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T he id en tification o f co m p eten cies for hospice ad m in istrators
in M ich igan , em p h asizin g an organ ization al life cycle
a d m in istra tio n m od el
Olson, Sharon Lee, Ph.D.
Michigan State University, 1988

UMI

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THE IDENTIFICATION OF COMPETENCIES FOR HOSPICE ADMINISTRATORS
IN MICHIGAN, EMPHASIZING AN ORGANIZATIONAL
LIFE CYCLE ADMINISTRATION MODEL
By
Sharon Lee Olson

A DISSERTATION
Submitted to
Michigan S t a t e U n i v e r s i t y
in p a r t i a l f u l f i l l m e n t o f t h e req uirem en ts
f o r t h e degree o f
DOCTOR OF PHILOSOPHY
Department o f Family and Child Ecology
1988

ABSTRACT
THE IDENTIFICATION OF COMPETENCIES FOR HOSPICE ADMINISTRATORS
IN MICHIGAN, EMPHASIZING AN ORGANIZATIONAL
LIFE CYCLE ADMINISTRATION MODEL
By
Sharon Lee Olson

The

purpose

of

this

Supplementary competencies

study
as

was

rated

to

identify

by hospice

Essential

and

adm inistrators

in

Michigan using a f o u r - s t a g e hospice l i f e c y c le a d m i n i s t r a t i o n model.
The s t u d y

f o c u s e d on f i v e

m a jo r o b j e c t i v e s :

s e l e c t i v e d e m o g r a p h i c and o p i n i o n d a t a ,
functions
(c)

to

(b)

(a)
to

to

compile

id en tify

what

t h e s e a d m i n i s t r a t o r s were performing a n d /o r d e l e g a t i n g ,

identify

their

p e r c e p t i o n s o f E s s e n ti a l

and Supplementary

competencies t h a t met consensus under f i v e a d m i n i s t r a t i v e s e c t i o n s ,
(d)

to

identify

demographic

factors

that

affected

the

reported

e s s e n t i a l i t y o f competencies, and (e) t o i d e n t i f y how t h e r e p o r t e d
essen tiality

and/or

delegation

organizational l i f e cycle stages.
in c lu d in g

a two-round

Delphi

of

competencies

varies

with

A f o u r - p h a s e methodology was used

technique.

The

survey

instrum en t

c o n ta in ed 17 demographic and opinion q u e s ti o n s and 201 competency
s ta t e m e n t s under f i v e major competency s e c t i o n s .

These s e c t i o n s

were a l s o grouped ac co rding t o a d m i n i s t r a t i v e f u n c t i o n s o f Planning,
Organizing, D i r e c t i n g , and C o n t r o l l i n g .

Sharon Lee Olson
S e v e n ty - e i g h t h ospice a d m i n i s t r a t o r s were surveyed.

Round I

resp ons e r a t e was 65% ( 5 1 ) , and Round I I was 63% (4 9).
S ignificant

demographic

findings

incl uded :

Age,

education,

hospice a d m i n i s t r a t i v e e x p e r i e n c e , and s a l a r y were h i g h l y v a r i a b l e .
Michigan hospice a d m i n i s t r a t o r s were p r i m a r i l y female, middle aged,
and working f u l l time with a d d i t i o n a l r o l e r e s p o n s i b i l i t i e s .

T h e ir

ho spice s e r v i c e ar ea p o p u la tio n on average was l e s s th a n 50,000, and
th ey served predominantly white p a t i e n t s / f a m i l i e s .

In Michigan, 88%

(43) o f t h e hospice a d m i n i s t r a t o r s endorsed a need f o r a hospice
a d m i n i s t r a t i o n c u r ri culu m .
O v e r a l l , 132 E s s e n t i a l
identified.

Of t h e s e ,

highest rated .
relations

and 69 Supplementary competencies were

37 reached

consensus

and were

also

the

Consensus items c l u s t e r e d in community and p u b l i c

and q u a l i t y a s s u r a n c e .

Supplementary competencies were

d e l e g a t e d more than t h e E s s e n t i a l ones, and d e l e g a t i o n oc curre d most
f r e q u e n t l y in p a t i e n t and fa m il y r e l a t i o n s .
S i g n i f i c a n t hospice l i f e c y c le f i n d i n g s were:

(a) In Michigan

f o u r d e f i n a b l e s ta g e s o f hospice program development were e v i d e n t ,
with n o t a b l e i n c r e a s e s in E s s e n t i a l competencies and d e l e g a t i o n from
Stage I through Stage IV; (b) 63% (32) o f t h e hos pic e s in t h i s study
were i d e n t i f i e d in Stage I I ;

(c)

a d m i n i s t r a t i v e e d u c a ti o n a l

needs

d i f f e r e d by s ta g e o f hosp ice development; and (d) t h e C o n t r o l l i n g
f u n c t io n was n o t s i g n i f i c a n t a c r o s s a l l s t a g e s o f program d e v e lo p ­
ment.

To "Schneids"

But a good l e a d e r , who t a l k s l i t t l e , when h i s work i s done,
h i s aim f u l f i l l e d , th ey w i l l say, "we did t h i s o u r s e l v e s . "
Lao Tzu

iv

ACKNOWLEDGMENTS

I would l i k e
chairperson,

Dr.

to

acknowledge th e

Norma

B obbitt.

s upport and p a t i e n c e o f my
Her

continued

e m p h a s is

on

p r o f e s s i o n a l i s m and e x c e l l e n c e guided my r e s e a r c h in a meaningful
and orga nize d manner.

Also,

I would l i k e t o acknowledge and thank

Drs. Don Melcer, Rosemary Walker, B i l l Hinds, and Bob G r i f f o r e .

My

a p p r e c i a t i o n i s a l s o extended t o t h e Department o f Family and Child
Ecology

for

f e llo w s h ip

s up port

and

e d u c a t io n a l g o a l s .

v

encouragement

in

meeting

my

TABLE OF CONTENTS
Page
LIST OF T A B L E S ................................................................................................

ix

LIST OF FIGURES................................................................................................

xi

Chapter
I.

II.

...................................................................................

1

Background o f t h e Problem .....................................................
I ss u es o f P r o f e s s i o n a l i z a t i o n ........................................
F i s c a l Iss ues ..........................................................................
Q u a l i t y - o f - C a r e I s s u e s .....................................................
S t a t e Lice nsure I s s u e s . ................................................
Statement o f th e Problem .....................................................
Purpose o f th e Study .............................................................
Research Questions ..................................................................
T h e o r e t i c a l D e f i n i t i o n s .........................................................
Conceptual Framework .............................................................
Basic Assumptions f o r th e Study ........................................
L im ita tio n s o f t h e Study .....................................................
Summary............................................................................................

3
4
6
7
8
9
11
13
17
18
24
24
25

INTRODUCTION

REVIEW OF LITERATURE

.................................................................

26

Hospice Overview ......................................................................
Hospice A d m i n i s tr a tiv e Components ...................................
S t a f f i n g and Personnel Management ...............................
P a t i e n t arid Family R e l a t i o n s ........................................
Community/Public R e l a tio n s ............................................
F is cal Management ..................................................................
Q u a lit y Assurance ..................................................................
A d m in i s tr a tiv e Theory .............................................................
A d m in is tr a t iv e S t r a t e g i e s ................................................
O rganizational L if e Cycle and A d m i n i s t r a t i v e
D y n a m i c s ...............................................................................
Competencies and Leadership Theory ...........................
Research on Competencies .....................................................
Competency Research in H e alth - R elate d
P r o f e s s i o n s ..........................................................................
Competency Research in Educational C u r r i c u la . .

26
30
31
39
42
46
48
51
53

vi

57
63
67
68
70

Page
Research Methodology .............................................................
Survey Methodology .............................................................
The Delphi Technique .........................................................
Summary............................................................................................
III.

IV.

V.

METHODOLOGY

74
74
77
84

......................................................................

85

Design o f t h e Study ..................................................................
Phase I .......................................................................................
Phase I I ...................................................................................
Phase I I I ...................................................................................
Phase I V ............................................................
O perational D e f i n i t i o n s .........................................................
H y p o t h e s e s ...................................................................................
D e s c r i p tio n o f t h e S a m p l e .....................................................
Techniques o f Data C o l l e c t i o n .
......................................
Data A n a l y s i s ...............................................................................
Ordinal Consensus ......................................................................
Summary............................................................................................

85
85
86
87
87
88
95
99
100
102
102
104

ANALYSIS OF RESULTS......................................................................

105

Response Rate--Round I and Round I I .................................
Use o f Round I and Round II D a t a ......................................
Summary o f F i n d i n g s ..................................................................
Research O b j e c t iv e
1
Research O b j e c t iv e
2
Research O b j e c t iv e
3
Research O b j e c t iv e
4
Research O b j e c t iv e
5

105
106
108
108
118
120
124
127

SUMMARY, DISCUSSION, IMPLICATIONS, CONTRIBUTION TO
HOSPICE ADMINISTRATION, LIMITATIONS OF THE
STUDY, AND RECOMMENDATIONS....... .............................................

134

Summary............................................................................................
D i s c u s s i o n ...................................................................................
Research O b j e c t iv e
1
Research O b je c tiv e
2
Research O b j e c t iv e
3
Research O b je c tiv e 4 ...........................................................
Research O b je c tiv e
5
I m p li c a ti o n s ...............................................................................
P o t e n t i a l C o n t r i b u t i o n s t o Hospice A d m in is tr a tio n .
L i m ita tio n s o f This Study .....................................................
Recommendations ..........................................................................

134
138
138
142
145
146
147
154
158
158
159

vii

Page
APPENDICES
A.
B.
C.

ROUND ONE AND ROUND TWO HOSPICE ADMINISTRATORS
INVENTORY............................................................................................

161

ESSENTIAL AND SUPPLEMENTARY COMPETENCIES WITH
PERCENTAGEDELEGATED SECTIONS A-E AND P, 0, D, C

185

. .

CORRESPONDENCE................................................................................

195

REFERENCES.........................................................................................................

197

viii

LIST OF TABLES
Table
3.1

Page
Summary o f Hospices by Type and P a r t i c i p a t i o n in
Hospice Medicare C e r t i f i c a t i o n ........................................

100

Numerical Summary o f Survey Items Within A d m in is tr a ­
t i v e S e c t io n s (A-E) and Functions (P, 0, D,
and C ) ............................................................................................

101

3. 3

Schedule f o r Obtain ing and Analyzing t h e Data

101

3.4

Summary o f Data A n a l y s i s ...............................................................

104

4.1

Summary o f Survey I nst rume nts Sent and Returned

105

4. 2

Overall Demographic Data Summary .............................................

109

4.3

Overall Opinion Data Summary ......................................................

112

4.4

Licensed and Exempt Programs Demographic Data
Summary............................................................................................

114

4. 5

Licensed/Exempt Program Opinion Data Summary ...................

117

4.6

Ratings o f E s s e n t i a l and Supplementary Competencies
by A d m i n i s t r a t i v e Functions (P, 0, D, C ) ..................

119

Percentage o f Competency Delegation by Adminis­
t r a t i v e S e c t io n s (A-E) and Functions (P, 0,
D, C ) .................................................................................................

119

Chi-Square Anal ysis o f t h e Delegation o f E s s e n t i a l /
Supplementary Competencies .................................................

120

Competencies Reaching Consensus by Competency
S e c t i o n s ........................................................................................

122

4 .10 Leik Scores and Mean Ra tings o f All Items Reaching
C o n s e n s u s ........................................................................................

123

3.2

4.7

4.8
4. 9

4.11

. . . .

. . .

Overall Means and Standard Dev iations f o r Rating o f
Competencies by S a la r y Grouping ........................................

ix

125

Page
4.12
4.13

4.14
4.15

4.16
4.17
4. 18
4.19
5.1

Means and Standard D ev iat ions o f Competency Ratings
by F u l l / P a r t - T i m e S t a t u s
...................................

126

Means and Standard D ev ia tion s o f Competency S t a t e ­
ments f o r Exempt and Licensed Program Adminis­
t r a t o r s ............................................................................................

126

Means and Standard D ev iat ions o f Competency Items
and S ize o f P o p u l a t i o n .........................................................

127

Numerical and Percentage Summary o f E s s e n ti a l and
Supplementary Competencies by Program Stage o f
Development and A d m in i s tr a tiv e Functions ..................

128

Summary o f Per centage o f Competencies Delegated, by
S e c ti o n s A-E and P, 0, D, C ................................................

130

Mean Competency Ratings and Standard D ev iat ion s
Across Program Stage o f Development ...............................

131

ANOVA o f Program Stage o f Development by Adminis­
t r a t i v e F u n c t i o n s ......................................................................

132

Chi-Square Ana lysis o f Deleg ation and Program Stage
o f Development ...........................................................................

133

Rank Ordering o f A d m i n i s t r a t i v e Educational Needs
by Program Stage o f Development ........................................

150

x

LIST OF FIGURES
Figure

Page

1.1

An Ecological Model f o r Hospice A d m i n is tr a tio n

2.1

Hospice A d m in i s tr a tiv e Competency Areas ............................

5.1

Perce ntage o f E s s e n t i a l and Supplementary
Competencies by Stage o f Program Development

5.2
5.3

. . .

. . .

A d m i n i s t r a t i v e S e c t io n s and Average Percentage
Delegated by Program Stage o f Development ..................
P, 0, D, C Functions and Delegation by Program
Stage o f D e v e l o p m e n t .................................................

xi

153

23
32
151
152

CHAPTER I
INTRODUCTION

The hos pice conc ep t, which speaks t o a " q u a l i t y o f l i f e u n t i l a
person d i e s , "
system t o

has begun a r e v o l u t i o n

in th e American h e a l t h car e

improve c a r e f o r th e dying.

This r e v o l u t i o n

has been

c a l l e d t h e "hospice movement," which emphasizes a program o f car e
ad d r e s s i n g medical, p s y c h o s o c ia l, and s p i r i t u a l
and fa m ily e x p erie ncin g
hospic e
dignity.
so cial,

is

to

provide

This

is

the

illness.

terminally

The

ill

accomplished by a s s u r in g

and s p i r i t u a l

curative e f fo r ts .

te rmin al

support w ithout

needs o f a p a t i e n t

the

primary goal

patient

a dea th

physical,

of
with

emotio na l,

need o f e x h a u s t i v e

While t h i s seems a simple, b a s ic r i g h t ,

it

has

become t h e p h i l o s o p h ic a l c o r n e r s t o n e on which hos pice i s b u i l t .
A major focus in ho spice c a r e i s pain and symptom c o n t r o l .

It

should be emphasized t h a t hos pice c a r e i s not merely co u n s elin g and
hand-holding o f p a t i e n t s .

Rather , Saunders (1978) noted t h a t i t i s

impeccable medical and n u r si n g c a r e , d e l i v e r e d by p r a c t i t i o n e r s o f
th e h ig h e s t competence.

Therefore,

adequate hospice t r a i n i n g

remains an e s s e n t i a l , ongoing c h a lle n g e .
In r e c e n t y e a r s , with th e r a p i d expansion o f hospic e programs
in t h e United S t a t e s ,
o f such programs.

i n t e r e s t has developed in t h e a d m i n i s t r a t i o n

While r e s e a r c h e r s a r e i n c r e a s i n g l y i n t e r e s t e d in

1

2
stu dy ing o t h e r a s p e c t s o f hospice c a r e ,
there is l i t t l e

Richie

(1984)

noted t h a t

inform ation a v a i l a b l e on t h e n a t u r e o f and c a r e e r

preparation

f o r hospice a d m i n i s t r a t i o n .

indicates a

need to more

This p a u c i t y o f r e s e a r c h

c a r e f u l l y d e f i n e and under stand th e s k i l l s

and knowledge base r e q u i r e d t o f u n c t io n as a hospice a d m i n i s t r a t o r .
C u r r e n t ly ,
fields:

hospice a d m i n i s t r a t o r s come from a wide range of

n u r s in g , s o c i a l work, h e a l t h c a r e a d m i n i s t r a t i o n , p a s t o r a l

c a r e , f i n a n c e , and acco un ting.

Each a d m i n i s t r a t o r b r in g s a s p e c ia l

blend o f education and ex pe rien ce t o t h e p o s i t i o n , y e t each does not
have

a

"blueprint"

p articu lar

set

adm inistration.

of

of
Also,

guidelines

knowledge

and

to

follow

sk ills

h e/s he has no b a s i s

in

developing

unique

to

t o what e x t e n t ?

hospice

f o r de te rm in ing which

a d m i n i s t r a t i v e t a s k s should or should not be d e l e g a t e d .
should indeed be d e l e g a t e d ,

a

I f tasks

Regardless o f v a r i e d

ed u c a tio n a l

backgrounds, hos pice a d m i n i s t r a t i o n inv olves

creating a

context for

e ffe c tiv e care.

as sured by

That c o n te x t can only be

e f f e c t i v e i n d i v i d u a l s t r a i n e d a c c o r d in g ly .
Five main q u e s tio n s about hospice a d m i n i s t r a t i o n a r e addr essed
in t h i s stu dy :
1.

What a r e t h e demographic c h a r a c t e r i s t i c s o f hos pic e admin­

i s t r a t o r s in Michigan?
2.

What f u n c t io n s a r e t h e s e a d m i n i s t r a t o r s performing a n d /o r

delegating?
3.

What a r e t h e E s s e n ti a l and Supplementary competencies hos­

p i c e a d m i n i s t r a t o r s in Michigan p e r c e iv e as n e c e s s a r y f o r c a r r y i n g
out t h e i r

role?

3

4.

Do demographic f a c t o r s d i f f e r e n t i a l l y a f f e c t t h e r e p o r t e d

e s s e n t i a l i t y o f competencies?
5.
th e

Does t h e s ta g e o f t h e o r g a n i z a t i o n ’ s l i f e c y c le i n f l u e n c e

reported

hospic e

essentiality

a n d /o r

delegation

of

competencies

for

adm inistrators?

I t was a n t i c i p a t e d t h a t answers to t h e s e q u e s t i o n s would help
clarify

the

interested

hospice

a d m in istra to r’s

professionals

toward

a

role

program

and
of

perhaps

study

that

guide
would

pr ov ide t h e s k i l l s needed t o become a hospice a d m i n i s t r a t o r .
The next s e c t i o n o f t h i s d i s s e r t a t i o n p r e s e n t s t h e background
f o r t h i s study and e n l a r g e s on var io u s ho spice i s s u e s t h a t s uppo rt
t h e need f o r t h i s r e s e a r c h .
Background o f t h e Problem
Hospice c a r e in th e United S t a t e s has grown r a p i d l y dur in g th e
p a s t decade.

Today t h e r e ar e approximately 1,600 ho spice programs

in o p e r a t i o n with
(Rooney, 1986).
is

many d i f f e r e n t

organizational

structure

models

As th e hospice concept gains widespread s u p p o r t , i t

being c h a l le n g e d p h i l o s o p h i c a l l y

to v a lid a te

its

efficacy,

to

grow and develop according t o r e g u l a t i o n s and s ta n d a r d s o f c a r e , and
t o do so with p r i m a r i l y a v o l u n t a r y e f f o r t .

I t has perhaps been th e

s u b j e c t o f more e v a l u a t i v e s t u d i e s than most h e a l t h c a r e i n n o v a tio n s
in r e c e n t h i s t o r y .

T h e re f o re , background knowledge on f o u r c u r r e n t

i s s u e s seems e s s e n t i a l f o r t h e r e a d e r .
o f t h e s e i s s u e s f o ll o w s .

A b r i e f d i s c u s s i o n o f each

4
Issues of P ro fe s sio n a liz a tio n
J u s t as hos pice i s beginning t o v a l i d a t e i t s e f f i c a c y ,
also

being

c h allen g ed

to

"professionalize"

n a t i o n a l and s t a t e l e v e l s .

itself

at

it

both

is
th e

N a t i o n a l l y , t h e most Immediate c h a l le n g e

t o ho spice a d m i n i s t r a t o r s has been e s t a b l i s h i n g hospice as a bona
fid e health care option.

The enactment o f P ub lic Law 97-248 o f the

Tax Equity and F is c a l R e s p o n s i b i l i t y Act (TEFRA) o f 1983 e s t a b l i s h e d
ho spice as a medicare reimbursement o p t i o n .
More r e c e n t l y , Congress passed t h e C onsolidated Omnibus Budget
R e c o n c i l i a t i o n Act o f 1985 (COBRA).

One p r o v i s i o n o f t h e law made

hospice c a r e a permanent p a r t o f t h e Medicare program.

COBRA a l s o

r a i s e d Medicare hospic e payment r a t e s and gave s t a t e s t h e a b i l i t y to
pro vide ho spice s e r v i c e s

under t h e Medicaid program.

In e f f e c t ,

t h i s has s h i f t e d th e hospice movement t o a hospice " i n d u s t r y . "
According t o t h e Health Care Financing A d m in i s tr a tio n

(HCFA),

279 out o f 1,500 hospic es had o btained Medicare c e r t i f i c a t i o n as o f
J u l y 1986 (Fackelman, 1986).

As o f February 1987, Michigan had 21

hospice

p r o g ra m s

M e d ic a r e

certified

(Olson,

1987).

Carolyn

F i t z p a t r i c k , chairwoman and p r e s i d e n t o f t h e 2,000-member National
Hospice O rga n iz a ti o n (NHO), a l s o noted t h a t Michigan was one o f th e
leaders

in

the

hos pic e

field .

Out

of

the

10

ho spice

regions

d e s i g n a t e d by th e HCFA, Region V ( o f which Michigan i s a p a r t ) has
th e

largest

number

of

h o s p ic e s ,

and

the

highest

p er cen tag e

of

p a t i e n t s r e c e i v i n g c a r e ( Health Care Weekly Review. May 26, 1986).
Also,

in c o n c e r t w ith p r o f e s s i o n a l i z a t i o n ,

th ree national

o r g a n i z a t i o n s have evolved which focus on ho spice c a r e .

The o l d e s t ,

5

th e National Hospice O r g a n iz a ti o n (NHO), was founded in 1977.
has

approxim ately

703

member

hospices,

including

39

(Bates ,

1986).

o r g a n i z a t i o n members a c r o s s t h e United S t a t e s

NHO
state

p rovid e s s t a n d a r d s t o e v a l u a t e t h e q u a l i t y o f hospice c a r e
provided

and

professionals

sponsors

numerous

educational

and n o n p r o f e s s i o n a l s .

meetings

for

NHO’ s ed u c a ti o n a l

It
being

hospice

goals

for

1986 focused on hospice a d m i n i s t r a t i o n and hospice a d m i n i s t r a t i v e
skills.

NHO s t a t e d t h a t t h e s i n g l e most important element in th e

o v e r a l l s ucc es s o f a hospice program i s t h e hospice a d m i n i s t r a t o r ’ s
a b i l i t y t o manage (Hospice L e t t e r . May 1986).
As a supplement t o t h e NHO, a second o r g a n i z a t i o n known as the
American S o c ie t y o f Hospice Care (ASHC) emerged in 1935.

The ASHC

fo cuse s on e d u c a t i o n , t r a i n i n g , and r e s e a r c h in h o s p ic e .

The t h i r d

o r g a n i z a t i o n t o develop was t h e American Hospice A s s o c i a t i o n (AHA),
which was organ ize d in J u l y 1985.

AHA developed from and i s j o i n t l y

su pported by t h e National A s s o c ia t io n o f Home Care (NAHC) and the
A s s o c ia ti o n o f Community Cancer Centers (ACCC).
is

committed t o

h e ig h t e n i n g

public

awareness

This o r g a n i z a t i o n
on ho spic e

issues,

b u i l d i n g a cohes ive ho s p ic e movement, and enhancing t h e development
o f t h e ho spice philos ophy t o en sure th e i n c l u s i o n o f a l l a s p e c t s of
te r m i n a l

care.

On

behalf

of

many

hospice

programs

affiliated

p r i m a r i l y with home h e a l t h a g e n c i e s , t h e ACCC s t r o n g l y ad voc ates f o r
i n c r e a s e s in reimbursement l e v e l s f o r hospice c a r e .
The e v o l u t i o n
presented

of

these

a professional

three

quandary

national

organizations

for

fledgling

the

has

hospice

6
movement.

H ospice

adm inistrators

are

being

encouraged

to

p a r t i c i p a t e in or become members o f t h e s e v a r io u s o r g a n i z a t i o n s .

As

y e t , i t i s u n c l e a r which one would b e s t r e p r e s e n t t h e i r own program
co nce rns.
F is c a l Iss u es
Two s t u d i e s (Kane e t a l . ,

1985; Brooks & Smyth-Staruch,

c h a l le n g e d th e b e n e f i c i a l outcomes o f hospice c a r e .
revealed

that

t h e r e was no d i f f e r e n c e

in

1984)

The Kane study

le n g th

of

s u r v iv a l

of

hospice and nonhospice p a t i e n t s and t h a t t h e r e was no d i f f e r e n c e in
terms o f physical f u n c t i o n i n g , symptom c o n t r o l , p a in , o r mood s t a t e .
Hospice p a t i e n t s ,
received.
that

however, were more s a t i s f i e d with t h e c a r e they

The Brooks study focused on c o s t s a v in g s .

ov er t h e

last

24 weeks o f

life,

payments

I t indicated

were

$9,362

for

nonhospice p a t i e n t s and $9,651 f o r hospice p a t i e n t s (Mor, 1985, p.
82).

It

must

be

noted

that

both

studies

have

been

strongly

c o n t e s t e d by th e hos pice f a c t i o n .
More r e c e n t l y , Smith and Veglia (1986) conducted a study a t th e
Veterans Adm inist rati on Medical Center, W ilkes-Barre, Pennsylvania.
These r e s e a r c h e r s focused on comparing th e u t i l i z a t i o n p a t t e r n s o f
l a b work, procedures, and s p e c i a l t h e r a p i e s between hospice and non­
ho s p ic e s u b j e c t s in t h e same s e t t i n g .

Through c o s t a n a l y s i s they

i d e n t i f i e d th e t o t a l c o s t o f a l l th e v a r i a b l e s f o r hospice c a r e t o
be $33,291 as compared t o $233,614 f o r th e nonhospice p a t i e n t .

The

stu d y a l s o r ev ea led t h e mean number o f d i a g n o s t i c t e s t s f o r hos pice

7
p a t i e n t s was .94 as compared t o 34.98 f o r nonhospice p a t i e n t s (Smith
& V eglia, p. 1).
Many o f th e a d m i n i s t r a t i v e ad ju stm ents t h a t need t o be made by
hos pic e s p a r t i c i p a t i n g in t h e hospice Medicare b e n e f i t a r e d r iv e n by
t h e l e g i s l a t i v e premise f o r c o s t containment o f f e d e r a l h e a l t h car e
dollars.
ties

Central

fiscal

and p r o f e s s i o n a l management r e s p o n s i b i l i ­

in t h e hospice Medicare b e n e f i t were inc luded t o p r o t e c t th e

i n t e r e s t s o f t h e p a t i e n t and l i m i t h e a l t h c a r e e x p e n d it u r e s f o r th e
taxpayer.
As a p a r t i c i p a t i n g p r o v id e r under hospice Medicare, a hospice
program

has

a

clearly

defined

amount

of

payments f o r c ar e r e l a t e d t o th e ter minal
drawn.
personal

money

from which

all

i l l n e s s o f p a t i e n t s ar e

The only excepti on i s f o r reimbursement t o t h e p a t i e n t ’ s
p h y s ic i a n .

Thus,

t h e hos pice must p r u d e n t ly manage i t s

hospice Medicare revenues.
Among hospice programs which began as

a direct

respons e

to

community needs, t h e r e i s now a s e r i o u s concern t h a t reimbursement
o p ti o n s w i l l a l t e r th e p h i l o s o p h ic a l es sence o f hospice c a r e .

Some

hospice a d m i n i s t r a t o r s b e l i e v e t h a t th e shape and form t h e i r hos pice
program t a k e s

w ill

be i n c r e a s i n g l y

determ ined

by t h i r d - p a r t y

reimbursement r a t h e r than by t h e needs o f th e p a t i e n t ,

f a m ily , and

community.
Qua! i t v - o f - C a r e Iss ues
About t h e same time t h e f e d e r a l arm was d e f i n i n g hospice c a r e
f o r reimbursement, t h e p r i v a t e s e c t o r was developing s ta n d a r d s f o r

8
quality care.
p u b lis h e d

The J o i n t Commission on Hospital A c c r e d i t a t i o n (JCAH)

Standar ds

for

Hospice

Care

in

1983.

These

s ta n d a rd s

c o n ti n u e t o be used today as c r i t e r i a f o r a v o l u n t a r y JCAH survey of
h ospice programs a c r o s s t h e United S t a t e s .

By t h e end o f 1985, the

number o f JCAH a c c r e d i t e d ho sp ices t o t a l e d 100 (McCann, 1985).
a d d i t i o n , JCAH has m an dat ed t h a t
offering

any J C A H - a c c r e d i t e d h o s p i t a l

hos pice s e r v i c e s must now be surveyed

hospic e s t a n d a r d s .

As o f 1985,

been mandatory

JCAH-accredited

for

In

participation
hospitals

against

in t h i s

th e

1983

survey has

offering

a

hospice

program.
S t a t e Licensure Iss u es
There i s a d r i v e f o r hospice l i c e n s u r e in many s t a t e s which
c e n t e r s on two i s s u e s :

(a) t r u t h in a d v e r t i s i n g and (b) l e g a l i t y .

The f i r s t i s s u e stems from th e p e r c e p tio n t h a t o r g a n i z a t i o n s which
a d v e r t i s e t o t h e p u b l i c t h a t they provide a hospice program o r o f f e r
h ospice

services

should

conform t o

certain

minimum s ta n d a r d s

of

care.
The second

i s s u e was prompted by th e

observation

that

many

h ospice s grew out o f community-based o r g a n i z a t i o n s u n a f f i l i a t e d with
t r a d i t i o n a l p r o v id e r s o f h e a l t h c a r e s e r v i c e s .
that

when t h e

professional

services,

operate le g a lly .
o f March

programs

1986,

began t o
th ey

pr ovide

discove re d

Rosen (1985) noted

n u r sin g

no r u b r i c

care

and o t h e r

under

which

Hospice l i c e n s u r e provide s t h i s l e g a l r u b r i c .
17 s t a t e s

had hospice

licensure

and

l i c e n s u r e r u l e s in d r a f t form w ith in t h e i r l e g i s l a t u r e s .

7 more

to
As
had

9
The s t a t u t o r y base f o r l i c e n s u r e hosp ice s in Michigan i s Pu blic
Law No. 368, s e c t i o n 21419 (as amended by 333.21411), which became
e f f e c t i v e October 31, 1984.

For hospice a d m i n i s t r a t o r s in Michigan,

t h i s means t h e i r programs must be surveyed y e a r l y f o r compliance t o
s t a t e hospice r u l e s u n l e s s th ey have met s p e c i f i c hospice l i c e n s u r e
exemption c r i t e r i a .
I f a program i s exempt from l i c e n s u r e
those

p r o g ra m s

are

not

a d m i n i s t r a t i v e co nc er ns .

w ithout

th eir

including

the

does not mean t h a t

own

special

kinds

of

Examples o f unique problems which s u r f a c e

in t h e exempt hospice programs a r e :
staff,

it

(a) p r i m a r i l y

adm inistrator;

(b)

"all-volunteer"

incon sisten t

funding

s u p p o r t; and (c) d e l i v e r y o f p r o f e s s i o n a l s k i l l s in a predominantly
rural

area.

Exempt hospic e

programs

are

also

includ ed

in

this

in v o l v in g

cost

stu dy.
In
s a v in g s ,

summary,

both

state

professionalization,

and

national

issues

reimbursement,

quality

of care,

and

s t a t e l i c e n s u r e pro vid e a backdrop f o r t h e environment in which a
hospice a d m i n i s t r a t o r must f u n c t i o n .
complex and o f t e n overwhelming,

The t a s k s a r e becoming more

e s p e c i a l l y f o r i n d i v i d u a l s who do

not have t h e e x p er ie n ce o r e ducational p r e p a r a t i o n .
Statement o f t h e Problem
Because hospice i s a r e l a t i v e l y new h e a l t h c a r e model, i t has
not been e x t e n s i v e l y e v a l u a t e d in t h e a r e a o f a d m i n i s t r a t i o n .
lim itation

of current

administration

is

literature

ap par en t

as

(Barton,

to

competencies

1977;

Bohnet,

The

for

ho spice

1982;

R ic h ie ,

10
1984;

Rossman,

1977; M cD onnell,

1986;

Story,

1983;).

O ften,

i n d i v i d u a l s who become involved in hospice c a r e

because o f t h e i r

philosophical

death

and c l i n i c a l

beliefs

regarding

and d y i n g

p r a c t i c e s f i n d themselves in a d m i n i s t r a t i v e r o l e s la c k i n g conceptual
and t e c h n i c a l s k i l l s needed f o r e f f e c t i v e management.
McLaughlin

(1983)

stressed

that

a well-run

hospice

program

r e q u i r e s e f f e c t i v e management p r a c t i c e s by t h e hospice a d m i n i s t r a t o r
t o manage peop le, s t a f f , v o l u n t e e r s , f i n a n c e s , community r e l a t i o n s ,
quality,

patient

care,

change,

growth,

e d u catio n

and

training,

r e c r u i t m e n t and r e t e n t i o n , mar keting, and r e s o u r c e s f o r t h e f u t u r e .
This study i d e n t i f i e s t h e competencies r e q u i r e d t o accomplish t h e s e
management t a s k s .
In plann ing
noted

that

and managing hospice programs,

hospice

adm inistrators,

lik e

Lamb (1985)

other

health

also
care

e x e c u t i v e s , must a s s e s s t h e i r base o f community s u p p o r t , under stand
funding

sources,

have

an

extensive

organizational

committee

s t r u c t u r e in p l a c e , and have a c l e a r idea o f o r g a n i z a t i o n a l
and o b j e c t i v e s .

g oals

As hos pice programs develop over time and become

more involved with th e t r a d i t i o n a l h e a l t h c a r e system, s uc ce ss w i l l
l a r g e l y be determined by program management.

For a d m i n i s t r a t o r s ,

t h i s means a thorough knowledge o f t h e hospice market, a c l e a r idea
of

costs

involved,

and

a ready

supply

of

resources

and

the

f l e x i b i l i t y t o i n i t i a t e programs capable o f meeting community needs.
Most d e s c r i p t i o n s o f h e a l t h s e r v i c e o r g a n i z a t i o n s presume t h a t
th ey e x i s t in a s t a t i c s t a t e .
a r e in c o n s t a n t e v o l u t i o n .

In f a c t , however, t h e s e o r g a n i z a t i o n s
Starkw ea ther and Kisch (1971) suggested

11

t h a t h e a l t h s e r v i c e o r g a n i z a t i o n s have t h e i r own l i f e c ycle and t h a t
each phase b r in g s new ty p e s o f r e s p o n s i b i l i t i e s f o r a d m i n i s t r a t o r s .
It

can

be s a i d

cycle."

that

hospice

is

evolving

through

its

own

"life

As t h i s i s o c c u r r i n g , hospice a d m i n i s t r a t o r s ar e s t r u g g l i n g

t o d e f i n e a base o f conceptual knowledge and t e c h n i c a l s k i l l s t h a t
w i l l a s s i s t them in meeting t h e r e s p o n s i b i l i t i e s o f t h e i r evolving
programs.

This

evolution,

for

example,

hospice programs moving t o l i c e n s u r e ,
to

hospice

Medicare

is

app ar en t

in

exempt

and l i c e n s e d programs moving

certificatio n

or

perhaps

JCAH

hospice

accreditation.
In every f a c e t o f h e a l t h c a r e , s u ccess fu l c l i n i c i a n s a r e o f te n
promoted

to

inclin atio n

administrative
for

positions.

adm inistration

They

or possess

may
the

not

have

th e

experience

and

academic p r e p a r a t i o n t o e n ab le them t o be s u c c e s s fu l a d m i n i s t r a t o r s .
General a d m i n i s t r a t i v e f u n c t i o n s and t h e o r e t i c a l approaches provide
models from which th e
According

to

this

hospice a d m i n i s t r a t o r can develop

researcher,

however,

hospic e

programs

insight.
are

in

d e s p e r a t e need o f an e f f e c t i v e a d m i n i s t r a t i v e e d u c a tio n a l model t h a t
meets t h e i r needs over t h e o r g a n i z a t i o n a l l i f e c y c l e .
Purpose o f th e Study
S p e c i f i c a l l y , t h i s study focused on f i v e major o b j e c t i v e s :
t o c o m p i l e s e l e c t i v e d e m o g r a p h i c and o p i n i o n
a d m i n i s t r a t o r s in Michigan,
hospice

adm inistrators

data

(a)

on h o s p i c e

(b) t o i d e n t i f y what f u n c t i o n s c u r r e n t
in

M ic higan

were

perform ing

and/or

d e l e g a t i n g , (c) t o survey c u r r e n t hospice a d m i n i s t r a t o r s in Michigan

12

on t h e i r

p e r c e p ti o n

of

E s s e n ti a l

and

Supplementary

competencies

which meet consensus under f i v e a d m i n i s t r a t i v e c a t e g o r i e s ,
identify

d e m o g r a p h ic f a c t o r s

reported

essentiality

of

which d i f f e r e n t i a l l y

competencies,

and

(e)

to

(d) to

affect

the

identify

how

o r g a n i z a t i o n a l l i f e c y c l e s ta g e s in f l u e n c e and d i f f e r e n t i a l l y a f f e c t
the

reported

essentiality

a n d /o r

delegation

of

competencies

for

ho spice a d m i n i s t r a t o r s .
A p r e l im i n a r y survey instrum en t developed by t h i s
c o n s i s t e d o f two p a r t s .
ch aracteristics
employment

in

to

history,

role

hospice

d esignation,

P a r t One addressed a d m i n i s t r a t i v e / h o s p i c e

include:

ho s p ic e ,

researcher

prior

responsibilities,
hospice

age,

sex,

employment
salary

education,
history,

range,

location,

length

of

administrative

employment

status,

patient/fam ily

ethnic

r e p r e s e n t a t i o n , type o f program c r e d e n t i a l i n g expected 1 y e a r from
t h e time o f survey , and th e a d m i n i s t r a t o r ’ s p e r c e p ti o n o f th e need
f o r e d u catio n al programs in hos pice a d m i n i s t r a t i o n .

Also surveyed

was t h e a d m i n i s t r a t o r ’ s r a t i n g o f t h e l i f e c ycle s ta g e o f hospice
development.
P a r t Two c o n s i s t e d o f a l i s t i n g o f 201 competency s ta t e m e n ts
under

fiv e

adm inistrators
s ta t e m e n ts

adm inistrative
in Michigan

were E s s e n ti a l

in

categories.

Current

1987 determined

if

the

hospice
competency

a nd/o r Supplementary as well

as

which

t a s k s r e p r e s e n t e d by t h e competency s ta te m e n ts were d e l e g a t e d .
Because no r e s e a r c h had been done on hospice a d m i n i s t r a t o r s in
Michigan,

th e

demographic d a t a

from t h i s

study

provided

initial

13
b a s e l i n e in fo rm ation and o f f e r e d i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h .
Also,

the

id en tificatio n

of

E ssential

hospice

adm inistrative

competencies can be used as g u i d e l i n e s t o a s s i s t hos pice programs in
determ ining

th eir

expectations

for

professionals

fillin g

the

adm inistrative role.
The i d e n t i f i c a t i o n o f t h e s e competencies may a l s o be us eful
providing

a basis

for

con tin u in g education

developing

curricula

and t r a i n i n g

in h o s p i c e a d m i n i s t r a t i o n .

in
for

Finally,

the

e v a l u a t i o n o f competencies which a r e d e l e g a t e d may be an i n d i c a t o r
o f t h e hospice program’ s s ta g e in t h e o r g a n i z a t i o n a l l i f e c y c l e .
Research Questions
The fo llow ing r e s e a r c h q u e s t i o n s a rose from O b j e c t iv e
One:

Number

t o compile s e l e c t i v e demographic and opinion d a t a on hos pice

a d m i n i s t r a t o r s in Michigan.
Al.

What i s t h e mean age in y e a r s f o r hospice a d m i n i s t r a t o r s ?

A2.

What a r e t h e p r o p o r t i o n s o f male and female a d m i n i s t r a ­

A3.

What i s t h e most f r e q u e n t l y i d e n t i f i e d e d u c a t io n a l

tors?
back­

ground?
A4.

What i s t h e mean number o f y e a r s e x p e r i e n c e

in hos pice

administration?
A5.

What i s

the

most

frequent

type

of

prior

employment

history?
A6.

What i s th e range o f t o t a l number o f y e a r s

administrator?

worked as an

14
A7.

What percentage o f a d m i n i s t r a t o r s

have a d d i t i o n a l

role

responsibilities?
A8.

What

1s th e most

frequent

salary

range

as

a hospice

administrator?
A9.
A10.

What i s t h e p r o p o r ti o n o f f u l l - t o p a r t - t i m e employment?
What i s t h e most f r e q u e n t

ho spice program c r e d e n t i a l i n g

d e s i g n a ti o n ?
A ll.

What p r o p o r t i o n o f hos pice a d m i n i s t r a t o r s a r e in r u r a l and

urban l o c a t i o n s ?
A12.

What were t h e p e rcenta ges o f

patient/fam ily ethnic rep re­

s e n t a t i o n s f o r t h e hospice programs in 1986?
A13.

What do hospice

a d m i n i s t r a t o r s p r o j e c t f o r t h e i r hospice

program c r e d e n t i a l i n g d e s ig n a t i o n 1 y e a r from t h i s survey?
A14.

What i s th e d i s t r i b u t i o n o f p er ceiv ed s t a t e o f development

f o r hos pic e programs?
A15.

What p er cen tag e o f hospice a d m i n i s t r a t o r s i d e n t i f y a need

f o r an ed u c a t io n a l program in hospice a d m i n i s t r a t i o n ?
A16.

What i s t h e most f r e q u e n t e d u c a ti o n a l need

i d e n t i f i e d by

hospice a d m i n i s t r a t o r s in Michigan?
A17.

What

is

the

most

preferred

method

of

ed u c a t io n a l

a s s i s t a n c e i d e n t i f i e d by hospice a d m i n i s t r a t o r s in Michigan?
The f ollow ing r e s e a r c h q u e s ti o n s a r o s e from O b je c tiv e Number
Two:

To I d e n t i f y what f u n c t i o n s c u r r e n t ho spice a d m i n i s t r a t o r s in

Michigan were performing a n d /o r d e l e g a t i n g .

15
Bl.

What

are

the

competencies

by

functions

( p la n n in g ,

o r g a n i z i n g , d i r e c t i n g , and c o n t r o l l i n g ) which hospic e a d m i n i s t r a t o r s
in Michigan i d e n t i f y as E s s e n t i a l and Supplementary?
B2.

To what degree

are

these

Essential

and

Supplementary

competencies d e l e g a t e d f o r each o f t h e major a d m i n i s t r a t i v e survey
components (Ref. Design o f t h e Study, Chapter I I I ) and each o f th e
f u n c t i o n s o f p l a n n in g , o r g a n i z i n g , d i r e c t i n g , and c o n t r o l l i n g ?
B3.

Do s i g n i f i c a n t

differences

exist

in

the

frequency

of

E s s e n t i a l and Supplementary competencies which ar e d e l e g a te d ?
The f ollow in g r e s e a r c h q u e s t i o n s a rose from O b j e c t i v e Number
Three:

To survey c u r r e n t

hos pice

t h e i r perception o f Essential

adm inistrators

in

Michigan on

and Supplementary competencies which

meet consensus under f i v e a d m i n i s t r a t i v e c a t e g o r i e s .
Cl.
under t h e
C2.

Whata r e th e
f i v e major

competency s ta t e m e n t s which meet consensus
a d m i n i s t r a t i v e survey components?

Will t h e r e be any

convergence t o consensus on t h e

Essen­

convergence t o consensus on t h e

Su pp le­

t i a l competencies?
C3.

Will t h e r e be any

mentary competencies?
The f oll ow ing r e s e a r c h q u e s t i o n s a r o s e from O b j e c t i v e
Four :

Number

To i d e n t i f y demographic f a c t o r s which d i f f e r e n t i a l l y a f f e c t

th e r e p o r t e d e s s e n t i a l i t y o f competencies.
Dl.

Is t h e r e a

s i g n i f i c a n t d i f f e r e n c e in th e mean r a t i n g o f

competencies based on t h e r e s p o n d e n t ' s age?
D2. Is t h e r e a

s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on th e r e s p o n d e n t ' s sex?

16

D3. Is t h e r e a

s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on t h e r e s p o n d e n t ' s e d u cati o n al background?
D4. Is t h e r e a

significant

d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on r o l e r e s p o n s i b i l i t i e s o f t h e a d m i n i s t r a t o r ?
D5. Is t h e r e a

significant

competencies based on s a l a r i e d o r
D6. Is t h e r e a

significant

d i f f e r e n c e in t h e mean r a t i n g o f
n o n s a la r i e d s t a t u s ?
d i f f e r e n c e in t h e mean r a t i n g of

competencies based on employment s t a t u s ?
D7.

Is t h e r e a s i g n i f i c a n t

com petencies

d i f f e r e n c e in

betw ee n a d m i n i s t r a t o r s

of

t h e mean

licensed

ratin g of

p r o g ra m s

and

a d m i n i s t r a t o r s o f exempt programs?
D8.

Is t h e r e a s i g n i f i c a n t

d i f f e r e n c e in

t h e mean

r a t i n g of

competencies o f a d m i n i s t r a t o r s with d i f f e r i n g s i z e s o f p o p u la t io n s
served by hospic e programs?
The f oll ow in g r e s e a r c h q u e s ti o n s a rose from O b j e c t i v e
Five:

Number

To i d e n t i f y how t h e r e p o r t e d e s s e n t i a l i t y a n d / o r d e l e g a t i o n

o f competencies v a r i e s with o r g a n i z a t i o n a l l i f e c y c l e s t a g e s .
El.

Do E s s e n t i a l

adm inistrative

and Supplementary

functions

of

p la nning,

competencies w i t h i n th e

organizing,

directing,

and

c o n t r o l l i n g vary with s t a g e o f program development?
E2.

Do E s s e n t i a l

and

Supplementary

competencies

that

are

d e l e g a t e d f o r each o f t h e major a d m i n i s t r a t i v e survey components and
each o f t h e
E3.

a d m i n i s t r a t i v e f u n c t io n s vary with s t a g e
Is t h e r e a s i g n i f i c a n t

d i f f e r e n c e in

t h e mean

competencies a c r o s s s ta g e o f hospice program development?

o f development?
ratin g of

17
E4.

Do t h e

adm inistrative
and

mean

ratings

o f competencies

f u n c t io n a r e a s o f planning,

con trollin g

vary

sig n ifican tly

across

the

organizing,

with

stage

four

directing,
of

prog ram

development?
E5.

Is t h e r e a

s i g n i f i c a n t d i f f e r e n c e in t h e frequency with

which competencies a r e d e l e g a t e d based on program s t a g e o f program
development?
T h e o r e tic a l D e f i n i t i o n s
C o n c e p ts which a r e

im portant

in

understanding

the

human

e c o l o g i c a l framework a r e as f o llo w s :
Ecology;

t h e p a t t e r n o f r e l a t i o n s between organisms and t h e i r

environment (Melson, 1980).
Environment:
organism.

the

totality

of

cir cu m sta nc es

surrounding

I t i s composed o f t h r e e i n t e r r e l a t e d environments:

an
th e

human beh av io ral environment, th e human c o n s t r u c t e d environment, and
t h e n a t u r a l environment (Bubolz, Eiche r, & Sontag, 1979).
The human beh av iora l

environment

human b e i n g s and t h e i r b i o p h y s i c a l ,

fHBEl:

an

environment

psychological,

of

and s o c i a l

behaviors.
The human c o n s t r u c t e d e n v i r o n m e n t

fHCE1:

an e n v i r o n m e n t

product

of

a l t e r e d o r c r e a t e d by human bein gs.
The

natural

environment

fNE):

a

s p a t i a l - t e m p o r a l , p h y s i c a l , and b i o l o g i c a l components.
o f energy i s a l s o r e p r e s e n t e d in t h e NE.

nature

with

The concept

18
Adaptation:

the

process

r e la tiv e ly stab le reciprocal

of establishing

and m a in ta in in g

a

r e l a t i o n s h i p w ith th e environment

(Mel son, 1980).
Adaptation p r e s s :

t h e demands o f an environment e x e r t e d upon a

system t o encourage a n d /o r f o r c e a d a p t a t i o n (Olson, 1988).
Conceptual Framework
In r e c e n t y e a r s a major tr a n s f o r m a t i o n in t h e u n d e rsta nding o f
h e a l t h and d i s e a s e has tak en p l a c e .

