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DATE DUE DATE DUE DATE DUE am C'JCIRC/DateDue.p65-p.15 LINE AND STAFF RELATIONSHIPS IN THE ADMINISTRATIVE STRUCTURE OF MEDIUM-SIZE HOSPITAL ORGANIZATIONS By Joan Marie Kuter A PROBLEM Submitted to the Dean of the College of Home Economics Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Institution Administration I964 ACKNOWLEDGMENTS The writer wishes to express her gratitude and appreciation to Professor Katherine Hart for her encouragement and guidance during the planning and preparation of this problem. Also, the writer is very grateful for the criticisms and sugges- tions received from Professors Dalton E. McFarland and Grace Miller and from Mrs. Marie Quance. TABLE OF CONTENTS Page INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . l OBJECTIVES OF THE HOSPITAL ORGANIZATION . . . . . . . . . . . . . . 2 LINE AND STAFF RELATIONSHIPS . . . . . . . . . . . . . . . . . . . 4 Duties of Line and Staff Departments . . . . . . . . . . . . . 4 Conflicts Between Line and Staff Personnel in Business Organizations . . . . . . . . . . . 5 Suggestions for Minimizing Line- Staff Conflict . . . . . . 7 LINE AND STAFF RELATIONSHIPS IN THE HOSPITAL ORGANIZATION . . . . . 9 Responsibilities of the Board of Trustees . . . . . . . . . . . l0 Responsibilities of the Hospital Administrator . . . . . . . . ll Role of the Medical Staff . . . . . . . . . . - . . . . . . . . l2 SUMMRY O O O O O O O O O O O O O O O O O O O O O O 0 O O 0 O O O O '4 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . l6 INTRODUCTION Hospital organizations are extremely complex social structures. The skills and efforts of widely divergent groups of professional, semi- professional and nonprofessional personnel are mobilized and integrated to meet the objectives of the hospital organization. In addition to the medical staff, which is highly specialized and departmentalized, there is the nursing staff which includes graduate professional nurses in super- visory and nonsupervisory positions, practical nurses and nurses aides. The administrator's staff includes department heads and personnel in paramedical departments such as dietary, pharmacy, social work, laboratory and medical technology; administrative departments such as medical records, business office, admissions, purchasing; and nonprofessional service departments including engineering and maintenance, laundry and house- keeping. Part of the nonprofessional staff includes clerical and secretarial personnel. At the head of these heterogeneous groups is the hospital board of trustees which has over-all formal responsibility for the hospital organization (lh). OBJECTIVES OF THE HOSPITAL ORGANIZATION The formal organization of the hospital depends upon the purposes of the hospital. The central concern of all hospitals is the life and health of the patient (42). However, a hospital organization may have several secondary objectives. Education of physicians, nurses and other medical and paramedical personnel, such as laboratory and X-ray techni- cians, can be one objective. In addition, public health work in prevention of disease and promotion of good health habits can also be a concern of the hospital. Advancement of research in scientific medicine is often another hospital objective (30). Objectives which hospital organizations have in common with business organizations are the desire for organizational stability and growth, and financial solvency including maintenance and survival. How- ever, all activities of the hospital are first keyed to the requirements of the patient (lh). Unlike the business organization, the hospital is still basically a nonprofit institution. However, today's hospital is a business with fiscal and personnel policies adapted from the rest of the business commu- nity. Whereas capital fund drives were once the main source of funds for hospital expansion, many hospitals now fund their expansion programs on borrowed money. Other practices adopted from business include considering depreciation on buildings and equipment and Interest on borrowed money as elements of cost (l9). The hospital is becoming the health center of the community. Services of the hospital to the community are being expanded and many medium-size hospitals now have outpatient clinics. The emergency department is also receiving increased use by members of the community. Because of the new services being offered as well as the more specialized skills now needed in the hospital, staffing patterns show that 2.5 persons, excluding the medical staff, are now employed by the hospital for every occupied bed. Modern health insurance programs provide for extensive hospital services and enable the patient to expect and demand the very best of care regardless of the seriousness of his illness (I9). In order to carry out their objectives with minimum confusion, hospitals, like other complex social organizations, rely upon formal written policies and procedures and formal authority for controlling the interaction and behavior of hospital personnel. The hospital organiza- tion has to rely on a human system with its consequent limitations for carrying out the many interrelated activities needed in the care of patients. Procedures for dealing with transient patients, each of whom requires individual care, need to be more flexible than operational procedures of a business corporation engaged in more routine activities. Nevertheless, the hospital tries to reduce as many procedures as possible to a set system so that even in an emergency each member of the hospital family will know his area of responsibility and accountability and act accordingly (IA). LINE AND STAFF RELATIONSHIPS Extensive literature on line and staff relationships in the business world has appeared in the past ten years. Articles on the line and staff relationships in hospital organizations are more recent. Most authors hold to the characteristic division between line and staff groups, but a few feel that in practice this distinction no longer exists (l2). Duties of Line and Staff Departments In so far as possible, with changes to meet its special needs, the formal organization of hospitals usually follows the ”line” and ”staff” organization of business