THE ANOMALIES OF HOSPITAL
ORGANIZATION: THE IMPLICATIONS
FOR MANAGEMENT
By
ALAN DONALD BAUERSCHMIDT
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUOIEMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1968
UNIVERSITY OF FLORIDA
3 1262 08552 2091
TABLE OF CONTENTS
Chapter Page
I NTRODUCT I ON 1
ORGANIZATIONAL OBJECTIVES 33
THE LINE ORGANIZATION 58
THE STAFF ORGANIZATION 103
AN ANOMALY: LINE IS STAFF AND STAFF IS LINE 123
AN ANOMALY: TWO CHAINS OF COMMAND \k2
I I I
IV
V
VI
V! 1
AN ANOMALY: HOSTPITALS ARE BECOMING MORE
BUREAUCRATIC IN STRUCTURE 158
VIII. THE PROTOTYPE ORGANIZATION 177
IX. TOWARD EUPSYCH I AN MANAGEMENT 229
APPEND IX 247
BIBLIOGRAPHY 264
B I OGRAPH I CAL SKETCH 276
CHAPTER I
INTRODUCTION
In spite of the variety of concepts which can be labeled as
organization theory each can be observed to have its basis in the
notion that a universality of organization structure exists and can
be described. This notion can be as fundamental, and as ancient, as
the discussions regarding the basic order of the universe and its
smallest parts. Or, it can be as sophisticated, and as current, as
the levels of order expressed in the concepts of general systems
theory. Cosmos is accepted over chaos through rational perception
whether first causes are attributed to a toss of the dice or a divine
wi sdom.
If the formal organization is taken out of the basic order of
the universe and examined in its separate characteristics, as is more
generally attempted by the theorist, the same universal form of
structure is commented upon. However, this common form of structure
is variously described as to its source. Some authorities mark the
pervasiveness of the universal structure as an attribute of its prob-
2
lem-solving and coordinative ability. Other authorities, of which
Herzberg and Etzioni are representative, see the existence of
Kenneth Boulding, "General Systems Theory — The Skeleton of
Science," Management Science, II (April, 1956), 197.
*\
James D. Mooney, in Principles of Organization (Revised Edition;
New York: Harper and Brothers, Publ i shers , 1 9^7) , p. 1, provides that:
universality of organizational structure in the predominance of a
3
particular organization in the social scheme.
Much of the controversy among authorities regarding the univers-
ality of organization structure hinges upon the place accorded to
"principles of organization" in the various concepts of organization
theory. There appears to be two distinct levels of analysis in this
regard: that which directs itself to observations about organization
and are descriptive of universal features; and, that which seeks to
prescribe for organization structure based upon the logic of
"Organization is the form of every human association for the attain-
ment of a common pupose," and that certain features are essential to all
forms of organization. Chester Barnard, in The Functions of the Execu-
ti ve (Cambridge, Mass.: Harvard University Press , 1938) , pp. 9^-95;
allows that both simple and complex forms of organization have their
similarity as impersonal systems of coordinated human effort. Rocco
Carzo, Jr. and John N. Yanouzas employ the systems concepts in Formal
Organization: A Systems Approach (Homewood, 111.: Richard D. Irwin, Inc.,
1967), p. 53^, to derive the concept of organization as a problem-solv-
ing routine based on a simple and natural human response to complex
tasks .
3
Frederick Herzberg maintains that the business organization has
provided its coloration to all other institutions that serve Western
society. See his Work and the Nature of Man (Cleveland, Ohio: The
World Publishing Co., 1 966) , p. 1. Amitai Etzioni, in "Authority
Structure and Organizational Effectiveness," Administrative Sciences
Quarterly, IV (June, 1959), 51, remarks that the concept of universality
can be traced to the fact that organization theory was originally dev-
eloped on the basis of observations and analysis of governmental and
private business bureaucracies. Contrasting the approaches of the social
versus the administrative scientist, Amitai Etzioni, i n Modern Organ iz-
ations (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1964) , p. 21 , pro-
vides that the scope of the former is much broader, and through struc-
tural analysis reveals much of the discrepancy occurring through ad-
herence to the earlier administrative model.
k
universals. However considered, the concept of principles pervades
the literature addressing itself to the study of organizations, with
the general context directed toward those facets of organization which
are universal. Even those investigators who mount the most vigorous
attack upon the pervasiveness of these universalities acknowledge
• 6
their presence in the attempt.
Many of the criticisms taken in regard to universality of organi-
zation structure are not directed toward the underlying principles, but,
rather, are directed at what must be considered as unique applications
of structure and process in specific types of organization. These
k
Representative of the descriptive approach are the comments of
William G. Scott, in Organization Theory: A Behavioral Analysis for
Management (Homewood, 111.: Richard D. I rwi n, Co . , 1 967) > P • 1^+9; and,
E. Wight Bakke, "Concept of the Social Organization," Modern Organization
Theory, ed . , Mason Haire (New York: John Wiley and Sons, Inc., 1959),
pp. 34-35. Amitai Etzioni, in A Comparative Analysis of Complex Organi-
zations (New York: The Free Press , 19&1 ) , p. xi i i , takes the second
approach to task without identifying the culprits. Mooney, p. 1, pro-
vides the classical example of the essentiality of certain organizational
features which justify the claim of principles.
Peter M. Blau and W. Richard Scott, in Formal Organizations (San
Francisco: Chandler Publishing Co., 1962), pp. 8-9, refer to: ". . .the
principles that govern organizational life." John M. Pfiffner and Frank
P. Sherwood, in Administrative Organization (Englewood Cliffs: N.J.:
Prentice-Hall, Inc., I960), p. 30, note that: ". . .the existence of a
common core of practice and pattern in organizations seems to have
achieved reasonably substantial consensus."
Chris Argyris refers to the basic "genes" of organizational
structure in Integrating the Individual and the Organization (New York:
John Wiley and Sons, Inc., 1964), pp. 14-15.
approaches have led to the concept of comparative analysis which will
reveal the fundamental nature of organizations. These approaches to
organization theory will receive major attention in this paper in view
of their central i ty to the question of anomalous structure.
The concept of a universality of organization structure underlies
o
the practice of management. This structure provides the basis for the
application of managerial techniques associated with the coordinative
process of management. Mooney points out, with certain mental agility,
the concept that administration, or management, presupposes organi zat ion--
yet management precedes organization for the coordinative process is
9
subordinate to management. It is on this basis that Mooney's principles
of organization have been misconstrued to imply that there exists one
best prescription for organization, rather than one best description.
Additional insight into the source of the management function in
the universality of organization structure is provided by John F. Mee,
Daniel Katz and Robert L. Kahn, remark in The Social Psychology of
Organizations (New York: John Wiley and Sons, 1 nc. , 1 966) , p. 110, that:
"Though there are undoubtedly unique aspects in any social situation,
there are also common patterns, and the deeper we go, the greater the
genotypic similarities become." Etzioni, Comparative Analysis, p. xi i i ,
provides the proposition that comparative analysis will reveal the uni-
versal propositions of organization theory if such exist.
william G. Scott, "Organization Theory: An Overview and an Appraisal,"
Journal of the Academy of Management, IV (April, 196l), 8.
q
Mooney, pp. J>-k.
James G. March and Herbert A.Simon, Organizations (New York: John
Wiley and Sons, Inc., 1958), p. 30.
who remarks on the historic appearance of management thought indepen^
dently 'n various countries of Western society which are presumed to
share in the characteristic structure. March and Simon note that the
task F. W. Taylor set himself in investigating the effective use of
human beings in industrial organizat ions--the management process — quickly
developed into the general task of organization theory: the analysis of
the interaction between humans and the social and task environments,
created by organizations. Katz and Kahn comment that much of existing
organization theorizing has been directed toward the development of
managerial philosophy and techniques to the detriment of acceptance of
the nuances of description and recognition of the openness of the organi-
13
zational system. In each of these instances it is apparent that a
vital link exists between the practice of management and the structure
of organizations.
If a universality of organizational structure exists and management
is the process of coordination within an organization then a process of
management can also be described which is universal to all organizations.
Terry has noted the consequence of such observations as follows:
Since the management process is universal, what is meaningful
about one manager's work applies likewise to that of all mana-
gers. The management process represents the common fabric of
John F. Mee, Management Thought in a Dynamic Economy (New York:
New York University Press , 1963) , p. xix.
12
March and Simon, p. 12.
3Katz and Kahn, pp. 26-27.
similarity among managers and serves to expedite the study of
management. It is universally found wherever men work together
to achieve common objectives. . . . There is ample evidence to
show that these managerial functions can be applied effectively
by the same managers to different enterprises.'^
While Koontz and O'Donnell remark:
Managers perform the same functions regardless of their place
in the organization structure or the type of enterprise in which
they are engaged. . .it means that anything significant that is
said about the functions of one manager applies to all managers
. . .it is now possible to develop a theory of management appli-
cable to all executives in all occupations. 5
It is, however, important to recognize that these authorities do not
imply that the methods of management will be alike in all organizations.
The identical nature of the process of management is limited to those
aspects of organizational structure which are universal and in accord
with the "principles" of organization. The process of management must
then be such functions as are organic to all organizational processes
and their related structures. And, with these processes of management
are associated various managerial techniques which provide the mechanism
16
for carrying out these organic functions.
If hospital organizations depart from the universal structure of
organization to any significant degree then the application of standard
14
George R. Terry, Principles of Management (5th ed. rev.; Homewood ,
111.: Richard D. Irwin, Inc., 1 968) .
Harold Koontz and Cyril O'Donnell, Principles of Management (3rd
Edition; New York: McGraw-Hill Book Co., 1964) , p. kS.
Ibid.
management techniques within the hospital structure would be inappropri-
ate. If these management techniques developed within the fields of
business and public administration are inappropriate, then a new source
of management technology for hospital institutions must be developed.
It therefore rests with a discussion of the universality of organizational
structure to determine whether the process of management and its associated
technology are justifiably transferable among organizations.
Two authorities who are perhaps representative of the critics
applying themselves to the concept of lack of universality among organi-
zational structures at this general level of consideration are Amitai
Etzioni and the co-authors Daniel Katz and Robert L. Kahn. Katz and
Kahn maintain that a single broad dichotomy can be made between organi-
zational structures of an economic and non-economic variety based upon
whether the transformation process accomplished by the organization is
1 8
related to the processing of objects or the molding of people. To
these authors the difference is so basic in its structural aspects that
transference of managerial techniques between the two must be actively
res i sted--wi th particular mention made to the transference of technique
19
between the industrial and hospital organizations. Etzioni, from
another point of view, provides for three basic structures of organization
which have "natural" barriers to the transference of both managers and
Etzioni, Comparative Analysis. Katz and Kahn.
1 8
Katz and Kahn, pp. 115-116.
19.bid.
their techniques. These separate organizational forms are identified
by the norm of compliance exacted in the managerial process and are
20
categorized as coercive, remunerative, and normative. Under this
analysis hospitals are classified as normative compliance organizations
while business organizations are characterized as exacting remunerative
21
compliance. Even those theoretical studies which do not provide for
rigid structural separation and encompass a more universal concept in-
clude sufficient doubt to suggest that transference of managerial tech-
22
niques may be precluded.
At a more pragmatic level it could be maintained that the appear-
ance of a separate field of management study such as hospital admini-
stration would indicate that an anomalous structure of organization
exists in hospitals. This phenomenon should suggest that the techniques
associated with the management process as universally defined have failed
23
in adaptation to some undefined hospital administrative process. If
the underlying structural anomalies can be identified as existing, in
20
Etzioni, Comparative Analysis, p. T]h .
21 Ibid. , p. hi.
22
Samuel W. Bloom maintains, in The Doctor and His Patient (New
York: The Free Press, 1963), p. 1 60 , that the analogy between hospitals,
in their present bureaucratic form, and the remainder of our social insti-
tutions, can be carried just so far before the path of hospital analysis
takes its own turn.
23
Paul J. Gordon, in "The Top Management Triangle in Voluntary Hospi-
tals (l)," Academy of Management Journal, IV (December, 1961), 205.
remarks on the complaints of hospital administrators that management
principles do not apply in their specialized field.
fact, then perhaps those managerial techniques which are unrelated to
such anomalies may yet be salvaged for transfer to the hospital organi-
24
zation. The significance of such an attempt lies well beyond the
limited area of hospital administration. Litchfield has commented that
in spite of abundant evidence supporting the conviction that there is
much in common in administration we appear to witness the lack of generic
administrative process through the appearance of a series of isolated
25
types of administration.
Quite specifically, it would appear to be necessary to determine
whether a complete dichotomy of structural forms exists, or whether the
departure of the hospital structure from the universal structure is
along a discernible continuum which allows for appropriate modification
of managerial methods. Broad dichotomies of structure, because of their
link to the management process, create extensive gaps between what might
appear superficially to be related disciplines of training and research.
Dichotomies of training and research inhibit the transfer of techniques
between the unrelated management processes even if "cut-and-try" methods
might prove successful. Separate disciplines of training and research
24
This possibility goes beyond the recommendation of Wallace S. Sayre,
in "Principles of Administration--!," Hosp i tal s, XXX (January 16, 1956),
34, to cut and try the principles for fit in the hospital situation.
25
Edward H. Litchfield, in "Notes on a General Theory of Admini-
stration," Administrative Sciences Quarterly, I (June, 1956), 7-8, re-
marks specifically on the appearance of such fields of study as hospital
administration, public administration, military administration, hotel
administration, and school administration.
10
create unique forms of terminology, and the foundations which prepare
students for participation in special programs of study tend to be
dichotomized in turn. If the process of management is unique to a busi-
ness form of organization then it would be senseless to require a prospec-
tive graduate student in hospital or educational admi ni stration to master
the essentials of an undergraduate program in business administration or
management. And, if the structural mechanisms of the separate forms are
such as to divide the management process into different forms the develop-
ment of techniques associated with the management of business organi-
zations should not be offered as a remedy for the many problems which
face our hospital institutions today. In turn, the business management
student should not expect to learn much of value through an understand-
ing of the management process in hospital organizations.
It would appear that the separate possibilities of dichotomy versus
continuum form two separate camps that defy simple resolution. If
organization theory is to be meaningful it must attempt to explain how
organizations seek to meet their goals by integrating personal skills
9 C
and productive resources. Organization theory must contain more than
27
the necessary abstraction of • a general model claimed by Etzioni. This
content must be such that it cuts across the ordinary distinctions between
■ i • -i- • ,• 28
the social science disciplines.
9 A
John G. Hutchinson, Organizations: Theory and Classical Concepts
(New York: Holt, Rinehart and Winston, 1 967) , p. 156.
27
Amitai Etzioni, Modern Organizations, p. 18.
9 Q
Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organizations — I," Administrative Sciences Quarterly, I (Sept-
ember, 1956), 64.
11
As Parsons has stated:
There is a tendency in our society to consider different types
of organizations as belonging to the fields allocated to dif-
ferent academic disciplines. . . . The tendency to divide the
field obscures both the importance of the common elements and „q
the systematic basis of the variations from one type to another.
Wilson observes that: "Hospitals are among the most complex organi-
zations in modern society, characterized by extremely fine division of
labor and an exquisite repertory of technical skills." Recognizing
this observation the search should be continued along the lines suggested
by Starkweather for the basis of an organization theory which encompasses
31
the special features of hospitals.
Perhaps the most basic division which is noted between hospital
organizations and the normative organizations within which managerial
techniques are highly developed is the non-profit nature of the former.
This basis for dichotomizing organization structures is often alluded to
in the more popularized writings and is offered in explanation of some
particular failing of one form of organization or another. Even in the
more sophi s i ti cated literature there is some structuring of organizational
types which introduce the suggestion of an economic motive providing the
29
Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Orqanizat ions--l 1 ," Administrative Sciences Quarterly, I (De-
cember, 1956), 238.
Robert N. Wilson, "The Social Structure of a Genera] Hospital,"
Annals of the American Academy of Political and Social Sciences, No. 3^6
(March, 1963) , p. 67.
3 1
David B. Starkweather, "The Classicists Revisited," Hospital Ad-
mi ni strat ion, XII (Summer, 1 967) , 69.
12
32
basis for the managerial process. This issue will not be pursued at
this point for it will be demonstrated that the question of the profit
nature of a particular organization is subsumed under the topic of
organizational objectives which is treated more fully in the following
chapter. For immediate purposes it would be sufficient to note that the
basic objective premise upon which managerial theory rests is the pro-
vision of service to that society of which the organization is a part.
In this respect the hospital and the business organization are basically
in accord.
It will be suggested that a significant departure between the fields
of business and public administration and that of hospital administration
exists in the degree to which the participants in the two similar struc-
33
tures identify with professional versus organizational norms and values.
It will therefore be argued that hospital organizations differ from the
universal organization structure to the relative degree in which each
34
employs professionals in various organizational roles. It will further
32
As mentioned before, Etzioni, in Comparative Analysis, p. xvi ,
identifies the bases of compliance in the control sources identified as
coercion, economic assets, and normative values, resulting in the sepa-
rate organizational forms of coercive, utilitarian, and normative com-
pliance. Parsons, in "Suggestions--! I ," pp. 228-230; provides four
organizational classifications of which two economic and integrative
organizations reflect a separating out of the hospital organization from
the structure provided for economic organizations.
33
Basil S. Georgopou los , in "The Hospital System and Nursing: Some
Basic Problems and Issues," Nursing Forum, V, No. 3 (1966), p. 14, re-
marks on this phenomenon in the hospital system.
34
Blau and Scott, pp. 206-214, note the remarkable separation be-
tween "bureaucratic" and "professional" organizations within a similar
13
be maintained that in this respect hospital organizations can be con-
sidered as a prototype lying at the extreme of a continuum along which
35
other organizations are proceeding.
The position will be taken that the professional participation in
hospital organizations includes the large number of members who are
emerging as professionals. Georgopoulos and Mann, indicate that those
on the road to profess ional ization include the nurses, the administrator,
the medical librarians, the medical technologists, the dietitians, and
others in paramedical positions. Etzioni would allow that these cate-
gories should only be classified as semi-professionals because they _do
appear as salaried members of organizations and accede to the authority
37
structure of the organization.
For purposes of discussion the criterion established by Vollmer and
Mills can be considered to apply; that is: "We suggest, therefore, that
the concept of 'profession' be applied only to an abstract model of
occupational organization and that the concept of 'professional ization '
context but directed toward the dissipation of the managerial functions
among various organizational members.
35
Paul J. Gordon, in "The Top Management Triangle in Voluntary Hospi-
tals (ll)," Academy of Management Journal, V (April, 1962), 66; and,
Gordon, "Top Management Triangle ( I ) ,"; p . 209, cites the hospital organi-
zation as a prototype but on a basis concerned with the multiple form of
contractual relationships existing between the patient, physician, and
hospi tal .
Basil S. Georgopoulos and Floyd C. Mann, "The Hospital as an
Organization," Hospital Administration, VII (Fall, 1962), 58.
37
Etzioni, Modern Organizations, pp. 77-78.
14
be used to refer to the dynamic process whereby many occupations can be
observed to change certain crucial characteristics in the direction of
a 'profession,' even though some of these may not move very far in this
TO
direction." The abstract model of a "profession" noted by Vollmer and
Mills is provided by Cogan, as follows:
A profession is a vocation whose practice is founded upon an
understanding of the theoretical structure of some department
of learning or science, and upon the abilities accompanying
such understanding. This understanding and these abilities are
applied to the vital practical affairs of man. The practices
of the profession are modified by knowledge of a generalized
nature and by the accumulated wisdom and experience of mankind,
which serve to correct the errors of specialism. The profession
serving the vital needs of man, considers its first ethical
imperative to be altruistic service to the client. *°
Other authorities included by Vollmer and Mills in their work provide
similar definitions to the above, but two should be mentioned who include
additional insight into the concept of profession. A. M. Carr-Saunders
states:
A profession may perhaps be defined as an occupation based upon
specialized intellectual study and training, the purpose of which
is to supply skilled service or advice to others for a definite
fee or salary. I say fee or salary. It is sometimes held that
the typical professions, or even that the only true professions,
are those in which the practitioners are free lance workers and
therefore remunerated by fee. . .remuneration is only of the
Howard M. Vollmer and Donald L. Mills (eds.), Profess ional izat ion
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966), pp. vii-viii.
39
Morris L. Cogan, "Toward a Definition of Profession," Harvard Edu-
cational Review, XXIII (Winter, 1953), ^9; cited by Vollmer and Mills,
p. vi i .
15
essence of the matter insofar as it may be direct and definite.
Greenwood considers the attributes of a profession to include: (1) syste-
matic theory, (2) authority, (3) community sanctions, (4) ethical codes,
and (5) a culture.
One of the largest occupational categories employed in the typical
general hospital is that of the professional, or registered, nurse.
Along with her "practical" counterpart, nurses make up the single largest
42
occupational component of the hospital structure. This is by no means
the extent of professional participation in general hospitals but the
.nurse is most typical in regard to the source of her professional identi-
. 43
f i cat ion .
40
A. M. Carr- Saunders, "Professions: Their Organization and Place
in Society," Profess ional ization, eds. Howard M. Vollmer and Donald L.
Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1 966) , p. 4.
41
Ernest Greenwood, "Attributes of a Profession," Profess ional iz-
at ion, eds. Howard M. Vollmer and Donald L. Mills (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1966), p. 10.
42
American Nurses' Association, Facts about Nursing (New York: Ameri-
can Nurses' Association, 1 967) , p. 19; and, American Hospital Association,
"Hospital Statistics," Hospitals: Guide Issue, ILI, 2 (August, 1, 1967),542.
43
American Nurses' Association, p. 19, includes 23.6 per cent of the
staff of American hospitals in the arbitrary category of professionals when
compared to the overall staffing count compiled by the American Hospital
Association, and reported in "Hospital Statistics," p. 452. Seventeen per
cent of the total staff of American hospitals are registered nurses, as
indicated by the same data; the American Nurses' Association does not con-
sider the practical nurse in the professional category, but they make up
approximately 7 per cent of the total hospital staff. The remainder of
the professional category included by the American Nurses' Association are
such occupations as medical technologist, dietitian, social worker, and
radiologic technologist. This method of classification is comparable to
that mentioned by Georgopoulos and Mann, p. 58.
16
Wessen notes that:
The ideology of the nurses. . .is an outgrowth of the history
of their profession. The very basis for the professional ization
of nursing was rooted in the necessity for improving the quality
of personnel who served hospital patients. In order to improve
personnel, it was necessary to implant in them ideals of service
of a very exalted sort; the profession of nursing thus became, in
the eyes of women like Florence Nightingale, a sacred calling.
While these factors may have played a large part in the degree of
professional ization which has taken place among the various categories of
occupations contained in the hospital structure, undoubtedly the close
proximity of that epitome of professional ization, the physician, can
also be counted among first causes. In most respects it can be recog-
nized that the abstract model of the professional is most closely re-
sembled by the concept of the physician in our society. The model of the
physician is close at hand in the hospital setting and the values and
attitudes of that profession are readily transferable to other partici-
pants in the health care system.
Other emergi ng professions may not have as ready a model at hand to
guide their striving for recognition as professionals; however, it cannot
be denied that a tendency toward such i ndent i f i cat ion is sought by many
diverse occupational groupings. ' There are many theories advanced as to
the reasons for this phenomenon beyond the simple motive of prestige.
kk
Albert F. Wessen, "Hospital Ideology and Communication between Ward
Personnel," Patients, Physicians and Illness, ed . E. Gartly Jaco (New
York: The Free Press, 1958), p. 463.
^Vollmer and Mi 1 Is, p. 2.
17
Blumer includes the striving for prestige as but one explanation among
many:
Professional ization represents an indigenous effort to introduce
order into areas of vocational life wnich are prey to the free-
playing and disorganizing tendencies of a vast, mobile, and dif-
ferentiated society undergoing continuous change. Profess ional -
ization seeks to clothe a given area with standards of excellence,
to establish rules of conduct, to develop a sense of responsibil-
ity, to set criteria for recruitment and training, to ensure a
measure of protection for members, to establish collective control
over the area, and to elevate it to a position of dignity and
social standing in the society. . . . The pursuit of such complex
goals is one of the most notable trends in the shaping of modern
life; the movement toward profess i ona 1 i zat ion is expanding in
scope and becoming more sophisticated in character .^6
Goode comments that the degree of industrialization of a society is a
hi
determining factor in the rate at which professionalism is advanced.
Industrial societies are increasingly dependent upon professional skills,
and the United States is probably typical in that there has been little
change in the ratio of traditional professions to total population, but
a many fold increase in total numbers of professionals to population has
occurred over a brief period of time. These newer professions as well
as those of a more traditional standing are increasingly finding their
46
Herbert Blumer, "Preface," Professional ization, eds. Howard M
Vollmer and Donald L. Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc.,
1966) , p. xi .
William J. Goode, "Community Within a Community: The Professions,"
American Sociological Review, XXII (April, 1957), 195.
Ibid.
18
49
place within the formal organization.
In respect to the degree of professional participation in the
formal structure of an organization the hospital may be considered a
model toward which other organizations are proceeding. The hospital
could be thoughtof as having provided a proving ground upon which
management solution to the problem attendent upon profess ional i zat ion
has been tested. Problems which hospitals are attempting to master
today may be the problems of general business management tomorrow.
If hospitals are representative of the universal structure of organi-
zations, departing along a continuum from the modal organization in
that degree to which it is marked by accommodation to the larger number
of participating professionals, and if business and other institutions
are progressing on a trend toward greater professional participation,
then the hospital may provide the solution to incipient managerial
problems or at least suggest the range of problems which will someday
have to be faced.
Many superficial aspects of the range of problems associated with
professional participation have already been commented upon in other
50
reports .
49 ,
Warren G. Bennis, in Changing Organizations (New York: McGraw-
Hill Book Co., 1966), p. 25, notes: "Professional specialists, holding
advanced degrees in such abstruse sciences as cryogenics or computer
logic as well as the more mundane business disciplines, are entering all
types of organizations at a higher rate than any other sector of the
labor market."
W. Richard Scott, "Professionals in Bureaucracies — Areas of Con-
flict," Professional ization, eds. Howard M. Vollmer and Donald L. Mills
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1 966) .
19
Scott comments that: "It appears that the higher the general prestige
of the professional group and the more central their skills to the
functioning of the organization, the more likely they are to be suc-
cessful in their attempt to control the conditions under which they
work, with the result that there is less actual conflict between
professionals and representatives of the bureaucracy." Kast and
Rosenzweig addressing themselves specifically to the situation in hospi-
tal organizations remark that a continual power conflict exists between
the various professionals and the administration, and that this conflict
52
resists analysis by the traditional models of organization. And,
William G. Scott comments that the impact of professional izat ion may be
so profound that the way of performing work in bureaucracies may become
53
obsolete, and new forms of organization must be revealed. Elsewhere
he notes, on this same basis, that the goal of organizational theory
must be the development of organizational forms which allow for the
opportunity of self-realization of the individual within the organi-
54
zation. This latter proposition, and its link with professional i-
zation in the prototype organization, will be of major concern in this
paper .
51 Ibid. , p. 275.
52
Fremont E. Kast and James E. Rosenzqeig, "Hospital Administration
and Systems Concepts," Hospital Administration, XI (Fall, 1966), 25.
William G. Scott, Organization Theory: A Behavioral Analysis, p. 260.
5Sbid., p. 258.
20
As has already been noted Katz and Kahn provide a sharp dichotomy
between those organizations whose through-put is the transformation of
objects versus those which are concerned with the molding of people —
essentially the separation of business from non-business forms of organi-
zation with hospitals and educational institutions included as typical
of the latter, and with due exception provided for those business organi-
zations labeled as "tertiary economic structures" which provide service
functions. ' While notable differences in the structure of organizations
and the process of management may be related to the materials which pro-
vide the basis for the productive process conducted in the organization
a more suitable differentiation is provided by the technological methods
employed in the processing function. In other words it is product which
dictates the technology of production and its associated managerial
process and organizational structure rather than the nature of the
material being transformed. The basis of this contention rests in the
observation that the objective of the organization, as it is linked to
the larger society, provides the basis for structure, process, and
technology.
New evidence indicates that the departure from the structure of the
universal organization is functionally related to the technology of
product i on .
55Katz and Kahn, p. 1 15.
This point will be more fully developed in Chapter II.
Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1965), p. 50.
21
That is: ". . .forms with similar production systems appeared to have
rg
similar organizational structures." The extremes of technology identi-
fied by Joan Woodward are production of units to customers' requirements
and continuous flow production of liquids, gases, and crystalline sub-
stances with mass production of individual items assuming a middle ground
59
position. " Intermediate between the mass production techniques and each
60
of the extremes lie batch methods of production. Woodward's study of
100 industrial firms in South Essex allowed a separation into those which
conformed to "mechanistic" and "organic" forms of organizational struc-
'61
ture. '"Mechanistic1 systems are characterized by rigid breakdown into
functional special i sm, preci se definition of duties, responsibility and
power, and a well developed command hierarchy through which information
62
filters up and decisions and instructions flow down." "'Organic'
systems are more adaptable; jobs lose much of their formal definition,
and communications up and down the hierarchy are more in the nature of
consultation than of the passing up of information and the receiving of
6^
orders." Woodward's conclusions provided that:
. . .there was a tendency for organic management systems to
predominate at the extremes of the technical scale, while
mechanistic systems predominated in the middle ranges. Clear
cut definition of duties and responsibilities was characteris-
tic of firms in the middle ranges, while flexible organization
58lbid. 59lbid., pp. 38-39. °l bid.
6 1
Woodward, p. 23, citing Tom Burns, Management in the Electronic
Industry—a Study of Eight English Companies. Social Science Research
Centre, University of Edinburgh; and Honor Croome, The Human Problem of
Innovation (H.M.S.O., I960) .
62lbid. 63l bid.
22
with a high degree of delegation both of authority and of
responsibility for decision-making, and with permissive and
participating management, was characteristic of firms at the
extremes. There was less "organizational consciousness" at
the extremes; it was the firms in the middle ranges which
found it easier to produce organization charts.
Much of the criticism over the employment of management techniques
associated with the management process derived from the structure of
the universal organization is based upon the concept that the manage-
65
ment process is exclusively associated with mass production technology. "
The defense of the integrity of a separate administrative process such
as hospital administration is often offered in terms of the inapplica-
bility of these productive techniques to the hospital situation.
Georgopoulos and Mann, in commenting upon the differences between hospi-
tals and business, include the following comment in regard to 'he former:
The nature and volume of work are variable and diverse, and
subject to relatively little standardization. The hospital
cannot lend itself to mass production techniques, to assembly
line operations, or to automated functioning. °
And elsewhere Georgopoulos comments:
. . .the main objective of the hospital is to render person-
alized care and treatment to individual patients, according
64
Woodward, p. 64.
£ r
Etzioni, in Comparative Analysis, p. 214, comments that utili-
tarian that is, economic organizations are as a rule highly routinized
He describes as typical of business organizations the mechanistic
structure and process described by Woodward.
66
Georgopoulos and Mann, p. 63.
23
to their particular problems and needs, rather than mass
production or the manufacture of some uniform product.
Consequently, much of the work in the system cannot be
standardized or mechanized . °7
However, as the work of Woodward indicates, the mass production model
of the business organization is a limited case.
This phenomenon of diverse forms of accommodation to technology is
well recognized in the management literature at the same time as the
universality of structure and management process is being supported.
Ernest Dale, the foremost empiricist in management thought, has
commented upon the diversity of technology employed in various enter-
prises and how the technology employed limits the structure of organi-
zation which can be utilized. But in spite of this diversity of
structure and associated technology, Dale maintains that common organi-
69
zational characteristics can be distinguished. Therefore, it can be
accepted that the management process and its collateral techniques are
associated with a wide range of organizational forms.
More important for present purposes is the observed similarity be-
tween the unit production methods of industry described by Woodward and
the patient care process performed in general hospitals. The product or
service produced in the unit production firm is tailored to the customer's
67
Georgopoulos, p. 12.
Ernest Dale, Management Theory and Practice (New York: McGraw-
Hill Book Co., 1965), p. 197.
69 Ibid.
Ik
specification. As Scott has noted, the foreman in charge must be highly
qualified and capable of handling the variety of technical problems
which often occur with the production of a customer's order under job
order conditions. The nurse in charge of the comparable task in the
general hospital faces a similar situation and must be as highly techni-
cally qualified. Each patient, in addition to being a unique personality,
is manifesting a disease condition unique to his individual characteris-
tics, and, in addition, has specified for him a course of treatment
peculiar to the individual evaluation of his physician. While the prod-
uct in each case is dissimilar from any other case and the specified
productive techniques are totally unrelated, the process itself, from a
structural and managerial point of view, is quite similar. In each case
it would be expected that an organic form of organization and mangement
would be present, and, in fact, such is found to be true.
In many respects the unit production industries reported by Woodward
are quite unsophisticated as compared to the typical general hospital
although they both adhere to the organic form of structure. For example,
Scott, reporting on the unit production method firms, noted that, because
of the small size of the job order shop, the technical staff usually is
not large; the staff has not usurped the foreman's prerogatives; and the
functions of planning organizing, and controlling still devolve on the
foreman to a great extent. As will be demonstrated, the hospital is
William G. Scott, Organization Theory: A Behavioral Approach, p. 3^5.
7,.bid.
25
quite different in these specific respects. It would therefore appear
that the technological process itself is determining of the organic
nature of the appropriate organizational structure.
1 t wi 1 1 be hypothesized that the hospital organization provides
a prototype for large and complex organizations devoted to the tasks of
unit production. It will be further hypothesized that the hospital
organization is descriptive of the organic forms of management associ-
ated with such organizations, and that, as Woodward describes it, a
technological continuum exists along which the fundamentals of the
management process and its associated techniques are transferable. It
will also be suggested that the prevalent trend is toward a reduction
of emphasis upon the production of products in the manner conducive to
assembly line techniques and a growing emphasis upon unit and process
72
methods of production. In that both of these latter technologies of
production employ organic methods of management and organization the
hospital will provide a model of successful accommodation as well as of
problems yet to be resolved.
73
Bell has described a discretionary model of organization. His
position is that three independent variables are associated with the
72_
I he arguments advanced by Marshall McLuhan, in Understand i nq
Media: The Extensions of Man (New York: The New American Library, 196*0,
pp. 281-282, are perhaps representative of the cultural implications
involved in the reduced employment of mass production techniques and an
increased emphasis upon unit production methods.
'Gerald D. Bell, Organizations and Human Behavior (Englewood Cliffs.
N.J.: Prentice-Hall, Inc., I967).
26
degree in which an employee of the organization can render judgment
and exercise discretion in the performance of his assigned tasks.
Bell's dependent variable is therefore the degree of discretion pro-
vided the employee. If extended to the organization as a whole one
can see the similarity with the organic structure described by Wood-
ward. Bell provides that the three independent variables which de-
termine discretion are the predictability of work, management control,
and profess ional izat ion . The individual will have relatively more
discretion in the accomplishment of his tasks if: the work assigned
is relatively i 1 1 -structured in respect to its patterned flow and the
method to be applied; management chooses to exercise loose control
over the employee, and; he is a professional by training. Bell further
believes that the independent variable, management control, can be con-
sidered related, or mutually determined, by the variables: predicta-
78
bility and professional ization. Blau and Scott also shed insight on
the relative laxness of management controls when the two factors of un-
predictability and profess ional i zat ion are operative by referring to the
schema of Parsons which allows for clean-cut breaks between the techni-
79
cal and management levels of the hierarchy in such situation.
7 Ibid. , p. 99.
Woodward, p. 23. Note that Bell's work and authorities are en-
tirely independent of the research conducted by Woodward in England.
76Bell, pp. 99-100.
77 1 bid. 78,,..
' Ibid. , p. 99.
79
'^Blau and Scott, p. 39.
27
Predictability, as expressed by Bell, is comparable to the in-
dustrial examples presented by Woodward as the unit production tech-
nology. The essence of unit production is uniqueness--that which could
not be predicted from past experience — the one-of-a-kind task demand,
totally unrelated to the work performed in the past, or that which will
be performed in the future. Bell is obviously describing a broader
phenomenon than the limited industrial example of Woodward.
It is, therefore, these two variables which are selected as rep-
resentative of the influences which suggest the hospital as a prototype
of organizational structure. I t wi 1 1 be maintained that the hospital
demonstrates a ready example of the influence of these two variables
when they are expressed in their most exaggerated form. Hospitals can
be considered as epitomizing the influence of professional ization of
the work force upon the organization structure. Hospitals represent the
furthest extent toward which unit methods of technological production
have been carried. If each of these factors can be considered as repre-
sentative of a trend within our society then one could expect that the
hospital would provide a model of the universal organization in transition.
It must be acknowledged that these two variables of interest are
not independent of one another except as a conceptual method of pro-
viding explanation of the phenomenon evidenced by the organic structure
of organization. Bell admits a relationship between the skills required
to master the unpredictable work assignment and the techniques associated
80
with the professional employee. Woodward remarks on a resemblance
On.
Ibid., pp. 99-100.
28
between the unit and process production firms in addition to their
organic structure, that being the degree in which each employs a large
ber of skilled workers in contrast to' the batch and mass production
num
81
firms. Vollmer and Mills also note the link between technological
advance toward sophi si t i cated techniques and rapid increase in profes-
8?
sional izat ion. It could also be argued that the link between the two
is not in the single direction of first, unit production technology and
then professional izat ion. Increased degrees of professional ization may
supply the value system which demands the treatment of the productive
act as a unique experience only amenable to unit production methods.