According t o Hancock (1985),

t h e emphasis has s h i f t e d from a s i m p l i s t i c , r e d u c t i o n i s t caus e-ande f f e c t view o f t h e medical model t o a complex, h o l i s t i c , i n t e r a c t i v e
h i e r a r c h i c systems view known as an e c o lo g ic a l model.

This s h i f t

may be so profound as t o c o n s t i t u t e a paradigm s h i f t o r a change in
th e c o l l e c t i v e mind s e t r e g a rd i n g what th e r u l e s a r e and what i s
possible

in c a r e f o r t h e dying.

From a broad focus t h e

concept i s c o n s i s t e n t with t h i s

emerging paradigm t h a t

hospice

calls

for

human s e r v i c e s t o be d e l i v e r e d from an e c o lo g ic a l p e r s p e c t i v e which
focu se s on t h e
Recent

interest

interaction
in

the

between persons and t h e i r environment.

ways

in

which

primary

social

networks

exchange s o c ia l s up por t i s based on c o n s i s t e n t evidence t h a t s o c ia l
s upport enhances in d iv i d u a l w e ll - b e i n g and a i d s in a d a p t a t i o n t o a
range

of

life

stresses

(Ell,

1984;

G ottlieb,

1983).

In

this

c o n t e x t , ho spice can be c h a r a c t e r i z e d as a p r o f e s s i o n a l l y devise d
s upport system t h a t in te n d s t o maximize a co m fort able f i t

between

dying persons and t h e i r ph ysic a l and s o c i a l environments and, t o th e
extent possible,

accomplish t h i s

by improving t h e

ability

o f th e

19
primary network t o engage in s up por t p r o v is i o n s f o r t h e p a t i e n t and
fa m ily .
In a paper e n t i t l e d

"An Ecological

Approach t o

th e

Family,"

Andrews, Bubolz, and Paolucci (1980) d e s c rib e d an e c o l o g i c a l system
as

having

three

organizing

co nce pts:

the

environed

unit,

th e

environment, and t h e p a t t e r n i n g o f t r a n s a c t i o n s between them.
ecological

approach

can

environment in depth.
th is

environment

environments:

as

be

further

delineated

by

This

examining

the

Bubolz, Eiche r, and Sontag (1979) envisi oned
being

composed

t h e human beha vior al

of

three

environment

in terrelated

(HBE),

the

human

c o n s tr u c t e d environment (HCE), and t h e n a t u r a l environment (NE).
t h e e c o lo g i c a l model,

one assumes t h a t

th e human organism,

In

known

a l s o as " the environed u n i t , " i n t e r a c t s with a l l envir onments, i . e . ,
the ph y sical,
environments,

biological,

psychological,

over space and time.

so cial,

This conceptual

and c u l t u r a l
model

can be

a p p l i e d t o hospice a d m i n i s t r a t i o n as f o llo w s .
The environment i s t h e t o t a l ho spice program t o in c l u d e those
a d m i n i s t r a t i v e r e s p o n s i b i l i t i e s r e l a t i v e t o th e n a t u r a l , t h e humanconstructed,

and t h e human b e h a v i o r a l

environm ents.

in v o lv es t h e b e havioral

management o f s t a f f t o

and

the

interactions

assuring th a t
identified,

with

psyc ho so cial

that

patient

and

stress-related

issues

in clu d e v o l u n t e e r s

fa m il y .

needs o f s t a f f
ar e

The HBE

This

i n c lu d e s

and p a t i e n t / f a m i l y
a d dress ed,

are

and t h a t

r e l a t i v e s t a t e o f e q u i l i b r i u m w it h i n t h e environment i s maintained
f o r employees and v o l u n t e e r s .

The HBE a l s o in c lu d e s a s h arin g of

common values on dea th and dying,

bereavement,

the g r i e f process,

a

20

and common g o a ls and i n t e r e s t s

1n pro viding

"help"

to

fam ilies.

Examples o f i n d i v i d u a l s i n t e r a c t i n g with t h e hospice a d m i n i s t r a t o r
in

the

HBE a r e :

coordinator,
physicians,
hospice

the

the

social

medical

p rogra m

volunteer
worker,

director,

h as

coordinator,
volunteers,

and

access

to

In

perhaps
support

th e

the

a

clergy,

nurses,

psychologist

from

ho spice

bereavement

th is

if

th e

p artic u la r

professional

discipline.

program,

an

important

psycho social

i n te rc h a n g e among s t a f f and v o l u n t e e r s occur s dur ing

th e i n t e r d i s c i p l i n a r y team meetings which ar e most o f t e n held on a
weekly b a s i s .
The HCE i n v o l v e s
adm inistrator
community
fiscal

m ajor

in t h e a r e a s

and

public

management.

resp o n sib ilities

of staffing

relations,

the

and personnel

program

The HCE a l s o

for

quality

includes

the

hospice

management,

assurance,

hospice

and

program’ s

a c c e s s i b i l i t y as a r e s o u r c e f o r t h e p a t i e n t / f a m i l y and community.
If

the

family

needs

equipment

such

as

a hospital

bed,

s u c tio n

machine, o r oxygen, t h e ho spice a d m i n i s t r a t o r must a r ra n g e f o r t hose
resources

to

be a v a i l a b l e .

presentation

on

I f t h e community r e q u e s t s

hospice

and/or

g rie f

issues,

a program

the

hospice

a d m i n i s t r a t o r must c o n s i d e r what outcomes t h e s e programs would have
on t h e

public

organize

and

m aterials

also

on ho spice

and/or

staff

p articip ate

in
in

time
the

allocated

to

presentation.

I n d i v i d u a l s i n t e r a c t i n g with t h e hospic e a d m i n i s t r a t o r in t h e HCE
in clude th e p h y s ic i a n , t h e hospice program medical d i r e c t o r , c l e r g y ,
a g e n c ie s ,

or

individually

contracted

personnel

who

can

provide

21
s p e c i a l i z e d s e r v i c e s t o t h e p a t i e n t / f a m i l y u n i t , n u r s in g p e r s o n n e l ,
v o l u n t e e r s , community programs, and t h e p a t i e n t / f a m i l y .
The NE in c l u d e s th e r u r a l o r urban s e t t i n g in which t h e hospice
a d m i n i s t r a t o r i s working.

I t a l s o c a p t u r e s th e energy e x p e n d i tu r e

r e q u i r e d t o s u s t a i n t h e hospice program o p e r a t i o n as well as family
energy expended in c a r i n g f o r a t e r m i n a l l y i l l fa mily member.
as

there

are

b a la n c e ,

times

when

integration,

fam ilies

experience

and s t a b i l i t y ,

there

f a m i l i e s e x p e r ie n c e s t r e s s and d i s o r d e r .

p e r io d s

are

also

of

Just

growth,

periods

when

The i n t e n s i t y o f s t r e s s

can be so overwhelming t h a t d i s r u p t i o n in f am il y system f u n c t io n i n g
o c c u r s , e s p e c i a l l y when phy sic a l and psych ic energy demands ar e too
great.

Bubolz and Whiren (1984)

noted t h e f o ll o w in g

assumptions

with r e g a rd t o energy:
♦S up plies o f human e n e r gy-p hys ical and ps y ch ic a r e l i m i t e d .
♦Any a l t e r a t i o n in t h e flow o f e n e r g y - m a t t e r ,

i n f o r m a ti o n ,

and

o t h e r r e s o u r c e s r e q u i r e s a d a p tiv e change.
♦Behavior o f i n d iv id u a l
energy

inputs

by

fa mily members may r e q u i r e a d d i t i o n a l

other

fa m ily

members

as

well

as

energy

o u t p u t s f o r o b t a i n i n g t h e s e s u p p o r ts .
♦High

energy

demands

create

"energy

c r e a t i v e behavior may not be p o s s i b l e .

s in k s "

where

adaptive

This r e s u l t s in s t i l l

g r e a t e r s t r e s s on t h e fam il y.
These concepts may be ap p lie d t o t e r m i n a l l y i l l f am ily members
being c ar ed f o r a t home.

T h e ir c a r e o f t e n p l a c e s e x c e s s i v e demands

on energy l e v e l s as well as o t h e r r e s o u r c e s t h e fa m ily uses t o cope.
Ad ditional

physica l

c a r e which needs t o be provided in v o lv es high

22

emotional

demands

usually

everyone concerned.
necessary
ter m inal

energy

over

an

extended

p eriod

of

time

for

Hospice c a r e seeks t o pr ovide f a m i l i e s with th e

input

required

to

sustain

them

in

coping

with

i l l n e s s as well as pr o v id in g suppo rt through bereavement.

Using an i n t e r a c t i v e team approach, t h e ph y s ic a l and emotional c a r e
as well as energy l e v e l s r e q u i r e d t o s u s t a i n t h a t c a r e become t h e
pro vin ce o f a l l s t a f f members and v o l u n t e e r s in t h e hos pice program.
The g r e a t e r t h e i n t e g r a t i o n o f t h e s t a f f ’ s energy and s e r v i c e s , th e
more s u c c e s s fu l hospice c a r e w il l be f o r p a t i e n t s and f a m i l i e s .
Adaptation
reorganize

the

is

th e

hospice

ability

of

program t o

change o r some new in p u t oc c u r s.

th e

ho spice

a state

of

adm inistrator
equilibrium

to

after

Demands o f th e environment ar e

e x e r t e d on t h e hospice program in what t h i s r e s e a r c h e r r e f e r s t o as
an a d a p t a t i o n p r e s s .
hospice

programs

This p r e s s seems t o be i n f l u e n t i a l

along

through

their

organizational

in moving

life

cycle.

Thus, from an e c o l o g ic a l p e r s p e c t i v e , hospice can be d e s c r i b e d as a
"fa mily e n a b l e r system" which focuses on th e needs o f t h e t e r m i n a l l y
i l l person and fa m ily as they themselves d e f i n e th o s e needs in th e
HBE, HCE, and NE.

S e r v ic e s o f f e r e d t o t h e p a t i e n t and fa m ily ar e

planned and c o o r d i n a te d on t h e p a r t o f many t o s upport and enable
th e fa mily in p rovid in g c a r e t o t e r m i n a l l y i l l
own environment.

This environment

is

i n d i v i d u a l s in t h e i r

h o p e f u l ly enhanced

by th e

i n t e r a c t i o n o f hospice p r o f e s s i o n a l s and n o n p r o f e s s i o n a l s a d d r e ss in g
th e h o l i s t i c needs o f t h e p a t i e n t and fam ily.
an e c o l o g i c a l model f o r ho spice a d m i n i s t r a t i o n .

Figure 1.1 p r e s e n t s

HOSPICE
ADMINISTRATOR
DECISION MAKING

HUMAN
BEHAVIORAL
ENVIRONMENT
♦Staffing and Personnel
Management
♦Community/Public
Relations
♦Quality Assurance
♦Fiscal Management
♦Patient/Family
Relations

II

DECISION MAKING

HUMAN
CONSTRUCTED
ENVIRONMENT
♦Staffing and Personnel
Management
♦Communi ty/Publi c
Relations
♦Quality Assurance
♦Fiscal Management
♦Patient/Family
Relations

NATURAL
ENVIRONMENT
*Rural/Orban Setting
♦Energy
♦Quality Assurance
♦Patient/Family
Relations

Figure 1 . 1 . —An ec ological model f o r hospice a d m i n i s tr a ti o n .

24
Basic Assumptions f o r t h e Study
The f ollow ing assumptions were made in o r d e r t o accomplish th e
o b j e c t i v e s o f t h i s stud y.
1.

Growth o f hospice c a r e in Michigan i s i n e v i t a b l e .

2.

Growth w i ll r e q u i r e competent a d m i n i s t r a t o r s who ar e p r e ­

pared t o adapt t o changing r e s p o n s i b i l i t i e s .
3.

Hospice a d m i n i s t r a t o r s ar e s u f f i c i e n t l y informed t o respond

t o s t a te m e n ts o f competency r e l a t i v e t o t h e i r j o b req u i re m e n t s .
4.

I n te r n a l and e x t e r n a l environmental demands w i ll r e q u i r e a

conceptual
personnel

knowledge and s k i l l

base in th e a r e a s o f s t a f f i n g

management, p a t i e n t and family r e l a t i o n s ,

and

community and

p u b l i c r e l a t i o n s , f i s c a l management, and q u a l i t y a s s u r a n c e .
L i m i t a t i o n s o f th e Study
1.

The sample s i z e o f l i c e n s e d hospice s i s small r e l a t i v e t o

t h e number o f hospice exempt programs; however,
that

because

of th is

researcher’s

v isib ility

it

is anticipated
among

licensed

programs, th e r e t u r n r a t e should be s u f f i c i e n t .
2.

The e s s e n t i a l i t y o f each competency i s only measured by th e

p e r c e p t i o n s o f those people in Michigan who respond t o t h e survey.
I t remains f o r a d d i t i o n a l

s t u d i e s t o determine t h e p e r c e p t i o n s o f

o t h e r hospic e a d m i n i s t r a t o r s throughout t h e United S t a t e s .
3.

This study used a long q u e s t i o n n a i r e , however an e f f o r t was

made t o use s u c c i n c t competency s ta t e m e n ts .

25
4.

Survey respo nses were e l i c i t e d a minimum o f two t im e s , and

t h i s may have de cr eased r e s p o n d e n t s ’ a t t e n t i o n and t h e p a r t i c i p a t o r y
response r a t e .
Summary
Chapter
research
applicable

I

in tr o d u ce d

questions,
to

hospice

th e

a human

problem

for

ecological

adm inistration,

terms, assumptions, and l i m i t a t i o n s .
o f l i t e r a t u r e r e l e v a n t t o t h i s study.

this

s tu d y ,

conceptual

theoretical

ge ner al

framew or k

definitions

of

Chapter I I c o n t a i n s t h e review

CHAPTER II
REVIEW OF LITERATURE

In t h i s c h a p t e r t h e review o f l i t e r a t u r e i s d i v i d e d i n t o f i v e
parts:
1.

Hospice Overview

2.

Hospice A d m i n i s t r a t i v e Components

3.

A d m i n i s t r a t i v e Theory

4.

Competency Research

5.

Research Methodology
Survey Methodology
Delphi Technique
Hospice Overview

Although

the

appearance

of

hos pice

programs

in

the

United

S t a t e s began in 1974, t h e concept has e x i s t e d f o r c e n t u r i e s .

The

word

for

"hospice"

travelers.

originally

meant

a p la c e

of

shelter

or

rest

During t h e medieval p e r i o d , hospic e s were m ain tained by

r e l i g i o u s o r d e r s f o r i n d i v i d u a l s on p ilg rim a g e s t o t h e Holy Land.
For c e n t u r i e s , t h e idea o f hospice s i g n i f i e d a r e f u g e where people
could

be

cared

for,

nourished,

and

impoverishment, c r i s i s , o r impending d e a t h .

26

loved

in

the

face

of

27
The

modern

terminally
Sisters

of

ill

hospice
persons

C h a r ity

in

designed

traces

prim arily

its

Dublin.

roots
In

A ikenhead ope ne d a home in D u b li n
"hospice."

Through

her

the

for

directly

the
to

mid-1800s,

th e

the

S isters

of

Irish

Sister

fo r th e dying,

leadership,

care

Mary

calling

it

estab lish ed

h o s p i t a l s f o r t h e s i c k and r e fu g e s f o r t h e poor and homeless.

This

work e v e n t u a l l y spread t o London where t h e S i s t e r s e s t a b l i s h e d St.
J o s e p h ’ s , t h e f i r s t B r i t i s h ho s p ic e .

S t . J o s e p h ' s a l s o se rved as a

model f o r o t h e r English h o s p ic e s , t h e most n o t a b l e o f which i s S t.
C h r i s t o p h e r ’ s Hospice, e s t a b l i s h e d in a London suburb by Dr. Cice ly
Saunders.

I t i s t o S t . C h r i s t o p h e r ’ s Hospice and i t s founder t h a t

th e United S t a t e s hos pice movement looked f o r guidance in t h e l a t e
1970s.
The hospice concept i s cons id e re d by some t o be a human r i g h t s
movement fo cu si ng not only on t h e t e r m i n a l l y

ill

p a tie n t’s rights

but a l s o on th e f a i l u r e o f t h e e x i s t i n g medical c a r e system in th e
United S t a t e s t o meet t h e needs o f th e dying ( F in n - P a r a d i s ,
The

im porta nt

aspect

involved

is

g iv in g

the

dying

1985).

patient

and

h i s / h e r fa m il y t h e ch oic e as t o where h e / s h e wants t o d i e and then
provid ing t h e "car in g measures" needed t o give a q u a l i t y t o th e l i f e
remaining.
The National Hospice O r g an izatio n d e f in e d ho spice as "a program
of

palliative

p s y c h o lo g i c a l ,
th e ir fam ilies.

and

s u p p o r ti v e

social,

services

and s p i r i t u a l

which

care

for

provid e s
dying

physical,

per sons

and

S e r v ic e s a r e provided by a m e d ic a lly s u p e rv is e d

i n t e r d i s c i p l i n a r y team o f p r o f e s s i o n a l s and v o l u n t e e r s " (NHO, 1981).

28

All hospic e programs ar e encouraged t o a s c r i b e t o a common s e t o f 16
s ta n d a r d s developed by t h e National Hospice O r g an izatio n in 1978 and
p a t t e r n e d a f t e r Dr. Cic ely Saunders’ s p r i n c i p l e s o f hospice c a r e .
T h e se s t a n d a r d s were a l s o

utilized

in d e v e lo p in g

the

hospice

Medicare c e r t i f i c a t i o n requ ire men ts (1983) and t h e Michigan Hospice
l i c e n s u r e r u l e s (1984).
1.

They ar e as fo llo w s :

The hos pic e program complies with a p p l i c a b l e l o c a l ,

and f e d e r a l

laws

and r e g u l a t i o n s

governing

th e

state,

organization

and

d e l i v e r y o f h e a l t h c a r e t o p a t i e n t s and f a m i l i e s .
2.

The hospice program pr ovid es a continuum o f i n p a t i e n t and

home c a r e s e r v i c e s through an i n t e g r a t e d a d m i n i s t r a t i v e s t r u c t u r e .
3.

The home car e s e r v i c e s ar e a v a i l a b l e 24 hours a day, 7 days

a week.

that

4.

The p a t i e n t / f a m i l y i s t h e u n i t o f c a r e .

5.

The hospice program has admission c r i t e r i a and procedures

reflect:

service,

(b)

(a)

the

physician

patient/fam ily’s

p artic ip a tio n ,

and

desire
(c)

and

need

for

diagnosis

and

prognosis.
6.

The hospice program seeks t o i d e n t i f y , t e a c h ,

coordinate,

and s u p e r v i s e persons t o g iv e c a r e t o p a t i e n t s who do not have a
fa m ily member a v a i l a b l e .
7.

The hospice program acknowledges t h a t each p a t i e n t / f a m i l y

has i t s own b e l i e f s a nd/or value system and i s r e s p e c t f u l o f them.

29
8.

Hospice c a r e c o n s i s t s o f a blending o f p r o f e s s i o n a l

n o n p rofe s sional

services,

provided

by an

interdisciplinary

and
team,

in c lu d i n g a medical d i r e c t o r .
9. S t a f f support i s an i n t e g r a l p a r t o f t h e hospice program.
10.

I n s e r v i c e t r a i n i n g and contin uing ed uca tion a r e o f f e r e d on

a program b a s i s .
11.

The goal

o f hospice c a r e

is

t o pr ovide symptom c o ntrol

through a p p r o p r i a t e p a l l i a t i v e t h e r a p i e s .
12.
physical,

Symptom co n tr o l
em otional,

i ncludes a s s e s s i n g and responding t o the

social,

and s p i r i t u a l

needs o f t h e

patient/

f am ily .
13.

The

hospice

program

prov ides

bereavement

services

to

s u r v i v o r s f o r a p eriod o f a t l e a s t 1 y e a r .
14.
(a)

There w ill

evaluation

of

be a q u a l i t y as su ra nce program t h a t i n c l u d e s :
services,

(b)

regular

chart

audits,

and

(c)

o r g a n i z a t i o n a l review.
15.

The h o s p i c e

p rogra m

m aintains

accurate

and

current

i n t e g r a t e d r eco rd s on a l l p a t i e n t / f a m i l i e s .
16.

The h o s p i c e

in p atient

p a t i e n t / f a m i l y p r iv a c y ,

unit

(b) v i s i t a t i o n

provides

space

and viewing,

for:

and

(c)

(a )
food

p r e p a r a t i o n by t h e f am ily.
Using t h e umbrella o f t h e s e s ta n d a r d s ,

p a t i e n t management i s

based on t h e p r i n c i p l e o f a g g r e s s i v e p a l l i a t i v e c a r e , which has as
its

primary o b j e c t i v e t o

a l l e v i a t e the d is tr e s s in g

symptoms t h a t

occur du rin g t h e advanced s ta g e s o f ter minal d i s e a s e .

This in cludes

not only th e c l i n i c a l t r e a t m e n t o f ph ysic a l symptoms, but s p i r i t u a l

30

and s o c i a l as w e l l .

Because p a l l i a t i v e c a r e means t o t a l

care for

t h e p a t i e n t , t h e " u n i t o f care" becomes t h e p a t i e n t and f am ily.
Hospice A d m in is t r a t iv e Components
The work o f a l l

hospice a d m i n i s t r a t o r s t y p i c a l l y c o n s i s t s of

c o o r d i n a t in g t h e a c t i v i t i e s o f v a r io u s p a r t s o f t h e hospice program,
relatin g

t h e prog ra m t o

its

environm ent,

and i n t e g r a t i n g

performance o f persons who work in t h e program so t h a t t h e r e
adequate i d e n t i f i c a t i o n

and commitment t o t h e program g o a l s .

hospice

also

adm inistrator

concurrently

as su mes

the

the
is
The

final

r e s p o n s i b i l i t y f o r h i s / h e r hospice program in s t r i v i n g t o meet th e
s ta n d a r d s d e s c r i b e d in t h e p r ev io us s e c t i o n .
resp o n sib ility
in d i v i d u a l

t o make j u d g m e n t s a s

ho spice program and y e t

It

t o wh at

i s a c h a lle n g in g
is

best

keep a p e r s p e c t i v e

for
of

the

future

growth f o r hos pice car e in th e broa de r c o n t e x t .
Kovner and Newhouser (1978) noted t h a t both th e formation and
a p p l i c a t i o n o f a d m i n i s t r a t i v e judgment i nv ol ve s k i l l s which can be
im p ro v e d .

This

researcher believes

th at

once a d m i n i s t r a t i v e

competencies a r e i d e n t i f i e d , i n d i v i d u a l s can b e t t e r i d e n t i f y ways in
which t h e i r s k i l l s can be e v a l u a te d and p o l i s h e d .

This may occur

through an i n d iv id u a l l e a r n i n g s i t u a t i o n o r through p a r t i c i p a t i o n in
a cu r ric u lu m model f o r hos pice a d m i n i s t r a t i o n .
Through a review o f p e r t i n e n t l i t e r a t u r e ,
t o r s ’ job d es c rip tio n s,

and r e g u l a t o r y

hospic e a d m i n i s t r a ­

statutes

f o r hos pic e c ar e

from both t h e s t a t e and f e d e r a l l e v e l , t h i s r e s e a r c h e r b e l i e v e s t h a t
there

are

five

major

"bedrock

co m ponen ts"

on

which

hospice

31

a d m i n i s t r a t o r s should focus t h e i r conceptual knowledge and t e c h n i c a l
sk ills.

These f i v e broad competency a r e a s a r e :

1.

S t a f f i n g and Personnel Management

2.

P a t i e n t and Family R e l a ti o n s

3.

Community/Public R e la t io n s

4.

F i s c a l Management

5.

Q u a l ity Assurance

The f i v e competency a r e a s ar e s c h e m a t ic a l ly r e p r e s e n t e d through
an e c o l o g i c a l des ig n in Figure 2 . 1 .

A d i s c u s s i o n o f each o f t h e s e

components f o ll o w s .
S t a f f i n g and Personnel Management
S t a f f i n g re quir em ents f o r hosp ice s vary g r e a t l y .
as

stage

of

geographic

development
area

of

covered,

the

rural

organization,
or

urban

ty p e

lo cation,

F acto r s such
of

program,
available

community r e s o u r c e s , funding s u p p o r t , and e t h n i c groups served ar e
dete rm in ing elements.
R e l a t i v e t o s t a t e o f development, P e t r o s i n o and Weitzel
noted t h a t

a new ho s p ic e g e n e r a l l y

requires

(1984J

p r o p o r t i o n a t e l y more

s t a f f members p e r p a t i e n t served than an e s t a b l i s h e d one because a
greater
refining

amount

of

time

is

consumed

r e c o r d i n g and r e p o r t i n g

community r e l a t i o n s h i p s .

in

establishing

procedures,

By c o n t r a s t ,

in d i v i d u a l may be t h e hos pice a d m i n i s t r a t o r ,
n a t o r , and t h e p a t i e n t c a r e c o o r d i n a t o r .

and e s t a b l i s h i n g

most ho s pic e s

develop i n i t i a l l y with "bar e bones" s t a f f i n g

pro c e d u re s ,

(Olson,

in Michigan
1986).

One

the volunteer co ordi­

This m u l t i p l e r o l e concept

Com m unity/
Public R e la tio n s

Staffing/
Personnel
M anagement

f

1

Fiscal
M anagement

t

DECISION MAKING

1

H ospice
A dm inistrator
1

DECISION MAKING

1

Pt/Fam ily
R elations

Figure 2.1:

Hospice a d m i n is tr a tiv e competency a r e a s .

Quality
Assurance.

33
may be b e n e f i c i a l
as

pro g ram s

in e a r l y program development, but u n f o r t u n a t e l y ,

grow and

increased

staffin g

needs

seem e v i d e n t ,

personnel f i n d i t d i f f i c u l t t o d i v e s t from t h e i r m u l t i p l e r o l e s .
As i d e n t i f i e d

in o r g a n i z a t i o n a l

life

cycle theory

( d is c u s se d

l a t e r ) , t h i s r e s e a r c h e r noted t h a t most hospice programs in Michigan
a r e perhaps in s t a g e I and I I o f development.
The ty pe
staffing.

of

program

certainly

p la y s

an

important

role

in

Both h o s p i t a l - b a s e d and home-health-agency-based hospice

programs seem t o be more a f f l u e n t in s t a f f i n g a v a i l a b i l i t y , whereas
t h e independent community-based a nd/or v o l u n t e e r - i n t e n s i v e hosp ice s
must o f te n work very hard t o i d e n t i f y p o t e n t i a l hos pice p e r s o n n e l .
The geographic

ar ea

served and l o c a t i o n

of the

hospice

im portant c o n s i d e r a t i o n s in determ ining s t a f f i n g needs.

are

The amount

o f t r a v e l time s t a f f members r e q u i r e t o make home v i s i t s determines
how many

home

location,

an

visits
urban

are

feasible

hospice

each

generally

day.

has

more

With

r e g a rd

to

w ell-established

s u p p o r tiv e s e r v i c e s a v a i l a b l e t o i t , and t h e r e f o r e s t a f f members can
e a s i l y make r e f e r r a l s .

By c o n t r a s t , s t a f f members in r u r a l hosp ice s

f r e q u e n t l y must pr ovide more s e r v i c e s themselves o r spend more time
t r a i n i n g and c o o r d i n a t i n g v o l u n t e e r s t o c a r r y out s upport s e r v i c e s .
A v a il a b le community r e s o u r c e s

affect

staffing

to

t h a t a hospice may be a b l e t o n e g o t i a t e f o r s t a f f i n g

the

extent

s u p p o rt.

A

s m a ll , v o l u n t e e r - i n t e n s i v e hospice program may n e g o t i a t e a c o n t r a c t
with

a local

home h e a l t h

agency t o

provid e

n u r sin g

h e a l t h aide supp ort f o r t h e hospice p a t i e n t and fam il y.

a n d /o r

home

34
There has not been e x t e n s i v e r e s e a r c h in th e ar ea o f e t h n i c i t y
and hospice c a r e , al though hospice programs i n d i c a t e an awareness o f
e t h n i c i t y needs.

For example,

a hospice program had d i f f i c u l t y

communicating with and meeting th e needs o f a P o lish p a t i e n t .

A

v o l u n t e e r who spoke P o li s h and was f a m i l i a r with t h e "old country"
made c o n s i d e r a b l e s t r i d e s with th e Po li sh p a t i e n t in a s s i s t i n g with
hospice c a r e .
Major r e s p o n s i b i l i t i e s f o r th e hospice a d m i n i s t r a t o r r e l a t i v e
to

staffin g

retention

and p e r s o n n e l

o f employees

are:

(including

recruitm ent,
volunteers),

o rien tatio n

and

management o f

the

i n t e r d i s c i p l i n a r y team, v o l u n t e e r s , medical d i r e c t i o n , r e d u c t i o n o f
staff

stress,

and maximization o f s t a f f

energy i n p u t s .

A brief

d i s c u s s i o n o f t h e s e r e s p o n s i b i l i t i e s f o llo w s .
Rec ruitment,
ongoing e f f o r t
which

is

physical,

orientation,

to orie n t

and

new s t a f f

retention.
using

comprehensive enough t o prep ar e
psychological,

sp iritu al,

and

There

remains

an o r i e n t a t i o n

an

program

s t a f f to

attend

to

th e

social

needs

of

the

p a t i e n t s / f a m i l i e s as well as t o a s s i s t new s t a f f in u t i l i z i n g s e l f care

strategies

staffing

for

for

hospice

them se lves .
care

is

According

determined

by

to
two

P rofitt

(1985),

factors:

(a)

p a t i e n t s ’ average l e n g t h o f s t a y (ALOS) in t h e hos pice program and
(b)

i n t e n s i t y o f s e r v i c e s r e q u i r e d by t h e p a t i e n t and fam il y.

s tu dy o f hospice p a t i e n t s in Cleveland, Ohio,

A

in 1981 r e v e a l e d an

ALOS o f 48.3 days with a median o f only 27.0 days (Brooks & SmithS t a ru c h , 1984).

Thus, many p a t i e n t s may be in th e ho spic e program

l e s s than 1 month.

For Michigan, F in n-P ar ad is (1983) i n d i c a t e d t h a t

35

hospice programs a r e c o n tin u in g t o i n c r e a s e s t a f f i n g l e v e l s .

Her

r e s e a r c h i n d i c a t e d t h a t t h e average s t a f f s i z e i n c r e a s e d from 1.6 in
1979 t o 8 . 8 in 1983.
The hospice a d m i n i s t r a t o r
s t a f f with e d u c a tio n a l

is

also

inservices.

responsible

for

These i n s e r v i c e s may r e l a t e t o

c u r r e n t c a r e i s s u e s such as ad m itt in g AIDS p a t i e n t s .
has

encouraged

programs

to

care

p rovid in g

for

AIDS

Although NHO

patients

(NHO P olicy

S ta te m en t, November 1985), many program a d m i n i s t r a t o r s a r e concerned
realistically

with

staff

attitudes,

c a r i n g f o r AIDS p a t i e n t s ,

staff

inservice

training

on

and perhaps denied reimbursement f o r th e

c a r e tendered (Hospice L e t t e r . January 1986).
The i n t e r d i s c i p l i n a r y
interdisciplinary
basis.

According

team,
to

team .

C ertain

which meets most
Michigan

hospice

staff

com prise

frequently

licensure,

on

the

the

a weekly
team must

c o n s i s t o f a n u r s e , p h y s ic i a n , v o l u n t e e r , s p i r i t u a l c o u n s e l o r (when
i n d i c a t e d by th e f a m il y ) ,

and s o c ia l worker.

Home h e a l t h a i d e s ;

p h y s i c a l , speech, a n d /o r occupationa l t h e r a p i s t s ; n u t r i t i o n i s t s ; and
p har m acists may a l s o be in c lu d e d .

Their major r e s p o n s i b i l i t y i s t o

plan and c o o r d i n a t e t h e s e r v i c e s pro vid ed.
team f u n c t i o n i s

This i n t e r d i s c i p l i n a r y

a l s o mandated by JCAH (1983),

Medicare

(Federal

R e g i s t e r #48, 1983) and Michigan Hospice r u l e s (Michigan Department
o f P u b li c Health Code, Act #368, PA 1978).

Fundamental t o t h e team

approach i s th e concept t h a t no one person has a l l th e answers and
that total

c a r e i s made e a s i e r by a v a r i e t y o f p e r s o n n e l ,

v a r i e t y o f r e s o u r c e s , working t o g e t h e r .

with a

The a d m i n i s t r a t o r monitors

36
t h e f u n c t i o n s o f t h e i n t e r d i s c i p l i n a r y team and in some programs in
Michigan

actually

directs

th e

team meetings

on

a

regular

b a s is

(Olson, 1986).
Volunteers.
us in g

extensive

direct

patient

Unique t o t h e hospic e concept i s t h e p r a c t i c e o f
volunteer
services,

services
which i s

to

provid e

both

s u p p o rt

mandated by both t h e

and

Michigan

Hospice Lice nsu re Rules and hospice Medicare c e r t i f i c a t i o n .

This

use o f v o l u n t e e r s demands r e c r u i t m e n t , r e t e n t i o n , ongoing e d u c a t i o n ,
and

co ordination

of

volunteers

by

a

volunteer

coordinator.

According t o hospice Medicare C e r t i f i c a t i o n , v o l u n t e e r s t a f f must be
managed as r e g u l a r hospice employees; t h e r e f o r e , i t i s incumbent on
t h e a d m i n i s t r a t o r t o ensure o r i e n t a t i o n ,

inservice education,

s u p e r v i s i o n which matches t h a t o f s a l a r i e d s t a f f .

and

Blum (1985) noted

t h a t a d m i n i s t r a t o r s must a l s o c o n s id e r l i a b i l i t y and l e g a l s a n c t io n s
a p p r o p r i a t e f o r both s a l a r i e d and v o l u n ta r y s t a f f .
Medical d i r e c t i o n .
by a medical

Every hospice must have medical d i r e c t i o n

d i r e c t o r who i s

This i n d i v i d u a l

currently

licensed

as

a physician.

i s co n s id e red an employee whether h i s / h e r s e r v i c e s

a r e provided by c o n t r a c t o r in a v o l u n t e e r c a p a c i t y .

In Michigan,

many hospice programs have v o l u n t e e r medical d i r e c t o r s s e r v in g most
f r e q u e n t l y in a p a r t - t i m e c a p a c i t y (Olson, 1986).

T e c h n i c a l l y , th e

medical d i r e c t o r answers t o t h e ho spice a d m i n i s t r a t o r .

He/she i s

t h e hospice program’ s primary r e s o u r c e and s u p p o rt f o r a p p r o p r i a t e
pai n management.

The medical d i r e c t o r a l s o i n t e r a c t s with a t t e n d i n g

p h y s ic i a n s who must dete rm in e , by v i r t u e o f admission c r i t e r i a ,
p a t i e n t ’ s 6-month terminal p r o g n o s is .

th e

The ho spice a d m i n i s t r a t o r and

37

th e medical d i r e c t o r must be at tu n e d t o b u ild i n g p h y s ic ia n support
t o a s s u r e co ntinued p a t i e n t r e f e r r a l s .
Staff s tre s s .

Vachon (1986) noted t h a t th e l a c k o f d e f i n i t i o n s

o f c l e a r p r o f e s s i o n a l r o l e s i s a major s t r e s s - i n d u c i n g f a c t o r in th e
hospice work environment.

However, McArdle (1985) noted t h a t i t i s

realistic

a w ell-functioning

to

ex pec t t h a t

have s t a f f t e n s i o n .

hos pice program w il l

Hospice s t a f f provide a wide range o f s e r v i c e s

and perform many c a r e - g i v i n g a c t i v i t i e s f o r t e r m i n a l l y i l l
and t h e i r f a m i l i e s .

patients

However, t h e i r work may a l s o produce s t r e s s and

a f f e c t t h e i r own emotional w e l l - b e i n g .

Research by Yancik (1984)

revealed

stress-producing

h o s pic e :

that

there

were

three

major

areas

in

s t a f f s up por t i s s u e s , emotional concern f o r p a t i e n t s and

th e i r fam ilies,

and management o f th e d i s e a s e p r o c e s s .

Of t h e s e

t h r e e , t h e l a c k o f s t a f f suppo rt proved t o be t h e g r e a t e s t o v e r a l l
producer o f s t r e s s .

Thus,

Yancik i n d i c a t e d th e need f o r hospice

a d m i n i s t r a t o r s t o improve t h e working c o n d i t i o n s o f hospice s t a f f
and t o i n c r e a s e communication with them.
Thus, one o f th e a d m i n i s t r a t o r ’ s r o l e s
stress.

i s t o reduce employee

S e t t i n g a s id e s p e c i f i c time f o r s upp ort group meetings i s

im po rta nt but a l s o r e q u i r e s t h a t s t a f f have s upport sources in t h e i r
daily a c tiv itie s .

Ongoing supp ort groups a r e a v a l u a b l e a s s e t t o

th e s t a f f w i t h i n t h e ho spic e program.
t h e m a j o r i t y o f s t a f f can a t t e n d with
group communication t e c h n i q u e s .

Meetings a r e o f t e n h e ld when
a group l e a d e r s k i l l e d

in

E f f e c t i v e communication on t h e p a r t

38
of

the

hospice

adm inistrator

is

perhaps

the

foundation

for

s u c c e s s f u l s t a f f s uppo rt e f f o r t s .
Energy

inputs.

address s t a f f i n g ,

Finally,

personnel,

energy

req uirem en ts

and f a t i g u e

th at

to

and p a t i e n t / f a m i l y needs can be very

demanding f o r t h e hospice a d m i n i s t r a t o r .
sinks"

ne ces sary

occur

can

Replenishing t h e "energy

be a c c o m p l i s h e d

by h a v i n g

o p p o r t u n i t i e s t o meet with o t h e r hos pice a d m i n i s t r a t o r s not only to
d i s c u s s programmatic i s s u e s but a l s o t o r e c e i v e pee r s u p p o rt .

As

one hospice a d m i n i s t r a t o r t o l d t h i s r e s e a r c h e r , " I t ’ s a very l o n e ly
jo b when you have no o t h e r

directors

to

talk

with."

Both th e

h o s p i c e a d m i n i s t r a t o r and h i s / h e r s t a f f may ex pend phenomenal
amounts o f energy c o o r d i n a t in g and d e l i v e r i n g p a t i e n t c a r e ,
covering

large

conditions.

geographical

The i s s u e

areas

o f "What i s

in

all

enough?

types

of

What i s

o f te n

weather

too much?"

remains an o f t e n unanswered q u e s tio n in p rovid ing hospice c a r e .
S t a f f i n g and personnel management, t h e r e f o r e , a r e key elements
in a d m i n i s t e r i n g a s u c c e s s f u l hospice program.
ties

of the

assuring
staff.

h o s p ic e

recruitment

adm inistrator
and o r i e n t a t i o n

focus

on

Major r e s p o n s i b i l i ­
staff

selection

and

f o r both pa id and v o l u n t e e r

The hospice a d m i n i s t r a t o r a l s o monitors t h e f u n c t i o n o f th e

i n t e r d i s c i p l i n a r y team while a s s u r i n g o v e r a l l medical d i r e c t i o n f o r
t h e program.

Woven through t h e s e f u n c t i o n s

s t a f f s t r e s s and a d m i n i s t r a t o r f a t i g u e .
this

component

is

knowledge

d i s c i p l i n e , and m o t i v a t i o n .

of

ar e

issues

In a d d i t i o n ,

personnel

evaluation,

involvin g

im plicit

in

e d u c a ti o n ,

39
P a t i e n t and Family R e la ti o n s
In

th e

hospice

program,

fa mily

primary c a r e - g i v i n g r e s p o n s i b i l i t i e s .

members

most

o f te n

assume

Spouses, c h i l d r e n , r e l a t i v e s ,

and f r i e n d s may c o n t r i b u t e t o o v e r a l l p a t i e n t c a r e .

What i s unique

about hospice i s t h a t t h e c a r e - g i v e r s ar e a l s o cared f o r by hospice .
The concept o f " u n i t o f c a r e " as d e s c r ib e d by Buckingham and Lupu
(1982) and r e q u i r e d by Michigan hospice l i c e n s u r e c l e a r l y i d e n t i f i e s
that

s e r v i c e s must extend t o and in c lu d e t h e

f a m il y .

Bass

and

Garland (1985) noted t h a t family members may be in more need than
anyone e l s e o f th e a s s i s t a n c e a hospice program can o f f e r .
program a d m i n i s t r a t o r
encourages

fam ilies

d elineation

of

to

this

means

become

specific

monitoring

involved

tasks

and

and

For th e

an

environment

stay

involved .

activ ities

for

that
The

fam ilies,

p a r t i c u l a r l y by t h e n u r sin g s t a f f who v i s i t t h e home s e t t i n g on a
reg u lar basis,

can be h e l p f u l .

In a d d i t i o n ,

i f th e p a t i e n t

M e d i c a r e - c e r t i f i e d h o s p i c e s h o u l d need m e d i c a l

in a

equipm ent,

the

hospice a d m i n i s t r a t o r must ensure t h a t t h e equipment i s a v a i l a b l e .
Equipment may

in clude

a

hospital

bed,

oxygen,

s u c ti o n

w a lk e r s , bedside commodes, and devices t h a t a s s i s t
patient

in and out o f bed.

machine,

in l i f t i n g

th e

In programs which a r e not hospic e -

Medicare c e r t i f i e d , t h e a d m i n i s t r a t o r t r i e s t o p o s tu r e t h e hospice
program as a r e s o u r c e t o r e f e r t h e fa mily t o o t h e r ag en ci es in th e
community which might

be ab le

to

assist

in

s e c u rin g

the

needed

s u p p l i e s or equipment.
P a t i e n t / f a m i l v r i g h t s and c o n f i d e n t i a l i t y .
f am ily r i g h t s and r e s p o n s i b i l i t i e s

as well

Assuring p a t i e n t /

as medical

info rm ation

40

c o n f i d e n t i a l i t y i s r e q u i r e d by both Michigan l i c e n s u r e and hospice
Medicare

certification.

Excerpts

o f Michigan

ho spice

licensure

r u l e s (October 1984) ar e as fo ll o w s :
R325.13110 P a t i e n t r i g h t s and r e s p o n s i b i l i t i e s r e a d s :
1.

"A hospice s h a l l

d istrib u te,

and

develop, adopt,

im plem en t

a

pos t in a p u b l i c p l a c e ,

policy

on

the

rig h ts

and

r e s p o n s i b i l i t i e s o f hospice p a t i e n t - f a m i l y u n i t s in accordance with
t h e re quire m en ts o f s e c t i o n s 20201, 20202, and 20203 o f t h e code."
2.

"A hospice s h a l l

patient-fam ily

u n it will

a s s u r e t h a t in fo rm ation t r a n s m i t t e d t o a
be

communicated

in

a manner t h a t

w il l

r easonab ly in s u r e t h a t t h e inf or m at io n i s under stood by t h e p a t i e n t fa m ily u n i t . "
R325.109 Development o f p o l i c i e s and proce dur es r e a d s :
(t) ( ii )
(t)
of the

(iii)

" C o n f i d e n t i a l i t y o f medical i n f o r m a t i o n ."
"Release o f in fo rm at ion o r t h e p r o v is i o n o f copies

info rm ation t o

patient-fam ily units

or a u t h o r i z e d

persons

upon th e w r i t t e n cons ent o f t h e p a t i e n t o r g u a r d i a n . "
Excerpts from th e hosp ice Medicare b e n e f i t which a l s o s upport
t h e s e require m en ts a r e :
418.60 Con ti nu ation o f c a r e r e a d s :
"The ho spic e does not d i s c o n t i n u e o r d im inish c a r e provided t o
a Medicare b e n e f i c i a r y because o f t h e b e n e f i c i a r i e s ’ i n a b i l i t y
pay."

to

41
418.62 Informed consent r e a d s :
"The hospice dem on strates r e s p e c t f o r an i n d i v i d u a l ’ s r i g h t s by
en s u rin g t h a t an informed co nsen t form t h a t s p e c i f i e s t h e ty pe o f
c a r e and s e r v i c e s t h a t may be provided as hos pic e c a r e dur in g th e
cour se o f t h e i l l n e s s has been obtained f o r every i n d i v i d u a l . "
418.74 (b) P r o t e c t i o n o f inform ation r e a d s :
"The

hospic e

s a fe g u a r d s

the

clinical

record

against

loss,

d e s t r u c t i o n and un authoriz ed u s e ."
C o n t i n u i t y o f c a r e must a l s o be as su r e d t o t h e p a t i e n t / f a m i l y
as p a r t o f t h e r i g h t s accorded them in r e c e i v i n g ho spice c a r e .

The

p a t i e n t ’ s plan o f c a r e should not be i n t e r r u p t e d f o r t h e p a t i e n t
moving from home t o a h o s p i t a l s e t t i n g o r h o s p i t a l t o home c a r e .
Bereavement c a r e .
h o s p ic e 's

Formalized bereavement s e r v i c e w i t h i n

organizational

stru ctu re

r e s p o n s i b i l i t i e s t o t h e f a m ily .

is

a natural

extension

the
of

I t i s im portant t o no te t h a t th e

p r o v is i o n o f bereavement c a r e i s mandated (but not reimbursed) under
c u r r e n t hospice Medicare l e g i s l a t i o n in t h e United S t a t e s and a l s o
mandated

as

a r eq uire men t

for

Michigan

licensure

(Hospice

325.13305, Michigan Department o f P ub lic H e a lth , 1984).

Rule

For hospice

l i c e n s u r e in Michigan, a d m i n i s t r a t o r s must en s u re t h a t bereavement
fo llow-up

to

fam ilies

is

available

fo llow ing th e p a t i e n t ’ s d e a t h .

for

a minimum o f

13 months

As bereavement p r e p a r a t i o n and car e

a r e p a r t o f r e g u l a r hospice s e r v i c e s , th e hospice a d m i n i s t r a t o r must
ensure t h a t bereavement e d u c a t i o n , m on ito rin g , and a s s i s t a n c e begin
e a r l y and co n ti n u e in a c o o r d in a te d f a s h i o n .

42
R e s p it e c a r e .

P a t i e n t and fa mily r e l a t i o n s a r e a l s o important

in t h e p r o v is i o n o f r e s p i t e c a r e .

According t o t h e hos pice Medicare

c e r t i f i c a t i o n model, r e s p i t e c a r e accommodates t h e fa m il y o r primary
c a r e - g i v e r by

pr o v id in g an a l t e r n a t e p l a c e f o r t h e p a t i e n t t o s ta y

when home c a r e - g i v e r s need a r e s t from t h e everyday p h ys ic a l
em otional
relative.

strain

of caring

for

the

term inally

ill

friend

and
or

The a d m i n i s t r a t o r must be a t t u n e d t o a p p r o p r i a t e r e s p i t e

s i t u a t i o n s f o r f a m i l i e s and t o a v a i l a b i l i t y o f s t a f f

in pro viding

t h e needed r e s p i t e c a r e .
Thus, hos pic e c a r e i s f o r and about p a t i e n t s and f a m i l i e s .
skills
manage

The

and knowledge base r e q u i r e d by a hos pice a d m i n i s t r a t o r t o
p atient

and

fam ily

relatio n s

includes

reference

a d m is s io n /d is c h a r g e c r i t e r i a , p a t i e n t / f a m i l y r i g h t s ,

to

patient/fam ily

c o n f i d e n t i a l i t y , c o n t i n u i t y o f c a r e , bereavement, and r e s p i t e c a r e .
Communitv/Public R e l a t i o n s
Lamb
widespread
w arranting

(1985)
belief

defined
that

is

hospic e

is

s u p p o rt
a

viable

p r o m o t i o n and d e v e l o p m e n t .

in f o r m a l ly o r g a n iz e t o
s upport

community

promote hospic e

usually targ eted

as

for

hospice

health

As g r o u p s
care,

care

or

community

priority.

might argue t h a t community r e l a t i o n s and p u b l i c r e l a t i o n s

th e

o ption

form ally

increased

an a d m i n i s t r a t i v e

as

One

a r e one

and t h e same; however, th ey can be d i f f e r e n t i a t e d .
Community r e l a t i o n s c a p t u r e t h e co m m u n ity ’ s i n v e s t m e n t in
hos pice

as

well

as

the

hospice

program’ s

ability

to

meet

th e

community’ s need f o r e d u catio n in t h e a r e a o f hospice c a r e , death

43
and dying,

and g r i e f / l o s s

issues.

