of the personnel depart- ments in this class of hospital. These directors tend to exploit the acceptance of their office as a geographic referral center for personnel applicants. Using their Office as a referral center for current employees, they attempt to meet competitive labor market pressures by reducing labor turnover. The directors in administrative hospitals attempt to meet these labor market pressures by improving the hospital's total personnel program, so that they can attract the quality of labor that they desire, at a cost in keeping with its contribution to hospital objectives. The directors in professional hospitals Operate directly and personally, while their counterparts Operate through the established hierarchy of authority and accomplish their Objectives through others. There- fore these behavior differences meet our expectations for this work—related factor. A third set of observations is the behavior of organizationally oriented directors in professional hospi- tals. The response of these directors to the tight labor market in a Metropolitan City has been one of caution in 150 the use of their Office within the hospital. This can be clearly seen in the following case: I won't fight nursing if they want to continue to do all of their own personnel work, because I realize that the prestige of the nurse walking into a job is a fact in whether or not she accepts the job with us or someone else. If she feels insulted that she must come down to the personnel department to fill out forms here and she walks out and we lose her--I would feel badly. In today's market you must do everything you can to get people. These directors tend to behave in such a way that employment difficulties cannot be directly charged to their department. Another director expressed this senti- ment in stating: I have told the department heads and supervisors that if they feel that there is a chance of losing an applicant by sending him down to this office that they should go ahead and do all the employment pro- cedures. These directors, though they tend to withdraw from many activities under stress, feel that they are particularly necessary to the hospital under these com- petitive conditions. This is evidenced in the following statement made by one of the directors: We have ads running in nine local papers and both major papers this week alone. They need the personnel department to take the influx of all these people who answer the ads. If there wasn't a personnel depart- ment the departments would have difficulty working with all these people calling in and wandering around. When the behavior of these directors under com- petitive conditions is compared to their behavior under change situations, we can see a behavior pattern emerging. These directors, in feeling the absence of a protecting 151 authority system, tend to withdraw from encounters and situations that involve members of the hospital organi- zation not similarly dependent on the administrator. A second expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different than the behavior of organi- zationally oriented directors in these hospitals. Though these directors are subject to similar environmental circumstances within the hospital, the attitudes of these directors tend to lead them to Opposing response patterns when subject to pressures raised by competition. The occupationally oriented directors interpret the problems posed to the hospital by a shortage of labor as an oppor- tunity to increase their activities and their zone of influence within the hospital and, as a consequence of this, have taken direct actions to reduce labor turnover by exploiting their referral services. The organization- ally oriented directors On the other hand interpret the competitive climate as a threat to their security and, as a consequence of this, tend to reduce their activities and their zone of influence to a level they can sustain and protect with the limited authority afforded them. Therefore, these behavior differences meet expectations for this work-related factor. The final set of observations for this work- related factor is the behavior of organizationally 152 oriented directors in administrative hospitals. The re- sponse of these directors to pressures caused by the tight labor market has been to insure that their hospi— tal's wage and benefit package is on an equal footing with those of other hospitals. Evidence of this can be observed in the following director's statement: Labor has been getting tighter and tighter. We have to constantly check what other hospitals are offering their employees, so we won't be placed at a dis- advantage. I have COpies of all the hospitals' em- ployee handbooks and we review any changes that they make, to make sure that we are current and that our employees receive what they could obtain elsewhere. We have to be careful that we stay in step with other hospitals. These directors indicate that their primary con- cern is that they don't want to be placed at a competitive disadvantage with other hospitals. Internal pressures caused by a shortage of labor has resulted in the person- nel department making adjustments to assist the operating departments in covering unfilled positions. This common practice was illustrated by one director, who said: I can't get registered nurses but I can get practi- cals. To supplement the work force I will give them two practicals for a registered nurse, as I will give them two aides for a practical nurse. I can make these decisions. The response of these directors to competitive pressure has been one of insuring equality and accommo- dation. When this behavior is compared with their be- havior under change conditions, we can see a behavior pattern emerging. These directors tend to treat their 153 Offices as assigned administrative-task centers, and as a consequence of this they tend to employ the hospital's authority system to meet administrative objectives, and they tend to restrict their jurisdiction to areas where they can exercise task authority. As a result of this pattern they tend to insure compliance with industry standards of wages and benefits, and to take direct action to accommodate for labor shortages within the operating departments. The third expectation was that the behavior of organizationally oriented directors in professional hospi- tals would be different than that of their counterparts in administrative hospitals. The possession of task au- thority in administrative hospitals permits the organi- zationally oriented director to respond to competitive induced pressures by taking actions to insure the