However one would approach this linkage between professional i -
zation and the individualized product within the organic organization
is not of the essence of the argument being presented. They can be
treated in their separate entities as suggested earlier or as a blend
of manifest phenomena in the manner related above. It is even possible
to relate additional factors such as increasing levels of education to
reinforce the dynamic process of cultural change which is shifting the
universal organization along the continuum toward an organic structure.
Of more practical importance is the availability of a prototype which
will assist in the understanding of the organizational processes in-
volved in the shift from mechanistic to organic structures.
Woodward, p. 61 .
82
Vol lmer and Mills, p. 22.
29
Other writers have suggested within a similar context the prototype
possibilities inherent in the hospital organizational structure. Bennis
allows that hospitals along with universities and research and develop-
ment organizations appear to mark the trend along which other organi-
zations are traveling, and he advises investigation of the problems and
attributes of these organizations for their prototype possibilities.
Perrow alludes to a natural history of organizational change and sug-
gests that profit-making organizations could look to hospitals and
other voluntary service organizations for possibilities in the areas of
84
tasks, authority, and goals. Freidson suggests that the study of
industrial sociology might benefit from study of the hospital organi-
Or
zation in regard to service industry relations with consumers. And,
Hughes provides that:
. . .the organizations in which professions work show patterns
of authority and interaction which, according to earlier theories
of organization, could not possibly work. They are, in general,
organizations with more staff than line; their special import-
ance for the study of social organizations is that they give us
new models to work on just when business organizations, which stu-
dents have been inclined to take as the prototype of rational
organization, are themselves becoming so cluttered by staff ad-
visors (of various old and new professions) that the line is
scarcely distinguishable, and this is very frustrating. The
Warren G. Bennis, "Organizational Developments and the Fate of
Bureaucracy," Industrial Management Review (Spring, 1 966) , p. 51.
84
Charles Perrow, "The Analysis of Goals in Complex Organizations,"
Readings in Organization Theory: A Behavioral Approach, eds. Walter A. Hill
and Douglas M. Egan (Boston: Allyn and Bacon, Inc., 1 966) , p. 143.
Or
Eliot Freidson, "Review Essay: Health Factories, The New Industrial
Sociology," Social Problems, XIV (Spring, 19&7), 493.
i?
30
newer generation of businessmen, instead of proposing that
universities, hospital, and government agencies (in which
the efforts of professional people are somewhat coordinated)
be run in a business-like fashion, may turn to these mad-
houses for ideas on how to organize their own enterprises;
for the staff people, insofar as they are really professional,
have another loyalty than that to their employers; they be-
long to professions which have some sense of solidarity and
autonomy .0°
If the hospital is accepted as a prototype and it can be demon-
strated that it lies on a continuum along which the universal organi-
zation can be described then the means of transference of management
principles from the modal organization to the prototype can be facili-
87
,tated. More important, it will be possible to consider the accepta-
bility of these principles in the prototype organization on the basis
of their relationship to the structure of organization. If a continuity
of structure does exist it may well be that new lessons learned in the
prototype can be transferred to the modal organization to ease the pains
of passage.
Or-
Everett C. Hughes, "The Professions in Society," Canadian Journal
of Economics and Political Science, XXVI (February, I960), 58-59.
87
For a discussion of the concept of principles of management and
their association with "principles of organization," see Terry, pp. 16-
17; or, Hutchinson's summary of the management principles, p. 103. The
link between the principles of management and the universal organization
is outlined by Ralph Currier Davis, in The Fundamentals of Top Manage-
ment (New York: Harper and Row, Publ ishers, 1951 ) , p. ~. For the con-
cept of application of these principles within the nursing function of
hospitals see: Thora Kron, Nursing Team Leadership (Philadelphia: W.B.
Saunders Co., 1961), p. v. Woodward, pp. 245-246, comments upon the
impact of her research on the accepted principles of management and the
reaction of the management community in this regard.
31
New interest is being generated in regard to the solution of social
problems using the techniques of business management. Zalaznick reports
in a recent article the trend in university schools of business to
broaden their scope to encompass diverse administrative problem areas,
including the health care field, in recognition of the broad trans-
QQ
ferability of managerial techniques. Much of the success of this
attempt, as noble as its aim, will be dependent upon a proper appreci-
ation of the organizational structure involved. As Cyert and March have
stated:
When we leave the area of the firm, we are likely to hear with
impressive frequency that the structure, position, task, or his-
tory of a certain organization is unique. What we tend to forget
is that the uniqueness in this sense is not an attribute of the
organization alone; it is an attribute of the organization and
our theory of organization. An organization is unique when we
have failed to develop a theory that will make it nonunique.
This uniqueness is less a bar to future theoretical success than
a confession of past theoretical failure.°9
This study will attempt to relate the methods of dynamic organi-
zational analysis which underlie the management process to the hospital
structure. The two factors of relative professional izat ion and sophisti-
cated unit production technology will be considered as the elements of
concern in the dynamic process. The Appendix to this report will relate
the substance of the dynamic analysis and its place within the variety of
Sheldon Zalaznick, "The M.B.A.: the Man, the Myth, and the Method,"
Fortune, LXXVI 1 (May, 1 968) , 168-171, 200,202, and 206.
On
Richard M. Cyert and James G. March, A Behavioral Theory of the
Firm (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1963), p. 287.
32
topics labeled as organization theory. The structure of hospital
organization will be briefly sketched in a form amenable to the dynamic
analysis — that is, the question of objectives will be investigated and
the structural elements of line and staff presented. With these estab-
lished it will be possible to investigate the anomalies of hospital
organization which have been reported by the authorities and which support
the allegation of a dichotomy of structure. The prototype organization
will then be described in terms of those characteristics which are
unique to this form of organization and as they relate to the dynamic
process itself. In conclusion the report will attempt to describe the
management process as it must cope with the most salient of the proto-
type characteristics from the coordinative point of view.
CHAPTER I I
ORGANIZATIONAL OBJECTIVES
The concept of formal organization implies a grouping of human
participants for the purpose of achieving specific objectives. Mooney
expresses this concept as follows: "Organization is the form of every
human association for the attainment of a common purpose." Although
many aspects of formal organization can be debated these two elements
of a multiple of participants and specific objectives are accepted by
all reporters as the fundamental characteristics of this form of social
unit. This expression of formal organization is a narrower construction
2
than the concept of social organization. Blau and Scott denote the
broader idea by the elements of human participation and a shared value
3
system. This shared value system may be construed as providing ob-
jectives to the social grouping; however, these values are accepted as
James D. Mooney, The Principles of Organization (Revised Edition;
New York: Harper and Brothers, Publishers, 1 9^+7 ) , P . 1 .
2_
l he following writers are representative of this view of formal
organizations. Rocco Carzo, Jr. and John N. Yanouzas, in Formal Organi-
zations: A Systems Approach (Homewood, 111.: Richard D. Irwin, Inc.,
19o7), p. 11, provide that: "Formal organizations are different from
other social institutions in that they are designed to accomplish an ex-
plicit purpose." Talcott Parsons, in "Suggestions for a Sociological
Approach to the Theory of Organizations--!," Administrative Sciences
Quarter ly , I (September 1 956) , 64, notes that: ". . .primacy of orienta-
tion to the attainment of a specified goal is used as the defining charac-
teristic of an organization which distinguishes it from other types of
social systems."
■3
Peter M. Blau and W. Richard Scott, Formal Organization (San Fran-
cisco: Chandler Publishing Co), pp. 1-5.
33
3k
4
residing in the culture of which the individual group member is a part.
Formal organizations, on the other hand, are characterized by objectives
which are formally selected for achievement. This purpose implied in
formal organizations when taken as its unique characteristic can be
demonstrated to provide the essential elements of organizational design
and, therefore, it is the source of the concept of universality of
structure.
The use of the word objective for this essential purpose in formal
organizations can be debated from a semantic point of view. In the
literature of management the word is found interchanged with the word
goal with no apparent resulting confusion; standard dictionaries imply
that the words, objective and goal, can be used synonomous ly . Specific
authorities usually define the words separately when they are to be
used for purposes of exposition. Hutchinson, for example, provides that
goals are guides for organizations while objectives are to the Individ-
ual what goals are to the organization. However, it would appear that
the consensus in regard to usage contained in the literature concerning
organizations relates the word objective to the common purpose implied
in these structures. For purposes of this report the word objective
will be used in a similar manner to denote the broad, overall purpose
inherent in formal organizations. Where the usage of the terms cited
from other sources in this regard conflicts with this intention the
k c
Ibid, pp. 4-5. J_bLd. , p. 5.
John G. Hutchinson, Organizations: Theory and Classical Concepts
(New York: Holt, Rinehart and Winston, 1 967) , p. 39.
35
meaning may be implied from the context in which it appears or the term
will be suitably clarified.
This definition of formal organization does not imply that the ob-
jective of the organization is determined by the human participants in
the organization itself, or by some selected segment of the participants.
The objective of the organization is resident in the values and needs of
the society which it serves — the management of the organization, at best,
performs an interpretive function which recognizes the apparent, or in-
cipient, desires of the society and develops the structure to service
these values and needs. It is this vital link between the organization
and society which is overlooked in many of the descriptive studies of
organizational structure, although in the practical affairs of man an
error arising in the interpretive function should quickly be corrected
by the nature of this link and the system by which it is supported.
Talcott Parsons speaks of this link between the organization and
society as resident in the power which is a generalized societal resource
allocated to the various organizations to act as an agent for the society
in the attainment of its various objectives. Davis clarifies the link
between society and the business organization by visualizing this power
in the expression of the right to private property and its interpretation
o
under law. In return for the authority granted by this institutional!-
Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organization--! I ," Administrative Sciences Quarterly, I (December.
1956), 226.
Q
Ralph Currier Davis, The Fundamentals of Top Management (New York:
Harper and Row, Publ ishers, 1951) , p. 91 .
36
zation of society's power the business organization is expected to pro-
9
vide the values which society desires. Dale simplifies this link in
the case of business enterprises by noting that these organizations
define their objective by determining what their customers are really
paying them for rather than narrowly identifying their objective with
a specific, and perhaps transient, product. John Mee makes this same
concept dynamic by noting the various environmental forces which cause
a constant process of objective interpretation by an organization if it
is to remain viable within the society which is the source of its authori
ty. While these latter authorities relate this concept of the source
of business objectives in the values desired by society, the power link
between all organizations and the society remain the same. In fact,
it can be maintained that the link of the voluntary hospital organiz-
ation to the society is typically through the mechanism of the right to
private property as described by Davis, rather than through the more
subtle mechanism of the right of association which determines the ob-
jectives of various political and purely social organizations.
This approach to the determination of the source of organizational
objectives has been criticised as being too idealistic and at variance
9
^1 bid.
Ernest Dale, 0 rqanization (New York: American Management Associ-
ation, 1967), p. 5^.
John F. Mee, Management Thought in a Dynamic Economy (New York:
New York University Press, 1 963 ) , p . 9^.
37
with the true nature of the organizational process. Etzioni remarks
that: "In practice, goals are often set in a complicated power play
involving various individuals and groups within and without the organi-
zation, and by reference to values which govern behavior in general and
the speci fi c behavior of the relevant individuals and groups in a particu-
12
lar society." This difference in regard to the methods whereby power
is employed in the establishment of objectives is explained by Parsons
to be the result of the level of analysis which is employed by the re-
13
searcher. He suggests that the determination of objectives through
individual power acts, as a theoretical design, has resulted from the
role and group analyses which have been performed on a mi cro-organi -
14
zational level, holding all other influences constant. More realistic,
he suggests, is an ackowledgment of the disciplinary powers of the
15
larger, encompassing society.
Closely linked to the argument advanced by the proponents of the
role and group behavior approach to the determination of objectives is
the apparent diversity of objectives contained within any single organi-
zation. Etzioni considers this to be a phenomenon resulting from the
perversion of the original objective of the organization derived from
1 6
society's desires. He maintains that once organizations are formed
1 2
Amitai Etzioni, Modern Organizations (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1964), pp. 7-8.
1 ?
""Parsons, "Suggestions. . .1," p. 67.
I4lbid. 15lbid.
16- . . c
Etz 1 on 1 , p . 5.
33
they acquire their own needs and these often become the masters of the
organization. Kast and Rosenzweig believe that traditional manage-
ment theory was amiss in assuming a clear-cut objective which provided
1 8
little insight into the multiple objectives of complex organizations.
These authors believe that systems theory will overcome this supposed
deficiency of traditional theory; this belief is supported in a similar
19
manner by Katz and Kahn. The latter authors maintain that in spite of
this oversight on the part of traditional theorists the stated objective
as expressed in policy may be a starting point in organizational analysis.
These criticisms in regard to the multiple objectives found in organi-
zations, negating the concept of a single objective inherent in the
traditional theory, would be valid, for such are observed to exist, if
traditional theory held such a point of view. However, such is not the
case, as will be elaborated later.
What is maintained, in the mainstream of management thought, is
the concept of the primacy of a single organizational object i ve--that
objective which is derived from the values and needs of the society in
its environmental context. This point is emphasized by Fox in his
1 8
Fremont E. Kast and James E. Rosenzweig, "Hospital Administration
and Systems Concepts," Hospital Administration, XI (Fall, 1966), 27.
19
Daniel Katz and Robert L. Kahn, The Social Psychology of Organi-
zations (New York: John Wiley and Sons, Inc., I966) , pp . 15-16.
20,.,
Ibid.
20
39
reiteration of the primacy of this objective in regard to business
enterpr i ses :
The right to engage in private business stems from the right of
private property, and this right may be modified, extended, or
withdrawn as society desires. A firm must be concerned with
formal goals — service to society—if it wishes to survive and
prosper. . . . For the success and sustained existence of such
a firm in our society depends on its ability, relative to the
ability of other producers, to meet the need of customers
efficiently .21
This service to society — the salable values that the business plans to
create and di str ibute— are defined as the primary service objectives of
22
the organization.
This concept of the discipline of the market place is well accepted
in economic theory as applied to the business organization. The apparent
pleasure or displeasure of the society is often witnessed through the
accountant's measure of profits gained or lost; however, first causes in
these cases must be attributed to the link between the organization and
the society as manifest in the primary service objective of the organi-
zation. Profits of a particular organization must ultimately be related
to the finesse with which the management of the organization has performed
its interpretive function.
The concept of profits as an organizational objective has often been
used as a mark of separation between various organizations. Tnis has been
2 1
Wi 1 1 iam McNai r Fox, The Management Process (Homewood, 111.: Richard
D. 1 rwin, Inc., 1963), p. 68.
22 Ibid., p. 69.
40
expressed as the basic dichotomy between the hospital and business
structures of organization by many commentators. Bloom considers the
profit motive as the fundamental difference in objectives between the
two forms of organization with the hospital substituting an orientation
toward service to the community in place of the 'baser' motivation of
23
the business organization. Georgopoulos and Mann extend this concept
even further by maintaining that the economic value of the hospital
organization's objectives are secondary to their social and humanitarian
2k
values. Undoubtedly this refers to some idea that the primary service
objective of the business organization is the product itself rather than
the utility which it provides to society. Yet this is at variance with
the observations of management theorists who reiterate an emphasis upon
the values provided to society in acknowledgment of the practical com-
ments of analysts who emphasize the necessity of business organizations
to define their objectives in terms of ultimate utilities rather than
narrowly upon specific products which may soon be outdated. The non-
profit categorization of voluntary hospital neither removes the conflict
among the internal membership of the organization in regard to the share
of each in the sustaining values provided by the enterprise, nor does it
eliminate the perverted emphasis upon the product itself rather than the
utility provided which may be as prevalent in non-profit organizations as
Samuel W. Bloom, The Doctor and His Patient (New York: The Free
Press, 1963), p. 167.
2k
Basil S. Georgopoulos and Floyd C. Mann, "The Hospital as an Organi-
zation," Hospital Administration, VII (Fall, 1962), 62.
41
those which contain membership sustained by profit.
Even those authorities who recognize the role of profits as a
measure of effectiveness unique to business organization fail to recog-
nize that other measures of performance are equally as valid in the
determination of the relative success with which the organization has
served its primary service objective. The use of a measure other than
profit does not remove the organization from the realm of economic per-
formance. Rosenberger, however, appears to express the concept that
25
the profit motive is determinant in the selection of management.
Nevertheless, it appears fallacious to argue that the selection of
organization leaders would be based on anything less than the ultimate
success of the organization in meeting its service objectives. Etzioni
appears to be the originator of this particular argument. Although
elsewhere he modifies this viewpoint to the extent that while both forms
of organization are responsive to measures of effectiveness the business
organization is able to facilitate this measurement through the availa-
27
bility of the profit gauge. This concession to a similarity among all
organizations is further extended by his recognition that the profit
measure of private business must be qualified by the vagaries of cyclical
. . 28
economi c act i vi ty .
25
Donald M. Rosenberger, "A New Look at Hospital Organizations,"
Hospitals, XXXVI (February 1, 1962), 44. .
o £
Amitai Etzioni, "Authority Structure and Organizational Effective-
ness ," AdmJj]jj_t£ajJ_y-e_^ IV (June, 1959), 49.
27
Etzioni, Modern Organizations, p. 9.
28....
Ibid.
42
It is rare in management literature to find a statement which
reflects profit as the objective of a business organization. This
notion appears more frequently in the writings of those outside of
the disciplines of management and economics where an attempt is being
made to differentiate the various forms of organization. Actually,
the terms profit organization and non-profit organization are legal
terms rather than some analytical device involved in the determination
of the organizational and managerial process.
One sociologist who has taken cognizance of the relationship of
29
the economic and social systems is Talcott Parsons. ' Based on his
studies of the institutional structure of society he asserts that profit
cannot be the primary organizational goal because profit-making is not
by itself a function performed on behalf of the society as a system.
Mee makes the same point by asking two questions:
What is the primary purpose of business enterprise — to serve
customers and provide employment or to utilize and increase
the capital of owners? Is profit the end product, or is it a
feedback means to provide more and better products and human
satisfactions for more people?3'
Urwick's position taken at an earlier time is just as adamant in regard
to the misconception in regard to profit and the objectives of the
29
See particularly Talcott Parsons and Neil J. Smelser, Economy and
Society (New York: The Free Press, 1956), for a structure of society
which incorporates the economic system.
Parsons, "Suggestions. . .1," p. 68.
31Mee, p. 74.
43
32
business organization. He maintains that profit is a stimulus to
individuals to participate in business activity, but, more important,
it is also a measuring rod, a test of the success with which the real
33
objectives of the business are being attained. Davis provides that
the objective of a business is service, while profit is a personal
3 if
objective of a businessman. A business will fail, Davis maintains,
when any important group within it, whether capital, management, or
labor, succeeds in subordinating the organization's primary service
35
objective to its personal interests. And, Terry incorporates the
economic argument of profits being a residual resulting from the pro-
duction and distribution of a product or service directed toward satis-
faction of the organization's primary objective of service to the
• * 36
society.
It could be maintained that many of the above writers cited have
a vested interest in emphasizing a primary objective of service to
society because they are of the management school of thought and would
be expected to support the transferability of the management process
across organizational lines. Nevertheless, it is found that this same
L. Urwick, The Elements of Administration (New York: Harper and
Row, Publishers, 1 9^3) , p. 11.
33i^id.
3^
Davis, p. 104.
J
36.
35 1 b I d . , p. 105
George R. Terry, Principles of Management (5th ed . rev.; Homewood .
111.: Richard D. Irwin, Inc., 1 S68) , pp. 37-38.
kk
conclusion is being derived in other approaches to organization theory
since the pioneering efforts of Parsons. The open-systems theory ex-
pounded by Katz and Kahn notes the appearance of intrinsic and extrinsic
37
functions performed by all organizations. The intrinsic function is
the transformation process which results in a product or service for
society, while the extrinsic functions are the relationship of the
organization in terms of inputs and outputs with its surrounding environ-
ment. Profit would be considered as an extrinsic link between the busi-
ness organization and the providers of capital inputs as it is subsidiary
39
to the primary transformation process. As they summarize this concept
in terms of the efficiency at which the organization performs the trans-
formation process and maintains its relationship with the surrounding
environment it matters not whether the organization is specified as
non-prof i t . For:
The concept of efficiency does not have meaning only for business
organizations, and the survival benefits of efficiency are not
limited to profit-making organizations. These notions are in-
herent in the characteristics of human organizations as open
systems. They remind us that the ultimate decision to give or
withold the needed organizational inputs lies in the environment,
and that the larger social environment in this way holds the
power of life and death over every organization.^'
The primary service objective of the hospital organization will only
37
Katz and Kahn, p. 62.
381 bid. 39lbid. 40|bid,
41
Ibid., p. ]6l.
45
briefly be mentioned at this point for the concept best receives
definition in its interplay with structural design. In fact, by
reference to the various authorities it is obvious that little dis-
agreement exists in regard to the primary service objective because
it is stated in the most general nature as it regards the service
provided to society. Georgopoulos maintains that little ambiguity
exists in regard to the primary organizational objective of hi gh-
gual ? ty care and service to the patient and the subordination of vari-
42
ous functions such as teaching and research to this objective.
Elsewhere he modifies this slightly by providing that the primary
objective of a hospital is to provide adequate care and treatment to
its patients, recognizing that such care must be within the limits of
43
medical knowledge and reasonable allocation of resources. Although
Wessen establishes a hierarchy of objectives for the hospital organi-
zation he awards the primary position to the giving of care to patients
As will be seen the other objectives on his hierarchy can be included in
the category of secondary and collateral service objectives. MacEachern
also identifies the primary function of the hospital as being the care
45
of the sick and injured. I t wi 1 1 be seen, however, that although
__ . . —
Basil S. Georgopoulos, "The Hospital System and Nursing: Some Basic
Problems and Issues," Nursing Forum, V (1966), 8-11.
43
Georgopoulos and Mann, p. 50.
44
Albert F. Wessen, "Hospital Ideology and Communications between
Ward Personnel," Patients, Physicians and Illness, ed . E. Gartly Jaco
(New York: The Free Press, 1958), pp. 458-459.
45 r
Malcolm T. MacEachern, Hospi ta 1 Organization and Management (Berwyn,
111.: Physicians' Record Company, 1962), p. 29.
kk
46
general agreement exists in regard to this statement of the primary
service objective of the hospital organization there can be considerable
disagreement in regard to the scope of this definition of objective
when it is employed in the analysis of the structure of the hospital
organization. This point will be further developed in the following
chapter.
Additional insight is provided by this definition of primary service
objective of the hospital organization as it is amplified by various
other authors. Wessen remarks that the "heart" of any hospital is the
patient ward, for it is here that the basic work, or primary service
46
objective, of the organization is carried out. A similar comment is
made by MacEachern in his definition of the functions of the nursing
service of the general hospital. In each case the locus of the
primary service objective of the hospital organization is found in the
nursing service and the ancillary patient care functions. As Katz and
Kahn would remark, it is here that the intrinsic functions of transfor-
mation are performed which result in the satisfaction of the primary
objective of the organization.
It is maintained that the service provided by the hospital organi-
zation as detailed by these expressions of a primary service objective
are identical in form with that provided by other organizations. The
hospital organization's link with the larger society follows a pattern
Wessen, p. 448.
47
'MacEachern, p. 512,
47
described for other organizations which provide a tangible service to
society. It is, therefore, not in the primary objective of the hospital
organization that a separation between the hospital and the universal
structure of organization will be discovered.
The importance of this point must be emphasized for it is with the
statement of organizational objective that the analysis of organizational
structure begins and it provides the thread of analysis throughout. The
basis of this argument is, as Dale states, "Organization cannot be di-
48
vorced from the idea of purpose." He includes this point as the first
49
of the classical principles of organization. Carzo and Yanouzas also
identify the classical concepts implied in this notion that the process
of organization begins with objectives. Before one can organize
intelligently, Terry maintains, one must know the aims of an organization.
nd this objective statement helps determine the type and number of
activities to be carried out, their relative importance, the type of
people to include, and the social groups which will probably be formed.
Woodward states that the first step in building an organizational struc-
52
ture is to determine what purpose the organization has to serve.
48
Dale, p. 9.
49
3 1 bid., p. 27.
Carzo and Yanouzas, p. 28.
51Terry, p. 286.
52
Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1965), pp. 123-124.
a
k8
Davis concurs that, "The characteristics and requirements of functions
and functional relationships are determined basically by the require-
53
ments for the satisfactory accomplishment of objectives."
Davis describes the process whereby the structure of organization
is developed from the organizational objective in his Principle of
5^
Functional Emergence. He outlines the process of division of the
objective of the organization into logical elements which are grouped
on the basis of their functional similarity to provide for the most
55
effective and economical attainment of this objective. In sum, the
values demanded by the customers of the organization are the determi-
nant of the structure which will be developed.
Simon's treatise on the decision-theory of organization described
a similar process of specialization which follows functional lines de-
rived from the object of the organization. An important consideration
in his argument is that this process implies the division and speciali-
zation of the overall organizational objective into sub-objectives
rO
which creates a hierarchy of objectives to match that of functions.
Simon demonstrates a comprehensive theory of decision-making based upon
this fundamental process of organizing derived from functional differenti-
ation.
53
Davi s , p. 18.
5Sbid., p. 328. 55lbid. 56lbid., p. 330.
57
Herbert A. Simon, Administrative Behavior (2nd ed.; New York: The
Free Press, 1957) , p. 190.
Ibid.
49
While each of these authorities who describe a process of functional
differentiation flowing from the service objectives of the organization
is identified with management theory, the same process is suggested by
work on organization theory in other disciplines. One example is offered
in Seeman and Evans report on an elaborate study to develop criteria of
59
performance in the hospital setting. Their study defined functional
elements within the structure of the hospital which were related to
specific sub-objectives of the overall organizational objectives and
60
established that these were identifiable as basic organizational uni ts .
In management theory perhaps the best summary of the process in-
volved in organizing the activities of enterprise based upon organization
objectives is provided by Koontz and O'Donnell. They describe the
fundamental logic of organizing by the following seven sequential steps:
1. establishment of enterprise objectives;
2. formulation of derivative objectives, policies, and plans;
3. determination of activities necessary to execute these
pol i cies and plans ;
4. enumeration and classification of these activities;
5. grouping of these activities in the light of human and
material resources available and the best way of using
them;
59
Melvin Seeman and John W. Evans, "The Objective Criteria of Perform-
ance," Medical Care: Readings in the Sociology of Medical Institutions,
eds. W. Richard Scott and Edmund H. Volkart (New York: John Wiley and Sons,
Inc., 1966), pp. 488-501.
An
Ibid. , pp. 489-491 .
Harold Koontz and Cyril O'Donnell, Principles of Management (3rd
Edition: New York: McGraw-Hill Book Co., 1 9^4) , pp. 212-213.
50
6. assignment to each grouping, normally through its head, of
of the authority necessary to perform the activities; and
7. tying these groupings together horizontally and vertically,
through authority relationships and information systems. °2
A recognition of the existence of a primary service objective in all
organizations obviously does not answer the question as to the source of
the variety of activities which are observed in every organization.
These activities can ultimately be traced to the primary purpose of the
organization, but their relationship to this objective is often tenuous
and remote. It would neither be correct to ignore the multiplicity of
unique goals which have been noted by observers, nor would it serve the
purpose of the organizational analysis which is being attempted. It may
already have been noted that the authorities cited have frequently
plural ized the concept of objective, and this should now be explained.
Davis broadly separates the objectives of organizational activity
into primary and secondary values to be supplied by organizational
Co
elements. " The primary values are those which have been defined as the
primary service objectives of the organization as discussed above.
Secondary values are those purposes which must be accomplished to dis-
64
charge satisfactorily the primary service objective. The secondary
values which the organization is designed to supply may be broadly sepa-
rated into the categories of purpose labeled by Davis as Collateral and
62... .
Ibid.
3Davis, pp. 100-101 .
64,..,
Ibid.
51
Secondary Service Objectives. As Fox has indicated:
Carefully formulated primary service objectives present a
detailed enumeration of the salable values that a firm plans
to create and distribute. They provide a frame of reference
within which col lateral and secondary objectives must be
developed and within which organization structure should be
des i gned . °°
This broadening of the objective base upon which the organization is
constructed should not de-emphasize the concentration upon the purpose
of the organization in relationship to the society it serves. Although
the criticism is believed to be unjustified, Scott has noted the possible
.overemphasis in traditional theory upon a singleness of purpose within
67
organizations. He believes that this emphasis has tended to obscure
68
the inner workings and internal purposes of the organization itself.
I t wi 1 1 be maintained that the primacy of the objective of service is
well taken as it bears upon the problems associated with organizational
analysis; however, due recognition of the collateral and secondary service
objectives must be included if this analysis is to be complete. Davis
provides that the collateral service objectives are those values which the
organization is expected to supply to groups that are a part of the organi-
69
zation. While Davis extends this concept broadly to groups which are
5 1 bid. , pp. 102-106.
66,.
Fox, pp. 69-70.
67
William G. Scott, Organization Theory: A Behavioral Analysis for
Management (Homewood, ill.: Ri chard D . I rwi n, Co. , 1 967) , p. 1 07.
ibid.
69
^Davis, p. 102.
52
associated with the organization and encompasses various social responsi-
bilities of the enterprise, the essential internal participants are the
owners and the workers. These collateral objectives are therefore the
values and needs which the individual participants require to be satis-
fied in order to elicit their continued contribution toward the satis-
faction of the primary service objective.
The secondary service objectives, as defined by Davis, include those
values that are needed by the organization to enable it to accomplish
its primary and collateral objectives with the required economy and
effectiveness. While this objective is subordinate to both the primary
and collateral objectives it is the vital link between the two. This is
apparent with the realization that in order to perform with satisfaction
the requirements of both the primary and collateral objectives there must
be a balance between the two, and this balance can only be obtained by
satisfaction of the secondary service objective of performance with re-
quired economy and effectiveness. The roots of this concept are contained
in the fundamental assumption of neo-classical economics which was eluci-
dated by Alfred Marshall as the 'great' Principle of Substitution. This
principle assumed that the manager would always arrange his resources in
the most efficient and effective manner technologically possible, for to
do otherwise would reduce his competitive position. This optimal balance
70
Ibid. , p. 105.
Alfred Marshall, Principles of Economics (8th ed.; London: Mac-
mil Ian and Company, Ltd., 1920), p. 550.
53
of resources is rather more elaborate in economic terminology, but it
implies the searching behavior of the manager who strives to discover
the one best way to accomplish the primary objective of the organization
and satisfy the demands placed upon the organization by its internal
membership. While this principle can be assumed in economic theory it
receives explicit recognition in management theory as the stated secondary
service objective of the organization.
This same combinatorial arrangement of objectives in organizations
is commented upon by other authorities who do not necessarily choose to
use the same terminology employed above. Simon discusses the equilibrium
of the organization in terms of the separate demands placed upon it by
72
the owners, the customers, and the workers. Each of these parties to
the activities of the organization has his individual needs which must be
met if the organization is to survive, and the composite objective which
can be obtained from this complex of needs is expressed as an organi-
zational objective which is separate and distinct from those of the indi-
73
vidual parties which remain as supplementary objectives. He relates
each of these objectives to inducements provided to the various partici-
pants and notes the variety of organizational forms which can be derived
by slight modifications of these relationships of objectives. Bennis
performs a similar analysis of the organizational process through a
72Simon, pp. 16-18. 7Sbid. , pp. 110-112.
73lbid.
5k
relationship of objectives which he equates to a system of reciprocity
among the members of the organization and a system of adaptability to
the internal and external environment. The former, of course, is
equivalent to the collateral service objectives while the latter is a
complex included under the separate classifications of primary and
secondary objectives.
It is in the collateral service objectives of the organization that
the part played by profits in the business organization are clarified;
however, it must be noted that profits are but one among many collateral
objectives which must be satisfied if the organization is to succeed.
Fox expresses this by noting: "Primary service objectives are objectives
of the organizat ion ; collateral objectives are those of the people associ-
ated with the firm, without whom primary objectives could never be
attained. Davis believes that collateral objectives are expected to be
satisfied in some reasonable degree without any material or unnecessary
sacrifice of the primary service objective. These include good wages
for employees, good salaries for executive employees, good dividends for
78
investors, and other values, both tangible and intangible. The in-
tangible aspects involved in collateral service objectives will be
Warren G. Bennis, Changing Organizations (New York: McGraw-Hill
Book Co. , 1966) , p. 7.
76Fox, p. 70.
77Davis, p. 10.
78lbid.
55
elaborated upon to some extent later in this study; however, it is
sufficient to note that this concept encompasses the broad range of
needs and values which participants in the organization will have appar-
ent and which can be satisfied in the process of participation. Berelson
and Steiner outline the ramifications of these intangibles in their ex-
79
pression of the objectives of the organization.
It is the relationship of this complex of primary, collateral, and
secondary service goals which explain the behavior of organizations.
The processes involved in the satisfaction of these objectives is the
subject of extensive literature which is not relevant to the present
study. However, there are certain aspects of this determining process
which are interesting from the point of view of hospital organization
and its comparison with the model of organization described in the
management literature. Cyert and March provide that the goals of organi-
zation (which can be read as a sub-set of the complex of objectives) are
a series of more or less independent constraints imposed on the organi-
zation through a process of bargaining among potential coalition members
because the organization is a coalition of participants with disparate
demands , changi ng foci of attention, and limiting ability to attend to all
organizational demands simultaneously. They also maintain that this
coalition, or bargaining process is not unique to the business organization
79
Bernard Berelson and Gary A. Steiner, Human Behavior: Shorter Edition
(New York: Harcourt, Brace, and World, Inc., 1967) , pp. 5^-55.
PO
Richard M. Cyert and James G. March, A Behavioral Theory of the Firm
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1963), p. ^3 .
56
but it is manifest in all organizations although the effect is not as
apparent in those enterprises which do not have the profit device of
81
measurement. Simon, however, maintains that the non-profit organi-
zation may not have as complicated a bargaining process, and conflict
will be much reduced allowing a more firm emphasis upon the primary
■_- 82
and secondary service objectives.
It is apparent that the range of objectives described in the
management literature can also be described as operative in the hospital
situation. While the hospital is generally a non-profit institution the
needs of its individual participants are diverse and often in conflict
with the primary and secondary service objectives. Rather than finding
itself in conflict with the dividend claims of shareholders which is
manifest in business organizations, the hospital must cope with the
needs expressed by its unique form of ownership, the community as a
whole. These needs may often be in addition to the values which the
society has in regard to health care and which are expressed in the
primary service objective of care of the sick, and injured. Many of the
subsidiary activities of the. hospital organization may be directed toward
the satisfaction of collateral needs expressed by this community owner-
ship. The justification for such activities as the provision of park-
ing lots for visitors, cafeterias and gift shops which cater to persons
Ibid., p. 285.
S imon, p. 121.
57
other than staff and patients, many of the public relations activities
of the administrator, and the support of volunteer associations, can
only be accepted under the concept of collateral values supplied to
ownership. These needs of ownership are expressed, and the refusal of
satisfaction on the part of management could have the same result as a
refusal of dividends to shareholders of a business organization. Un-
doubtedly the hospital administrator would welcome the clear-cut demands
of the profit seeker in preference to the diverse demands which owner-
ship places upon the limited resources of the hospital organization, and
which is often difficult to legitimize to other internal participants.
In the following two chapters the concepts of objectives developed
in this chapter will be employed to explain the structure of organi-
zation which exists in general hospitals. As has been noted the struc-
ture of organization can be explained by relating organizational ele-
ments to the objectives which they serve. I t wi 1 1 be found that as
described in management literature the hospital conforms to the princi-
ple that the line of the organization has responsibility for the primary
service objectives while the broad concept of staff elements serve the
collateral and secondary service objectives inherent in all organized
• • 83
forms of act i vi ty .
83Davis, p. 100-101
CHAPTER I I I
THE LINE ORGANIZATION
The line of an organization refers to the chain of authority and
responsibility which exists in an organization and provides for a
specialization of the tasks associated with the creation and distri-
bution of the primary service values which the organization has chosen
to identify as its primary service objective. Each element in this
"primary chai n-of-command" is unalterably identified with the process
involved in the creation and distribution of this primary service value,
The removal of any element of this structure of tasks would result
directly in the failure, to satisfy the primary service objective.
The line of an organization is created by a process of devolution
of authority and responsibility for specific aspects of the work associ-
ated with the satisfaction of the primary service objective. This pro-
cess results in a hierarchy of organizational elements extending from
the head of the organization to the operative performers responsible
for the tasks which create the value that is the objective of the
organization. These elements are often identified as to their level in
this hierarchy of authority and responsibility by such designation as
units, departments, and divisions which imply that a lesser unit is
2
subordinate to the superior department, and so on. In the line of
Ralph Currier Davis, The Fundamentals of Top Management (New York:
Harper and Row, Publishers, 1950, pp. 333-338.
2lbid., pp. 338-3^0.
58
59
the hospital organization the comparable elements may be designated as
teams, units, wards, and departments with much the same implication as
to a differentiation of the tasks to be accomplished and a necessary
subordination of one level to another.
The elements of the line hierarchy are considered organic to the
purpose of the organization. That is, these functional elements must
be contained in the body of the organization in some form. The defi-
nition of the organic nature of a function is an attribute of its re-
lationship to the primary service objective of the organization. In the
business manufacturing organization these organic functions are considered
3
to be production and distribution. In the case of the hospital organi-
zation with the primary service objective of care and treatment of the
sick and injured the organic functions would be such care and treatment.