The ho spice program must

t a i l o r e d t o meet t h e needs o f t h e in d i v i d u a l l o c a l community.
can only

be accomplished

and p o l i t i c a l

by knowing c u l t u r a l ,

influences

in c o n c e r t

with

social,

and p r o f e s s i o n a l e d u catio n i s c r i t i c a l

This

economic,

a know ledg e

community p r o f i l e and gaps in h e a l t h c a r e d e l i v e r y .

be

of

the

On-going p u b l i c

t o f a c i l i t a t e understanding

and s u b sequentl y may pr ovid e funding s up por t f o r ho s p ic e c a r e .
Public

relatio n s,

"marketing" a c t i v i t y .
the

community.

on

special serv ices.

other

hand,

is

o ften

called

I t focuses on how hospice i s "perceiv ed" in

Marketing

c o n tin u in g e f f o r t ,

the

th e

hospice’s

services

has

emphasizing t h e h o s p i c e ’ s q u a l i t y

to

be

of care

a
and

Health c a r e p r o f e s s i o n a l s , p u b l i c p o licy -m ak e rs ,

and th e community a r e e s s e n t i a l

in developing

both community and

p u b l i c r e l a t i o n s f o r hos pice c a r e .
Community e d u c a t i o n .
s m all

H istorically,

community b e g i n n i n g s .

T hese h o s p i c e s

r e l a t i o n s with t h e l a r g e r community.
about what hospice does

had t o

estab lish

The p u b l i c needs i n form ati on

and about t h e

dea th t h a t make hospice work.

hospic e s u s u a l l y have had

attitudes

toward l i f e

and

As ho s pic e s become more e s t a b l i s h e d

in t h e community, th e y a r e being u t i l i z e d as a r e s o u r c e f o r programs
in g r i e f and l o s s u n r e l a t e d t o terminal i l l n e s s (Olson, 1986).

The

hospic e a d m i n i s t r a t o r must be a t tu n e d t o meeting t h e s e community
needs w it h i n

program s t a f f i n g

bureaucratic

phase

of

the

constraints.

organizational

As i n d i c a t e d
life

cycle

in

th e

( d is c u s s e d

l a t e r ) , i f t h e s e needs a r e not met by r e s p o n s i b l e a d a p t a t i o n on th e

44
agency’ s p a r t ,

i t can l e a d t o reduced p u b l i c concern and eventual

d im inutio n in th e flow o f p u b l i c re so u r c e s (Blau, & S c o t t , 1962).
Ne ao tiation/com m unication.

The "community" a l s o in c lu d e s o t h e r

h e a l t h c a r e p r o v id e r s with whom t h e hos pice program must i n t e r a c t .
For hospice programs
adm inistrator

is

seek ing

required

to

hospice Medicare c e r t i f i c a t i o n ,
develop c o n t r a c t u a l

the

agreements with

a c u t e - c a r e o r l o n g - t e r m - c a r e h o s p i t a l s in t h e community t o provide
f o r ac ute

symptom c o n t r o l

types of c o n tractu al
phys ical

therapy,

and r e s p i t e

care.

In a d d i t i o n ,

a g r e e m e n t s m ight be r e q u i r e d

speech t h e r a p y ,

occu pational

to

therapy,

other

provide
and o t h e r

co u n s elin g t h e p a t i e n t and fa m il y may need.
To a g r e a t e x t e n t t h e r e p u t a t i o n and c r e d i b i l i t y o f a hospice
ar e based on t h e communications t h a t
persons

representing

c o m m u n ic a tio n

must

ho spice personnel

community r e s o u r c e s .
be

a

prim ary

M aintaining

concern

for

the

have with
effective
hospice

a d m i n i s t r a t o r , e s p e c i a l l y when p a t i e n t c a r e i s provided by various
health care p ro fessio n als.
care,

24-hour

staff

The combination o f i n p a t i e n t and home

availability

(often

by

contract

services),

r e s p i t e c a r e , and v o l u n t e e r placement r e q u i r e s a c o n cer ted e f f o r t to
en sure t h e c o n t i n u i t y o f c a r e so e s s e n t i a l t o t h e p a t i e n t and family
( P e t r o s i n o & W eitzel, 1984).
Co mpet ition.

Competition in h e a l t h c a r e ,

particularly

among

p r o v id e r s o f home c a r e , t o in c lu d e hospice, i s now a r e a l i t y in most
communities
always

(Moga,

und er sta nd

1985).
the

Patients

distinction

and r e f e r r a l
between

sour ce s do not

traditional

home

car e

s e r v i c e s which focus on c u r a t i v e nursing c a r e , versus th e h o l i s t i c

45

p a l l i a t i v e approach in ho spice c a r e .

F r e q u e n t ly ,

th e c o m p e ti tiv e

environment in home h e a l t h c a r e p r e v e n ts p a t i e n t s from hea rin g about
hos pice programs and knowing t h a t
available.

a choice

of

ty p e s

of care

is

The hospice a d m i n i s t r a t o r needs a knowledge o f marketing

te chniques in o r d e r t o a s s u r e t h a t t h e hospice program message is
e f f e c t i v e l y communicated t o th e p u b l i c .
Competition has a l s o developed among hos pic e programs w ith in
t h e same community.
programs

which

administrators

Consumers may have a ch oice between two hospice

may c a r r y
in

this

identical

situation

credentials.

must

increase

Thus,
their

hospice
marketing

e f f o r t s t o as su r e t h a t d i s t r i b u t i o n o f r e f e r r a l s i s in t h e i r f a v o r.
G ov er n in g b o a r d r e l a t i o n s .
relations

f u n c t io n r e q u i r e s

A n o t h e r community and p u b l i c

i n t e r a c t i o n with th e governing board.

The board comprises a v a r i e d p r o f e s s i o n a l mix o f people concerned
with

promoting

hospice

care

in

their

community.

The

hospice

a d m i n i s t r a t o r i s ac co untab le t o th e board f o r d a y - t o -d a y o p e r a t i o n s
of

th e

hospice

program.

T h e re f o re ,

communication

is

essential

between h i s / h e r board and t h e hospice employees and v o l u n t e e r s .

The

hospice a d m i n i s t r a t o r in es se nc e becomes t h e " l i n k i n g pin" between
t h e s e two groups o f people.
In

summary,

encompasses

sk ills

the
and

com m unity/public
knowledge

relatio n s

required

in

the

component
areas

of

communication, knowledge o f a v a i l a b l e community r e s o u r c e s and use of
t h o s e r e s o u r c e s , c o n t r a c t u a l n e g o t i a t i o n s , and work with a governing
board.

46
F is c a l Management
H isto rically ,

pay

or

in su r an ce coverage as c o n s i d e r a t i o n s f o r reimbursement.

Care

is

provided

Michigan

regardless

hospices

of

have n o t

ability

to

used

pay.

ability

According

to

to

Hospice Licensure Rule R325.13107:
The ho spice a d m i n i s t r a t o r s h a l l implement f i n a n c i a l p o l i c i e s
and pro c e d u re s , approved by t h e governing body, accord ing to
sound bu s in es s p r a c t i c e , i n c l u d i n g , but not l i m i t e d t o , a l l of
th e f o llo w in g :
(a) p a y r o l l , (b) budget, (c) a c c e p tin g and
accounting f o r g i f t s and d o n a ti o n s , (d) keeping and s u b m it tin g
such r e p o r t s and r e c o r d s as r e q u i r e d by t h e department and
o t h e r a u t h o r iz e d ag e n c ie s .
Reimbursement.

As o f January 1, 1986, l e g i s l a t i o n in Michigan

now r e q u i r e s commercial h e a l t h insu rance companies t o o f f e r coverage
f o r hospice c a r e whenever th ey i s s u e o r renew p o l i c i e s which provide
coverage f o r i n p a t i e n t h o s p i t a l c a r e .

The hos pice Medicare b e n e f i t

i s a major reimbursement o ption although hosp ice s say Medicare r u l e s
are

burdensome and expensive

benefit,

to

implement.

the

Medicare

b e n e f i c i a r i e s with a l i f e expectancy o f 6 months o r l e s s

can e l e c t hospice cover age.

P a t i e n t s must waive a l l o t h e r Medicare

s e r v i c e s exce pt f o r p h y s ic i a n c a r e .
rates

Under

for

continuous

four

different

home c a r e ,

levels

inpatient

Hospice programs a r e pai d f l a t
of

care,

care:

routine

and r e s p i t e

home

care.

care,
While

hospice s a r e s t r u g g l i n g t o make th e changes n e c e s s a r y t o q u a l i f y f o r
Medicare reimbursement, th e y a r e a l s o being f or ce d t o a d j u s t t o t h e
c o m p e tit iv e

health

care

environment.

Competition

for

community

d o l l a r s may f o r c e n o n c e r t i f i e d hosp ice s out o f b u s in e s s e n t i r e l y or
may push them t o make t h e changes n eces sar y t o q u a l i f y f o r f e d e r a l
dollars.

47

Fund r a i s i n g .
to

be

importa nt

Community fund r a i s i n g and g r a n t w r i t i n g appear
alternatives

hospic e s e r v i c e s .
full

advantage

in

securing

additional

funding

Hospice a d m i n i s t r a t o r s must be c r e a t i v e and t a k e
of

community

financial

s u p p o rt.

This

in c lu d e s

a g g r e s s i v e f u n d - r a i s i n g cam p aig n s s u p p o r t e d by d o n a t i o n s
i n d i v i d u a l s and o r g a n i z a t i o n s .
is

for

a gift-generating

from

Owen (1985) noted t h a t hospice c ar e

program.

These d onations

result

from th e

d o nor’ s i n t e r e s t in hospic e c a r e , s a t i s f a c t i o n with hospice s e r v i c e s
r e c e i v e d , o r d i r e c t s o l i c i t a t i o n by t h e hospic e program.
While hospice programs cannot be expected t o s u r v i v e on g i f t s
alo ne, some communities have found l o c a l age nc ies such as t h e United
Way and v a r io u s v o l u n t e e r s e r v i c e a s s o c i a t i o n s
fin an cial

support.

contracts,

and do n atio n s

overall

financial

A ll

the
ar e

management

expected

as

a resource

revenues

from

f o r e c a s t as p a r t o f th e
planning

by

th e

for

grants,

budget and

adm inistrator

and

governing body.
Volunteer c o s t s a v i n g s .
h o s p i c e M e d ic a r e b e n e f i t

The r o l e v o l u n t e e r s
is

also

a fiscal

play under th e

consideration.

A

M e d i c a r e - c e r t i f i e d hospice program i s r e q u i r e d t o m ain ta in v o l u n t e e r
s t a f f s u f f i c i e n t t o pr ov ide a d m i n i s t r a t i v e o r d i r e c t p a t i e n t car e
t h a t a t minimum equals 5% o f t h e t o t a l
paid

hospice

e m p lo y e e s

and

re quire m en ts can be e a s i l y

contract

ac hieve d,

p a t i e n t c a r e hours o f a l l
staff.

Although

these

t h e time s p e n t documenting,

r e c o r d i n g , and computing t h e f i g u r e s i s c o n s id e r a b l e (Tehan, 1985).

48
As hospice programs evolve through t h e i r

organizational

life

c y c l e , f i s c a l management o f ho spice becomes more and more complex.
Hospice a d m i n i s t r a t o r s a r e now encouraged in c u r r e n t l i t e r a t u r e to
review

budgeting

and

fiscal

practices

s p e c i f i c programs (Lamb, 1985).
the

opportunity

delivery

to

define

of serv ice

organization aliv e .

a

fin a n c ia l or organizational
decisions

th at,

in

t o th e f i s c a l

financial

them

to

their

system

sk ills

that

n eed ed

blends

the

kee p

the

to

(1976) suggested t h e r e ar e no p u r e ly
actions,

reality ,

o r g a n i z a t i o n a l ter ms .

apply

The hospice a d m i n i s t r a t o r now has

and p r a c t i c a l
Silvers

and

are

In summary,

but r a th e r a d m in istra tiv e

expressed

in

financial

or

t h e knowledge and s k i l l s r e l a t e d

component o f a hospice program in c lu d e knowledge of

reimbursement modes,

bud geting,

fund

raising,

grant

w riting,

and

c o s t- c o n ta i n m e n t s t r a t e g i e s .
Q u a lit y Assurance
The "growing pains" and o f t e n i n c o n s i s t e n t f i n a n c i a l

position

o f many hospice programs do not e l i m i n a t e t h e need f o r a thorough
q u a l i t y - a s s u r a n c e program.

Although hospice programs

in Michigan

vary in s i z e and in scope o f s e r v i c e , a l l programs p u r p o r t t o have a
common mission o f p r o v id in g t h e b e s t p o s s i b l e c a r e

t o t h e dying

p a t i e n t s and t h e i r f a m i l i e s .
A oualitv-assurance
responsible

for

assuring

q uality -assu ran ce plan.
of care,

plan.

The h o s p i c e

adm inistrator

is

t h e development and implementation o f a
This plan should in c l u d e s p e c i f i c s t a n d a r d s

methods o f d a t a c o l l e c t i o n ,

a time frame f o r c o l l e c t i n g

49
data,

and methods f o r Implementing any ne ces sary r e v i s i o n s t o the

plan.

A s o l i d q u a l i t y - a s s u r a n c e program can then p r o v id e a b a s is

for a to tal

progr am e v a l u a t i o n .

desig ned t o

A quality-assurance

achieve t h e most d e s i r e d e f f e c t

program

fo r the p a tie n t

and

fa m il y c o n s i d e r s program philoso phy, p o l i c y , and procedural f a c t o r s .
To accomplish t h i s ,
systematic

proc es s

hos pice s e r v i c e .

administrators
f o r monitoring

must

implement

and e v a l u a t i n g

a planned
the

Such i n p u t i s garnered from c l i e n t s ,

and

quality

of

staff,

and

community in a l l environments which would include home c a r e as well
as

inpatient

organizational

care.

The

results

are

then

used

de sig n o f t h e program and shape th e

p r a c t i c e s o f a l l i n d i v i d u a l s a s s o c i a t e d with ho s p ic e .
achieved by c o n t in u a l

to

adjust

the

attitudes

and

E xcel le nce i s

s c r u t i n y a g a i n s t hos pice s t a n d a r d s o f c a r e .

McArdle (1985) noted t h a t a g r e a t deal o f a hos pice manager’s energy
i s devoted t o e v a l u a t i o n , which occurs on a d a i l y b a s i s .
Regulatory g u i d e l i n e s .

Q u a lit y - a s s u r a n c e re qu ir em ents a r e als o

mandated by JCAH, hos pice Medicare, and Michigan ho spice l i c e n s u r e
as f o ll o w s :
JCAH:

There i s an ongoing q u a l i t y as surance program designed

t o o b j e c t i v e l y and s y s t e m a t i c a l l y monitor and e v a l u a t e t h e q u a l i t y
and a p p r o p r i a t e n e s s o f p a t i e n t / f a m i l y c a r e , pursue o p p o r t u n i t i e s to
improve p a t i e n t / f a m i l y c a r e , and r e s o l v e i d e n t i f i e d problems.
Medicare:
integrated,

A hospice must conduct an ongoing,

comprehensive,

s e l f - a s s e s s m e n t o f th e q u a l i t y and a p p r o p r i a t e n e s s o f

c a r e provided in c lu d in g i n p a t i e n t c a r e , home c a r e , and c a r e provided
under arrangement.

50

Michigan hospice l i c e n s u r e :
i m p l e m e n t,

Hospice programs must develop and

t h r o u g h an i n t e r d i s c i p l i n a r y c o m m i t t e e ,

quality-assurance

program.

P r o fe s s io n a l

s ta n d a rd s

developed o r adopted in t h e following a r e a s :
team s e r v i c e s ,

(b)

patient

an o n g o i n g

must

also

be

(a) i n t e r d i s c i p l i n a r y

and family as t h e

unit

of care,

(c)

symptom c o n t r o l , (d) c o n t i n u i t y o f c a r e , and (e) home c a r e s e r v i c e s .
T hese

standards

require

that

the

adm inistrator

assure

that

i n d i v i d u a l s charged with q u a l i t y - a s s u r a n c e a c t i v i t i e s in t h e program
collect

and analyze d a t a ,

and recommend change and r e - e v a l u a t i o n

when n eces sar y (Michigan Hospice Rule R325.13111).
As t h e s e req uirem en ts su gges t, th e q u a l i t y - a s s u r a n c e program i s
self-d irected ,
specific
principles.

w ith each in d iv id u a l

quality-assurance
It

is

a

hospice t a i l o r i n g

pro gram

pro cess

that

to

meet

prov ides

its

own

quality-of-care
useful

inform ation

concerning t h e use and a p p r o p r i a t e n e s s o f s e r v i c e s , as well as th e
quality of care.

The in formation g ath er ed i s such t h a t i t becomes

useful t o t h e hos pice a d m i n i s t r a t o r in a s s u r i n g :
staff,

(a) competence o f

(b) t h e a p p r o p r i a t e and c o s t - e f f e c t i v e use o f r e s o u r c e s ,

(c)

compliance with f e d e r a l and s t a t e r e g u l a t i o n s , and (d) p r o v i s i o n o f
a p p r o p r i a t e info rm at ion t o t h e governing body, i . e . , i f t h e program
i s p rovid ing good c a r e and meeting d es ig n a te d goals (McCann & Enck,
1986).
In summary,
efficiently

q u ality

hospice

and a p p r o p r i a t e l y

in

services

must

an ever-changing

government r e g u l a t i o n s , consumer a c t i v i s m ,

be d e l i v e r e d
environment

of

and budget l i m i t a t i o n s .

51
The hospice a d m i n i s t r a t o r must have knowledge and s k i l l s r e l a t e d to
q u a l i t y - a s s u r a n c e t h e o r y and p r a c t i c e s ,

h o s p i c e r e g u l a t o r y and

s t a t u t o r y r eq u irem en ts , u t i l i z a t i o n review, and program e v a l u a t i o n .
A d m i n i s tr a tiv e Theory
Planning, o r g a n i z i n g , d i r e c t i n g , and c o n t r o l l i n g a r e important
features

of

adm inistration.

In

addition,

a

review

of

general

a d m i n i s t r a t i v e f u n c t i o n s and a d m i n i s t r a t i v e approaches i s cogent t o
t h i s s tu d y .

D r e s s i e r (1978) s t a t e d :

A d m in istr atio n i s a complex s e t o f t a s k s r e q u i r i n g both
t h e a c q u i s i t i o n o f t e c h n i c a l s k i l l s and i n t e r p e r s o n a l
competence.
U n f o r tu n a t e ly , most young a d m i n i s t r a t o r s have
r e c e i v e d l i t t l e formal p r e p a r a t i o n f o r t h i s r o l e . The problems
e n c o u n t e r e d in p e r f o r m i n g a d m i n i s t r a t i v e r o l e s a r e b o th
d i f f i c u l t and complex and r e q u i r e a high de gr ee o f i n g e n u ity
and p e r s i s t e n c e , (p. 360)
More r e c e n t l y , Dubrin (1984) noted an e f f e c t i v e l e a d e r almost
a lw a y s

has

to

be

technically

or

professionally

p a r t i c u l a r l y when l ead in g a group o f s p e c i a l i s t s .

com petent,

He s t a t e d :

I t i s d i f f i c u l t t o e s t a b l i s h r a p p o r t with s u b o r d i n a te s when you
do not under stand what th ey ar e doing and th ey do not r e s p e c t
your t e c h n i c a l s k i l l s . At a minimum t h e manager o f s p e c i a l i s t s
has t o be "snow-proof" (not r e a d i l y b l u f f e d by s u b o r d i n a t e s ) .
I t i s not always n e c e s s a r y f o r t h e manger t o d i s p l a y t e c h n i c a l
competence when f i r s t placed in t h e j o b .
Employees w i l l give
t h e i r l e a d e r a r e a s o n a b le p e r i o d o f time t o become o r i e n t e d ,
but they w i l l l o s e r e s p e c t f o r t h e manager who c o n t i n u a l l y
r e l i e s on o t h e r s in t h e department t o make d e c i s i o n s o r provide
guidance, (p. 259)
The

ro le

of

the

professional

hospice

adm inistrator

is

r e i n f o r c e d by l e g a l , r e g u l a t o r y , and a c c r e d i t i n g a g e n c i e s , a p o s tu r e
which

many

of

the

beginning

undertake (McDonnell, 1986).

hospice

programs

did

not

wish

to

Indeed, hos pice a d m i n i s t r a t i o n cannot

allow t h e hospice concept t o become b urie d w i t h i n t h e maze o f the

52

a l r e a d y e x i s t i n g h e a l t h c a r e d e l i v e r y system,

th e r e b y undermining

th e b a s ic p r e c e p t o f q u a l i t y c a r e f o r t h e t e r m i n a l l y i l l .
reason,

the

following

four

classic

adm inistrative

For t h i s

functions

are

emphasized as they apply t o hos pice a d m i n i s t r a t i o n .
1.

Planning:

objectives,

statin g

involves
prem ises

identifying
and

assum ptions,

s p e c i f i c d e t a i l e d plans f o r hospice c a r e .
noted

that

planning

is

th e

hospice

pro cess

goals

and

and d e v e l o p i n g

Levey and Loomba (1973)

o f making d e c i s i o n s

p r e s e n t t o bring about an outcome in t h e f u t u r e .

in

Wilson

th e

(1976)

r e l a t e d t h a t planning br id g e s t h e gap between where th e program is
and where i t wants t o go.
action

which

logically

I t i s t h e most fundamental a d m i n i s t r a t i v e
pr ecedes

all

other

management

functions

(McDonnell, 1986).
2.

Organizing:

in v o lv es how th e hospice a d m i n i s t r a t o r groups,

a s s i g n s , and c o o r d i n a t e s a c t i v i t i e s needed t o accomplish g o a l s and
objectives.

It

i s p rovid in g mechanisms f o r

how t h e jo b w i l l

be

done.
3.

Directing:

in volv es being a ble t o m o t iv a te ,

and l e a d hospice s t a f f as well as t e a c h ,
them

into

the

organization.

An

a d m i n i s t r a t i v e f u n c t io n i s d e l e g a t i o n .

supervise,

im portant
It

communicate,
and i n t e g r a t e

task

in

th is

i s perhaps one o f th e

most d i f f i c u l t a d m i n i s t r a t i v e concepts t o implement, and y e t i t
absolutely v ita l

that

it

be done

(Wilson,

1976).

is

The important

i s s u e in volves being r e a l i s t i c about o n e ' s own l i m i t a t i o n s , both in
time

and

knowledge.

According

to

Wilson,

delegation

does

not

53
e l i m i n a t e work;

it

simply changes

it.

As a person

delegate a p p ro p riately , a m u ltip lie r e f f e c t occurs.

is

a b le

to

The time spent

doing one jo b can be s pent in e n a b lin g s e v e r a l people t o do numerous
jobs.

This r e s e a r c h e r used t h e concept o f d e l e g a t i o n t o explore

which f u n c t i o n s hospice a d m i n i s t r a t o r s in Michigan d e l e g a t e and then
determ ined i f c e r t a i n

a d m i n i s t r a t i v e c o m p e t e n c i e s were i n d e e d

delegated.
4.

Controlling:

i s t h e p r o c e ss o f monitorin g and e v a l u a t i o n .

I t i s e s s e n t i a l in de te rm in in g i f events have conformed t o p la n s f o r
p r o v id in g q u a l i t y c a r e .
This r e s e a r c h e r b e l i e v e s

that

hos pic e a d m i n i s t r a t i v e

leaders

must be dynamic and e c l e c t i c while holding f a s t t o hospice i d e a l s
and e s s e n t i a l v a l u e s .
direct,
must

and c o n t r o l

also

be

I n d i v i d u a l s must be a b le t o p l a n , o r g a n i z e ,
as p a r t o f t h e i r r o l e r e s p o n s i b i l i t i e s .

creative

through d e l e g a t i o n .

and d i s c o v e r
Each o f t h e

how t o
five

hospice

components on t h e survey inst rum ent included
functions j u s t discussed.

tap

staff

They

resources

adm inistrative

subsets

of the

four

This r e s e a r c h e r analyzed t o what degree

t h e s e f u n c t i o n s were used and t o what degr ee th ey were d e l e g a t e d .
Administrative S tra te g ie s
Arnold e t a l .

(1971) noted t h a t t h e

o r g a n i z a t i o n has been e c l e c t i c .
science,

psychology,

s tu dy o f a d m i n i s t r a t i v e

Concepts from s o c io l o g y , p o l i t i c a l

economics,

and

m athem atics

h av e

been

in te rc h an g ed in t h e p r o c e s s .

These f i e l d s have been a r i c h source

of

the

co ncepts

for

adding

to

underst anding

of

adm inistrative

54
b e havior .

During t h e

past

them es o r c o n c e p t u a l
adm inistrative

s e v e ra l

decades

certain

modes have p a t t e r n e d

knowledge and s k i l l s .

the

Pres en ted

identifiable

development o f
her e

is

a brief

overview o f f o u r major a d m i n i s t r a t i v e s t r a t e g i e s .
The

structural

appro ac h.

This

approach

to

administration

s t a r t e d with a focus on how work should be d iv id e d and how t h i s
d i v i s i o n o f l a b o r could be made more r a t i o n a l .

Weber (1957), Gulick

and Urwick (1937), Mooney and Re iley (1939), and Taylo r (1952) a l l
emphasized s t r u c t u r a l

ratio n ality .

The und er ly ing

assumption was

t h a t a l l t a s k s could be s e p a r a t e d i n t o d i s c r e t e p a r t s and t h a t jo b
f u n c t i o n s c o u l d be d e l i n e a t e d by c l e a r - c u t
positio ns.

T hese

tasks

were

to

be

boundaries

coordinated

between

through

a

hierarchical s tru c tu re of authority.
The p r o c e s s ap pro ac h.
g a in in g

popular

As t h e m e c h a n is tic management model was

ac ceptance,

Roethlisberger

and

Dickenson

(1939)

in tro duce d r e s e a r c h t h a t s u b s t a n t i a t e d th e need f o r s o c i a l

pr oc es s

t o be tak en

proc es s

appeared,
management,
focus

of

resolution

i n t o acc ou nt.

A f lood o f s t u d i e s on s o c i a l

and c o n c e p t s su ch as human r e l a t i o n s ,
and i n t e r p e r s o n a l
adm inistrative
of

conflict

communications became p o p u la r .

attention

which

in d i v i d u a l and t h e o r g a n i z a t i o n .
s o c ia l

p artic ip a tiv e

is

was on m o t i v a t i o n

inherently

present

The

and t h e

between

th e

Arg yri s (1957) a l s o emphasized th e

pr o c e ss with h i s theme o f "job en la r g em en t."

He i n d i c a t e d

t h a t j o b c o n t e n t could expand t o in c lu d e a wider range o f t a s k s and
thus broaden t h e worker ’ s c o n t r o l over h i s r e s p o n s i b i l i t i e s .

55
The decis ion-m akina ap proach.
on t h e

decision-making

organization.

proc es s

Simon (1947) in tro duce d a focus

as

a new way o f

looking

at

th e

Problem s o lv i n g r a t h e r than s p e c i f i c kinds o f t a s k s

o r a c t i v i t i e s was emphasized.

This r e s u l t e d in v a r i a t i o n s in th e

team concept w i t h i n th e o r g a n i z a t i o n a l s t r u c t u r e .

Levey and Loomba

(1973) noted t h a t r e g a r d l e s s o f th e n a t u r e o r ty pe o f d e c i s i o n , th e
f ollow ing elements o f d e c i s i o n making must be c o n s c io u s ly co nsid ere d
in t h e a d m i n i s t r a t i v e p r o c e ss :
1.

Who i s t h e d e c i s io n maker and what a r e t h e o b j e c t i v e s ?

2.

What

is

the

context

and e n v i r o n m e n t

of

the

decision

problem?
3.

What ar e t h e a l t e r n a t i v e co urses o f a c t i o n ?

4.

What ar e t h e assumptions r e g a rd i n g t h e f u t u r e ?

5.

What ar e t h e consequences o f a l t e r n a t i v e cour se s o f a c t i o n ?

6.

Whati s th e cho ice according t o a d e c i s i o n c r i t e r i o n ?

7.

How w ill t h e r e be implementation and c o n t r o l ?

In a ctu al p r a c t i c e , t h e d e c i s i o n maker i d e n t i f i e s t h e problem
and i t s

hierarchical

nature,

states

th e o b j e c t i v e s

f o r which th e

problem i s being pe rce ived and fo rm ulated, t e s t s t h e re sp o n s iv e n e ss
o f t h e environment in l i g h t o f t h e
relevant

relatio n sh ip s

between

stated objectives,

the

variables,

identifies

sp ecifies

the

c o n s t r a i n t s o f t h e problem, and chooses a course o f a c t i o n according
to

a decision

criterion.

Since

the

dec ision-making

process

is

u s u a l l y dynamic in n a t u r e , th e a d m i n i s t r a t o r e x e r c i s e s c o n t r o l over
the

im plem entation o f d e c is io n s

by c o n t i n u a l l y

observing

the

56
o u t p u t s and making n eces sar y changes in t h e i n p u ts by using feedback
c h annels .
The

ecological

approach.

Mel son

(19 8 0 )

noted

that

an

e c o l o g i c a l p e r s p e c t i v e emphasizes on d i f f e r e n t l e v e l s common themes,
among them s y s t e m - e n v i r o n m e n t r e l a t i o n s ,
r e c i p r o c a l change.

interdependence,

and

The f i v e a d m i n i s t r a t i v e competency a r e a s used in

t h i s r e s e a r c h a r e in r e a l i t y based on system-environment r e l a t i o n s
adopted from t h e e c o l o g i c a l framework d e s c ri b e d in Chapter I .

I t is

im po rta nt to r e c a l l t h a t in t h i s approach communication and d e c i s i o n
making provide a means f o r a s s i m i l a t i n g and p r o c e ss i n g t h e flow of
in fo rm atio n from th e i d e n t i f i e d competency a r e a s as r e p r e s e n t e d in
Figure 2.1 p r e se n te d e a r l i e r .

In terms o f t h e ch oic e o f a co u r se of

a c t i o n from among many a l t e r n a t i v e s , th e d e c i s i o n s made in any one
component must be based on a n a l y s i s o f t h e p a t i e n t / f a m i l y as well as
th e

state

o f t h e o t h e r components.

The hospice

adm inistrator’s

d e c i s i o n s d i r e c t th e hospice and ensure implementation o f p o l i c i e s
and procedures

reg ard in g

all

activities

in

all

components.

The

a d m i n i s t r a t o r ’ s r o l e can be consid ered a c i r c l e o f a c t i o n in which
he/s he i n t e r a c t s t o a g r e a t e r o r l e s s e r degree with each component.
I t i s c r i t i c a l t h a t a d m i n i s t r a t o r s monitor th e program’s environment
to

anticipate

required

change

from t h e

and

b r in g

adaptation

about

p r e ss

the

appropriate

ex per ienced

by

re sp onses

the

hospice

program.
In summary, t h i s r e s e a r c h e r has i d e n t i f i e d t h a t t h e t a s k s o f
t h e h o s p i c e a d m i n i s t r a t o r a r e complex and o f t e n

o v e r w h e l m in g ,

e s p e c i a l l y f o r i n d i v i d u a l s whose background i s c l i n i c a l

and whose

57

training

has not q u a l i f i e d them f o r managing such complex t a s k s .

G e n e r a l a d m i n i s t r a t i v e f u n c t i o n s such as p l a n n i n g , o r g a n i z i n g ,
d irectin g ,

and

adm inistrative

co n tro llin g ,

approaches,

in

p ro vide models

a d m i n i s t r a t o r can develop i n s i g h t .
hospice

pro g ram s

are

addition

in

to

th eo retical

from which t h e

According t o t h i s

desperate

need

of

hospice

researcher,

an

effectiv e

a d m i n i s t r a t i v e model which meets t h e i r needs over t h e o r g a n i z a t i o n a l
l i f e cycle.
O r g a n iz a ti o n a l Lif e Cycle and
A d m i n i s t r a t i v e Dynamics
A review o f o r g a n i z a t i o n a l l i f e c y c le t h e o r y seems a p p l i c a b l e
t o t h i s review o f l i t e r a t u r e because i t uses an e c o l o g i c a l model.
Also, i t i s important t o n o te t h a t hospice programs in Michigan can
be

seen

as

ev olvin g

through

their

own l i f e

cycles

and

are

in

d i f f e r e n t s ta g e s o f development r e l a t i v e t o s e r v i c e s th ey provid e .
Haire (1959) noted t h a t o r g a n i z a t i o n s have l i f e c y c l e s analogous t o
th o s e o f i n d iv id u a l

and fa m il y s t r u c t u r e s .

O r g a n iz a t io n s may be

thoug ht o f as having s t r o n g w i l l s t o s u r v iv e and having s t a g e s o f
development from b i r t h t o d e a t h .

Some o r g a n i z a t i o n s

have normal

development while o t h e r s a p p a r e n t l y have a r r e s t e d development.
are

in f lu e n c e d

S ta rk w ea th er

by

and

and
Kisch

have

an

(1971)

in f l u e n c e
stated

e n t e r p r i s e may become c o n t i n g e n t on i t s

that

on

their
the

readiness

All

environment.

survival

of

an

and a b i l i t y

to

r e o r g a n i z e and adapt t o changing c o n d i t i o n s in s o c i e t y .

The f o u r

58
l i f e c y c l e phases h e a l t h s e r v i c e o r g a n i z a t i o n s may e x p e r ie n c e a r e as
f o l 1ows.
The

search

phase.

In

th is

phase

of

its

life

cycle,

an

o r g a n i z a t i o n i s o f co urse young and s m a ll, having been c r e a t e d in
respon se t o t h e p r e s s u r e o f s o c ia l f o r c e s .

Messinger (1955) noted

t h a t t h e o r g a n i z a t i o n i s in ascendancy, when l e a d e r s and members in
an o r g a n i z a t i o n

identify

that

tr a n s f o r m s o c ia l

discontent

something

into e ffe c tiv e

needs

to

action.

be done

to

The r a t e

of

in n ovation i s high, p e r m i t t i n g p o l i c i e s o r pro ce du res t o be q uickly
modified as personnel

seek t h e

prope r

approach

f i r s t g en er ate d t h e o r g a n i z a t i o n ’ s fo rm ation.

to

problems

that

P atien ts or t h e i r

r e p r e s e n t a t i v e s ar e f o rm ally o r in f o r m a l ly in cl uded in t h e d e c i s i o n ­
making p r o c e s s , and t h e i r s u g g e s ti o n s and c r i t i c i s m s a r e sought with
genuine i n t e r e s t .

The a d m i n i s t r a t i v e s t r u c t u r e o f an agency a t t h i s

phase i s informal and open.

The s t a f f i s growing, and t h e r e must be

an o p p o r tu n i t y f o r new members t o be f u l l y i n t e g r a t e d .
eg alitaria n

feeling

betw ee n

s t a f f members,

and

There i s an
p olicies

are

developed by s h a rin g and pooling t h e p e r s p e c t i v e s and judgments of
many.
In t h i s phase t h e l e a d e r s h i p element i s c r u c i a l , but t h e r e i s
a l s o a b u i l t - i n dilemma.

The l e a d e r in t h i s s t a g e must s e t a tone

o f f l e x i b i l i t y and p er m is siv en e ss

i f the organization

e s s e n t i a l ad ju stmen ts t o i t s new environment.
charism atic

leadership,

achieved

this

at

early

agency’ s c h i e f o f f i c i a l .

since
time

public

t o make

The agency a l s o needs

recognition

by t h e personal

is

can b e s t be

visib ility

of

th e

U n f o r t u n a t e ly , t h e q u a l i t i e s o f charisma

59

and t h e q u a l i t i e s o f p a r t i c i p a t i v e l e a d e r s h i p a r e not o f t e n found in
the

same

individual.

Another

characteristic

of

the

leadership

element in t h i s phase i s t h a t competence i s u s u a l l y more in s u b j e c t
m atter

rather

tha n

in

adm inistration.

demands r e l a t i v e l y l i t t l e

The

by way o f management,

flow in l a r g e measure toward i t s p r o f e s s i o n a l
w ork.

Another

small

o b stacle

which m ust

be

organization

and i t s

resources

and p a t i e n t s e r v i c e

s u rm o u n te d

before

an

o r g a n i z a t i o n can pass i n t o t h e second o r "su ccess" phase has t o do
with o r g a n i z a t i o n a l
little
that

stress
stress

stress.

There may be e i t h e r to o much o r too

in an o r g a n i z a t i o n .
is

low,

March

o r g a n i z a t i o n a l apathy r e s u l t s .
w ill

not c o l l a p s e ,

If aspiration

but i t s

remains well

and

I f achievement comes so e a r l y
Simon

(1 95 8)

suggested

th at

Under t h e s e circum st ances t h e agency

inno vation and expansion w i l l
above achievement,

stress

be slow.

will

be too

high and may r e s u l t in f r u s t r a t i o n and burnout.
Whether an o r g a n i z a t i o n t h r i v e s depends l a r g e l y on th e degree
o f accep tance accorded i t by th e community.
large

part

on

the

rendered t o p a t i e n t s .

quality

and

This i s dependent in

appropriateness

of

the

Maslow (1962) d i s c u s s e d th e dilemma o f th e

opposing p u l l s between growth and s e c u r i t y as m o t i v a t o r s .
“t o Maslow, when t h e s e p u l l s a r e e q u a l l y ba lance d,
dominates.

services

Thus, a p a r a l l e l

According

s e c u r i t y always

i s s u e may s u r f a c e in which growth and

change o f t e n l o s e out when an o r g a n i z a t i o n becomes concerned more
about i t s s u r v i v a l th an i t s impact.

60
The success p h a s e .
"form alization"

Stark w ea th er and Kisch (1971) used t h e word

to describe

occur in t h i s phase.

the

internal

structural

changes

that

There i s reduced dependence on t h e personal

a t t r i b u t e s o f t h e founding l e a d e r s and an i n c r e a s e in more r o u t i n e
control.

Jobs become s p e c i a l i z e d , and a h i e r a r c h y o f a u t h o r i t y and

central

adm inistration

component.

The s t a f f ’ s

im m e d ia te

patient

re quire m ents
other.

develops,

of

attention

needs

s e c u rin g

A satisfactory

on t h e
the

strengthening
often
one

becomes d i v id e d

hand

e n terp rise’s

balance

is

t h e management
between

and f u t u r e - o r i e n t e d
financial

usually

base

achieved

on th e

with

enough

a d m i n i s t r a t i v e focus t o avoid t h e r i s k s t o s u r v i v a l i n h e r e n t in th e
s ea rc h

phase.

There

is

still,

however,

enough c l i e n t

foster

the

provision

of

needed

services

at

adequate

focus

to

levels

of

quality.
This

phase a ls o

includes

a sh ift

in

pro fessio n al-ad m in istrativ e rela tio n sh ip
adm inistrative control.
the

agency’s

balance

of

the

in f a v o r o f i n c r e a s e d

The d e s i r e d p e r s o n a l i t y s p e c i f i c a t i o n s f o r

leadership

undergo

change,

s p e c i a l i s t s who l e d th e o r g a n i z a t i o n in i t s
re p l a c e d

the

by a d m i n i s t r a t o r s

with

and

su b ject-m atter

e a r l y development ar e

s tr o n g managerial

skills.

This

change in t h e type o f c o n t r o l seems i n e v i t a b l e even though one might
wish t h a t l e a d e r s h i p p a t t e r n s which encouraged both in n o v atio n and
e f f e c t i v e implementation could be preserved (S tarkwea ther & Kisch,
1971).
The timing o f th e l e a d e r s h i p t r a n s i t i o n i s very im p o rta n t.

It

can come prem at ure ly through overemphasis o f t h e agency’ s need f o r

61

e f f e c t i v e communication and command, t h e r e b y denying an o r g a n i z a t i o n
i n n o v a t iv e l e a d e r s h i p a t a time when i t i s s t i l l
1961).

On t h e

dela yed, l e a v in g

other

the

hand, i t s occ urre nc e

organization

unprepared

needed ( S e lz n ic k ,

can

be

for

the

excessively
time

when

charismatic leadership eventually departs.
The change in c h a r a c t e r o f l e a d e r s h i p ,

sometimes ar rang ed by

desig n but f r e q u e n t l y o c c u r r i n g ad hoc, l a r g e l y d i c t a t e s th e f u t u r e
co urse o f th e o r g a n i z a t i o n and t h e r a t e o f i t s advance i n t o t h e much
l e s s p r o d u c tiv e phase t h a t o f t e n f ollows t h e su ccess phase.

Few

governing boards t h a t make e x e c u t iv e s e l e c t i o n s c l e a r l y see t h e s e
im plications.

As a r e s u l t

the lead ersh ip

in h e a l t h

service

o r g a n i z a t i o n s f r e q u e n t l y o s c i l l a t e s f o r a time between e x c l u s i v e l y
p r o f e s s i o n a l and s t r i c t l y managerial t y p e s , with n e i t h e r pro viding
t h e combination o f q u a l i t i e s

t h e agency could i d e a l l y use .

What

does occur due t o t h e s h i f t i n g and r e s h i f t i n g o f l e a d e r s h i p i s the
e x p e n d it u r e o f o r g a n i z a t i o n a l energy.

In t h i s ,

a c e r t a i n momentum

and s o c i a l f o r c e i s l o s t t h a t seldom i s r e g a in e d .
One
cy c le o f
In many

final

f a c t o r im po rta nt t o t h e s ucc es s phase in

th e l i f e

o r g a n i z a t i o n s i s t h e almost u n i v e r s a l d r i v e toward b ig n e s s .
ways t h i s

in te re st is

w arranted,

since the

economic

s t r u c t u r e o f s o c i e t y g iv e s advantage t o l a r g e r i n s t i t u t i o n s .

This

advantage in c lu d e s t h e most fundamental concept o f a g r e a t e r chance
o f "long -ru n" s u r v i v a l .
The

bureaucratic phase.

general,

as an o r g a n i z a t i o n

Blau and S c o t t (1962) noted t h a t in
becomes more complex in

i t s internal

62
workings i t a l s o becomes i n c r e a s i n g l y d i f f e r e n t i a t e d from t h e l a r g e r
s o c ia l

system.

While t h e p u b l i c may seem t o s u f f e r most by t h i s

development, t h e agency i t s e l f can be t h e u l t i m a t e l o s e r .

Changes

in s o c ia l f o r c e s t h a t a r e not met by r e s p o n s i b l e a d a p t a t i o n on the
agency’ s p a r t l e a d t o a l a c k o f p u b l i c
m iss io n .

Reduced

public

concern

in

interest
turn

in t h e

agency’ s

eventually

causes

a

diminution in t h e flow o f p u b l i c r e s o u r c e s t o t h e agency.
As

the

through

organization

the

addition

com m u n ic a ti o n

and

grows,

of

its

sta ff

internal

necessary

co o rdination.

structure

to

assure

A ctiv ities

changes
adequate

previously

done

in f o r m a lly and v o l u n t a r i l y ar e now done by a r i s i n g p r o p o r t i o n o f
the

to tal

personnel

functions.
energy

complement

Such o r g a n i z a t i o n a l

from

the

Interestingly,

agency’ s

given

over

to

staff

control

maintenance work n a t u r a l l y d r a i n s

productive

and

creative

capacity.

a t t h i s p o i n t th e more im ag in ative people begin to

le a v e th e o r g a n i z a t i o n .

Also worth n oting in t h i s

phase i s t h a t

informal communications concerning p a t i e n t needs o f te n can no longer
r each th e h ig h e r l e v e l s ,

and no one lower in t h e o r g a n i z a t i o n i s

empowered t o a l t e r p o l i c y .
The s u c c e ss io n
organization

to

phase.

The

impetus

spawn a new u n i t

which

and thus

triggers

start

agai n

a

large

the

full

o r g a n i z a t i o n a l l i f e c y c l e i s in p a r t a mystery, p a r t i c u l a r l y as t o
time

and

F requently,

d etail;
a

organization to

yet

new u n i t

it

also

w ill

seems

be

compete s u c c e s s f u l l y

somewhat

established
for c lie n ts.

predictable.

w ithin

the

old

Within h e a l th

s e r v i c e o r g a n i z a t i o n s t h e t r a n s i t i o n appears t o be caused more o f te n

63

than not by t h e need f o r p r o f e s s i o n a l s w i th in t h e o r g a n i z a t i o n t o
e x e r c i s e more in d i v i d u a l

responsibility

and i d e n t i f y

new ways to

s erv e p a t i e n t s (S ta rkw eather & Kisch, 1971).
Thompson and NcEwan (1961) noted t h a t beneath t h e p r o g r e s s io n
o f o r g a n i z a t i o n s through t h e d i f f e r e n t l i f e c y c le phases t h e r e ar e
some b a s i c

p r i n c i p l e s t h a t perhaps

in f l u e n c e t h e cour se o f e v e n t s .

set

the

lim its

or

indirectly

One i s t h e n e c e s s a r i l y r e c u r r e n t

pr oce ss o f r e a p p r a i s i n g and e v a l u a t i n g program goals and o f d e f i n i n g
the desired r e la tio n

between an o r g a n i z a t i o n and i t s

First,

either

a

change

in

demands r e a p p r a i s a l
p o l i c i e s and g o a l s .

the

organization

or

and p r o b a b l e a l t e r a t i o n

environment.

its

environment

of organizational

Second, l e a d e r s h i p personnel w e l l - s u i t e d t o one

s ta g e a r e o f t e n i l l - f i t t e d t o a n o th e r .

T hird, mechanisms o f review

and

To

self-evaluation

ar e

essential.

o r g a n i z a t i o n s must un dertake

such

appraisals

c o n t i n u a l l y t o keep pace with t h i s
theory.

This

researcher

hospice

programs

has

viable,

hospice

periodically

if

" i n e v i t a b l e change" l i f e

adapted

by d e l i n e a t i n g

remain

s ta g e s

th e
of

life

cycle

development

c ycle

theory
in

not

to

which

hospice a d m i n i s t r a t o r s in Michigan b e l i e v e t h e i r program t o be.
Competencies and Leadership Theory
In posing t h e i r t h e o r y on l e a d e r s h i p b e h a v io r , Ross and Hendry
(1957) l i s t e d th e f ollow ing main c h a r a c t e r i s t i c s o f a l e a d e r :
1.

Empathy

2.

Membership in t h e group

3.

C o n s idera ti on

64

4.

Sergeancy (e nthus iasm, e x p r e s s i v e n e s s , a l e r t n e s s )

5.

Emotional s t a b i l i t y

6.

D es ire f o r and r e c o g n i t i o n o f th e l e a d e r s h i p r o l e

7.

Intelligence

8.

Competence

9.

Cons istenc y

10.

Self-confidence

11.

A b i l i t y t o s hare t h e l e a d e r s h i p r o l e

What i s

the

relationship

between t h e

characteristics

listed

above and competencies which an a d m i n i s t r a t o r should po s ses s?