equality of the hospital's competitive position and to compensate for labor shortages. In the professional hospital these directors are unable to exercise full task authority, and when subject to competitive pressures tend to surrender their activities to those whose task related authority appears superior to their own. Therefore, these behavior differences meet the expectations for this work—related factor. A fourth and final expectation was that the behavior of occupationally oriented directors in 15A administrative hospitals would be different than that of organizationally oriented directors in these hospitals. The difference in attitudes between these director types is reflected in their behavior under competitive pressures. The occupationally oriented directors seek to compete by Offering a superior "employee package," while the organi- zationally oriented directors seek competitive equality. The occupationally oriented directors respond to labor shortages by considering the redesigning of work as- signments to match work objectives with alternative lower labor costs, while the organizationally oriented directors respond by accepting current work assignments and, there- fore, matching work objectives with alternative higher labor cost under conditions of short labor supply. There- fore, these behavior differences meet expectations for this work-related attitude. Behavior and Authority The first set of observations for this work— related factor is the behavior of occupationally oriented directors in professional hospitals. These directors tend to establish the authority that they need and desire through their own efforts and, as a consequence of this, there is a tendency by others in the hospital to resist these efforts. This situation is reflected in the following case: 155 Now this department head I have got to watch. I don't trust him. I suspect that he's possibly gotten word to the other guys and perhaps they don't want this department to go as well—-they don't want me to show-up anybody. He burned me once, but I'll win him over—-he doesn't realize it yet, but he needs a good personnel department. He will. Another instance reported demonstrates the basic behavior pattern of these directors of establishing and sustaining their authority through direct positive acts. Some departments keep putting in requests for changes on dates not corresponding to payroll dates. This is how they used to let us know how important they were, but for me it just created work for my girls. SO, I printed calendars with payroll dates marked on them and passed them out. When they challenged this ex- pense I proved to everyone involved that the calen— dars cost less than the overtime that some department heads were causing in my department-—I just don't seem to have this problem anymore. These directors rely on their evidence and the justice of their positions, rather than the hierarchy Of authority, in acquiring and maintaining the authority that their competency requires. The relative feeling of independence by these directors from hospital authority systems, and their strong identification with occupational purposes was again in evidence in the behavior of these directors. A second set of Observations is the behavior of occupationally oriented directors in administrative hospi- tals. These directors tend to develOp and maintain their authority by emphasizing their status as competent person— nel experts. As one director expressed it: 156 The very first thing you do is establish your status. This is how you avoid problems. You do this by creating an illusion--let's say, Of being a specialist, an authority. Sometimes you have to analyze your Oppo- sition to see what you can do for them to win them over. --It appears to the department heads here that all the wonderful things they have received were pio- neered by me——another thing, if you write a policy, teach it and it's effective, it's hard to knock the teacher. Another director in expressing this sentiment re- veals the basic behavior Objective for this authority factor of these directors. He stated: The peOple here know that I know what I am talking about. They have been very reasonable in accepting reason. I realize that I am only a staff person, but the "line" aspects of staff keep me very busy. These directors tend to derive their status from their occupation experiences and knowledge, and they tend to reinforce and implement their status.within the hospi- tal's organizational framework. When their authority be- havior is related to their behavior under the earlier work-related factors, the emerging behavior pattern of hospital administrative influence by the director becomes clearer. The evolving pattern suggests that the director's behavior objectives tend toward influencing all adminis- trative activities to use personnel occupation norms and values in their performance. A first expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different than that of their counterparts in administrative hospitals. The directors in professional 157 hospitals concentrate their efforts on developing au- thority rights for their department, while their counter- parts in administrative hospitals concentrate their efforts on developing personal influence in the established au— thority system. The directors in professional hospitals tend to compete with the operating departments for their authority, while those in administrative hospitals tend to occupationally impress operating department heads to obtain their authority. Therefore, these behavioral differences meet the expectations for this work-related factor. A third set of observations is the behavior of organizationally oriented directors in professional hospi— tals. These directors exhibit extremely weak authority behavior in the personnel area. The behavior of these directors was well expressed by one director who said: "I don't rock the boat." These directors who are unable to establish a personnel identity within the hospitals, beyond their records activities, tend to exercise be- havior of avoiding conflicts and the testing of their authority. This is demonstrated in the following case: The employee has no one to come to and ask a question without going directly to their department head. This is both good and bad. Depends on how you want to look at the particular problem. They (the employee) now pick up the phone and call me direct without going through their department head, but how am I going to tell this to the department head? --This last call-- the employee wanted to know about sick time pay. Now, let's put it this way, if I work too