Those facilities directly involved in care and treatment, such as the
nursing service and the ancillary services, would be a portion of the
chai n-of -command. The complete removal of any one of these functions
from the hospital organization would mean the failure of satisfaction of
this objective although thefunction may be undifferentiated and con-
tained within another unit at some particular point in time.
Wi 1 1 i am McNai r Fox, The Management Process (Homewood, 111.: Richard
D. I rwin, Inc. , 1963) , p. 77.
While this is not a complete list the ancillary services include
laboratories, x-ray, physiotherapy, occupational therapy, surgery, etc.
Note, that by definition of organic functions this would not include
such accepted hospital units as central supply and pharmacy which are
auxilliary to the primary service objective of care and treatment.
re or car a
c.'ip;iv
oi . :e
' - ad >y is ure of :.-.v
■ s : " i ur thai this object : w
- orde: ed or ir.pl i c >y a
a.-.c in i . •. . !
< ira] hosp i ta :._ ,-, i t rr.av
■■ ■■■ '■"' E existing , ■ th i n the h >s ■ i ta 1 ;tr_iv
i ted t such care sr.d tr atmer.t as ore' ji
.•'■-■■•'• " hospital ... but o.-a amo . many e< . ce; within the h; a
c2i"e system em \o) d .. ,. iciar. vvnest purpose or objective if
thiS ' "■"•'' :' • • ■ ■ • i " ■ - L! - :- rare.- : ir.divi< ... is
■ of d]s a. This . . s . .
""' ' concerning ti tn care syste.r. In res social setting.
r ore....- to .. fusion whicr, has occurred in the recent
■ ' '- ' c • 5 ^esirab c consider the hierarchy of objectives which
exists :~ — health care system, at least to ..... extent tc which it
!rr-P!n9&s upon the discussion o\= hospital structure. T.-.c health care
system as c whole r -.e obje* :ivc t .' providing a state o .T well-being
organic tunctions involved i:o cure and prevention of disease, however
— -— -■- be defined .... ,.,: point in time. One among other insti-
■ '- - ■ -:". ■ -•■' -"• the cure of disease is the body oi individ-
uals "h0 ar ■'■' - :-S Physicians. Phys • ciftr.s are also concerned wi th
---, -J» i-'.is io ties i ce the point except to the
extent 'n which they employ the hospital to assist in this ^rforz. The
PhysicIan ss a curer . ,: disease will ,-,-. various alternative m« thods in
ias
61
returning his patient to health-- in the respect that a hospital is a
sub-function directly employed in the cure of disease but not alone
capable of performing this function, it is an organic element of the
health care system. However, it must be emphasized that it is the
physician who has the primary objective of cure while the hospital h
but an element of this objective in its charge--care and treatment of
the patient under the physician's charge.
This point is quite straightforward and accepted when the process
of organizational analysis is performed. It only becomes confused when
the elements of the health care system are studied in their individual
parts and synthesis from this level upward is attempted. Any study of
the scope of facilities provided in the modern hospital would conclude
that the range of care and treatment feasible is quite extensive, how-
ever, the actual contribution of the hospital organization to the syst
objective of cure and prevention of disease is limited by the nature of
the system and its connection of interrelated parts. This is not meant
in any way to disparage the contribution of the hospital to the overall
system of health care, but is directed toward an appreciation of the
basis upon which many studies of hospital organization have been made
and the results which have been reported.
To argue that the hospital is anomalous in regard to the structure
em
Observations such as reported by Basil S. Georgopou los , in "The
Hospital System and Nursing: Some Basic Problems and I ssues," Nursing
Forum, V (1966), 8-35, that the hospital exercises more control over
nurses than doctors, lose much of their import when analysis rather than
synthesis is employed in organizational study.
62
of the health care system is to take a position in regard to alterna-
6
tive methods of delivering health care to society. Many of these same
arguments could be made in regard to the "feeder" plants of industry
which play their part in the production and delivery of goods to society
in a similarly complex manner. To provide that these plants ought to be
integrated with the companies which they serve is merely to observe that
alternative methods of providing for the needs and wants of society are
feasible. The actual choice among alternative methods must be based
upon principles of selection which go beyond the relative complexity
of an existing system. Although complexity of structure is acknowledged
to have its attendent costs, simplicity of structure gives no assurance
of being less expensive. Each must be evaluated in terms of the ob-
jective to be served rather than on the basis of ease of comprehension.
The points of duplication within the health care system which are com-
mented upon by the Somers are undoubtedly valid, and the gaps which
exist in the system are well known; however, the remedy to these dis-
crepancies, including the comprehensive planning system suggested by
these authors, may well remain an unacceptable, and therefore an unevalu-
ated, alternative.
In describing the line organization which exists in the voluntary
general hospital and its relationship to the primary service objective
Herman Miles Somers and Anne Ramsay Somers, Medicare and the Hospi-
" -r I s : issues and Prospects (Washington, D.C.: The Brookings Institute,
"i S57) , pp. 51-55.
7 ! b i d .
63
of the organization the following chai n-of -command can be described.
The upermost level in this chain is the board of trustees, the final
internal authority in regard to the purpose established for the hospital
organization and the link with the ownership maintained by the community.
One of the most important functions of the board, as in any corporation,
is the selection of the operating executive. It is in this act of desig-
nating the head of the organization that the first devolution of line
authority is accomplished, and the initial link in the primary chain-of-
command is created. The functions of the administrator of the hospital
as the operating executive are those responsibilities designated by the
board of trustees. The process of selection of the hospital admini-
strator and the delegation of authority to this executive have been well
Q
discussed and do not require extensive comment at this point. An inter-
esting discussion of the characteristics of these operating executives
is provided by Etzioni, who identifies three types of hospital admini-
9
strators. These he classifies as the physician-administrator; the semi-
expert administrator, who may be a physician with administrative train-
ing or a trained hospital administrator; and, the lay administrator, who
is neither a physician nor a professional hospital administrator, but a
- ,. ,, 10
person with management training or experience in another field.
Q
Raymond P. Sloan, in Today ' s Hosp i tal (New York: Harper and Row,
Publishers, 1966), pp. 119-139, provides an excellent description of
these processes.
9
Amitai Etzioni, "Authority Structure and Organizational Effective-
ness, Administrative Sciences Quarterly, IV (June, 1959), 53-59.
Ibid.
64
Etzioni's position in regard to the relative effectiveness of each of
these types of operating executives will be considered later as the
major propositions in regard to the anomalies of hospital organization
are treated in some detail.
Directly under the hospital administrator the line of the hospital
organization devolves upon the nursing and ancillary services. As
mentioned before the chain within these organic elements is described
in terms of departments, wards or units, and teams or stations, down to
the primary operative performers. There may be an intervening level
between the administrator and the head of the nursing or ancillary depart-
ment designated as associate or assistant administrator, but this level
of the hierarchy will be discussed below as a separate topic.
The director of nursing and the ancillary department heads derive
their authority from the hospital administrator and assume responsi-
bility to this official for the accomplishment of their assigned duties.11
The use of the term director of nursing services connotes the often
found grouping of both line and staff elements at the department level
beneath a single superior responsible for this major component of the
organizational activities. Examples of such arrangements would be the
grouping of various wards under departmental service classifications
such as medical, surgical, and pediatrics, along with the line element
of surgery and the staff element of central surgical supply all in a
Malcolm T. MacEachern, Hospital Organization and Management
(Berwyn, 111.: Physicians' Record Company, 1962), p. 518.
65
direct chain of responsibility to the director of nursing. These sepa-
rations of elements reflect a differentiation of the tasks to be per-
formed based upon product in the case of the medical specialty wards
and the process to be facilitated in the case of surgery. This basis
for differentiation of the organic function is typically found in the
universal structure along with other possible methods described by
n • 12
Davi s .
There seems to be no question of the identification of the nursing
function as an organic element of the hospital organization. Wilson
provides that the nurse is the full-time symbol of the atmosphere of
13
the organizat ion--that is, care and treatment. He also emphasizes
this identification by noting that the nurse is, in effect, the day-to-
day decision maker in regard to the functions carried out in the organi-
14
zation. Georgopoulos comments that the nurses comprise the only group
in the hospital that is always present at the center of work and the
major group through which the organization can insure continuity of work
1 2
Davis, p. 3^3, provides for elemental differentiation by: product,
commodity, or service; process or method; equipment or other dominant
physical factors; and, physical dispersion of activities on some geographi'
cal basis. Each of these bases, in addition to the fundamental functional
differentiation, are represented in hospital organization at the various
levels of the line. Even geographical differentiation occurs in respect
to wing arrangements on the hospital wards which facilitate a logical
separation of areas which are too large for primary supervision.
13
Robert N. Wilson, "The Social Structure of a General Hospital,"
Annals of the American Academy of Political and Social Science, No. 346
(March, 1963), p. 67.
14
Ibid., p. 72.
66
over time. ' The nursing service is described by Brown as the right arm
of the hospital administrator in the carrying out of the v? tal functions
of the organization. And, if the subtle point often referred to in
the management literature as an identification of the line is employed,
it is discovered that the nurse is the i ni t iator of action in the hospital
organ izat ion .
At the operative level of the line nursing organization there appear
two basic forms within which the segmentation of tasks takes place.
These two forms are case assignment and a specialization of work in some
functional ized manner. Brown remarks on the extensive degree of speciali-
zation and task functional izat ion which has taken place in the hospital
organization and which has produced an extended line chai n-of-command
1 8
below the registered nurse. Christman and Jelinek suggest that this
specialization has been wasteful of nursing personnel and recommend a
shortening of the chai n-of-command to put registered and practical nurses
1Q
back in direct contact with the patient. The benefits and disadvantages
involved in extended chai ns-of-command with extensive specialization of
Georgopou los , p. 14.
Esther Lucile Brown, Newer Dimensions of Patient Care: Part 2; Im-
proving Staff Motivation and Competence in the General Hospital (New York:
Russell Sage Foundation, 1962) , p . 61 .
Eleanor C. Lambertson, in "Reorganize Nursing to Re-Emphasize Care,1
Modern Hospi tal , CVi I I (January, 1967), 68, remarks: "Since the patient
is housed in a unit supervised by the nursing department, the therapeutic
and institutional services are generally initiated, coordinated, facili-
tated or referred by the nurse in charge."
Brown, p. 53 .
19
Luther P. Christman and Richard C. Jelinek, "Old Patterns Waste
Half the Nursing Hours," Modern Hospital, CVI I 1 (January, 1967), 78.
67
the primary operative functions versus shortened chains with tasks more
enlarged and generalized are discussed by Georgopoulos in a manner famil-
iar to the management student concerned with the operation of business
20
enterprises. ihese matters will be discussed more fully in their re-
lationship to the prototype characteristics of the hospital organization
and have only been mentioned at this point to illustrate the extension
of the primary chai n-of -command in the hospital situation.
The ancillary departments of the hospital organization are similar
to the nursing departments in their extension of the line of command to
primary operative specialization. In large part these departments are
differentiated one from another on the basis of process or method employed
in satisfaction of their contribution to the primary service objective.
The purely therapy departments are a process specialization of the
organic function of treatment while the laboratories and x-ray have a
functional differentiation between diagnosis and treatment beneath the
department level. A brief listing of these ancillary functions and their
21
organization arrangement is provided by Brown.
The designation of associate and assistant administrators along with
assi stants-to the administrator has become more and more popular in
hospital organizations. The classification of these officers in regard
to their relationship to the line organization is as varied as are the
functions which are assigned to these positions. In many cases, when
Georgopoulos, p. 26.
2 1
Brown, pp. 56-60.
68
they are subjected to analysis, these designations are only substitute
titles for departmental positions which are inherent in the organization.
In other cases it would appear that minor service levels are being de-
veloped which are separate from the major service levels discussed
22
above. Under these circumstances the minor service level created under
the position of the administrator would be considered to provide no basic
differentiation of the task of administration in spite of the desig-
nation which is assigned to the position. The relationship between the
administrator as the operating executive of the organization and the
functionally or process differentiated department head remains
essentially undisturbed if the line is to remain intact.
A particularly favorite assistant designating mechanism at the
present time is to group the various operating departments into the
classification of professional and administrative (or business). In
respect to the observation that these are artificial classifications
without organic meaning beyond an approximate separation of primary and
secondary/collateral objectives of the organization they must be con-
23
sidered as staff positions to the administrator, as outlined by Litterer.
In many cases the staff nature of these roles is borne out by the quali-
fications of the incumbents, those recruited for these positions being
22
Davis, pp. 352-353, declares that major service levels represent
broad, basic differences in the kind of service, either operative or
executive, that is required by an organization. The levels and grades
within a major service level are designated as minor service levels.
23
Joseph A. Litterer, The Analysis of Organizations (New York: John
Wiley and Sons, Inc., I965), pp. 3^0-3^2.
69
largely recent graduates of programs in hospital administration with
generalized training rather than a specialized background in the func-
tions which appear to have been subordinated to these positions. This
is not to say that such staff roles will not facilitate the training of
these individuals for greater responsibility.
Another variation on this same approach of interposing an executive
level between the administrator and the operating department heads is
2k
discussed by Davis as the development of a "fractional" service level.
In essence this provides for the designation of a department head as
assistant to the administrator to allow for a staff relationship between
the specialist and the administrator in addition to the primary relation-
ship which already exists. Again, any line connotation which is implied
by this arrangement is at best artificial, and it should not be expected
to solve the operating problems which called the arrangement into being.
The designation of an associate administrator is perhaps representa-
tive of a line accommodation in the structure of the primary chain of
command, when such designation is in the singular. An associate adminis-
trator interposed between the administrator and the operating department
heads provides for an often necessary separation between the internal
and external duties of an administrator. in these cases the associate
administrator becomes the operating executive, responsible to the adminis-
trator for all internal matters including the coordination of the func-
25
tions assigned to the department heads.
2^Davis, p. 362.
25 Ibid., pp. 361-363.
70
The role of the physician in the hospital structure is most ambig-
uous and remains an issue in every discussion of hospital organization.
This position of the physician in the hospital can only be understood
by reflecting upon the historical perspective provided by the health care
system in this country. Bloom discusses this perspective in terms of the
developing role which the hospital has played in the system in response
26
to the changing needs and goals of society. From a refuge for the
pauper and the friendless, the hospital has evolved into a center con-
27
taining the complex tools of medicine provided by an advanced technology.
However, the physician has retained his independence from this structure
28
which provides the wherewithal for the practice of his craft. Bloom
believes that this historic fact may be lost sight of as a blending of
the duties of the profession with the mission of the hospital becomes
A 29
more pronounced.
This same evolution of the role of the hospital is traced by Freid-
son, who notes that the impetus for this changing role was the physician
30
rather than the lay clientele. The conscious demand for these new
facilities stemmed from the physician rather than the client who had
26
Samuel W. Bloom, The Doctor and His Patient (New York: The Free
Press, 1963), pp. 145-147.
27lbid. 28Lbid. 29lbid.
Eliot Freidson, "Client Control and Medical Practice," Medical Care:
Readings in the Sociology of Medical Institutions, eds. W. Richard Scott
and Edmund Volkart (New York: John Wiley and Sons, Inc., 1 966) , p. 448.
71
31
these new services imposed upon him. Freidson believes that it is
questionable to designate the patient as the customer of the hospital
for under these circumstances the layman, while he pays for the services,
32
has little control over their use. Wilson views the physician as
having been the guest of the hospital with very special prerogatives
that allowed him to dominate many aspects of the situation which usually
33
are reserved to the owners. This same point is taken by Bloom, who
regards this phenomenon as a result of the potency of the physician's role
in the healing process, although his dependence upon the facilities pro-
vided by the hospital and the increasing competence of the nurse have
served to balance the effect of the physician's apparently dominating
■ c, 34
influence as a guest.
These authorities, however, see the evolutionary process as incom-
plete. Bloom views the physician's interests as blending with those of
the hospital thus leading to a new sense of ownership and responsibility
on the part of the doctor. Guzzardi believes that changing circum-
stances make a broader responsibility on the part of the physician in-
evitable. Rayack sees the physician as increasingly becoming an
31.. . . 32.,.,
Ibid. Ibid.
33
Robert N. Wilson, "The Physician's Changing Hospital Role," Human
Organization, XVIII (Winter, 1959-60), 177.
34
J Bloom, p. 147.
35 1 b T d . , p. 153.
Walter Guzzardi, Jr., "What the Doctor Can't 0rder--but You Can,"
Medical Care: Readings in the Sociology of Medical Institutions, eds.
W. Richard Scott and Edmund H. Volkart (New York: John Wiley and Sons,
Inc., 1966), p. 541 .
72
organization man dependent upon a host of institutions to perform his
work and through this process losing his traditional independence of
37
responsibility for the management of these institutions. However,
these comments are essentially speculation as to what the future holds
for organized medicine and the health care system. Of immediate im-
portance in defining the line of the hospital organization is the determi-
nation of the present role, if any, of the physician in this structure.
One prevalent approach to the role of the physician is obtained by
enlarging the scope of the hospital primary service objective to include
the accomplished healing of the patient. If this approach is taken the
place of the physician becomes quite ambiguous if it is maintained that
he is not a member of the organization. MacEachern appears to straddle
the fence in this regard, maintaining that the hospital's mission is
healing but then not adequately relating the physician to the process of
organization involved, and finally providing for the delegation of
authority to the nebulous "medical staff" and allowing for certain
•30
parallel line authority. C. Wright Mills allows that this ambiguity
of roles describes a new entrepreneur attached to but not a part of the
39
hospital. And, Sloan, who also maintains that the hospital must have
37
Elton Rayack Professional Power and American Medicine: The Econom-
ics of the American Medical Association (Cleveland, Ohio: The World Pub-
1 ishing Co., 1967) , pp. 39-40.
3 MacEachern, pp. 157-158.
39
C. Wright Mills, White Collar: The American Middle Class (New
York: Oxford University Press, 1956), p. 116.
73
some finality to its purpose beyond a mere contribution to the well-being
of society, provides a unique role for the physician which defies
description as employee or consultant but may perhaps be categorized as
40
an independent contractor. In each case the conundrum is provided by
the expanded primary service objective awarded to the hospital organi-
zation .
From the legal point of view the position of the physician in the
hospital has been quite clear in maintaining an essential customer-enter-
prise relationship. MacEachern appears to recognize this by noting that
the law does not require a corporation to furnish its services to every-
41
one who applies. The courts have followed a quite consistent position
in this regard by maintaining the right of the private hospital organi-
42
zation to select those persons who will be welcome to use it facilities.
This customer relationship of the physician to the hospital is reinforced
by the substantive rights to practice awarded to the physician by the
courts when the hospital is owned by the public. This continuing trend
toward a customer interpretation is reinforced by even more recent
^°c 1 11
S loan, p . 11.
41
MacEachern, p. 162.
42
John F. Horty, Nathan Hershey, Eric W. Springer, and Donald M.
Stocks, Student's Guide to Hospital Law (2nd Edition; Pittsburgh, Pa.:
Health Law Center, Graduate School of Public Health, University of
Pittsburgh, 1962) , p. 138.
43lbid.
74
44
decisions of the courts.
But, perhaps, the most telling argument for the customer role of
the physician is provided by the attitude of the doctors themselves.
As Bloom notes, the physician traditionally does not take responsibility
for the organization and management, which are the essential line func-
45
tions of the hospital. And MacEachern's dictum that the board should
pass the responsibilities for the treatment and care prescribed within
the hospital to the practicing physicians appears less as a line dele-
gation and more like a recognition of a fai t accompl I , for the physician
46
can have it no other way. However, the large degree of power which
the doctor wields within the hospital organization, and which is well
47
noted, cannot be denied.
Undoubtedly the most popular view taken of the hospital by the
physician is to regard these facilities as his "workshop," a place where
he can obtain extra care for his patients and receive a combined consul-
tation beyond that which he could obtain by referring his patient to a
48
specialist. This concept of the hospital as a tool of the physician
44
Arthur H. Bernstein, "Medical Staff Appointments, Pro and Con,"
Hospitals, ILII (May, 1968), 99.
^Bloom, p. 150.
46
MacEachern, p. 158.
47
Oswald Hall, "Some Problems in the Provision of Medical Services,"
Canadian Journal of Economics and Political Science, XX (1954), 461.
48
Albert F. Wessen, "Hospital Ideology and Communication between
Ward Personnel," Patients, Physicans and Illness, ed. E. Gartly Jaco
(New York: The Free Press, 1958), p. 461.
75
which maintains the essentia] customer relationship between the two is
noted by Perrow, who believes that the physician will use that hospital
49
which provides the best facilities for the care of the patient. The
administrator's duties as the operating line executive, as outlined by
MacEachern, is the provision of those facilities necessary to the
physician for the proper treatment of patients; this statement is perhaps
as complete a summary of the function and purpose of the hospital organi-
50
zanon as can be made. While no comparisons are attempted, Etzioni
implies that this arrangement is not dissimilar from that which exists
, . . . 51
in other segments or the service industry.
This independence of the physician from internal responsibility and
management of the hospital appears to be a unique American approach to
the organization of health care. " Although Wilson believes this to be
a passing phenomenon he agrees that what the American physician has had
was a workshop designed for his convenience. " This aura of convenience
appears to have been dictated by the physician's definition of his own
49
Charles Perrow, "Organizational Prestige: Some Functions and Dys-
functions," Medical Care: Readings in the Sociology of Medical Institutions.
eds. W. Richard Sco'ct and Edmund H. Volkart (New York: John Wiley and Sons,
Inc., 1966), p. 563.
5 MacEachern, p. 102.
"* Amitai Etzioni, Modern Organizations (Englewood Cliffs, N.J.: Pren-
tice-Hal 1 , Inc. , 1964), p. 78.
^ Roul Tunley, The American Health Scandal (New York: Dell Publishing
366).
Wilson, "The Physician's Changing Hospital Role," p. I78.
76
role and the support he expected to be provided by the hospital.
Tunley, for one, believes that this peculiar arrangement of free pas-
sage in and out of the hospital organization by the physician without
responsibility to the organization being exacted, is part of what he
describes as the scandal of American health care when it is compared
55
with the system in operation in other countries. Georgopou los , how-
ever, believes that this concept of the hospital providing a doctor's
workshop is gradually passing from the scene; while Wilson indicates
that the physician is undergoing a shift from his older charismatic
role in the hospital setting to a more nearly bureaucratic niche within
57
the structure. However much the present situation of the physician's
role within the hospital organization is deplored, it still remains
descriptive to provide that the doctor is not typically of the hospital,
but, instead, is a customer of these facilities provided by the community
for his use.
This transition of the hospital to a position as a major segment
of the health care system with its employment as a facility for the use
of the physician appears to have placed the patient himself in an un-
defined role in regard to the hospital. Undoubtedly the immediate impact
5\iall , p. 460.
55T ,
l un ley .
Basil S. Georgopou los , "Hospital Organization and Administration:
Prospects and Perspectives," Hospital Administration, IX (Summer, 1964),
30.
Wilson, "The Social Structure of a General Hospital," p. 67.
77
upon the patient is the loosening of the ties which traditionally held
between the physician and the person who sought his care. Simmons and
Wolff note that while the physician profits from the specific economies
and conveniences of the workshop his patient experiences a widening of
the social distance between himself and the person with which he has
rO
contracted for care. The patient has undoubtedly taken second place
in this present arrangement although most people believe that the hospi-
59
tals exist primarily for the benefit of the sick person. Flores main-
tains that while it is true that the patients are the recipients of
whatever care is provided the hospital really exists to make it possible
for the physician to practice medicine in the most effective manner pro-
vided by that science. Wilson has remarked that the two most important
actors in the hospital plot, the physician and the patient, are both only
guests on the scene.
While Blau provides that there is a marked difference between the
customer of a business enterprise and that of a customer of a service
industry it is still difficult to ascribe a customer role to the patient
62
in the hospital. The patient finds that his life is ruled in both
Leo W. Simmons and Harold G. Wolff, "Hospital Practice in Social
Science Perspective," Medical Care: Readings in the Sociology of Medical
1 nst i tut ions , eds. W. Richard Scott and Edmund H. Volkart (New York:
John Wiley and Sons, Inc., i960), p. 477.
59
Florence Flores, "Role of the Graduate Nurse Today," The New
Enoland Journal of Medicine, CCLX1I (September 6, 1962), 487-491.
Ibid.
Wilson, "The Social Structure of a General Hospital," p. 70.
Peter M. Blau and W. Richard Scott, Formal Organizations (San Fran-
cisco: Chandler Publishing Co., 19&2), p. 59.
78
minor and major detail in the hospital by total strangers. ' Simmons
and Wolff observe that:
In the hospital the patient is "admitted" and "discharged" and
all the visitors are under rules, while at home the physician
is "on call" and can be "changed," and the nurse is "hired" and
can be "fired." In the home "prescriptions" are requested and
filled out, but in the hospital "orders" are written and must
be enforced. °4
As Parsons has noted, a customer relationship can only exist when there
is some shared basis of knowledge between the customer and the party
65
being dealt with. While Parsons attributes some special relationship
between the patient and the physician, it is difficult to see any basis
for bridging the gulf which exists between the patient and the hospital.
Perrow remarks that this communications gap renders the patient in-
capable of judging the care which is rendered or interpreting the
hospital experience in its totality. If the patient is to be con-
sidered as a customer of the hospital organization then his knowledge
of the service received can only extend to the most superficial aspects
of the institutional care provided, which is unlikely to compare
favorably with the size of the bill which is tendered.
3Simmons and Wolff, pp. 482-483.
64lbid., pp. 483-484.
£ r
Talcott Parsons, The Social System (New York: The Free Press,
1950, p. 441.
Perrow, "Organizational Prestige," p. 563.
67lbid.
79
To argue that both the physician and the patient are the customers
of the hospital would be to deny the basic orientation of the various
hospital personnel to the demands levied against the organization by the
68
doctor in attendance. On the other hand to maintain that the patient
is the customer while the physician acts as a control agent in the
customer's activities within the organization, as Etzioni argues, is
to reduce the role of customer to the perfunctory paying of bills which
69
is hardly the economic function implied in the term — customer. This
conception of the role of the patient also provides little in the way of
significance for organizational analysis. Perhaps the best analysis of
the part which the patient plays in the hospital organization is pro-
vided by Wessen. He maintains that:
. . .the patients are not so much a part of their social system
[the members of the hospital organization] as a vital reference
group in the midst of which the personnel operate, which they
serve, and toward which they orient many of their actions and
attitudes. 71
If it were not for the human quality involved it would be quite easy to
Donald M. Rosenberger, in "A New Look at Hospital Organizations,"
Hospitals, XXXVI (February, 1962), 43, considers the various cate-
gor ies wi thi n which the physician and patient could be placed in regard
to the hospital organization and arrives at the conclusion that both are
customers .
69
Amitai Etzioni, "Administration and the Consumer," Adm? ni strati ve
Sciences Quarterly, III (September, 1958), 253.
7°Wessen, p. 253.
7,lbid.
80
equate this statement to the orientation of the worker in industry to-
ward the raw material of production and the product in its various
stages of completion. Such of course is not entirely the case; however,
in spite of the special characteristics involved, the orientation of
management, in its control over the worker in the production process and
the emphasis placed upon the primary service objective, will be much the
same in both the hospital and the manufacturing concern.
There can be no doubt that a profound change occurs in the indi-
vidual when he assumes the sick role in American society, particularly
when this role involves hospitalization. Freidson has described this
role in terms of an hour-glass description of society with the waist of
the figure denoting a point where the patient passes from his normal
72
reference group to a new role with the health care system. Freidson's
essay is mainly concerned with the passing of the patient from his
physician, by consultation, to a specialist as providing the waist of
73
the two systems. At this point the patient no longer controls the
relationships which exist; he is then the object of the process involved
74
no matter how humane the considerations which are provided. In like
manner it can be recognized that the patient's role in the hospital
organization is as a portion of the process which the structure has been
72
Eliot Freidson, "Specialties Without Roots: The Utilization of
New Services," Medical Care: Readings in the Sociology of Medical Insti-
tutions , eds. W. Richard Scott and Edmund H. Volkart (New York: John
Wiley and Sons, Inc., 1 966) , pp. 455-A-57.
73 1 bid. 74!bid.
81
designed to facilitate. To maintain a customer orientation for the
patient would be a futile exercise in semantics.
It is in these two unusual roles, the patient and the physician,
that we discover the root of the discrepancy of description between the
hospital and the universal organization. The only present parallels
that can be cited between the role of the patient as the article in
process and situations of a like nature in organizations which are de-
scribed to be of the universal character would involve children being
processed under the customer oriented direction of a parent. In each
case where the party in process is an adult with the ordinary customer
control exercised by an authorized agent the anomalous nature of the
organization is cited, although this particular arrangement has little,
if any, structural connotation to the internal organization. The
problem undoubtedly does not rest with the human characteristics of the
client, but, rather, with professional characteristics of the agent.
This point must be amplified for it is here that the confusion arises
which appears to attribute an internal, line role to the agent rather
than the customer role outlined above.
The power of the physician to affect the internal workings of the
hospital organization is not the authority provided by organization
theory to internal membership. Rosenberger has described the physician
as not only a customer and a beneficiary of the hospital organization
but also as an informal partner in an informal joint venture; while
75
Rosenberger, pp. 43-44.
82
Gordon detects a negotiated relationship based upon a power and control
76
relationship that is constantly being subjected to renegotiation. The
root of this power or informal authority as it is variously described
can be considered to rest in the prestige associated with the medical
profession as it applies in the peculiar hospital situation. Brown sees
the basis for the part which this occupational prestige plays as residing
in the evolutionary development of medicine and the health services which
allowed the physician to precede the other professional groups in their
development as the primary guardian of health. In addition to this
longer tradition the physician is favored by longer periods of training
and study, legal precedent, and a particularly fortunate socio-economic
78
position. Brown remarks: "As a consequence of all these factors,
physicians have had and continue to have the greatest authority, the
highest status, and the largest prestige of any group within the hospi-
79
tal." Significantly, Wessen notes that this respect for the doctor's
prestige is systematically indoctrinated in hospital personnel, and it
80
finds its greatest strength among those second in presti ge--the nurses.
Even the advent of "team medicine" has not loosened the physician's
. . 81
prestigious position.
Paul J. Gordon, "The Top Management Triangle in Voluntary Hospi-
tals (ll)," Academy of Management Journal, V (April, 1962), 72.
Brown, p. 66.
781t16. 79Lbid.
80w I CI
Wessen, p. 4-54-.
8 1
Bloom, p. I67.
83
But, as some authorities have noted, this power which stems from
the charismatic prestige of the physician cannot be solely explained
by the factors considered above; it appears also to be a function of
the autonomous role which the physician plays in his association with
the hospital organization. The physician's autonomy has been laden
with the power, expressed as both explicit and implicit authority, to
direct the course of the organization. While the other professional
groups associated with the enterprise do not hold the same degree of
prestige as the physician their seeming inability to influence hospital
policy appears to be more a function of their internal membership in
the organization.
The possibility of a misinterpretation of the role of the physician
as the presiding figure in the healing process to include the concept
that he i s of the organization, rather than the customer, can have its
disastrous effects upon the management of the institution. Confusion
in regard to the objective of the hospital can lead to the executive
of the organization being held accountable for results over which he
Or
holds no effective decision-making authority. If the description,
held by many, of the physician as an internal member of the organi-
zation, were correct, then the right to command held by the administrator
Wi 1 son, p . 1 77.
83ibid.
Wessen, p. 4o3 .
5Davis, p. 17.
84
would not exist and his position would disappear. The situation
would be as Gordon has described it, where on a day-to-day basis the
corporation and its executives have no legal or organizational means
87
to control the service which the hospital has been set up to render.
Rather, it is from the surrounding organizations which make up the
environment of the hospital that the primary service objective of the
00
organization is determined. One of these organizations which is
primarily involved in the determination of the hospital's objectives
on a dynamic basis is the membership of practicing phys i cians--the
customers of the hospital organization. This process of interaction
involves the surrender of certain sovereignty on the part of both organi-
zations but it does not mean an incorporation of the two parties or a
89
modification of the structure for administration.
Much of the dilemma in regard to the position of the physician
in the structure of the general hospital has arisen from the nature
of the studies which have explored this issue. Those accounts which
subscribe an internal role to the physician have been largely socio-
logical in origin, but there also appears to have been considerable
90
feedback into management studies.
Koontz and O'Donnell, p. 66.
0-7
Gordon, p. 72.
00
Blau and Scott, pp. 196-197.
8W
90_
The concern in hospital administrative literature with the issue
of finding a basis for management participation on the part of the privi
leged physician is indicative of the dilemma arising when the doctor is
85
As Blau and Scott have remarked the objective of social science
studies is the explanation of various aspects of social organization
91
and the orderly structure of social life. This depends in the modern
lexicon, as Katz and Kahn describe it, upon the concept of open systems
studies which link the various subsystems, systems, and supersystems ,
92
depending upon their degree of autonomy, into a total social system.
The approach of open-systems theory is in contrast to traditional
organizational theories which tend to view the human organization as a
closed system and disregard the nature of organizational dependency on
93
its environment. Katz and Kahn believe that the traditional approach
awarded an undefined, internal role in the hospital organization. The
present suggestions, and practices, include the utilization of various
committee arrangements which practice remains essentially unevaluated
at this point. If organization theory were to suggest any resolution
of this contrived situation it would provide for complete incorporation
of the practicing physicians into the structure of the organization on
a salaried basis. There appears to be some trend in this direction with
a subsequent modification of the hospital primary service objective to
include the broader healing goal inherent in the work of the physician.
This aspect of the dynamics of the health care system toward a
centralization of the healing function is a major issue in American
medicine. Tradition and the ethics of the medical profession are
actively resistant to a modification of the present doctor-patient re-
lationship which would allow the suggestion of an authority superior to
that of the physician in the healing process. It could also be sug-
gested that the physician has little interest in the management responsi-
bilities associated with, internal membership. Much like American labor,
the physician sees little to gain in disturbing the favorable advantage
which he presently holds in the negotiated order of the system.
91
Blau and Scott, p . 1 .
^ Daniel Katz and Robert L.Kahn, The Social Psychology of Organi-
zations (New York: John Wiley and Sons, 1 nc. , 1 966) , p. 58.
93
^Ibid. , p. 29.
86
has lead to an overconcentrat ion on principles of internal functioning
of organizations which ignores the feedback from the environment which
is essential for organizational survival. This opening of the
boundaries of organizations has allowed the analyst to redefine the
structure of the organization and the nature of participation to serve
his particular purpose, which is accepted as his prerogative; however,
the user of these results must be on guard against employing a descrip-
tive analysis which is supported by a purpose at variance with that of
95
the user.
The problem of the boundary to be enclosed in a particular study
is well recognized in open-systems theory. Blau and Scott refer to this
as the fundamental methodological dilemma in the study of social organi-
96
zations. Argyris, in establishing the boundaries for his studies
prescribes the philosophy of extending the boundary of the segment under
analysis to the extent that influences from the environment are neutral-
97
ized. Katz and Kahn describe the analytical problems, and the socio-
logical implications, involved in the concept of partial inclusion where
94
y Ibid.
95
Litterer, pp. 6-9. The work of Amitai Etzioni, in A Comparat i ve
Analysis of Complex Organizations (New York: The Free Press, 1961), pp.
18-21, is illustrative of the careful outlining of boundary positions in
the open-systems approach, here directed toward developing of compliance
structures. This outline should forewarn the management student of
indiscriminate adaptation of the conclusions derived to broader areas of
concern .
96
J Blau and Scott, p. 222.
97
Chris Argyris, Integrating the Individual and the Organization
(New York: John Wiley and Sons, Inc., 1964), p. 122.
87
93
a participant is "of" two or more organizations at a boundary position.
This is the dilemma of the salaried nurse and her professional associ-
ation, or the worker and his union, which creates competing cross-
99
pressures upon the individuals and the organizations. Sociological
literature would describe the physician as being in this dilemma of
partial inclusion in the hospital and in his profession; however, a
truer approximation of the situation when the doctor is a privileged
physician would be to describe his allegiance as solely to his profession.
If a sufficient isolation of the phenomenon of the physician as a
customer of the hospital organization is accomplished it is relatively
easy to describe a unique situation in light of the degree of control
J L • , • • • , . . 100
exercised by the doctor in his transactions with the organization.
The position of management literature in regard to the boundary
positions of organizations is well established. This issue was re-
opened by Barnard in his attempt to synthesize many of the concepts of
the informal organizational theorists with the traditional constructions
of management theory. He considered the concept of the customer as a
"member" of the organization to demonstrate the freedom of management
98
3 Katz and Kahn, pp. 50-51.
Paul J. Gordon, "The Top Management Triangle in Voluntary Hospi-
tals (l)," Academy of Management Journal, IV (December, 1961) 205.