The

answer

and

can

be

best

stated

by

quotin g

Campbell,

C o r ball y,

Ramseyer (1966):
I t becomes ap p a r e n t t h a t something more than p o s s e s s i o n of
a p r e s c r i b e d s e t o f t r a i t s c h a r a c t e r i z e s t h e l e a d e r . This f a c t
l e t s students of ad m in istration consider leadership behavior-t h e ways in which a l e a d e r o r a d m i n i s t r a t o r (and we hope t h a t
t h e s e terms a r e synonymous) uses t h e t r a i t s and a b i l i t i e s
he/she has.
In t u r n , t h i s has l e d t o an e m p h a s is on
competencies r a t h e r th an t r a i t s .
A competency i s r e l a t e d t o
th e a b i l i t y t o do something; in t h e ca se o f t h e a d m i n i s t r a t o r ,
i t i s t h e a b i l i t y t o behave in a way which r e s e a r c h and our
val ue c r i t e r i a show i s e f f e c t i v e a d m i n i s t r a t i o n b e h a v io r , (p.
316)
Katz
i n c lu d e

(1955)

expanded

technical,

technical s k il l

human,

the

context

of

and conceptual

"way

of

sk ills.

behaving"
He d e f in e d

to
a

as t h e a b i l i t y t o have a p r o f i c i e n c y in a s p e c i a l

kind o f a c t i v i t y ,

especially i f i t

was d e f i n e d as t h e a b i l i t y
b u i l d a c o o p e r a t i v e team.

in volves methods.

t o work with o t h e r s
Conceptual s k i l l ,

Human s k i l l

in a group o r t o

ac co rding t o Katz, i s

t h e a b i l i t y t o observe t h e e n t e r p r i s e as a whole.

This r e s e a r c h e r

65
blended

all

three

definitions

into

the

text

of

201

competency

s ta t e m e n t s in s e c t i o n I I o f t h e survey in st r u m e n t .
Education p la y s i t s
Many t i m e s

it

is

in

p a r t in t h e development o f competencies.

high

school

that

an

individual

becomes

i n t e r e s t e d in a p r o f e s s i o n and a competency p a t t e r n s t a r t s t o form.
In

an a s s o c i a t e

deg re e o r

undergraduate

program,

the

competency

p a t t e r n c o n s i s t s o f accruin g a conceptual knowledge base which might
include:

human growth and development, methods o f t e a c h i n g ,

process,

and many o t h e r s .

de ve loping t e c h n i c a l

skill

e x p e r i e n c e s t o l e a r n from,
develop h i s / h e r s k i l l s

Experience
patterns.

is

also

The g r e a t e r

im portant

in

the v a rie ty of

th e more t h e a d m i n i s t r a t o r i s

and knowledge base.

group

a b le t o

Kovner and Neuhauser

(1978) noted t h a t e x p er ie n ce i s a tempering process t h a t matures th e
adm inistrator’s

judgment

and

provides

it

with

the

sort

of

d i s p o s i t i o n a l c o n t r o l t h a t produces c o n s is t e n c y .
In reviewing l i t e r a t u r e on l e a d e r s h i p t h e o r y ,
be t h r e e broad c l a s s i f i c a t i o n s t h a t o v e r la p .
"great

man"

function.

theory,

(b)

group

fu nction,

t h e r e seemed t o

They a r e :
and

(c)

(a)

th e

situational

The f i r s t t h e o r e t i c a l c o n s t r u c t i s t h e " g r e a t man" th e o r y

o f l e a d e r s h i p , in which t h e l e a d e r s h i p q u a l i t i e s a r e co n s id e red t o
be i n h e r e n t in th e i n d i v i d u a l .

B o r g a t ta , Bales ,

and Couch (1954)

extended t h i s t h e o r y t o conclude t h a t g r e a t men tend t o make " g r e a t
groups"

in t h e sense t h a t major f a c t o r s o f group performance and

member s a t i s f a c t i o n sim u lt a n e o u s ly i n c r e a s e .
The

second

theory

of

leadership

concerns

group

functions.

Leadership i s d e f i n e d as t h e performance o f t h e s e f u n c t i o n s in o r d e r

66

to

achieve

group g o a l s .

Car twright

and Zander

(1953)

made th e

f ollow in g sta te m e n t concerning t h i s theory:
Leadership c o n s i s t s o f such a c t s by group members as those
which a id in s e t t i n g group g o a l s , improving t h e q u a l i t y o f the
i n t e r a c t i o n s among members, moving t h e group toward i t s g o a l s ,
b u i l d i n g c o h e s i v e n e s s o f t h e g r o u p o r making r e s o u r c e s
a v a i l a b l e t o t h e group, (p. 538)
The t h i r d
situ atio n al

th e o r y

of

fu nction

leadership

which

emphasizes

contains

four

leadership

as

a

situ a tio n -sp e c ific

elements:
1.

The s t r u c t u r e o f i n t e r p e r s o n a l r e l a t i o n s with t h e group.

2.

Group c h a r a c t e r i s t i c s .

3.

Characteristics

of the t o ta l

culture

in which t h e group

e x i s t s and from which group members have been drawn.
4.

Physical c o n d i t i o n s and th e t a s k s with which th e group i s

c o n f ro n t e d .
Ross and Hendry (1957) noted t h a t th e n a t u r e o f any l e a d e r s h i p
p a t t e r n i s determined by th e s o c ia l o r g a n i z a t i o n , t h e s o c ia l c lim a te
w it h in t h e o r g a n i z a t i o n , and t h e valu e system o f t h a t o r g a n i z a t i o n .
The a d m i n i s t r a t o r does not have time t o t h i n k o f a l l t h e v a lu e s t o
be matched in t h e decision-making p r o c e s s , y e t t h e r e a r e c o n t r o l l i n g
valu es o f t h e p a r t i c u l a r environment which w i l l shape a d m i n i s t r a t i v e
d e c i s i o n s and judgment (Kovner & Newhouser, 1978).
Dubrin (1984) noted t h a t durin g t h e l a s t two decades t h e r e has
been

a

declining

in terest

in

understanding

c h a r a c t e r i s t i c s , and beha viors o f l e a d e r s the m se lves .
that

substantial

research

has

shown t h a t

the

tra its,

He suggested

leadership

is

best

67
understood when t h e l e a d e r ,

th e

which

analyz ed .

th e y

are

placed

are

followers,

and t h e

situation

Nevertheless,

the

in

leader

remains an important c o n s i d e r a t i o n in under stan ding l e a d e r s h i p , and
without e f f e c t i v e l e a d e r s , most o r g a n i z a t i o n s cannot p r o s p e r .
Research On Competencies
From a review o f l i t e r a t u r e i t i s e v i d e n t t h a t t h e r e has been
c o n s id e r a b l e

research

concerning

the

competencies

of

knowledge,

s k i l l s , v a l u e s , i n t e r a c t i o n s , and a t t i t u d e s a p p l ie d in v a r io u s areas
of a d m in istra tio n , h e a lth - r e la te d p ro fe s sio n s ,

and e d u c a t i o n a l

curricula.

Research done by McCleary (1973) o u t l i n e d s i x s t e p s f o r

developing

a

program o f

competency-based

adm inistration.

These

s t e p s a r e as f ollow s :
1.

Assess competency needs.

2.

S p ecif y competencies.

3.

Determine competency components and performance l e v e l s .

4.

I d e n t i f y competency a tt a i n m e n t .

5.

E s t a b l i s h assessment o f competency a t t a i n m e n t .

6.

V a l i d a t e com petencies,

a t ta in m e n t pr o c e d u re s ,

and a s s e s s ­

ment system.
The pro ce dures used in t h e McCleary s tu dy c o n s i s t e d o f r o l e a n a l y s i s methodology.

F i r s t , an inst rum ent was developed a f t e r t h e

review o f t h e l i t e r a t u r e on f u n c t io n s in l e a d e r s h i p r o l e s .
critical
eight

i n c i d e n t s were developed t o r e f l e c t each f u n c t i o n .

leaders

were

selected

to

be

representative

p o p ula tion and in t e r v i e w s were conducted.

of

the

Second,
Third,
study

Fourth, a panel o f judges

68
reviewed a l i s t o f 46 a c t i v i t i e s ,
and p i l o t - t e s t e d

with

a

group

and an in str u m en t was f i n a l i z e d

of

10

career

e d u catio n

perso ns.

F i n a l l y , t h e instrum en t was r e v i s e d and s e n t t o 60 s u p e r i n t e n d e n t s .
Competency Research in HealthRelated P r o fe s s io n s
In 1974-1975, t h e American D i e t e t i c A s s o c i a t i o n (ADA) conducted
a

ro le-d elin eatio n

p e r s o n n e l.

study

for

clinical

This 15-month study was t o d e l i n e a t e

appropriate ro le fu n ctio n s,
s ta te m e n ts

en try-level

(co mpeten cies).

and r e q u i s i t e
Competencies

d ietetic

t h e a c tu a l

and

knowledge and s k i l l

co ver ing

food

service,

c l i n i c a l n u t r i t i o n , and general s k i l l s were d e f in e d f o r t h e r o l e s of
communicator,

fa c ilitato r,

educator,

professional.

By consensus,

skill

manager,

advocate,

and

and knowledge s ta te m e n t s

were

form ulated through group d i s c u s s io n (Ba ird, 1980).

Products o f th e

stu dy i ncluded:

(a) s ta te m e n ts o f major and s p e c i f i c performance

responsibilities

for

req u isite

knowledge

each

level

of

practice,

for

ea ch

level

of

(b)

s ta te m e n ts

practice,

and

of

(c)

a

c o r r e l a t i o n o f s p e c i f i c performance r e s p o n s i b i l i t i e s with knowledge
statem ents.
Another
supplementary,

study
and

t h e r a p i s t s (OTs).
by OTs;

by

White

emerging

(1 98 0)

researched

competencies

needed

by

essen tial,
occupationa l

The study focused on d e f i n i n g competencies needed

validating

the

essential,

supplem entary

and e m e r g in g

competencies needed by OTs; and d e r i v i n g an e d u c a t io n a l
life lo n g professional
list

of

124

development.

competency

s ta te m e n ts

model

for

The q u e s t i o n n a i r e c o n ta in e d
and

a

person al

data

a

section

69

containing

16 d e m o g r a p h i c

variables.

supp orted t h e c o nclu s io ns o f e s s e n t i a l
for direct

client

service,

Findings

of

the

study

competencies a t e n t r y le v e l

occu pationa l

th e r a p y

c l i e n t s e r v i c e , and OTs i n t h e s c h o o ls .

theory,

indirect

White a l s o found t h a t th e

e s s e n t i a l competencies d i d not r e p r e s e n t t e c h n i c a l changes in s k i l l s
but r e f l e c t e d a respons e t o s o c ia l and p o l i t i c a l p r e s s u r e s .
Relative

to

h o s p ic e ,

Basiles

(1982)

collected

data

from

a

sample o f 49 i n t e r d i s c i p l i n a r y team members from 6 hospic e s in th e
United S t a t e s .

Ten i n d i v i d u a l s r e p r e s e n t e d a panel o f e x p e r t s in

v a r io u s f i e l d s o f h e a l t h c a r e d e l i v e r y , and 29 competencies r e l a t e d
t o t h e a r e a s o f emotio na l, i n t e r p e r s o n a l , and p r o f e s s i o n a l a b i l i t i e s
were i d e n t i f i e d .

The r e s u l t s o f h i s study demonstrated t h a t t h e

panel

and

of

experts

the

practitioners

exhibited

high

positive

i n t e r g r o u p agreement r e g a r d i n g th e valu e o f t h e competencies under
s tu dy.
Richie (1984) conducted r e s e a r c h on 68 h ospice a d m i n i s t r a t o r s
to

id en tify

a

list

and

ranking

of

the

perceived

top

a d m i n i s t r a t i v e f u n c t i o n s performed.

He a l s o g e n e r a te d a l i s t

rank in g

skills/com petencies

carry

of the

out

their

perceived

to p

identified

five

role.

To o b t a i n

a

five

needed

measure

of

and
to
th e

importance re sp onde nts place d on t h e f u n c t io n s (by rank ing them from
1 - h i g h e s t t o 5 = l o w e s t ) , average ranks were computed along with
s ta n d a r d d e v i a t i o n s .

The d a t a i n d i c a t e d t h a t hospice a d m i n i s t r a t o r s

in an i n s t i t u t i o n a l

s e t t i n g were more l i k e l y

adm inistration,

p atient

care,

and

to

personnel

mention

overall

work,

whereas

70
independent a d m i n i s t r a t o r s

were more l i k e l y

work, p u b l i c r e l a t i o n s , and fund r a i s i n g .
adm inistrative

functions

and p a t i e n t

to

mention

personnel

In both s e t t i n g s o v e r a l l

care

ranked

high

( 1 .5 4 ,

SD

+ . 2 8 ) , but i n s t i t u t i o n a l ho s p ic e a d m i n i s t r a t o r s place d h ig h e r value
on l e a d e r s h i p and c o o r d i n a t i n g a c t i v i t i e s , wh ile independent hos pice
program a d m i n i s t r a t o r s

p laced h i g h e r value on personnel

fu nd

regard

raising.

With

adm inistrators l i s t e d

to

sk ills,

in stitu tio n al

" a b i l i t y t o apply c l i n i c a l

n u r s in g

work and
hospice
sk ills--

p a r t i c u l a r l y a knowledge o f o n c o lo g y - -t o p a t i e n t care"

as 1.9

+ .7 5 ) .

" a b i l i t y to

The independent hospice a d m i n i s t r a t o r s l i s t e d

en gage in g e n e r a l
solving,

adm inistrative a c tiv itie s ,

decision

m ak in g ,

delegation

of

(SD

i n c l u d i n g p r o b le m

auth o rity ,

planning,

personnel a d m i n i s t r a t i o n , o r g a n i z a t i o n , and d e l i v e r y o f s e r v i c e s " as
1.96 (SD + 1 .0 2 ) .
Competency Research in Educational C u r r ic u la
White
approach

(1 980 )
having

noted t h a t
two p r i m a r y

competency-based e d u c a tio n
ch aracteristics:

first,

is

precise

l e a r n i n g o b j e c t i v e s d e f in e d b e h a v i o r a l l y in a s s e s s a b l e te rm s ,
known t o

both

th e

teacher

and l e a r n e r .

Competencies

an

are

and
first

i d e n t i f i e d as gener al g o a l s , then s t a t e d as performance o b j e c t i v e s
which

have

com pleting

a
the

stated

behavior

learning

l e a r n e r s ’ performance w i l l
second c h a r a c t e r i s t i c

is

to

effo rt,

be

changed,

conditions

for

by which

the

1974).

The

and a s t a n d a r d

be judged

(Davis e t

accountability.

a l.,

Each l e a r n e r knows th e

l e a r n i n g e x p e c t a t i o n , a c c e p t s r e s p o n s i b i l i t y f o r doing t h e a c t i v i t y ,

71
and ex pects

to

be

held

ac counta ble

for

meeting

th e

established

conditions.

E a r l i e r , Elam (1978) had developed a l i s t o f e s s e n t i a l

elements o f competency-based e d u catio n al programs which included :
1.

Competencies

should

be

derived

from

the

role

of

th e

p r a c t i t i o n e r , and should be s p e c i f i e d in beha vior al terms which ar e
made p u b l i c in advance.
2.

Assessment c r i t e r i a should be competency based and s p e c i f y

expected l e v e l s o f mastery.
3.

Assessment

of

learners

should

be

based

prim arily

on

performance.
4.

L e a r n e r s ’ p r o g re s s through t h e program should depend on

demonstrated competency.
5.

The i n s t r u c t i o n a l program should f a c i l i t a t e development and

e v a l u a t i o n o f competencies.
In a s t u d y

focusing

on c o m p e t e n c i e s

in

adult

education,

Chamberlain (1960) asked 90 a d u l t l e a r n e r s t o l i s t 45 s ta t e m e n t s o f
competencies in o r d e r o f importance using t h e Q - so r t te c h n i q u e .
the

statem ent

of

findings,

Chamberlain

indicated

that

In
the

resp onden ts were s u r e o f t h e i r r a t i n g s a t t h e beginning and t h e end
o f t h e l i s t but were u n c e r t a i n o f th o s e r a t i n g s in t h e middle.

For

t h i s reason he focused t h e g r e a t e s t c o n s i d e r a t i o n in t h e a n a l y s i s t o
th e f i r s t 15 and l a s t 15 s t a t e m e n t s .
be a p p r o p r i a t e t o

use

in

competencies because in t h i s
was not a p p l i c a b l e ,

Q - s o r t methodology would not

identifying
stu dy,

hospice

adm inistrators’

rank o r d e r i n g o f competencies

and t h e competency items were to o numerous t o

f e a s i b l y manage by Q - s o r t .

Also t h i s r e s e a r c h e r wanted t o ensure

72

that all

items were e q u a l l y co ns idered r a t h e r th an t h e f i r s t

and

l a s t groups o f items.
Competency-based p r o f e s s i o n a l education evolved in t h e a r e a o f
home economics with th e development o f competencies a t a n a t i o n a l
workshop in

February 1974.

As s t a t e d

in t h e i r

Competency-Based

P r o f e s s io n a l Education in Home Economics p u b l i c a t i o n (AHEA, 1974):
Assessment o f p r o f e s s i o n a l competence o f t h e home economist i s
e s s e n t i a l i f s y s te m a tic procedures a r e t o be developed f o r
d e t e r m i n i n g e f f e c t i v e n e s s o f home e c o n o m ic s p r o f e s s i o n a l
programs. Competency development must not end a t t h e g r a n t i n g
of the b accalau reate degree.
The home e c o n o m i s t n e e d s
c on tinued p r o f e s s i o n a l growth, (p. 3)
Mokma

(1975)

completed

a

study

of

the

assessment

of

the

l e a d e r s h i p r o l e in emerging c a r e e r ed uca tion programs in Michigan.
The l i t e r a t u r e review covered t h e a n a l y s i s o f r o l e s f o r deter m ining
c u rri culu m c o n t e n t using an approach c a l l e d " f u n c ti o n a c t i v i t i e s . "
Once t h e s e f u n c t io n a c t i v i t i e s were i d e n t i f i e d ,

the a c t i v i t i e s

or

t a s k s then served as a b a s i s f o r i d e n t i f y i n g s p e c i f i c competencies
i . e . , s k i l l s , knowledge, and a t t i t u d e s needed by personnel occupying
the p a r tic u la r

occu pat ion .

This approach has a l s o

been used

in

plann in g vocati onal ed uca ti on c u r r i c u l a .
Another

study

done

by Howard

(1 978)

used

a

three-phase

methodology t o i d e n t i f y and v a l i d a t e change agent competencies in
e d u c a ti o n .

Phase One c o n s i s t e d o f a review o f l i t e r a t u r e r e l a t i v e

t o change agent r o l e s and d u t i e s ,

while Phase Two involved p i l o t

t e s t i n g t h e most important competencies t h a t were r e l e v a n t t o th e
final

investigation.

Phase

Three

focused

on

validating

th o s e

competencies through em piri ca l t e s t i n g o f a 3 7 - item l i s t reviewed by

73

272 people.

This r e s e a r c h e r used a f o u r- p h a se methodology modified

t o in c lu d e t h e Delphi techniqu e in t h e f o u r t h phase.
In th e a r ea o f s o c ia l work e d u cati o n , Berkman (1985) noted t h a t
th e number o f s o c i a l workers employed in h e a l t h c a r e in th e United
S t a t e s has more than doubled s in c e t h e e a r l y 1960s, with e s t i m a t e s
o f s o c ia l
numbers
social

workers now a t approximately 4 5 , 000).

of

health

concentrations

developed

work, th e c h a ll e n g e faced by s o c ia l

develop

health

curricula

that

with found ation c o n t e n t .
th at

being

the

beginning

With i n c r e a s i n g

integrated

in

s ch ools

of

work f a c u l t i e s was t o
health-specific

content

There was c l e a r agreement among f a c u l t y

social

worker

in

health

under st an din g o f t h e m i l i e u o f th e system.

care

required

an

To accomplish t h i s ,

13

knowledge base a r e a s were i d e n t i f i e d with s p e c i f i c competencies in
each a r e a .

The Massachusetts General Hospital

P r o f e s s i o n s has implemented t h i s
content

in

different

the
levels

major

areas

must

of practice

p e r c e p t i o n was t h a t t h i s

program,
be

through

I n s t i t u t e o f Health

aware t h a t

continually
co n t in u in g

some o f th e
reinforced

education.

at
The

knowledge was b a s i c f o r beginning s o c ia l

work p r a c t i c e in h e a l t h c a r e .
In t h e p r e s e n t s tu d y ,
needs,

specifying

compo nen ts

in

com petencies,

fiv e

adm inistrators.
performance l e v e l s ,

t h e focus was on a s s e s s i n g competency

It

broad

and

co m petency

remains

for

determ ining
sections

fu tu re

study

competency-attainment c r i t e r i a ,

c o m p eten cy
for

to

hospice
determ ine

and assessment

74
mechanisms a s m e n t i o n e d

in t h e p r e v io u s

r e v i e w o f c o m petency

research.
Research Methodology
This
D elphi

section

technique,

in c lu d e s

a

review

advantages

of

survey

methodology,

and d i s a d v a n t a g e s

of the

th e

D elphi

te c h n i q u e , and a review o f s t u d i e s using th e Delphi te c h n i q u e .
Survey Methodology
S ur vey
describing

research

has,

and p r e d i c t i n g

as

its

action,

between two o r more v a r i a b l e s

prim ary

focus,

o r e x p l a in in g

(Oppenheimer,

the

the

1973).

survey r e s e a r c h can be c l a s s i f i e d as s o c i o l o g i c a l

goal

of

relationship
V a r ia b le s

in

and psy cholo gica l

and a r e usefu l when r e s e a r c h e r s a r e i n t e r e s t e d in how s o c i o l o g i c a l
i n f o r m a t i o n such a s d e m o g r a p h i c d a t a r e l a t e s
v a r i a b l e s such as o p i n i o n s ,

attitudes,

to psychological

and beh av io r .

Warwick and

L ininger (1975) noted t h a t t h e survey i s an a p p r o p r i a t e and us eful
means o f g a t h e r i n g inform ation under t h e fo llowin g t h r e e c o n d i t i o n s :
1.
2.

When t h e g o a ls o f r e s e a r c h c a l l f o r q u a n t i t a t i v e d a t a .
When th e

in fo rm ation

sought

is

r e a s o n a b ly

specific

and

f a m i l i a r t o th e resp o n d en ts .
3.

When t h e

researcher

has c o n s i d e r a b l e

prior

knowledge o f

p a r t i c u l a r problems and t h e range o f r es pons es i s l i k e l y t o emerge.
According t o
best

method

Babbie

available

(1983),
to

the

survey r e s e a r c h
social

scie n tist

is

pro bably th e

interested

c o l l e c t i n g d a t a on a p o p u l a tio n too l a r g e t o observe d i r e c t l y .

in
The

s t r u c t u r a l n a t u r e o f t h e in st rum ent a l s o pr ov ides an o p p o r t u n i t y t o

75

c o l l e c t comparable d a t a from a l l resp onden ts f o r use in q u a n t i t a t i v e
analysis.

It

is

also

efficient

and

less

costly

than

in -d e p th

i n t e r v i e w s , in which much time i s spe nt t a l k i n g t o in fo r m a n t s .
F u r t h e r , Babbie (1973) noted t h a t survey in s t r u m e n t s ar e useful
in

secondary

analysis

by

other

researchers

later

on.

The

development o f a survey instrum en t provid e s a mechanism f o r th e r e ­
examination o f t h e o r i g i n a l f i n d i n g s .

In t h e cas e o f t h i s r e s e a r c h ,

i t provided an o p p o r tu n i t y f o r l i s t i n g

i d e n t i f i e d competencies o f

hospice a d m i n i s t r a t o r s which may lead t o new programs o f i n s t r u c t i o n
in hospice a d m i n i s t r a t i o n .

Babbie (1983)

a l s o noted t h a t

survey

r e s e a r c h i s g e n e r a l l y s tr o n g on r e l i a b i l i t y because o f t h e s ta n d a rd
inst rum ent

which

elim inates

unreliability

in

observations.

en su re r e l i a b i l i t y , he recommended s ev eral p o i n t s .

To

F i r s t , construct

an in str um ent t h a t asks r e l e v a n t q u e s t i o n s which t h e r es po nde nt i s
l i k e l y t o be a ble t o answer.

Second, be c l e a r on what i s asked so

t h e s u b j e c t ’ s own u n r e l i a b i l i t y can be reduced.
specificity.

T h ir d ,

incorporate

Fourth, ask f o r t h e same in form ation more than once by

us ing t h e same o r s i m i l a r q u e s t i o n s .

L a st, use r a t i n g measurements

t h a t have been proven r e l i a b l e in prev io us r e s e a r c h .
The r a t i n g mechanism used t h i s survey was t h e L i k e r t s c a l e .

It

was s e l e c t e d because o f i t s wide use as an a t t i t u d e s c a l e and f o r
i t s d e p e n d a b i l i t y as a measuring in strum ent f o r q u a n t i f y i n g r e s e a r c h
info rm ation (Ary e t a l . , 1975).

Research has i n d i c a t e d t h a t as th e

number o f p o s i t i o n s in a r a t i n g s c a l e i n c r e a s e s , t h e usage o f th e
neutral,

uncertain,

don’t

know o ption d e c r e a s e s

(Matell

& Jacoby,

76
1972).

A five-level

res ponse was p r e s e n te d t o t h e resp ondents in

t h i s s tu dy.
Strengths

of

survey

research.

There

weaknesses i n h e r e n t in survey methodology.

are

stren g th s

and

The s t r e n g t h s a r e t h a t

with t h e preplanned d es ig n o f survey r e s e a r c h , r e s u l t s a r e uniform
and r e l i a b l e , e s p e c i a l l y in comparison t o th e method o f o b s e r v a t i o n
(Williamson e t a l . ,

1982).

Survey r e s e a r c h a l s o e n a b le s f l e x i b l e

a n a l y s i s o f s u b j e c t s and i s s u e s because many q u e s t i o n s can be asked
about a p a r t i c u l a r t o p i c .
research

measurement

research

can

population.

is

accurately

Furthermore, t h e r e l i a b i l i t y
high.

Finally,

describe

th e

th e

o f survey

results

characteristics

of
of

survey
a

large

Also, a l a r g e number o f s u b j e c t s can be surveyed c o s t

e f f i c i e n t l y through t h e use o f t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e .
Weakness o f survey r e s e a r c h .
standardized

questions

are

Babbie (1983) noted t h a t because

designed

to

be a p p l i c a b l e

to

all

s u b j e c t s , s u p e r f i c i a l a n a l y s i s may r e s u l t because o f t h e tendency o f
surveys t o

re veal

a g r e a t e r scope o f in f o r m a ti o n ,

e x p l a i n i n g in -d e p th r e l a t i o n s h i p s .

as opposed to

Also s in c e survey r e s e a r c h must

be r e s t r i c t e d t o q u e s ti o n s resp o nden ts are l i k e l y t o know, t h i s may
r e s u l t in a r t i f i c i a l
(Babbie,

1983).

question

of

f i n d i n g s s i n c e only s e l f - r e p o r t s a r e measured

Williamson e t a l .

accuracy concerning

(1982)

noted t h a t

self-reports.

there

A final

is

a

weakness

i d e n t i f i e d i s t h a t although they ar e f l e x i b l e in one s en se by th e
amount o f info rm ati o n t h a t can be o b ta in e d , surveys r e q u i r e t h a t an
i n i t i a l study desig n remain unchanged and i n f l e x i b l e thr ou gho ut t h e
e n tire research.

77

The Delphi Technique
Rowland and Rowland (1984) noted t h a t t h e Delphi tech n iq u e i s a
simple
making,

and

efficient

method

policy s e ttin g ,

p r e s e n t e d her e in c l u d e s :

of

a s s u r in g

and pl anning.

participatory

The review o f

d e c i s io n
literature

(a) t h e h i s t o r y , purposes and philosophy

o f t h e Delphi Technique ( h e r e a f t e r r e f e r r e d t o as D e lp h i) ;
process o f t h e Delphi,

in c lu d in g m o d i f i c a t i o n s ;

(c)

(b) the

advantages of

t h e Delphi; and (d) d isad v a n ta g es o f th e Delphi.
This tech n iq u e was developed over a decade ago a t

th e

Rand

C orpor ation by 01a f Helmer as a way o f p r e d i c t i n g f u t u r e events and
was dubbed "Delphi" a f t e r th e famous o r a c l e o f t h a t a n c i e n t c i t y .
Helmer (1967) used t h e o pin io ns o f i n t e r n a t i o n a l e x p e r t s t o p r e d i c t
changes

needed

for

th e

s u rv iv a l

of

man.

In

his

research,

he

p e r m it t e d th e e x p e r t s t o r e v i s e t h e i r p r e d i c t i o n s on a n a l y s i s o f th e
f u t u r e in t h r e e rounds.

Helmer’ s method i s based on an in te rm ed iar y

who o b t a i n s consensus from a panel

o f e x p e r t s on t h e p r o b a b i l i t y

t h a t f u t u r e events w i l l occ ur .
The process o f t h e Delphi t e c h n i q u e .

The s t e p s in t h e Delphi

te c h n iq u e d e s c r ib e d by Helmer (1967) a r e summarized as f o ll o w s :
1.

S e l e c t i n g a panel o f e x p e r t s .

2.

Independent q u e s ti o n i n g o f t h e e x p e r t s .

3.

Feeding

inform ation

about

the

responses

b ack

to

respondents.
4.

I n v i t i n g t h e resp onden ts t o r e v i s e t h e i r p r e d i c t i o n s .

the

78
Although Helmer suggested
total

repeating

the

above process

to

a

o f f o ur rounds, Young (1977) found t h a t in 49 d i s s e r t a t i o n s

she reviewed, 34 used t h r e e rounds and m o d i f i c a t i o n s t o th e Delphi
technique included v a r i a t i o n s in s e l e c t i o n o f th e panel o f e x p e r t s ,
f or mat, number o f rounds, and i n t e r v a l between rounds.

E ssentially,

t h e Delphi technique uses a q u e s t i o n n a i r e t o determine t h e views and
a t t i t u d e s o f t h i s panel o f e x p e r t s r e l a t i v e t o t h e t a s k b e fore them
and t o d e l i n e a t e th e a r e a s o f concern t o t h e i n t e r m e d i a r y .

Since

t h e q u e s t i o n n a i r e i s completed anonymously, a h ig h e r number o f f rank
answers i s l i k e l y ,

e s p e c i a l l y where i d e n t i f i c a t i o n o f t h e opinion

h o ld e r would r e s u l t

in

reduced

creativity,

biase d

estim ates,

or

c o n s tr a i n e d s u g g e s ti o n s .
U sually
generation

the

of

altern ativ es

first

new o r
from

r ound

of

additional

the

questioning

problem

committee

encourages

s ta t e m e n t s ,

members.

A fter

issues,

the
or

su fficien t

d i s c u s s i o n t o in s u r e t h a t a l l p a r t i c i p a n t s understand what i s being
soug ht, each member r e c e i v e s a q u e s t i o n n a i r e .

The p a r t i c i p a n t s ar e

asked t o respond t o t h e q u e s t i o n n a i r e and t o comment on t h e phr as ing
o f t h e q u e s ti o n s , and t o add f u r t h e r q u e s t i o n s / s t a t e m e n t s t h a t th ey
r e g a rd as s i g n i f i c a n t .
rephrasing,

which i s

This i s v a l u a b l e in two r e s p e c t s .
s u ggested,

may t r a n s l a t e

the

issues

First,
from a

t e c h n i c a l jar gon t o t h e normal vocabulary o f t h e r e s p o n d e n ts ,
second, th e a d d i t i o n a l

and

s ta te m e n ts o f t h e i n d i v i d u a l s involved ar e

reflected.
Between each round o f q u e s t i o n n a i r e s t h e l a t e s t opin io ns o f th e
panel members a r e analyze d, compiled, and pooled.

This pr oc es s o f

79

recirculating

the

questionnaire

consensus i s reached.

for

review

is

repeated

until

a

Chung and F e r r i s (1971) noted t h a t t h e Delphi

i s an a tte m p t t o overcome i n f l u e n c e o f dominant p e r s o n a l i t i e s

in

f a c e - t o - f a c e group i n t e r a c t i o n f o r d e c i s i o n making.
S e l e c t i o n o f th e panel o f e x p e r t s .

Helmer and Rescher (1959)

l i s t e d c r i t e r i a f o r t h e use o f e x p e r t s in p r e d i c t i o n , which include d
l e v e l o f knowledge o f t h e person about t h e t o p i c .

Characteristics

o f t h e panel o f e x p e r t s should a l s o be matched t o t h e n a t u r e and
purposes

of

the

Delphi

s tudy .

Dal key

(1968)

noted

p a n e l i s t must a l s o be an e x p e r t in h i s / h e r own r i g h t
avoid c r e a t i o n o f a s i t u a t i o n

that

each

in o r d e r t o

in which someone’ s p o i n t o f view i s

summarily accepted w it h o u t q u e s ti o n .
This

study

adm inistrators
relative

to

us ed

in

the

Michigan

ed ucati onal

expertise
whose

of

78

backgrounds

preparation

and t h e

which th ey were a d m i n i s t r a t i v e l y r e s p o n s i b l e .
experts

on t h e

adm inistrative

current
were

ty pe

hospice

heterogeneous

of

hospice

for

B a s i c a l l y , th e y were

resp o n sib ilities

for th e ir

own

program.
With

r e g a rd

to

panel

size,

Weatherman

and

Swenson

(1974)

r e p o r t e d t h a t prev ious s t u d i e s using t h e Delphi had panels under 50
members.

By c o n t r a s t , White (1980) s t a r t e d with a random sample o f

842 p a n e l i s t s and a 37% r e t u r n r a t e in round one and 301 p a n e l i s t s
in round two with
in itial

a 77% r e t u r n

rate.

This

m aili n g t o 78 ho spice a d m i n i s t r a t o r s

expected r e t u r n r a t e o f approximate ly 60%.

researcher

used

an

in Michigan with an

I t was a n t i c i p a t e d t h a t

80
t h i s r e s e a r c h e r ’ s e x t e n s i v e v i s i b i l i t y in t h e f i e l d o f hospice c a r e
in Michigan would encourage th e h ig h e r r e t u r n r a t e .
Interval

betwee n r o u n d s .

Another p ro c e d u ra l

r e l a t e d t o t h e le n g t h o f time between rounds.
months between rounds f o r an i n t e r n a t i o n a l
t h a t t h e time be sh ort en ed t o f a c i l i t a t e

q uestion

is

Helmer (1966) used 2
s tu d y ,

but recommended

a b e t t e r res ponse r a t e .

Gazzola (1971) used 5 weeks f o r a four-ro un d s tu d y .

Young (1977)

noted t h a t i t i s advantageous t o plan t o pr e v e n t time d e l a y s .

This

r e s e a r c h e r planned 1 month between rounds.
Advantages and d isadva nta ges o f t h e Delphi t e c h n i q u e .

The com­

b i n a t i o n o f t h e Delphi tech n iq u e and survey methodology was expected
to

improve

both

validity

and r e l i a b i l i t y

of

this

s tu d y .

Some

n o t a b l e c h a r a c t e r i s t i c s and advantages o f t h e Delphi pr ocedure were:
(a) by use o f t h e q u e s t i o n n a i r e s t h e r e was anonymity and e x c e s s iv e
i n f l u e n c e o f d o m in a n t i n d i v i d u a l s was r e d u c e d ,
feedback by a

sequence o f rounds between

(b)

controlled

which a summary o f

previous round r e s u l t s was communicated t o each

th e

panel member, and

(c) i n t u i t i v e i n s i g h t s o f th e panel o f e x p e r t s enhanced t h e i n t e r n a l
v a l i d i t y o f t h e survey instrum en t (Helmer, 1967).
The e a r l y s t u d i e s d e a l i n g with s o c ia l
le ss co stly to
experts

i s s u e s noted t h a t i t was

conduct a Delphi study than t o assembly t h e panel o f

together

at

one

time.

Weatherman

and

observed t h a t Delphi was cons id e re d an i n t e r e s t i n g

Swenson

(1975)

t a s k by panel

members a t t r i b u t i n g t h e i n t e r e s t t o in fo rm ation feedback.

Cyphert

and Gant (1971) observed t h a t t h e Delphi tech n iq u e can be a us eful

81
method t o mold opinion and t o c o l l e c t i t , whil e Ue lty (1973) found
t h a t t h e Delphi method r e s i s t e d m a n i p u la tio n .
Disadvantages o f t h e

Delphi

t echnique

incl uded

the

critical

problem o f a c u i t y in p r e d i c t i n g t h e f u t u r e and t h e time s pent in
completing t h e s e r i e s o f rounds n e c e s s a r y f o r consensus.

Malone

(1973) s t a t e d t h a t consensus may be c o n t r i v e d , while Womble (1974)
d e s c r i b e d Delphi as a "conformity movement" and r e q u e s t e d r e s p e c t
f o r t h o s e who d i f f e r .
Research using th e Delphi t e c h n i q u e .
Home Economics A s s o c i a t i o n

In 1973,

t h e American

involved members in a Delphi

study o f

"The Future o f Home Economics," which provided t h e framework f o r
d iscu ssio n

for

the

Eleventh

Lake P l a c i d

Conference

for

Home

Economics in 1974 (Lee, 1973).
Rhodes (1976) found t h e Delphi method s u c c e s s fu l in deter minin g
which

competencies were e s s e n t i a l

college
resulting

system

of

Tennessee.

for

teachers

S e v e n ty - fo u r

in

the

experts

were

in t h r e e rounds o f i n p u t and group feedback.

t h e competencies

under

scrutiny,

th e

investigator

s t a t e w id e consensus had been a t t a i n e d and t h a t

community
used,

Regarding

concluded

t h e Delphi

that

method

gained co nvergent e x p e r t op in io n .
C o p ela n d

(1 977)

us ed

consensus on competencies
teachers.

the
for

D e lp h i
evaluating

to

id entify
industrial

and g a i n
arts

a

s tu d e n t

Three groups o f i n d u s t r i a l a r t ed u c a to r s were used, with

a high r a t e o f agreement between each group on t h e ra nkin g o f each
competency l i s t i n g .

82
The Delphi tech n iq u e was a l s o used 1n a study done by Young a t
Michigan S t a t e U n i v e r s i t y in 1977 on th e development o f a fa mily
s t u d i e s program a t t h e c o l l e g e l e v e l .

One purpose o f t h a t study was

t o c o n t r i b u t e t o t h e t h e o r y o f t h e Delphi method by comparing p anels
that

had

w ith in

hierarchical,

sp ecialist

committee

heter og en eo us ,

and g e n e r a l i s t

evaluated

the

and

groups.

objectives

homogeneous

sections,

A 15-member
and

ad v is o r y

p ilo t-tested

q u e s t i o n n a i r e completed by 104 persons in s i x Delphi p a n e l s .
one c o n tain ed

123

items

d erived

from th e

review

of

Round

literature.

P a n e l i s t s ’ s u g g esti o n s were added in rounds two and t h r e e .
study used a f o u r - p o i n t L i k e r t - t y p e s c a l e .

the

The

S t a t i s t i c s reported to

p a n e l i s t s were median and i n t e r - q u a r t i l e range.

R e s u lts o f t h i s

stu dy showed t h a t t h e Delphi method was s u i t a b l e f o r t h e development
o f a program in fa m ily s t u d i e s a t th e c o l l e g e l e v e l .

Convergence t o

consensus on o b j e c t i v e s was complete by round two.
White
essen tial,

(1 980 )

used t h e

supplem entary,

o c cupational t h e r a p i s t s .
in clu d ed :

D elphi

technique

to

determ ine

the

and e m e r g in g c o m p e t e n c i e s nee ded by
She used a t h r e e - p h a s e methodology t h a t

(a) phase o n e - - i d e n t i f y i n g a l i s t o f competencies from a

l i t e r a t u r e review,

(b) p h a s e t w o - - p i l o t - t e s t i n g t h e com p e te n c y

i n v e n t o r y w i t h f i v e American O c c u p a t i o n a l

Therapy A s s o c i a t i o n

Fellows, and (c) phase t h r e e - - o b t a i n i n g r es po nses from Fellows o f
th e American Occupational Therapy A s s o c i a t i o n , cu r ricu lu m d i r e c t o r s
o f programs f o r occ upational t h e r a p i s t s and a s s i s t a n t s , and a random
sample o f g r a d u a t e s w i t h i n 5 y e a r s o f g r a d u a t i o n .
o b ta in e d in two rounds.

Opinions were

Feedback from round one was given as means

83

and frequency o f respo nses
Likert-type scale.

in each o f t h e

five

intervals

of

a

Findings from t h i s study r e v e a l e d t h a t ac r o ss

a l l p a n e l i s t s t h e p r o p o r t i o n s o f competencies reaching an E s s e n ti a l
consensus were 60%,

0% Supplementary

(indicating

0 supplementary

competencies o b t a i n i n g c o n s e n su s ), and 28% Emerging.
In

1983 B a s i l e s

evaluate

selected

used

th e

Delphi

tech nique

competencies

needed

by

Through a review o f l i t e r a t u r e ,

e x p e r t s review t h e 29 competencies.
th e

experts’

identify

hospice

team

and

members.

he s e l e c t e d competencies and then

used t h e Delphi te c h n iq u e and th e L i k e r t

validate

to

respon ses

scale to

His f i n a l

with

49

have 10 panel

s t e p was t o c r o s s -

hospic e

practitioners.

These p r a c t i t i o n e r s r a t e d th e competencies only once.

Each o f the

29 competencies was reviewed s e p a r a t e l y t o f a c i l i t a t e a n a l y s i s and
discussion of the data.

S t a t i s t i c a l analysis consisted of a t - t e s t

f o r independent samples, a n a l y s i s o f v a r i a n c e , and a p a i r e d t - t e s t
(fi < . 0 5 ) .
A lt h o u g h
believes

th e

competencies

t h e D e lp h i

is

tech n iq u e w i l l
for

hospice

not w idely used,

th is

be extr emely b e n e f i c i a l

administrators

in

com petencies

p ractitio n er,"

and

"should

be d e r i v e d

through

th is

from t h e

research

in

Michigan

allows and encourages p a r t i c i p a t o r y d e c i s i o n making.
noted,

researcher

the

defining

because

it

As Elam (1978)
ro le

of

the

p ractitio n ers

themselves had input in d e f i n i n g t h e i r own competencies.

84
Summary
This c h a p t e r p r e s e n te d a review o f l i t e r a t u r e ,
an overview

of

hos pice

care,

hospice

which included

adm inistrative

components,

a d m i n i s t r a t i v e t h e o r y , o r g a n i z a t i o n a l l i f e c y c l e t h e o r y , competency
research,

and r e s e a r c h methodology,

methodology

and

the

Delphi

in clu d in g

tec h n i q u e .

a review o f

Chapter

III

survey

presents

d e t a i l e d d i s c u s s i o n on r e s e a r c h methodology s p e c i f i c t o t h i s stu d y.

a

CHAPTER III
METHODOLOGY

The purpose o f t h i s

study was t o

n eed ed f o r h o s p i c e a d m i n i s t r a t o r s
includes

descriptions

of

the

identify

the

i n M ic h i g a n .

design

of

the

competencies
This

s tu d y ,

chapter

operational

d e f i n i t i o n s , hypotheses, sample, te c h n iq u e s o f d a t a c o l l e c t i o n , and
proce dur es f o r d a t a a n a l y s i s .
Design o f th e Study
The r e s e a r c h design involved a fou r- p h ase methodology d e s c r ib e d
below.

I t in cluded:

(a) t h e development o f a r e s e a r c h instrum en t

des igne d t o a s s e s s competencies o f hospice a d m i n i s t r a t o r s
Phases

I,

II,

and

III;

and

(b)

em pirically

validating

competencies using th e Delphi tech n iq u e in Phase IV.
to

use t h e Delphi

lite ra tu re

the

The d e c i s io n

t e c h n i q u e was based in p a r t on t h e review o f

and a l s o

adm inistrators

through

need

th is
to

be

r e s e a r c h e r ’ s view point
actively

involved

in

that

hospice

defining

their

p r o f e s s i o n a l competencies.
Phase I
The

purpose

of

this

phase

was

in str u m e n t by i d e n t i f y i n g p o t e n t i a l

to

generate

items

for

the

competencies ac cording t o t h e

f u n c t i o n s o f planning, o r g a n i z i n g , d i r e c t i n g , and c o n t r o l l i n g which

85

86
a r e needed by hos pice a d m i n i s t r a t o r s .

This was accomplished

by

review in g:
1.
and

L iteratu re re la te d to adm inistration,

leadership

theory.

R ationale:

to

competency t h e o r y ,

develop

a

base

of

a d m i n i s t r a t i v e t h e o r y and i d e n t i f y ge ner al l e a d e r s h i p competencies.
2.

Social p o l i c y l e g i s l a t i o n a t t h e s t a t e and f e d e r a l

Rationale:

to

identify

specific

competencies

required

level.
from

a

s t a t u t o r y base a t both t h e s t a t e and f e d e r a l l e v e l s .
3.

Hospice a d m i n i s t r a t o r j o b d e s c r i p t i o n s .

review and i d e n t i f y

adm inistrative

jo b

R ationale:

requ ir em ents

to

from var io u s

types o f hospice programs in both urban and r u r a l s e t t i n g s .
4.

To i d e n t i f y each competency s ta te m e n t as i t r e l a t e d t o th e

human b e h a v i o r a l ,
R ationale:

human c o n s t r u c t e d ,

and n a t u r a l

environm ent.

t o a s s u r e t h a t an e c o l o g i c a l framework co ntinued t o be

e v i d e n t in t h e development o f t h e survey in s tr u m e n t.
Phase II
To v e r i f y th e f i v e p o t e n t i a l
both

the

review

of

literatu re

competency a r e a s g e n e r a te d from
and

hospice

ad m inistrator

job

d e s c r i p t i o n s , t h i s r e s e a r c h e r a l s o compared t h e proposed competency
areas

with

a list

of

competency

areas

submitted

by t h e

hospice a d m i n i s t r a t o r o f Hospice o f S o u t h e a s te r n Michigan

former
(HSEM),

t h e l a r g e s t f r e e s t a n d i n g ho s p ic e in Michigan.
Also, as Hospice C oordinator f o r Michigan, t h i s r e s e a r c h e r had
th e o p p o r t u n i t y t o observe 30 l i c e n s e d hos pice programs in Michigan
and 25 hospice Medicare

certified

programs

and

to

consult

with

87
numerous exempt

h o s p ic e s .

According t o t h e s e o b s e r v a t i o n s ,

th e

competency a r e a s used in t h i s r e s e a r c h were b e lie v e d t o be r e l e v a n t
and a p p r o p r i a t e f o r hospice programs in Michigan.
Phase I I I
Based on a combination o f Phases I and I I , a p r e l im i n a r y twop a r t survey in st rum ent e n t i t l e d th e Hospice A d m i n i s t r a t o r s Inventory
was p r e t e s t e d

by f o u r former hospice a d m i n i s t r a t o r s

in Michigan.

They e v a lu a te d th e instrumen t and o f f e r e d s u g g e s ti o n s which helped
promote c l a r i t y and s p e c i f i c i t y .

The r a t i o n a l e f o r using t h i s p i l o t

group o f former hospice a d m i n i s t r a t o r s was t o avoid contam in ating
t h e study sample.
various

These f o u r i n d i v i d u a l s were r e p r e s e n t a t i v e o f th e

organizational

ty pe s

of

hospice

programs

in

the

state.

Based on t h e i r s u g g e s t i o n s , a p p r o p r i a t e r e v i s i o n s were made in the
q u e s t i o n n a i r e b e fore Phase IV was implemented.
Phase IV
This phase focused on e m p i r i c a l l y v a l i d a t i n g t h e competencies
i d e n t i f i e d from t h e r e v i s e d Hospice A d m in is t r a to r s

I n v e n to ry .

The

Delphi tech n iq u e f o r o b t a i n i n g opinions o f a panel o f e x p e r t s was
used.

This

study

us ed

the

expertise

a d m i n i s t r a t o r s as t h e panel o f e x p e r t s .

of

78 c u r r e n t

hospice

Since t h e in v e n to ry was a

long one, only two rounds were used t o survey p a n e l i s t s .

88
Operational D e f i n i t i o n s
Several d e f i n i t i o n s r e l e v a n t t o t h i s study ar e inc luded in t h i s
section.