corporations. The traditional division between line and staff authority is as follows. Line authority, the central chain of command, has ultimate control in making decisions which affect others and in commanding others to act. The staff has limited authority with no right to command, though a staff executive has line control over personnel in his staff department. Duties of a staff specialist are limited to those auxiliary activities which help line personnel fulfill their responsibilities. These activities may include research, planning, recommending, advising, or assisting. In any case, the line executive does not have to follow the advice of the staff specialist in reaching his decision. The line executive can accept, modify or reject advice offered by the staff specialist except where top line management has decided that specified staff advice or services must be used in a particular area (I, 5, 3i). Staff services came into being because with the increase in size and complexity of modern social organizations, no one person can be well informed in all areas necessary for effective decision making. Line authority needs assistance to plan intelligently for the future and to carry out daily operations successfully. In the decision-making process staff work is the means to an end, not an end in itself. Without good staff work, management would be unable to make effective decisions. Conflicts Between Line and Staff Personnel in Business Organizations From the time staff specialists have been part of business, there have been conflicts between line and staff personnel. Some researchers on line and staff relationships consider these conflicts inevitable while others feel that if conflicts cannot be completely resolved they can at least be minimized (IO, 35, #6). Several reasons why conflicts between line and staff personnel arise in organizations are suggested by Toussaint (#6). Although line and staff departments have different responsibilities, their goals should be congruent with organization objectives. In practice, however, staff personnel are sometimes concerned with their own special area and fail to visualize the organization's objectives as a whole. Line and staff personnel may have different opinions of the nature of each other's work which can easily lead to misunderstanding. Sometimes the loyalties of the two groups differ. Staff specialists, many of them members of pro- fessional groups, often have greater loyalty to their professional colleagues and societies than to the organizations for which they work. Line personnel, on the other hand, tend to be ”company men” and have pre- dominant loyalty to their own individual work groups. In general, staff personnel have intensive formal training while those in operating or line management, especially in the lower echelons, are trained on the job. The line supervisor has a common sense approach to problem solving and sometimes feels that staff personnel are too theoretical to be of help to him. In addition, line supervisors may view the intervention of staff personnel as a limitation of their authority. McFarland (32) pointed out that staff men often have easier access to top management than do line personnel. This gives staff personnel some implied authority in the eyes of line management. Research by Myers and Turnbull (35) and McFarland (32) showed that in practice strict adherence to the division of line and staff authority in decision making does not always exist. In some cases, as with person- nel and industrial relations, the staff department has almost complete autonomy in making and carrying out decisions related to its area of competence. Occasionally this practice occurs because of the necessity for uniform enforcement of personnel policies. It sometimes seems easier for the staff department to execute the policies itself than to train the line department to do so. This tends to be poor practice because it limits the authority of line management and leads to empire building on the part of the staff department. Another practice which leads to conflict between line and staff personnel is the use of staff departments to help police the activities of line personnel. When staff reports serve as a control measure, they lead to antagonism between line and staff departments which is costly to morale and makes effective collaboration almost impossible (33). Suggestions for Minimizing Line-Staff Conflict In spite of the abuses of line authority which can occur by staff groups, staff specialists have a definite role to play in modern complex organizations and will have an increasingly important role in the future. Staff departments receive whatever authority they have from line manage- ment. Top line management should clearly specify the roles staff departments are to play and specify what type of authority and how much they are to have. Top management can also specify the staff department's areas of responsibility and accountability. If staff personnel try to usurp the authority of line management, they should be stopped by their superiors before conflicts can arise. Occasionally, because of their special skills, staff departments are asked to carry out and implement decisions made by line management. If abused, this is an area where staff departments can exert more authority than was originally intended (I). Some suggestions for improving line-staff relationships follow. One prime need is for both the line and staff personnel to understand each other's roles. The staff person must know his own specialty but still be aware of the needs of the organization as a whole. He must have a clear concept of how his work fits into the total operation of the organization. The more areas in which the staff person can assist, the greater value he has for the organization. This does not mean that a staff man should become the “generalist” advocated by Sampson (39), but he should at least be familiar with those phases of the organization which are essential to his effective functioning. Creativity is possible, but the staff person must try to recognize the needs of the individual executive or department with whom he is work- ing. If he does not understand the viewpoint of the line personnel, his advice will not fit the requirements