Chester I. Barnard, The Functions of the Executive (Cambridge,
Mass.: Harvard University Press, 1938).
theory from that of economics; however, his conclusions derived from
the theory of organization as a coordinative process was to exclude
the acts of consumers even though they were contemporaneous and closely
102
linked with many of the actions of management. His analysis had
demonstrated that the inclusion of "persons" as such in the structure
of organizations would unnecessarily limit the concept of "organization,1
and, therefore, it was more proper to consider them in the perspective
of their roles as determined by the structure itself. This point in
management theory is amplified by Davis in his reiteration of the term
"personnel" to include only those persons who have accepted an obli-
104
gation for the performance of certain assigned functions. Davis
also points out that those responsibilities are determined by the
characteristics of the values that must be created for the accomplish-
ment of the organizational objective. ' This definition of the bounda-
ries of the organization being prescribed by the goals of the organi-
zation is explicitly stated by Parsons, who notes that it is through
, ,. . 106
goals, not persons per se, that organizations are defined.
The specific purposes of the numerous sociological studies of the
hospital organization are varied. Much of the information provided can
be of interest to hospital managers if the purpose of the study is
102lbid., pp. 70-7K 1Q3lbid., p. 72.
Davi s , pp . 15-16.
Ibid.
Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organizations — I," Administrative Sciences Quarterly, I (Sep-
tember, 1956), 64-67.
89
understood as it provides insight into the total system of which the
hospital is a part. The cited study by Freidson provides considerable
understanding of the role which is played by the patient in the health
care process and should generate a more favorable perspective in deal-
ing with the patient on a day-to-day basis. Other reports which tend
to encourage the concept of the physician as a "team" member because of
his peripheral association with the hospital membership are unlikely to
provide reasonable guidance for the hospital manager. Still another
report suggests that the potential for a take-over of the hospital by
1 09
the physicians is apparent. Such concepts of the structure of the
hospital organization serve little purpose for the executives responsible
for the management of the organization and could actually be harmful to
the individual manager who attempted to exercise a measure of control
over the physician other than that normally associated with a customer.
The extent to which sociological studies can distort the structure
of organizations beyond the point where they can be of assistance to
management is exemplified by the normative compliance structure described
by Etzioni as representative of the hospital organization. He sees no
107Freidson, "Client Control," pp. 259-271.
10831oom, pp. 160-161 .
Perrow, "The Analysis of Goals in Complex Organizations," p. 135.
110David B. Starkweather, in "The Classicists Revisited," Hospital
Administration. XI 1 (Summer, 1967), 69-80, makes many of the same
comments in regard to sociologically based studies.
Etzioni, Comparative Analysis, p. 21.
90
reason why privates should be included in the organizational structure
of the army when patients are not included as the lower level in the
1 12
hierarchy of the hospital. By so including the patients as members
of the hospital organization he is then able to demonstrate that they
comply through normative measures while other organizations including
those of an economic variety insure compliance of the lower levels of
the hierarchy by remunerative devices. It is through this simple
device of arbitrary boundaries that his comparative analysis derives
the conclusion that the business and hospital organization are dissimi-
lar. A similar position is taken by Bloom, who maintains that patients
1 14
are a part of the social structure where long-term illness is involved.
Freidson, however, in his essay which suggests the hospital as a proto-
type organization, has taken exception to those studies which attempt
to include the patient as a member of the hospital organization.
It is well accepted that sociological studies have their place in
1 1 6
management theory. Quite early in the development of this theory,
Barnard noted that the single explanation of organizational behavior pro-
vided by economic theory was insufficient by itself to provide the insight
necessary to explain the functioning of the executive. He utilized the
112!bid. 113lbid., p. 42.
1 14
3 loom, p. 161 .
Eliot Freidson, "Review Essay: Health Factories, The New Industri-
al Sociology," Social Problems, XIV (Spring, 1 967) , 495.
116
Koontz and O'Donnell, p. 32.
Chester I. Barnard, Organization and Management (Cambridge, Mass.:
Harvard University Press, 1948), pp. 112-125.
91
method of varying the boundaries of the organization to gain broader
1 1 8
insight into the organizational process for management purposes.
However, as Koontz and O'Donnell note, there are various organization
1 19
theories, each serving its own purpose. The organization theory re-
quired for management purposes must concern itself with the authority-
activity structure of an enterprise and the goal-seeking process which
takes place within this structure as well as with the problems of human
relat ions .
This extensive argument which has been presented in support of the
physician as the customer of the hospital organization rather than as
an internal member of the hierarchical structure has not been made at
the expense of those physicians who can by definition be included in
such membership. These are the salaried or contract physicians who
have internal roles in the organization and are of the line organi-
zation, usually at some management level in the structure. This cate-
gory of line physician would also include the residents in training and
the interns on more transient line assignments who are found in the
larger training hospitals. It is obvious that in these cases where
physicians are directly responsible for organic functions other than the
ancillary departments the primary service objective will more broadly
contain the healing assumption.
I l Q
Barnard, The Functions of the Executive, p. 69.
119Koontz and O'Donnell, p. 208.
Ibid.
92
It has been noted by a number of authorities that a tendency
appears to exist in American society toward greater internal membership
in the hospital organization by physicians. Guzzardi cites the Ford
Hospital in Detroit as providing a model of the organization with all
121
physicians on a salaried basis. He believes that as more new physi-
cians become accustomed to earning a salary from the hospital during
their training periods they will be less reluctant to continue the same
122
arrangement on a permanent basis. Gilb recognizes that this tendency
is already prevalent and notes that this raises new structural problems
for the hospital in light of the traditionally independent character of
123
the profession. She believes that the accommodation that will come
about may possibly resemble the position of the faculty in a university
124
sett i ng.
In those hospital institutions which are fortunate enough to have
a complete staff of physicians, Brown notes, these doctors are responsi-
ble to the administrator for the areas which would otherwise by under
125
the jurisdiction of the nursing staff. However, it should be noted
that while these physicians are of the line, responsible to the head
operating executive, there is usually a medical director at an
121Guzzardi , p. 542.
122
Ibid.
123
Corinne L. Gilb, Hidden Hierarchies (New York: Harper and Row
Publ ishers, 1966) , p. 102.
124
Ibid.
125n
Brown, p. 62.
93
intervening level with considerable decentralized authority for the
purely medical functions, much as the nursing director intervenes in
the typical organization with an appreciable degree of decentralized
authority. Again, while the tendency may be toward the fusing of the
hospital organization and the medical profession into a single struc-
ture, the more typical organization is not of this variety at present,
and, therefore, this variation will not be of major concern in this
report.
The general hospital considered as a business organization serv-
ing a clientele may broadly be classified as a member of the amorphous
service industry. In various ways the hospital has unique characteris-
tics as a member of this industry. As Etzioni, and others, have noted
the hospital is one of a group of service organizations which can be
1 26
classified as predominated by professional participants. The con-
clusions reached by the authorities who make this observation, however,
are at variance with what has been presented in this paper. Etzioni
remarks that the intervention of the professional, as the operative
performer in the organization, between the service provided and the
consumer, allows for a separation of the consumption-control sequence
127
found in normal market operations. While this separation may be true
for the patient-physician relationship it is hardly so for that which
exists between the physician and the hospital when the physician is
i .-, /•
Etzioni, Comparative Analysis, p. 51.
127
Etzioni, Modern Organizations, p. 97.
Sh
accepted as the customer of the hospital; the physician as consumer of
the services provided by the hospital is most knowledgeable of the
product being provided and has a large measure of control in the ex-
change process. Rosenberger ' s description of the relationship between
the physician as the customer and the nurse as the operative performer
in the hospital is quite clear on this point.
In one other respect the hospital is unusual in the practices of
the service industries although, perhaps, not remarkably so. This is
in the control exercised by the organization over whom shall be allowed
to make themselves available to the services provided. The hospital
accepts a responsibility to the ownership of the facility that the
customers shall be qualified in the employment of the services provided,
This is essentially a further extension of society's concern with whom
shall be allowed to practice medicine and to what degree they are compe-
129
tent in various segments of the profession. If the physician's con-
trol in the exchange process is said to be balanced by control exer-
cised by the organization It would be in respect to this initial selec-
tion of those physicians who will be granted privileges in the hospital.
This same selection process is exercised by any business organization
but on a much less formal basis, and like the business organization,
the hospital has the right to terminate the relationship as speci fied in
the contractual agreement.
128s k n
Rosenberger, p. 44.
129
Freidson, "Review Essay," p. 493.
95
As in the other service industries the operative performers of the
hospital organization come into close contact with the customers; as a
consequence the customer is able to direct or attempt to direct the
worker at his tasks. In fact, as Parsons expresses it, this is a
1 3 1
prerequisite for the service classification. MacEachern details this
customer control in the hospital as a function of medical authority, al-
though the word authority has a special meaning in organizational termi-
1 32
nology and might better be expressed as a control relationship.
Woodward notes the interconnection between the service and production
industries in the unit-production case where the desires of the customer
133
largely provide the immediate direction for the operative performers.
The fine line of distinction between the service and production indus-
tries provided by a distribution function is obscured when this function
is a part of the production process as in the case of the hospital organi
zation.
This relationship between the customer being served and the organi-
zation providing the service may be an important result of the prototype
Howard S. Becker, "The Professional Dance Musician and His Audi-
ence," Professional i zation, eds. Howard M. Vollmer and Donald L. Mills
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966), pp. 212-213.
13 1
talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organizations--!," Administrative Sciences Quarterly, I (Sep-
tember, 1956) , 71 .
132
MacEachern, p. 528.
133
Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1965), p. 158.
96
characteristics of the hospital organization, and it should be explored
further now that it is considered as a customer-organization relation-
ship rather than a phenomenon explained by informal authority. Perhaps
the most unusual aspect of the hospital as a representative of the
service industries concerned with unit-production is the extent to which
the physician as a customer interacts with participants throughout the
134
organization. " While there are areas of the organization with which
he is not concerned the physician goes beyond what would be considered
as the normal points of entry for a customer. It could be said that
the physician traverses the organization both vertically and horizon-
tally to insure that each facet of the care and treatment being rendered
to his patient is to his specification. He is undoubtedly accepted as
the expert on how the care and treatment is to be provided and he in-
tends to insure that the specification is accomplished much as any
service customer who cannot rely on the control device of final rejection
135
of the product. The doctor is unwilling to accept the formal relation-
ship which might be prescribed by the organization to control his re-
lationship with the established structure. His frequent encounters with
the operative performers of the organization develop the semblance of an
informal relationship that may make many of his specifications of an
implied category. " Many of these specifications both implied and
Blau and Scott, p. 60.
1 35
J Freidson, "Review Essay," p. 497.
136Hall, p. 460.
97
explicit can be interpreted by either the physician or the operative
137
performer as emergency in nature. Although the operative performers
who are in contact with the customer-physician are usually classified
as professionals they must hold their professional judgment in abeyance
when they are playing this complicated role, or they must learn to exer-
cise this judgment with a discretion developed through constant associ-
138
ation with the physician. But servicing the values of the customer
is but one part of the operative performer's tasks in the hospital
organization; in addition there are a variety of functions which are
139
responsive to the internal maintenance function of the organization.
It has only been quite recently that nurses as operative performers in
the hospital organization have begun to define the internal aspects of
their role to any great extent, and it remains questionable as to what
the exact nature of this definition will be or to what extent this will
140
modify the physician-hospital relationship. If the "team nursing"
concept continues to be received with favor, the professional nurse in
her line supervisory role in the hospital organization will undoubtedly
reinforce her position as coordinator and system integrator through her
role as the intermediary between the organization and the physician much
137lbid., p. 462.
TOO
Lyle Saunders, "The Changing Role of Nurses," I ssues in Nursi ng,
ed. Bonnie Bui lough and Vern Bui lough (New York: Springer Publishing Co.,
Inc., 1966), p. 120.
Brown, p. 62.
l40Flores, pp. 487-491.
as the salesman has served to regularize the relationship between the
customer and the operative performer in unit-production firms of in-
dustry .
This latter point is perhaps the greatest insight that can be
obtained by this digression into the part which the physician plays in
the operations of the hospital organization. To separate the doctor
from the internal membership of the organization is not simply an aca-
demic exercise, but, rather, a mechanism which suggests a course of
action for the managers of hospital enterprises. It is believed that
too much effort has been expended in attempting to regularize an authori-
ty relationship which does not exist. The failings of management theory
to supply the answers required in the hospital situation is not the re-
sult of the inappropriateness of this theory to the particular organi-
zation, but, rather, the failure has been in the attempt to apply the
portions of this theory concerned with internal authority relationships
between superiors and subordinates to what is essentially a customer
relationship. Given this situation it is not surprising to find that
physicians will not submit to the line authority of the hospital execu-
tive since no basis for this authority exists. Within this context the
most successful administrators have been those who have subscribed to
the philosophy that authority has been decentralized to the physician,
although they would be quite unwilling to demonstrate a retraction of
141
M. M. Johnson and H. W. Martin, "A Sociological Analysis of the
Nurse Role," Prof ess iona 1 izat ion, eds. Howard M. Vollmer and Donald L
Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966), pp 206-211
99
this authority given the proper emergency situation.
Social forces may someday provide an internal role for the physi-
cian in the hospital organization on a scale which makes this the mode
for the industry. Management theory must then be re-examined for in-
sight on how the authority relationships should be constructed with
observation of those hospital organizations which presently conform to
that model. Although authorities have been cited who predict this in-
corporation of the physician, traditional patterns and the active resis-
tance of the physicians must first be overcome. It would therefore be
recommended that the present pattern of organization be accepted as that
which must be accommodated by sound management theory.
In large respect what has remained unrecognized at the adminis-
trative management levels has been accepted on the more practical opera-
tive management levels of the hospital organization and the necessary
accommodation by nurses and other operative performers has traditionally
been accomplished. Dale's recommendation in regard to the designation
of customer coordinators to supplement the work of sales representatives
when the product or service is of a particularly complex variety could be
extended to the ancillary departments and consolidated at a higher level
142
in the nursing service. Woodward's work specifically addresses itself
to the customer-organization coordination problem in the unit production
firm. Again, many of her observations in regard to the "organic"
l42Dale, p. 181.
Woodward, p. 158.
00
organization have been implemented by the hospital organization in
recognition of the necessity to survive, rather than through an under-
standing of the management process involved. What is probably lacking
in the hospital organization is the broader organizational efficiencies
which serve to make up for the technical inefficiencies which are in-
trinsic to special order production and management. Her observa-
tions were that unit-production firms were most successful in terms of
efficiency when overall management controls were de-emphasized and self-
145
control by individual operative employees was encouraged by management.
To a large extent, and again by default, these are the practices found
in the successful hospital organizations. The necessity for accommo-
dation to the physician-customer are best accomplished at the operative
level of the organization; however, the management of the organization
must be supportive of the efforts of the workers to perform these ac-
commodations and insure that these numerous deviations are coordinated
throughout the organization.
Perrow also suggests two areas within which top administrative
management can provide the necessary conditions for operative performance
self-control which are conducive to the organic organization necessary
under unit-production conditions, although he does not appear to recog-
nize the true organizational situation. He recommends the promoting of
an independent basis for judging competence on the part of the operative
1 Uf>
performers in lieu of maintaining close supervision over their work.
144 145
Ibid. '^Ibid.
IHOPerrow, "The Analysis of Goals," p. 136.
101
In addition to this he provides that top executive management in the
hospital must support the operative performers and the intervening
levels of the hierarchy in the conflicts which arise with the physicians
147
as customers. The hospital should also be most careful in the selec-
tion of its clientele, the physicians to be awarded practicing privi-
leges, to insure that the demands of these customers are not beyond the
x i. , 148
resources or competence of the hospital.
It should be obvious that the executive's use of management theory
in this new context of the organizational structure of hospitals must
be judicious. There is a great deal of management lore which has been
accumulated in regard to the marketing management function, only some
of which will be useful in the particular situation, largely because of
the dictates of unit-production. Management rules such as, "The customer
is always right," are neatly balanced with such admonitions as expressed
by Urwick that: "To allow the individual idiosyncracies of a wide range
of customers to drive administration away from the principles on which it
149
can manufacture most economically, is suicidal." Actually, as can be
noted as a theme throughout this essay, it is expected that as much can
be learned to the benefit of management theory from the structure of the
hospital, once it is placed in proper perspective, as hospital management
can learn from management theory. Those hospitals which can be observed
•I j, Q
Perrow, "Organizational Prestige," pp. 564-565.
L. Urwick, The Elements of Administration (New York: Harper and
Row, Publishers, 1943), p. 29.
102
are viable institutions which have made the necessary, but not neces-
sarily the best, accommodations to the situations which they face,
however unmanaged these accommodations may originally have been.
CHAPTER IV
THE STAFF ORGANIZATION
The line of an organization may be thought of as complete unto
itself in terms of its ability to provide satisfaction of the primary
service objectives of the organization. In the hospital organization
the structure which has been discussed as the line, the nursing and
ancillary departments, is all that is really necessary to provide for
the care and treatment of the sick and injured as specified by a
practicing physician. The devolution of the line which was discussed
in the previous chapter and which appears as departments, wards or
units, and sections and teams, emanating from the authority and
responsibility held by the administrator as the operating executive
designated by the board of trustees, and culminating in the operative
performers as the lowest line element in the organization, reflects a
specialization of the tasks associated with the creation and distribu^
tion of the values for which the hospital organization was established.
It is this portion of the organization which is vital to its existence,
and, therefore, it is awarded a primacy of regard in all matters of
organizational concern.
However, these line elements of the organization are but a part
of the organization which is observed in practice. There are many
organizational elements which are not involved in the creation and
distribution of the primary service element but which support the
103
104
line structure of the organization by attendence upon the collateral
and secondary service objectives of the enterprise whether the
organization is that of the hospital or any other except the most
rudimentary of structures. These elements of the organizational
structure are generally referred to as the staff of the organization.
The concept of a staff structure contained within an organization
has had a varied history in management literature and is only now
beginning to take on a resemblance in theory to the structure which
exists in actuality. The original conceptions of a staff element
separate from the line were in recognition that not all elements of
the organization were directly involved in the creation and distribution
2
of the values which made up the primary service objective. It is
from this basic point of departure that staff elements of an organi-
zation are defined as containing those functions which are directed
toward the satisfaction of collateral objectives of providing for
the values desired by the members of the organization and the secondary
service objectives of providing the primary and collateral objectives
3
in an economical and effective manner. This leads to the contention
'John G. Hutchinson, in Organizations: Theory and Classical
Concepts (New York: Holt, Rinehart and Winston, 1 967) , p. 65, asserts
that the line-staff structure is the only organizational form capable
of meeting the diverse requirements of modern organizations.
Keith Davis, Human Relations at Work (3rd ed. rev.; New York:
McGraw-Hill Book Co. , 1967)=, p. Mh.
-*Ralph Currier Davis, The Fundamentals of Top Management (New
York: Harper and Row Publ ishers, "1950 , p. 372.
105
that the staff of an organization does no work and therefore contributes
no basic values that the line would not otherwise create if there were
Li
no staff. The organization must provide for the co.iateral and
secondary service objectives in any case, so the development of staff
elements is a specialization of these functions and a separation of
these specialized elements out of the line functions concerned with
the primary service objective.
In the purest sense the functions performed by the staff of an
organization are managerial in origin and retain the nature of this
characteristic in practice. It is therefore a part of managerial work
that an executive assigns to someone outside the line chain-of-command.
It is a delegation of managerial work to people who do not supervise
line operations. In this same context Mooney considers the staff as
an expansion of the personality of the executive in recognition of the
limited amount of time available to the single line manager and the
requirement to have specialized knowledge available to the executive
while still retaining the final right of decision-making with the line
chain-of-command of the organization.' The growth of an organization
Ibid,
^William H. Newman, Charles E. Summer, and E. Kirby Warren, The
Process of Management (2nd ed. rev.; Englewood Cliffs, N.J.: Prentice-
Hall, Inc., 1967) , p. 101 .
6lb?d., p. 103.
'James D. Mooney, The Principles of Organization (Revised Edition;
New York: Harper and Brothers," Publ ishers , 1947), p. 41.
106
resulting from an increased demand for the primary service values
can be accommodated by a devolution of the line tasks leading to
greater specialization of the primary operative tasks and a spreading
of the load of managerial work, but this makes little provision for
o
the specialization of managerial tasks. As the line devolves with
growth the chai n~of -command becomes extended requiring an expansion
of the managerial functions of planning, organizing, and controlling
at each level of the line hierarchy. If this growth of the line
continues without the development of a staff structure to support
it, there is a tendency for the organization to resort to highly
centralized controls at the upper reaches of the hierarchy. °
However, in addition to the managerial burden which is placed
upon the line executive under these circumstances, it is more than
likely that the individual managers in the chain of line authority
are essentially oriented toward the operative aspects of the tasks
associated with the primary values of the organization. The executive,
by training and experience, will be knowledgeable about these areas of
the enterprise and therefore tend to emphasize these values to the
neglect of the supporting objectives which require an expertise beyond
R. C. Davis, p. 363.
9lbid., p. 373-
] Ojbld. , p . 36A .
11,,.,
Ibid.
107
that held by the line executive in the complex organization.
For this variety of reasons the development of a staff organization
can be predicted; under the circumstances of a growing organization
the coordinative problems which will be amassed cannot be solved
through further devolutions of the line structure without subjecting
the organization to the threat of strangulation under highly central-
1 3
i zed controls. To properly decentralize managerial control the line
executives along the hierarchy of the primary cha in-of-command must be
provided with the assistance of the various areas of technical knowl-
edge supplied by a staff organization.
In this relatively pure conception of the relationship of the
staff structure to that of the line the staff is said to evolve out
of the duties and tasks associated with the line managerial levels of
the organization. ' 5 The staff is a specialization of the managerial
tasks of planning, organizing, and control 1 ing--the coordinative
activities required in any organized endeavor. '° In addition to the
expertise associated with these organic management functions, the staff
provides a specialization of the tasks associated with the accomplishment
12,
bid,
1 3 ibid. , p. 366.
"ibid.
15lbid., p. 370.
16ibid.
108
of the collateral and secondary service objectives which are subsidiary
to the line activities directed toward satisfaction of the primary ser-
vice objectives. 17 This separating out of the managerial tasks can be
considered as a phased process dependent upon the volume of activity
to which the organization is subjected in the creation of the primary
values and the relative importance of the individual staff functions in
the support of this activity."
Davis summarizes the factors which lead to this separation of the
staff from the line in his principle of functional emergence which
outlines the impetus behind the differentiation and independent grouping
of the staff functions. '° This principle will be applied in discussion
of the prototype characteristics of the hospital organization in a later
chapter.
Davis provides for tests of the staff nature of various functions
as an assistance in the analysis of organizations, 2^ Essentially,
these are related to the nature of the objectives which the particular
organizational element are designed to serve. Just as the line segments
of the organization devolve to provide a specialization in the creation
of the primary values supplied by the enterprise, the staff elements go
through a secondary devolution to provide an operative specialization in
the creation of the collateral and secondary service values of the
17lbid., p. 791.
I8lbid., p. 375.
'9|bid.
20 Ibid., pp. 388-389,
109
organization required by both line and other staff elements.21
Therefore, if an organizational element does not directly participate
in the creation or distribution of primary service values it is
probably a staff segment of the organization and its devolution from
a separate, evolved managerial element can be traced.22
As mentioned before, this is the basis for the pure theory of
staff organization in the line-staff form of structure. In practice,
however, the elements associated with organizational structure are
not as clearly defined as theory would allow. Many organizational
elements appear to combine both line and staff characteristics, while
many of the units within an organization which are clearly supportive
of the line structure do not neatly fit into the classification which
has been provided for staff organization. In the expanded theory of
organization, therefore, further sub-^classi f icat ions of staff elements
are provided which retain the purity of the line concept but cloud the
issue in regard to the staff.
This phenomenon of a complexity of staff elements was noted by
Barnard, who alleged that the executive portions of an organization
were made up of many individuals who were not involved in the management
functions of the enterprise. 23 The only basis for grouping this large
component of the individuals associated with the organization was
therefore the fact that the work they performed was not of_ the
2. 1 Ibid.
22lbid., p. 791 .
23chester I. Barnard, The Functions of the Executive (Cambridge,
Mass.: Harvard University Press, 1933) , p. 215-
110
organization, but rather the specialized work of maintaining the
organization in operation. While he would categorize these members
as of the executive group they would not all be considered as per-
forming management within the organization. ■* Again, this only serves
to reiterate the function which the broad category of staff serves in
support of the collateral and secondary service objectives of the
organization but now it is recognized that many of the functions
performed are only indirectly associated with the tasks of planning,
organizing, and controlling the operations of the enterprise.
Litterer notes this disparity between theory and practice and
marks the development of new theoretical concepts to accommodate the
26
real world. The bulk of elements found in organizations, which cannot
be identified directly with the creation and distribution of the primary
service values, can be classified as either pure staff elements associa-
ted directly with the management functions in the traditional mode of
thinking or as auxiliary departments which perform functions for the
27
entire organization. ' Pure staff elements, therefore, can be identi-
fied by their association with particular line management positions
while auxiliary elements are global in their assistance to the line
Ik:
bid,
25|b?d.
Joseph A. Litterer, The Analysis of Organizations (New York:
John Wiley and Sons, Inc., 1965) , pp. 33^-335.
27
Ibid,
Ill
and other staff units. 2^ Litterer further sub-classifies these auxiliary
elements into specialized staffs which perform managerial work, or serve
as advice giving units across the organization and operating service units
which serve the organization in a physical sense. 29 However, he procedes
to note that many staff entities may combine these functions to some
degree. 30
While R.C, Davis primarily discussed the purely managerial role of
the staff elements he also recognizes the facilitating functions performed
by many of these organizational units, 3' His method of analysis provides
that all staff units can be identified as being of either a coordinative
or a technical variety; coordinative staffs provide a specialization of
the managerial functions of control while technical staffs are associated
with the specialization of the managerial planning functions.^2 Within
this scheme of analysis he notes that the technical staffs frequently
perform facilitating functions for the entire organization in addition to
the planning tasks which have evolved from line management .33 However, it
might be noted that in most cases which are cited by Davis, the planning
functions performed by these technical staff units are subsidiary to their
2Slbid. , pp. 3^0-3^5.
29, bid.
30 1 b 1 d .
31 R. C. Davis, pp. 402-405.
32lbid.
33 i bid.
112
major facilitating tasks carried out by these segments of the
organization. His particular citation of the typical personnel depart-
ment as representative of a technical staff is indicative of the primacy
of the supportive role of this form of organization.
While it is true that the functions performed by these specialized
units would be performed by the line organization if the staff elements
were not provided it is difficult to associate these facilitative tasks
with the management function directly. it is interesting to note that
the categorization of staff units by Davis into the coordinative and tech-
nical groupings includes but two of the three traditionally discussed
organic management functions. He provides that the third of the manage-
ment functions -- organizing -- remains largely undifferentiated from
line management itself, and, therefore, evolution of this function to
staff elements has not taken place. -*
Other authors who discuss the role of staff elements within the
structure of organizations provide various classifications of the
different types of units which occur in practice. Hutchinson identifies
personal and general staff units with the former associated with individ-
ual line managers and the latter performing tasks in a particular func-
tional area which are available to any individual or group in need of
"36
assistance. Dale uses the term general staff to refer to those
elements which are concerned with managerial functions while specialized
^ibid., p. A02.
55 I b id . , p. 685.
-* Hutchinson, p. 66
113
staff departments is a term reserved for those units which perform
auxiliary work, relieving line executives of these burdens and allowing
them to concentrate on their primary task of management .^7 Keith Davis
refers to a trichotomy of the staff elements into advisory, service,
and control categories with the first involved as specialized counsel
to management, the second performing the facilitating functions, and
the third supporting management in its coordinative tasks.' Carzo
and Yanouzas look to the highly developed staffs which exist in
military organizations to note the parallel in any organizational
forms of the advisory and service categories of staff. ^°
Perhaps, the most comprehensive discussion of the peculiarities
associated with the facilitating functions performed within organizations
is provided by Koontz and O'Donnell. The facilitating elements, which
they label as service departments, are separate from both staff and line
in their association with other elements of the organization.^ Staff
and line connote organizational relationships while service departments
"5 7
-^'Ernest Dale, Organizations (New York: American Management
Association, 1 9^7) > p. 81 .
•30
Keith Davis, p. 17&.
■3Q
-^Rocco Carzo, Jr., and John N. Yanouzas, Formal Organizations;
A Systems Approach (Homewood, Illinois: Richard- if] i rwin , Inc. , 19o7) ,
Harold Koontz and Cyril O'Donnell, Principles of Management
(3rd Edition; New York: McGraw-Hill Book Co., 1964) , pp. 264-265.
^Ibld.
■-. .
•
ror . -. " . . - ... ~iCy
is rat ha
. . ...... r
in ti ."....
...
. nor , .
. t!
of s :s, • . .
■ ;re. ; \ ^ :
o _ . . . i n support
service d ..us
csa of ~- -ol or
..-. uc h a r< ... rd
r 'si .... -con Lrol"
"t of pur
.._..,'.
... in providing
" . ... ." ^.'
...'..:._...:..- vie
.... ■/:..- s;
.. . . y, .■ ror prac; a-
Fur.ct i or " .'._,
- _ . .. *. &a W ! tfl .....
... _ . > _ o . rune c » or; a .
.ci c . . . / ~. . roi c nc ut
..■:..■; ty of v,^^h
„..■,._... . . f
. . c .- ...... [za~ ions .:. ... tar
115
chapters .
Because service departments reflect a consolidation of tasks
performed throughout the organization an issue arises as to the degree
to which this centralization of activities should be carried. Once
a centralization of functions is suggested the decision must be ren-s
dered as to the organizational location of the service element. '
V/hen the service provided is diffused throughout the organization the
question is never raised as to what good organizational practice might
be in regard to these units. ^° Each line or staff manager is able to de-
cide how and when these functions may be performed in support of his
unit. With centralization these prerogatives are removed from the
individual manager's control.
In particularly large enterprises the calculus which determines the
relative benefits which will accrue from the differentiation and central-
ization of service units will weigh heavily in favor of such special izat ion. ^9
The opportunities for such centralization will be greatly increased under
these circumstances. However, the larger the organization, the more remote
the particular activity will become from any individual management unit.
^Ibid., p. 303.
^Ibid.
^ibid.
^3 1 bid.
50 1 bid.
116
It is, therefore, necessary to balance the economies and efficiencies
which such service departments may provide with the diseconomies and
inefficiencies resulting from the loss of control over these activities
by the operating executives .5"
One of the problems involved in utilizing this more modern analysis
of organizations which provides for service elements is in the distinc-
tion of the form of authority which these elements contain, Within the
more traditional concept the question of whether these elements have
line or staff authority must be asked, Mooney recognized this problem
in reference to organizational units which appeared to have both line
and staff characteristics, but offered no solution. ^2 McGregor appears
to classify the service departments as line' elements of the organization
because they emphasize the generalized managerial skills rather than
53
specialized professional skills normally associated with staff off icials . JJ
Koontz and O'Donnel, who have contributed the most to this form of
analysis appear to beg the question through their categorization of ser-
vice departments as groupings of activities rather than managerial roles.
It would appear that in the sense in which the service departments repre-
sent the bringing together of the tasks associated with operative perform
mance in both line and staff departments and the creation of a managerial
51 Ibid., p. 311.
5zMooney, p. 36.
53oouglas McGregor, The Human Side of Enterprise (New York; McGraw-
Hill B 00k Co., Inc., I960), p. 171.
^Koontz and O'Donnell, p. 296.
117
unit to coordinate these activities the authority which it employs must
be considered as distinct and subject to specific analysis in each
particular case.
;t is remarkable to observe that in the case of the typical hospital
organization the pure staff elements are relatively unevolved and remain
contained within the managerial elements of the organization. On the
other hand, the service elements appear to be well differentiated and
separated from the parent line organization. This may well be a result
of the relatively small size of hospitals as compared to business organi-
zations which manifest the development of staff elements as a function of
growth in the volume of business. 55 However, the degree to which the
service department concept has been employed in hospitals has no ready
explanation, and, therefore, this provides the possibility for discussion
of this phenomenon as a prototype characteristic of these organizations,
According to Davis, the failure of evolution of staff elements
merely reflects the accomplishment of the managerial functions in the
line executive positions.-30 In the hospital organizations, however, the
extensive development of service components appears to have diffused the
line management functions throughout the organization on an apparently
functional basis. This, of course, accounts for the relatively large
span-of-control which the administrator exercises in the hospital
organization when compared with American business. 57 |t will remain the
55r.c. Davis, p. 420
56|bid., p. 425.
57Dale, p. 95-
118
subject of analysis to determine whether this characteristic of the
hospital organization is amenable to explanation in the manner suggested
by Dale, who believes that either status aspirations or a sense of the
importance of a particular function of the unit causes extended spans of
management , or whether other factors are involved. 5°
As previously discussed, many hospital organizations provide a
separation of the functional departments into professional and business
segments by a level of administrative management intervening between the
administrator and the functional area managers. If the purely s-taff
advisory services which are rendered by the service departments were
considered alone it would be possible to detect a separation by this
mechanism of the line departments and the rudimentary staff functions.
The executive in charge of the business functions would then fit the
classification of chief-of^staf f provided in the military organization.
However, more than staff elements are involved in these service departs
ments in the hospital organization ^^ many of the managerial functions of
the line have been devolved rather than evolved to these units. By the
same token there are elements within the organizational segment under the
professional classification which contain similar advisory functions to
line management which would be excluded from the staff grouping suggested.
It would therefore appear, as outlined by Rosenberger, that no logical
basis exists for this broad dichotomy of the hospital organ izat ion. 59
58
Ibid. , p. Sk.
59Donald M. Rosenberger, "A New Look at Hospital Organizations,1
Hospitals, XXXVI (February 1, 1962), 45-46.
119
Various outlines of the structural organizations of general
hospitals are provided in the literature with associated functional
statements concerning the duties assigned to the various elements. °0
Perhaps the most authoritative of these outlines is that provided by
MacEachern. Utilizing this outline it is possible to categorize the
various hospital departments into five segments based upon the functions
which they are assigned; these are; line, staff, service departments,
line and service departments, and staff and service departments. In the
first category, as discussed in the previous chapter, are the nursing
and ancillary departments. Among the elements discussed by MacEachern,
only one, the public relations director, can conceivably be classified
as being a pure staff function; however, this function cannot be con<--
sidered as a differentiated unit in the typical hospital.
There are numerous differentiated hospital departments which can be
conceived of as typically service departments. These would include the
medical library and the admission unit on the before mentioned professional
side of the house and the utilities and maintenance department in the
category mentioned as business affairs, along with housekeeping, laundry,
and information. Both the accounting^-purchasing-supply elements and the
personnel department would be considered as combined staff and service
"^Representative of these outlines are: Esther Lucile Brown,
Newer Dimensions of Patient Care: Part 2 (New York: Russell Sage
Foundation, 19o2) , pp. 57~60; and, American Hospital Association,
Uniform Chart of Accounts and Definitions for Hospitals (Chicago:
American Hospital Association, 1959) •
^Malcolm T. MacEachern, Hospital Organization and Management
(Berwyn, Illinois: Physicians1 Record Company, 1962).
120
departments. One department, food service, could be included as being
both a line and service department in nature, if it is recognized that
this department is directly involved in the primary service objective
to the extent to which it provides special diets as ordered by a
phys ic ian.
Both of the combined staff and service departments found in the
typical hospital organization contain the potential for the separation
of the advisory and activity aspects of their function. In American
business the personnel department as a service activity is often found
separated from the staff advisory service of industrial relations. This
is often a reflection of the increased managerial attention required when
the work force is organized as a bargaining unit. Likewise, the routine
physical functions of accounting are more likely to be a service activity
with the advisory control staff as a separate element in the organization.
When this separation is accomplished the staff elements are normally
located as an advisory area of top management allowing the service
activities to direct their routine activities at a lower level, perhaps,
on a more decentralized basis throughout the organization. Undoubtedly
there is a factor of size which it would seem prevents such separation
in the typical hospital organization; however, as the magnitude of the
problems associated with personnel planning and management control become
more aggravated, which situation appears to be developing in the case of
American hospi ta Is today , such staff elements may be indicated.
Such an arrangement will permit the hospital administrator to
121
maintain the uniquely large span-^of^control which allows for direct
interaction between the top executive and the operating departments.
As outlined in the previous chapter, the present arrangement which
introduces the assistant administrator as an intervening level between
the administrator and the various department organizations provides
a poor substitute for a more typical staff arrangement. Creating an
artificial separation between the business and professional areas of the
hospital organization is in reverse of the coordinative requirements
which are apparently needed between them. The hospital is comparable to
a village or a ship which is complete unto itself -- to splinter the
cooperating entities into segments which then group unlike functions has
little to commend it. The rush toward professional administration in
American hospitals undoubtedly created a gap in the availability of
trained and experienced persons to fill these positions; however, this
situation has been alleviated to a great extent, and to continue the
practice of utilizing what should be valuable staff positions as a
training ground for inexperienced "general ists" is in wasteful ignorance
of the real problems which the hospital faces. The American health care
system has gained the time, or if not it must, to provide a career based
upon well-rounded experience throughout the various hospital departments
and meaningful staff positions for its future administrators much in the
same manner as business managers are developed in American industry.
This chapter and the previous two have attempted to provide a
perspective of hospital organization. With this basis it is now possible
122
to investigate a few of the salient arguments which have been advanced
in regard to the anomalous nature of these organizations , and to look
at these contentions from a modified point of view which adheres more
closely to the universal organization. It will then be possible to
analyze the hospital organization for its prototype characteristics and
investigate the ramifications of these characteristics as items of
managerial concern.