They ar e d e f i n e d in t h e c o n te x t in which th ey a r e used in

th is dissertation.
Hospice;

A c e n t r a l l y adm inist ered program o f p a l l i a t i v e and

s u p p o r t i v e s e r v i c e s which provide s p h y s i c a l ,

p s y c h o l o g i c a l,

and s p i r i t u a l c a r e f o r dying persons and t h e i r f a m i l i e s .
a r e provided by a m edically s up er vis ed

social

S er v ic es

i n t e r d i s c i p l i n a r y team of

p r o f e s s i o n a l s and v o l u n t e e r s .
Hospice
governing
chief

adm inistrator:

body,

e x e c u tiv e

either

A person

d irectly

officer,

for

who

o r through

th e

is

responsible

the

governing

adm inistrative

to

a

body’ s

operation

of

a

ho spice program.
H o s p ita l- b a s e d h o s p i c e :

An acute c a r e h o s p i t a l with s t a f f and

beds d es ig n a te d f o r t h e p r o v is i o n o f c a r e f o r t h e dying.
F reest anding
assigned

to

hospice

providing

A facility

care

to

the

with
dying

all

beds

and

p atien t.

It

staff
is

an

independent economic e n t i t y governed by i t s own a d m i n i s t r a t i v e s t a f f
and board.
Home-health-aaencv-based h o s p i c e :

An agency which c o o r d i n a t e s

n u r s i n g and r e l a t e d h e a l t h c a r e s e r v i c e s t o p a t i e n t s in t h e i r homes
and i n c l u d e s , as one o f i t s s e r v i c e s , a hospice program o f c a r e f o r
p a t i e n t s and f a m i l i e s .
Communitv-based

hospice:

A p rogr am which

provides

c o o r d i n a t e s hos pice s e r v i c e s in th e home f o r th e community.
s e p a r a t e and economically autonomous program.

and

It is a

89

I n t e r d i s c i p l i n a r y te am ;
nurse,

s o c ia l

worker,

A group c o n s i s t i n g

clergy,

d i s c i p l i n e s who i n t e r r e l a t e

volunteer,

in

of a physician,

and members

an e f f e c t i v e

of

working

related

relationship

en a b li n g t h e p r o v is i o n o f hospice s e r v i c e s t o p a t i e n t s and f a m i l i e s .
Functions;

The p la n n in g , o r g a n i z i n g , d i r e c t i n g ,

and c o n t r o l ­

l i n g a c t i v i t i e s in which a h o s p i t a l i s involved.
Planning f u n c t i o n :
It

is

The most b a s ic o f a d m i n i s t r a t i v e f u n c t i o n s .

fu n d am en tally choosing a f u t u r e

alternatives.

course

of

action

from

I t g iv e s d i r e c t i o n t o f u t u r e program growth.

Organizing f u n c t i o n :

Involves how t h e hospice a d m i n i s t r a t o r

gro ups, a s s i g n s , and c o o r d i n a t e s a c t i v i t i e s t o accomplish g o a l s and
objectives.
D irecting
communicate,

fu n ctio n :

teach,

as

Involves
well

as

being

delegate

able

and

to

m otivate,

supervise

hospice

staff.
Controlling f u n c tio n :

The pr oc es s o f monitoring and e v a l u a ­

tion.
Competencies:

Skills,

knowledge,

and

attitudes

i d e n t i f i e d as n e c e s s a r y t o f u n c t io n in a p r o f e s s i o n a l

which

role

ar e

(Klemp,

1979).
E ssen tial com petencies:

Those c o m p e t e n c i e s which h o s p i c e

a d m i n i s t r a t o r s in Michigan r a t e on t h e average h i g h e r than o r equal
t o 4.0 on t h e Hospice A d m i n i s t r a t o r s Inventory I I .

90
Supplementary co m pet en ci es ;

Those competencies which hospice

a d m i n i s t r a t o r s in Michigan r a t e on th e average h ig h e r than 2 . 5 , but
l e s s than 4 . 0 on th e Hospice A d m in is tr a to rs Inventory I I .
Delegation:

To commit t o on e’ s agent or r e p r e s e n t a t i v e .

Delphi t e c h n i q u e :

A s e t o f pro ce dures t o e l i c i t and r e f i n e t h e

opinio n o f a group o f people (Weatherman & Swenson, 1974).

A simple

and e f f i c i e n t method o f a s s u r i n g p a r t i c i p a t o r y d e c i s i o n making.
Panel o f e x p e r t s :
have e x p e r t i s e
s tu d y ,

the

Persons i n v i t e d t o form a Delphi panel who

in th e

panel

field

o f hospice a d m i n i s t r a t i o n .

comprised a l l

current

In t h i s

hospice a d m i n i s t r a t o r s

in

Michigan as o f December 1986.
Consensus:

A degree o f w ith in-g ro up agreement where over 50%

i s cons id e re d achievement o f consensus (Gazzola, 1971).
Convergence t o c o n s e n su s :
agreement on a given
cons ensus,

item.

respondents’

A degree t o which resp ondents reach
Using

w i th i n -g r o u p

the

Leik formula

consensus

as

for

or d in a l

acc ep ted

when

equal t o o r h ig h e r than 75% (Leik, 1966).

the

Licensed h o s p i c e :

A hospice program which complies with a l l

hospice

defined

rules

as

by M ic higan

hospice

licensure

require m ents R325.13101-R325.13307.
Exempt h o s p i c e :

A hos pice program which complies with a l l o f

t h e f ollow ing req u irem en ts :

(a) pr o v id e s s e r v i c e s t o n o t more than

seven p a t i e n t s p e r month on a y e a r l y average, (b) does not charge o r
r e c e i v e any f e e s f o r goods o r s e r v i c e s provided,

and (c) does not

r e c e i v e t h i r d p a r t y reimbursement f o r goods o r s e r v i c e s prov ided.

91
Hosoice M e d i c a r e - c e r t i f i e d

program:

A licensed

program

in

M ic h ig an which m a i n t a i n s c o m p l i a n c e w i t h t h e H o s p i c e M e d ic a r e
Cond itions o f P a r t i c i p a t i o n 418.50-418.98 (Medicare [HCFA] Federal
r e g i s t e r #48, p. 45309-10).
Education:
s ta t e m e n t ,

Seven r e s p o n s e c h o i c e s were

"Please check th e

highest

included

e d u c a t io n a l

level

in

the

achieved:

(a) High school diploma, (b) A s s o c i a te degree in _____ , (c) Diploma
in

n u r s i n g _____ ,

(d)

degree in _____ , ( f )

Bac helor’ s

degree

in ______,

(e)

M a s te r ’ s

Ph.D. in _____ , o r (g) Other ______."

Open-

ended r esp onses allowed t h e r e s e a r c h e r t o e v a l u a t e more s p e c i f i c a l l y
the

type of degree

attained

rather

than j u s t

knowing

if

the

a d m i n i s t r a t o r had a de g r e e .
Present

employment:

For

purposes

of

this

s tu d y ,

present

employment r e l a t e d t o how long t h e a d m i n i s t r a t o r had been in h i s / h e r
current position.
the statement:

Responses were s o l i c i t e d in y e a r s and months t o

"P le ase i d e n t i f y t h e number o f year s/m on ths you have

worked as a ho spic e a d m i n i s t r a t o r in t h e program you a r e c u r r e n t l y
directing."
researcher

As ho spice i s a new program o f c a r e in Michigan, t h i s
was

interested

in

how long

adm inistrators

had

been

d i r e c t i n g t h e i r programs.
P r i o r employment h i s t o r y :
in t h e s ta t e m e n t :
reflects

yo ur

employment:

"Please check t h e s ta te m e n t which most a c c u r a t e l y

employment
(a)

Five resp ons e ch oic es were included

working

status
in

a

1 year
health

prior

related

h o s p ic e , (b) working in a nonhealth r e l a t e d f i e l d ,

to

yo ur

field

current

other

than

(c) working in a

hospic e program but not i n an a d m i n i s t r a t i v e c a p a c i t y ,

(d) working

92

in

a hospice

program in

an a d m i n i s t r a t i v e

capacity,

or

(e)

not

working."
Administrative h i s t o r y :
in t h e s ta t e m e n t :

Three respons e choice s were included

" P le a se i n d i c a t e t h e t o t a l

have worked as an a d m i n i s t r a t o r :
related fie ld ,

o r (c)

number o f y e a r s you

(a) in h o s p ic e ,

(b)

in a h e a l t h

in a nonhealth r e l a t e d f i e l d . "

Respondents

were a l s o asked t o s p e c i f y in which f i e l d s th e y had a d m i n i s t r a t i v e
e x p e r ie n c e .
Role r e s p o n s i b i l i t i e s :
th e s ta t e m e n t:

Two response choices were in cl uded in

"Pleas e check t h e sta t e m e n t which most a c c u r a t e l y

r e f l e c t s your r o l e r e s p o n s i b i l i t i e s :
administering

the

adm inistering

hos pice

the

resp o n sib ilities."

program,

hospice

(a) I am only r e s p o n s i b l e f o r
or

(b)

program

I
and

am r e s p o n s i b l e
additional

for
role

I f resp onden ts r e p l i e d t o t h e second c h o ice they

were then asked t o d e l i n e a t e t h e i r a d d i t i o n a l r o l e r e s p o n s i b i l i t i e s .
Salary range:
s ta t e m e n t :

(f)

ch o ic e s were

(b) under $10,000 p er y e a r ,

(d) $15,000-$20,000 pe r y e a r ,
$25,000-530,000 p e r y e a r ,

over $35,000 per y e a r . "
knowledge

included

"P le ase check your c u r r e n t s a l a r y range:

--unsalaried,
year,

Eig ht response

that

ho spice

(a) v o l u n t e e r

$10,000-$15,000 per

(g) $30,000-535,000 p e r y e a r ,

both

a

th e

(e) $20,000-525,000 p e r y e a r ,

This range
is

(c)

in

selection

relatively

o r (h)

was based on th e
young

movement

in

Michigan and uses many v o l u n t e e r a d m i n i s t r a t o r s (Olson, 1986).
Hourly employment s t a t u s :
in t h e s t a t e m e n t :

Two resp ons e ch oices were included

" P lease check your employment s t a t u s :

(a) f u l l

93
tim e,

or

(b)

p a rt tim e."

If

resp ond ents

replied

to

the

second

ch oice th e y were then asked t o s p e c i f y th e number o f hours worked
p er week.

the

Hospice d e s i g n a t i o n :

Four response choice s were inc lud ed in

statem ent:

check th e

"Please

statem ent

r e f l e c t s t h e s t a t u s o f your hospice program:

which
(a)

currently

licensed

as

a

h o s p ic e , (b) exempt from l i c e n s u r e , (c) hospice Medicare c e r t i f i e d ,
or

(d)

o t h e r _____ ."

This

last

open-ended resp ons e allowed th e

o p p o r tu n ity f o r hospice a d m in is t r a to r s

to

in dicate

additional

program s t a t u s .
Hospice l o c a t i o n :
s ta t e m e n t :

Two response cho ice s were includ ed in th e

"P le as e check t h e p o p ulation most a p p r o p r i a t e t o your

hospic e s e r v i c e a r e a :

(a) pop. < 50,000,

(b) pop. > 50,000 but <

100,000, (c) pop. > 100,000 but < 250,000, o r (d) pop. > 250,000.
P atient/fam ilv
were include d

ethic

in t h e

representation:

sta t e m e n t:

"P leas e

p a t i e n t / f a m i l i e s in your program f o r 1986:

Five

resp on se

indicate
(a)

ch oices

th e number o f

Black,

(b) White,

(c) American I n dia n, (d) Asian, and (e) Hispanic .
Program f o r e c a s t :
s ta t e m e n t :

Four response ch oices were include d in t h e

"What do you a n t i c i p a t e

program t o be fine y e a r from now:

th e

status

o f you r

hos pice

(a) l i c e n s e d as a h o s p ic e ,

(b)

exempt from l i c e n s u r e , (c) hos pice Medicare c e r t i f i e d , o r (d) o t h e r
."

The l a s t open-ended response allowed t h e o p p o r tu n i t y f o r

ho spice a d m i n i s t r a t o r s t o

i n d i c a t e any a d d i t i o n a l

program s t a t u s .

This r e s e a r c h e r b eli ev ed program f o r e c a s t i s an importa nt p r e d i c t o r

94
of

anticipated

program growth

as

well

as

stab ility

within

th e

included

in

pr ogram's o r g a n i z a t i o n a l l i f e c y c l e .
Program development:
t h e s ta te m e n t:

Four response choices were

"P leas e check t h e s ta ge o f development you b e l i e v e

your hospice program t o be in c u r r e n t l y :

(a) s t a g e one, (b) s ta g e

two, (c) s t a g e t h r e e , o r (d) s t a g e f o u r .
Stage one h o s p i c e :
developing p o l i c i e s

The hospice program i s

and proce dure s,

developing

newly organized,
and f i l l i n g

staff

p o s i t i o n s , and perhaps i s h ighly v o l u n t e e r i n t e n s i v e .
Stage two h o s p i c e :

t h e hospice i s becoming more e s t a b l i s h e d in

t h e community, r e f e r r a l s a r e i n c r e a s i n g ,

s t a f f p o s i t i o n s a r e being

added, and a d m i n i s t r a t i o n i s f o r m a liz in g .
Stage t h r e e h o s p i c e :

A d m in istr atio n i s becoming more complex

with t h e a d d i t i o n o f more s t a f f .
s e r v i c e s and t h e census
highly

unlikely

that

The hospice i s adding a d d i t i o n a l

i s remaining high.

a hospice

For Michigan,

program would

reach

stage

it

is

three

w ithout meeting s t a t e hospice l i c e n s u r e re q u i re m e n ts .
Stage f o u r h o s p i c e :
structure.
a large

There i s a h ighly complex o r g a n i z a t i o n a l

Expansion i s o c c u r rin g through s a t e l l i t e o p e r a t i o n s , and

number o f

employees

is

needed

to

accommodate

increased

service areas.
Hospice a d m i n i s t r a t i o n

education

ch oices were included in t h e s t a te m e n t :

fo recast:

Two r e s p o n s e

"Do you b e l i e v e t h e r e i s a

need f o r a hospice a d m i n i s t r a t i o n e d u cati o n al c urri cu lu m :
o r (b) no."

(a) y e s ,

I f t h e re sp onde nts r e p l i e d "yes" th e y were asked t o

95
complete

two more q u e s t i o n s

relatin g

to

hospice

educational

programs.
Hospice e d u catio n al a r e a s :
in t h e s ta te m e n t:
most h e lp f u l

"Which e d u cati o n al

t o you:

(a)

Management,

(e)

a r e a s do you f e e l

S t a f f i n g and Personnel

P a t i e n t and Family R e l a t i o n s ,
F iscal

Six respons e choi ce s were included
would be

Management,

(b)

(c) Community/Public R e l a t i o n s ,

(d)

Q u a lit y Assurance,

and

(f)

Other _____

Respondents were asked t o s p e c i f y t h e ar ea i f th ey i n d i c a t e d
O ther

.

Educational a s s i s t a n c e :
th e s ta te m e n t :

Education Units
(c)

Six response choices were includ ed in

"P le ase check which method o f e d u catio n al a s s i s t a n c e

i s most p r e f e r a b l e t o you:

credits,

(f)

(a)

(CEU) c r e d i t s ,

college/university

seminars/workshops f o r Continuing
(b)

seminars/workshops w i th o u t

certification/degree

c o l l e g e / u n i v e r s i t y l i f e l o n g ed uca tion c o u r s e s ,
educa tion programs, or ( f ) o t h e r _____ ."

CEU

program,

(d)

(e) a d u l t c o n tin u in g

Respondents were asked t o

s p e c i f y o t h e r e d u catio n al a s s i s t a n c e i f th ey i n d i c a t e d ( f ) .
Hypotheses
The

follow ing

research

objectives

were

generated

with

hypotheses s p e c i f i c t o O b je c ti v e s 2, 3, 4, and 5.
Research O b je cti v e 1 :

To compile s e l e c t i v e demographic and

opinion d a t a on hospice a d m i n i s t r a t o r s

in Michigan.

d a t a f o r hospice a d m i n i s t r a t o r s in Michigan included:
(b)

p r o p o r t i o n o f male t o female a d m i n i s t r a t o r s ,

ed u c a ti o n a l

background,

(d)

mean number

of

Demographic
(a) mean age,

(c) most f r e q u e n t

years

ex p er ien ce

in

96
hospice a d m in is tr a tio n ,

(e)

most

frequently

id en tified

p rio r

employment h i s t o r y , ( f ) mean t o t a l y e a r s worked as an a d m i n i s t r a t o r ,
(g )

most

frequent

identified

current

salary le v e l,

ho urly employment,

(h)

and

(i)

most

to

the

hos pic e

most

frequently

frequently

identified

ro le r e s p o n s ib ility designation.
Demographic d a t a r e l a t i v e
(a)

most

frequent

h ospice

service

area

programs

in c lu d e d :

by p o p u l a t i o n ,

(b)

most

f r e q u e n t l y i d e n t i f i e d c u r r e n t hos pice c r e d e n t i a l i n g , (c) p e r c e n ta g e s
of p atient/fam ily
1986,

and

(d)

ethnic

the

representations

most

for

hospice

frequently id e n tifie d

stage

programs
of

in

ho spice

development.
Opinion d a t a

from t h e

hos pice a d m i n i s t r a t o r s

in c lu d e d :

(a)

what c r e d e n t i a l ing t h e hospice program would have 1 y e a r from t h i s
survey, (b) i f t h e r e i s a need f o r an e d u cati o n al program in ho spic e
adm inistration,

(c) th e most f r e q u e n t l y i d e n t i f i e d e d u c a ti o n a l a r e a

need, and (d) t h e most p r e f e r r e d method o f e d u c a t io n a l a s s i s t a n c e .
S t a t i s t i c s used f o r O b j e c t iv e 1
fre qu en cy .

Note t h a t

O b j e c t iv e

were

1 is

mean, median,

descriptive

in

SD,

and

nature

and

t h e r e f o r e no hypotheses were g e n e r a t e d .
Research

O b je c tiv e

2:

To

identify

what

functions

current

hospice a d m i n i s t r a t o r s in Michigan a r e per forming a n d / o r d e l e g a t i n g .
The r e s e a r c h q u e s ti o n s were:
1.

What

are the

org a n iz in g [ 0 ] , d i r e c t i n g

competencies by f u n c t i o n s
[D],

and c o n t r o l l i n g

(p la n n in g

[P ],

[C]) which hospice

a d m i n i s t r a t o r s in Michigan i d e n t i f y as E s s e n t i a l and Supplementary?

97
2.

To what

degree

are

these

E s s e n ti a l

and

Supplementary

competencies d e le g a te d f o r each o f th e major a d m i n i s t r a t i v e survey
s e c t i o n s (A-E) and a l l f u n c t i o n s (P, 0, D, and C)?
A supplem entary

hypothesis

postulated

for

th is

research

o b j e c t i v e was:
Ho 1:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e frequency o f

E s s e n t i a l and Supplementary competencies which a r e d e l e g a t e d .
S t a t i s t i c s used f o r O b j e c t iv e 2 were

mean, £D, fre quency, and

chi-square.
Research O b je c tiv e 3 :
in

Michigan

on t h e i r

To survey c u r r e n t hospice a d m i n i s t r a t o r s

perception

of

E s s e n ti a l

and

Supplementary

competencies which meet consensus under f i v e a d m i n i s t r a t i v e s e c t i o n s
(A-E).
Ho 2:

There w i l l not be respondent convergence t o consensus

> 75% on t h e E s s e n t i a l competencies (mean = > 4 ) .
Ho 3:

There w i l l

not be respondent convergence t o consensus

> 75% on th e Supplementary competencies (mean « > 2 . 5 < 4 ) .
The s t a t i s t i c used f o r O b j e c t iv e 3 was t h e Leik formula.
Research O b je c tiv e 4 :
differentially

affect

the

To i d e n t i f y demographic f a c t o r s which
reported

essentiality

of

com petencies.

The f o ll o w in g hypotheses were t e s t e d :
Ho 4:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on t h e r e s p o n d e n t ’ s age.
Ho 5:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on t h e r e s p o n d e n t ' s sex.

98
Ho 6:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on t h e r e s p o n d e n t ' s ed u c a tio n a l background.
Ho 7:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g of

competencies based on r o l e r e s p o n s i b i l i t i e s o f th e a d m i n i s t r a t o r .
Ho 8:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f

competencies based on s a l a r i e d o r n o n s a la r i e d s t a t u s .
Ho 9:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g of

competencies based on employment s t a t u s .
Ho 10:
of

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g

competencies

between

adm inistrators

of

licensed

programs

and

a d m i n i s t r a t o r s o f exempt programs.
Ho 11:
of

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g

com petencies

for

adm inistrators

w ith

differin g

sizes

of

p o p u l a t i o n s served by t h e h ospice program.
S tatistics

used

for

O b j e c ti v e

4 were

ANOVA,

and

Scheffe

procedure (when a p p l i c a b l e ) .
Research Objec tive 5 : To i d e n t i f y how t h e r e p o r t e d e s s e n t i a l i t y
a n d /o r d e l e g a t i o n of competencies v a r i e s with o r g a n i z a t i o n a l
c y c le s t a g e s .
1.

life

The r e s e a r c h q u e s ti o n s were:

What

are

the

a d m in istrativ e functions

com petencies

(P, 0,

w ithin

each

area

of

D, and C) t h a t a r e i d e n t i f i e d as

E s s e n t i a l and Supplementary in each s t a g e o f program development by
hospice a d m i n i s t r a t o r s in Michigan?
2.

Which o f t h e s e

Essential

and Supplementary competencies

w i t h i n each o f t h e major a d m i n i s t r a t i v e s e c t i o n s (A-E) and each o f

99
the functions

(P,

0,

program development?
Ho 12:
ratings

of

There

D,

and C)

are

d e le g a te d

in

each

s ta g e

of

The hypotheses were:
are

competencies

no

significant

when

compared

differences
across

stage

in
of

the

mean

hospice

program development.
Ho 13:

There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g s

o f th e f o u r a d m i n i s t r a t i v e f u n c t i o n a r e a s (P, 0, D, and C) based on
program s t a g e o f development.
Ho 14:

There i s no s i g n i f i c a n t d i f f e r e n c e

with which competencies ar e d e l e g a te d

in t h e frequency

based on program s ta g e

of

development.
S t a t i s t i c s used f o r O b jectiv e 5 were mean, SD, frequ en cy , c h i s q u a re , ANOVA, and t h e Scheffe procedure (when a p p l i c a b l e ) .
D e s c r ip tio n o f th e Sample
The

sam ple

for

th is

study

included

all

current

hospice

a d m i n i s t r a t o r s in Michigan, as o f December 1986, when t h e r e were 78
hospice

programs

in

Michigan.

Of t h e s e ,

48 were

exempt

from

l i c e n s u r e , 30 were l i c e n s e d , and 25 were hos pice Medicare c e r t i f i e d
(Olson, 1987).

Table 3.1 provide s a summary o f hos pice s by ty p e and

p a r t i c i p a t i o n in hospice Medicare c e r t i f i c a t i o n .

100
Table 3 . 1 :

Summary o f Hospices by Type and P a r t i c i p a t i o n in
Hospice Medicare C e r t i f i c a t i o n (H - 78)

Hospice Type

M

Home h e a l t h agency based
Community based ( i n d . )
F reest anding
Hospital based

10
60a
1
7

% o f Total

No. Hospice
Medicare C e r t .

13%
77
1
9

9
9
1
6

a F o r t y - e i g h t programs (61%) were c l a s s i f i e d exempt from
1i c e n s u r e .

I t should be noted t h a t because t h e t o t a l p o p u l a t io n was used
r a t h e r than a sample, t h e a s s o c i a t i o n among v a r i a b l e s
was p r e c i s e ,

due t o

the fa c t

that

as measured

t h e r e was no chance t h a t

th e

a s s o c i a t i o n could be due t o sampling e r r o r (Babbie, 1973).
Techniques o f Data C o l l e c t i o n
The H o s p i c e A d m i n i s t r a t o r s
S e c ti o n s I and I I .

Inventory

(HAI)

consisted

HAI I conta ined 17 demographic v a r i a b l e s ,

of
and

HAI I I c o nta ined 201 competency s ta t e m e n ts which were c a t e g o r i z e d by
a d m i n i s t r a t i v e s e c t i o n (A-E) and a d m i n i s t r a t i v e f u n c t i o n s (P, 0, D,
and C).

Table 3 . 2 pr o v id e s a numerical summary o f items w i th in each

area.
Tog eth er, t h e HAI I and HAI I I c o n s i s t e d o f 218 v a r i a b l e s in
Round I .

The survey form was 15 pages, one o f which was in fo rm al.

101
Table 3 . 2 :

Numerical Summary o f Survey Items Within A d m i n i s t r a t i v e
S ecti o n s (A-E) and Functions (P, 0, D, and C)
PI anning

Organiz­
ing

Direct ing

Control ling

S t a f f i n g and personnel
Patient/fam ily r e l .
Communi t y / p u b l i c r e l .
F is c a l management
Q u a lit y as su ra nce

12
11
9
9
10

9
12
10
7
11

12
8
9
8
6

18
12
11
8
9

51
43
39
32
36

Total

51

49

43

58

201

A d m i n i s t r a t i v e Area
A:
B:
C:
D:
E:

In HAI I I ,
ab so lu tely

a L i k e r t r a t i n g s c a l e o f 5 t o 1 was used with 5 °

necessary,

4 -

highly

u n c e r t a i n , and 1 * no nn ecessary.
s ta te m e n t

using

Tota

the

Likert

necessary,

3 « useful,

2 =

Respondents r a t e d each competency

scale

a d m i n i s t e r i n g my hos pice program I : "

to

answer

the

statement,

"In

Appendix B c o n t a i n s Round I

and Round I I o f t h e Hospice A d m i n is t r a to r s

I n v ento ry .

Table 3.3

o u t l i n e s t h e schedule which was used f o r o b t a i n i n g and a n aly zin g th e
data.

Table 3 . 3 :

Schedule f o r Obtaining and Analyzing t h e Data

Action
Pilot testing
Round I mailed
Follow-up l e t t e r s
Round I d a t a analyzed
Round I I mailed
Follow-up l e t t e r s mailed
Round I I d a t a analyzed

Date
April 1987
May 13, 1987
May 29, 1987
June 1987
J u l y 29, 1987
August 4, 1987
Aug.-Dec. 1987

102

«

Data Ana ly sis
Because many o f t h e v a r i a b l e s o f i n t e r e s t being measured were
o rd in al,

the

evaluating

researcher

single

used

competencies

nonparam etric

procedures

and t h e d e l e g a t i o n

assumption o f nonpa ra metric q u a l i t i e s
expected t h a t resp o n s es would not

when

function.

was n e c e s s a r y

since

The
it

be normally d i s t r i b u t e d .

was
All

competency items were g e n e r a t e d on th e assumption t h a t some o f th e
r e s p o n d e n t s would c o n s i d e r t h e co m p etency s t a t e m e n t s E s s e n t i a l
( i . e . , 4 o r 5 on t h e L i k e r t s c a l e ) .

Thus, th e skewed n a t u r e o f th e

expected resp on se rendered p a r a m e tri c assumptions no nval id f o r some
a s p e c t s o f t h i s study .
Param etric

analysis

was

adm inistrative

fu n ctions

(P,

adm inistrative

sectio n s

com petencies.

(A-E)

used
0,
by

in

D,

examining

and

using

C)
mean

and

the

four

fiv e

ratin g s

major
of

the

F iv e -fa c to r an alysis v e r if ie d t h a t the adm in istrativ e

s e c t i o n s were very r e l i a b l e .
Ordinal Consensus
To develop a measure o f consensus r e q u i r e s t h a t t h e d i s p e r s i o n
o f r es pon ses be m easurable.
im plies

no d i s p e r s i o n ,

r esp onses w i l l
dispersion
properties.

In t h e ide al

whereas

little

be widely d i s p e r s e d

measure

itself

is

a

over

c a s e , p e r f e c t consensus
consensus
available

pe r c e n t a g e

and

im plies
options.

th u s

has

that*
The

o r d in a l

The r e s e a r c h e r used t h e f ollo w in g formula developed by

Leik (1966) t o d e f i n e an a p p r o p r i a t e measure o f o r d i n a l cons ensus.

103
D - 2 Z(d - 1)
m - 1

Where D i s a p e r c e n t a g e , a measure o f o r d in a l d i s p e r s i o n , i t becomes
a p e r c e n t a g e o f consensus when s u b t r a c t e d from 1 ( t o t a l c o n s e n su s ).
The cum ulative frequency o f re spon se s i s d, and m equals t h e number
o f o p t io n s in t h e s c a l e .
This measure i s
number o f
central

choice

free

of lim itations

options,

tendency,

as

well

and assumptions

as

due t o sample s i z e
concerns

about

about

intervals

and

skewness,

between

cho ice

o p t i o n s ; y e t i t a c c u r a t e l y r e f l e c t s t h e degree t o which c h o i c e s ar e
spread over th e s e t o f o p t i o n s a v a i l a b l e .
measure i s

a sum di v id e d

by i t s

Furthermore, because th e

maximum p o s s i b l e v a lu e ,

p e r c e n t a g e , hence a r a t i o s c a l e v a r i a b l e .

D is

a

Convergence t o consensus

i n d i c a t e s t h e degree t o which t h e r e spondents reach unanimity on a
given

item.

According

It

to

consensus

is

Leik,

a nonpa ra metric
complete

would

be

researcher

used

the

acceptable

degree

consensus

complete
score
of

measure
would

d ispersion

of

.7 5 o r

convergence

of

of error
be

w h il e

responses.

g reater
for

1.0

variance.

both

as

the

ze ro
This

minimal

E ssential

and

Supplementary competencies.
The

Delphi

pr oc es s

included

r esp onses back t o t h e resp o n d e n t s .

f e e d in g

information

For t h i s

reaso n,

about

the

t h e mean o f

each item was given as feedback t o t h e resp ondents in Round I I s i n c e
i t was a s t a t i s t i c a l
those

r eading

the

average o f r esp onses and e a s i l y under stood by

competency

statements.

Table

3.4

p r o v id e s

summary o f t h e s t a t i s t i c a l a n a l y s i s pr oce dur es used f o r t h i s s tu d y .

a

104

Table 3 . 4 :

Summary o f Data Analysis

Purpose

Data Used

Statistics

1.

Feedback t o p a n e l i s t s

Round I

Mean

2.

To determine E s s e n t i a l
and Supplementary
competencies

Round I

Mean, §Q, fre quency,
chi-square

3.

To determine convergence
t o consensus

Rounds I
and II

Leik formula

4.

To determine i n t e r n a l
r e l a t i o n s h i p o f th e
adm inistrative sections
(A-E) and t h e f u n c t io n s
(P,0,D,C)

Rounds I
and II

F a c to r a n a l y s i s

Round I

ANOVA, Schef fe

5. To determine mean r a t i n g
d i f f e r e n c e s according t o
demographic v a r i a b l e s
6.

To d e s c r i b e demographic
v a r i a b l e re sp onses

Round I

Mean, median, SD,
frequency

7.

To determine t h e r e l a t i o n s h i p between s e c t i o n s
(A-E), f u n c t io n a r e a s
( P,0 ,D ,C ), d e l e g a t i o n ,
and s t a g e o f hospice
development

Round I

C h i- sq u a r e , ANOVA,
S ch ef fe

Summary
Chapter I I I includ ed a d i s c u s s i o n o f t h e s tudy des ig n using a
four-phase

methodology,

description

of

the

sample,

methods f o r d a t a a n a l y s i s .
t h i s stu dy.

operational
te c h n iq u e s

d efin itio n s,
of

data

hypotheses,

collection,

and

Chapter IV c o n t a i n s th e f i n d i n g s from

CHAPTER IV
ANALYSIS OF RESULTS

This

chapter

contains

the

results

o b j e c t i v e s o u t l i n e d in Chapter I I I .
from hospice
research
collection

adm inistrators

study.

in

th e

the

research

The d a t a c o n s i s t e d o f respons es

survey

instrum ent

used

in t h i s
for

17 demographic and opinion q u e s ti o n s

H o s p ic e A d m i n i s t r a t o r s
s ta t e m e n t s

to

in Michigan who p a r t i c i p a t e d

A tw o-part

co ntai ned

relevant

I n v e n t o r y I ( H A I- I)

Hospice

A d m i n i s tr a to rs

data

in th e

and 201 co m peten cy

Inv en tory

II

(H AI-II).

Appendix A c o n t a i n s t h e f i n a l v e r s io n o f th e instrum en t used in t h i s
stu dy.
Response Rate--Round I and Round II
Table 4.1 c o n t a i n s a summary o f th e r a t e o f resp onse t o each o f
th e two rounds o f survey.

Table 4 . 1 :

Summary o f Survey In stru ments Sent and Returned

Round I
Round II

Sent

Returned

Used

78
78

51
49

51
45a

aThree surveys were r e c e iv e d a f t e r t h e d a t a a n a l y s i s had been
completed, and one uncompleted survey was r e t u r n e d .

105

106
Overal 1, t h e r e was a 65% r e t u r n r a t e f o r Round I and a 63%
r e t u r n r a t e f o r Round I I .

I t i s important t o no te t h a t Michigan

hospic e s a r e r e q u i r e d by law t o be e i t h e r l i c e n s e d o r found exempt
from l i c e n s u r e .
Licensed
Exempt

These

two d i v i s i o n s

hospice programs

programs,

must

on t h e

meet

other

were

state

hand,

used

in

licensing

do not have

this

stud y.

standards.
t o meet

s t a n d a r d s , al though many o f them may be p r e p a r i n g t o do so.

such
When

s t a t i s t i c a l l y p o s s i b l e , comparison was made on t h e s e two groups.

It

was expected t h a t s i g n i f i c a n t d i f f e r e n c e s in r a t i n g and d e l e g a t i o n
o f competencies could r e s u l t from t h i s d i f f e r e n c e .
In Round I o f t h i s s tu d y , re sp onde nts incl uded 90% (27 o r 30)
o f th e l i c e n s e d programs, 50% (24 o f 48) o f th e exempt programs, and
85.7% (18of 21) o f t h e hospice Medicare c e r t i f i e d programs.
Use o f Round I and Round II Data
The D elphi

technique

was employed

in

two r o u n d s .

This

t e c h n iq u e encouraged p a r t i c i p a t i v e d e c i s i o n making by allowing inp ut
and r e - e v a l u a t i o n

on t h e competency s ta t e m e n t s .

demographic and opinion q u e s t i o n s .
additional

Round I included

Respondents were asked f o r any

com pe tency s t a t e m e n t s t h e y t h o u g h t m i g h t have been

om itted in each o f th e f i v e major competency a r e a s .

/

The Round I

survey d i d not g e n e r a te a d d i t i o n a l competency s ta t e m e n t s f o r Round
II.

As s p e c i f i e d in t h e Delphi pro ce dure, t h e mean s c o r e on each

competency s tate m en t was provided in Round I I f o r t h e res p o n d e n ts .
Bec ause

the

item s g e n e ra te d

p o t e n t i a l l y im portant com petencies,

for

th is

s u r v e y w er e

all

c o n s e n s u s was more l i k e l y

107
to

occur

on

items

th at

were

at

the

high

end

of

the

scale

( E s s e n t i a l ) , weakening p a r a m e tric assumptions o f i n t e r v a l and normal
distribution.

However,

could be consensus

th e

possibility

the

existed

that

there

on items t h a t were r a t e d lower on t h e s c a l e .

t h i s s tu d y , i t was t h e h i g h e s t r a t e d
s u p p o rti n g

also

necessity

for

or d in a l

In

items t h a t reached cons ensus,
statistical

analysis

when

possible.
The Leik formula was a p p l ie d t o each competency sta te m e n t

in

Round I and Round II as a nonparametric measure o f c o n s i s t e n c y o f
respon se from one

respondent t o t h e n e x t.

T h i r t y - s i x competency

s ta t e m e n ts reached

consensus a t a l ev el o f > 75% in Round I .

One

a d d i t i o n a l competency sta te m e n t reached consensus a t t h a t same lev el
in Round I I .

Those competency s ta te m e n t s t h a t met consensus

in

Round I were omitted from Round II in o r d e r f o r t h e r a t e r t o focus
on t h e remaining items.
th e h i g h e s t r a t e d

item s.

This e li m i n a t e d 36 items which were a l s o
In t h e i r absence,

t h e resp o n s es became

more normally d i s t r i b u t e d .
Very l i t t l e
remaining items,

change was noted

in t h e o v e r a l l

ratings

o f the

i n d i c a t i n g t h a t r a t i n g s o f items in Round I were

r e l i a b l e in s p i t e o f t h e pr es en ce o f t h e 36 consensus item s.

Round

I was then used as t h e p r i n c i p a l so urce o f in form ation f o r t h e most
g e n e r a l l y a g r e e d on E s s e n t i a l

and S u p p l e m e n t a r y c o m p e t e n c i e s .

Also, Round I contained t h e demographic d a t a used f o r th o s e a n a l y s e s
o f demographically r e l a t e d hypothese s.

108
Summary o f Findings
Results of the analyses of the fiv e

research objectives

ar e

d i s c u s s e d in t h e f oll ow ing s e c t i o n s .
Research O b j e c t iv e 1
To compile s e l e c t i v e demographic and op inio n d a t a on hospic e
a d m i n i s t r a t o r s in Michigan.
Overall
overall

demographic d a t a summary.

demographic c h a r a c t e r i s t i c s

Table 4.2

summarizes th e

of the respondents,

which

incl ud ed age, sex , ed u c a t io n a l background, p r e s e n t employment, p r i o r
employment h i s t o r y ,
salary

ran ge ,

adm inistrative histo ry ,

employment s t a t u s ,

role r e s p o n s ib ilitie s ,

hos pice l o c a t i o n ,

patient/fam ily

e t h n i c r e p r e s e n t a t i o n , and hospice d e s i g n a t i o n .
This

survey

revealed

that,

overall,

M ic h i g a n

hospice

a d m i n i s t r a t o r s were p r i m a r i l y female, middle-aged, and working f u l l
tim e,

with

additional

adm inistration.

ro le

resp o n sib ilities

F if ty - s ix percent

(31)

other

than

just

had a b a c h e l o r ’ s degree or

beyond in e d u c a t i o n , and 54% came from a h e a l t h - r e l a t e d background
a t l e a s t 1 y e a r b e f o re being h i r e d as hospic e a d m i n i s t r a t o r .

I t is

im port ant t o n o te t h a t Michigan hos pice a d m i n i s t r a t o r s o v e r a l l
an

average

of

adm inistration,
Salary

was

27

months

which

also

was

of

current

h ig h ly

v ariable.

experience

variable

T hirty-six

had

in

hospice

(SD +

23.9

months).

percent

( 18 )

of

the

a d m i n i s t r a t o r s were e i t h e r v o l u n t e e r s o r e a r n in g under $10,000 pe r
y e a r , whereas a n o th e r 20% (10) c l u s t e r e d around an income o f $20,000
t o $25,000 p e r y e a r .

109

Table 4 . 2 :

Overall Demographic Data Summary
Overal1
(51 o f 78)

AGE
SEX
Female
Male
EDUCATION
High school diploma
A s so ciate degree
Diploma in nursing
B ac helo r’ s degree
M aster’ s degree
Doctoral degree
Other

44 y e a r s
N - 50

SD

(± 10.4)

88% (45)
12% ( 6)
N - 51
2%
8%
18%
30%
26%
6%
10%
N=

( 1)
( 4)
( 9)
(15)
(13)
( 3)
( 5)
50

4. CURRENT HOSPICE ADMINISTRATOR EXPERIENCE: Total number o f
months worked as a hos pic e a d m i n i s t r a t o r .
27 months
(+ 23.9)
N * 49
5.

PRIOR EMPLOYMENT: Employment 1 y e a r p r i o r t o c u r r e n t employment.
H e a l t h / n o t hospice
54% (27)
Nonhealth
14% ( 7)
Hospice/not a d m i n i s t r a t o r
12% ( 6)
Hospice a d m i n i s t r a t o r
12% ( 6)
Not working
8% ( 4)
M <= 50

6.

TOTAL NUMBER OF YEARS IN ADMINISTRATION
2.3 y e a r s
In hos pice
3.2 years
In h e a l t h r e l a t e d
1.7 y e a r s
In nonhealth
N = 49

7. ROLE RESPONSIBILITIES
Only a d m i n i s t r a t i v e
Ad ditional r o l e s

40% (20)
60% (30)
U - 50

(± 2.14)
(± 4.63)
(± 5.94)

110
Table 4 . 2 :

Continued
Over al1

8.

9.

SALARY RANGE
Volunteer
Under $10,000
$10,000-15,000
$15,000-20,000
$20,000-25,000
$25,000-30,000
$30,000-35,000
Over $35,000
EMPLOYMENT STATUS
Full time
P a r t time

16%
20%
8%
4%
20%
8%
8%
16%
N=

SD

( 8)
(10)
( 4)
( 2)
(10)
( 4)
( 4)
( 8)
50

60% (29)
40% (19)
U = 48

10.

HOSPICE SERVICE AREA: The pop u lati o n most a p p r o p r i a t e t o t h e
hospice’ s service area.
Under 50,000
55% (28)
50,000-100,000
19% (10)
100,000-250,000
14% ( 7)
Over 250,000
12% ( 6)
N = 51

11.

PATIENT/FAMILY ETHNIC REPRESENTATION, 1986 (inc om plete d a t a
reported)
1.4%
B1 ack
38.0%
White
American Indian
.1%
Asian
.1%
Hispanic
.3%
N - 40

12.

HOSPICE DESIGNATION: Of 51 (65%) hosp ice programs in Michigan
t h a t responded:
Licensed
27 (90% o f a p o s s i b l e 30 programs)
Exempt
24 (50% o f a p o s s i b l e 48 programs)
Hospice Medicare c e r t .
18 (72% o f a p o s s i b l e 25 programs)

Ill

O v e r a l l , t h e most f r e q u e n t l y mentioned hos pice program s e r v i c e
a r e a was

less

than

50,000 p o p u l a t i o n .

Also,

according

to

this

s tu d y , hospice programs se rved p a t i e n t s / f a m i l i e s o f p r i m a r i l y white
ethnic

origin.

It

should

be

noted

that

the

data

reported

on

p a t i e n t / f a m i l y e t h n i c r e p r e s e n t a t i o n were incomplete and t h e r e f o r e
n o t c o n s id e re d by t h i s r e s e a r c h e r t o be r e l i a b l e f o r a n a l y s i s .
F i f t y - t h r e e p e r c e n t (27) o f t h e a d m i n i s t r a t o r s who responded t o
t h e survey ad ministere d a l i c e n s e d hos pice program, while 47% (24)
a d m i n i s te r e d an exempt program.

Sixty-s even p e r c e n t

(18)

o f th e

l i c e n s e d programs were a l s o hospice Medicare c e r t i f i e d .
Over all opinion d a t a summary.

Table 4 . 3 summarizes th e o v e r a l l

opinio n d a t a , which involved th e following types o f q u e s t i o n s :

(a)

What d i d t h e hospice program a n t i c i p a t e i t s s t a t u s t o be 1 y e a r from
survey?

(b) What s t a g e o f development was t h e hospice in?

(c) Was

t h e r e a need f o r hospice a d m i n i s t r a t i o n ed uca tional c u r r i c u l a ?
Which ed u c a t io n a l

(d)

areas would be most helpful t o th e a d m i n i s t r a t o r ?

and (e) What method o f e d u c a ti o n a l a s s i s t a n c e was p r e f e r r e d ?
Of th o s e a d m i n i s t r a t o r s who responded t o t h e survey, 71% (35)
a n t i c i p a t e d t h e i r hospice program would become l i c e n s e d ,
anticipated

th ey would remain exempt,

49% (22)

29% (14)

anticipated

they

would become hos pice Medicare c e r t i f i e d , and 10% (5) i n d i c a t e d t h e i r
program would apply f o r JCAH a c c r e d i t a t i o n f o r hospic e c a r e .
Michigan,
their

the

hospice

majority
to

be

significance of th is
f u r t h e r in Chapter V.

in

of

hospice

Stage

f in d i n g

II

for

administrators
of
the

(63%)

b e l ie v e d

program development.
data

analysis

is

For

The

discussed

112
Table 4 . 3 :

Overall Opinion Data Summary
O ver al1

13.

PROGRAM FORECAST IN 1 YEAR: What does t h e hospice program
a n t i c i p a t e i t s s t a t u s t o be 1 y e a r from survey:
Licensed
71% (35)
Exempt
29% (14)
Hospice Medicare c e r t .
49% (22)
Other
14% ( 7 ) a
N - 49

14.

PROGRAM DEVELOPMENT: Hospices i n d i c a t e d t h e s ta g e o f de v e lo p ­
ment th ey b e lie v e d t h e i r hospice t o be i n .
Stage I
16% ( 8)
Stage 11
63% (32)
Stage I I I
13% ( 7)
Stage IV
8% ( 4)
N - 51

15.

EDUCATIONAL FORECAST: Is t h e r e a need f o r hos pice a d m i n i s t r a t i o n ed u c a t io n a l c u r r i c u l a ?
Yes
88% (43)
No
12% ( 6)
N = 49

16.

EDUCATIONAL AREAS:
helpful.

Educational a r e a s t h a t would be most

Q u a l ity as surance
Staffing/personnel
F is c a l
Community/PR
Patient/fam ily
Other
17.

Rank
1
2
2
4
5

79%
74%
74%
58%
33%
18%
N-

(34)
(32)
(32)
(25)
(14)
( 8)
43

EDUCATIONAL ASSISTANCE: What method o f e d u c a t io n a l a s s i s t a n c e
is preferred?
Seminars/workshops f o r CEUs
59% (26)
Seminars/workshops no CEUs
27% (12)
College/univ. c e r t./d e g r e e
27% (12)
C o l l e g e / u n i v . l i f e l o n g ed.
23% (10)
Adult c o n ti n u in g ed.
25% (11)
U - 44
a Five w i l l be JCAH a c c r e d i t e d f o r hos pice c a r e .

113

O v e r a l l , 88% (43) o f t h e hos pice a d m i n i s t r a t o r s r e p o r t e d t h a t
t h e r e was a need f o r a d i s t i n c t hospice a d m i n i s t r a t i o n e d u catio n al
cu r ric u lu m and t h a t t h e ed u c a tio n a l a r e a o f Q u a lit y Assurance would
be

most

helpful

to

them .

F ifty-nine

a d m i n i s t r a t o r s who r e s p o n d e d t o

the

percent

( 26)

of

survey p r e f e r r e d

to

the
have

ed u c a tio n a l a s s i s t a n c e provided through seminars and workshops f o r
c o n tin u in g education u n i t s (CEUs).
Licensed/exempt demographic d a t a summary.
t h e r e p o r t e d demographic d a t a
programs.

and 24 a d m i n i s t r a t o r s

responded t o t h e survey.
f ound

in

adm inistrative
p r o g ra m s
e x p e r ie n c e

and exempt

hospice

As noted p r e v i o u s l y , t h e r e were 27 a d m i n i s t r a t o r s

l i c e n s e d programs

were

by l i c e n s e d

Table 4 . 4 summarizes

age,

experience.

tended

to

education,
However,

have l e s s

and

no d i f f e r e n c e s

current

adm inistrators

health -related

(44%) when compared with

programs (63%).

from exempt programs who

When examined s e p a r a t e l y ,
sex,

from

from

p rio r

adm inistrators

hospice
exempt

employment

from l i c e n s e d

Also, exempt programs had t h e h i g h e s t percentage

(22%) o f a d m i n i s t r a t o r s

with

nonhealth-related

experience

1 year

p r i o r t o employment.
Over h a l f o f both
adm inistrators

had

the

exempt

additional

sig n ifican t difference

in

role

role

and

licensed

ho s p ic e

responsibilities.

responsibilities

was f o r

program
The

most

licensed

programs in Stage I I o f development (X2 « 9 . 2 0 , d f = 3, fi < . 0 5 ) .

114
Table 4 . 4 :

Licensed and Exempt Programs Demographic Data Summary
Licensed
(27 o f 30)

1.