of the situation. If he tries to visualize problems as line personnel see them, the staff man should not have to ”sell” an idea or program to line management. The advice he gives will be well thought out, sound and reliable. The staff person should feel responsible for successful application of his advice if it is accepted by line personnel. The staff specialist should avoid flaunting his knowledge and keep in mind the fact that line management does not have to accept his recommendations. However, if the line personnel feel that the staff person is sincerely trying to help them do a more effective management job, they will be more likely to give greater consideration to his advice. If the staff specialist and a level of line management disagree, they should both have the right of appeal to their common line superiors. If a favorable attitude prevails in addition to top management support, the staff man will be more likely to be of real assistance to line management in reaching and carrying out effective decisions. A successful working relationship between line and staff personnel will be achieved only if both groups make a sincere effort to understand each other's viewpoints (IO. 33. A6) - LINE AND STAFF RELATIONSHIPS IN THE HOSPITAL ORGANIZATION Until about I960, reports on formal research dealing with line and staff relationships as they function within the hospital organiza- tion were extremely limited. Etzioni (ll) suggested that in professional organizations the line and staff relationships are reversed from those in a business organization. Using the hospital organization as an example, he inferred that the doctors and nurses perform the line or goal activ- ities of the hospital and that the administrator and his staff serve in a ”staff” or advisory role. Heyd (23) disagreed with this viewpoint and stated that the medical staff in the hospital works most successfully in the kind of climate provided by an effective line organization, that of the administrator and his staff. The medium-size hospital, lOO to 350 beds, has some of the typical staff departments found in the business organization. These include personnel, public relations, legal, accounting, safety, and security. These departments have their own specific roles to fulfill but operate in an advisory and service capacity. The departments most often report directly to either an assistant administrator or the administrator, and decision making is his responsibility. However, the line organization in hospitals differs markedly from that of the business organization. Where a business organization gen- erally has a single line of authority operating from the chief executive officer down, hospital organizations function with three lines of 9 IO authority. One line of authority emanates from the board of trustees, one from the administrator and the third from the professional medical staff (14, I7). Responsibilities of the Board of Trustees The board of trustees has ultimate authority and over-all responsibility for the hospital organization. Over the years, there has been a changing role for board members in the hospital. Once board members were philanthropists who financially supported the hospitals in the care of the poor, took an active part in the daily affairs of the hospital and often handled routine administrative duties. Today, members of the board of trustees may still be philanthropists, but administrative duties are the responsibility of the hospital administrator and his staff (43). Members of the board of trustees are elected by the board and serve on a voluntary basis. They are not paid employees of the hospital. The board's primary responsibility is to exercise general control over the affairs of the hospital organization. The duties include determining the policies of the institution with relation to community needs and serving as an organ of review and appraisal of these policies. As far as financial responsibilities are concerned, the board must provide adequate financing, see that accurate financial records are kept, and enforce businesslike control of expenditures. The board must see that equipment and facilities consistent with the needs of the hospital organization are provided. As part of its legal responsibility, the board of trustees must be aware of the privileges granted to the II medical staff and be sure that all services, professional and lay- administrative, are provided by well-trained, properly qualified personnel. Long-range planning such as hospital expansion and plant improvements are also a major responsibility of the board. A subcommittee of the board on public relations is responsible for education of the public in matters pertaining to the hospital organization (IA, 30, #3). Responsibilities of the Hospital Administrator The board of trustees grants executive authority to the adminis- trator. As a result, members of the board of trustees relinquish the right to deal directly with any other person or department in the hospital. The line of procedure is through the administrator. The governing board should not involve itself with details and day-to-day operation of the hospital. This would handicap the administrator and undermine his author- ity. The administrator is a skilled, well-trained manager and should be treated as such. His responsibilities should be well defined, and he should be held accountable to the board of trustees for fulfilling them. The administrator's primary responsibility is to coordinate the activities of the entire hospital organization and to promote the welfare of personnel and patients. He is a liaison officer between the governing board and different departments of the hospital. The administrator must make sure that all policies laid down by the board of trustees are followed. He must communicate and interpret these policies to the medical staff and lay personnel and communicate their wishes and ideas to the governing board. The administrator selects all department heads. He delegates responsibility and authority to them and should give them considerable I2 autonomy in operating their own departments. The department heads have the authority to select their own department personnel. However, the administrator holds ultimate responsibility for