CHAPTER V
AN ANOMALY: LINE IS STAFF AND STAFF IS LINE
Amitai Etzioni has argued that the hospital organization is
basically dissimilar from that of the universal organization described
in the management literature. He asserts that in the universal struc-
ture the line of the organization, the executives, are identified as
managers while the staff are experts. The staff has no direct authority,
but, rather they act as advisors to the line or have limited authority
over specified, functional areas. Managers, because they direct the
major goal activities of the organization, are awarded line authority,
while experts deal only with the secondary activities which are means
to the organizational goals and therefore are limited in the authority
which they can exercise. 3 Etzioni further insists that the role of the
expert is the creation and institutionalization of knowledge while the
manager's role is the integration of organizational systems directed
toward the major goal activities of the organization.^ Because of these
differences in roles the expert and the manager will differ in their type
of personalities. The expert will have a limited perspective and will be
^Amitai Etzioni, "Authority Structure and Organizational Effective-*
ness," Administrative Sciences Quarterly, II (June, 1959), ^3-^7-
2lbid., p. 45.
3 1 bid.
*Hbid., pp. 45-46.
123
124
committed to abstract ideas and therefore will be less practical.
The managers, on the other hand, will have an extensive, though limited
knowledge of many areas, and with this broader perspective will tend to
be more skilled in human relations. Overall, the manager will be a
general ist while the staff man will be a specialist.
As a consequence of these factors the manager will tend to identify
with the goals of the organization and obtain his personal values from
the organization itself. The expert will have internalized the values
of his specialized field and identify himself with others of his
specialty outside of the particular organization. As a consequence the
expert will be more transient to the organization while the manager will
view his career as within the particular organization.' It is therefore
not surprising to note that managers rather than experts will rise to the
o
top executive position, and so appear, in nost organizations.
This phenomenon is most frequently found in American business
organizations because of the nature of the profit objective in these
institutions." As long as the objective of the organization is not the
service or utility created and with which the expert can identify then no
other structure can produce the results desired. Profit accrues from the
5lbid., p. 46.
6lbid.
7lbid., pp. 46-47.
8 1 b Id . , p. 48.
9 i b id. , p. 49.
25
success of the integrative efforts of the manager; his ability to
coordinate the effots of many experts in the production of a product
or service in the most successful manner. '^ When the expert attempts
to lead the enterprise the values of his specialized field intrude upon
the economic values of the organization.'' "Manager orientations and the
institutional goals of private business seem to match."'2 "When an
expert orientation dominates, this is dysfunctional to the organizational
purpose." ^
Etzioni sums up the salient characteristics of the structure of
business organizations by stating that: "Managers direct the major goal
activities and have the major authority; experts deal with means and are
1 k
in minor and subordinated authority positions." He questions the
universality of this concept of organization beyond the business enter-
prise and suggests that although political and religious organizations
appear to conform to this structure it is by adaptation, and, therefore,
it is ill-suited to the situation.^ However, other organizations clearly
deviate from this mode of structure and conform to an organizational
arrangement more nearly suited to their purpose. These he identifies as
1 A
professional organizations. D
iQibid.
11 Ibid. , pp. ^9-50.
1 2lbid. , p . 50 .
1 3i bid.
Ifrlbid., p. 51 •
15j_bj_d_.
16 1 b i d .
126
Professional organizations have as their major goal the creation
and institutionalization of knowledge.'' These organizations would
include various research institutions, universities, schools, and
hospitals which contain these values as their primary goals. " Research
inst i tututes and universities are concerned with the creation of knowl-
edge, universities and schools with the spreading of knowledge, and
hospitals with the application of knowledge. "
In these professional organizations the roles prescribed for the
universal structure appear to be reversed. 20 The major goal activity of
these organizations is expertness, while managers in these structures
are mainly concerned with the secondary activities. While Etzioni
questions the concepts of line and staff in these structures, if such
22
exist, the roles have become exchanged in these organizations.
Managers in professional organizations provide advice about the economic
and administrative implications of various proposed actions, but the
expert, the professional, through the specialized knowledge of the
objective of the organization, decides what action will be taken, 23
Etzioni notes that many of the objections leveled against experts
1 7 i b T d .
l8!bid.
PP- 5
19|bid.
20|bId.
p. 52
21 Ibid.
22Ibid.
23|bid.
127
in private business are also manifest against administrators in
professional organizations.2^ The specialist in the business organi-
zation is accused of having a limited perspective and trained incapa-
city. In the professional organization the administrator is criticized
for holding the values of economy and efficiency over that of the primary
objectives of the organization. -> In the business organization an over-
influence on the part of experts threatens both the organizational
objective and even the existence of the firm. In professional organic
zations over- inf 1 uence by administration undermines the goals of the
organization and inhibits the conditions for the creation and application
of knowledge. 27
These arguments of Etzioni are reiterated and to some extent
amplified in his later writings. 2° Other earlier authorities have
suggested various aspects of this same thesis. Parsons has commented upon
2<5
this phenomenon of reversed roles in regard to the university organization. •*
2k
Ibid.
25|bid.
26lbid., p. 53-
27|bid.
28
Amitai Etzioni, A Comparative Analysis of Complex Organizations
(New York: The Free Press, 1961); and, Modern Organizations (Englewood
Cliffs, N.J.: Prentice-Hall, Inc., 1964T
"Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organizations -- II," Administrative Sciences Quarterly, I
(December, 1956), 236.
128
Hall has commented upon the predominance of technical personnel in
the hospital organization as an anomaly of these structures .3° Brown,
in essential agreement with Etzioni, concludes that this manifestation
within hospital organizations is basically part of the argument concern-
ing the existence of two lines of authority which will be considered in
the next chaper. Gordon, while considering this thesis has contested
the argument in regard to specialists and general ists by arguing that
the parties involved in hospital organizations often defy these categori-
zations.-^
While much of Etzioni 's argument is based upon the role of the
physician in the hospital organization a simple reiteration of the
argument presented in Chapter III will not dispel the implications provided
by this thesis when the overall participation of professionals in these
organizations is recognized. Many of the present occupants of positions
within the hospital organization are professionals at the present time
and many other groups are actively seeking such recognition by the
development of the value system and science-based background usually
associated with the specialist. Although Etzioni indicates that the
3°0swald Hall, "Some Problems in the Provision of Medical Service,"
Canadian Journal of Economics and Political Science, XX (195^), ^58.
^Esther Lucile Brown, Newer Dimensions of Patient Care: Part 2
(New York: Russel 1 Sage Foundation, 1962) .
32Paul J. Gordon, "The Top Management Triangle in Voluntary
Hospitals (11)," Academy of Management Journal, V (April, 1 962) , Ik.
129
organizational situation is different when the line is composed of
semi-professionals the tendency is toward the emergence of full
profess ional izat ion for these groups. 33
This drive for profess ional ization by internal members of the
hospital organization is related in many accounts; one of these, which
first appeared as an editorial, has been included by Vollmer and Mills
in their work and recounts the striving for such status by the occupa-
tional grouping which has come to take the title of medical technologist. 3**
Goode questions the feasibility of realization of the aspirations of many
of these groups including the nurses and the pharmacists; however, he
maintains that the final decision rests with the public which is served
by these ind i vidual s . 35 |t would appear that as long as these occupations
remain free to define themselves and to take the steps which lead to
professional recognition the possibility for public acceptance of the
desired status exists. 3° The main block to recognition of the aspiration
of these occupations could either come from the organization which
53
Etzioni, Modern Organizations, p. 87.
3^"Medical Technology," Profess ional izat ion, eds. Howard M.
Vollmer and Donald L. Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc.,
1966) , p. 20.
35william J. Goode, "Community Within a Community: The Professions,"
American Sociological Review, XXII (April, 1957), 36.
36,
bid.
130
utilizes their skills or the customers of these organizations as
comprising their public. Bloom maintains that the physician as the
customer of the hospital organization appears to encourage the aspira-
tions for professional status on the part of the nurses by more and
more acceeding to the contention that the body of knowledge which is
nursing may be separate from that of medicine, and the physician is
increasingly relying on the nurse and other skilled persons within the
hospital organization to perform their tasks independent of the doctor's
direction.-^' If this tendency continues these occupations may well gain
the monopoly of judgment which Greenwood ascribes to the profess ional .3°
It cannot be denied that the line of the hospital organization
consists of specialists. Georgopoulos has outlined the degree to which
nursing has gained an expertise beyond that which had traditionally
applied, and he maintains that nursing, like many other professions, is
continuing on a trend toward sub-specialization along with many other of
the occupations employed in the hospital organization. 39 However, the
employment of experts in the line organization as managers is not unique
to the category of structure which Etzioni has labeled as professional.
■^'Samuel W. Bloom, The Doctor and His Patient (New York: The Free
Press, 1963), p. 91.
^"Ernest Greenwood, "Attributes of a Profess ion ," Profess ional i ^
zat ion, eds. Howard M. Vol lmer and Donald L. Mills (Englewood Cliffs,
N.J.: Prentice-Hall, Inc., 1966) , p. 12.
3°Basil S. Georgopoulos, "The Hospital System and Nursing: Some
Basic Problems and Issues," Nursing Forum, V (1966), 26.
131
Woodward has noted that specialists often have line roles in the
business organization. " She maintains that no matter how specialized
an executive might be from a knowledge and skill point of view, he remains
a line manager if he is responsible for specific end results.^' Litterer
has indicated a similar conclusion by emphasizing that a line or staff
designation is not dependent upon any inherent characteristics or unique
properties of the position or the individual, but, rather, such designa-
tion is determined by the relation of the position to organization
goals. ^ just as the line designation is not a result of a characteristic
general ist background in the case of the line executive, the staff member
must not necessarily have a specialist point of view. R, C. Davis has
remarked that while it is true that technical staffs are generally com-
posed of specialists the higher reaches of these branches are often
composed of executives with a much broader perspective. ^3 |n the case of
the coordinative staff executives, they are most likely to have a general-
ises orientation toward the organization. 4 The executive concerned with
organizational control will have characteristics and a viewpoint which is
^Ojoan Woodward, Industrial Organization : Theory and Practice
(London: Oxford University Press, 1965) , p. 100.
^Ibid.
^2Joseph A. Litterer, The Analysis of Organizations (New York:
John Wiley and Sons, Inc., 1965) , p- 33^-
^3Ralph Currier Davis, The Fundamentals of Top Management (New
York: Harper and Row, Publ ishers, 195D , p. 39^-
^Ibid.
132
closely akin to that of the line.
It would appear redundant to again attack the profit objective which
is a point in Etzioni's argument for this has already been well treated.
However, if this primary profit objective of business organizations were
accepted it would only be changed so that in non-profit organizations
46
the line would be directed by other objective motivations. While Dale
maintains that this motivation would be the welfare of the public served,
this could be amplified to state the highest quality and quantity of
welfare at the lowest possible cost. ' It would still be necessary for the
line executives to perform the integrative functions necessary to coordi-"
nate the total endeavor in satisfaction of this objective.
Professionalism has its impact upon the structure of organizations in
a way more subtle than that described by Etzioni. The specialization
which he describes as typical of staff in the universal organization is a
result of the increased complexity of the line management functions of
planning, organizing, and controlling and the need for the specialist's
expertise in these areas. The use of staff is but a special way of dividing
up managerial work. To some degree there are alternatives provided for
^lbid. , p. 410.
Ernest Dale, Organizations (New York: American Management Associa-
tion, 1967) , p. 61 .
^Ibid.
William H. Newman, Charles E. Summer, and E. Ki rby Warren, The
Process of Management (2nd ed. rev.; Englewood Cliffs, N.J.: Prentice-Hall,
Inc., 1967), p. 101.
133
overcoming the obvious complexities of the management function as are
discussed in the previous chapter. Devolution of line authority should
obviously be considered in these situations. Newman, et a! . , warn
that staff and service units, while relieving the complexities of manage-
ment, are tributary to the mainstream of management, and inevitably com-
pl icate an organization structure. ° A manager should see a clear
advantage in utilizing staff elements, for simplicity is a virtue in
organizing an enterprise.-*0 The criterion by which an auxiliary unit is
justified is basically the assurance that adequate attention will be
provided to a secondary operation by establishing a technical competence
outside the specialty of the operating executive through such a unit,
thereby, relieving the busy executive from minor chores that otherwise
would be a nuisance. ->'
All of this is relatively straightforward. There are alternative
arrangements of structure which will insure the satisfaction of the
primary objective and it remains to management to make such selection.
The real question, however, is the determination of the point where the
chores of management become so onerous that they detract from the primary
service values of the organization. It would appear that the hospital
organization provides some special insight on this topic for it appears
49 i b Id . , p. 126.
50|bid.
51 Ibid.
134
that a heavy specialization in the line organization, and more accu-
rately -- advanced professional ization, has created a unique applica-
tion of the principles involved.
Etzioni has remarked within a different context from the argument
which is now being discussed, that when people with strong professional
orientations take over managerial roles, a conflict between these roles
and their professional orientation usually occurs.52 As the nurses and
ancillary personnel strengthen their professional identification using
the ever apparent physician as their model they tend to pattern their
regard for the managerial tasks associated with their roles as somehow
detracting from their status much in the same manner of the doctor. 53
This disinclination to accept the chores of management is usually expressed
as a desire to emphasize the clinical work and the direct patient func-
tions which is the heart of their professional identification.5^ Various
schemes have been derived to relieve the nurses, for one, of the tasks
of management.55 The evolution of the managerial functions to staff and
the devolution and separation of the auxiliary management tasks in the
case of the hospital organization can be considered as a function of the
52
Etzioni, Modern Organizations, p. 79.
53Hall, p. 461.
"Basil S. Georgopoulos, "Hospital Organization and Administration:
Prospects and Perspectives." Hospital Administration. IX (Summer, 1964), 31
rr
H ,, +J-Ulher.P' Cnristman and Richard C. Jelinek, "Old Patterns Waste
Half the Nursing Hours," Modern Hospital. CVI I i (January, 1967), 78-81.
135
limited managerial orientation of the line executiyes which is typically
found in the professional organization. Complexity of the managerial
functions would be expected to occur at an earlier stage in these organic
zations due to this orientation of the managerial incumbents away from
managerial concern. Evolution of staff elements and devolution and
separation of service elements would both appear earlier than in the
universal organization and be deeper in structure at any point in the
growth of comparable organizations. Woodward supports this contention
by noting the same phenomenon in what she describes as the organic organ i"
zations which were identified in her investigations of industrial organi-
zations. 5° She has remarked that under these circumstances the line of
the organization appears to be disintegrating as executive respons i bi 1 i«
ties are more extensively being conferred upon specialist staffs. 57
Pure staff evolution, however, should not provide the manifestation
of formal authority exercised by the staff which would be central to
the thesis advanced by Etzioni, that roles have become reversed. Apparently
the observations of Etzioni are directed toward the functional authority
exercised by the service departments exclusive of their staff roles.
Staff elements of an organization may gain some degree of informal autho-
rity by the nature of their specialized knowledge or their location in
association with higher level executives; however, this is relatively easy
^"Woodward, p. 65.
57lbid.
136
to recognize and rectify where necessary. 5° The functional authority
of the service unit, however, is of the line variety through its
devolution from a line function as an operative management task. 59 Staff
and service elements because of their frequent combination are often
confused as to the type of authority which they exercise, ° Again,
Koontz and O'Donnell are referred to for their clarification of staff
as an organizational relationship and service departments as an activity
of organ izations. '
The creation of the service department entity is a process of
devolving line authority for specific managerial tasks and separating it
from the line of the organization for independent grouping and accomplish-*
ment under the imperatives imposed by the secondary service objectives of
efficiency and economy. ^ Woodward has remarked on the non<--staff charac-
teristics of these service elements and their impact upon the coordinative
5°Douglas McGregor, The Human 'Side of 'enterprise (New York; McGraw->
Hill Book Co., Inc., I960) , p. 30.
59rocco Carzo, Jr., and John N. Yanouzas, Formal Organizations; A
Systems Approach (Homewood, Illinois; Richard D~ I rw i n f I nc. , 1967) ,
p. 55.
60
Newman, et al . , p. 116.
"'Harold Koontz and Cyril O'Donnell, Principles of Management
(3rd edition; New York: McGraw-Hill Book Co. , 1964) , p. 292
John G. Hutchinson, Organizations: Theory an
(New York: Holt, Rinehart and Winston, 1967) , p. 3%
^John G. Hutchinson, Organizations: Theory and Classical Concepts
137
process in the industrial organization.^ |t appears obvious to the
service department specialist that he should have control, and therefore
authority, over the functions for which he is responsible. However,
this allocation of authority is not without its consequences. Scott
indicates that such grants of authority are clearly not envisioned by
traditional theory which maintains the concept of unit of command which
appears to be violated by functional authority. "5 |n the business opera"
tion the splitting off of management tasks is usually viewed with concern
by line managers for they see their authority being removed while they are
still largely held responsible for results, ° Line managers find them-^
selves remote from vital functions necessary for their operations. 7
In the hospital organization the decision to specialize and
differentiate some aspect of the managerial tasks of line executives is
welcomed through its affinity to the professional role to which the line
adheres. Yet the complaints which are exercised over specialist
supervision and the difficulty involved in coordination of the line
63
-^Woodward, pp. 166-167.
^Davis, pp. 458-459.
0->William G. Scott, Organization Theory: A Behavioral Analysis for
Management (Homewood, I 1 1 inoi s : Richard D. I rwin Co. , 1967) ,
p. 116.
66Koontz and O'Donnell, p. 310.
^Newman, etal . , p. 128.
138
functions is much the same in the business organizations ,°° The logic
of functional izat ion of managerial tasks is as clear as when first pro-
nounced in the writing of F.W. Taylor. 9 To argue that these elements
are staff in nature denies the apparent fact that the work of the
service units is not advisory.™ Keith Davis has commented that the
benefits of functional izat ion are largely economic, but its disadvantages
are primarily in human relations.'' If these economic advantages are
additionally weighted by the imperatives of profess ional i zat ion the
explanation of the intensive functional izat ion of managerial tasks in
hospital organizations is understandable. It will remain for a later
discussion of the prototype characteristics of the hospital organization
to determine whether the human relations disadvantages of such structural
elements are adequately counterbalanced.
It then appears that the reversal of roles which Etzioni notes in
professional organization, particularly the hospital organization, is
less a function of the specialist characteristic of the professional but
more an acceleration of a structural process which is well recognized in
the management literature. Rather than ascribing a line role to the
68Brown, p. 71.
"Carzo and Yanouzas, p. 5^.
7°Woodward, p. 167.
'Keith Davis, Human Relations at V/ork (3rd ed. rev.: New York:
McGraw-Hill Book Co. , 1967) , p. 173.
139
staff elements, the service departments have developed with the
necessary functional authority to perform their assigned tasks. As a
body these staff elements may appear to encompass the general ist role
but individually their perspective is limited to the special ists ' s tasks.
As is indicated the concern over the devolution of functional
authority to service elements is not peculiar to the professional
organization. McGregor's significant work builds upon a theory of
control which is essentially the domain of the staff and service groups
72
in the business organization. His conclusions provide, in a manner
dissimilar to Etzioni's argument, that a reversal of line and staff
73
roles has occurred in the industrial organizations of this country.
That is, the line -- the central and fundamental authoritative chain-of-
command -- is becoming increasingly dependent upon tne proliferating
specialized staff groups.' In an even stronger statement, Galbraith
has taken the position that the government- industrial complex which
dominates the American scene is ruled by the "technostructure" of these
organizations. '•' Through analysis this "technostructure" is revealed as
the staff and service element of these organizations. On this basis
72McGregor.
73lbid., p. 155.
7Sbid.
'^John Kenneth Galbraith, The New Industrial State (Boston:
Houghton Mifflin Company, 1 9^7) -
140
alone it could be argued that Etzioni's thesis merely supports the
contention that the hospital organization is of the universal structure.
In spite of this recognition of a changing organizational structure
which these authors reveal it is apparent that the hospital has been
influenced by this dynamic process to a more advanced degree than the
modal organization. Woodward's studies of industrial organizations in
England, while perhaps not representative of the American situation,
indicate that the development of organic forms of organization with an
adherence to a structure of functional authority are but the leading
edge of all organizations.'" In the hospital organization the degree to
which devolution and separation of managerial tasks has taken place is
remarkable. However, it is questionable whether even advanced devolution
of authority over these tasks, with separation and elevation of these
functions within the organizational hierarchy, can develop a complex of
functional authority which would outweigh the remaining operative
management functions of the traditional line of the organization."
What is being observed in the hospital organization is a mode of line
'"Woodward, p. 65.
''R.C. Davis, pp. 14-15; provides that executive management is
divisible into two categories: administrative and operative management.
The latter is essentially the management of groups -- the face-to-face
work of the manager as the leader in the accomplishment of the day-to-
day tasks of the organization. Administrative management is the longer-
range project tasks which must be undertaken by management. The con-
tention is here that administrative management is more amenable to
staff and service department separation.
141
and staf f^service department separation peculiar to advanced profess
s ional ization within an organization. To the degree in which other
organizations experience the same influx of professionals this phenomenon
is indicative of the tendency of the universal organization. The profes"
sional character of the contained occupations encourages this form of
devolution and separation and the organistic nature of the hospital
structure has not been restrictive of the tendency. In other forms of
organization with more traditional outlooks this dispersion of the
management functions has been more inhibited.
This explanation of the phenomenon observed by Etzioni, and in
other respects by McGregor and Galbraith, is not beyond the pale of
existing organization theory and its structural dynamics. It is main^
tained that the structure of the universal form of organization has
been adapted in the professional organization along the lines suggested
by this theory. The dynamic process has been extended beyond the bounds
normally encountered in the typical organization but the logical exten-
sion is apparent. This raises new problems for the prototype organization,
but it also suggests the success of the theory as a basis for the prin^
ciples of management.
CHAPTER VI
AN ANOMALY: TWO CHAINS OF COMMAND
The second major contention of an anomaly of hospital structure
which sets this organization apart from the universal organization is
what Harvey L. Smith has described as the basic duality of hospitals.
He maintains that two main lines of authority <v lay and professional «"•
exist in the hospital. The one is that hierarchy which extends from
the trustees through the administrator and the department heads to the
various categories of hospital workers. 2 While the second line of
authority is composed of the various roles held by professional persons
in the organization •*« especially the physicians. 3 The physician, or
anyone acting for the physician, can abrogate or countermand any direct
tive or order which emanates from the administrative hierarchy. While
the physician may have little formal authority in the organization his
actual authority is very great indeed.-5
The physician and his agents including the nurses and other ward
'Harvey L. Smith, " Two Lines of Authority Are One Too Many,"
Modern Hospital , LXXXIV (March, 1955), 59-64.
2lbid., p. 59.
3| bid.
^1 bid.
5|bid.
142
143
personnel have the capability to exert power throughout the hospital
structure. Some areas appear to be reserved for administrative rule,
others are reserved for professional rule, while still other areas of
the organization are best described as hybrids. It is in this last
area that the many conflicts of jurisdiction arise.
This phenomenon of dual authority is not entirely unique to
hospital organizations. Other human structures which contain profes-*
sional competence appear to manifest many of these same features, with
the university providing a ready example.' This situation is the result
of attempting to handle two different principles of administration within
one organization. The more typical organization functions through the
exercise of bureaucratic authority " which the management theorists would
describe as formal authority. In the hospital organization, as typical
of professional organizations, this authority is accompanied by a measure
o
of charismatic authority in the hands of the professionals. The primary
characteristic of charisma in the hospital organization is its defiance
of administrative regulation. ° These posessors of charisma resist being
encompassed in the bureaucratic organization JO It is the special problem
of the hospital that it is an administrative structure which must contain
and regulate charismatic professional persons who are defiant of lay
6
Ibid.
7|bid.
8lbid.,
, pp. 59-60
9|bid.,
, p. 60.
°l bid.
144
regulation.11 Therefore, both the administrators and the professionals
are authoritative figures but for different, and conflicting reasons.12
Smith recalls the observations of Barnard who provided that two types
of status exist in all organizations.^ Scalar status is that which is
inherent in a position in view of its hierarchical rank.12* Functional
status accrues, on the other hand, from the nature of the work performed
which may not be limited to the particular organization.^ |n organiza-
tions orders generally emanate from those who have higher status than the
recipient. However, in the hospital organization a person may be subordi-
nate to two or more individuals who have either higher scalar or functional
authority.16 This duality of authority is matched by a basic duality of
purpose within the organization itself ., that is, whether the objective
of the organization is of a service or business variety. '7 Employees are
therefore confused by the conflicting demands of "money" and "service"
being issued in the forms of orders by persons with either scalar or
functional authority.
On another basis of duality which Smith observes in the hospital
structure he anticipates the argument presented by Etzioni which was the
"Ibid.
l2lbid.
13lbid.
"ibid.
■Slbld.
16
Ibid.
]7|bid.
H5
topic of discussion in the previous chapter. He notes that the physicians
are referred to as the staff but their authority is not typically advisory.
While they are labeled as staff they intervene with authority of adminis-
trative rules and procedures. ° And while they are staff they are responsibl'
for the major goal activities of the organization. 20
While Smith presents many of his arguments in terms of the physician's
role in the hospital he does not limit the duality of structure which
appears to exist to this group. He makes specific mention of the various
professionals, or emerging professions, which play their part in the hospi-
tal structure, and he attributes to them the same characteristics of the
physicians in regard to the appearance of two lines of authority. 2^ Each
of these professional groups within the hospital structure manifests the
charismatic behavior noted in the case of the physician. * Unlike the
workers in industry who organize and express demands for money without
altering the administrative authority structure the proton-professionals
of the hospital organization develop professional group relationships
which ask for changes in status and recognition which is the essence of
the internal hierarchy of authority. 3 it is therefore, as in the previous
argument in regard to the anomalous structure of hospital organization,
18 I bid. '
1 3l bid.
20lbid.
21 Ibid., p. 63.
22lbid.
23lbid.
146
impossible to dispel the contentions of this position held by Smith by
reiterating the fact that physicians are not of the organization.
The arguments presented by Smith in his article have been well
received and appear in many citations by other authorities. Wessen has
carried this apparent structural anomaly down to the ward level of the
organization but amplifies it to encompass the entire range of functional
authority exercised in hospitals, ^ Georgopoulos and Mann incorporate
this argument as a basic factor in their work. 5 /\nd Georgopoulos main-
tains the argument in his later work. ° As mentioned before, Etzioni has
employed this argument in support of his contention that the line and
staff roles are reversed in hospital and other professional organizations. '
However, at a later point in time he appears to accept that what is being
discussed, at least in the case of physicians, is essentially two parallel
?8
organizations.
Albert F. Wessen, "Hospital Ideology and Communications between
Ward Personnel," Patients, Physicians and Illness, ed. E. Gartly Jaco
(New York: The Free Press, 1958), pp. 451-452.
-•Basil S, Georgopoulos and Floyd C. Mann, "The Hospital as an
Organization," Hospital Administration, VII (Fall, 1962), 59
26
Basil S. Georgopoulos, "The Hospital System and Nursing: Some
Basic Problems and Issues," Nursing Forum, V (1966), 14.
'Amitai Etzioni, "Authority Structure and Organizational Effec-
tiveness," Administrative Sciences Quarterly, Iv (June, 1959), 59.
28
Amitai Etzioni, A Comparative Analysis of Complex Organizations
(New York: The Free Press, 1961) , p. 225.
147
Further citations of Smith's argument are made by other authors.
Scott has used this thesis to advance the propostion that the amount of
conflict between the professionals and administrators is reduced in
those organizations which contain professionals of high versus low
prestige. " And, Bloom, by adding a third, and separate, authority
source to the situation, specifically the trustees, maintains that two
of these power groups often enter into cooperative agreements to offset
the relative power of the third authority. '0 Somers and Somers, employe
ing Bloom's extension of the argument, incorporate the concept of an
anomalous structure in voluntary general hospitals into their call for
reform of the health care system. 3'
The significance of Smith's argument is contained in the traditional
edict of organization theory that there must be unity of command in an
organization if the objective of the enterprise is to be attained. **■
Scott, in particular, addresses himself to this aspect of Smith's
-'W. Richard Scott, " Professionals in Bureaucracies ^ Areas of
Conflict," Professional ization, eds. Howard M. Vol lmer and Donald L.
Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1967), p. 275.
-* Samuel W. Bloom, The Doctor and His Patient (New York: The Free
Press, 1963) , p. 162.
3'Herman Miles Somers and Anne Ramsay Somers, Medicare and the
Hospitals: Issues and Prospects (Washington, D.C.: The Brookings Institute,
1967), p. 51.
Henri Fayol , General and Industrial Management (London: Sir
Isaac Pitman and Sons, Ltd., 1949), pp. 24-26.
148
position. 33 While Carzo and Yanouzas discuss the obvious dissimilarity
between the hospital organization and the universal structure in the same
context, harking to many of the warnings expressed by traditional theory
in this regard. 3^
Starkweather is perhaps the only writer who has attempted to answer
the argument from a managerial theory point of view. 35 He visualizes the
two lines of authority presented by Smith as being cooperative systems
running on parallel tracks. 3° The link between the two systems, much as
in the case of railroad tracks, are ties which bind the lines together,-"
The ties which are common to all organizations and in this case to the
two separate line organizations are the functions of management. There"
fore, in the case of the hospital organization the physicians and the
administrators have a common objective of service and each is utilizing
the functions of management to further that objective. 3° However, the
two lines can be thought of as sharing the one set of management functions,
just as the rails of a railroad share the common ties
39
3-^WilliamG. Scott, Organization Theory: A Behavioral Analysis
for Management (Homewood, Illinois: Richard D",~ I rwjn Co. ,' 19(S7), p. 108.
34Rocco Carzo, Jr., and John N. Yanouzas , ' Formal Organization : A
Systems Approach (Homewood, Illinois: Richard D~ I rw i n , Inc. , I967) ,
p. 44.
-^David B. Starkweather, "The Classicists Revisited," Hospi tal
Administration, XII (Summer, I967), 69-8O.
36lbid., p. 70.
37 Ibid. , pp. 70-71.
38lbid., p. 71.
39 Ibid . , p. 73-
149
In one area of the functions the physicians may command more of the
decision-making area while in another, less. The tendency will be for
the two lines of administrative and medical staff power to balance off,
one-wi th-the-other , in the exercising of the management elements. '
Even if the doctors are accepted as a portion of the internal
organization it would be unnecessary to defend the traditional concepts
of unity of command in the eyes of many organizational theorists. Simon
maintains that the unity of command described in the typical traditional
theory has never existed in any administrative organization. And, Dale
describes various situations in the business organization which clearly
are violations of the concept of unit of command yet which are considered
as necessary for the effective functioning of particular organizations. 3
Even R. C. Davis constructs a similar concept for the universal structure
in an organization having experienced extensive staff evolution with the
creation of administrative and operative management lines of authority.
Another variation on the theme of two lines of authority contained
^°lbid.
k] Ibid., p. 78.
42 ,
Herbert A. Simon, Administrative Behavior (2nd ed.; New York:
The Free Press, 1957) , p. 25.
■^Ernest Dale, Organi zat ion (New York: American Management
Association, 1967), pp. 9 1 -94 .
Ralph Currier Davis, The Fundamentals of Top Management (New
York: Harper and Row, Publishers, 195U, pp. 439-443.
150
within an organization is provided by Katz and Kahn.^-> They maintain
that all social organizations contain an executive and a legislative
function. Some organizations fuse the executive function concerned
with the execution of policy and the legislative function concerned with
the establishment through common consent, of this policy. ' In the
business organization this is typically true. ° in other organizations,
for example, the university, these functions are separate. " The faculty
determines policy and the administration executes it. Urwick has made
the same observation, and has taken much the same position, at an earlier
time. 5°
It should be noted that an acceptance of the doctor as a part of the
hospital organization is not a universally held concept, however, much
that would affect the argument made in relationship to the two lines of
authority in these organizations. Hall, for one, holds the view that the
physicians are outside of the hospital organization; however, this does
not make it any less necessary that cooperative behavior be exercised by
-"Daniel Katz and Robert L. Kahn , The Social Psychology of Organiza-
t ions (New York: John Wiley and Sons, I nc. , 1 966) , p. 45.
^6lbid.
^ibid.
Mlbld.
**9|bid.
•* L. Urwick, The Elements of Administration (New York: Harper
and Row, Publishers, 1943) , p. 54.
151
the parties to the healing process. 51 Lentz makes much the same point
in indicating that the physician's prestige may be on the wane in regard
to it providing him with the authority necessary to accomplish his tasks
as an independent practioner.-*2 Brown takes a position close to that of
this essay that the physician is external to the hospital organization
and, therefore, perhaps in a competing chain-of -command. 53
Whether the physician is excluded from the hospital structure,
therefore attributing the power which he exercises in the organization
to that expected of the customer, albeit a customer powerful in prestige,
it is still necessary to accept that an authority is held by those
professional persons who are legitimately described as of the hospital
organization. However, before dealing directly with this subject it is
necessary to consider some aspects of the customer-organization relation-
ship which exists when the physician is considered external to the
organization. Etzioni in an earlier article noted that the hospital
organization accommodated to the prestigious physician as a customer through
a process which has been described by Selznick as co-optation. 5** Selznick
argues that if an organization faces a power problem in its internal or
-> Oswald Hall, "Some Problems in the Provision of Medical Services,"
Canadian Journal of Economics and Political Science, XX (195*0, **59-
52
Edith M. Lentz, "Hospital Administration -- One of a Species,1
Administrative Sciences Quarterly, I (March, 1957), 459-^60,
-'■'Esther Lucile Brown, Newer Dimensions of Patient Care: Part 2
(New York: Russell Sage Foundation, 1 962) , p. 65-
-^Amitai Etzioni, "Administration and the Consumer," Administrat ? ve
Sciences Quarterly, III (September, 1958), 260.
152
external environment it will attempt to resolve the situation by incor-
porating the dissident element into the body of the organization to the
degree necessary under the circumstances. ■* The hospital organization
has attempted to modify the power relationship of the physician by institu-
ting such measures as the joint conference committee which allows the
pressure of the customer relationship to be directed into a more respon-
sible outlet. As Etzioni presents it, this is an alternative to
the difficult process of indoctrinating the members of the hospital
organization to the service role which they play in regard to the
customer.-5' As discussed in Chapter III, the reasoning behind the
development of the joint conference committee and other mechanisms for
gaining the cooperation of the physician has generally been misunderstood
by the operating officials of the hospital organization. It has been
accepted that this institutionalized role in the management of the
organization was something which the physician should have been accommo-
dating to before these measures. It might be better for hospital adminis-
trators to realize that a natural process of accommodation to the powerful
role of the physician as customer has been at work. Those persons within
the organization who directly serve the physician have been developing a
status more nearly equal to the customer. 5° As the nurses and other
55philip Selznick, "Strengthening Leadership--Co-optat ion,"
Human Relations in Administration, ed. Robert Dubin (2nd Edition;
Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1961), pp. 360-3&2.
56
57
Etzioni, "Administration and the Consumer," pp. 258-259.
Ibid.
->°Robert N. Wilson, "The Social Structure of a General Hospital,"
Annals of the American Academy of Political and Social Science, No. 3^*6
(March, 1963), p. 73-
53
ancillary department workers find a place in the professional sun, the
doctor's aura is diffused and dimmed.'*" The monopoly of professional
status, and its concomitant power in the customer-organization relation-
ship has been broken with the rise of new professional groups within
the organization and the increased dependence of the physician upon
technical assistance in the healing process. Ryack has commented that
the physician no longer finds himself as the prime mover in the health
care process -- he must compete with many other occupations for the
6l
prestige associated with healing of the sick.
The power relationship which develops under these circumstances
cannot be said to be unique to the hospital organization. Any business
organization which is dependent upon a single customer or a relatively
small group of like customers will undoubtedly feel at a disadvantage
in the relationship. In most of these situations the customer will more
than likely have a technical capability equal to that within the organi-
zation which is directly in contact with the customer. The company will
undoubtedly attempt to maintain a status relationship which is as nearly
equal between the two as is possible under the particular circumstances.
Katz and Kahn refer to this necessity for the business organization to
maintain its autonomy and resist domination by its customer group when
59Robert N. Wilson, "The Physician's Changing Hospital Role,"
Human Organization, XVI II (Winter, 1959-60), 1 81 -
6oBloom, p. 165.
Elton Rayack, Professional Power and American Medicine: The
Economics of the American Medical Association (Cleveland, Ohio: The
World Publishing Co., 1967) , pp. 62-63.
\5k
62
this type of relationship exists. It cannot be said that the situation
in the hospital organization is much different from these business
examples; what is interesting, however, from a management point of view,
is the observation of how the solution to this problem is evolving in
the hospital organization. The hospital may always remain a unique case
in respect to the fact that the customer is also professionally oriented;
however, the individualized service which the organization of the future
will be providing to its customers will make the customer-organization
relationship quite as intimate as that exercised in the hospital setting.
The degree to which the customer will be professionally oriented toward
the product being consumed may well be as high in many less exceptional
cases as the tempo of technology increases and provides the opportunities
for external economies of scale and complete service department separation
from the parent organization. The trend toward such service department
separation appears to be on the increase as organizations begin to
realize that purchased services have become more economical than provid-
ing such services internal to the organization. In each such case the
relationship which develops between the serving organization and the
corporate customer is of a power sort which is not easily explained by
reference to the organization with many, relatively unsophisticated
customers. Rather, in those organizations serving technically oriented
clientele it would be expected that the personnel in contact with the
customers would be of relatively high prestige w? thin the organization.