AGE

2.

SEX
Female
Male

3.

4.

EDUCATION
H.S. diploma
Assoc, degree
D ip./nursing
Bach, degree
M aste r’ s degree
Doctoral degree
Other

43 y e a r s
N = 26

SB
+ 9 .3 9

Exempt
(24 o f 48)
44 y e a r s
N = 24

93% (25)
7% ( 2)
N - 27

83% (20)
17% ( 4)
N = 24

-4% (1)
23% (6)
23% (6)
31% (8)
7% (2)
12% (3)
N = 26

4%
(1)
12.5% (3)
12.5% (3)
38% (9)
21% (5)
4% (1)
8% (2)
N = 24

CURRENT HOSPICE ADMINISTRATION EXPERIENCE:
months worked as a hospice a d m i n i s t r a t o r .
29 mos.
(+28.5)
N - 26

SD
+11.61

Total number o f
22 mos.
N = 23

(±16.8)

PRIOR EMPLOYMENT: Employment 1 y e a r p r i o r t o c u r r e n t
44% (10)
H e a l t h / n o t hosp.
63% (17)
22% ( 5)
Nonhealth
7% ( 2)
Hospice/not
17% ( 4)
admin.
7% ( 2)
4% ( 1)
Hospice admin.
19% ( 5)
13% ( 3)
Not working
4% ( 1)
N - 23
N - 27
6.

7.

TOTAL NUMBER OF YEARS IN ADMINISTRATION
In hospice
2.8 years
(+2.35)
In h e a l t h r e l
4.4 years
(+5.35)
(+1.59)
In nonhealth
.7 y e a r s
N - 27

1. 7
2. 0
3.0
N-

ROLE RESPONSIBILITIES
Only admin.
37% (10)
A dditio na l r o l e s
63% ;(17)
U « 27

43% (10)
57% ; (13)
N = 23

years
years
years
22

(±1.72)
(+3.37)
(+8.86)

115

Table 4 . 4 :

Continued
Licensed
(27 o f 30)

8.

9.

10.

SALARY RANGE
Volunteer
Under $10,000
$10,000-15,000
$15,000-20,000
$20,000-25,000
$25,000-30,000
$30,000-35,000
Over $35,000
EMPLOYMENT STATUS:
Full time
P a r t time

SB

Exempt
(24 o f 48)

SD

-

3.5% (1)
3.5% (1)
33% (9)
15% (4)
15% (4)
30% (8)
N = 27

35%
39%
13%
9%
4%

(8)
(9)
(3)
(2)
(1)

N = 23

•

89% (24)
11% ( 3)

HOSPICE SERVICE AREA: The
hospice’s service area.
Under 50,000
33%
50,000-100,000
19%
100,000-250,000
26%
Over 250,000
22%
N=

24% ; ( 5)
76% (16)

po p u l a t io n most a p p r o p r i a t e t o t h e
(9)
(5)
(7)
(6)
27

79% (19)
21% ( 5)
N = 24

11.

PATIENT/FAMILY ETHNIC REPRESENTATION, 1986 (incomplete d a t a
reported)
2.4%
.2%
Black
55.0%
23.0%
White
- .1%
Amer. Indian
.2%
Asian
.3%
.2%
Hispanic
N = 19
N = 21

12.

HOSPICE DESIGNATION: Of 51 (65%) hospice programs in Michigan
which responded:
Licensed - 27 (53%)
Exempt
- 24 (47%)

116

S eventy-fo ur p e r c e n t
either

volunteers

or

N i n e t y - t h r e e p er cen t

(17)

of

receiving
(25)

exempt a d m i n i s t r a t o r s

salaries

of the

were r e c e i v i n g s a l a r i e s equal

the

under $10,000

licensed

were

per year.

program a d m i n i s t r a t o r s

t o o r above $20,000 t o $25,000 per

year.
Licensed/exempt opinion d a t a summary.
resp on ses
programs.

to

the

op in ion

items

by

Table 4 . 5 summarizes th e

licensed

and

exempt

hospice

The respon ses t o t h e program f o r e c a s t r e v e a l e d t h a t 43%

(10) o f t h e exempt programs expected t o move t o l i c e n s u r e 1 y e a r
from survey, while 56% (13) expected t o remain in t h e exempt s t a t u s .
Also, 77% (20) o f t h e a d m i n i s t r a t o r s o f l i c e n s e d programs expected
t h e i r programs t o apply f o r hospice Medicare c e r t i f i c a t i o n .
A m a j o r i t y o f both l i c e n s e d and exempt program a d m i n i s t r a t o r s
saw t h e i r hospice programs in Stage I I , and both groups endorsed a
nee d f o r h o s p i c e

adm inistration

educational

curricula.

Most

s t r i k i n g was t h e 91% (21) endorsement by t h e exempt hospic e program
adm inistrators.
Regarding e d u catio n al

areas,

82% (18) o f a d m i n i s t r a t o r s

from

l i c e n s e d programs i d e n t i f i e d Q u a l ity Assurance and F is c a l Management
as

the

highest

educational

needs,

w hile

81%

(1 7)

of

the

a d m i n i s t r a t o r s from exempt hospice programs i d e n t i f i e d S t a f f i n g and
Personnel Management as t h e h i g h e s t e d u catio n al need.

Both l i c e n s e d

and exempt program a d m i n i s t r a t o r s p r e f e r r e d e d u c a t io n a l
in t h e form o f seminars and workshops f o r CEUs.

assistance

117
Table 4 . 5 :

Licensed/Exempt Program Opinion Data Summary
Licensed

Exempt

13.

PROGRAM FORECAST IN 1 YEAR: What does t h e hospice program
a n t i c i p a t e i t s s t a t u s t o be 1 y e a r from survey:
Licensed
-43.0% (10)
Exempt
-56.0% (13)
Hospice Medicare c e r t .
77% (20)
.9% ( 2)
Other
23% ( 6 )
.4% ( 1)
N - 26
N = 23

14.

PROGRAM DEVELOPMENT: Hospices i n d i c a t e d t h e s ta g e o f de v e lo p ­
ment th ey b e lie v e d t h e i r hospice t o be i n .
Stage I
7% ( 2)
25% ( 6)
Stage I I
52% (14)
75% (18)
Stage I I I
26% ( 7)
Stage IV
15% ( 4)
N = 51
N - 24

15.

EDUCATIONAL FORECAST: Is t h e r e a need f o r hospice a d m i n i s t r a ­
t i o n educational c u r r i c u l a ?
Yes
85% (22)
91% (21)
No
15% ( 4)
9% ( 2)
N = 49
N = 23

16.

EDUCATIONAL AREAS:
helpful.

Educational a r e a s t h a t would be most

Staffing/personnel
Patient/fam ily
Community/PR
F is cal
Q ua lit y as su ran ce
Other
17.

R a n |(
1
5
4
1
1

56% (15)
26% ( 7)
44% (12)
82% (18)
82% (18)
22% ( 5)
N = 43

Ra n k
1
5
4
2
2

81% (17)
33% ( 7)
62% (13)
67% (16)
67% (16)
14% ( 3)
N = 21

EDUCATIONAL ASSISTANCE: What method o f e d u c a tio n a l a s s i s t a n c e
is preferred?
Seminars/workshops f o r CEUs
69% (16)
48% (10)
Seminars/workshops no CEUs
30% ( 7)
24% ( 5)
C o lle g e /u n iv . c e r t . / d e g r e e
26% ( 6)
29% ( 6)
C o ll e g e /u n iv . l i f e l o n g ed.
26% ( 6 )
19% ( 4)
Adult co n ti n u in g ed.
35% ( 8)
14% ( 3)
K - 23
ii - 21

118
Research O b jectiv e 2
To i d e n t i f y what f u n c t i o n s c u r r e n t hospice a d m i n i s t r a t o r s
Michigan ar e performing a n d /o r d e l e g a t i n g .
Ope ra tiona l d e f i n i t i o n s .

in

The fo llowing o p e r a t i o n a l d e f i n i t i o n s

a r e r e s t a t e d f o r review in t h e a n a l y s i s o f t h i s o b j e c t i v e .
Essential

competencies

are

th o s e

competencies

that

hospice

a d m i n i s t r a t o r s in Michigan r a t e d on th e average h i g h e r than o r equal
to 4. 0 on th e Hospice A d m i n is t r a to r s Inventory I I .
Supplemental competencies a r e th o s e competencies t h a t hospice
a d m i n i s t r a t o r s in Michigan r a t e d on t h e average h ig h e r th an 2.5 but
l e s s th an 4.0 on t h e Hospice A d m i n is tr a to rs In ven tory I I .
1.

What

are

th e

Or ganizing [D], D i r e c t i n g

competencies

by

functions

[D], and C o n t r o l l i n g

[C])

(Planning

which hospice

a d m i n i s t r a t o r s in Michigan i d e n t i f y as E s s e n ti a l and Supplementary?
Findings.
Essential

and

Table 4 . 6 i d e n t i f i e s t h e number and p er cen ta g e o f
Supplementary

competencies

a d m i n i s t r a t i v e f u n c t io n s (P, 0,
100% o v e r a l l

were

rated

as

D, and C).
either

as

th ey
Of t h e

E s s e n ti a l o r

S i x t y - s i x p e r c e n t (132) were r a t e d as E s s e n t i a l
34% (69) were r a t e d as Supplementary.
0,

D,

and C),

Essential.

more th an

relate

to

th e

201 v a r i a b l e s ,
Supplementary.

com petencies,

and

Within a l l f o u r f u n c t i o n s (P,

h a lf of these

items were found

to

be

The Planning f u n c t io n demonstrated th e h i g h e s t number o f

E s s e n t i a l competencies (7 5), whereas t h e D i r e c t i n g f u n c t i o n had th e
l e a s t (53%).

[P],

119
Table 4 . 6 :

Ratings o f E s s e n t i a l and Supplementary Competencies by
A d m i n i s t r a t i v e Functions (P, 0, D, C)

Function

Total
Possible

Essential

of
Total

Supplementary

Planning
Organizing
Directing
Controlling

51
49
43
58

38
32
23
39

75
65
53
67

13
17
20
19

2.

%

of
Total

%

25
35
47
33

To what degree a r e t h e s e E s s e n ti a l and Supplementary compe­

t e n c i e s d e le g a te d f o r each o f th e major a d m i n i s t r a t i v e s e c t i o n s (AE) and each o f t h e a d m i n i s t r a t i v e f u n c t i o n s (P, 0, D, C)?
Findings.

Table 4 . 7 p r e s e n t s t h e p er cen tag e o f competencies

d e l e g a t e d a c r o s s a l l a d m i n i s t r a t i v e s e c t i o n s (A-e) and a l l f u n c t io n s
(P,

0,

D,

C).

While

not

tested

for

statistical

significance,

P a t i e n t and Family R e l a t i o n s tended t o have t h e h i g h e s t percentage
of

Essential

and

Supplementary

competencies

that

were

(45%), with Q u a lit y Assurance being t h e lowest ( 2 0 ) .

d e le g a te d

The D i r e c t i n g

f u n c t i o n o v e r a l l was a l s o most l i k e l y t o be d e l e g a t e d .
Table 4 . 7 :

Perce ntag e o f Competency Delegati on by A d m i n i s t r a t i v e
S e c t io n s (A-E) and Functions (P, 0, D, C)
P la n ­
ning

Organiz­
ing

Staffing/personnel
Patient/fam ily
Comm./public r e l .
F i s c a l management
Q u a lit y assu ran ce

.22
.29
.16
.31
.20

.34
.50
.30
.33
.22

Ave.

.24

.33

S e c ti o n
A:
B:
C:
D:
E:

%

Control ling

Ave
%

.31
.60
.31
.34
.31

.22
.44
.17
.21
.10

.26
.45
.23
.30
.20

.37

.22

D irect­
ing

120
A supplem entary

hypothesis

postulated

for

th is

research

o b j e c t i v e was:
Ho 1 : There i s no s i g n i f i c a n t d i f f e r e n c e in th e frequency o f
E s s e n t i a l and Supplementary competencies which ar e d e l e g a t e d .
Findings.
analysis

Table 4 . 8 p r e s e n t s th e f i n d i n g s from t h e c h i - s q u a r e

of the

Essential

and Supplementary competencies and th e

e x t e n t t o which th ey were d e l e g a t e d .

The a n a l y s i s i n d i c a t e d t h a t

t h e E s s e n ti a l competencies were not as l i k e l y t o be d e l e g a t e d as th e
Supplementary com petencies.
not ac cepted.

In t h i s cas e t h e n u ll

h y p o th e sis was

A complete l i s t i n g o f t h e E s s e n ti a l and Supplementary

competencies f o r S ectio n s A-E and t h e percentage f o r which each of
t h e P, 0, D, and C f u n c t i o n s were d e le g a te d i s p r e s e n te d in Appen­
d i x B.

Table 4 . 8 :

Chi-Square An alysis o f t h e Deleg ation o f E s s e n t i a l /
Supplementary Competencies
Total Cases
Observed

E s s e n t i a l Competencies
Supplementary Competencies

1,883
1,105

Expected

Mean %
Delegated

2036.60
951.40

28
32

X2 = 36. 38, d f = 2, fi < .001

Research O b j e c ti v e 3
To survey c u r r e n t hospice a d m i n i s t r a t o r s in Michigan on t h e i r
p e r c e p t io n o f E s s e n t i a l and Supplementary competencies which
meet consensus under f i v e a d m i n i s t r a t i v e s e c t i o n s (A-E).

121
Oper ational d e f i n i t i o n .
is

restated

for

objective:

purposes

The following o p e r a t i o n a l
o f review

C o n v er g en ce t o

in

consensus

the

is

resp on dents reach agreement on a given item.
fo r ordinal

consensus,

definition

analysis

the

degree

of
to

th is
which

Using t h e Leik formula

respondent w ithin-group

consensus

was

accepted when equal t o or h igher than 75%.
Findings.
Round I ,

T h i r t y - s i x competency s ta t e m e n ts met consensus

and one competency stat em en t met consensus on Round I I .

These were a l s o t h e h i g h e s t r a t e d v a r i a b l e s .
of

the

on

consensus

C lustering

of

the

item s

fell

w ithin

competencies

the

occurred

F o r t y - s i x p e r c e n t (17)
Planning
most

heavily

a d m i n i s t r a t i v e s e c t i o n o f Community/Public R e la t io n s
Q uali ty Assurance (36%).

function.
in

(31%) and

the
in

Table 4 . 9 provides a l i s t i n g o f consensus

items by S e c t io n s A-E.
Ho 2 : There w ill be no respondent convergence t o consensus >
75% on t h e E s s e n ti a l competencies (mean > 4 . 0 ) .
Findings.

Table 4.10 summarizes t h e f in d i n g s o f v a r i a b l e s t h a t

met consensus.

All 37 competencies (100%) t h a t met consensus (> 75)

a l s o had a mean o f < 4 . 0 .

The lowest mean sco re o f th e competencies

reaching consensus was 4.48 .

Th e re fore , t h e n u ll h y po th esis was not

acce pted .
Ho 3 : There w ill be no respondent convergence t o consensus >
75% on t h e Supplementary competencies (mean > 2 . 5 < 4 . 0 ) .
Findings.

Of t h e 69 competencies t h a t were i d e n t i f i e d as Sup­

plementary, none reached consensus.
f o r Supplementary items was accepted.

T h e re fore , th e n u ll h y p o th e s i s

122

Table 4 .9 :

Competencies Reaching Consensus by Competency Sections
Section A:

S ta ffin g and Personnel Management

Apply e ffe c tiv e communication s k i l l s .
Function as a lia is o n between th e governing board and hospice s t a f f .
Total * 2; Percentage o f Section A * 4*
Section B:

P a tie n t and Family R elations

Develop c o n f id e n tia lity p o lic ie s .
Develop bereavement p o lic ie s .
Develop c o n tin u ity o f c a re p o lic ie s and procedures.
Provide c o n f id e n tia lity f o r th e p a tie n t/fa m ily .
Provide an ongoing bereavement program.
Communicate th e hospice philosophy to the p a tie n t/fa m ily .
Total = 6; Percentage o f S ection B = 13%
Section C:

Community/Public R elations

Plan hospice se rv ic e s which meet th e needs o f the community.
Plan s tr a te g ie s to In crease community a w a re n e ss/p a rtic ip a tio n In hospice.
Plan s tr a te g ie s to Increase p h ysician aw a re n e ss/p a rtic ip a tio n in hospice.
Plan s tr a te g ie s to Increase c le rg y a w aren e ss/p a rtic ip a tio n 1n hospice.
Plan s tr a te g ie s to In crease governing board a w a re n e ss/p a rtic ip a tio n in hospice.
Provide program s ta tu s re p o rts to the governing board.
Coordinate hospice care w ith o th e r community h ea lth ag en c1 es/fac1 H t1 es.
Speak to In te re s te d groups about hospice.
Communicate the hospice philosophy to th e conmunlty.
Communicate to th e governing board about c u rre n t hospice tre n d s /is s u e s .
Be accountable to th e governing board f o r the h o sp ic e's day-to-day o p e ratio n s.
M aintain e ffe c tiv e conmunlcation with comnunlty resource ag encies.
Total = 12; Percentage o f Section C * 31%
S ection D:

F iscal Management

Develop a mechanism to account f o r g i f t s and donations to th e hospice.
Provide fo r a ccu rate accounting o f g i f t s and donations to th e hospice.
Monitor hospice ex p en d itu res.
Assure a ccu rate accounting o f g i f t s and donations.
Total ■ 4; Percentage o f Section D = 12%
S ection E:

Q uality Assurance

Understand q u a lity assu ran ce.
Plan fo r ap p ro p riate use o f re so u rc es.
Plan a q u a lity assurance re p o rtin g mechanism to th e governing board.
Develop hospice standards o f c a re .
Develop a plan fo r q u a lity assu ran ce.
Develop a program e v a lu a tio n .
Plan an o rg an izatio n al design which r e f le c ts q u a lity hospice c a re .
Provide competent s t a f f .
Provide fo r ev alu atio n of a l l s e rv ic e s .
Communicate q u a lity assurance Issu es to th e governing board.
Assure competence o f s t a f f .
Monitor compliance w ith s t a t e hospice re g u la tio n s .
Assure ap p ro p riate and e f f i c i e n t use o f re so u rce s.
Total = 1 3 ; Percentage o f Section E = 36%

123

Table 4 .1 0 :

Le1k Scores and Mean Ratings o f All Items Reaching Consensus

Item
No.
063
0111
P54
Cl 31
0176
C45
Dll 9
Cl 96
D122
0177
P100
064
Cl 59
PI 71
Dll 6
PI 01
P55
C162
Cl 67
Cl 97
Cl 99
033
PI 68
P96
0112
PI 72
PI 66
aD79
P57
P141
PI 87
PI 03
PI 74
PI 02
Cl 32
0148
PI 73

V ariable
Provide c o n f id e n tia lity fo r th e p a tie n t/fa m ily .
Provide program s ta tu s re p o rts to the governing board.
Develop c o n f id e n tia lity p o lic ie s .
Be accountable to th e governing board fo r the h o sp ic e 's
day-to-day o p e ra tio n s.
Provide competent s t a f f .
Function as a lia is o n between th e governing board and
hospice s t a f f .
Communicate th e hospice philosophy to the conmunlty.
Assure competence o f s t a f f .
Communicate to th e governing board about c u rre n t hospice
tre n d s /is s u e s .
Provide fo r ev alu atio n o f a l l se rv ic e s.
Plan s tr a te g ie s to In crease community awareness/
p a r tic ip a tio n 1n hospice.
Provide an ongoing bereavement program.
Monitor hospice ex p en d itu res. *
Develop hospice stan d ard s o f c a re .
Speak to in te re s te d groups about hospice.
Plan s tr a te g ie s to In crease physician awareness/
p a r tic ip a tio n 1n hospice.
Develop bereavement p o lic ie s .
Assure accu rate accounting o f g i f t s and donations.
Plan fo r a p p ro p ria te use o f re so u rc es.
Monitor compliance w ith s ta te hospice re g u la tio n s.
Assure ap p ro p riate and e f f i c i e n t use o f reso u rces.
Apply e f f e c tiv e conmunlcation s k i l l s .
Plan a q u a lity assurance rep o rtin g mechanism to the
governing board.
Plan hospice se rv ic e s which meet th e needs o f th e
conmunlty.
Coordinate hospice c a re w ith o th e r conmunlty h ealth
a g e n c le s/fac 1 11t1 e s .
Develop a plan f o r q u a lity assurance.
Understand q u a lity assu rance.
Conmunlcate the hospice philosophy to the p a tie n t/fa m ily .
Develop c o n tin u ity o f c a re p o lic ie s and procedures.
Develop a mechanism to account fo r g i f t s and donations
to th e hospice.
Conmunlcate q u a lity assurance Issu es to th e governing board.
Plan s tr a te g ie s to In c re a se governing board awareness/
p a r tic ip a tio n 1n hospice.
Plan an o rg a n iz a tio n a l design which r e f le c ts q u a lity
hospice c a re .
Plan s tr a te g ie s to In crease c le rg y a w are n e ss/p articip atio n
In hospice.
M aintain e ffe c tiv e communication w ith community resource
agencies.
Provide fo r a ccu rate accounting o f g i f t s and donations
to th e hospice.
Develop a program e v a lu a tio n .
a Round II consensus Item .

Le1k

Mean

88.04
87.50
86.95

4.75
4.74
4.73

86.45
85.87

4.72
4.71

83.33
83.33
82.60

4.66
4.66
4.64

82.29
81.52

4.63
4.62

81.25
81.11
79.78
79.39
79.16

4.63
4.61
4.58
4.57
4.57

79.16
78.88
78.40
78.40
78.26
78.26
77.66

4.52
4.59
4.56
4.55
4.55
4.55
4.56

77.38

4.53

77.08

4.53

77.08
76.66
76.59
76.19
76.08

4.53
4.52
4.52
4.52
4.53

76.08
76.08

4.51
4.51

76.04

4.51

75.55

4.50

75.00

4.51

75.00

4.48

75.00
75.00

4.48
4.48

124

Research O b je c t iv e 4
To i d e n t i f y demographic f a c t o r s which d i f f e r e n t i a l l y a f f e c t th e
r e p o r t e d e s s e n t i a l i t y o f competencies.
Ho 4 ; There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f
competencies based on t h e r e s p o n d e n t ’ s age.
Findings.
.69, d f = 4 ) .

ANOVA by t h e v a r i a b l e age was not s i g n i f i c a n t (F =
The nu ll h y p o th e s i s f o r age was a ccep ted .

Ho 5 : There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f
competencies based on th e r e s p o n d e n t ’ s sex.
Findings.
.56, d f = 1 ) .

ANOVA by t h e v a r i a b l e sex was not s i g n i f i c a n t (F =
The nu ll h y p o th e s is f o r sex was a ccep ted .

Ho 6 : There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f
competencies based on t h e r e s p o n d e n t ’ s e d u c a tio n a l background.
Findings.

ANOVA by t h e v a r i a b l e e d u catio n al background was not

s i g n i f i c a n t (F = .92, d f = 3 ) .

The null h y p oth esis f o r e d u cati o n al

background was accepted.
Ho 7 : There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f
competencies based on r o l e r e s p o n s i b i l i t i e s o f t h e adm inis­
trator.
Findings.

ANOVA by t h e v a r i a b l e r o l e r e s p o n s i b i l i t y was not

s i g n i f i c a n t (F = .08, d f = 1 ) .

The n u ll h y p o th e sis f o r r o l e r e s p o n ­

s i b i l i t i e s was accepted.
Ho 8 : There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g o f
competencies based on s a l a r i e d o r n o n s a l a r i e d s t a t u s .
Findings.
deviations

Table

4.11

presents

o f t h e competency items

the

means

based on t h e

and

reported

l e v e l o f t h e hospice a d m i n i s t r a t o r f i n d i n g s f o r s a l a r y .
d i f f e r e n c e s (one-way ANOVA:

standard
salary

Significant

£ = 3 . 6 2 , d f = 4, j> < .01) showed a

t r e n d f o r h i g h e r - p a i d a d m i n i s t r a t o r s t o r a t e competency items h ig h e r

125

as w e l l .

F u r th e r s t a t i s t i c a l

a n a l y s i s using t h e Scheffe procedure

r e v e a l e d no two groups were s i g n i f i c a n t l y d i f f e r e n t (ft < . 0 5 ) .

The

n u ll h y p o t h e sis f o r s a l a r y was not acce pte d.

Table 4.1 1:

Overall Means and Standard D e viations f o r Rating o f
Competencies by S a la r y Grouping

N

S a l a r y Level
Volunteer
Under $10,000
$10,000-20,000
$20,000-25,000
Over $25,000

6
10
6
10
16

Mean Competency
Rating
3.78
3.73
3.97
4.24
4.44

SD
+
+
+
+
+

.59
.66
.38
.54
.45

F = 3 . 6 2 , d f - 4, ft < .01

Ho 9 : There i s no s i g n i f i c a n t d i f f e r e n c e in th e mean r a t i n g o f
competencies based on employment s t a t u s .
Findings:

Table 4.12 p r e s e n t s th e r e s u l t s

part-tim e sta tu s.

f o r f u l l - t i m e and

One-way ANOVA I n d ic a t e d t h a t ho spice a d m i n i s t r a ­

t o r s who were employed f u l l time r a t e d t h e i r competency s ta te m e n t s
s i g n i f i c a n t l y h i g h e r t h a n d i d h o s p i c e a d m i n i s t r a t o r s who were
employed p a r t time (£ - 8 . 4 8 , d f * 1, ft < . 0 1 ) .

The n u ll h y p o t h e s is

was n o t ac cepted.
Ho 10: There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g
o f competencies between a d m i n i s t r a t o r s o f l i c e n s e d programs and
a d m i n i s t r a t o r s o f exempt programs.
Findings.

Table 4.13 p r e s e n t s t h e r e s u l t s o f t h e mean compe­

ten cy r a t i n g s f o r a d m i n i s t r a t o r s o f l i c e n s e d and exempt programs.

126
ANOVA f i n d i n g s

indicated

that

adm inistrators

of

licensed

hospice

programs r a t e d t h e i r competency s ta te m e n ts s i g n i f i c a n t l y h ig h e r than
d id a d m i n i s t r a t o r s o f exempt hos pice programs (F = 10.71, d f = 1,
fi < . 0 1 ) .

The n u ll h y pothesis f o r program s t a t u s was not ac cepted.

Table 4.1 2:

Means and Standard D ev iat ions o f Competency Ratings by
F u ll/ P a r t - T im e S t a t u s

Employment S t a t u s
Full time
P a r t time

14

Mean Competency
Rating

SD

29
18

4.31
3.85

+ .49
+ .56

£ = 8 . 4 8 , d f = 1, e < .01

Table 4.1 3:

Means and Standard D ev iat ions o f Competency Statements
f o r Exempt and Licensed Program A d m i n i s t r a t o r s

Program S t a t u s
Exempt
Licensed

N

Mean Competency
Rating

SD

24
27

3.82
4.33

+ .59
+ .48

F = 10.71, d f = 1, j) < .01

Ho 11 : There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g
o f competencies f o r a d m i n i s t r a t o r s with d i f f e r i n g s i z e o f
p o p u la tio n served by t h e hospic e program.
F indings.

Table

4.14

presents

the

means

and

standard

d e v i a t i o n s o f competency items based on s i z e o f p o p u la ti o n served by
the

hospice

p r o g ra m .

ANOVA f i n d i n g s

indicated

th at

as

the

127

population

service

area

increased,

hospice

adm inistrators

dem onstrated a s i g n i f i c a n t in c r e a s e 1n t h e i r o v e r a l l
competency s ta te m e n ts
statistical
Group

1

analysis

(under

sig n ifican tly

(F « 5.81 ,
using

50,000)

d ifferen t

the
and

df

■ 3,

Scheffe
Group

.001).

procedure

3

(p. < . 0 5 ) .

j> <

means o f th e
F u r th e r

indicated

that

(100,000-250,000)
The n u l l

were

hypothesis

for

p o p u l a tio n s e r v i c e ar ea was not acc ep ted.

Table 4.14:

Means and Standard Dev iations o f Competency Items and
Size o f Population

P opulation Size

N

Under 50,000
50,000-100,000
100,000-250,000
Over 250,000

26
10
7
6

Mean Competency
Rating
3.84
4.21
4.57
4.53

SD
+
+
+
+

.56
.45
.37
.48

F = 5.81 , d f = 3, e < .001

Research O b jectiv e 5
To i d e n t i f y how th e r e p o r t e d e s s e n t i a l i t y a n d / o r d e l e g a t i o n o f
competencies v a r i e s with o r g a n i z a t i o n a l l i f e c y c l e s t a g e .
1.
tions

What competencies w ith in each a r ea o f a d m i n i s t r a t i v e f u n c ­
(P, 0,

D, C) ar e i d e n t i f i e d as E s s e n t i a l

and Supplementary

acc ording t o s ta g e o f program development by hospice a d m i n i s t r a t o r s
in Michigan?
Findings.

Table 4.1 5 p r e s e n t s summary d a t a o f E s s e n t i a l

Supplementary competencies by s ta g e o f program development.

and

Within

Table 4.15:

Numerical and Percentage Summary o f Esse ntial and Supplementary Competencies by
Program Stage o f Development and Administrative Functions
Stagei I

Function

Essen.
N

%

Stage II

Supp.
N

%

Essen.
N

%

Stage I I I
Essen.

Supp.
N

%

N

%

Stage IV

Supp.
N

%

Essen.
N

%

Supp.
N

%

Planning

24 (47)

25 (49)a

36 (71)

15 (29)

45 (88)

6 (12)

49 (96)

2 ( 4)

Organizing

26 (53)

22 (45)a

33 (67)

16 (33)

46 (94)

3 ( 6)

47 (96)

2 ( 4)

Directing

22 (51)

20 (46)a

18 (42)

25 (58)

38 (88)

5 (12)

38 (88)

5 (12)

Control1i ng

28 (48)

28 (48)

39 (67)

19 (33)

47 (81)

10 (17)a

47 (81)

11 (19)

Total

100 (50)

126 (63)

75 (37)

176 (87)

181 (90)

20 (10)

95 (47)a

24 (12)

P e r c e n t a g e s do not t o t a l 100 across rows due t o items t h a t were not r ated as e i t h e r Essential
o r Supplementary.

129

t h e f u n c t io n s o f Planning, Or ganizing,

Directing,

and C o n t r o l l i n g ,

E s s e n ti a l competencies in c r e a s e d f o r hospice a d m i n i s t r a t o r s , whereas
Supplementary competencies d ecr ea se d as t h e program s t a g e in c r e a s e d .
S tatistical

analy sis

of

differences

in

the

mean

ratin g

of

competencies by program s ta g e o f development and t h e a d m i n i s t r a t i v e
f u n c t i o n s ar e r e p o r t e d under Ho 12 and Ho 13.
2.

Which o f t h e s e E s s e n ti a l and Supplementary competencies ar e

d e l e g a t e d f o r each o f t h e major a d m i n i s t r a t i v e s e c t i o n s

(A-E) and

each o f t h e f u n c t io n s (Planning [ P ], Organizing [ 0 ] , D i r e c t i n g [D],
and C o n t r o l l i n g [C]) by s t a g e o f program development?
Findings.

Table 4.16 provid e s a summary o f th e p e r c e n ta g e o f

competencies t h a t were d e le g a t e d

for

all

sections

(A-E)

f u n c t i o n s (P, 0, D, C) by s ta g e o f program development.

and a l l

Deleg ation

tended t o i n c r e a s e as th e program moved from Stage I t o Stage IV.
Overall,

P a t i e n t and Family R e l a t i o n s ( Sec tion B) demonstrated th e

highest

p er ce ntag e

of

delegation

across

all

stages

of

program

development, while Q u a li ty Assurance (S e c tio n E) dem onstrated
fewest d e l e g a t e d

item s.

T e s ts

of

significance

on d e l e g a t i o n

th e
by

program s ta g e o f development a r e shown in Table 4.1 9 .
Essential

and Supplementary competencies with t h e p er cen ta g e

each item was d e le g a te d were compiled f o r each l i f e c y c l e s t a g e .
Ho 12:
There a r e no s i g n i f i c a n t d i f f e r e n c e s in t h e mean
r a t i n g s o f competencies when compared ac r o ss s t a g e o f hospice
program development.
F indings.

Table 4.17

sum m arizes t h e means

and

standard

d e v i a t i o n s o f t h e ANOVA a n a l y s i s f o r mean s c o re s o f competencies

130
Table 4.16:

Summary o f Percen tage o f Competencies Delegated, by
S e c t i o n s A-E and P, 0, D, C.

Function

Stage I

Stage I I

Stage I I I

Stage IV

S ection A - - S t a f f i n g and Personnel Management
PI anning
Organizing
Directing
Controlling
Sec. % Del.

4%
8
16
11
10

22%
36
33
22
27

29%
47
27
24
30

41%
47
54
43
43

S e c tio n B - - P a t i e n t and Family R e la t io n s
Planning
Organizing
Directing
C o n tr o l 1ing
Sec. % Del

7
15
23
14
14

27
48
60
41
43

38
77
75
64
63

59
79
100
89
80

S e c tio n C--Community/Public R e l a t i o n s
Planning
Organizing
Directing
C o n t r o l 1ing
Sec. % Del

2
7
8
7
6

18
31
30
17
24

23
45
50
18
34

13
32
55
20
30

31
32
41
34
35

41
42
34
15
33

18
29
45
9
24

37
45
41
16
35

S e c ti o n D --F is cal Management
Planning
Organizing
Directing
Controlling
Sec. % Del

18
17
17
7
15

32
36
36
21
31

S e c ti o n E - - Q u a lit y Assurance
PIanning
Organizing
D irecting
Controlling
Sec. % Del

1
1
6
0
1

23
23
33
12
22

131

a c r o s s program s t a g e o f development.

Hospice a d m i n i s t r a t o r s r a t e d

t h e com p e te n c y s t a t e m e n t s s i g n i f i c a n t l y h i g h e r as t h e program
i n c r e a s e d in s ta g e o f development

(£ « 3 . 1 1 ,

df -

2,

j) < . 0 5 ).

F u r th e r s t a t i s t i c a l a n a l y s i s using th e Scheffe procedure i d e n t i f i e d
Groups I and I I I & IV as s i g n i f i c a n t l y d i f f e r e n t (j) < . 0 5 ) .

The

n u ll h y p o th e sis f o r mean s c o r e o f competencies compared with program
s t a g e o f development was not acce pted .

Table 4 .17:

Mean Competency Ratings and Standard D eviati o ns Across
Program Stage o f Development

Stage o f Development
I
II
I I I & IVa

N

Mean Competency
Rating

SD

3.73
4.08
4.40

+ .31
+ .63
+ .41

7
31
11

F = 3 . 1 1 , d f = 2, £ < .05
aStage I I I and Stage IV were c o l l a p s e d t o r e p r e s e n t one group;
th u s d f = 2.

Ho 13: There i s no s i g n i f i c a n t d i f f e r e n c e in t h e mean r a t i n g s
o f t h e f o u r a d m i n i s t r a t i v e f u n c tio n a r e a s (P, 0, D, C) based on
program s ta g e o f development.
Findings.
hypothesis.

Table 4.18 summarizes t h e ANOVA f i n d i n g s o f t h i s

The Planning, Or ganizing, and D i r e c t i n g f u n c t io n s were

s i g n i f i c a n t l y d i f f e r e n t a c r o s s ho spice program s ta g e s o f development
(£ < . 0 5 ) .

The Sch ef fe procedure i n d i c a t e d t h a t Groups I and I I I &

IV were a l s o s i g n i f i c a n t l y

(£ < .05)

different

in t h e

Planning,

132
Organizing, and D i r e c t i n g f u n c t i o n s .

The C o n t r o l l i n g f u n c tio n was

not s i g n i f i c a n t a c r o s s program s ta g e o f development (F = 1.59, d f =
2 ) , nor d i d th e Schef fe procedure i d e n t i f y s i g n i f i c a n t l y d i f f e r e n t
groups w i th i n t h e C o n t r o l l i n g f u n c t i o n .
accepted

for

the

however,

the

n u ll

P la nn ing,

The nu ll hyp o th esis was not

Organizing,

h y p o th e sis

was

and

accepted

Directing
for

the

functions;
Controlling

function.

Table 4.1 8:

ANOVA o f Program Stage o f Development by A d m i n i s t r a t i v e
Functions
Means by Program Stages

Function

I
(N = 8 )

Planning
Organizing
Directing
Controlling

3.68
3.73
3.62
3.80

II
(N = 32)
4.17
4.09
3.96
4.09

I I I & IV
(N = 11)
4.44
4.48
4.4 0
4.32

O v eral1
Mean

4.16
4.13
4.01
4.10

F-Value

4.27*
3.75*
3.30*
1.59

♦ S i g n i f i c a n t a t th e .05 l e v e l .

Ho 1 4 : There a r e no s i g n i f i c a n t d i f f e r e n c e s in t h e frequency
with which competencies ar e d e l e g a t e d based on program s t a g e of
development.
Findings.

Table 4.19 p r e s e n t s t h e f i n d i n g s o f t h e c h i - s q u a r e

a n a l y s i s o f frequency o f competencies t h a t were d e l e g a t e d by s t a g e
o f program development.

Deleg ation s i g n i f i c a n t l y i n c r e a s e d as the

program advanced in s ta g e o f development (X^ * 311.13, d f « 2, £ <
. 0 0 1 ).

The null h y p o th e sis was not ac cepted.

133
Table 4.19:

Chi-Square An alys is o f Deleg ation and Program Stage o f
Development.

Stage o f Development
I
II
I I I & IVa

Cases
Observed

Expected

X*

158
1,927
903

468.71
1874.82
644.47

311.13

df
2

£
<.001

aStages I I I and IV were c o lla p s e d f o r t h i s a n a l y s i s ; thus d f =

2.

Summary
This c h a p t e r
question.

included th e

findings

The next c h a p t e r p r e s e n t s

related

the overall

t o each r e s e a r c h
summary o f th e

stu dy, d i s c u s s i o n and c o nclus io ns by r e s e a r c h o b j e c t i v e s ,
by i m p l i c a t i o n s and recommendations.

followed

CHAPTER V
SUMMARY, DISCUSSION, IMPLICATIONS, CONTRIBUTION TO
HOSPICE ADMINISTRATION, LIMITATIONS OF THE
STUDY, AND RECOMMENDATIONS

This

chapter presents

th e

discussion of the findings,
contribution

this

study

overall

summary o f

the

s tu d y ,

th e i m p l i c a t i o n s o f t h e f i n d i n g s ,

has made t o

hospice

a
the

adm inistration,

the

l i m i t a t i o n s o f t h e stu dy, and th e recommendations.
Summary
Hospice programs a r e a r e l a t i v e l y new phenomenon in American
health care.
"cure"

has

T h e ir p h i l o s o p h i c a l
frequently

t r a d i t i o n a l medical
and mature,

it

come

from

settings.

rated

programs.
as

becomes n e c e s s a r y t o

This

E ssential

adm inistrators

grass-root

in

for

study ex plored
and

the

identify
th e
the

Supplementary
late

rather

s our ce s

than

outside

of

As t h e programs i n c r e a s e in number

competencies which a r e e s s e n t i a l
these

emphasis on "car e"

1980s.

th e

con tinue d

adm inistrative
viability

perceived
by
The

competencies

M ic h ig a n
purpose

of

hospice
for

su ch

i d e n t i f i c a t i o n was t o determine not only th e need f o r a d m i n i s t r a t i v e
hospice education programs but a l s o t o f o rm a li z e general e d u c a tio n a l
content areas.

At p r e s e n t such e d u catio n al programs a r e not l i k e l y

t o e x i s t based on a competency model.

134

135
The

purpose

adm inistrators’

of

th is

study

perceptions

of

was

to

E ssential

exa m ine

hospice

and

Supplementary

competencies f o r hospice a d m i n i s t r a t o r s in Michigan.

The fo llowing

o b j e c t i v e s were i d e n t i f i e d as a r e s u l t o f t h e i n t e n t o f t h e study:
1.

To compile

selective

demographic

and

opin ion

data

on

h ospice a d m i n i s t r a t o r s in Michigan.
2.

To i d e n t i f y what f u n c t i o n s c u r r e n t hospice a d m i n i s t r a t o r s

in Michigan i n d i c a t e th e y a r e performing a n d / o r d e l e g a t i n g .
3.

To survey c u r r e n t hospice a d m i n i s t r a t o r s

t h e i r perception of Essential

in Michigan on

and Supplementary competencies which

meet consensus under f i v e a d m i n i s t r a t i v e c a t e g o r i e s .
4.

To i d e n t i f y demographic f a c t o r s which d i f f e r e n t i a l l y a f f e c t

t h e r e p o r t e d e s s e n t i a l i t y o f competencies.
5.
and

To i d e n t i f y how o r g a n i z a t i o n a l l i f e c y c l e s t a g e s i n f l u e n c e

d ifferen tially

affect

the

reported

essen tiality

and/or

d e l e g a t i o n o f competencies f o r hospice a d m i n i s t r a t o r s .
A four-phase

methodology

was

us ed

to

o b j e c t i v e s and t o answer t h e r e s e a r c h q u e s t i o n s .
of generating

items

for

the

instrum en t

usin g

accom plish

these

Phase I c o n s i s t e d
state

and

federal

s o c i a l p o l i c y l e g i s l a t i o n , hospice a d m i n i s t r a t o r s ’ j o b d e s c r i p t i o n s ,
and l i t e r a t u r e

related

to

adm inistration,

competency t h e o r y ,

and

leadership theory.
Phase I I involved grouping t h e competencies i n t o r e l e v a n t a r e a s
and d e l i n e a t i n g them ac co rding t o t h e a d m i n i s t r a t i v e f u n c t i o n s o f
planning, organizing, d ir e c tin g ,

and c o n t r o l l i n g

fo r a survey

i n stru m ent e n t i t l e d t h e Hospice A d m i n i s t r a t o r s I n v e n to ry .

Part I of

136

this

in st rum ent

c o n ta in e d

17 demographic

and

op in ion

questions,

wh ile P a r t I I conta ined 201 competency s ta t e m e n t s .
Phase I I I involved p i l o t t e s t i n g t h e In ven tory by f o u r former
Michigan

hos pic e

adm inistrators

o r g a n i z a t i o n a l program t y p e s .

representing

the

various

hos pice

Revision o f t h e In ven to ry followed to

p r e p a r e i t f o r d i s s e m i n a t i o n in Phase IV.
Phase
process

IV used

the

o f 78 h o s p i c e

collected

the

Delphi

technique

adm inistrators

in

in

a

two-round

M ichigan.

d e m o g r a p h i c and o p i n i o n d a t a

in

Part

survey
Round

I

of

I

the

In ve nto ry in a d d i t i o n t o t h e r esp onses on t h e competency s ta t e m e n t s
in P a r t I I .

Round I I provided feedback with t h e mean s c o re o f each

competency s ta te m e n t and asked t h e a d m i n i s t r a t o r s t o again r a t e th e
competency s ta te m e n t s ex cl uding th o s e which reached consensus in the
f i r s t round.

Of 78 a d m i n i s t r a t o r s surveyed, 51 (65%) responded to

Round I and 49 (63%) responded t o Round I I .
ar e r e q u i r e d by law t o

be e i t h e r

licensure.

involved

licensed
certified.

This
programs

study

o f which

18

licensed
re sp onses

(72%)

were

Hospices in Michigan
or

found exempt from

from 27
also

(90%)

hospice

o f th e
Medicare

Twenty f o u r (50%) o f t h e a d m i n i s t r a t o r s who responded

were from exempt hospice programs.
For Michigan, i t was im port an t t o c o n s id e r t h e c r o s s - s e c t i o n o f
resp onses by l i c e n s e d o r exempt s t a t u s and t h e o r g a n i z a t i o n a l s t a g e
o f development because
size,

com plexity,

programmatic o p e r a t i o n s

and a c c o u n t a b i l i t y .

vary with

program

Exempt programs tend t o be

"g ra s s r o o t s " programs which ar e h ig h ly v o l u n t e e r i n t e n s i v e and ar e

137.
not r e q u i r e d t o meet s t a t u t o r y re quire m en ts f o r t h e ty p e and q u a l i t y
o f hospice c a r e they pr o v id e .

These programs a r e c o n s id e re d t o be

Stage I o r Stage I I hos pice s in terms o f o r g a n i z a t i o n a l l i f e c ycle
development.

However, l i c e n s e d programs a r e guided by s t a t e

perhaps f e d e r a l )

(and

require men ts f o r t h e type and q u a l i t y o f hospice

care d eliv ered .

These programs a r e co n s id e red Stage I I o r beyond in

t h e i r s t a g e o f o r g a n i z a t i o n a l development.
G e n e r a l ly , programs i n Stage I a r e small and v o l u n t e e r i n t e n ­
sive.

As t h e y progre ss through

th e

stages,

th e y

are

likely

to

become complex, with i n c r e a s i n g numbers o f s a l a r i e d employees, r e g u ­
lated

by s t a t e

a nd/or f e d e r a l

guidelines

p a r ty reimbursement f o r s e r v i c e s

and enmeshed

rendered.

in

third-

Such f a c t o r s

may

pro foundly a f f e c t responses t o what items might be c o n s id e re d

as

E s s e n t i a l o r Supplementary as well as which items a r e d e l e g a t e d .
Respondents
return ra te .
nature of t h i s

of

licensed

programs

carried

a

higher

Two f a c t o r s may have a f f e c t e d th e r e t u r n .
r e s e a r c h e r ’ s employment,

overall
F i r s t , by

each l i c e n s e d hospice had

been p e r s o n a l l y v i s i t e d

for licensure

a n d / o r h o s p ic e Medicare

surv ey .

these

there

Second,

w i th i n

programs

seemed t o

be

keen

i n t e r e s t f o r program e v a l u a t i o n and assessment o f j o b f u n c t i o n .
The number o f a d m i n i s t r a t o r s from exempt programs d id r e p r e s e n t
a t l e a s t 50% o f t h e i r programs o v e r a l l .

As noted on one r e t u r n e d

survey i n strum ent which was not complete, t h e exempt hospice program
a d m i n i s t r a t o r s might have been discouraged by t h e le n g t h y
in str um ent r e q u i r i n g two rounds o f involvement as well

survey

as by th e

138
co n te n t o f th e survey, which may have seemed to o s o p h i s t i c a t e d f o r
t h e i r " g ra ss r o o ts " program.
The time f o r completing both rounds was 4 months with 2 months
pas si ng from t h e f i r s t round t o th e second.
mailed approximately 2 weeks a f t e r th e

Follow-up l e t t e r s were

initial

m a i lin g s

f o r both

rounds.
Data a n a l y s i s

f o c u s e d on f o u r r e s e a r c h

questions

and

14

hypotheses using p ar am etric and nonparametric t e s t i n g .

Since t h e

n a tu r e

adhere

of

the

scaling

for

competency

items

did

not

to

p ar am etric assumptions, t h e Leik formula was i n c o r p o r a t e d in t h i s
study t o measure o r d in a l

consensus among th e resp onden ts on t h e i r

responses t o t h e item s.

T h ir t y - s e v e n competency s t a t e m e n t s , which

clustered

a round

community and

assurance,

reached consensus.

public

relatio n s

and

These items were a l s o t h e

quality
highest

rated.
Discussion
A d i s c u s s io n

of the

f in d i n g s

f o r each o f t h e f i v e

research

o b j e c t i v e s f o llo w s .
Research O b je c tiv e 1
To compile s e l e c t i v e demographic and opinion d a t a on hospice
a d m i n i s t r a t o r s in Michigan.
This was t h e f i r s t

study t o compile demographic and opinion

inform ation on hos pice a d m i n i s t r a t o r s in Michigan.
hospice

adm inistrators

aged, and working f u l l

in

Michigan

are

prim arily

time with a d d i t i o n a l

I t revealed th a t
female,

middle

role re s p o n s ib ilitie s

139
o t h e r than a d m i n i s t r a t i o n .

These a d d i t i o n a l

role

responsibility

f i n d i n g s ar e im portant when viewed from th e o r g a n i z a t i o n a l s t a g e of
development.