hard on the 158 employee's request it undermines the supervisory capacity of the department head, or if I inform the department head or the supervisor that the employee has questions then it undermines the faith the em- ployee has to discuss the case with me. SO I take the tack that if the employee calls me I will direct them to the prOper way of conducting this business by suggesting they go through their supervisor. It's like walking on eggs as you're well aware of. These directors, again under this factor, avoid encounters with other organization members because of be- havior insecurity. These directors who are dependent on a hierarchy of authority are apparently unable to act without its direct support for their behavior. The simple act of giving an established answer to a policy question is "like walking on eggs" for these directors because it is not clear to them that their authority to perform this task has been granted and accepted as legitimate by others in the organization. The second expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different from the behavior of organi- zationally oriented directors in these hospitals. Though these directors are subject to similar organizational en- vironment the difference in their occupational attitudes has a marked affect on their authority behavior. The oc- cupationally oriented director has an alternative authority source, his occupation, that is not recognized by organi— zationally oriented directors and the use of this alter- native source provides these directors with a basis for 159 direct action and a means of determining this authority. The organizationally oriented directors appear unable to exercise authority in the personnel area. Therefore, these behavior differences meet the expectations for this work—related factor. A fourth and final set of Observations is the be- havior of organizationally oriented directors in adminis— trative hospitals. These directors tend to View their authority as stemming from their position in the organi- zation and in particular from the tasks they have been assigned. Their behavior in the use of their authority can be Observed in the following case: The administrator asked me to head a committee to rewrite our policy book. I talked with her and found out what kind of changes we should make and then I called the committee (department heads) together and I said: "We will rewrite the first six pages of the old book and you have one week to work on it." A few members objected but I explained to them what the administrator wanted and the need to write quickly and well so that we could give it to the employees. The administrative—task orientation of these di- rectors produces authority behavior centered in the task Objective. These directors, in establishing their au- thority within the hospital, do so by explaining its need to fulfill assigned tasks. The authority behavior of these directors in areas not directly covered by task au- thority tends to be defensive. This is evidenced in the following director's statement: 160 When I make a suggestion to a department head and he isn't very receptive I tell him that if you want to do it, fine, if you don't that's OK too, but let's record that the suggestion was made and you turned it down. Now if I agree with a person when they turn a suggestion down--no record is necessary. But, if in the future someone complains, I want the record to show that we did suggest changes. These directors exercise the assigned authority of their positions and tend to protect the position and use of their authority through the department's record system. When this authority behavior is compared with the behavior under the earlier described factors it became quite clear that the underlying behavior pattern of these directors is based on their assigned tasks rather than their functional specialiZations. The be- havioral efforts of these directors appear to be directed toward the successful completion of the tasks, and not the overall personnel product of which these tasks are a part. The third expectation was that the behavior of organizationally oriented directors in.professional hospi- tals would be different from that of their counterparts in administrative.hospitals. The directors in adminis- trative hospitals exercise with confidence a wide range of activities derived from their tasks, and as a conse- quence exercise confidently the authority inherent in their position. .The directors in professional hospitals do not exercise the authority inherent in their positions because Of insecurities about the acceptance of their 161 task assignments as centralized personnel tasks by other members of the organization. Therefore, this behavior difference meets the expectations for this work-related factor. A fourth and final expectation was that the be- havior of occupationally oriented directors in adminis- trative hospitals would be different from that of organi- zationally oriented directors in these hospitals. The occupationally oriented directors tend to establish their authority through occupational status, while the organi- zationally oriented directors tend to establish theirs through task-status. The occupationally oriented di- rectors tend to use their authority to direct the person- nel activities of operating departments, while the organi- zationally oriented directors tend to use their authority to suggest changes in the personnel activities of the Operating departments. Therefore, these behavioral differ- ences meet our expectations for this work-related factor. Behavior and Service The first set of observations for this work- related factor is the behavior of occupationally oriented directors in professional hospitals. These directors tend to interpret their service contribution to the hospi- tal and its members in terms Of objectives that best meet the needs of both the hospital and the particular member 162 being served. An example of this can be Observed in the following case: There are some areas where I don't feel there really is a need for more help if the department head were doing his job. If I really don't think there is a need to employ another person, I just say I'm looking and I'll let you know if I find someone. I think that if I can force department heads to make some other arrangements we can help the departments help the hospital in reducing its payroll costs. This is part of the job. This independent interpretation of needs, and selection of objectives based on occupational norms and values tends to be present in all the service activities by these directors. Another director in