62
Katz and Kahn, pp. 58-59
155
There can be no doubt that much of the confusion in regard to the
hospital organization has been caused by the distortion which resulted
from attempting to force the description of the structure by including
the physician as part of the line of the organization. Once this
artificiality is removed the perspective becomes clear and a familiar
organizational phenomenon becomes apparent. Smith employed the analysis
of organizational status provided by Barnard. This analysis is a portion
of Barnard's attempt to synthesize the formal and informal theories of
management. 3 In fact, Smith is employing a portion of the informal theory
of authority. He is maintaining the position that the authority held by
an individual within an organization is sometimes different than that
provided by the organization in its hierarchical scheme and that this
informal authority may be dysfunctional to the organization purpose.
However, in the case under consideration we discover that a very real
purpose is served by the development of a functional status through the
means of increased occupational prestige in the case of nursing and
ancillary personnel — mainly that this prestige is required to offset
the prestigious position of the customer, the physician, and thereby
maintain the stability of the organization with its surrounding environ-
ment.
The basis for the striving for prestige in the case of nursing and
many other occupations contained in the ancillary groups of the hospital
organization has often been expressed in a vague manner. Henderson
"^Chester I. Barnard, Organization and Management (Cambridge, Mass.:
Harvard University Press, 1958) , pp. 207-2^.
156
provides that medical care will never reach its fullest development
until a peer-relationship is established among those In the health
professions. It would appear that organization theory and particu-
larly its dynamic applications might be utilized to good advantage in
explaining much of the phenomenon of increasing professional ization
both in service organizations and industry. -*
It might be said that this blind reaction to one organizational
problem creates a multiple of new problems for the enterprise. In
providing a balance between the organization and its environment the
internal balance between organizational elements is disturbed. Perhaps
as in the case presented by Smith, two lines of authority or even more
are being created through the organizational prestige accruing to the
professional members. There is a real possibility that profess ional F"
zation of more and more occupational groups will herald the separation
of the executive and legislative functions in new organizational set-
tings where traditionally they were fused. Kornhauser recounts one of
the salient features of the professional outlook, the necessity for
Virginia Henderson, The Nature of Nursing (New York: The Mac-
mil Ian Company, 1 966) , p. 67.
"^Burton R. Clark, in "Faculty Organization and Authority,"
Professional Ization, eds. Howard M. Vollmer and Donald L. Mills
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966), p. 287, describes
this increasing tendency toward profess Ional ization of occupational
groups in various organizations, in addition to recounting many of the
dysfunctional consequences.
157
66
autonomy within the organization. However, there are other
organizational accommodations which appear to be inherent in the
professional attitude. In particular, the already noted tendency
for professionals to evolve and devolve managerial functions and tasks
to staff and service department echelons of the organization. Where
profess iona 1 izat ion gains the individual status through prestige and
ultimately an increased measure of organizational authority, line
authority is gained by service department groups in adequate counter-
balance through the mechanism of functional authority. '
William Kornhauser, "Scientists in Industry: Conflict and
Accommodation," Profess ional izat ion, eds. Howard M. Vollmer and Donald
L. Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966), p. 292.
k^This point, and the entire concept of organizational balance,
receives elaboration in a later chapter concerned with the prototype
characteristics of hospital organization.
CHAPTER VI I
AN ANOMALY: HOSPITALS ARE BECOMING MORE BUREAUCRATIC IN STRUCTURE
Edith Lentz describes the present organizational situation in
American hospitals as one in which the structure is passing from a more
traditional concept to that of the bureaucratic model. The traditional
form of hospital organization provided for a highly centralized form of
structure with strict authoritarian control exercised by the trustees
over the business affairs of the organization and by the physicians over
the professional activities carried out by the nursing personnel. The
trustees looked on the hospital as their feudal estate and visited it
daily to give personal direction to the staff who were treated as the
serfs of the estate both in regard to the subsistence wages provided and
the paternalistic direction to which they were subjected.-' The superin-
tendent, who was the forerunner of today's administrator, was merely
another of the workers who required constant supervision by the board in
his conducting of the business type activities of the organization.
Edith M. Lentz, "Hospital Administration -- One of a Species,"
Administrative Sciences Quarterly, I (March, 1957), A56-A63.
2lbid. , pp. 456-457.
3 I b i d .
Ibid., p. 457.
158
159
The role of the physician was independent of the organization;
however, as a guest to the estate of the trustees he was given powers
to match his prestige in supervising the work of the employees of the
hospital. Much as the owner-entrepreneur might elicit the assistance
of a works superintendent the board would invest the physician with the
authority to oversee the endeavors of the paid employees. Under this
relationship the physician would deal directly with the board, circumvent-
ing whatever authority structure that might exist in the organization.'
But to most extents the structure of the organization was loosely formed
with many of the individual employees dealing directly with the members
of the board in a manner typical of the rudimentary business organization.
In terms of organization theory authority was centralized in the executive
position with little if any devolution of authority and accountability for
the management functions in spite of the differentiation of the operative
functions.
The hospital today has undergone a metamorphoses which is similar to
that which must have occurred in business as these organizations moved
from the owner-entrepreneur form to the corporate structure." As the
structure of the organization became more complex with the introduction of
Slbid., pp. 458-459.
6 1 b i d .
7 1 b I d .
8 Ibid. , p. 459.
160
new professional personnel occasioned by the rapid advance in medical
technology it was no longer possible to coordinate and control operations
through the occasional supervisory activities of the separate members of
the board. Even the more frequent supervision performed by the "guests"
of the house was insufficient because their competence did not span the
range of functions being accomplished. An active, day-to-day coordinator
and controller of all of the functions of the establishment was required
and the role of the hospital administrator became institutionalized in
a manner similar to that of the professional manager in industry.9
The advent of the professional administrator, however, brought with
it the complex of structural rules and regulations which are the hallmark
of the bureaucratic organization.10 In order to make possible the
orderly coordination of the activities of the hospital it was necessary
to establish the lines of communication and control which makes this
form of organization workable.11 No longer is it possible for the phy-
sician, who continues as a "guest" of the house, to make his end runs
to the trustees if the activities of the enterprise are to remain
coordinated. And to the extent that coordination of the entire range of
activities of the hospital organization must be accomplished the physician
must conform to the controls established for the proper operation of the
Jlbid,
0,
ibid
11 Ibid
161
12
enterpr i se.
However, the bureaucratic form of organization has not completely
replaced the more traditional form. -^ The transition is not yet complete.
What presently exists is a three part power structure consisting of the
board, the physician, and the administrator.1^ The physician finds it
difficult to accommodate to the bureaucratic structure in the hospital
phase of his activities. -* The autonomy necessary for his functioning
in the healing process is not easily susceptible to the submission
required by the organization. " However, with the increase in technology
and the availability of the specialized help provided within the hospital
structure the physician finds that the bulk of his work still remains
outside of the hospital organization. '
The tasks of the administrator are compl icated by this arrangement
and it is difficult for him to manage the institution for which he holds
responsibility. The prestige of the physician intrudes into many of
l2lbid.
13|bid.,
, pp. 459-^60
lZ>lbid.
ISlbld.,
, p. ^59.
16lbid.
1 7|bid.
l8lbid.,
, p. kGO.
162
the activities which the administrator is attempting to coordinate.
Much of this same form of prestige is held by internal members of the
organization upsetting the usual balance of positional authority which
exists in the bureaucratic organization. '9 |n addition, the professional
identification of these internal members strengthens their desires for
autonomous positions within the organization creating further control
problems for the administrator and his staff.20 The administrator trained
in the procedures of business management can only be frustrated by this
situation leading to still further emphasis upon the logical process
implied in the bureaucratic form of structure.
Much of this same argument is presented by Burling, Lentz, and
Wilson in an earlier work. As elaborated therein, the problems associa~
ted with hospital structure are primarily a function of the stage within
which the particular organization finds itself. Those organizations which
still have a heavy element of the traditional structure find that the
bureaucratic imperatives are quite painful. Those organizations which
have successfully made the transition and become true bureaucracies find
this structure quite compatible with the health care situation.22
19lbid.
20 lb id., p. i»6l.
21Temple Burling, Edith M. Lentz, and Robert Wilson, The Give and
Take in Hospitals (New York: G. P. Putnam's Sons, 1956), pp. 317-333.
22lbid., pp. 331-332.
163
Many other authorities note a trend toward bureaucratization of
the hospital organization and other structures which have traditionally
maintained the autonomy of the professional worker. Gilb has commented
that an historic movement has existed which will lead to the wholesale
bureaucratization of all work as predicted by Max Weber. 3 Wilson
agrees with this contention to the point of maintaining that the
bureaucratic mold is both logical and historically appropriate for the
physician. 4 Hall, however, would disagree with Lentz in regard to the
existence of a tendency toward the development of bureaucratic structures
in hospital organizations. -* In his viewpoint the hospital organization
had its roots in the bureaucratic tradition, having historically been
organized by religious orders and military and governmental establishments.
Each of these has added its own distinctive measure of bureaucratic
structure to the present hospital organization. '
Other authorities also agree on the occasion for the rise of the
bureaucratic form of organization. Perrow is in agreement with Lentz in
23r,orinne L. Gilb, Hidden Hierarchies (New York: Harper and Row,
1966) , p. 231.
2Z|Robert N. Wilson, "The Physician's Changing Hospital Role,"
Human Organization, WIN (Winter, 1959-60), 179-
25oswald Hall, "Some Problems in the Provision of Medical Services,"
Canadian Journal of Economics and Political Science, XX (195*0, 458.
26lbid.
26
27
Ibid.
164
respect to the need for administrative coordination; however, he sees
the cause in the concern of the various parties to the hospital
organization becoming aware of the need for more efficient and economi-
cal operations in the face of a health care system which has become
increasingly interdependent and specialized. Gilb concludes that the
rise of the bureaucratic form of organization in the health care field
is the result of technological advances in medicine, the bulk of new
knowledge, the availability of capital, and socioeconomic changes that
have made large-scale undertakings more feasible as well as necessary. °
Blau and Scott maintain that the development of the bureaucratic form
for a particular organization is a natural consequence of the search for
some routine and a stable means of economic support which all enterprises
will experience at some point in their existence. Gouldner suggests
that the bureaucratic solution is advanced when the parties to an
organization perceive some group within the enterprise failing to perform
their role obi igations . ' ' "Bureaucratic measures are thus a response to
Charles Perrow, "The Analysis of Goals in Complex Organizations,"
Readings in Organization Theory: A Behavioral Approach, ed Walter A.
Hill and Douglas M. Egan (Boston: Allyn and Bacon, I nc. , 1966), p. 136.
29Gilb, p. 98.
^Peter M. Blau and W. Richard Scott, Formal Organizations (San
Francisco: Chandler Publishing Co., 1962), p. 31.
3'Alvin W. Gouldner, Patterns of Industrial Bureaucracy (New
York: The Free Press of Glencoe, 1954) , p. 231 .
165
a breakdown in a social relationship; they are a defense against the
tensions which arise when the expectations that two parties have of
each other are no longer adequately meshed and complementary."^
Within this context then the bureaucratic organization can be
considered as an attempt to provide clearly marked lines of communica-
tion and authority through a formal status structure with stated goals
and a system of explicit rules and regulations. 33 Bennis dimensional izes
the bureaucratic structure by a division of labor based on specialization,
a well-defined hierarchy of authority, a system of rules covering the
rights and duties of employees, a system of procedures for dealing with
work situations, an impersonality of interpersonal relations, and pro-
motion and selection based on technical competence. 3^ Gouldner sees
the fruits of such forms of organization in the reduction of status-
located tensions stemming from close supervision in addition to reducing
tensions throughout the organization as a whole which stem from the
interaction of persons with different value and belief systems, breaks
in the chain-of-command , short circuited communications, and the
challenge to the legitimacy of management, to mention a few.-'-' However,
32,
bid,
33Blau and Scott, p. 14.
3\farren G. Bennis.
Co. , 1966) , p. k-S.
3^Gouldner, p. 240.
-* Warren G. Bennis, Changing Organizations (New York: McGraw-Hill
Book Co. , 1966) , p. 4-5.
166
the rationality of the bureaucratic model does not remain unquestioned
with respect to overlooking the individual within the structure. 3°
And, Georgopoulos and Mann specifically question its application as a
structural form of organization when the individuals involved have
professional characteristics
37
The point which is raised in regard to the feasibility of the
bureaucratic structure in the case of professional participants along
with other aspects of this form of organization suggests many questions
in regard to its application. Wessen remarks that it would hardly be
applicable to describe the hospital as a bureaucracy when the caste
system which prevails in these organizations is observed.-*" Blau and
Scott would add that both the traditional and charismatic authority of
the professionals, and the stability of social order which they provide,
are unlikely to be easily upset. 39 Wilson, at a later point, sees no
simple resolution of the juxtapositon of the professional with a
rising tide of bureaucracy. The tendency to engineer the ambiguity
5/
Joseph W. McGuire, Theories of Business Behavior (Englewood
Cliffs, N.J.: Prentice-Hall, Inc., 1964) , p. 29.
''Basil S. Georgopoulos and Floyd C. Mann, "The Hospital as an
Organization," Hospital Administration, VII (Fall, 1962), 19-
^ Albert F. Wessen, "Hospital Ideology and Communication between
Ward Personnel ," Patients, Physicians and Illness, ed. E. Gartly
Jaco (New York: The Free Press, 1958) , p. h5Q.
^Blau and Scott, pp. 30-31.
^Robert N. Wilson, "The Social Structure of a General Hospital,"
Annals of the American Academy of Political and Social Science, No. 3^6
"(March, 1963), p. 74.
167
out of jobs which prevails in this form of structure does not fit the
41
criteria of professional work. The professional's resistance to such
forms of structure and the attendant consequences of their incorporation
in this form of organization has been well summarized by Scott. ^
In addition to the specific opposition of the professional to
assuming a bureaucratic role there are many more generalized objections
to the use of this model of organization. The work of Merton, and
others, have outlined these commonly known objections to the dysfunc-
tional aspects of the bureaucratic model. ■* Perrow has commented in
this vein by noting that if administrative dominance is based primarily
on the complexity of basic hospital activities rather than the role of
the hospital in the community then the operative orientation of the
organization may be toward financial solvency, careful budget controls,
efficiency, and minimal development of services. Etzioni
questions the entire concept of bureaucratization of the hospital
Frederick Herzberg, Work and the Nature of Man (Cleveland,
Ohio: The World Publishing Co. , 1 966) , p. 65.
42
W. Richard Scott, "Professionals in Bureaucracies -- Areas of
Conflict," Professional ization, eds. Howard M. Vollmer and Donald L.
Mills (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1967), pp. 265-275
^Robert K. Merton, "Bureaucratic Structure and Personality,"
Complex Organizations: A Sociological Reader, ed. Amitai Etzioni
(New York: Holt, Rinehart and Winston, 1961), pp. 48-61.
^Perrow, pp. 136-137.
168
organization if the uniqueness of each patient's case is accepted,
which fact is in direct opposition to the concepts of rout inization
of service implied in the bureaucratic model. ■*
The anomalous character of the contention that hospital
organizations are becoming more bureaucratic in structure resides in
the notion that the hospital is tending toward the universal structure
as described in the sociological literature where bureaucracy is taken
as the model organization. Rather it is the purpose of this study to
present the argument that the hospital organization is of the universal
structure with notable characteristics which mark it as a prototype for
the changing circumstances which all organizations must face in the
future. In particular the two features common to hospital organizations,
professional ization of internal members with the associated value placed
upon autonomy, and unit-production techniques which defy routinizat ion
of procedure, appear to be antithetical to the bureaucratic model which
is suggested as representative of the universal structure. It would
therefore appear to be worthwhile briefly to investigate the degree to
which the bureaucratic organization describes the present universal
structure.
One of the most serious disabilities of the bureaucratic form of
organization as described in the literature is the emphasis upon
-'Amitai Etzioni, Modern Organizations (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1964) , p. 53.
^Blau and Scott, p. 32.
169
control. ' However, the issue of control has no place in the
traditional theory of the rational bureaucratic organization in spite
of the admonitions that coordination and control are synonymous. °
Dubin asserts that if all other systems in an organization were per-
fectly operative there would be no need for control. ^ Carzo has also
remarked that Weber's model of bureaucracy is one of perfection much
like the model of a machine without friction. ->0 That the universal
organization Is not of the bureaucratic description can be attributed
to the human inhabitants of these organizations. Scott provides that
the "perfection assumption" of this classical theory requires an exact
match between the capacity of the individual and the authority of the
function.-3 March and Simon also comment on the assignment problem in
organizations as being the root cause of the development of a theory of
Chris Argyris, Personality and Organization (New York: Harper
and Row Publishers, 1957) , p. 131 .
^"Joseph A. Litterer, The Analysis of Organizations (New York:
John Wiley and Sons, Inc., 1965) , p. 233-
^Robert Dubin, Human Relations in Administration (Englewood
Cliffs, N.J.: Prentice-Hall, Inc., 1961), p. 389-
-'Roc co Carzo, Jr., and John N. Yanouzas, Formal Organization:
A Systems Approach (Homewood, Illinois: Richard D. Irwin, Inc., 1967),
p. 27.
^William G. Scott, Organization Theory: A Behavioral Analysis
for Management (Homewood, Illinois: Richard D. I rwin, C. , 1 967) , p. 112.
170
centre" to accompany formal theories of organization.
It would almost seem as if the bureaucratic concept were
self-defeating. The structured field which constitutes the bureau-
cratic organization provides the need for control as an almost inevit-
able psychological consequence.5-5 Many of the dysfunctional aspects
of the pathologically described bureaucracy such as the displacement
of goals and alienation of the individual participants would disappear,
along with the need for controls, if personalities could be shaped to
fit specific organizational roles.-14 Today the emphasis in organizations
is placed upon the selection and education of individuals to fill roles
within organizations. •3 As will be seen in the prototype discussion of
the hospital organization these imperatives appear to be less and less
critical in these structures, since the imperatives which cause an
active resistence to the rationality of the structural organization are
less apparent in the health care organization.-'0
J James G. March and Herbert A. Simon, Organizations (New York;
John Wiley and Sons, inc., 1958), pp. 25-26.
CO
-'•'Victor A. Thompson, "Bureaucracy and innovation," Admi ni strat i ve
Sciences Quarterly, X (June, 1965), 20.
•* Etzioni, Modern Organizations, p. 75.
55:bio;. , o. 63.
5°Gouldner, p. 236, outlines the factors which are involved in
such resistence.
171
While Georgopoulos maintains that a large segment of hospital
administration clings to a concept of business administration which
emphasizes the requirements for extensive control, 57 it appears to be
well recognized that this avenue affords little opportunity for the
solution of the problems of hospital management. Brown believes
that hospital administrators when compared with managers of industry
and business, have been lax in informing themselves about the recent
findings in the social sciences. ->° Whether this is true or not there
can be no doubt that management has made itself aware of the changing
circumstances of organizational structure and in particular, the link
between the requirement for coordination and the necessity for
control. This is particularly true in the case of those organizations
which employ professional personnel. And it would appear to be most
apparent in the hospital situation. ^ It is becoming more apparent also
Basil S. Georgopoulos, "Hospital Organization and Administration:
Prospects and Perspectives," Hospital Administration, IX (Summer,
1964), 25.
rO
Esther Lucile Brown, Newer Dimensions of Patient Care: °art 2
(New York: Russell Sage Foundation, 1S62) , p. Vf.
59 Ibid. , p . 50
60Argyris, pp. 137-138.
6 1
Etzioni, Modern Organizations, p. 16.
°^Ronald G. Corwin, "The Professional Employee: A Study of Con-
flict in Nursing Roles," American Journal of Sociology, LXVI (June, 1961),
66.
172
in such cases as reported by Woodward where the increased efficiencies
derived from rationalization of organization structure is minimal
because of the uncertainty involved in the production processes and the
probability of error in the setting of standards in the unit-production
industries.
It would appear that the organization which Lentz is attempting
to describe, and toward which she believes hospitals are tending, is
less that of the bureaucratic form described in sociological literature,
and more that of the modern business organization upon which the prin-
ciples of management are based. It is regrettable that so much of the
writings concerning hospital organization have emanated from a sociolo-
gical background with its reliance upon the bureaucratic model. Even
among sociologists the qualifications of this model which they present
appear to have reduced the value of the original conception of a
bureaucracy. Etzioni has remarked on the disadvantages of using the word
bureaucracy as a synonym for organization. Blau and Scott reserve the
term bureaucracy to connote a specific syndrome found in some organiza-
tions. -> Wilson separates bureaucracy from formal rational bureaucracy.
■^Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1965), p. 178.
^Etzioni, Modern Organization, p. 3.
65Blau and Scott, p. 208.
Wilson, "The Physician's Changing Hospital Role," p. 177.
173
Georgopoulos and Mann refer to hospitals as being quasi-bureaucracies .
Thompson provides for the monocratic bureaucracy as distinct from other,
less well-defined, forms of organizations.
Bureaucracy as a concept has now become a target for change, ° with
Bennis predicting that bureaucracies, as such, will pass from the scene. ?0
In the management oriented literature this is well documented. Dale has
remarked that management process organization theory has long since
passed beyond the bureaucratic model. Terry has noted the emphasis upon
the individual and groups in organization theory and the de-emphasis of
structural concepts of the bureaucratic variety. Litterer provides that
bureaucratic descriptions of organization tend to resemble management
73
descriptions but in most important ways they differ. Keith Davis main-
tains that the bureaucratic description must be reserved for governmental
organizations for it would be entirely inapplicable in the business
°'Georgopoulos and Mann, p. 53.
Thompson, p. **.
69Will iam G. Scott, p. 247.
Warren G. Bennis, "Organizational Developments and the Fate of
Bureaucracy," Industrial Management Review (Spring, 1 9^6) , pp. A 1 -55 -
'Ernest Dale, Organ izat ion (New York: American Managment Associa-
tion, 1967), p. 35.
'George R. Terry, Principles of Management (5th ed . rev.;
Homewood , Illinois: Ri chard D. 1 rwin, I nc. , 1968) , p. 281.
'^Litterer, p. 12.
Mk
situation where the imperatives of competition generally rule.^
Koontz and O'Donnel] suggest that the expression and phenomenon of
bureaucracy may have some limited application in the description of
business organizations particularly in the case of service department
elements of the structure.75 it is highly possible that the phenomenon
which Lentz is attempting to report in the case of the hospital is of
this latter variety.
The structure of the business organization which can be taken as
the universal model with its basis for the principles of management is
of a more dynamic form than that provided by the bureaucratic descrip-
tion. It would be expected that hospital administrators who were
students of management theory would be exposed to this dynamic model
rather than the static bureaucratic formula. Also, therefore, it would
be expected that this tendency which Lentz reports can be hoped to lead
to logical conclusions provided by management theory and the accommoda-
tion of the structural form of organization to suit the hospital situa-
tion. This conclusion would recognize that the traditional bureaucratic
model is not appropriate when applied to non-routine, "creative"
decisions and activites. The apparent dependence of administrative
superiors upon their operative subordinates in the hospital organization
Keith Davis, Human Relations at Work (3rd ed. rev.; New York:
McGraw-Hill Book Co. , 1967) , p. 166"!
75Harold Koontz and Cyril O'Donnell, Principles of Management
(3rd Edition; New York: McGraw-Hill Book Co., 1964) p. 312.
76 '
Fremont E. Kast and James E. Rosenzweig, "Hospital Administration
and Systems Concepts," Hospital Administration, XI (Fall, 1966), 26.
175
should make administrators aware that bureaucratic solutions are
inapplicable. ' The means of motivation of individuals is readily at
hand in the hospital environment where the opportunities for individual
achievement and a sense of recognition are available to the lowest level
of operative performer, which will not remain unrecognized by the manage-
ment-trained hospital administrator who holds the bureaucratic form of
organization in its correct perspective.'
To be most beneficial to management theory, observations about
hospital organization should not be cast within the descriptive model
provided by the bureaucratic structure which has little application in
the business situation. The accommodations in respect to organizational
control which have been accomplished in hospital organizations concerned
with unit-production and employing professional workers would be of par-
ticular benefit to general management theory and this can obviously not
be accomplished within a bureaucratic model. The transfer of manage^
ment techniques to the hospital situation will only be accomplished if
both forms of organization are described in similar terms which ignore
the artificialities of descriptive devices such as the bureaucratic
structure. Woodward has commented on the inadequacies of organization
theory to describe the organic structure typified by unit-production
77Blau and Scott, p. 232.
'Frederick Herzberg, Bernard Mausner, and Barbara Bloch Snyderman,
The Motivation to Work (2nd Edition; New York: John Wiley and Sons,
Inc., 1959), p. 125.
176
techniques and professional participation -- it would appear that hospital
organizations could make a significant contribution in this regard if the
description of these organizations were related to the universal struc-
ture rather than the bureaucratic model ,'°
It should be recognized that hospital organizations are accomplishing
a startling change in their structural form. Whether these changes began
with what Lentz refers to as a "traditional" structure or, as Hall main-
tains, their traditional bureaucratic form, the item of interest is the
structure which is evolving. Merely to pass this off as a new form of
bureaucratic organization would be to miss the vast amount of data which
analysis of this structure could provide. Woodward has noted that the
problems which arise with the passage of an organization from batch
methods of production to unit-production methods are insignificant when
compared to the problems associated with an enterprise moving toward batch
Q/-v
production. !f hospitals are becoming more bureaucratic, with routini-
zation of productive activities in the batch-method format, then severe
organizational problems should be expected. However, if instead hospitals
are continuing unit-production methods, or are moving toward greater
employment of these techniques this phenomenon should be reported as such,
for the dissipation of organizational problems through this movement
will be of immense value to managerial theory.
79Woodward, p. 181.
80 Ibid. , p. 209.
CHAPTER VI I I
THE PROTOTYPE ORGANIZATION
The anomalies of hospital organization which have been discussed
are exclusively the result of sociological studies which attempt to
describe the social structure of this organization. These attempts
are not without success in noting that the description of the hospital
organization departs from the concept of a modal structure in many sig-
nificant respects; however, the purpose served by these departures is
not well documented. To a large extent, as would be expected, these
descriptions concentrate on the human element contained within the
hospital organization. While it would serve little purpose to ignore
this element, the human factors must be considered as a segment of a
larger productive system containing imperatives of its own, and the
whole as linked by a system of management designed to provide a co-
ordinated enterprise.
The present chapter will attempt to consider these factors as a
dynamic interaction which results in a unique application of structure
to accomplish specific results — the purpose of the enterprise. While
the model of hospital organization which is discussed is taken as typi-
cal of this form of structure it is necessarily a construction which
ignores all but the points being considered and therefore is unrepre-
sentative of any specific organization. Because it is a dynamic in-
terpretation rather than a static description the various phases of
177
178
organizational change are distinct from changes elsewhere in the struc-
ture except where these are of particular interest. The emphasis will
constantly be upon the prototype characteristics of the hospital organi-
zation when it is subjected to this dynamic analysis provided by manage-
ment theory.
Perhaps the most salient feature of the hospital organization is
the marked organic nature of its structure when it is compared to more
mechanistic structures which are amenable to human engineering. This
concept of an overall separation of organizations into the nature of
their basic structure was first developed by Burns and Stalker.1 They
view mechanistic structures as being conditioned by a situation of rela-
tive stability where the specification of functions can be accomplished
and maintained over a significant period of time. The problems and
tasks of the enterprise can be broken down and assigned to the various
functional areas which are specified within the structure and the co-
ordination of these elements can be accomplished through a rout inizat ion
of organizational procedures. These forms of organization are marked
by a well established command hierarchy which is well understood through-
out the enterprise. In contrast the organic form of structure is
adapted to unstable conditions where problems and requirements for action
on the part of organizational participants cannot readily be broken down
Tom Burns and G. M. Stalker, "Mechanistic and Organic Systems,"
Readings in Management, ed. Ernest Dale (New York: McGraw-Hill Book'co
1965), pp. 23^-236.
2j_bid., p. 234. 31 bid. ^t bid.
179
and distributed. Because of this dynamic situation the organization is
constantly subject to the definition of tasks and functions by the indi-
c
vidual participants rather than through the command hierarchy. Much
of the communication exercised in this form of organization is lateral
through the structure rather than vertical via a command hierarchy. The
proper functioning of this form of organization is heavily dependent upon
the conception of purpose which each individual participant holds of the
• +• 8
organ i zat ion.
Burns and Stalker believe that the major determinant of the organic
or mechanistic nature of a particular organization's structure is a func-
tion of the degree to which the various roles within an organization
have had the opportunity to develop a traditional status relationship
q
with one another. Under the dynamic conditions of change in purpose
and procedure this historic basis for relationships cannot develop; how-
ever, once developed the responsiveness of the organization to a change
in circumstances will be severely limited. Much of the energies of the
mechanistic organization will be expended upon the clash of participants
over power and status if change is introduced. Therefore, the viability
of these forms of organizations must be subject to serious question when
exposure to change, or the reduction of routi nization is introduced upon
the scene.
Woodward has used these definitions of two contrasting forms of
5lbid. Ibid. 71 bid.
8lbid. 9lbid., pp. 234-235. 10lbid.
180
organizational structure in her studies.11 The mechanistic organizations
are characterized by a rigid breakdown into functional specialism, pre-
cise definition of duties, responsibilities and power, and a well dev-
eloped command hierarchy through which information filters up and de-
1 2
cisions and instructions flow down. The organic structures are more
adaptable; jobs lose much of their formal definition, and communications
up and down the hierarchy are more in the nature of consultation than of
the passing up of Information and the receiving of orders.13 A large
proportion of the firms she studied conformed to the organic structure
to some degree, a fact which she attributes both to the locale of the
study area, which contained many new and developing industries, and the
viability factor — those firms which cannot adapt in a changing environ-
ment are less likely to provide surviving specimens.14 However, when
all organizations investigated were measured against a criterion of
degrees of success those which more closely conformed to the model of
the organic structure were significantly overrepresented in the highly
successful category. In addition, there was demonstrated a close
correlation between success and the variables of type of structure and
form of technology employed. Successful mass-production firms were
more likely to have a mechanistic form of structure while the structure
of the unit-production and process firms was more likely to be of the
Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1 So5 ) .
]2i°JA., P- 23. 13J_bld. 'Vnd., p. 25.
15Ulid., p. 33. l6lbid.. pp. 68-72.
181
organic variety.
The presence of characteristics of these two varieties of organi-
zational structure has not gone unrecognized in this county; however,
most of the observations have been subsumed, unfortunately, under the
traditional controversy between the formal and informal schools of
management theory. Generally the compromise has been made that both
concepts apply in every organization while the link between the specific
form and its predominance under particular technological conditions has
gone unrecognized. It still remains to be seen whether these American
theories can be sorted out to provide additional substance to the con-
tention that specific technologies of production largely dictate the
formality of organization structure. To some extent the present writings
which direct themselves to such applications of organization theory still
concentrate on the preference of one theory over another without speci-
1 8
fying the circumstances. However, excellent descriptions of the or-
ganic organization, such as that presented by Likert, are availalbe for
,. . 19
application given the proper circumstances.
The ambiguities of organizational structure which have been presented
as anomalies of hospital organization are essentially manifestations of
17 Ibid.
1 8
Fremont E. Kast and James E. Rosenzweig, "Hospital Administration
and Systems Concepts," Hospital Administration, XI (Fall, 1966), 26.
Rensis Likert, "A Motivational Approach to a Modified Theory of
Organization and Management," Modern Organization Theory, ed . Mason Haire
(New York: John Wiley and Sons, Inc. , 1959) , p. 186.
182
the organic nature of the structures involved. The hospital lacks the
mechanistic features of those organizations which are able to regular-
ize their accommodations with the environment which they serve. The
hospital must exist in an environment in which diverse and unique demands
upon its capabilities are constantly being exercised to which it must re-
spond in a spirit of service. Rigid regulation of its procedures which
would allow for the reduction of the ambiguities which are involved and
a clarification of the organizational structure is impossible under
these circumstances.
This link between the organic organization which has been described
and the methods employed in hospital organizations has been noted.
Georgopoulos and Mann provide that the hospital when its organization
20 .
is explored, is basically a human rather than a machine system. In
addition to the organization being composed of human participants the
product itself is a composition of human reaction to the process
21
employed. The hospital organization must manifest a structure which
permits a heavy reliance upon the members of the organization to co-
ordinate their activities on a voluntary, informal and expedient basis
22
which in turn accommodates the ambiguities of the human element.
Elsewhere, Georgopoulos has noted that the concepts of mass production
20
Basil S. Georgopoulos and Floyd C. Mann, "The Hospital as an
Organization," Hospital Administration, VII (Fall, 1962), 53.
21
Daniel Katz and Robert L. Kahn, The Social Psychology of Organi-
zations (New York: John Wiley and Sons, I nc. , 1966) , p. 116.
22
Georgopoulos and Mann, p. 53.
183
and uniform products has only a very limited application, or acceptance,
23
in the hospital situation. Rosenberger has specifically identified
the hospital of today as an "odd-lot" job shop, to use the language of
• j 24
1 ndustry .
In the literature of management the question of organic versus
mechanistic structures is usually reduced to a discussion of the basic
dilemma which exists between providing invididual freedom and reaping
the economic benefits of organizational efficiency and order, with
consideration given to whether either system of organization will be
26
the best overall in terms of some calculus which is yet to be derived.
However, there appears to be an increasing recognition that the question
involved is only relevant to the productive circumstances involved.
Keith Davis takes this point of view in his discussions of the impera-
tives which dictate the requirements for open communication and personal
27
contacts across chai ns-of-command . While Argyris acknowledges that
whatever the benefits to be obtained in terms of human satisfaction from
the organic form of organization, this structure is quite often determined
23
Basil S. Georgopou los , "Hospital Organization and Administration:
Prospects and Perspectives," Hospital Administration, IX (Summer, 1964), 26.
24
Donald M. Rosenberger, "A New Look at Hospital Organizations,"
Hospitals, XXXVI (February 1, 1962), 43. .
25
George R. Terry, Principles of Management (5th ed. rev.; Homewood ,
111.: Richard D. Irwin, Inc. , 1968), p. 285.
26
Ibid.
27
Keith Davis, Human Relations at Work (3rd ed . rev.; New York:
McGraw-Hill Book Co., 1967) , p. 182.
184
by factors beyond the control of the humanistic inclinations of manage-
28
ment .
Actual adaptations of the organic form of organizations have largely
been of the accidental variety—creatures of ci rcumstance--rather than
of management design, at least until quite recently. As Bennis has
noted, the essence of the organic structure is spontaneous adaptation to
29
the needs of the system. ' It would require either an overwhelming
ignorance of management theory or abject resignation in the face of over-
whelming circumstances to avoid the imperatives of present theory which
require management to function as the organizer of the enterprise and
dictate the proper form of organization. More recently specific forms
of organization have been developed in industry which incorporate the
opportunities for organic determination of structure within a larger
frame of enterprise organization. Bennis discribes these organic forms
of structure as the project organization based upon "temporary systems"
developed to handle specific problems to be solved in an adaptive and
30
rapidly changing manner. These temporary systems will consist of
groupings of strangers with diverse skills who will be presented with a
problem which in interaction with the technical capabilities of the par-
ticipants will evolve a structured relationship among them which will
3 1
satisfythe immediate situation. Once the problem is resolved, which
— _____ _____________________________
Chris Argyris, Integrating the Individual and the Organization
(New York: John Wiley and Sons, I nc. , 1964), p. 185.
29
Warren G. Bennis, Changing Organizations (New York: McGraw-Hill
Book Co., 1966), p. 8.
30lbid., p. 12 31lbid.
185
may be a matter of days or months, the structure will be abandoned for
new groups with new problems.
This project, or "Task-force," form of organization is a reasonable
adaptation of the organic concepts of organization when the "problem" is
of major proportions and will command a significant amount of the enter-
prise's resources. This is not the essence of the matter in the hospital
or other unit-production organization. While in the case of the hospital
the service to be rendered to the patient may be lifesaving, and in that
respect important, the problem situation may be one of a thousand experi-
enced by the organization throughout a single day. Woodward reports
that the unit-production firms included in her study which met the cri-
32
terion of success were of the simple line variety. Needless to say
these firms were in no respect comparable in size to the typical hospi-
tal organization, nor were the technical requirements of the task, beyond
the capability of the "generalist" in this size firm. Significantly,
however, two of the large process-production firms included in her study
which also were measured by success were of a functional structure and
operated as organic organizations calling upon the expertise of functional
specialists to supervise and coordinate, as necessary, the multiple prob-
33
lem situations which arose during the course of the enterprise operations.
In addition, many of the "successful" batch-production firms which were
intermediate between the unit-production and mass-production firms, while
woodward, p. 64.
33 I bid. . p. 118-122.
186
appearing to conform to a line-staff organization, actually provided
functional authority informally to the staff elements and operated in
an organ i c manner.