Most hosp ices surveyed were in Stage I I .

This means

t h a t a d d i t i o n a l s a l a r i e d s t a f f most l i k e l y have been added but not
t o t h e e x t e n t t h a t i t t o t a l l y f r e e s up t h e a d m i n i s t r a t o r t o focus
p r i m a r i l y on d i r e c t i n g t h e program.
energy

is

required

to

Consequently,

meet

the

more and more

m ulti-faceted

program

r e s p o n s i b i l i t i e s a t a time when p a t i e n t census i s a l s o i n c r e a s i n g .
One q u e s tio n which was not answered by t h i s r e s e a r c h was:
additional
stress,

role

responsibilities

resignations,

related

d ifficu lties

to

such f a c t o r s

as

Are
job

a n d / o r t h e e a s e w i t h which

a d m i n i s t r a t o r s ar e a ble t o d e l e g a t e ?
Curren t hos pice a d m i n i s t r a t i v e exper ien ce was h ig h l y v a r i a b l e
with an o v e r a ll average o f 27 months (SD + 2 3 . 9 ) .

This im plies very

high t u r n o v e r f o r some programs and r e l a t i v e s t a b i l i t y f o r o t h e r s .
One could ask why so many hospice a d m i n i s t r a t o r s have n o t been in
t h e i r jobs longer.
the

finding

The r e s e a r c h e r p o s i t s t h a t t h i s may r e l a t e to

that

the m ajority

of

hospice

i d e n t i f i e d as Stage I I in t h e i r development.
the

transition

from Stage

I to

change occurs (Olson, 1988).
may be

ill-su ited

p ossibility

that

for

Stage

II

p r o g ra m s

have

been

I t i s u s u a l l y during
that

an a d m i n i s t r a t i v e

Leadership s u i t e d f o r t h e f i r s t s ta g e

another.

A ls o one

must

consider

a d m i n i s t r a t o r s who responded t o th e

from very newly organized hospice programs.

the

survey were

What can be done t o

a s s i s t Michigan hospice a d m i n i s t r a t o r s t o develop t h e i r competencies
in o r d e r t h a t th e y might

stay

in

their

adm inistrative

positions

140

lon ger ?

This w i ll

be more f u l l y

explored

in

the

discussion

of

Research O b je c ti v e 5.
Another f in d i n g was t h a t 27 (54%) o f t h e resp ondents had p r i o r
h e a l t h (but not hospice) e x p e r i e n c e .
are ad m in istrato rs learn in g
h o s p ic e ,
w ell.
(but

This i n d i c a t e s t h a t not only

adm inistrative

sk ills

specific

to

but th e y may a l s o be l e a r n i n g t h e ho s p ic e philosop hy as

O v e r a l l , only s i x (12%) were working in th e hospice s e t t i n g
not

in

adm inistration)

1 year

p rio r

to

th eir

current

employment.

Again, t h e h ospice movement i s r e l a t i v e l y young, but a

concern

this

of

researcher

is

that

hos pice

adm inistrators

t y p i c a l l y not coming from w i th in t h e ranks o f h o s p ic e .
t h i s a trend?
outcome o f

Is i t i n c r e a s i n g ?
not

having

professionals

in

philosophy

many ways

traditional

in

health

care

which

adm inistration?
is

th e

settings

Is

Could i t be t h a t t h i s i s j u s t th e

any pr og ra ms

hospice

Why?

ar e

o p p o s it e
(e.g.,

specifically
Since

of

the

the
one

emphasis on

" c u r e , " p e r s o n - o r i e n t e d r a t h e r than i n s t i t u t i o n a l ,

train

hospice
found

"car e"

holistic

in
over

rather

t h a n s e g m e n te d ) t h e numbers o f a d m i n i s t r a t o r s whose p r i n c i p a l
background i s t r a d i t i o n a l h e a l t h c a r e poses major c o n cer n s.
t h e y make t h e t r a n s i t i o n ?

Does t h e i r t r a d i t i o n a l

focus o v e r r i d e th e hos pic e philosophy?

How do

adm inistrative

Are t h e competencies they

i d e n t i f y as important t r u l y r e l a t e d t o ho s p ic e , o r do th ey r e f l e c t
t h e competencies n e c e s s a r y t o blend hos pic e programs i n t o mainstream
h e a l t h c are?

141
A dditional
research are:

q u e s t i o n s which

cannot

be a n s w e r e d

from t h i s

Has hospice opened up a new employment o p p o r tu n i t y

f o r h e a l t h c a r e a d m i n i s t r a t o r s in g e n e r a l ?

Do governing boards tend

t o equ ate previous h e a l t h c a r e a d m i n i s t r a t i o n o r perhaps no h e a l t h
a d m i n i s t r a t i o n e x p er ien ce as s u f f i c i e n t f o r hospice a d m i n i s t r a t i o n ?
How w i ll t h i s a f f e c t ho spice a d m i n i s t r a t i o n in t h e f u t u r e ?
O v e r a l l , only 36% o f
$25,000 per y e a r .

These

Hospice O r g a n iz a tio n

t h e re sp ond en ts earned an income o f over
f i n d i n g s can be compared with a National

Hospice

Personnel

Compensation

Study,

which

r e v e a l e d t h a t t h e mean s a l a r y f o r hospice a d m i n i s t r a t o r s a c r o s s th e
n a t i o n was $25,700 (NH0, 1987).

In Michigan, s a l a r i e s have tended

t o be v a r i a b l e and lower perhaps because t h e r e have been no d a t a on
what a d m i n i s t r a t o r s have been p a id ,
and hospice l o c a t i o n .

program s t a g e o f development,

In Michigan, 28 (55%) o f th e hospice programs

have a s e r v i c e a r e a o f l e s s than 50,000.
Program f o r e c a s t s o f s t a t u s 1 y e a r from t h i s

survey i n d i c a t e d

t h a t only e i g h t o f th e exempt programs t h a t responded t o t h e survey
expected hospice l i c e n s u r e , f o u r programs expected hospic e Medicare
c e r t i f i c a t i o n , and f i v e programs expected JCAH a c c r e d i t a t i o n .

This

would i n d i c a t e some c o n s e r v a t i v e s h i f t s f o r t h e exempt programs in
th e

forthcoming

year

licensure is s t i l l

and t a k e s

into consideration

that

a r e l a t i v e l y new o p tio n in Michigan.

hospice
I t also

ta k e s c o n s id e r a b l e time and e f f o r t t o groom a program f o r r e g u l a t o r y
survey.
F inally,
p r o g ra m s

in

although
th is

i n c o m p l e t e d a t a were r e p o r t e d ,

study tended

to

care

for

p rim arily

hospice
w hite

142

patients/fam ilies.

This s u p p o rts

(not f a v o ra b ly )

the observation

t h a t hospice c u r r e n t l y tends t o be a w h i t e / m i d d l e - c l a s s phenomenon.
I t has been noted t h a t some m i n o r i t y groups which have s t r o n g family
and r e l i g i o u s t i e s may be p r o v id in g h o s p i c e - l i k e c a r e f o r themselves
and n o t p e r c e i v e a need f o r h o s p ic e .
socioeconomic c a t e g o r i e s may not

Many o t h e r s who a r e in low

have access

system in g e n e r a l , much l e s s h o s p ic e .

to

the

health

care

More s p e c i f i c e t h n i c s t u d i e s

a r e needed f o r hospice a t both th e s t a t e and n a t i o n a l l e v e l s .
Research O b je c tiv e 2
To i d e n t i f y what f u n c t i o n s c u r r e n t hospice a d m i n i s t r a t o r s
Michigan ar e performing a n d / o r d e l e g a t i n g .
T h i s s t u d y f ou nd t h a t
id en tified

132

competencies.

hospice a d m in is tr a to r s

E ssential

Of a l l

com petencies

and

e x p lain ed in s e v e r a l ways.
response

bias

i n M ic h ig an
Supplem entary

th e q u e s ti o n s devised f o r t h i s s tu d y ,

one had a mean sco re o f h ig h e r than 2 . 5 .

s tr o n g

69

This

in

f in d i n g

ever y
can

be

F i r s t , t h e res po nde nts could have had a

toward

rating

e v e rything

as

im p o rt a n t.

A

second p o s s i b i l i t y provide s v a l i d a t i o n o f the i n v e s t i g a t o r ’ s pr o c e ss
of

generating

competency

s ta te m e n t s

that

were

applicable.

deter mine which o f t h e s e two f a c t o r s i s most l i k e l y ,
would have t o be included in a f u t u r e s tudy .

"foil"

To
items

For t h e purpose o f

t h i s stu dy, i t was assumed t h a t t h e d i f f e r e n c e s between r a t i n g s o f
Essential

and

valid findings.

Supplementary

items

r e p r e s e n te d

both

reliable

and

143
Of t h e

five

management,
relations,

adm inistrative

patient
fiscal

and

sections

fam ily

management,

(staffing

relatio n s,

and personnel

com m unity/public

and q u a l i t y a s s u r a n c e ) ,

81% o f th e

items w i t h i n q u a l i t y

as su ran ce were cons id e re d E s s e n t i a l .

a s su r an ce r e p r e s e n t s

an e v a l u a t i o n o f t h e q u a l i t y

program and

how well

services

ar e

provided.

Q u a l ity

of the

hos pice

When examined

o r g a n i z a t i o n a l s t a g e o f development, t h e number o f E s s e n t i a l

by

items

remained high because a prime f a c t o r in remaining a v i a b l e hospice
program i s t h e q u a l i t y o f s e r v i c e s provided.
demonstrated t h a t a d m i n i s t r a t o r s

These f in d i n g s a l s o

in Michigan placed high val ue on

t h e a d m i n i s t r a t i v e a r e a o f q u a l i t y as surance a c r o s s a l l s t a g e s .
The lowest

number o f

s e c tio n s occurred

E s s e n tia l

in s t a f f i n g

competencies

and p e r s o n n e l

overall

w i th in

management

(47%).

However, a p r o g r e s s i v e i n c r e a s e occur red in E s s e n ti a l
for

this

ar ea

as

programs

advanced

in

s ta g e

of

competencies

organizational

development.
Within th e f u n c t io n s o f pla nning,
contro llin g ,

th e planning fu n ctio n

organizing,
contained

38

directing,
(75%)

and

of the

E s s e n t i a l competencies while t h e d i r e c t i n g f u n c t io n had t h e lowest
number i d e n t i f i e d as

E s s e n ti a l (2 3).

when

that

one

considers

f u n c t io n wh ile d i r e c t i n g

These

planning i s

a

f i n d i n g s seem r e a s o n a b le

critical

adm inistrative

in volv es a high degree o f d e l e g a t i o n

of

tasks.
The respondents*

ratings

also

indicated

that

the

Essential

competencies were l e s s o f t e n d e le g a t e d than were t h e Supplementary
ones.

Overall,

the

adm inistrative

a r ea

of

patient

and

fa mily

144

r e l a t i o n s c a r r i e d t h e h i g h e s t d e l e g a t i o n (45%), followed by f i s c a l
(30%), s t a f f i n g and personnel (26%), community and p u b l i c r e l a t i o n s
(23%), and f i n a l l y q u a l i t y as su ra nce (20%).
f u n c t io n

was d i r e c t i n g

relations.

(60%)

in t h e

The h i g h e s t d e le g a t e d

area of p a tie n t

and family

As s t a t e d in t h e above par agraph, t h e d i r e c t i n g f u n c t io n

had t h e lowest i d e n t i f i e d E s s e n ti a l competencies but now was a l s o
th e h i g h e s t d e l e g a te d .
Of a l l a r e a s , competencies in p a t i e n t and fa mily r e l a t i o n s were
most l i k e l y t o be d e l e g a t e d by th e hos pice a d m i n i s t r a t o r .
in p a r t i c u l a r r e q u i r e s a high degree o f t r a c k i n g
(e .g .,

assuring

24-hour o n - c a ll

av ailab ility

and involvement
of all

provided and a t t e n d i n g t o p a t i e n t / f a m i l y c r i s e s ) .
the

a d m i n i s t r a t o r was absorbed

fam ily

relatio n s,

there

adm inistrative areas.

in

trying

to

This ar ea

services

Consequently, i f

manage

would be no t i m e t o

patient

attend

to

and

other

Hospice a d m i n i s t r a t o r s who have a d d i t i o n a l

r o l e r e s p o n s i b i l i t i e s f o r p a t i e n t c a r e o f te n f in d i t very d i f f i c u l t
t o a b d i c a t e t h a t a d d i t i o n a l r o l e (Olson, 1988).
The f u n c t io n t o be d e l e g a te d th e l e a s t was c o n t r o l l i n g (10%) in
the area of q u a lity assurance.
quality

assurance

had

the

One could conclude again t h a t as
highest

of

E ssential

competencies, t h e s e would n o t be d e l e g a te d as f r e q u e n t l y .

Also, t h e

a d m i n i s t r a t o r must assume f i n a l
q u a l i t y o f c a r e being prov ided.

percentage

r e s p o n s i b i l i t y f o r t h e d a y - to -d a y
Consequently,

it

seems p l a u s i b l e

t h a t c o n t r o l l i n g would be more c a u t i o u s l y d e le g a te d th an perhaps t h e
other functions.

145

Research O b jectiv e 3
To survey c u r r e n t hospice a d m i n i s t r a t o r s in Michigan on t h e i r
p e r c e p t io n o f E s s e n t i a l and Supplementary competencies which
meet consensus under f i v e a d m i n i s t r a t i v e c a t e g o r i e s ( S e c tio n s
A-E).
T h i r t y - s i x competency s ta t e m e n ts met convergence o f > 75% on
Round I , and one competency s tatem en t met convergence on Round I I .
The se c o m p e t e n c i e s were a l s o

the

highest

rated

and t h e r e f o r e

co n s id e red E s s e n t i a l .
Highest c l u s t e r i n g

of these E ssential

and r e l i a b l e

items

occurre d in th e a r e a s o f community/public r e l a t i o n s (12 [32%]) and
quality

assu ran ce

(13

[35%]).

In

the

area

of

community/public

r e l a t i o n s , hos pic e a d m i n i s t r a t o r s agreed t h a t plan ning s t r a t e g i e s t o
in c r e a s e community awareness f o r hospice was im po rta nt as well
their

ability

to

communicate.

They agreed

that

th ey

as

needed t o

communicate with th e community, with t h e ho spice governing board,
and with o t h e r community r e s o u r c e a g e n c i e s .
this

researcher

refers

to

as

the

"adaptation

community in v o l v e s , t o a l a r g e e x t e n t ,
a s s e s s t h e community needs.
on i t .

Responsiveness t o what
p r e s s " 1 from

th e

f r e e - f l o w communication t o

The hospice program’ s success depends

Nonresponsiveness by t h e ho spice program t o t h i s " a d a p t a t i o n

p r e s s " r e s u l t s in decr ea se d i n t e r e s t in and concern f o r t h e hospice
program and reduced a v a i l a b i l i t y o f r e s o u r c e s (Olson, 1988).

A d a p t a t i o n p r e s s : t h e demands o f an environment e x e r t e d upon
a system t o encourage a n d /o r f o r c e a d a p t a t i o n .

146
In t h e

area of q u a lity assurance,

hospice a d m i n i s t r a t o r s

in

Michigan agreed t h a t knowledge o f q u a l i t y as surance was E s s e n t i a l as
well as developing s ta n d a r d s o f hospice c a r e , pr o v id in g and a s s u r in g
competent s t a f f , e v a l u a t i n g a l l s e r v i c e s , and plan ning and a s s u r i n g
a p p r o p r i a t e and e f f i c i e n t use o f r e s o u r c e s .
health

care

prog ram

in

the

1980s

Again, v i a b i l i t y o f any

depends

on

systems

of

accountability.
The lowest a r e a o f important and consensus items was s t a f f i n g
and personnel management (4%).

This r e s e a r c h e r p o s i t s t h a t s ta g e s

o f hos pic e development with var ying personnel needs and i s s u e s could
perhaps account f o r t h e low number o f items which reached consensus.
Hypothetically,

s t a f f i n g needs in a Stage I ho spice c a r i n g f o r an

average o f f i v e p a t i e n t s

a month

is

c o n s id e r a b l y

different

from

th o s e in a Stage IV ho spice c a r i n g f o r 30 p a t i e n t s on any given day
o f t h e month.
or w ritten

Stage I hospice s may not even have personnel p o l i c i e s

job

descriptions,

whereas

Stage

IV h o s p ic e s

may

be

s t a f f i n g more than one hospice l o c a t i o n .
Research O b j e c t iv e 4
To i d e n t i f y demographic f a c t o r s which d i f f e r e n t i a l l y a f f e c t th e
r e p o r t e d e s s e n t i a l i t y o f competencies.
S tatistical

analysis

of

demographic

factors

which

d i f f e r e n t i a l l y a f f e c t e d t h e r e p o r t e d e s s e n t i a l i t y o f t h e mean o f th e
competencies

was

significant

n o n s a la r i e d

statu s,

(j) <

.01)

full-tim e/part-tim e

with
status,

regard

licensed

lic e n su r e - e x e m p t programs, and p o p u la tio n s e r v i c e a r e a s .
s i g n i f i c a n t f o r se x, e d u c a t i o n , o r age.

to

salary/
ve rsu s

I t was not

147

From t h i s
salaries,

s tu d y ,

worked

full

ho spice
ti m e,

administrators

ad m in is te r e d

who

licensed

earned

higher

programs,

and

whose programs served i n c r e a s i n g l y l a r g e r s e r v i c e a r e a s tended t o
rate

all

competencies

h ig h e r

in

degree

of

importance.

It

is

im po rta nt t o n o te t h a t t h e s e f a c t o r s c o r r e l a t e h ig h ly with in c r e a se d
program s ta g e o f development as w e l l .

Independent o f t h i s

stud y,

t h e r e s e a r c h e r has observed t h e fo llowin g sequence o f e v e n t s :
hospice

p rogra m g r o w s ,

employee,

h e/she e a r n s

becomes l i c e n s e d

the

adm inistrator

a h ig h e r

salary,

and e v e n t u a l l y

serves

th e

becomes a f u l l - t i m e

and t h e

hospice

program

a wider p o p u la tio n

as

s ta ffin g cap acities increase.
Research O b je c ti v e 5
To i d e n t i f y how t h e r e p o r t e d e s s e n t i a l i t y a n d /o r d e l e g a t i o n of
competencies v a r i e s with o r g a n i z a t i o n a l l i f e c y c le s t a g e s .
Hospices have been observed t o be evolving through t h e i r own
organizational l i f e cycle.
of organizational
each s t a g e ,

The i n v e s t i g a t o r suggested f o u r s ta g e s

development f o r hosp ice s with

and

cycle

stag es

of

and

adapted

to

h ospice programs by t h i s

r e s e a r c h e r based on her o b s e r v a t i o n s

of

hospice

her work and on o r g a n i z a t i o n a l

development

involvem ent
was

programs

m otivation,

(Olson,

a theoretical

through

1988).
construct

lead ersh ip

w it h in

sty le,

community

which i n c l u d e :

indicators

Life
ap p li e d

T h ir ty -tw o (63%) o f th e hospice programs in t h i s
themselves as being in Stage II o f development.
concerns r e l a t e d t o t h i s f i n d i n g .

theory.

study i d e n t i f i e d
There a r e sev er al

148
F i r s t , th e proposed l i f e c y c le model may o r may not be he lp f u l
in s e l f - r e p o r t i n g o f programs in d i f f e r e n t l i f e c y c le s t a g e s .

Self-

r e p o r t i n g may need t o be compared t o an e x t e r n a l assessment o f th e
program as w e l l .

Based on t h i s i n v e s t i g a t o r ’ s p o s i t i o n a t th e time

o f th e study as S t a t e Hospice C oo rdinator f o r Michigan, such a l a r g e
p r o p o r t i o n o f programs i d e n t i f y i n g themselves as being in Stage II
seems a c c u r a t e .

Most programs in Michigan a r e r e l a t i v e l y new and

have been l i c e n s e d w i t h i n t h e p a s t 3 y e a r s .

In t h i s i n s t a n c e , s e l f -

r e p o r t i n g seemed r e l i a b l e .
S econd,

assu m ing t h a t

self-rep o rtin g

o f p rogra m s t a g e

of

development i s a c c u r a t e , then t h e general r e s u l t s o f t h i s study ar e
o v e r r e p r e s e n t e d by programs in Stage I I
f a c t o r s may c o n t r i b u t e t o t h i s .

o f development.

Several

For i n s t a n c e , i t may be t h a t o f a l l

t h e programs in Michigan, th e ones which responded were l i k e l y t o be
in Stage I I .

This might be because programs in Stage I I were more

l i k e l y t o have d i r e c t c o n t a c t with t h i s
s u rv eyor .

i n v e s t i g a t o r as l i c e n s i n g

Given t h a t o ver 90% o f t h e l i c e n s e d programs responded,

p e r s o n - t o - p e r s o n c o n t a c t by t h i s

i n v e s t i g a t o r with Stage I I ,

and IV hospic es may have been a f a c t o r in t h e i r r e sp o n s e .
Stage

II

programs

may be

overrepresented

awareness o f th e

need t o

assess

because

com petencies

of

as

III,
Also,

heightened

a resu lt

of

proportion

of

r e g u l a t o r y surveys on t h e i r programs.
T h ir d ,

it

is

likely

that,

s in c e

the

largest

nonrespondents from t h e t o t a l p o p u la t io n were exempt programs, Stage
I

was

Finally,

the

most

because

u n d e r re p r e s e n te d
of

th e

of

relatively

th e

s ta g e s

lim ited

in

number

this
of

stu dy.
programs

149

id entified

as S tage

III

and

IV ( f o r

purposes

of

a n a l y s i s ) , t h e s e two s t a g e s were o f te n combined.

sta tistic a l

The f in d i n g s may

n o t a c c u r a t e l y r e p r e s e n t t h e range o f competencies and degree o f
d e l e g a t i o n which t a k e s p l a c e .

Future s t u d i e s may need t o t a k e place

a t a time when a g r e a t e r p r o p o r t io n o f Stage I I I

and IV hos pice

programs ar e a v a i l a b l e .
Figure 5.1 i n d i c a t e s t h a t as hosp ice s
development,
while

the

the

percentage

Supplementary

of

E s s e n ti a l

competencies

increased

in s ta g e o f

competencies

d e crease d.

What

in c r e a se d
may

have

happened in t h i s study i s t h a t many items were r a t e d lower in e a r l y
program s ta g e o f development because th e
competency had y e t t o be en co unter ed .
these

findings,

it

would

approximately

5 years.

Essential

by

s ta g e

of

M ic h ig a n

be

more

evenly

the

program

relating

to

th e

To examine t h e s t a b i l i t y o f

be u s e f u l

Would

issues

to
same

repeat

th is

study

in

competencies

emerge

as

hos pices

in

stag es

of

development?

d istributed

Would

across

the

development?
As t o t a l
finding

item pool f o r E s s e n t i a l

suggests

th at

the

competencies i n c r e a s e d ,

adm inistrative

ro le

complexity as th e program p r o g r e s s e s in development.

this

increases
Thus,

in
more

mature programs r e q u i r e more complex a d m i n i s t r a t i v e competencies.
This i n c r e a s i n g
examined

in

terms

sh ift
of

in

E s s e n tia l

potential

id e n t i f i e s the educational

competencies can a l s o

ed u c a tio n a l

needs.

Table

needs o f h o sp ice a d m i n i s t r a t o r s

be
5.1
in

Table 5.1:

Rank Ordering of Administrative Educational Needs by Program Stage o f Development
Rank

Stage I I I / I V

Quality assurance

1

Staffing /p er so nnel mgt.

2

Fiscal management

2

Qu ality assurance

Community/public r e l .

3

Staff in g/p erso nnel mgt.

2

Fiscal management

2

Fiscal management

4

Community/public r e l .

3

Community/public r e l .

2

Quality assurance

5

P a t i e n t and family

4

Rank

Stage I

Rank

1

Staffing /p er so nnel mgt.

1

1

P a t i e n t and family

1

Stage II

P a t i e n t and family

151
Michigan by program s ta g e o f development.

Stages I I I and IV were

c o l l a p s e d because o f t h e small number r e p r e s e n t e d .

100

"

-

ESSENTIAL COMPETENCIES

80 -

h-

Z
LU
o
cc
LU
£L

60 -

40-

20

-

SUPPLEMENTARY COMPETENCIES

IV

III
STAGE

Figure 5 . 1 :

Percentage o f E s s e n ti a l and Supplementary
competencies by s ta g e o f program development.

According t o th e ho spice l i f e c y c le model, ed u c a ti o n a l programs
could be planned which meet t h e needs o f hos pic e a d m i n i s t r a t o r s in
a l l s t a g e s o f hos pice development.
Also, t h i s study found t h a t t h e need f o r hospice a d m i n i s t r a t o r s
to delegate within the ad m in istrative sections
the

hospice

developed.

Specifically,

(A-E)

th e y were

i n c r e a s e d as

more

likely

to

152
d e l e g a t e w it h i n p a t i e n t and family r e l a t i o n s
w i t h i n q u a l i t y as s u r a n c e .

and n o t t o d e l e g a t e

From t h i s stu d y one can i d e n t i f y th o s e

a r e a s t h a t i n c r e a s e d in d e l e g a t i o n as t h e h ospice program i n c r e a s e d
in s ta g e o f development and th o s e a r e a s t h a t tended t o remain f a i r l y
constant.

This i s

s i g n i f i c a n t because hospice a d m i n i s t r a t o r s can

begin t o e v a l u a t e t h e i r own d e l e g a t i o n s k i l l s and a n t i c i p a t e t h e i r
delegation
sections.

effectiveness

or lim its

in

certain

adm inistrative

Figure 5.2 i d e n t i f i e s t h e a d m i n i s t r a t i v e s e c t i o n s and th e

average p er cen tag e d e l e g a t e d by s ta g e o f program development.

100

Sec. A

Sec. B Sec. C

Sec. D

Sec. E

STAFFING/
PRSNNL.

PT./ COMM./
FAMILY PUBLIC

FISCAL
MGT.

Q.

Figure 5 . 2 :

A d m i n i s t r a t i v e s e c t i o n s and average p er cen tag e
d e l e g a t e d by program s t a g e o f development.

153
Finally,

delegation

adm inistrative
co ntrollin g

can a l s o

functions
by

prog ra m

dem onst rat es t h a t in t h i s
adm inistrative

f u n c t io n s

to

th e

d irecting,

and

Figure

5.3

s tudy , d e l e g a t i o n i n c r e a s e d in a l l

four

of

planning,

stage

as

be e v a lu a te d

th e

of

ac cording

organizing,
development.

hospice

increased

in

s ta g e

of

development.

60

50 -

40
HI

o

cc

.

30 -

Ill

Q.

20

-

1

10-

I;
0 -4—
PLANNING

Figure 5 . 3 :

As noted

ORGANIZING

4

I

DIRECTING CONTROLLING

P, 0, D, C f u n c t i o n s and d e l e g a t i o n by program
s t a g e o f development.

in Chapter

IV,

pla nning,

organizing,

and d i r e c t i n g

f u n c t i o n s were s i g n i f i c a n t l y d i f f e r e n t by s t a g e o f development (j) <
. 0 5 ) , while t h e c o n t r o l l i n g f u n c t io n was n o t .

This s u g g e s ts t h a t

th e a d m i n i s t r a t i v e c o n t r o l l i n g f u n c t io n s not only remain t h e lowest

154

d e l e g a t e d but a l s o remain f a i r l y c o n s i s t e n t thro ug hou t t h e h o s p i c e ’ s
development.

A b a s i c t e n e t f o r hospice a d m i n i s t r a t o r s a c r o s s a l l

s t a g e s o f development 1s t o c o n tr o l and a s s u r e t h e q u a l i t y o f ca re
pr ovide d.
I m p li c a ti o n s
In a d d i t i o n

to

the d iscu ssio n

of the

research

objective

f i n d i n g s , f i v e ge ne ral i m p l i c a t i o n s w ill be d i s c u s s e d .
1.

What a r e t h e i m p l i c a t i o n s f o r d i f f e r e n t i a t i n g

prog ra m

s ta g e s o f development in hospice?
2.

What i s t h e s i g n i f i c a n c e f o r e d u catio n al programs based on

t h e f i v e a d m i n i s t r a t i v e s e c t i o n s suggested in t h i s study?
3.

What ar e t h e i m p l i c a t i o n s o f t h e r e l a t i v e l a c k o f hospice

a d m i n i s t r a t i v e ex pe rienc e?
4.

What a r e t h e i m p l i c a t i o n s o f th e e t h n i c composition o f hos­

p i c e p a t i e n t s on f u t u r e program development?
5.

What ar e t h e i m p l i c a t i o n s o f an o r g a n i z a t i o n a l

l i f e cy cl e

approach t o te a c h in g s t r a t e g i e s ?
F i r s t , d e f i n a b l e s ta g e s in hospice program development r e q u i r e
s i g n i f i c a n t l y d i f f e r e n t a d m in is tr a tiv e com petencies.

In many

i n s t a n c e s f o u r d e te r m in a n ts have been s i g n i f i c a n t in t h e t r a n s i t i o n
from one s t a g e t o a n o t h e r .
process,

(b)

funding

source,

adm inistrator.
model

self-care
and

They a r e :

strategies
(d)

the

of

(a) t h e on-going e v a l u a t i o n
staff,

leadership

(c)

stab ility

com petencies

The i m p l i c a t i o n s o f t h i s o r g a n i z a t i o n a l

reach beyond hos pice and can be a p p l i e d

to

of

of

a

the

l i f e cy cl e

many type s

of

155

organizations.

Courses

in

L if e

Cycle

A dm in istr a tio n

would

be

a p p l i c a b l e t o a wide range o f p r o f e s s i o n s as well as t o members of
t h e h o s p i c e ’ s Board o f D i r e c t o r s .
S econd,
sections

th is

in

study

which

id en tified

134

(67%)

of

fiv e
the

major

adm inistrative

com p e te n c y

statem ents

s t a t i s t i c a l l y supported a high congruence in f i v e f a c t o r s .

This i s

s i g n i f i c a n t in s t a t i s t i c a l l y v a l i d a t i n g th e competency items under
the sections of:

staffing

and personnel

management,

patient

and

family r e l a t i o n s , community/public r e l a t i o n s , f i s c a l management, and
q u a l i t y as su r a n c e .
F o rty -th ree

(88%)

adm inistrators

in

of

M ic h ig a n

the

surveyed

iden tified

a

hospice
nee d

program

for

hospice

a d m i n i s t r a t i o n e ducational c u r r i c u l a .

Twenty-six (59%) p r e f e r r e d to

received

seminars

th is

inform ation

through

c o n tin u in g educa tion c r e d i t s .

and w or k sh o p s

for

Respondents i d e n t i f i e d t h a t o v e r a l l

t h e i r e d u catio n al needs were rank or de red as f o l l o w s :

(1) q u a l i t y

assurance,

(2)

staffin g

(3)

management,

(4)

community/public

and p e r s o n n e l

management,

relations,

and

(5)

fiscal

patient

and

fam il y r e l a t i o n s .
A dditionally,

th is

study

ho spice s ta g e s o f development.

iden tified

educational

An educ ationa l

needs

by

model which t a k e s

i n t o account t h e s t a g e s o f hos pice development can g r e a t l y enhance
the effectiveness

o f t e a c h i n g modules.

As shown in t h i s

ho spice a d m i n i s t r a t o r s need t o

be c o n t i n u a l l y

com petencies

with

to

keep

pace

th eir

learning
hospice

s tu d y ,

Essential
program’ s

156
organizational

changes.

T h i s can be a c c o m p l i s h e d

through

an

e d u c a t io n a l program which s p e c i f i c a l l y ad d r ess es programmatic i s s u e s
by s ta g e o f o r g a n i z a t i o n a l development.
working

with

colleges

and

adm inistrative cu rricu la,

S t a t e hospice o r g a n i z a t i o n s

universities

could

a n d /o r th e National

establish

hospice

Hospice Organization

could develop a hospic e a d m i n i s t r a t i o n c e r t i f i c a t i o n c u r ric u lu m .
T h ir d ,

this

study

identified

that

hospice

adm inistrators

in

Michigan had on average a l i t t l e more than 2 y e a r s o f e x p er ien ce in
hospice a d m i n i s t r a t i o n a t a time when over h a l f t h e ho spice programs
in

M ic h ig an

were

development.
essentially

considered

This

means

very l i t t l e

to

th at

be

in

Stage

hospice

adm inistrative

II

of

hospice

adm inistrators

with

e x p er ien ce were t r y i n g

to

cope with very d i f f i c u l t a d m i n i s t r a t i v e i s s u e s unique t o Stage II
such as :

i d e n t i f i c a t i o n o f s t a b l e funding s o u rc e s , s t a f f expansion,

l i c e n s i n g , and hos pice Medicare c e r t i f i c a t i o n

(Olson,

1988).

This

l a c k o f previous hospice a d m i n i s t r a t i v e e x p er ien ce i m p lies t h a t a
co n cer ted e f f o r t should be in p r ogre s s t o a s s i s t and s upport new
a d m i n i s t r a t o r s through t h e i r tenuous program growth.
In a d d i t i o n ,
from h e a l t h

a l a r g e p er ce ntag e o f t h e s e a d m i n i s t r a t o r s came

(not hospice)

e x p e r ie n c e .

This

has

im plications

hospice a d m i n i s t r a t i o n perhaps 10 t o 20 y e a r s from now.

for

Ad ditional

l o n g i t u d i n a l r e s e a r c h i s needed which can address t h e s e q u e s t i o n s :
Will ho spic e a d m i n i s t r a t o r s tend t o have a d i l u t e d a d m i n i s t r a t i v e
base o f knowledge which i s not s p e c i f i c t o hospice ?
health

adm inistration

degree

suffice?

Will a general

Over t i m e ,

how w i l l

157
adm inistrators

with

specific

hospice

adm inistration

skills

fare

compared t o a d m i n i s t r a t o r s with no hospice exper ien ce ?
F our th,

although

the

data

collection

on

ethnicity

of

th e

p a t i e n t s / f a m i l i e s being cared f o r in t h i s s tu dy was incomplete,
still

it

supported o t h e r r e s e a r c h which has i d e n t i f i e d t h a t ho spic e in

America may be p r i m a r i l y an o ption f o r white f a m i l i e s .
r e l a t e d t o pla nning,
eth n icity

issues

devel oping ,
w er e

adm inistrators.

The

only

Survey items

and o r g a n i z i n g s t a f f t r a i n i n g on
rated

as

im plications

of

Supplem entary
these

item s

by

the

rem aining

Supplementary in th e f u t u r e may del ay a wider use o f hospice

by

v a r i o u s e t h n i c groups.
Finally,

th is

study

iden tified

overall

E ssential

Supplementary competencies f o r hospice a d m i n i s t r a t o r s
programs

however,

i s l i k e l y t h a t they would miss t h e s p e c i f i c needs o f

adm inistrators.

be

As n o t e d ,

based

on

E ssential

these

in Michigan.

Educational
it

could

and

general

com petencies

findings;

in S tage

hospice s a r e p r o p o r t i o n a l l y l e s s than f o r a Stage IV h o s p ic e .

I

The

i m p l i c a t i o n s o f t h i s a r e t h a t an o v e r a l l c a t e g o r i z a t i o n o f E s s e n ti a l
and Supplementary competencies i s not a c c u r a t e
define

the

hospices

by

stage

of

if

development.

one chooses to
R ather,

if

g e n e r a l i z a t i o n s a r e made, i t i s only th e consensus items which have
ap p licab ility overall.

This r e s e a r c h e r sup p o rts an o r g a n i z a t i o n a l

l i f e c y c l e approach t o t e a c h i n g s t r a t e g i e s which i s more s p e c i f i c
and b e t t e r meets t h e needs o f t h e a d m i n i s t r a t o r s .

158
P o t e n t i a l C o n t r i b u t i o n s t o Hospice A d m in is t r a t io n
P otential

co ntributions

from

th is

study

to

hospice

adm inistration are:
1.

The i d e n t i f i c a t i o n and c a t e g o r i z a t i o n o f ho spic e adminis­

t r a t i v e competencies.

Such a l i s t i n g can be usefu l f o r program and

e d u c a tio n a l development.
2.

jjJJL hospice

The i d e n t i f i c a t i o n o f consensus items on which

a d m i n i s t r a t o r s in Michigan ag r e e .

As t h e s e items were t h e h i g h e s t

r a t e d , th ey were a l s o th e most E s s e n t i a l .
3.

The i d e n t i f i c a t i o n o f o r g a n i z a t i o n a l s t a g e s o f development

as a p p lie d t o hospice ( s e e page 94 f o r s ta g e d e f i n i t i o n s ) .
identification

can a id

ho spice

adm inistrators,

ho spice

Such

boards

of

d i r e c t o r s , and s t a f f in underst anding program growth and change.
L i m i t a t i o n s o f This Study
This s tudy was l i m i t e d in i t s bro ad er a p p l i c a t i o n because o f a
r e l a t i v e l y small N and i t s l i m i t a t i o n t o Michigan.

Also, programs

in

be

Stage

I were

underrepresented.

Would t h i s

a pr o b le m

n a t i o n a l l y i f t h e survey was r e p l i c a t e d on a l a r g e r s c a l e ?
one

should

c o n s id e r

how t h e

programs

could

be more

I f so,

effectively

surveyed.
R e l a t i v e l y l i t t l e d a t a was a l s o a v a i l a b l e f o r Stage I I I and IV
h o s p ic e s
these

in Michigan.

stages

of

However,

development

it

is

possible

nationally

i n d i v i d u a l l y t o b u i l d a l a r g e r d a t a base.

that

could

programs
be

in

surveyed

159
F i n a l l y , survey in str um ent q u e s ti o n s on a d m i n i s t r a t i v e h i s t o r y
( t o t a l number o f y e a r s in a d m i n i s t r a t i o n ) and p a t i e n t / f a m i l y e t h n i c
representation
analysis.

did

not

elicit

accurate

The q u e s t i o n s would have t o

data

for

be r e v i s e d

statistical
if

the

survey

i n stru m ent i s used a g a i n .
Recommendations
This study o f hospice a d m i n i s t r a t i v e competencies r e p r e s e n t s an
initial

investigation

in t h e f i e l d .

Clearly,

fu rth e r research

is

encouraged and needed in t h e a r ea o f ho spice a d m i n i s t r a t i o n .

For

M ichigan,

and

th is

stu d y has

provided

an

in itial

demographic

e m piri ca l d a t a base from which t o expand knowledge o f t h e complex
t a s k s r e q u i r e d t o a d m i n i s t e r a hospice program.
that

M ic h ig a n

continue

to

build

its

data

I t i s recommended
base

on

hospice

a d m i n i s t r a t o r s through i t s s t a t e hospice o r g a n i z a t i o n .
Also, i t i s recommended t h a t r e s e a r c h c o n ti n u e in t h e a r e a s of
hospice l i f e c y c le s ta g e s as well
hospice a d m i n i s t r a t i v e f u n c t i o n s
and c o n t r o l l i n g ) .

Longitudinal

as a more in - d e p th a n a l y s i s of
( p la n n in g ,

organizing,

directing,

s t u d i e s could be done on hospice

programs t o a s s e s s t h e v a l i d i t y o f t h e hospic e l i f e

c y c le model.

This stu d y could a l s o be r e p l i c a t e d in Michigan t o e v a l u a t e s h i f t s
in s t a g e s o f development.

For example, 5 y e a r s from now w i l l

th e

m a j o r i t y o f hospice s s t i l l be in Stage I I ?
A dditionally,
clearly

defined

developed in t h i s

delegation
under th e
s tu d y .

of
five

It

is

competencies

needs

to

major a d m i n i s t r a t i v e
recommended t h a t

this

be

more

sectio n s
survey be

160
used in o t h e r s t a t e s by hospice s t a t e o r g a n i z a t i o n s t o e v a l u a t e i t s
accuracy

in

Identifying

Essential

and Supplementary

competencies

in clu d in g th o s e which a r e d e l e g a t e d .
Finally,

program a d m i n i s t r a t o r s

c y c l e e d u catio n al needs.

have c l e a r l y

identified

life

I t seems r i s k y t o r e l y on general h e a l t h

c a r e a d m i n i s t r a t i v e models t o c a r r y

us

into

tomorrow.

C a li f a n o

(1986) noted t h a t t h e h e a l t h c a r e i n d u s t r y o f tomorrow i s going t o
be un re co gniza bly d i f f e r e n t .
depends

on how we shape

He noted, "whether i t w i l l be b e t t e r

it"

(p.

10).

It

c o l l e g e s which support and tea ch an e c o l o g ic a l
course

offerings

adm inistration.

which
Hospice

address
programs

health
ar e

a

is

recommended

that

framework c o n s id e r
care

small

life

example

cycle
of

th e

h o l i s t i c approach needed in t h e l a r g e r arena where o r g a n i z a t i o n a l
l i f e c y c le i s s u e s occur.
Rogers
needed

in

(1971)
order

to

noted
fully

that

a

broad er

understand

h o l i s t i c a n a l y s i s in a d m i n i s t r a t i o n .

ecological

and recognize

approach
the

need

is
for

He s t a t e d :

Since a broad er e c o lo g ic a l approach i s needed in o r d e r t o f u l l y
understand man’ s r e l a t i o n s h i p s with h i s environment, i t fo llo w s
t h a t many e x i s t i n g , w e l l - i n t e n d e d o r g a n i z e d p a t t e r n s and
programs which were form ulated in th e co n te x t o f a more l i m i t e d
v i e w p o i n t a r e l i k e l y t o p r o v e i n a d e q u a t e , p e r h a p s even
dangerous in t h e long run. Ex pe die nti al d e c i s i o n s w i l l always
remain a p r a c t i c a l n e c e s s i t y . But expediency as a way o f l i f e
i s q u i t e d i f f e r e n t from expediency tak en as a n e c e s s a r y , but
recognized incom plete, i n t e r i m measure, (p. 206)

APPENDICES

APPENDIX A
ROUND ONE AND ROUND TWO HOSPICE ADMINISTRATORS INVENTORY

161

HOSPICE ADMINISTRATORS INVENTORY
Please complete Sections I and II of the Inventory and return in the enclosed
envelope by JUNE 1, 1987.
8BCTION I: BACKGROUND INFORMATION
1. _____ Age
2. ____
(I)

Female

Hale
(2)

3. EDUCATION Please check ( ) the highest educational level
achieved.
code:
(1)____ High School Diploma
(2)____ Associate degree in _________________
(please specify)
(3)____ Diploma in Nursing
(4)____ Bachelor's degree i n _________________
(please specify)
Minor: ________________
(5)____ Master's degree in _____________ ~
(please specify)
Minor:_________________
(6)____ Doctoral Degree in _____________________
(please specify)
Minor:_____________________
(7)____ Other ________________________
(please specify)
4.PRESENT EMPLOYMENT Please identify the number of years/months you have
worked as hospice administrator in the program you are currently directing.
_______ (years)
_______ (months, if newly hired)
5. PRIOR EMPLOYMENT HISTORY Please Check ( ) the statement which
most accurately reflects your employment status one (1) year
prior to your current employment,
code •
(1)___ Working in a Health related field OTHER THAN hospice
please specify;______________________________
(2)___ Working in a non-Health related field
please specify;________________________________
(3)___ Working in a hospice program but not in an administrative
capacity.
(4)___ Working in a hospice program in an administrative capacity.
(5)
Not Working

162
6.

a d m i n i s t r a t i v e h i s t o r y Please indicate the TOTAL number of years
you have worked as an administrator.
code:
(1)
in hospice
(2)
in a health related field (please specify)_____________
(3)
in a non health related field (please specify)_____________

7. ROLE r e s p o n s i b i l i t i e s Please Check ( ) the statement which most
accurately reflects your role responsiblitles.
code:
(1,)____ I am ONLY responsible for administering thehospice program.
(2)
I am responsible for administering the hospiceprogram AND
other roles. Please specify other rolesj_________________
8. SALARY RANGE Please check ( ) your current salary range.
code:
(1)
Volunteer-Unsalaried
(2)___ Under $10,000 per year
(3)___ $10,000- $15,000 per year
(4)___ $15,000-$20,0Q0 per year
(5)J
$20,000-$25,000 per year
(6)___ $25,000-$30,000 per year
(7)___ $30,000-$35,000 per year
(8)___ Above $35,000 per year
9. EMPLOYMENT STATUS Please check ( ) your employment status,
code:
(1)
Pull-time
(2)___ Part-time (please specify t of hours per week) __
10.HOSPICE DESIGNATION Please check ( ) the statement which
currently reflects the status of your hospice program,
code:
(1)___ Licensed as a hospice
(2)___ Exempt from Licensure
(3)___ Hospice Medicare certified
(4)___ Other: (please specify)_______________________
11. HOSPICE LOCATION Please check ( ) the population most appropriate to
your hospice service area.
code:
(1)___ (pop. less than 50,000)
(2)___ (pop. greater than 50,000 butless than100,000)
( 3 )___ (pop. greater than 100,000 but less than 250,000)
(4)___ (pop. greater than 250,000)
12. PT/PAMILY ETHNIC REPRESENTATION Please indicate the number of pt./families
in your program for 1986.(January 1986- Dec.1986)
(1)
Black
(2)
White
(3)
American Indian
(4)
Asian
(5)
Hispanic

163

13. PROGRAM FORECAST What do you anticipate the status of your
hospice program to be ONE year from now?
Please check ( )
code:
(1)___ Licensed as a hospice
(2)
Exempt from Licensure
(3)___ Hospice Medicare certified
(4)
Other:(Please specify)_______________________________
14. PROGRAM DEVELOPMENT Please check ( ) the stage of development you
believe your hospice program to be currently in.
code:
(1)____ STAGE ONE: perhaps newly organized, developing policies and
procedures, developing and filling staff
positions, perhaps highly volunteer intensive.
(2)____ STAGE TWO: established in the community, referrals are
Increasing, staff positions being added,
administration formalizing.
(3)

STAGE THREE: administration becoming more complex, adding
more staff, adding additional services,
census remaining high.

(4)____ STAGE FOUR: highly complex organizational structure, expansion
through satellite operations, large number of
employees to accomodate increased service area.
15.HOSPICE ADMINISTRATION EDUCATIONAL FORECAST Do you believe there is
a need for a hospice administration educational curriculum?
Please check ( ):
code:
(1)__ yes
(2)__ no
If you indicated a YES answer please complete the two questions on the next
page.
If you indicated a HO answer please continue on to SECTION II.

164

16. HOSPICE EDUCATIONAL AREAS Which educational areas do you £eel
would be most helpful to you.(You may check more than one area)
code:
(1)____ Staffing and Personnel Management
(2)
Patient and Family Relations
(3)
Community/Public Relations
(4)
Fiscal Management
(5)
Quality Assurance
(6)___ Other:_____________________________
(please specify)
17.

a s s i s t a h c e Please check ( ) which method of educational
is most preferrable to you.

educational

assistance
code:
(1)____
(2)____
(3)____
(4)____
(5)____

Seminars/Workshops for CEU credits
Seminars/ Workshops without CEU credits
College/ University certification/degree program
College/University Lifelong Education courses
Adult Continuing Education Programs
PLEASE CONTINUE ON TO SECTION II

165

SECTION 11
ROSPXCE ADMINISTRATORS INVENTORI
Please circle the nubtt to the right of each atataaent which best represents
TOUR response as to how essential each stateaant Is for TOUR particular
hosolce program then Indicate whether the stateaent Is delegated.---------5-Absolutely Necessary
4-Hlghly Necessary

3 ■ Useful
2* Uncertain

l“Not Necessary

SECTION A
STAFFING AND PERSONNEL MANAGEMENT
IThla section INCLUDES volunteers!
H i.