the actions of all departments and is accountable to the board of trustees for them. The wishes of the medical staff cannot be disregarded by the administrator. His coordinative role among the multiple lines of author- ity is very important. Effective communication with the medical staff is essential to a smoothly functioning hospital organization. Since the administrator has no direct line control over the medical staff, he must achieve his goals by personal transactions, persuasion and negotia- tion. Thus he operates in a ”staff” role in his relations with the medical staff (30). Efficient communication with the nonmedical personnel is also important in the administrator's role of planning and problem solving for the organization. The administrator must be the best informed, full- time executive in the hospital organization in order to be able to propose and execute programs of administrative and organizational improvement (I4, l7). Role of the Medical Staff The medical staff is outside the lay-administrative line of authority of the hospital organization but is almost in complete charge of medical policies and medical practices. According to legal defini- tion, the hospital cannot engage in the practice of medicine; medicine must be practiced by the individual. Doctors are not employees of the hospital but are guests who are granted practice privileges (lh). l3 The governing board can neither originate nor implement medical policy but, in the last analysis, is responsible for it. It must share responsibility for hospital care with the medical staff, its professional advisor, since members of the board of trustees are personally not com- petent to pass judgment on the professional care of the patient. The board of trustees holds legal responsibility for seeing that all members of the medical staff are professionally competent. Since the board of trustees is not qualified to judge the competence of a physician, it must seek advice from the medical staff as to the character and competence of individual physicians whom it considers for appointment to the medical staff (30). The doctor is a professional who is a recognized master of his particular body of knowledge and is committed to using his knowledge and skills in accordance with standards set by his profession (l8). His authority is great when it comes to a patient's medical needs. The doctor's role in this case is neither ”line” nor ”staff” but is termed “functional“ authority. The physician must have freedom to practice but still must be accountable to the governing board for the details of medical work, results and good medical practice (30, #l). The medical staff has its own organization and constitution. It makes its own rules and regulations and is mainly a self-regulating body. The administrative work of the medical staff is largely through committees. Liaison with the board of trustees is usually through the hospital administrator who keeps the med- ical staff informed of the policies of the board of trustees and the board informed of the wishes of the medical staff. The nedical chief of staff is generally invited to meetings of the board of trustees in an advisory capacity (IA, l7). SUMMARY The presence of several lines of authority in the hospital organization creates administrative and operational problems. Formal organizational coordination is made more difficult. With multiple lines of authority, situations arise in which it is not clear where authority and responsibility lie. Such a situation frequently occurs where large num- bers of personnel, particularly members of the nursing staff, must take orders from their supervisors and from doctors. The lay authority and professional authority to which nurses and paramedical personnel are sub- ject are not always compatible. Multiple lines of authority can act as a system of ”checks and balances” which may be good for the organization. Division of authority can also reduce the burden of responsibility in situations whene responsi- bility may be too great for one individual. Therefore, multiple lines of authority require the maintenance of a very delicate balance of power in the hospital organization. That is why lines of authority, responsibility and accountability must be drawn as concisely as possible. To insure a smoothly functioning hospital organization, the administrator, with board approval, determines formal policies and written rules and regulations. Effective communication among all groups is necessary for proper coordina- tion of hospital activities. Georgopoulos and Mann (l4) state that multiple lines of authority in the hospital are virtually inevitable. This is due to the fact that lh l5 much of the work in the hospital is performed by influential professionals and not by low-status workers and because of the high degrees of profes- sionalization and specialization characteristic of the organization. The nature and volume of work are variable and diverse, and the hospital has relatively little control over its work load. Therefore, personnel must be flexible and informal coordination must operate effectively. In an effort to increase their operational efficiency, hospital organizations have adopted some of the policies and practices used in business. The traditional view of ”line” and ”staff” is used and modified in relation to the medical staff. Social science researchers have recently begun to study the patterns of organization, lines of communication and social interaction of hospital groups (IA, 25). Their basic tools are the research methods used in other complex social organi- zations. Hopefully, results of their work will show that these tools are applicable to study of the hospital organization. As a result of their work, we should better understand the complicated functioning of the hospital organization and will be able to improve hospital services. l0. l2. l3. l4. BIBLIOGRAPHY Allen, Louis A. Management and Organization. New York: McGraw-Hill Book Co., Inc., I958. 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COLLECE EASTIUUEWHL.MKJHGAN Problen If. s. 1964 Kuter, Joan Karie Line ard Staff Relationships in the Administrative Structure Cf Medium—Size Hospital Organizations IIIIIIIIIIIIIII'IIIII’III'IIIIIIIIIII 31293 02466 9388