discussing a recent experience reveals the typical service behavior of these directors. He stated: I have a department head who wanted to interview 20 people for a job. She didn't say this, but this has been our experience. She was losing a supervisor-- going to retire and so we advertized. ‘We got a line on a pretty good girl. I said hold it. We set up a few things. We stalled setting up the interview and conveyed the impression it would take a long time to find someone. Then we set up an interview for her and, after the interview, we called her and asked what She thought of the applicant. She asked if any- one else had come in and we said no. So, she de- cided to bring this one in. These directors, in concentrating on needs and objectives, tend not to concern themselves with the qualities of the means that they employ. When the be- havior of these directors is compared across the work- related factors, the behavior pattern that emerges appears to indicate that these directors tend to act as resident occupational specialists rather than as members of the 163 hospital's authority system. These directors tend to, directly and independently, substitute occupational norms and values for those of the hospital in their behavioral experience within the hospital. A second set of Observations is the occupationally oriented directors in administrative hospitals. These directors tend to devote most of their service behavior to supervisory training and development activities. It is through the supervisors that these directors hope to best serve the hospital's personnel needs. As one di- rector stated: Supervisory training must be considered in every action taken by the department. Hospital super- visors are far behind those in other industries in their development, and every contact that I make I view as an opportunity to train. Another director stated: The only way that I could make any headway in our general personnel programs was to spend a great deal of my time working with the supervisors to train them in good personnel practices. The importance of these services was expressed by still another director, who stated: The routine things that the personnel department performs just can't meet today's problems. We need better supervisor-subordinate relations; we need lower personnel costs; we need a dozen changes in hospital practices. These can only be done through the super- visors and any good personnel man in a hospital will tell you that he spends a lot of time here. These directors interpret that their client's major needs do not revolve around personnel tasks, but are centered in the personnel management activities 16A performed by supervisors and department heads within the hospital. When the behavior of these directors is com- pared across the work-related factors, the behavior pattern that emerges appears to indicate that these di- rectors tend to act as a functional specialist within the hospital organization. The behavior of these directors tends toward teaching other members of the organization to accept personnel norms and values as a basis for their operating practices, and, in order to achieve their ob- jectives, they tend to use the established authority system as a convenient means rather than accepting it as a restricting factor on their own behavior. The first expectation was that the behavior Of occupationally oriented directors in professional hospi- tals would be different than that of their counterparts in administrative hospitals. Though all occupationally oriented directors recognize a responsibility Of identify- ing hospital needs and of implementing services to meet them, there is a difference in behavioral paths taken be- cause Of the differences in authority structures between hospital types. In the professional hospital these di- rectors act directly and independently to influence super- visor behavior through their use and performance of person- nel department tasks. In the administrative hospital the directors rely on the authority structure and their ac- ceptance as personnel directors to contact, influence and 165 teach supervisors in order to improve their personnel be- havior. Therefore, this behavioral difference meets the expectations for this work—related factor. A third set of observations is the behavior of organizationally oriented directors in professional hospi- tals. These directors who have experienced behavioral difficulties in the three earlier factors are able to perform some services for the hospital. 'These services tend to be related to the public relations spectrum of the hospital, rather than to personnel administration. The behavior of these directors indicates a willingness on their part to absorb activities that will not bring them into conflict with the dual authority system in *these hospitals. Evidence of this can be Observed in the following director's statement: Now I started handling patient complaints because there really isn't anyone else that would do it. Every once in a while we get a complaint that a nurse was very abrupt with a patient or told them off. I don't doubt that it happened. I just talk to the nurse and try and get her to see the point of view of the patient. In the handling of these complaints, the di— rectors do not attempt to correct the situation or even to bring pressure to bear on Operating department's be— havior, but tend to restrict their behavior to the task of letting the offending employee know that a complaint was received. The process of taking on additional ac- tivities was typically illustrated by another director, who stated: lllll ‘I‘ I. E l 166. I have been handling the patient relations activities, you know the complaints. We had a volunteer who did this and when she left I took it over, and another thing I also coordinate the ladies auxiliary. These women do a lot Of work for the hospital and it is important that a hospital executive recognize them and work with them. I have been doing this ever since the wife of a member of our medical staff decided to give it up. The apparent behavior of these directors is an effort to take on these activities in order to develOp a full time position in the hospital. With the director feeling unable to perform many personnel tasks as was evidenced in the first three factors, there is a need on his part to add work that he can perform in order to justify his existance in the organization. AS'a person- nel director the basic behavior pattern revealed by these work-related factors indicates that these directors are unable to perform most personnel activities because their task authority is not widely accepted