« 1M
M
9 n0 n
s-« f» n a
O
- o9 .e
o»«u
a s s - €3

n adalnlsterlng ay hospice prograa I:
1. plan staff developaent.
2. understand aotlvatlonal theories.
3. plan recrultaent strategies.
4. develop staffing patterns.
5. develop personnel policies and
procedures.
6 understand stress aanageaent theories.
7. develop personnel grlevence procedures.
8 . develop staff contracts.
9. plan staff asslgnaents.
10 . develop staff training for pt/faally
ethnicity needs.
Pll. plan 24 hour staff availability.
P12. plan resource support for staff.
013. organize personnel policies and
procedures.
014. provide stress aanageaent prograas for
staff.
015. provide training on ethnicity Issues.
016. provide support resources for staff.
017. coordinate patient care asslgnaents.
018. provide for aedleal direction.
019. provide coaannlcatlon lnservices.
020. take on-call asslgnaents.
021. provide on-call availability of staff.
D22. teach lnservlces.
023. direct all personnel activities.
024. conduct perforaance reviews.
025. conduct staff recrultaent.
026. hire qualified personnel.
027. conduct staff aeetlngs.
028. teach the hospice philosophy to staff.

5
5
5
5
5
S
5
5
5
5
S
S
5
S
5
5
5
5
5
5
5
5
5
5
5
5
5
5

m
91
9i

u

4o>

&

D29.
030.
031.
032.
033.
C34.
C3S.
CSS.
C37.
CSS.
C39.
-C40.
C41.
C42.
C43.
C44.
C45.
C46.
C47.
C48.
C49.
C50.
C51.

lead the Interdisciplinary tean Meetings.
ceansel staff.
conduct stress redaction classes.
negotiate staff contracts.
apply effective coanunlcatlon skills.
Initiate disciplinary action.
nonltor recrnltawnt.
nonltor staff orientation.
sapervlse hose visits.
nonltor staff stress levels.
nonltor the on-call schedule.
sapervlse the Interdisciplinary tean.
nonltor personnel contract renewals.
resolve staff lssaes/cosplalnts.
nonltor support resources for staff.
attend the Interdisciplinary tean
neetlngs.
function as a liaison between the
governing board and hospice staff.
assure 24 hour availability of staff.
schedule staff nestings.
docuaent staff nestings.
engage In research relative to
staffing and personnel.
nonltor the personnel files.
nonltor disciplinary action.

5
S
5
5
5
5
5
5
S
5
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5
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5
5
5
5
5
5
9
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Cowents and/or additions to the conpetencles In this section:

In adnlnlsterlng ay hospice prograa I:
P52. develop pt/fenlly adnlsslon end
dlschar9 e criteria.
P53. develop pt/fanlly coaplalnt aechanisas.
P54. develop confidentiality policies.
P55. develop bereavenent policies.
P56. nnderstand grief/loss theories.
P57. develop continuity of care policies
and procedures.
P58. plan for ethnicity needs of the
pt/fanlly.
P59. plan for acute synpton control
procedures.
P60. develop a pt/fanlly rights policy.
P61. develop respite care options for the
faally.
P62. develop a coaprehenslve needs
assessnent for the pt/fanlly.
063. provide confidentiality for the
pt/fanlly.
064. provide an ongoing bereavenent prograa.
065. provide for ethnic needs of the
pt/fanlly.
066. coordinate pt/fanlly transfers.
067. provide for continuity of care.
066. provide for resolution of pt/fanily
eoaplalnts.
069. provide for acute synpton control.
070. provide respite care for the fanlly.
071. aake hone visits.
072. provide for the spiritual needs of the
pt/fanlly.
073. provide for the physical needs of the
pt/fanlly.
074. provide for the eaotlonal needs of the
pt/fanlly.
075. direct the bereavenent progran.
076. eossnnlcate confidentiality policies
to the pt/fanlly.
077. coHmnlcate their rights to the
pt/fanlly.
078. coaannleate adnlsslon/dlscharge
criteria to the pt/fanlly.

Absolutely
Necessary
Highly
Necessary

MOTION B
PATIENT AND FAMILY RBLATIONS

168

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079. eosnunlcate the hospice philosophy
to the pt/fanlly.
DIO. discuss gxlef/loss Issues with the
pt/fanlly.
D ll. sake bexeaveaent visits,
012 . do the Initial pt/fanlly assessment,
CI3. nonltor pt/fanlly confidentiality,
CH. resolve pt/fanlly coaplalnts.
C85. nonltoe continuity of care,
CSC. nonltor bereavenent followup.
C87. assure pt/fanlly physical needs are net.
CH. assure pt/fanlly spiritual needs are net
CI9. assure pt/fanlly emotional needs axe net
C90. nonltor faally Involvement In the
patient's care.
C91. assure pt/fanlly rights are respected,
C92. nonltor pt/fanlly visits,
C93. nonltor pt/fanlly adnlsslons
and discharges.
C94. engage In research relative to the
pt/fanlly.

Cosnents and/or additions to the conpetencles In this section:

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169

•aCTIOR c
COHHUNXTT/FUBMC UUTIONS

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In adalnlsterlng ay hospice prograa I:
S
095. understand current coaannlty needs for
health care.
P96. plan hospice services which aeet the
needs of the coaannlty.
P97. develop Marketing strategies.
P98. develop contracts with conannlty health
care agencies/faellltles.
P99. develop bereavenent education prograns
for the coannnlty.
P100. plan strategies to Increase eonaunlty
avareness/partlclpatlon In hospice.
P101. plan strategies to Increase physician
avareness/partlclpatlon In hospice.
P102. plan strategies to Increase clergy
avareness/partlclpatlon In hospice.
P103. plan strategies to Increase governing
board avareness/partlclpatlon In
hospice.
0104. provide hospice orientation to
conannlty groups.
0105. Identify Individuals to potentially
fill governing board vacancies.
0106. provide ongoing Marketing activities.
0107. coaaunlcate pain aanageaent protocals
to physicians.
0108. provide lnservlces for clergy.
0109. provide lnservlces for physicians.
0110 . provide hospice orientation to
the governing board aenbers.
0111 . provide prograa status reports to the
governing board.
0112 . coordinate hosplee care vlth other
coaannlty health agencles/facllltles.
0113. provide bereavenent support for the
coaannlty.
0114. laplenent Marketing strategies.
0115. contact physicians In the coannnlty.
0116. Sbeak to Interested groups about
hospice.
0117. contact clergy In the coaannlty.
0118. aeet vlth other hospice adainlstrators.
0119. coaaunlcate the hospice philosophy to
coaannlty.

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4

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4

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5

4

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4

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5
5
5

4
4
4

3
3
3

2
2
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1
1
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( )
( )
( )

5
5
5

4
4
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3
3
3

2
2
2

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( )
( )

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4

3

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0120 . lead bereavement support groups.
0121 . vrlte aedla articles on hospice care.
0122 . coanunleate to the governing board

about current hospice trends/issues.
C123. nonltor marketing strategies.
C121. evaluate the connunlty's perception
of hospice care.
C125. nonltor all public relations strategies.
C126. review all media articles before
publication.
C127. oversee all proaotlonal activities
sponsored by hospice.
C128. nonltor couaninlty Issues/trends which
nay affect the hospice prograa.
C129. schedule governing board nestings.
C130. docuaent governing board nlnutes.
C131. be accountable to the governing
board for the hospice's day to day
operations.
C132. nalntaln effective comnlcatlon vlth
connunlty resource agencies.
C133. engage In research relative to
coanmnlty/publlc relations.
Coanents and/or additions to the conpetencles In this section:

171

MCTXOR 0
FISCAL HMAGBOEHT

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In administering ay hospice program I:
P134. plan tba hosple* budget.
P13S. develop land raising strategies.
P13S. plan grant proposals.
P137. develop cost containment strategies.
P138. plan financial statenents.
P139. develop a staff benefits plan.
P140. develop reimbursement policies
and procedures.
P141. develop a mechanism to account for
gifts and donations to the hospice.
P142. develop liability coverage for staff
and board members.
0143. utilize coaputer programing assistance.
0144. provide ongoing funding support.
0145. provide liability coverage for
staff and board members.
0146. Interpret financial statements.
0147. provide for
a balanced budget.
0146. provide for
accurate accountingof
gifts and donations to the hospice.
0149. provide for
salary Increases.
D150. direct grants that are awardedto the
hospice program.
D151. conduct fund raising.
D152. communicate fiscal Issues to staff and
governing board.
D153. prepare financial statements.
D154. compute volunteer cost savings.
0155. recommend salary Increases.
0156. write grant proposals.
0157. prepare/Issue payroll checks.
C158. monitor revenue resources.

monitor hospice expenditures.
monitor Insurance claim processing.
monitor liability Insurance renewal.
assure accurate accounting of gifts
and donations.
C163. assure continued cost savings by
volunteers.
Cl«4. engage In research relative to fiscal
management.
ci«s. monitor cost containment.
Cl59.
CltO.
C161.
C162.

5
5
5

4
4
4

9
3
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4

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1

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5

4

3

2

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5
5

4
4

3
3

2
2

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Coaments and/or additions to tha competencies In this section:

173

Not
Necessary

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4

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3

2
2

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4
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2
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1
1
1
1
1

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Delegated

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In adnlnlstezlng ay hospice program I:
P166. understand quality aasnranca.
0167. plan £or appropriate nse of resources.
P168. plan a quality assurance reporting
nechanlsn to the governing board.
P169. plan for re-evaluatlon of quality
care Issues.
P170. plan quality assurance lnservlces.
P171. develop hospice standards of care.
P172. develop a plan for quality assurance.
P173. develop a prograa evaluation.
P174. plan an organizational design which
reflects quality hospice care.
P175. develop utilization review aeehanlsas.
0176. provide conpetent staff.
0177. provide for evaluation of all services..
0178. provide for concurrent aedlcal record
reviews.
0179. provide reviews of all hospice
standards.
0180. provide for revlev/evaluatlon of all
contracted services.
0181. provide an ongoing evaluation of
services.
0182. provide for re-evaluatlon of quality
care Issues.
0183. provide quality assurance lnservlces.
0184. function as a aenbez of the quality
assurance cosnlttee.
0185. provide for quality assurance studies.
0186. provide for retrospective aedlcal
record reviews.
D187. coaannlcate quality assurance Issues
to the governing board.
0188. coaannlcate the laportance of quality
assurance to staff.
0189. lead the quality assurance eoaalttee
neetlngs.
0190. do quality assurance studies.
0191. do the prograa evaluation.
0192. teach quality assurance lnservlces.
C193. assure sufficient data collection to
support quality assurance studies.
C194. nonltor the quality assurance plan.
C19S. assure re-evaluatlon of quality care
Issues.

Useful

Absolutely
Necessary
Highly
Necessary

MCTIOtl 8
QUALITY A8SUKMCB

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174

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CISC, assure coapetence of staff.
C197. aonltoc compliance vlth stata hospice
regulations.
CDS. aonltoc coapllanco vlth federal hospice
regulations.
CDS. assure appropriate and efficient ose
of resonrces.
C200. engage In research relative to quality
assurance.
C201. aonltor contracted services.
Consents and/or additions to the coapetencles In this section

PLSASS RSTURM THE HOSPICE ADMINISTRATORS COMPETENCE INVEHTORT BTMAIL TO:
Sharon Olson R.N. M.S.
2117 Rolling Brook Lane
Bast Lansing, Ml.48823

s.
*
s

175

houho n o
SOSPICX ADMINXITIATOCJ ZMVntTOHX

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h n n n lc e w m t m th a n l n d le n te uh«t-t»«r H a
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do mot

In adnlnlsterlng ay hospice prograa I:
PI. plan staff devolopaant.
P2. nnderatand aotlvatlonal theories.
P3. plan recroltaent strategies.
P4. develop staffing patterns.
P5. develop personnel policies and
procedures.
P6 understand streaa aanageaent theories.
P7. develop personnel grievance procedures.
PI. develop staff contracts.
P9. plan staff asslgnaents.
P10. develop staff training for pt/fanlly
ethnicity needs.
Pll. plan 24 hour staff availability.
P12. plan resource support for staff.
013. organise personnel policies and
procedures.
014. provide stress aanageaent progress for
staff.
015. provide training on ethnicity Issues.
014. provide support resources for staff.
017. coordinate patient care asslgnaents.
Oil. provide tor aedlcal direction.
019. provide connlcatioo lnservlces.
020 . take on-call asslgnaents.
021 . provide on-call availability of staff.
022 . teach lnservlces.
023. direct all personnel activities.
024. conduct perforaance reviews.
025. conduct staff recrultaent.
021 . hire qualified personnel.
027. condoet staff nestings.
021 . teach the hospice philosophy to staff.

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3.15
3.19
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4.08
4.02
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3.04
4.17
4.04
4.01
3.63
2.19
3.95
4.29
4.23
4.04
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4.19
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4.15
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D29.
D30.
031.
032.
*033.
C34.
C35.
C3S.
C37.
C3I.
C39.
C40.
C41.
C42.
C43.
C44.
•C45.
C46.
C47.
C48.
C49.
C50.
C51.

lMd the Interdisciplinary tean Meetings.
counsel staff.
conduct stcass rodaction classes.
negotiate staff contracts.
apply affective cossnnlcatlon skills.
initiate disciplinary action.
aonltor recrultasnt.
Monitor staff orientation.
supervise hoas visits.
Monitor staff stress levels.

Monitor the on-call schedule.
supervise the Interdisciplinary tean.
nonltor personnel contract renewals.
resolve staff lssues/coaplalnts.
Monitor support resources for staff.

attend the Interdisciplinary tean
nestings.
function as a liaison between the
governing board and hospice staff.
assure 24 hour availability of staff.
schedule staff nestings.
docunent staff nestings.
engage in research relative to
staffing and personnel.
nonltor the personnel files.
nonltor disciplinary action.
COMTIMUI Ob VO rSEXT PAGZ

177

s ic t io h •
PA T IO T MID PAMILY ULATXOMS

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In adalnlsterlng ay honplen prograa I:
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IS2. d m l o p pt/fanlly adalsslon and
5
3
discharge erltnrln.
3
P53. develop pt/fnally eonplalnt aechanlsns. 5
3
5
•P54. dev*lop confidentiality policies.
3
ep55. develop beseavenent policies.
5
S
3
P5(. nnderstand grlef/loss theories.
•P57. develop continuity of care policies
S
3
and procedures.
P58. plan for ethnicity needs of the
3
5
pt/fanlly.
P59. plan for acute synpton control
3
procedures.
5
3
P(0. develop a pt/fanlly rights policy.
5
PCI. develop respite care options for the
3
5
family.
P(2. develop a eoaprehenslve needs
5
3
assessaant for the pt/fanlly.
*063. provide confidentiality for the
3
S
pt/fanlly.
3
*(X4. provide an ongoing bereavenent progran. S
0(5. provide foe ethnic needs of the
3
pt/fanlly.
5
3
0(4. coordinate pt/fanlly transfers.
S
3
5
0(7. provide for continuity of care.
0 (6 . provide for resolution of pt/fanlly
conplalnta.
3
5
3
5
0(9. provide for acute synpton control.
3
5
070. provide respite care for the faally.
5
3
071. ante hone visits.
072. provide for the spiritual needs of the
5
3
pt/fanlly.
073. provide for the physical needs of the
pt/faaily.
9
3
074. provide for the eaotional needs of the
3
pt/faaily.
S
3
D75. direct the bereavenent prograa.
5
D7(. coanunieate confidentiality policies
3
to the pt/fanlly.
5
D77. coanunieate their rights to the
3
pt/fanlly.
5
D7I. couaonlcate adalsslon/dlscharge
3
S
criteria to the pt/fanlly.
Asmiaes (•) mdicates that you
HBD TO IBSPOHD TO TUT IHN

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D7I. connunlcate the hospice philosophy
to the pt/fanlly.
DIO. discuss grief/loss issues vlth tha
pt/fanlly.
Dll. nske bereavenent visits.
Dll. do tha Initial pt/fanlly aaaaaaaant.
CI3. aonltoz pt/fanlly eonfldantlallty.
CI4. raaolva pt/fanlly eonplalnts.
CIS. nonltor continuity of eara.
CM. nonltor baraavanant follov-up.
CI7.aaanza pt/fanlly phyalcal naada ara net.
Cll.assure pt/fanlly aplrltnal needs ara net.
CIS.assure pt/fanlly eaotlonal needs ara net.
CIO. nonltor fanlly lnvolvenent in the
patient's care.
Cll. assure pt/fanlly rights ara respected.
CI2. nonltor pt/fanlly visits.
Cll. nonltor pt/fanlly adnlsslons
and discharges.
CI4. engage In research relative to the
pt/fanlly.

3
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9

5

4

3

7

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5
5
5
5
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5
5
5
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4
4
4
4
4
4
4
4
4
4

3
3
3
3
3
3
3
3
3
3

2
2
2
2
2
2
2
2
2
2

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5
5

4
4
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3
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(
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( ) 4.30
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4.14
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4.27
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4.30
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4.25
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179

nCTXOR c
COHHUNXTT/PUBLIC ULATXONS

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ASTHtlCXS (•) IHDICATH8 THAT YOU DO MOT
HBD TO USPOMD TO THAT XTSM

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In adalnlsterlng mg hospice prograa X:
095.. understand current conannlty mads for
iMAlth care.
•096. plan hosplea sazvlcas which aeet tha
naads of tha conannlty.
097. davalop aarketlng strategies.
098. davalop contracts with conannlty haalth
cate agenclan/facllitlas.
P99. davalop bazaavaaant aducatlon pzogzaas
for tha conBonlty.
•P100. plan ntzataglas to lncreaaa conannlty
awareness/participation In hoaplca.
•P101. plan ntzataglas to lnctaaaa physician
awazanass/paztlclpatlon In hosplea.
•P102. plan ntzataglas to lnczeasa clergy
avazanass/paztlcipatlon In hospice.
•0103. plan ntzataglas to lncroase governing
board avareness/partlclpatlon In
hospice.
0104. provide hosplea orientation to
conannlty gzonps.
0105. Identify Individuals to potentially
fill governing board vacancies.
OIOS, provide ongoing aarketlng activities.
0107. coaannlcate pain aanageasnt pzotocals
to physicians.
OlOt. provide lnservlces for clergy.
0109. provide lnservlces for physicians.
0110 . provide hospice orientation to
the governing board nenbers.
*0111 . provide prograa status reports to the
governing board.
*0112 . coordinate hospice care with other
conannlty haalth agencies/facilities.
0113. provide bereaveaent support for the

D114. lnpleaent aarketlng strategies.
D115; contact physicians in the coaaonity.
*D11S. speak to Interested group* about
hospice.
0117. contact clergy In the eoaannlty.
Dill, aeet with other hospice adalnlstrators.
*0119. conannlcate the hospice philosophy to
conannlty.

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Bean
( I 4.34
4.53
4.14
4.17
3.95
4.63
4.S9
4.51
4.51
4.48
4.10
3.91
3.71
3.55
3.54
4.36
4.74
4.53
4.08
4.06
4.20
4.57
4.19
4.34
( ) 4.66

180

3*3

iifl
D120 . lud bereavenent support groups.
DX21. writs Mdls srtielss on hosples cars.
*0122 . coanunieate to tbs govsrnlng board
about currant hosplea trsnds/lssuss.
C123. nonltor aarkstlng stratsglss.
C124. svalunts tbs coananlty's parcsptlon
of hosplea cars.
C125.nonltor all public rslatlons stratsglss.
C126. rsvlsv all nadla artlclss before
publication.
C127. ovsrsss all pronotlonal activities
sponsorsd by bosplea.
C128. nonltor cosBunlty lssuss/trsnds which
nny affact tbs hosplea progran.
C129. schsduls govsrnlng board nestings.
C130. docunsnt governing board nlnutes.
•C131. be accountable to the governing
board for tbs hospice's day to day
operations.
5
C132. nalntaln affective cosnunlcatlon vlth
conaunlty resource agencies.
5
C133. engage In research relative to
cosaunity/publlc relations.
S
CONTINUE ON TO NEXT PAGE

n0 3
m

s

*•8
nean
3.35
4.11
4.63
3.97
4.20
4.19
4.29
4.31
4.33
3.06
3.79
4.72
4.48
3.29

181

MCTION D
FISCAL HAMAGSHWT

• *
UTBtlCM (•) INDICATES THAT YC*J DO MOT
MBO TO ISSPOND TO THAT ITM

*

In administering ay hospice program I:
P134. plan tha hosplea bud9 at.
P135. davalop fond raising stratagles.
P136. plan grant proposals.
P137. davalop cost containment strategies.
P130. plan financial statements.
P139. davalop a staff -benefits plan.
P140. davalop reimbursement policies
and procedures.
•P141. davalop a mechanism to account for
gifts and donations to the hospice.
P142. develop liability coverage fox staff
and board naabexs.
0143. utilize conputer programing assistance
0144. provide ongoing funding support.
0145. provide liability coverage for
staff and board members.
0144. Interpret financial statements.
9147. provide for a balanced budget.
01 10 . provide for accurate accounting of
gifts and donations to the hospice.
0143. provide for salary Increases.
D150. direct grants that are awarded to the
hospice program.
D151. conduct fund raising.
D152. coamunlcate fiscal Issues to staff and
governing board.
0153. prepare financial statements.
0154. compute volunteer cost savings.
0155. recomwnd salary Increases.
0154. write grant proposals.
0157. prepare/Issue payroll checks. C154. monitor revenue resources.

e

.

8-8

m t

m

M
■

M
o■
•

1
4j

.

<

mean
4.41
4.04
3.62
4.00
3.02
2.05
3.20
4.51
5
5

5

4.26
3.04
4.25

5
5
5

4.20
4.15
4.33

5
5

4.40
3.51

5
5

3.50
4.04

5
5
5
5
5
5
5

4.40
3.70
3.50
3.62
3.40
3.20
4.09

182

04 >» M
• u >•
**
* 3 >.3
a •aw
o• Om M
a
CP

a2S 1

•C159. aonltor hospice expenditures.
C160. nonltor insurance claia processing.
C1C1. aonltoc liability Insurance reneuel.
•C1S2. assure accnrate accounting of gifts
and donations.
ClS3, assure continued cost savings by
volunteers.
C1S4. engage la research relative to fiscal
aanageaent.
C1C5. aonltoc cost contalnaent.

a

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I

>.
s
w
3
3.
a
9
9
0 *
*» U
&
&&
asan
i
< ) 4.5S
l
( ) 3.54
l
( ) 4.09

5
S
S

4
4
4

s
3
3
3

S

4

3

2

l

(

) 4.55

S

4

3

2

l

(

) 4.00

5
5

4
4

3
3

2
2

l
l

( ) 3.19
( ) 4.14

CONTIRUB ON TO NBXT PAG!

2
2
2

183

ebctxoh i
QUALITY ASSURANCE

ASTERICR8 (*) INDICATES THAT YOU DO MOT
NEED TO ISSPOHD TO THAT ITEM

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0*
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+9W
8
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Im
mm* m
ft
Ut V*
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mm 0U
£ mmm i

In adalnisterlng ay hosplea prograa I:
•PISS, understand quality assuranea.
•P167. plan Cor appropriate use of resources.e
*P168. plan a quality assurance reporting
aechanlsn to the governing board.
P169. plan for re-evaluatlon of quality
care Issues.
P1T0. plan quality assurance lnservlces.
•P171. develop hospice standards of care.
•P172. develop a plan for quality assurance.
P173. develop a prograa evaluation.
•P174. plan an organisational design which
reflects quality hospice care.
P175. develop utilisation review nschanlsaa #
*0176. provide eoapetent staff.
*0177. provide for evaluation of all serviceS .
0176. provide for concurrent aedlcal record
reviews.
0179. provide reviews of all hospice
standards.
0180. provide for review/evaluation of all
contracted services.
0111. provide an ongoing evaluation of
services.
0182. provide for re-evaluatlon of quality
care issues.
0183. provide quality assurance lnservlces.
0184. function as a aeaber of the quality
assurance cossilttee.
0185. provide for quality assurance studies.•
0186. provide for retrospective aedlcal
record reviews.
•D187. coaaunlcate quality assurance issues
to the governing board.
0188. coasanlcate the laportance of quality
assurance to staff.
0189. lead the quality assurance coaulttee
neetlngs.
0190. do quality assurance studies.
0191. do the prograa evaluation.
0192. teach quality assurance lnservlces.
C193. assure sufficient data collection to
support quality assurance studies.
C194. aonltor the quality assurance plan.
C195. assure re-evaluatlon of quality care
Issues.

■
m
**
•
I

•
a
«
•f U
s s

•o
**
m
o
m*
2

5
5

4
4

3
3

2
2

1
1

asan
< > 4.52
< ) 4.55

5

4

3

2

1

< ) 4.53

5
5
5
5
5

4
4
4
4
4

3
3
3
3
3

2
2
2
2
2

1
1
1
1
1

(
<
<
(
<

)
>
>
>
)

4.47
4.14
4.57
4.52
4.48

5
5
S
5

4
4
4
4

3
3
3
3

2
2
2
2

1
1
1
1

<
(
<
<

)
)
>
>

4.50
4.07
4.71
4.62

5

4

3

2

1

c > 4.33

5

4

3

2

1

t > 4.39

S

4

3

2

1

< > 3.93

5

4

3

2

1

< ) 4.41

5
5

4
4

3
3

2
2

1
1

< ) 4.34
i > 3.97

5
5

4
4

3
3

2
2

1
1

( > 4.35
( > 4.09

5

4

3

2

1

< > 4.19

5

4

3

2

1

t > 4.51

5

4

3

2

1

< i 4.43

5
5
5
5

4
4
4
4

3
3
3
3

2
2
2
2

1
1
1
1

<
<
4
(

5
5

4
4

3
3

2
2

1
1

( ) 4.15
( > 4.39

5

4

3

2

1

( ) 4.38

) 3.58
t 3.91
1 -3.90
) 3.64

184

•0196. assart coapottnce of staff. •C197. aonltor coapllanct vlth stato hosplct
rogolatlons.
C19I. aonltor cospllanca vlth ftdoral hosplct
regulations.
•C199. assort approprlats and afflclsnt use
of rosonrcts.
C200. tngage In rtssarch rslatlvo to quality
assaranct.
C201. aonltor contracted strvlcts.

5

4

3

2

1

( ) 4.64

5

4

3

2

1

( ) 4.55

5

4

3

2

1

( > 4.31

5

4

3

2

1

( ) 4.55

5
5

4
4

3
3

2
2

1
1

( ) 3.42
( ) 4.04

PLSASI RITUM SOUND TWO OF THE HOSPICK ADMINISTRATORS COMPETENCY INVENTORY BY
•••AUGUST 10, 19«7**«
NAIL TO:
Sharon Olaon R.N. M.S.
2217C Stonehedge
East Lanalng, Ml.48623

APPENDIX B
ESSENTIAL AND SUPPLEMENTARY COMPETENCIES AND PERCENTAGE
DELEGATED SECTIONS A-E AND P, 0, D, C

185
ESSENTIAL AND SUPPLEMENTARY COMPETENCIES AND PERCENTAGE
DELEGATED SECTIONS A-E AND P, 0, D, C,
S ec tion A:

S t a f f i n g and Personnel Management
% Delegated

E s s e n ti a l Competencies (Planning!
Plan s t a f f development
Plan 24-hour s t a f f a v a i l a b i l i t y
Develop personnel p o l i c i e s and pr ocedures
Plan s t a f f assignments
Plan r e s o u r c e s upp ort f o r s t a f f
Understand s t r e s s management t h e o r i e s
Supplementary
Plan r e c r u i t m e n t s t r a t e g i e s
Understand m otiv ational t h e o r i e s
Develop s t a f f i n g p a t t e r n s
Develop personnel g r ie v an ce procedures
Develop s t a f f c o n t r a c t s
Develop s t a f f t r a i n i n g f o r p t . / f a m i l y e t h n i c needs
Content Mean = 3 . 8 5
E s s e n ti a l Competencies (Organizing)
Coordinate p a t i e n t c a r e assignments
Provide f o r medical d i r e c t i o n
Provide o n - c a l l a v a i l a b i l i t y o f s t a f f
Organize personnel p o l i c i e s and procedures
Provide communication i n s e r v i c e s
Supplementary
Provide support r e s o u r c e s f o r s t a f f
Take o n - c a l l assignments
Provide s t r e s s management programs f o r s t a f f
Provide t r a i n i n g on e t h n i c i s s u e s

Content Mean « 3.89

.20
.47
.20
.35
.20
.04
.25
.02
.20
.24
.14
.35
Ave. % D e l. = 22%

.57
.37
.33
.22
.35
.24
.37
.37
.25

Ave. % D e l . = 34%

186
E s s e n ti a l Competencies ( D i r e c t i n g )
Apply e f f e c t i v e communication s k i l l s
Teach t h e hospice philosophy t o s t a f f
Conduct s t a f f meetings
Hire q u a l i f i e d personnel
Counsel s t a f f
Conduct performance reviews
Supplementary
Teach i n s e r v i c e s
D i r e c t a l l personnel a c t i v i t i e s
Lead th e I n t e r d i s c i p l i n a r y team meetings
N egoti ate s t a f f c o n t r a c t s
Conduct s t r e s s re d u c tio n c l a s s e s
Conduct s t a f f r e c r u i tm e n t
Content Mean - 4.00

.04
.35
.14
.24
.22
.24
.49
.49
.63
.33
.49
.24
Ave. % D e l . = 31%

E s s e n ti a l Competencies ( C o n t r o l ! i n a l
Function as a l i a i s o n between t h e governing board
and ho s p ic e s t a f f
Assure 24-hour a v a i l a b i l i t y o f s t a f f
Resolve s t a f f i s s u e s /c o m p l a i n t s
Schedule s t a f f meetings
Supe rvise t h e I n t e r d i s c i p l i n a r y team
Monitor s t a f f o r i e n t a t i o n
Monitor s t a f f s t r e s s l e v e l s
Supplementary
Monitor d i s c i p l i n a r y a c t i o n
Document s t a f f meetings
Monitor personnel f i l e s
Monitor s u p p o rt re s o u r c e s f o r s t a f f
I n i t i a t e d is c ip lin a ry action
Attend t h e I n t e r d i s c i p l i n a r y team meetings
Supe rvise home v i s i t s
Monitor r e c r u i t m e n t
Monitor personnel c o n t r a c t renewals
Monitor t h e o n - c a l l schedule
Engage in r e s e a r c h r e l a t i v e t o s t a f f i n g and personnel

Content Mean - 3.94
Section Mean - 3.92

.08
.24
.18
.14
.29
.22
.20
.10
.33
.27
.20
.20
.12
.55
.14
.22
.41
.06

Ave. % D e l . = 22%
Sec. % D e l . = 26%

187

Section B:

Patient and Family Relations
% Delegated

E s s e n ti a l Competencies (Planning)
Develop c o n f i d e n t i a l i t y p o l i c i e s
Develop bereavement p o l i c i e s
Develop c o n t i n u i t y o f c a r e p o l i c i e s and pro ce du res
Develop a p t . / f a m i l y r i g h t s p o l i c y
Understand g r i e f / l o s s t h e o r i e s
Develop p t . / f a m i l y com plaint mechanisms
Develop p t . / f a m i l y admission and d i s c h a r g e c r i t e r i a
Develop r e s p i t e o p t io n s f o r th e fa mily
Develop comprehensive needs assessment f o r p t . / f a m i l y
Supplementary
Plan f o r a cute symptom c o n t r o l procedures
Plan f o r e t h n i c needs o f t h e p t . / f a m i l y
Content Mean = 4 . 2 7
E s s e n t i a l Competencies (Organizing!
Provide c o n f i d e n t i a l i t y f o r t h e p t . / f a m i l y
Provide an ongoing bereavement program
Provide f o r r e s o l u t i o n o f p t . / f a m i l y complaints
Provide f o r c o n t i n u i t y o f c a r e
Provide f o r th e ph ysic a l needs o f th e p t . / f a m i l y
Provide f o r th e s p i r i t u a l needs o f t h e p t . / f a m i l y
Provide f o r th e emotional needs o f t h e p t . / f a m i l y
Supplementary
Provide f o r ac ute symptom c o n tr o l
Provide r e s p i t e c a r e f o r t h e fa mily
Make home v i s i t s
Coordinate p t . / f a m i l y t r a n s f e r s
Provide f o r e t h n i c needs o f t h e p t . / f a m i l y

Content Mean = 4 . 1 5

.12
.33
.25
.20
.16
.16
.25
.27
.51
.53
.35

Ave. % D e l. = 29%

.27
.57
.27
.43
.65
.67
.63
.65
.47
.45
.57
.35

Ave. % D e l . = 50%

188
E s s e n t i a l Competencies ( D i r e c t i n g !
Communicate t h e hospic e philosophy t o t h e p t . / f a m i l y
Communicate t h e i r r i g h t s t o t h e p t . / f a m i l y
Communicate ad m is s io n /d is c h a r g e c r i t e r i a t o t h e
pt./fam ily
Discuss g r i e f / l o s s i s s u e s with t h e p t . / f a m i l y
Do t h e i n i t i a l p t . / f a m i l y assessment
Supplementary
Communicate c o n f i d e n t i a l i t y p o l i c i e s t o t h e
pt./fam ily
Make bereavement v i s i t s
D i r e c t t h e bereavement program
Content Mean = 3. 99
E s s e n t i a l Competencies ^ C o n t r o lli n g )
Assure p t . / f a m i l y r i g h t s a r e r e s p e c t e d
Resolve p t . / f a m i l y complaints
Assure p t . / f a m i l y s p i r i t u a l needs a r e met
Assure p t . / f a m i l y phy sica l needs a r e met
Monitor p t . / f a m i l y admissions and d i s c h a r g e s
Assure p t . / f a m i l y emotional needs ar e met
Monitor bereavement follow-up
Monitor c o n t i n u i t y o f c a r e
Monitor fa m ily involvement in t h e p a t i e n t ’ s c a r e
Monitor p t . / f a m i l y v i s i t s
Monitor p t . / f a m i l y c o n f i d e n t i a l i t y
Supplementary
Engage in r e s e a r c h r e l a t i v e t o t h e p t . / f a m i l y
Content Mean = 4 . 1 4
S e c t io n Mean = 4 . 1 5

.53
.59
.57
.59
.65
.57
.65
.63

Ave. % D e l . = 60%

.45
.29
.57
.57
.37
.55
.45
.37
.59
.45
.31
.29
Ave. % D e l. = 44%
Sec. % D e l. = 45%

Section C:

Community/Public Relations
% Delegated

E s s e n t i a l Competencies (Planning!
Plan s t r a t e g i e s t o i n c r e a s e community awareness/
p a r t i c i p a t i o n in hospice
Plan s t r a t e g i e s t o I n c r e a s e p h y s ic ia n awareness/
p a r t i c i p a t i o n in hospice
Plan hospice s e r v i c e s which meet t h e needs o f t h e
community
Plan s t r a t e g i e s t o i n c r e a s e governing board
a w a r e n e s s / p a r t i c i p a t i o n in hos pice
Plan s t r a t e g i e s t o i n c r e a s e c l e r g y awarenes s/
p a r t i c i p a t i o n in hospic e
Understand c u r r e n t community needs f o r h e a l t h c a r e
Develop c o n t r a c t s with community h e a l t h c a r e
agencies/facilities
Develop marketing s t r a t e g i e s
Supplementary
Develop bereavement e d u catio n programs f o r th e
community
Content Mean = 4.37

.

.18
.16
.06
.06
.20
.04
.12
.18
.51
Ave. % D el. = 16%

E s s e n t i a l Competencies (Organizing)
Provide program s t a t u s r e p o r t s t o t h e governing board
Coordinate ho spice c a r e with o t h e r community h e a l t h
agencies/facilities
Provide hospice o r i e n t a t i o n t o communitygroups
Provide hospice o r i e n t a t i o n t o t h e governing board
members
I d e n t i f y i n d i v i d u a l s t o p o t e n t i a l l y f i l l governing
board va cancie s
Provide bereavement s u p p o rt f o r th e community
S u p p I ementarv
Provide ongoing marketing a c t i v i t i e s
Communicate pain management p r o t o c o l s t o p h y s ic i a n s
Provide i n s e r v i c e s f o r c l e r g y
Provide i n s e r v i c e s f o r p h y s ic i a n s

Content Mean « 4.12

.02
.20
.37
.37
.18
.45
.24
.55
.41
.43

Ave. % D e l . = 30%

190

E s s e n t i a l Competencies ( D i r e c t i n g )
Communicate t h e hos pice philosophy t o th e community
Communicate t o t h e governing board about c u r r e n t
hos pice t r e n d s / i s s u e s
Speak t o i n t e r e s t e d groups about hos pice
Meet with o t h e r hospice a d m i n i s t r a t o r s
Contact p h y s ic i a n s in t h e communUy
Contact c l e r g y in t h e community
Write media a r t i c l e s on ho spice c a r e
Implement marketing s t r a t e g i e s
Supplementary
Lead bereavement s upport groups
Content

Mean - 4. 24

.35
.02
.35
.02
.35
.37
.43
.24
.73
Ave. % D e l . = 31%

E s s e n t i a l Competencies ( C o n t r o l l i n g )
Be ac counta ble t o t h e governing board f o r th e
h o s p i c e ’ s d a y - to -d a y o p e r a t i o n s
Maintain e f f e c t i v e communication with community
r e so u r c e age ncies
Monitor community i s s u e s / t r e n d s which may a f f e c t t h e
hospice program
Oversee a l l promotional a c t i v i t i e s sponsored by
hospice
Review a l l media a r t i c l e s b e fore p u b l i c a t i o n
Evaluate t h e community’ s p e r c e p t io n o f hospice c a r e
Monitor a l l p u b l i c r e l a t i o n s s t r a t e g i e s
Supplementary
Monitor marketing s t r a t e g i e s
Schedule governing board meetings
Document governing board minutes
Engage in r e s e a r c h r e l a t i v e t o community/public
relations
Content Mean = 4.14
Sec ti on Mean - 4.21

.02
.14
.06
.16
.14
.16
.10
.12
.25
.59
.10

Ave. % D e l . = 17%
Sec. % Del. = 23%

191

Section D:

Fiscal Management
%

E s s e n ti a l Conroetencies (P lann inal
Develop a mechanism t o account f o r g i f t s and
d onations t o t h e hospice
Plan t h e ho spic e budget
Develop l i a b i l i t y coverage f o r s t a f f and board
members
Develop c o s t containment s t r a t e g i e s
Develop fund r a i s i n g s t r a t e g i e s
SuDolementarv
Plan f i n a n c i a l s ta te m e n ts
Plan g r a n t propo sa ls
Develop reimbursement p o l i c i e s and procedures
Develop s t a f f b e n e f i t s plan
Content Mean > 3 . 9 0
E s s e n t i a l Competencies (Organizing!
Provide f o r a c c u r a t e accounting o f g i f t s and
do n atio n s t o th e hospice
Provide f o r a balanced budget
Provide ongoing funding supp ort
Provide l i a b i l i t y coverage f o r s t a f f and board
members
I n t e r p r e t f i n a n c i a l s tatem en ts
SuDolementarv
Provide f o r s a l a r y i n c r e a s e s
U t i l i z e computer programming a s s i s t a n c e
Content Mean - 4.01

Delegated

.31
.31
.27
.22
.41
.53
.27
.22
.25
Ave. % D el. = 31%

.41
.31
.31
.29
.35
.33
.33
Ave. % D e l. = 33%

192
E s s e n t i a l Competencies ( D i r e c t i n g )
Communicate f i s c a l i s s u e s t o s t a f f and governing
board
Conduct fund r a i s i n g
Supplementary
Prepare f i n a n c i a l s ta te m e n ts
Recommend s a l a r y i n c r e a s e s
Compute v o l u n t e e r c o s t savings
D i r e c t g r a n t s t h a t a r e awarded t o t h e hospice
program
Write g r a n t p r o p o sa l s
P r e p a r e / i s s u e p ayro ll checks
Content Mean = 3 . 7 2
E s s e n t i a l Competencies ( C o n t r o l l i n g )
Monitor hos pice ex p e n d i tu r e s
Assure a c c u r a t e accounting o f g i f t s and do n atio n s
Monitor c o s t containment
Monitor revenue r e s o u r c e s
Monitor l i a b i l i t y i n su r a n c e renewal
Assure continue d c o s t savings by v o l u n t e e r s
Supplementary
Monitor insu rance claim p r o c e ss in g
Engage in r e s e a r c h r e l a t i v e t o f i s c a l management
Content Mean = 4 . 0 4
S ec tion Mean = 3 . 9 1

.16
.41
.63
.20
.39
.14
.29
.49
Ave. % D e l. = 34%

.12
.22
.16
.24
.25
.25
.29
.14
Ave. % D e l . = 21%
Sec. % D e l. = 30%

193

Section E:

Quality Assurance
% Delegated

E s s e n ti a l Competencies (Planning)
Develop hospice s ta n d a r d s o f c a r e
Plan f o r a p p r o p r i a t e use o f r e s o u r c e s
Plan a q u a l i t y assu ran ce r e p o r t i n g mechanism t o t h e
governing board
Develop a plan f o r q u a l i t y as surance
Understand q u a l i t y as suran ce
Plan an o r g a n i z a t i o n a l de sig n which r e f l e c t s
q u a l i t y hos pice c a r e
Develop a program e v a l u a t i o n
Plan f o r r e - e v a l u a t i o n o f q u a l i t y c a r e i s s u e s
Plan q u a l i t y as su ra nce i n s e r v i c e s
Develop u t i l i z a t i o n review mechanisms
Supplementary
None
Content Mean = 4 . 4 5

.24
.08
.22
.31
.04
.10
.22
.22
.33
.31

Ave.

%

E s s e n t i a l Competencies (Organizing!
Provide competent s t a f f
Provide f o r e v a l u a t i o n o f a l l s e r v i c e s
Provide an ongoing e v a l u a t i o n o f s e r v i c e s
Provide reviews o f a l l hospice s t a n d a r d s
Function as a member o f t h e q u a l i t y as surance
committee
Provide f o r r e - e v a l u a t i o n o f q u a l i t y c a r e i s s u e s
Provide f o r co n c u r re n t medical r e co rd reviews
Provide f o r r e t r o s p e c t i v e medical r e cord reviews
Provide f o r q u a l i t y a s su r an ce s t u d i e s
Supplementary
Provide q u a l i t y assu ran ce i n s e r v i c e s
Provide f o r r e v i e w / e v a l u a t i o n o f a l l c o n t r a c t e d
services
Content Mean = 4 . 3 2

D e l. = .20

.10
.16
.24
.25
.12
.20
.31
.33
.22
.33
.20
Ave.

%

D e l . = 22%

194
E s s e n t i a l Competencies ( D i r e c t i n g )
Communicate q u a l i t y a s su r an ce i s s u e s t o th e
governing board
Communicate th e importance o f q u a l i t y assu ran ce
to s t a f f
Supplementary
Do q u a l i t y as surance s t u d i e s
Do th e program e v a l u a t i o n
Teach q u a l i t y as surance I n s e r v i c e s
Lead t h e q u a l i t y a s su r an ce committee meetings
Content Mean - 4.01
E s s e n t i a l Competencies ( C o n t r o l ! i n a l
Assure competence o f s t a f f
Monitor compliance with s t a t e hospice r e g u l a t i o n s
Assure a p p r o p r i a t e and e f f i c i e n t use o f r e s o u r c e s
Monitor t h e q u a l i t y a s su r an ce pl an
Assure r e - e v a l u a t i o n o f q u a l i t y c a r e i s s u e s
Monitor compliance with f e d e r a l hospice r e g u l a t i o n s
Assure s u f f i c i e n t d a t a c o l l e c t i o n t o support
q u a l i t y a s su r an ce s t u d i e s
Monitor c o n t r a c t e d s e r v i c e s
Su p o Iementarv
Engage in r e s e a r c h r e l a t i v e t o q u a l i t y as suran ce
Content Mean - 4.2 8
S ection Mean = 4 . 2 9

.12
.12
.35
.27
.49
.53
Ave. % D e l . = 31%

.10
.10
.06
.14
.08
.10
.22
.10
.08
Ave. % Del. 10%
Sec. % Del. 20%

APPENDIX C
CORRESPONDENCE

195
ROUND-ONE LETTER
Dear Hospice A d m i n i s t r a t o r ,
For t h e p a s t f o u r y e a r s I have been a d o c t o r a l s tu d e n t in
Family Ecology a t Michigan S t a t e U n i v e r s i t y , and I am now a t th e
d i s s e r t a t i o n s t a g e . As I have t r a v e l e d t o many hospice programs in
Michigan and shared a d m i n i s t r a t i v e program co nce rns, i t seemed
e s s e n t i a l t h a t r e s e a r c h be pursued which would help t o b e t t e r d e f i n e
what s k i l l s and competencies were needed t o e s t a b l i s h hospice
a d m i n i s t r a t i o n as a c r e d i b l e p r o f e s s i o n a l o p ti o n in h e a l t h c a r e .
What you do m a t t e r s , and y e t no one r e a l l y und er stan ds a l l t h a t you
do. T h e re fore , I am asking you t o work t o g e t h e r with me on a study
t h a t w i l l d e f i n e h o s p ic e a d m i n i s t r a t i o n in M ichigan.
My
d issertation is entitled:
"The I d e n t i f i c a t i o n o f Competencies f o r
Hospice A d m in is tr a to rs in Michigan."
With your help t h i s two-round study w i ll bring us t o consensus
on t h e competencies as you i d e n t i f y them f o r ho spice a d m i n i s t r a t o r s
in Michigan.
Round One w ill give you t h e o p p o r tu n i t y t o r a t e
competency s ta te m e n ts as t o how e s s e n t i a l you f e e l th e y a r e .
It
w ill a l s o provide t h e o p p o r tu n i t y t o add competency s ta te m e n t s which
you f e e l t h i s r e s e a r c h e r has i n a d v e r t e n t l y o m itted .
In Round Two you w i l l r e c e iv e t h e r e v i s e d survey t o r a t e t h e
competency s ta t e m e n t s a g a in . The goal i s t o o b t a i n consensus on th e
competencies under f i v e broad a d m i n i s t r a t i v e c a t e g o r i e s .
Every
a d m i n i s t r a t o r ' s response i s c r i t i c a l t o make t h i s a v a l i d study!
Important p o i n t s t o remember a r e :
1. This survey i s n o t sponsored by, o r r e l a t e d t o , th e Michi­
gan Department o f P ublic Health Hospice Coo rdina tor p o s i t i o n .
2. P a r t i c i p a t i o n in t h i s survey i s v o l u n t a r y ; resp ondents
remain anonymous, and t h e r e i s no p e n a lt y f o r n o n p a r t i c i p a t i o n .
3. The d u r a t i o n o f p a r t i c i p a t i o n in t h i s survey extends from
May 1987 (Round One) u n t i l June 1987 (Round Two).
4. A summary o f t h e survey r e s e a r c h w i l l be s e n t t o a l l
resp o n d en ts .
P lease complete th e en clos ed Hospice A d m in is tr a t o r s In ve ntory
(Round One) and r e t u r n i t t o me in t h e enclosed s e l f - a d d r e s s e d ,
stamped envelope by ____________
. DO NOT IDENTIFY YOUR HOSPICE
PROGRAM OR YOUR NAMET Demographic d a t a w i ll only be r e q u e s te d on
t h e f i r s t round.
Thank you very much f o r your supp ort in t h i s im porta nt r e s e a r c h
project.
Most S i n c e r e l y ,

Sharon Olson, R.N., M.S.
2117 Rolling Brook Lane
East Lansing, MI 48823

196

ROUND-TWO LETTER

J u l y 29, 1987
Dear Hospice A d m i n i s t r a t o r ,
Thank you f o r completing t h e Hospice A d m in is tr a to r s Inventory
(Round One). For your i n fo r m a tio n , I have i n d i c a t e d t h e mean score s
o f each item a f t e r t h e "del eg at ed " column on t h e r i g h t . I f th e item
has an a s t e r i s k (*) t o t h e l e f t o f t h e number i t means t h a t as a
group you have reached consensus on t h a t item and you do not need to
s c o re i t a g a i n .
There were 33 items which reached consensus in
Round One.
Your f i n a l c o n t r i b u t i o n on Round Two i s c r i t i c a l t o t h i s
research.
Plea se complete t h e Hospice A d m i n i s tr a to r s Inventory
Round Two and r e t u r n i t t o me in t h e en closed s e l f - a d d r e s s e d ,
stamped envelope by August 10, 1987.
Again, I a p p r e c i a t e yo ur supp ort in t h i s stu dy .
Sincerely,

Sharon Olson, R.N., M.S.
2217 C Stonehedge
East Lansing, MI 48823

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