Organization theory provides little descriptive leeway between the
line-staff and functional forms of organization, and while the hospital
organization is generally described in line-staff terminology it appears
that through the extensive development of the service department concept
and ancillary department funct iona 1 izat ion a functional form of struc-
ture may be evolving. The success of this form of organization is
entirely dependent upon an organic method of operat ion--there is little
which can be routinized in this scheme of organization beyond the state-
ment of broad areas of functional competence and the sense of dependence
which must exist. The only purpose which this form of organization can
serve is to provide the opportunity for interaction among the various
areas and levels of competence on a problem-solving basis. However,
in both the project form of organic organization reported by Bennis,
and the functional form of organic organization reported by Woodward,
an essential element of the structure is the role of coordinator, below,
or on a parallel level of the organization with the functional elements,
in the hospital organization this function would appear to be performed
within the nursing staff if the functional form of organization holds
34
'bid. , pp. 102-122.
35
Bennis, p. 12.
Woodward, p . ] ] 8.
187
the key to the organic description of the hospital organization. How-
ever, it would be premature to suggest such a conclusion without con-
sidering the other ramification of hospital organization which has been
suggested as entering into the determination of the prototype charac-
teristics of these structures.
The hospital organization is not alone in containing the charac-
tersitic of unit-production technology although in terms of size and
volume of activity which is directed toward such production it would be
considered as unique. In addition, however, the hospital organization
is marked by the degree to which it employs professional workers in the
accomplishment of its unit-production tasks. Smith has commented that
hospitals are a seed-bed of professional izat ion through the association
which exists in these organizations with existing professional groups
37
and the training activities to which the hospital is committed. This
concentration of professional workers must be considered as a unique
■5 o
attribute of the hospital organization. It would therefore be expected
that this unique manifestation of hospital organizations would lead to a
variety of complicated issues in regard both to management and organization,
Perhaps the most significant ramification of professional ization and
the root cause of many problems which it creates within organization is
37
Harvey L. Smith, "Two Lines of Authority are One Too Many," Modern
Hospital , LXXXIV (March, 1955), 63.
■3 0
Edith M. Lentz, "Hospital Administration — One of a Species," Admini-
strative Sciences Quarterly, I (March, 1957), 46 1 -462 .■
39
Basil S. Georgopoulos, "The Hospital System and Nursing: Some Basic
Problems and Issues," Nursing Forum, V (1966), 14.
39
188
the basic identification of these individuals with the supra-goals of
their profession over the goals of the organization within which they
.1 40 T, _■ , . .
are employed. They tend to make poor organization men because their
loyalties are divided between their professional values and organization
41
demands. The values of a professional group are its basic and funda-
mental beliefs, the unquestioned premises upon which its very existence
42
rests. Such an external identification prevents the development of
the process of identification with organizational goals outlined by
Simon as a prerequisite to satisfactory performance of an individual
43
within the productive enterprise. " In return for professional identi-
fication with the values of this supra-organizat ion the professional is
insured of the protection of his rights as an organizational member
44
through the cooperative efforts of this externa] organization.
This identification with the social values of the profession has a
twofold effect upon the hospital organization. For one, the professional
worker will be only partially involved in the activities of the organi-
zation as a life work, although his degree of involvement may have high
40
Benni s , p . 12.
41,,.,
Ibid.
42
Ernest Greenwood, "Attributes of a Profession," Profess ional i -
zation, eds. Howard M. Vollmer and Donald L. Mills (Englewood Cliffs,
N.J.: Prentice-Hall, Inc., 1966) , p. 16.
43
Herbert A. Simon, Administrative Behavior (2nd Edition; New York:
The Free Press, 1957), p. 205.
44
Corinne L. Gilb, Hidden Hierarchies (New York: Harper and Row,
Publishers, 1966), p. 53.
potency. When the value system of the professional is obtained
within the organizational setting it would be expected that a high
degree of compatabi 1 i ty between professional and organizational values
would exist. The professional worker obtains his value system through
training and this training in the case of health care workers is
largely provided within the institutional setting of the hospital organi
46
zation. However, the profession as such maintains control over the
rules for admission of novices and the methods of training employed in
the hospital as a training institution. Even beyond the control exer-
cised over training of these categories of workers the professional
association exercises control of standards for operation of the hospital
48
organization through their accreditation bodies.
The most salient outward manifestation of professional izat ion is
the specialized competence of these employees and the authority which
49
they command in regard to their field of knowledge. " Hall believes
that this competence will direct the individual to command a functional
area of the organization rather than to be simply satisfied with
_
Katz and Kahn, p. 134.
46
W. Richard Scott, "Professionals in Bureaucracies—Areas of Con-
flict," Professional ization, eds. Howard M. Vollmer and Donald L. Mills
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1967), p. 271.
47
'Lentz, pp. 460-461 .
48
Paul J. Gordon, "The Top Management Triangle in Voluntary Hospitals
(I I ) ."Academy of Management Journal, V (April, 1962), 67.
49
^Davis, p. 292.
190
providing a servi ce. Although the professional may recognize the need
for the integration of various functions within an organization, he
believes that he should have considerable freedom to perform functions
in his area as he thinks they should be done. The key word in any
discussion of the professional, and which may well be separate from the
52
degree of competence which they hold, is autonomy. "They want to have
some choice about the kinds of projects on which they work and the ways
53
that they approach problems." Moreover, Hall believes, as has been
demonstrated in the hospital organization, that as an occupation obtains
professional status these workers will strive to escape administrative
control and they will seek to be incorporated, on a policy-making basis,
54
in the official system of authority of the organization.
The third manifestation associated with the professional worker,
and which is closely associated with a high degree of competence and
desire for autonomy, is the prestige which these employees command, or
seek to elicit from their associates within the organization. Brown has
specifically noted this ramification associated with the drive toward
profess iona 1 izat ion in the case of nursing and ancillary personnel in
the hospital organization. This prestige-seeking behavior in the case
Oswald Hall, "Some Problems in the Provision of Medical Services,"
Canadian Journal of Economics and Political Science, XX (1954), 465. •
51
Davis, p. 292,
I
54;
52lbid., p. 289. 53lbid
'Hall, p. 465.
Esther Lucile Brown, Newer Dimensions of Patient Care: Part 2
(New York: Russell Sage Foundation, 1962), p. 114.
191
of the emerging professions will be demonstrated by an aggrandizement
of the prestige-bearing aspects of their duties. "They will strive for
parity with the established specialties within work institutions, while
demanding positions superordi nate to those of more recent invaders."
The tendency will be toward the deflection of menial and humble
qg
aspects of their work to lower breeds of workers.
The contrast between the professional employee and the other workers
in the organizational setting is quite marked. The regular worker will
be quite aware of his dependence upon the other parties to the enter-
prise while the professional will seek autonomy as the only reasonable
59
method for the accomplishment of his tasks. In Simon's terms, the
bounds to rationality of the professional worker will be less constrained
and he will seek the authority of decision-making in broader areas.
Blau and Scott would tend to identify the professional worker as the
"cosmopolitan" as against the "local" who finds his identity in the
working situation and develops values which are in consonance with the
61
organization. The "cosmopolitan" on the other hand tends to obtain
his recognition from his professional peer who accords with his value
system and the organization is regarded as merely a vehicle which permits
56Hall, p. 465.
57lbid. 581 bid.
59Scott, pp. 269-270.
60
S imon, p . 241 .
6 1
Peter M. Blau and W. Richard Scott, Formal Organizations (San Fran-
cisco: Chandler Publishing Co., 1962), p. 64.
192
A?
him to pursue his professional goals. As Kron reports in the case of
nursing peronnel, the transition of the worker to a professional cate-
gorization develops a sense of frustration with the administrative
chores previously performed but now not central to the professional
identification which has been developed.
Each of these features of the professional worker suggests the
setting provided by the organic organization which has been described
previously. Scott lists various areas of conflict which exist between
the professional employee and his organizational employer within what
he describes as the bureaucratic setting, but which can be interpreted
as the modal organization complete with appropriate control machinery.
These are the professional's resistance to organization rules and
standards and the supervision of deisgnated superiors, and the con-
ditional loyalty which the professional awards to the organization.
This manifests itself in an independence of the professional from organi-
zational pressures and demonstrates his inclination to serve the customers
of the organization as his personal clientele in the manner of service
66
normally associated with the free professional.
Davis, p. 288.
63
Thora Kron, Nursing Team Leadership (Philadelphia: W.B. Saunders
Company, 1961 ) , p . 9.
64
Scott, pp.. 268-269.
6*bid,
66siau and Scott, p. 7k.
93
It has been noted that these values of the professional which are
antithetical to the usual forms of organization are highly regarded in
what have come to be called " i nnovational" organizations, a term closely
67
linked with the organic structure which is being considered. Thompson
has described the innovational organization as being characterized by
a structural looseness, generally, with less emphasis on narrow, non-
duplicating, non-overlapping definitions of duties and responsibilities —
the innovational organization is not as highly stratified as the modal
68
organization. In these innovational organizations, departmentali-
zation must be arranged so as to keep parochialism to a minimum but
with some overlapping and duplication permitted and with some vagueness
69
about jurisdictions which will encourage a good deal of communication.
Thompson further notes, that in these forms of organization professional
orientations and loyalties will be stronger than could possibly exist
70
in more formal structures.
Whether by calculation or circumstance those organizations which
contain an intensive participation on the part of professionals appear
to have a characteristically more decentralized decision-making structure,
Hutchinson makes this observation in the case of hospitals by noting
Mason Haire, "I ntroduct ion--Recurrent Themes and General Issues in
Organization Theory," Modern Organization Theory, ed . Mason Haire (New
York: John Wiley and Sons, Inc., 1959), p. 5.
68
Victor A. Thompson, "Bureaucracy and Innovation," Admi ni strat i ve
Sciences Quarterly, X (June, 1965), '3.
69 1 bid., p. 15. 7°lbid., p. 13.
Howard M. Vol Imer and Donald L. Mills, eds., Professional ization
(Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1966) , p. 146.
71
19^
within the frame of reference of the "acceptance theory" that the zones
of acceptance are much narrower in the lower reaches of these organi-
72
zations than is typically found elsewhere. This observation would be
supported by the contentions of the professional's need for autonomy in
the exercise of his skills and competence. In these forms of organization
management's primary significance is no longer as the apex of the
authority pyramid, but, rather, its central function is the design of
impersonal mechanisms of control which become the substitute for the
73
directives of superiors. Furthermore in these situations the standards
which become management's control are derived from the values held by the
profession. In the professional organization there must clearly be
compatabi 1 i ty among the measures of success provided by superiors, peers,
and the public being served.
The values contained within the professional frame of reference pro-
vide the motivation of the professional worker within the organization.
While this topic will be the subject of the final chapter of this essay,
the professional organization provides a prototype of organizational
structure designed to satisfy the higher-;. 1 needs of man through its
72
John G. Hutchinson, Organizations: I heory and Classical Concepts
(New York: Holt, Rinehart and Winston, 1 967) , p. 79.
'^Blau and Scott, p. 185.
7^
Joseph H. Fichter, "What Determines Success," Profess ional izat ion,
eds. Howard M. Vollmer and Donald L. Mills (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1966), p. 146.
75lbid.
195
accommodation of the values of competence and autonomy. This factor has
76
been commented upon by Scott. More traditional forms of organization
at best can only provide for the satisfaction of lower and intermediate
77
levels of human needs. As those needs become satiated within the
familiar context of organization new forms of structure will be developed
to accommodate the developing higher needs. Keith Davis sees this
phenomenon as already on the scene and as a part of the growing tendency
78
for profess ional izat ion of various occupations. The outlet for satis-
faction of these emerging human needs is the organization that is devoted
79
to intellectual and creative work. Thompson has commented that the
form of organization which is conducive to these satisfactions may be
impossible to value in terms of costs or benefits to society, but it
will be innovational and, therefore, organic, which is a fair appraisal
Of)
of the organizations of the future.
With these two factors of unit-production and advanced profess ional i -
zation of the work force clearly in mind it is possible to investigate
the dynamic process which is involved in the determination of this or-
ganic structure and to trace the development of the prototype organization
William G. Scott, Organization Theory: A Behavioral Analysis for
Management (Homewood, I 1 ].: Richard D. I rwi n, Co. , 1 9&7) > P • 78]
Abraham H. Maslow, Toward a Psychology of Being (Princeton, N.J.:
Van Nostrand Co., I nd . , 1962), pp. 31-33.
78
Davis, p. 291
I
30.
79lbid
Thompson, p. 20.
96
from its earlier stages where it more closely approximated the modal
organization. The point of departure is provided by the discussions of
the universal organization which appears in the literature. The proto-
type organization itself has been loosely described in terms of the
organic organization. It would be hoped that this analysis will provide
a firmer description, in organizational terminology, of the exact nature
of the hospital structure and, thereby, the organic organization.
In spite of the pronouncements in regard to the decentralized
nature of the innovational organization an investigation of the hospi-
tal organization would reveal the appearance of some tendency toward
recentral izat ion of authority. The traditional concept of the line
operative performer in the hospital organization can be visualized as
the nurse working directly with the physician in the care of the patient
and having the full authority necessary to carry out her functions which
spanned the requirements of the patient during hospitalization. Whether
this concept of the nursing function ever existed, and Brown takes ex-
O l
ception to this, the present arrangement is radically different. The
operative performers in this line activity today are often other than the
8?
professional nurse. The professional nurse has devolved the responsi-
bility for direct patient care and becomes an echelon of supervision
over the operative performers of the organization bringing the authority
Esther Lucile Brown, "The Need for Differentiation of Nursing
Service," 1 ssues in Nurs i ng, eds. Bonnie Bui lough and Vern Bullough
(New York: Springer Publishing Co., Inc., 19&6), p. 1 07 -
Ibid.
197
of nursing up into the hierarchy of the hospital organization, and
separating it from performance in satisfaction of the primary service
va lues .
The concepts of centralization and decentralization are variously
described in the management literature. Hutchinson describes decentrali-
zation as simply the exercise of authority as near as possible to the
Oo
point where problems originate. Etzioni alleges that decentralization
is relative to the kinds and degrees of authority which subordinates
84
hold in the exercise of their assigned tasks. The more broadly these
tasks are expressed the greater the decentralization of authority at any
particular level of the organization and the greater the autonomy of the
Or
individual in the accomplishment of his tasks. ' Simon provides for two
methods of decentralization which have the same effect; the individual
may not have operating rules specified for his activities leaving him
free to make decisions as he sees necessary, or he is specifically dele-
gated responsibility for designated decisions which must be made within
the organization. In either case the individual has the opportunity to
weigh competing considerations, and he does not have to accept conclusions
87
reached by others in the organization.
Ot
Hutchinson, p. 99.
84
Amitai Etzioni, Modern Organizations (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1964), p. 28.
8W
Simon, p. 234.
87,bid.
98
To place this concept within a context which can be considered
in comparative terms to the phenomenon which exists in the hospital
these simple definitions can be amplified. Simon provides, that for
decentralization of authority to be meaningful the individual who is to
exercise authority as an organizational decision-maker must have the
means available to render these judgments — that is he must be provided
with the organizational resources necessary to derive the premises
88
upon which his decisions will be rendered. This concept can be demon-
strated by considering a level of the organization where decisions of
some magnitude are to be rendered. Terry demonstrates the concept of
feasible decentralization of authority by postulating a structure of
organization where the authority holder has funct ional ized service
elements reporting directly to him, and then he detaches these elements
from the authority holder and places them at a higher level in the
89
organization. In the first case the authority holder is autonomous of
the remainder of the organization to the extent that the funct ional i zed
services provide the resources necessary to exercise his authority. In
the second case, although his authority may remain the same, he is de-
pendent upon other organizational elements beyond his sphere of control.
Only in the first case would Terry allow that decentralization of authori
90
ty exists. These considerations are separate from the pure notion of
PQ
Ibid. , p. 227.
89
"Terry, pp. 3^6-3^+9.
9°,bid.
whether an individual in an organization shou Id have a certain degree
of authority. Various criteria for decentralization, or centralization,
of authority exist which tend to ignore the feasibility of such an organi
zation structure. Hutchinson allows that decentralization of authority
is the wave of the future, because computer systems will allow the upper
reaches of management to provide real-time control over the actions of
91
their subordinates. This supposes that control rather than the avail-
ability of organizational resources is the issue. R. C. Davis believes
that the degree of decentralization of authority within an organization
is dependent upon the degree of standardization of procedures which can
be accomplished and the degree to which emergency situations must be
92
accommodated within the organization. By these criteria it would be
expected that the unit-production hospital organization would be highly
decentralized. Elsewhere Davis asserts that decentralization must have
as its prerequisite the availability of sufficient numbers of competent
93
personnel. Again, if this is accepted as a determining criterion, the
hospital would be expected to be a decentralized form of organization,
at least down to the professional nursing level suggested earlier. It
appears, however, that these individual criteria must be weighed against
the cost of making an administrative unit of the organization truly
91
J Hutchinson, p. 159.
92 /
Ralph Currier Davis, The Fundamentals of Top Management (New
York: Harper and Row, Publishers, 1950, pp. 309-310.
93 I bid., p. 315.
200
autonomous, as is suggested by Dale on the basis of his investigations
which reveal a continuing tendency toward centralization of authority
with increased economy and efficiency of operations.
The true nature of the hospital organization in regard to these
concepts of centralization and decentralization of authority which are
topics normally considered in terms of the mechanistic form of organi-
zation are revealed by a simple observation of any older hospital build-
ing and its architectural design. These facilities demonstrate, much
as the fossil remains of a previous civilization uncovered by an archeolo-
gist, a culture which existed within the hospital at a previous time.
Within these antedated structures there are complete diet kitchens on
each ward, broom closets which could contain complete maintenance
facilities, supply closets on each ward which in total provide more
space than the storage facilities of the centralized supply service,
medicine cabinets and narcotic lockers which out-space the modern
pharmacy, and autoclaves and sterilizers, which if they exist at all in
the modern hospital, are located in a central -surgi cal supply element
of the organization. Instead of commenting that they built buildings
differently in those days, the remark should be that they structured
organizations in a dissimilar fashion in the past.
Brown recounts the previous organization which existed in American
hospitals as providing anthropological evidence of the autonomous struc-
ture of organizational elements which had existed and of the centralization
94 ,
Ernest Dale, Organizat ion (New York: American Management Associ-
ation, 1967), p. 119.
201
95
of activities which has taken place. This description matches that
provided by Carzo and Yanouzas in regard to the autonomous administrative
96
unit. These units characteristically resemble a total organization,
within which virtually all of the decisions and actions necessary to
97
achieve a general purpose can be taken.
Therefore the organizational structure which exists in hospitals
today cannot be discussed in terms of centralization or decentralization,
and the autonomy which the professional employee seeks defies remedy
through the propositions provided by the mechanistic structure of organi-
zation even if this were the actual desire of the professional person.
Profess ional i zat ion is in essence, specialization and differentiation
98
of spheres of interest and concern. As Simon has noted, the problem
of organization cannot be considered separately from that of employee
specifications — position descriptions are less dictated by organization
structure, as organizational structure is dictated by the characteristics
99
of available manpower. To decry the massive relocations of authority
which has taken place in the hospital organizations is to deny the shift
in professional izat ion which has manifest itself within these structures.
The restructuring of the nursing role within the hospital organization
95
Brown, Newer Dimensions, p. 13.
96
Rocco Carzo, Jr., and John N. Yanouzas, Formal Organization: A
Systems Approach (Homewood, 111. : Richard D. I rwi n, I nc. , 1967), pp. 64-66,
98
3 Gilb, p. 105.
99Simon, p. 228.
202
which Is presently taking place must be understood within this larger
context .
The present issue in hospital organization is involved with the
definition of the role of the professional nurse and the structure of
the autonomous area within the organization which is her concern. While
Litterer adheres to the terminology of centralization and decentrali-
zation which may not be appropriate to this situation he notes that there
are different types of functional izat ion each of which provides different
c 1 00 . . . L .
areas of autonomy. He mentions management functions, business func-
tions, and manufacturing functions. To this could be added nursing
functions as an organic funct ional izat ion of the hospital organization.
In each of these areas a minimal level of autonomy can be described
1 02
which is complete in an area of professional specialization. Beyond
This minimum area any further funct iona 1 ization must be considered as
task specialization. The autonomous nursing unit is then circumscribed
by the definition of the nursing funct ion--the task specialization may
take place within this area but such elements as are created are some-
thing less than nursing per se.
As previously related, substantial evidence exists to indicate that
the suzerainty of the professional nurse has been delimited in the not
too distant past. However, there is little to indicate that a satisfactory
accommodation has been obtained by the funct ional i zat ion of the food
Joseph A. Litterer, The Analysis of Organizations (New York:
John Wiley and Sons, Inc., 1 965) , p. 383.
10L., 102.,..
Ibid. Ibid.
203
preparation and serving tasks, the drug and supply manipulation duties,
or the cleaning and maintenance chores, to mention a few. Some persons
1 03
would indicate that functional ization has gone too far. Others would
1 Ok
maintain that it has not gone far enough. Moreover, still others
would appear to confuse the issue of task specialization within an
autonomous area with functional ization. In so doing they argue that
the nurse has been removed from the patient care function. MacEachern
reports that three patterns of assignment are typical within the functional
area of nursing: the functional method, the case method, and the nursing-
team method. ' The first method has little to separate it from the
description of the nursing-team method as both are essentially an appli-
cation of task specialization. The only significance which can be derived
from this separation is that in the case MacEachern describes erroneously
as the functional method the workers who receive the task assignments are
fully competent to perform the entire nursing function while under the
team method the workers have skill limitations which would prevent a
l nR
larger assignment. Under both these methods a supervisory level is
103Kron, p. 11.
\0k
Luther P. Christman and Richard C. Jelinek, "Old Patterns Waste
Half the Nursing Hours," Modern Hospital , CVI I I (January, 1967), 77-81.
Brown, Newer Dimensions, p. 10.
Ibid.
Malcolm T. MacEachern, Hospital Organization and Management (Ber-
wyn, 111.: Physicians' Record Co. , 1962) , pp. 52^-525.
Ibid.
204
provided which has cognizance over the complete nursing function. Under
the case method the complete nursing function is performed by a single
1 09
individual as its name suggests. The research of Jelinek would sug-
gest that the nursing-team method of performing the nursing function was
employed in those institutions which he studied, because he discovered
that the addition of more registered nurses to the ward complement does
not increase the amount of patient care provided. If the other two
forms of assignment had been employed it would be expected that patient-
care would have increased proportionately.
But, in fact, it is not necessary to employ research studies to
demonstrate that the nursing-team is the most frequently employed method
of providing for the accomplishment of the nursing function. Kron has
commented that today the role of the nurse is changing from one who
1 12
qi ves care to one who d ? rects and supervi ses the care given by others.
However, the trend to team leadership as the role for the professional
nurse is not without its detractors. Hughes argues that the emerging
professionals ignore the mandate of society by passing their traditional
1 13
tasks onto the shoulders of subordinates in their search for prestige.
10 w
Richard C. Jelinek, "A Structural Model for the Patient Care Oper-
ation," He£Uh_Se£_yj_ce^_R^se^^ II (Fall-Winter, 1967), 226-242.
111,..,
Ibid.
1 12,.
Kron, p. v.
1 13
Everett C. Hughes, "The Professions in Society," Canadian Journal
of Economics and Political Science, XXVI (February, I960), 57.
205
Glib remarks that task specialization within a functional area provides
the seed-bed for further functional ization through the development of
1 14
vocational associations. Brown fears that increasing task speciali-
zation within the hospital will result in a sub-division of tasks at the
lowest echelons which provides jobs of little content or prestige much
in the manner of American industry.
These fears are not only the concern of interested by-standers.
The nurse herself resists the further fragmentation of the role which
she is attempting to define as that of a professional, however reluc-
tant she is to assume the managerial role which is provided under the
concepts of team nursing. Henderson has attempted to describe the essence
of the nursing function within a professional context by providing that
the nurse supplies the patient with knowledge, will, and strength to
perform his daily activities and to carry out the treatment prescribed
1 1 6
for him by the physician. She maintains that society wants and ex-
pects this service from the nurse and that no other worker is able, or
willing, to provide it. Apparently, the organization disagrees by
casting the nurse into the managerial role implied by team-nursing.
The team concepts which have been suggested in industry as leading
1 14
Gilb, p. 102.
Brown, p. 13.
1 1 6
Virginia Henderson, The Nature of Nursing (New York: The Mac-
mi 1 Ian Co. , 1966) , p. 21 .
117lbid. p. 68.
206
to the organic form of organizational structure should be considered as
a variety different from the hierarchical arrangement provided within
the nursing-team concept although it does not rule out this modification.
McGregor believes that the industrial team within the organic organi-
zation will be made up of partners on a co-equal level, and that they
will choose the leader in each problem situation on the basis of his
1 1 8
competence in the particular area. However, Likert believes that the
organic team concepts are amenable within a superior-subordinate relation-
ship when the superior is recognized as providing a coordinative and
1 19
supportive requirement. It seems obvious that in the literature con-
cerned with industrial organizations different forms of structure have
been included under the concept of team management. In the hospital
organization, nursing-team organization still means the formal superior-
subordinate hierarchy and will be so considered in this essay.
While it has been necessary to intrude upon topics which will require
further discussion from another point of view, the question of centrali-
zation and decentralization is essentially beside the point when the
organic form of organization is being discussed. If the organic organi-
zation is viewed as a static entity many of the manifestations of the
mechanistic structure seem to appear although these may well only be
Douglas McGregor, The Professional Manager, eds. Caroline Mc-
Gregor and Warren G. Bennis (New York: McGraw-Hill Book Co., 1 967 ) ,
pp. 84-96.
1 1 9
Rensis Likert, New Patterns of Management (New York: McGraw-
Hill Book Co., Inc., 1961), p. 116.
207
transitional tendencies. The appearance of a re-centralization of the
nursing function may herald the development of new functional areas which
are being devolved for future separation and elevation within the struc-
ture. It is, however, difficult within the developing lexicon of the
organic form of organization to employ such mechanistic terms as centrali-
zation of authority.
Lambertson has commented upon the evolution away from the nursing
service of the various institutional functions of the hospital organi-
zation by noting that after the normal working hours these functions
120
again become the responsibility of the nursing staff. While her source
of knowledge of the evolutionary process which has taken place is unique
there is nothing otherwise remarkable about this process as a common
organization dynamic. Woodward has described this process of evolution
of functional elements to divisional status in preference to previously
121
popular departmentat iona 1 arrangements in British industry. Litterer
has described the institutionalization of what he refers to as staff
122
elements as a process of specialization of the management function.
The unusual feature in hospital organization is that in the process of
restructuring the nursing role various management tasks which were
traditionally associated with the nurse have been assigned to separate
service departments. This evolution of the management tasks in the
120
Eleanor C. Lambertson, "Reorganize Nursing to Re-Emphasize Care,"
Modern Hospital , CVi I I (January, 1 967) , 68-71 .
121Woodward, pp. 1 09-1 18.
122Litterer, pp. 335-338.
hospital organization is remarkable in the extent to which it has been
carried .
The process by which managerial tasks are separated from an organi-
zational position and assigned to such service elements is described by
R. C. Davis, although he includes service elements as comparable to
123
staff elements in his analysis. His beginning stage of staff evolu-
tion is the point where the tasks involved are performed by the line
manager along with the tasks normally associated with his function--a
period of line integration. This stage is followed by a period with-
in which the tasks associated with the element to be evolved are differ-
entiated from the functions of the manager which are to be retained,
and specialized help is employed to perform these tasks under the dir-
1 25
ection of the line manager. This period is referred to by Davis as
distinct staff differentiation and is not dissimilar to the procedure
followed in the devolution of line tasks to operative performers under
the impetus of increased volumes of activity associated with the creation
or distribution of the primary service values of the organization, ex-
cept that in this case the tasks contain the potential for classification
as staff and service functions through their only indirect association
with the primary service objective. The third stage of this evolutionary
process, which Davis refers to as complete staff differentiation, is also
not dissimilar to the devolut ionary aspects followed in the case of line
di f ferent i at ion.
123
Ralph Currier Davis, pp. 376-384.
12Sbid.t p. 379. 125lbid., pp. 379-380. 126lbid., p. 380.
209
The task elements which have been differentiated to a single individual
are now dispersed among a group of individuals and a managerial unit
is formed under the line manager with responsibility for the management
of these tasks assigned to a person reporting directly to the line
127
manager. The fourth stage in this process, which for reasons dis-
cussed later may or may not be accomplished, is called the period of
1 9 ft
staff integration. This stage is reached when it is recognized that
staff elements of a similar nature have been created throughout the
organization. The grouping of these elements within their own depart-
mental structure would be advantageous. This stage would also require
some decision as to the proper portion of the organization to which the
129
newly created department should be attached for supervisory purposes.
Again the criteria for each of these stages are not being discussed so
that they may be considered along with the special circumstances exist-
ing in the hospital organization.
The fifth and sixth stages which Davis discusses are also alterna-
tive possibilities in the evolution of staff and service departments
within the organizational structure. The stage of staff elevation is
a possible alternative at the time of staff integration. It implies
that the departmentalized elements or some portion of them may be shifted
to report directly to top management of the organization or, at least, to
some higher level of the organization than that to which they were origi-
nally attached. The sixth stage, as an alternative, provides for a
127lbid. 128lbid., pp. 380-382. 129lbid.
130lbid., pp. 382-383.
210
period within which staff decentralization is accompl i shed--essent i al ly
a retrograde movement if the other stages are considered as progressive.
It is interesting that this evolutionary stage may either provide for
movement to a lower level in the hierarchy but with the retention of
departmental status, or it may encompass the return of staff elements to
line supervision at the lower reaches of the hierarchy as a divided
function.
The final stage which Davis provides in this process of staff
1 32
evolution is entitled "complete staff separation." His examples are
mainly obtained from industry and would be difficult to visualize in the
hospital setting; however, a number of similar processes have become
frequent occurences on the health care scene. Many hospitals are
grouping their efforts in data-processing and purchasing and creating a
corporate identity for these functions separate from any individual
hospital. Other hospitals have discontinued providing food-service and
janitorial services as an internal function and are now purchasing such
services from private contractors. In each of these cases where the
interna] management control of a function passes beyond the boundaries
of the organization, complete staff separation can be said to have
occurred .
This then is essentially the dynamic analysis which can be applied
in the investigation of the staff and service department phenomena which
appears in any organization. As Davis notes, different functions are
frequently at different stages of staff evolution at any point in time.
131lbid., p. 383. 132lbid.,p. 384. 133lbid., 383.
211
However, it is probable that any element of the organization is in pro-
cess of change at any point in time, and those elements which appear to
be static may only be reflecting the gathering of forces which make a
future change probable.
Dale believes that the evolution of these elements is largely a
question of the economic factors involved, at least in the case of busi-
ness organizations. He recognizes that non-quantitative factors such
as the ability of specialists to perform the tasks at hand may be the
deciding factors; however, these must still be recognized in the profit
and loss statement. -^ R. C. Davis generally adheres to the concept
that staff and service departments owe their existence to the impera-
tives provided by the secondary service objectives of performance of the
primary and collateral service objectives with efficiency and economy,
however, the criteria for the evolutionary process of these functions
may only be so determined in a round-about manner. He thinks that those
task elements which have the greatest growth potential and are least
similar to those with which they, are grouped are most likely to be
differentiated first and set up in independent positions, and this is
particularly true if these elements tend to become more complex and
1 36
technical with organization growth. He also provides, however, that
task elements may be associated with dissimilar functions when the size
13^Dale, p. 105.
135
Ibid. , p. 107.
l36Ralph Currier Davis, p. 375-
212
of the organization does not permit their economical independent develop-
e tl
138
137
ment. Their association with dissimilar functions may also be the
result of their complementary nature in regard to that function.
Complete staff differentiation may often be noted when other functional
areas of the organization have requirements which can be satisfied by an
139
expansion of the task elements contained elsewhere in the organization.
Davis is able to summarize these criteria for staff evolution in his
concept of the principle of functional emergence which provides that
the tendency of a given function toward differentiation and independent
grouping tends to vary directly with: the degree of dissimilarity be-
tween the particular function and the function with which it is grouped;
the degree of correlation between its growth and development and the
growth of the organization as a whole; and, the tendency of the function
140
to become increasingly complex and technical with growth. While Fox
is basically in accord with this analysis he argues that sometimes it is
very difficult to affix responsibility unless dissimilar functions,
which otherwise might be separated, are grouped together within the same
141
administrative element. He also notes that functions may be assigned
to administrative elements which contain individuals who have evidenced
the greatest interest in the function or who have the greatest capacity
'37lk.^ 138., . , 139... .
Ibid. I oi d. Ibid.
140,,.,
Ibid.
141
Willi am McNai r Fox, The Management Process (Homewood, 111.: Richard
D. Irwin, Inc. , 1963) , p. 84.
213
142
for implementing the function in the proper manner. However, he
also recognizes that these concessions to personal attributes must not
be pushed to a point at which the basic rationale of the organization
143
structure becomes confused.
Davis also comments on reasons why a staff or service function
144
should be split, or decentralized. If the function is placed in
direct physical contact with the function which it serves, this service
can be modified to suit the specific needs of the organizational element
145
to which it is attached. The service may also be rendered more
promptly for it can be coordinated directly with the principal functions
which it serves as the need arises, particularly in those cases where
146
time is an important factor. However, while such arrangements may
increase the independence of the particular functional unit it will also
place an increasingly heavy burden upon the management function in that
unit.
As indicated previously there is a basis in each one of these
criteria provided in the management literature for applying an economic
calculus to the decision-making problem involved in the determination
of the organizational structure which should exist. Such does not appear
to be the case in the hospital organization where the criteria for staff
and service department functional ization is argued on bases peculiar to
142.,., 1^3,...
Ibid. Ibid.
144
Ralph Currier Davis, p. 253 -
Ibid. Ibid.
214
the professional organization, although economic implications are often
alluded to in these arguments. Henderson has perceived that in this
country nurses have insisted that members of their occupation must be
freed from all non-nursing tasks so that an environment can be developed
within which they can function on a peer relationship with other pro-
147
fessional medical workers. Rourke has commented that the professional
has traditionally exhibited a reluctance to undertake administrative
responsibility and that he has openly subscribed to the idea that it is
._, . . ,148
important to avoid wasting professional talent on management tasks.
It can be imputed that Rourke is referring to both the management func-
tions and the tasks associated with these functions which receive defi-
nition in the service department setting. Corwin traces this phenomenon
among nursing personnel as being one of the impacts involved in the shift
from diploma to degree programs where an increasing emphasis is placed
149
upon professional izat ion. The diploma programs, on the other hand,
provided an institutional setting wherein the aspiring nurse could become
accustomed to the acceptance of the administrative tasks which were
traditionally part of the nursing function.
Henderson, p . 31.
148
Francis E. Rourke, "Bureaucracy in Conflict: Administrators and
Professionals," Ethics, LXX (April, I960), 222.
149
Ronald G. Corwin, "The Professional Employee: A Study of Conflict
in Nursing Roles," American Journal of Sociology, LXVI (June, 19&1), 605.
]50,bid.
215
At the present time various proposals exist for extending the
differentiation process within the nursing function of the hospital
organization to accord with the professional izat ion of the nursing role.
While these schemes are amenable to the analysis provided by Davis in
the Stages of Staff Evolution they do not necessarily conform to the
Principles of Functional Emergence which he elucidates. Brown summa-
rizes the proposals that lay managers assume the administrative tasks
associated with the nursing function. ' One proposition is distinct
staff differentiation of these tasks within the nursing function with
the assignment of these managerial tasks to an individual above the
competence of a clerk or secretary but not requiring the specific medi-
152
cal and nursing knowledge and judgment contained in the nurses's role.
Under this concept the "ward manager" would report directly to the nurse
in charge of the ward as implied in the concept of staff differenti-
1 53
ation. Another variation of this concept is complete staff differ-
entiation and integration of these managerial tasks utilizing a similar
type of individual, but having this person report to an echelon of the
hierarchy above the nursing department. A more recent report summar-
izes a less radical evolution of many of the managerial tasks through a
process of complete staff differentiation and elevation to the level of
the head of the nursing department where these functional elements will
perform staff services to the entire nursing department.
Brown, p. 63.
152 ibid. 153lbid. 154!bid.
1 55
Everett A. Johnson, "Nursing Reorganization Strenghthens Head
Nurse Role, Provides Special Nursing Consultants," Hospitals, 1LI1
(June 16, 1968), 85-90.
216
It may appear difficult to understand why, after the extensive
differentiation and separation of nursing tasks, the nursing role would
appear cluttered with extensive management responsibilities. It would
be logical to assume that the transfer of responsibility from the nurs-
ing function to newly created functional departments responsible for
service activities would lessen the managerial responsibilities remain-
ing to the nurse. However, evolution out of operative tasks of manage-
ment does not necessarily reduce the scope of the management functions
nor the responsibility of the manager to provide the coordination neces-
sary to the accomplishment of the primary tasks which are assigned.
Many of the management functions can be enumerated as physical tasks
which are amenable to differentiation and separation but others can
only remain as conceptual matters which appear to remain with the
manager. R. C. Davis has analysed the management functions of planning,
organizing, and controlling into elemental units for the purpose of dis-
cussing their feasibility for staff differentiation.156 He concludes
that while many aspects of the managerial functions could conceivably be
separated to staff and service department echelons, essential elements
i ve act i on-
of the control funct ion— d i rect ion , supervision, and correct
are less readily assigned.'57 The function of direction reinforces unity
of command and therefore basically a line function.'58 The line func-
tion of supervision is a reflection of the lines of authority and
1 ^6
Ralph Currier Davis, pp. 407-408.
157ibld., p. 407. 158ibid., pp. 702-703.