in these dual- hierarchy organizations. The second expectation was that the behavior of occupationally oriented directors in professional hospi- tals would be different than that of organizationally oriented directors in these hospitals. The occupationally oriented directors do perform personnel services within these hospitals by Operating directly and independently of established hospital practices, norms and values. The organizationally oriented director is only able to provide service to the hospital by adding activities not directly 167 related to personnel administration. Therefore, this be- havior difference meets the expectations for this work- related factor. A fourth and final Observation is the behavior of organizationally oriented directors in administrative hospitals. These directors tend to offer personal rather than personnel services to organization members. Evidence of this can be Observed in the following case: I have real sorrow for some of our people who have been garnished and have their backs to the wall. I will go to bat for them and it might take me two days to get it cleared up. Here's one, this girl had really had it and this credit company was really pushing her. I talked to them and told them if this girl goes down and jumps off the bridge you have your- self to account for this because you are pushing her toward it. They worked out an agreement with me. Now this took a lot of my time. The girl was happy and a good worker. Another case typical of these directors: This office is considered by many department heads as an office without ears. All they want is some- body to talk too and to relax. They don't expect anything. Now this is poor management on my part. I could probably accomplish more in the day-time if I listened less. These directors, in considering their major service contribution to be the maintenance of employee morale, tend to approach this task as they have the tasks in the preceding three factors, on a unitary basis. When the behavior of these directors is compared across the four job—related factors, the behavior pattern that emerges indicates a high task commitment by these 168 directors who tend to act as administrative-task special- ists rather than personnel functional specialists. A third expectation was that the behavior of organizationally oriented directors in professional hospi- tals would be different from that of the counterparts in administrative hospitals. The directors in professional hospitals elect to perform non—personnel service tasks which tend to assist the administrator in meeting the public relations duties of his Office, while the directors in administrative hospitals perform personnel service tasks, which tend to meet the morale needs of individuals within the hospital. Therefore, these behavioral differ- ences meet the expectations for this work—related factor. A fourth and final expectation was that the be- havior of occupationally oriented directors in adminis- trative hospitals would be different than that of organi- zationally oriented directors in these hospitals. The occupationally oriented directors invest their service energies in attempting to influence the personnel climate within the hospital, while the organizationally oriented directors tend to direct their energies toward meeting the morale needs of individuals within the hospital. Therefore, these behavioral differences meet the expec- tations for this work-related factor. 169 Behavior and Directors In confirming the hypothesis we revealed that among the seventeen hospital personnel directors studied, four role—behavior patterns exist. The frequency of these patterns for this sample is indicated in Table A. The favorable and unfavorable consequences of these patterns on hospital operating practices will now be briefly examined. TABLE A.--Location of Personnel Directors by Orientation Characterization Location of directors Occupation Organization ' Orientation Orientation Professional Hospitals 2 A Administrative Hospitals A 7 The most frequently exhibited role-behavior pattern was that Of the organizationally oriented di- rectors in administrative hospitals. These directors, as was indicated in the examination Of work—related factors, can be best characterized as "administrative task special- list-personnel." The most favorable feature of this pattern is that the director's Operate within the es- tablished authority network, respect the hospital's norms and values, and concentrate their energies on achieving the assigned tasks. The most unfavorable features of this 170 pattern are that task Objectives tend to supersede larger personnel objectives, that the hospital's net afforded a functional specialist, and that personnel practices and activities, once established, are difficult to change. Another role behavior pattern was that of the occupationally oriented directors in administrative hospi- tals. These directors can best be characterized as "personnel functional specialist." The most favorable features of this pattern are that the personnel function tends to be externally competitive and internally de- velOped, that order and direction is brought to bear on personnel management activities throughout the hospital, and that improvements in personnel programs are part of the normal routine. The least favorable features of this pattern are that there is a tendency to superimpose personnel occupation norms and values over these of the hospital and other occupations and professions, that the hospital's established authority system is not accepted as a directing and allocating instrument, and that there is a tendency by these directors to attempt to control the hospital's human resources. A third behavior pattern was that of the organi- zationally oriented directors in professional hospitals. These directors can best be characterized as "adminis— trative assistants-personnel." The most favorable features of this pattern are that records are centrally 171 available and that necessary public relations activities not otherwise provided for by this class of hospital are achieved. The most unfavorable feature of this pattern is that there are not any meaningful personnel functions or activities centralized in the personnel Office. The least frequently exhibited pattern was of the occupationally oriented director in professional hospitals. These directors are best characterized as "resident personnel specialist." The most favorable feature of this pattern is the independent ability of these directors to centrally direct some personnel ac- tivities. 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