217
responsibility which form the structure of the organization and there-
1 59
fore it too is inherent in the managerial role. Davis concludes
that any considerable delegation to staff echelons of responsibility
for direction, supervision, and corrective action would be tantamount
i 6o
to managerial abdication.
It would therefore appear that as long as the nursing function
remains Identified with the primary objective of the hospital organi-
zation, which it must, there will remain a managerial role for nursing
personnel which cannot be avoided, however professionalized this role
becomes. But this does not explain the range of managerial tasks which
now exist in the nursing services. Saunders refers to the increasing
1 6 1
managerial or administrative aspects of the nursing role. Marksch
describes the daily round of the nurse's life which indicates the in-
1 go
tensity of the administrative demands which are placed upon her, a
description which is not dissimilar to that presented by Roethl i sberger
1 63
in his report on the industrial supervisor. The supervisor in indus-
try finds himself as the "man-i n-the-mi ddle" in the working situation-
responsible to everyone but with little effective control over the
159lbid., p. 708. l60lbid., p. 408.
Lyle Saunders, "The Changing Role of Nurses," I ssues in Nurs i ng,
eds. Bonnie Bullough and Vern Bullough (New York: Springer Publishing
Co. , Inc., 1966), p. 126.
1 62
Hans 0. Marksch, "Nursing Dilemmas in the Organization of Patient
Care," Nursing Outlook, V (January, 1957), 31-34.
1 63
F. J. Roethl i sberger , "The Foreman: Master and Victim of Double
Talk," Harvard Business Review, ILI1I (September-October, 1965), 22-37."
218
164
affairs which surround him. Similarly, as Corwin has described the
hospital situation, the nurse finds herself torn between professional,
humanitarian, and bureaucratic chores, she has no independent method of
, ... 165
resolving the working situation.
In large part this increase in the administrative workload which
the nurse supervisor experiences is a direct result of the differenti-
ation and separation which has already taken place out of the nursing
function. New organizational units have come into being to encompass
these functions and these units each have their separate demands which
must be met by the nurse. Woodward notes how in industry the separa-
tion of production administration from the supervisor of production
operations has given rise to many problems as the relationship between
1 fifi
the two must be controlled. Wessen discovers the identical phenomenon
in the hospital situation where the functional ization and separation of
service activities has resulted in the appearance of many persons on
the ward floor who are not responsible to the nurse but whose activi-
ties she must coordinate in the accomplishment of the primary service
objective of the organization. While many of the menial tasks which
were involved in the management of the nursing function have been removed
Ibid.
Corwin, p. 607.
Woodward, p. 214.
1 67
Albert F. Wessen, "Hospital .Ideology and Communication between
Ward Personnel," Patients, Physicians and Illness, ed . E. Gartly Jaco
(New York: The Free Press, 1958), pp. 452-453. ,
219
from the nurse's authority these tasks return to haunt the service in
their requirement for coordination and sometimes in the demands for
reports and procedures which must occupy the concern and time of the
nurse supervisor. Litterer summarizes the effects of the institutionali-
zation of the staff functions as an outgrowth from the managerial func-
tion as consisting of a trimming of the manager's job and therefore
making it less important, the downgrading of unique personal skills
previously required of the manager, and the reduction of the managerial
job to the point where the portion remaining is more easily subjected
, 168
to control .
The present suggestions for an evolution of a ward manager's posi-
tion out of the nursing function would appear to be the final stage of
an evolutionary process which has continued down through the years as
the nurse has attempted to define her professional role in the organi-
zation. Functional ization and separation of the operative tasks of
management appear to have gone as far as they possibly can; the admini-
strative tasks of management of the nursing function are proposed for
the ward manager as a separate functional entity. What, If anything,
remains which can be identified as management could reveal the essence
of the coordinative function.
There is obviously a fine line which must be drawn in the definition
of what is management under the circumstances of advanced functional i-
zation created by profess ional ization and existing in an environment of
1 68
Litterer, pp. 359-360.
220
unit-production. It is generally agreed that the nurse will remain
the decision-maker in this funct ional ized setting when the primary
169
service objectives are involved. Whatever the nature of the co-
ordinative function which will be involved in decision-making under
such an organizational arrangement the nurse must be skilled in the
requirements of this task in addition to the specialized duties of her
profession. The nurse will have to be familiar with the management
process and be trained in its methods.
It has been feared that the functional izat ion of management would
172
destroy the manager's job if carried to extremes. Koontz and O'Donnell
believe that well-managed concerns recognize that functional authority
should be used sparingly and only where a real necessity exists, for if
a manager loses his authority to plan, organize, staff, direct, and
I73
control the activities within his department he can no longer manage.
Too great a proliferation of functional authority delegations provides
the danger of a breakdown of the unity of command. While each of
these functional entities may have only a modicum of this form of line
169
Robert N. Wilson, "The Social Structure of a General Hospital,"
Annals of the American Academy of Political and Social Science, No. 3^6
(March, 1963), p. 72.
Likert, "A Motivational Approach to a Modified Theory of Organi-
zation and Management," p. 193.
Stuart A. Wesbury, Jr., "Courses in Management Needed in Pro-
fessional Training," Hospital Topics (September, 1 967 ) , pp. 68-70.
1 72
Harold Koontz and Cyril O'Donnell, Principles of Management (3rd
Edition, New York: McGraw-Hill Book, Co., 1964), p. 276.
173lbid. '^Ibid.
22
authority, in total they may outweigh the authority which remains to
the individual line manager.
R. C. Davis also recognizes that if his dynamic analysis is carried
to its logical conclusion of complete functional ization the line manage-
1 76
ment role would disappear along with the primary line organization.
Every executive would be a specialist and would hold primary line
authority with respect to the primary operations involving his specialty.
The necessary result would be that the top administrative level of the
organization would contain the only remaining executive who could make
178
decisions for the organization as a whole. But Davis is not overly
concerned with the possibilities existing in this situation for economic
considerations would rule the decision as to how far functional ization
could proceed, and this criterion would insure that the integrity of
the line organization was maintained because of its responsibility in
179
regard to the primary service objective.
Nevertheless a real question exists in various forms of organization
where functional ization has been extensively employed as to the feasi-
bility of maintaining the more traditional line-staff form of organi-
zation and the concepts associated with it. McGregor suggests that
17 W
Ralph Currier Davis, p. 465.
1771 bid. 178lbid. 179lbid., pp. 431-432.
180
Douglas McGregor, The Human Side of Enterprise (New York: McGra
Hill Book Co., Inc., I960), p. 16.
222
functional ization has progressed to the point where new forms of manage-
1 Oi
ment are necessary. Woodward's investigations reveal that the charac-
teristics of extensive functional ization are quite advanced in many
successful organizations with staff and service groups holding signifi-
1 ft?
cant authority over traditional line activities. However, she ob-
served that a characteristic which was common to all successful firms
was a status system which gave adequate recognition to the importance
of the critical functions. The observations of Simon in regard to
the acceptance of authority conclude that authority, unless buttressed
by other forms of influence, is relatively impotent in the managerial
184
process .
This would suggest that the degree of functional ization which has
taken place in the hospital organization has been a rational process for
this type of organization when it is considered against a background of
professional ization and unit methods of producing a complex product. The
product characteristics would dictate a full range of technical and sup-
portive skills beyond the capacity of the general ist and a line form of
organization. However, it is observed that this form of organization was
traditional in the earlier days of the health care system, and as Wood-
ward has noted in industry, it is the predominant style in other forms of
l8llbid., pp. 173-175.
Woodward, pp. 166-1 67.
1 83 I b i d . , pp. 126-217.
184..
Simon, p. 227.
223
unit-production firms which are not bound by the complexity of skill
requirements to seek a new form of structure. The line form of organi-
ation would appear to provide the autonomy desired by the professional
if the associated factor of specialism is ignored; however, an additional
factor in the professional make-up is the abhorrence of the operative
tasks of management necessarily associated with the autonomy implied
in the decentralized line operation.
The alternative form of organization which is immediately suggested
under these circumstances is that which has been outlined as the line-
staff form of structure. However, this structure requires a routiniza-
tion of productive procedure to allow the full weight of the specialist
staff skills and service department facilitating activities to be brought
to bear. It also requires a great deal of formality in the management
process. Together these requirements appear to be in opposition to the
unit-production requirements of the hospital situation. Nevertheless,
this form of organization appears, from the static descriptions which
have been provided, to have been employed as a transitional mechanism in
the organization of the hospital structure. The anomalies of hospital
organization which have been recounted reflect the disturbance which
this transition from the line structure occasioned. As long as this
form of structure was coexistent with a continuation of unit-production
techniques and an increasing trend toward professional izat ion of occu-
pational skills its failure was foreordained. The pressures for routini-
zation of procedures which Lentz has decried as the advent of bureaucracy
224
and others deplored as mechanization and mass-production of health are
all indications of this transition of the hospital organization through
a line-staff form of organization which is the only route available under
the circumstances to arrive at a viable form of organization. The
static description of two chai ns-of-command noted by Smith reflects a
stage in the transition of the hospital organization to its new form.
Etzioni's notation on the confusion of roles within the hospital struc-
ture merely reflects the searching for an organizational identity in an
organization in transition.
The logical conclusion of this evolution of structure is some vari-
ation on the theme of the functional organization. On the basis of the
descriptions which have been provided it is difficult to maintain that
the epitome of structural form has been attained in any existing hospital
organization although all indications appear to indicate that this form
of organization will be the ultimate result of the transitional form
which now exists. Its merits provide that unit-production can be
accomplished through the constant interaction of skilled experts, and
the autonomy of the specialist can be maintained within his particular
functional area. However, the detractions of this form of organization
are numerous especially when it is revealed as a further extension of the
1 8^
line-staff form of structure. 3 But it should be noted that the objec-
tions which have been offered to this form of organization are not its
1 8^
''Fox, pp. 95-96.
225
1 86
structural defects but concern over the foibles of its human inhabitants.
It is therefore necessary to explore the peculiar characteristics of the
professional organization to determine the method whereby these valid ob-
jections can be removed as the evolutionary process proceeds.
It must first be realized that the descriptions of the functional
form of organization are basically cast within the mechanistic model and
yet can only be appreciated when viewed as an organic form of organization.
By that, it is meant that maximum interaction is a prerequisite to suc-
cessful accomplishment of the primary service objective of the enter-
prise. Many of the objections to this form of organization show concern
that intrusion of one element of the organization upon the affairs of
another will be actively resisted. The usurption of formal authority by
one element from another will be the cause of jealously guarded relation-
ships. However, it has been observed that in the hospital organization
the professional employee appears to welcome the passing of managerial
tasks and the authority associated with them. Perhaps the reaction in
industry has been different through its cultural emphasis upon the pres-
tige associated with the managerial function and the skills of the
general ist. In the hospital organization the professional welcomes the
shedding of these tasks for he views his autonomy within the context of
a value system external to the organization itself.
The functional organization, if it is to be attained and proved
successful, must provide a parity within the power relationships which
1 oc
McGregor, p. 146,
226
will exist. This concept of organizational balance has been central to
1 87
the discussion of any organizational form of structure. Scott has
discussed these power ramifications in regard to the mechanistic struc-
1 00
ture. R. C. Davis offers a discussion of balance of organizational
structure and its bearing in the case of staff groups which can be -taken
189
as an incipient form of the functional arrangement. Within a socio-
logical context of organization theory, Etzioni has commented upon the
requirements imposed by dual leadership of the expressive and instru-
mental type which appears to be the developing format within the func-
190
tional organization.
In the professional organization with a functional structure the
power of the professional rests in the prestige and status which is
resident in such an occupational classification. The power implied is
directed toward the primary service objective of the organization through
the link between externally maintained professional values and the values
of the organization. While the involvement of the professional organi-
zation will be less than complete it would be expected that the potency
of this involvement would be high because of this essential value link.
The Unity of Doctrine would be expected to be maintained intact.
l87Dale, p. 31.
l88William G. Scott, p. 253.
189
Ralph Currier Davis, pp. 535-537.
190
Amitai Etzioni, "Dual Leadership in Complex Organizations,"
American Sociological Review, XXX (October, 1 965) , 689-195.
227
The power of the other functional elements of the organization,
which have generally been discussed as staff and service elements in
this essay, would be resident in the task assignment which is involved.
However, it would be expected that this would be additionally reinforced
as full functional ization is attained by the increased specialization and,
perhaps, professional ization of these occupations if such is not already
the case. A sound basis for this profess ional ization, in the case of
ancillary and facilitating personnel of the hospital organization, is
generally expected to be provided by the indoctrination and training
programs for these individuals, which will include an emphasis upon in-
corporation of a value system compatable with the primary service ob-
jective of the organization. This purpose would be additionally served
by the suggested development of future hospital administrators through
the functional divisions of the organization where the value system which
has been inculcated in these individuals can become part of the larger
organization.
The provision of a common value system among all the members of the
organization through these devices should maintain the essential elements
which are imposed by the mechanistic, unity of command. The organic form
of organization which has been described in terms of the functional for-
mat would provide the spontaneous adaptation to the need of the system
required under unit-production. There would be a coordination of equals
on a voluntary, informal, and expedient basis much as in the case of the
project or innovational organization which is proving its success in
228
organizations which do not have the requirement for multiple adapta-
tions within a brief period of time. Likert's description of these
optimal forms of organization appear to be well-suited in the hospital
organization, and may well be apt comment on the form of organization
191
which is evolving within these structures.
As Rosenberg has stated, it appears that the voluntary hospital may
represent one of the more advanced and complex forms of successful
192
organization in relation to its size in American society. ' It can be
considered as a pioneer in the development of forms of structure and
voluntary human cooperation which emphasizes the persuasive force of
193
ideas rather than the coercive powers of authority. The hospital
organization appears to demonstrate the possibilities which exist for
the successful combination of professional activities with an admini-
strative structure while still maintaining the concepts of service. As
such it represents a prototype for the service oriented organization
which will undoubtedly play an increasingly expanding role in the Ameri-
can economy.
1 Ql
3 Likert, p. 185.
192 ,
Rosenberger, p. 42.
193lbid.
CHAPTER IX
TOWARD EUPSYCHIAN MANAGEMENT
By recognizing the more limited primary service objective of the
hospital organization, which does not encompass the entirety of the
healing process, it has been possible to define the structure of the
typical, voluntary, general hospital in a manner amenable to the analysis
of organizations outlined in the management literature. The exclusion
of the physician from this structure has allowed the hospital organiza-
tion to be defined in the traditional line and staff format, and by
dynamic analysis to be interpreted as a variation of the universal
structure. This analysis demonstrated that the typical hospital is
pursuing an evolutionary path along a continuum toward a functional
structure under the impetus of the imperatives associated with the related
factors of unit production and professional ization of the work force
employed in this organization. The salient anomalies of hospital organi-
zation which have been reported tend to vanish under this analysis or
reveal themselves as manifestations of the factors which have been sug-
gested as being determinant of this prototype organization.
As a pattern of organizational structure which can be expected to
result from the continued evolution of organizations which are of the
present modal type it would be of benefit to investigate this structure
in terms of its accommodation to the nature of the mature individual.
229
230
As has been noted, the advent of professional izat ion with its attendant
functional ization has greatly reduced the authoritarian character of
the hospital. Professionals prefer maximum freedom and autonomy in
their work and are adverse to the regimentation implied in more formal
organizations. This would appear to place a heavier requirement on
the coordinative functions of management within the hospital and increase
the pressures upon the administrator .3 However, there appears to be a
high degree of agreement about the principal objective of the hospital
organization among the participants and the personal needs and goals
of the different members seem to be in accord with this objective.
This agreement of objectives does not span all of the requirements that
the various participants place upon the organization; as Lentz has noted,
no one is getting rich on a hospital salary, but many are leading rich
lives in terms of satisfaction. 5 The professional adheres to an ethic
of service, by definition, rather than the unrestrained pursuit of
sel f- interest.
Basil S. Georgopoulos and Floyd C. Mann, "The Hospital as an
Organization," Hospital Administration, VII (Fall, 1962), 54.
2lbid. , p . 19.
■3
^Edith M. Lentz, "Hospital Administration — One of a Species,"
Administrative Sciences Quarterly, I (March, 1957), 461.
h
Georgopoulos and Mann, p. 62.
^Lentz, p. 462.
"Corinne L. Gilb, Hidden Hierarchies (New York: Harper and Row,
1966), p. 235.
231
It appears that professionalism is associated with the concept
of the operative nature of higher level needs within the individual.
Greenwood sees this association in the professional's impulse to per-
form maximally rather than restricted to factors of self-interest.'
"Professional work is never viewed solely as a means to an end; it is
o
the end itself.1 The professional's work receives his total involve-
ment and from this he obtains primarily psychic satisfactions and secon-
darily monetary compensat ion.-' Wilson believes that this is an important
factor in converting what would otherwise be a nightmare to the formal
organization theorist into a viable scheme of work, for in fact the
work of the hospital is accomplished with admirable dispatch.
Thompson believes that the relative success of all forms of the
organic organization has this attribute of providing the professionally
motivated individual with the opportunity to become successful, as his
professional values might dictate success. The organization provides
^Ernest Greenwood, "Attributes of a Profession," Professional iza-
t ion , eds. Howard M. Vollmer and Donald L. Mills (Englewood Cliffs,
N.J.: Prentice-Hall, Inc., 1966), p. 15-
8lbid. , p . 17.
9lbid.
10Robert N. Wilson, "The Social Structure of a General Hospital,"
Annals of the American Academy of Political and Social Science, No. 3^*6
(March, 1963), p. 73
Victor A. Thorn
Sciences Quarterly, X (June, 1965), 11
Victor A. Thompson, "Bureaucracy and Innovation," Administrative
232
the individual with an avenue for such reward through the opportunity
1 2
for professional growth and the esteem of his knowledgeable peers. '*
The research conducted by Herzberg, etal_. , indicated that perhaps
the set consisting of achievement, recognition, responsibility, advance-
ment, and the work itself is an all important source of satisfaction
in these situations. •> These sources of satisfaction are substantiated
in part by Woodward who notes that in the case of the uni t-product ion
firms which she investigated the nature of the work itself and the
responsibility associated with it called forth a unique effectiveness
on the part of the individual workers.
Keith Davis detects a positive relationship between the factors
presented by Herzberg as the motivators of managerial and professional
employees in organizations and the higher-level needs discussed by
Maslow in his writings. '-> The research conducted by Blai suggests the
1 6
same conclusion specifically for professional employees. Brown
12lbid,
^Frederick Herzberg, Bernard Mausner, and Barbara Bloch Snyderman,
The Motivation to Work (2nd Edition; New York: John Wiley and Sons,
Inc., 1959), p. 60.
Joan Woodward, Industrial Organization: Theory and Practice
(London: Oxford University Press, 1 965) , p. 1 59-
'5|<eith Davis, Human Relations at Work (3rd ed. rev.; New York:
McGraw-Hill Book Co. , 1967) , p. 36.
^Boris Blai, Jr., "A Job Satisfaction Predictor," Personnel
Journal (October, 1963) , p. ^55-
233
definitely suggests that self-actualization and self-realization are
the prime motivators in the case of professional workers in hospitalsJ?
McGregor outlines the same conclusion in other types of organizations
I o
which employ the professional worker.
Perhaps the best evidence for this higher-level need motivation
in the case of the professional worker is provided by the writings of
1 9
Maslow. -' He maintains that at the highest level of the need hierarchy
there is a fusion, or synergy, of selfish and altruistic motives.
This point has already been noted in regard to the professional in the
hospital organization, and this is supported by Herzberg, who remarks
that such must be the case in hospitals where self-interest and the
spirit of service would most likely be sundered in view of the generally
? 1
poor extrinsic rewards provided. In each case, Maslow has discovered
that the mark of the individual who is operating at the higher levels
of the need hierarchy is in the devotion to some task or duty which is
'Esther Lucile Brown, Newer Dimensions of Patient Care: Part 2
New York: Russel 1 Sage Foundation , 1962) , p. 115.
1 8
Douglas McGregor, The Human Side of Enterprise (New York: McGraw-
Hill Book Co., Inc., I960) , p. 43-
19
Abraham H. Maslow, Toward a Psychology of Being (Princeton, N.J.:
D. Van Nostrand Co., Inc., 1962).
20 1 b i d . , p. 192.
Frederick Herzberg, Work and the Nature of Man (Cleveland, Ohio:
The World Publishing Co., 1966), p. 183-
234
outside his own sel f-interest and contains the set of values which
22
are associated with a professional identification.
This is not to say that it would be expected that all professionals
or emerging professionals will have the characteristic of an operative
need for self-actualization, but such a motivation will be incipient in
the value system of their vocation. The research of Herzberg indicates
that the professional has the capacity through his work to obtain satis-
factions of this higher-level need, but if this work is pursued within
an organization setting the potential for dissatisfactions in terms of
maintenance needs will also be present. -> Replication of the early
Herzberg studies within the hospital setting has indicated that this
phenomenon of high satisfaction with the positive motivators and dissatis-
faction in regard to the maintenance factors provided by the organization
24
is typical in the case of nursing personnel.
These observations in regard to the high potency of the higher-level
needs in the case of the professional worker are substantiated by Katz
and Kahn. They believe that profess ional i zation of the staff of an
Abraham H. Maslow, "A Theory of Metamot ivation : The Biological
Rooting of the Value-Life," Journal of Humanistic Psychology, VII
(Fall, 1967), 94.
23
Herzberg, et al . , p. 111.
^Herzberg, pp. 92-129-
^Daniel Katz and Robert L. Kahn, The Social Psychology of Organi
zations (New York: John Wiley and Sons, Inc., 1 966) , pp. 368-370.
235
organization suggests the characteristics of an expressive rather than
26
instrumental cycle of rewards. The professional obtains much of
his reward from the exercise of his skills, ' indicating that relative
to other workers, and proportionate to the instrumental rewards pro-
vided by the organization, the professional worker will receive a higher
degree of satisfaction within the organization.
The early work of Parsons indicates that this higher-level need
satisfaction may not be exclusive with the professional worker. ° He
states that the apparent dichotomy between altruistic and egoistic
motives in the case of professionals and other occupational groupings
may merely be a reflection of institutional patterns of values which
are split into two groups. Both groups, when they rise to a level of
satisfaction beyond the basic needs, may be motivated by self-realization
with the measure of such satisfaction in the case of managerial employees,
for example, being supplied by typically egoistic values. ^' Two individ-
uals may both be seeking self-realization, but one manifests this through
an altruistic pattern of behavior while the other strives for satisfaction
through means which are normally associated with egoistic motivation.-*
26lbid., p. 133.
27
Ibid,
28lbld., p. 370.
°Talcott Parsons, "The Professions and Social Structure," Social
Forces, XVII (May, 1939), 457-^67.
30 I b ! d . 31lbid. 32|bid.
236
The profit score-card is typical of this latter phenomenon.
Management practitioners and theorists have been well aware of the
need for synthesis between the goals of the individual and the objec-
tives of the organization. Simon maintained that such an integration
was essential to the decision-making process and suggested that the
value system of the individual participants in the organization must
reflect the values of the organization for such are the essential pre-
■3-3
mises in the decision-making situation. J Likert points out that such
agreement in values must extend to each level of the organization in
terms of the goals of the individuals working at that level and the
sub-objectives of the organization which are prescribed for accomplish-
ment at that echelon of the structure.-* It is generally recognized
that this is an essential function of the coordinative process of
management which may prove to be quite difficult and requires a measure
of ingenuity on the part of the manager. 35 For many organizations this
process of synthesis may be reduced to an unconditional demand for loyalty
to the values of the organization.-* This method of integration, as
33herbert A. Simon, Administrative Behavior (2nd ed.; New York:
The Free Press, 1957), p. 12.
34
Rensis Likert, "A Motivational Approach to a Modified Theory of
Organization and Management," Modern Organization Theory, ed. Mason
Haire (New York: John Wiley and Sons, Inc., 1959), p. 206.
■3 r
William McNair Fox, The Management Process (Homewood, Illinois:
Richard D. Irwin, Inc., 1963) , p. Ik.
3°Talcott Parsons, "Suggestions for a Sociological Approach to the
Theory of Organizations -- I," Administrative Sciences Quarterly, I
(September, 1956) , 81.
237
Parsons suggests, may well be out of place with the norms of the
larger society wherein the values of the individual are derived. 37
The professionally oriented organization may well be the advance
guard of a tendency toward a maturity of organizational structure to
match a developing psychological maturity of man. As professional iza-
tion of the various occupational groupings expands and the motivations
of the individuals who identify themselves with such professional value
systems rise above the more basic levels of needs the structure of a
broader group of organizations will have to be modified to accommodate
the satisfaction of higher level needs. To some extent this requirement
for change will be manifest by the internal management problems arising
through the demands for autonomy on the part of professionals or emerging
professionals. It would also be expected that this problem might make
its appearance through the mechanism of an external demand for the modi-
fication of the objective base upon which the structure of the enterprise
is established. In this latter case the contention is that the values of
the organization should approximate those of the individuals who man its
structure if a congruency of individual goals and organizational objec-
tives is to be obtained. This point is supported by Parsons in his
discussion. Etzioni, is also generally of the opinion that such a
tendency toward the evolution of organizational structure is apparent in
39
the society of the United States for many of the same reasons. J Mee
37ibid.> p. 84 38lbid., p. 67.
^^Amitai Etzioni, A Comparative Analysis of Complex Organizations
(New York: The Free Press, 1961), pp. 310-311.
238
agrees that future managerial organizing processes will consider
human satisfactions and need fulfillment of a modified variety which
reflects this psychological maturing of man. °
It would, therefore, be expected that other organizations are
committed to following the pattern which is developing within the proto-
type hospital organization. The impact of professional ization is al-
ready apparent in many other organizations. Keith Davis notes this fact
through the appearance of higher-level needs on the part of individuals
in a variety of organizations. Blau and Scott recognize this require-
ment in the apparent potential for expanded specialist roles in automated
plants, ^ which point is reiterated in the research conducted by
Woodward. ^ a much broader brush is applied by C. Wright Mills who main-
tains that the rise of professionalism is the result of the technological
revolution and the involvement of science in ever widening areas of
economic life. He indicates that as business has become enlarged and
complicated the skills needed to operate it have become difficult to
John F. Mee, Management Thought in a Dynamic Economy (New York:
New York University Press, 1 963) , p. 106.
Davis, p. 479-
^2Peter M. Blau and W. Richard Scott, Formal Organizations (San
Francisco: Chandler Publishing Co., 1962), p. 249-
^Woodward, p. 96.
hh .
C. Wright Mills, White Collar: The American Middle Class (New
York: Oxford University Press, 1956) , p. 1 13.
239
acquire through apprenticeship, thus requiring the business organization
to become a market for educated labor including the various emerging
professions. -* It would, therefore, appear that the hospital as a
prototype organization would provide a model both of feasible structure
as well as of management problems which are incipient in such organiza-
tions.
The hospital is an example of the organic organization, wherein
much depends on voluntary discipline and professional self-control with
a ready acceptance by each individual of the interdependence necessary
to accomplish the objectives of the enterprise. ° "Much depends on the
spontaneous day-to-day adjustments which organizational members are able
and willing to make so as to accommodate the patient and one another and
to facilitate each other's work." ' The structure of the hospital appears
to be loosely enough defined so that restructuring in light of the prob-
48
lems at hand is possible. The cost of this flexibility within the
hospital structure has been the devaluation of authority and positional
status and the recognition of the need to apportion power and influence
among the organizational members. -*
45lbid., p. 137.
Basil S. Georgopoulos, "The Hospital System and Nursing: Some
Basic Problems and Issues," Nursing Forum, V (1966), 16.
^Ibid., p. 15.
4°Thompson, p. 16.
2*9lbid. , p. 18.
240
The hospital has had one distinct advantage in the formulation
of this form of structure. The necessity for explicit control mechan-
isms in this type of enterprise has never been great because of the
congruency of the values of the individual participants with the objec-
tives of the organization.50 Etzioni suggests that this congruency may
not be as easily obtained in those organizations which do not have the
advantage of serving cultural goals which support a normative com-
pliance.5 It would appear that the hospital has had many of the advan-
tages suggested by McGregor as necessary for the employement of new forms
of management.52 Typically the hospital is, as Maslow suggests, holistic
53
in structure. There is a mutual interdependence among the members of
the hospital organization which leads to a reliance upon one another and
a contribution from each that would not be expected if they had acted
individual ly.5^
In the management literature these observations are often relegated
to a sphere of study separate from that of organizational structure. As
Amitai Etzioni, Modern Organization (Englewood Cliffs N.J •
Prentice-Hall, Inc., 19&4) J p. 5^
Etzioni, Comparative Analysis, p. 82.
5 McGregor, p. 49.
Abraham H. Maslow, Eupsychian Management: A Journal (Homewood,
Illinois: Richard D. Irwin, Inc. and The Dorsey Press, 1965), p. 98.
5^i bid.
241
has been indicated these factors of interest are inalterably interwoven
with the elements of structural construction usually considered. It is
no longer possible to relegate the interactions inherent in the organic
form of organization to an informal sphere of explanation. These concepts
which are determinant in the organic structure must be incorporated into
the basic structure of the modern organization.
McGregor's argument suggests that a genuine innovation in managerial
strategy is required rather than a simple refurbishing and patching of
old theories. •* He sees this as first a requirement to accept less limi-
ting assumptions about the nature of the human resources which management
is attempting to control, and, secondly, a readiness to adapt the structure
56
and process of management to new assumptions which are being formulated.-*
Much of the reluctance to accept these modifications to organization theory
rests in the apprehensions regarding the fate of the more familiar forms
of organization. Argyris sees no real need for the abandonment of the
ancient pyramidal structure in the incorporation of these new concepts
about the nature of man. ' The essence of this structure will be retained
in the requirement of management to rise above the day-to-day matters of
operations and to look ahead through planning toward the maintenance of
^McGregor, p. 57.
56ibid.
57chris Argyris, Integrating the Individual and the Organization
(New York: John Wiley and Sons, Inc. , 1964) , p. 194.
242
rg
the organization's link with society. Dale suggests that educated
people are never entirely rational, hence the requirement for some form
59
of coordination, at least on a standby basis, within the organization. J
It also may not be necessary for any organization to be entirely organic
or mechanistic for apparently gradations of each form of structure are
possible. Nevertheless, in any organization where the spirit of
scientific inquiry is required to be present and flourish the essence of
6l
the organic organization must be well established. This latter point
is directly linked with the evolving nature of man's needs in fields
beyond that of science, and, therefore, it is extended to the total realm
. . 62
of organized activity.
The psychological maturity of man has two interlinking aspects in
terms of the structure of organizations. First, the organization must
satisfy the higher-level psychological needs of the participants. To
provide for anything less than such satisfactions would involve the loss
to the organization of the talents of these individuals as they operate
58lbid., p. 195.
■'"Ernest Dale, Organization (New York: American Management Associa-
tion, 1967), pp. 139-140.
60lbid., p. 140.
Warren G. Bennis, Changing Organizations (New York: McGraw-Hill
Book Co., 1966), p. 21.
62Herzberg, p. 170.
243
63
at these higher levels. The suggestions that man can seek satisfaction
of higher-level needs outside the organization ignores the ever increas-
64
ing necessity for the talents which are released at the higher need level.
What appears to be best for people is often what is best for production. '
The second facet of this maturity of man will be the requirement
that the organization must be prepared to provide the individualized
economic goods and services demanded by a more psychologically mature
society. A society which rises above the operative level of basic needs
of its members and passes beyond the emulative desires inherent in the
intermediate level needs of belonging and status will find its organizations
required to provide those unique outputs associated with the mature indivi-
dual. Woodward sees this trend as apparent in an increasing standard of
living which calls forth a requirement for 'bespoken' suits and gold-pla-
ted limousines and a general increase in the number of firms which cater
to individual idiosyncracies.
As a general tendency then, it would be expected that the primary
service objectives of organizations in terms of the values which they must
provide society will have a level of mature interest attractive to the
mature organizational participant. Organizations will provide tasks with
63 1 bi d . , pp. 189-190.
Bennis, p. 13-
65woodward, p. 137.
66lbid. , p. 43.
244
more meaningful and satisfactory opportunities under these circumstan-
67
ses. ' Jobs will provide sufficient variety, complexity, challenge,
and exercise of skill to engage the ability of workers and gratify
their needs for personal expression. Herzberg and his associates
believe that the greatest fulfillment of man is to be found in activities
that are meaningfully related to his own needs as well as those of
society. ° In the hospital this is readily realized.''0 It is not
impossible that this mesh of individual and social values will be more
prevalent as a manifestation of organizations throughout society.
In speculating on new forms of organization theory Abraham Maslow
has posed the situation where 1,000 self-actualizing persons were located
on a sheltered island and described the regulation of their activities
as Eupsychian Management.'1 Eupsychia, in his terms, is a culture which
implies psychological healthiness on the part of its members, and
eupsychian management is the administration of organizations which contain
psychologically healthy individuals.'2 He believes that from self-
67
Warren G. Bennis, "Organizational Developments and the Fate of
Bureaucracy," Industrial Management Review (Spring, 1966), p. 53.
68
Katz and Kahn, pp. 363-364.
°°Herzberg, et al . , p. 139.
70Katz and Kahn, pp. 133-134.
Maslow, Eupsychian Management, p. xi
72.bid.
245
actualizing persons it can be learned what the ideal attitude toward
work might be under the most favorable circumstances.7-^ Given the
right organizational situation work tends to improve people, and this
in turn tends to improve the organization. 7^ This improvement in the
organization can be related in terms of financial or economic success
as well as by any other measure which might be applied.
The essential results of Maslow's speculation on the eupsychian
organization would be the flexibility of structure which allows the
participants to select their leader in any particular situation on the
basis of his unique characteristics and competency to handle the
problems at hand.'° These selected leaders would have to be able to
give up their powers as the problem situation is modified, for healthy
people have no need for power for the sake of power alone.'' In such an
organization personality traits of a general sort would be secondary to
78
skill and capability and the general requirements of the situation.
73,
bid. , p. 1 .
7Zflbid,
75
Ibid., p. k]
76lbid., pp. 149-150.
77lbid., p. 151.
78 Ibid . , p. 152.
246
79
Functional leadership would be the managerial format, and every
man in his ideal organization would be able to assume leadership when-
80
ever he was the one most suitable for the problem at hand.
It will not be pretended that the hospital organization describes
such a Utopian society. Yet it can be maintained that the hospital
provides the setting for the participation of highly motivated individ-
uals with an organizational goal compatible with the values of both
its participants as well as the larger society. In many respects the
hospital would be expected to be in the forefront of the exploration
for new structural formats and new methods of management and thereby
can be considered to provide a prototype situation.
73ibid
80
Ibid., p. 131
APPENDIX
THEORIES OF ORGANIZATION AND THE BASIS FOR DYNAMIC ANALYSIS
Mason Haire has noted that organization theory is a rare thing in
the social sciences in that it is the natural focus of several
disciplines. Haire recalls the parable of the blind man describing an
elephant and equates it with the attempts of theorists to describe
organization; each begins the description from a different point of view
o
and with a different purpose in mind. "In this situation we can expect
— and we find -- not only different approaches to the problem, but
different views of what the problem is."-^ Scott has also remarked that
organization theory is not a homogeneous science based on generally
accepted principles, but, rather, various theories of organization have
been, and are being evolved.
Terry notes the existence of theories of organization bearing the
labels: classical theory; neo-classical theory; fusion theory; systems
Mason Haire, "Introduction — Recurrent Themes and General Issues
in Organization Theory," Modern Organization Theory, ed. Mason Haire
(New York: John Wiley and Sons, Inc. , 1953) , p. 2.
21 bid .
3 I bid .
William G. Scott, "Organizational Theory: An Overview and an
Appraisal," Journal of the Academy of Management, IV (April, 1961), 8.
2A7
248
5
theory; and, quantitative theory. Scott subsumes many of the various
approaches to organization theory under the categories: classical, neo-
classical; and modern. Alexis and Wilson incorporate a variety of
contributions to organization theory under the classifications: struc-
tural approaches; motivational approaches; and decision-making approaches.
Koontz and O'Donnell, who have specifically addressed themselves to the
proliferation of managerial and organizational theories, describe the
semantic jungle occasioned by such approaches as: the empirical school;
the human behavior school; the social systems school; the decision theory
8
school, and the mathematical school. They proceed then to describe what
they call the operational school which concentrates on the management
process, and which provides a focus for the contributions of the other
schools.-' Needless to say, their admonition in regard to the "management
theory jungle," has not stilled the angry voices which demand recognition
George R. Terry, Principles of Management (5th ed. rev.; Homewood,
Illinois: Richard D. Irwin, Inc., 1968), pp. 282-284.
c
William G. Scott, Organization Theory: A Behavioral Analysis for
Management (Homewood, Illinois: Richard D. Irwin, Co., 1967), p. 102.
7
Marcus Alexis and Charles Z. Wilson, Organizational Decision
Making (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1967), P- 4.
o
"Harold Koontz and Cyril O'Donnell, Principles of Management
(3rd edition; New York: McGraw-Hill Book Co., 1964), pp. 26-37.
9 Ibid. , pp. 27-29.
249
as the legitimate organization theory. However, their contribution
has undoubtedly made managers more aware of the insight provided by
the various schools.
It would be impossible to describe the methods of organizational
analysis employed in this paper as belonging to any of the above listed
approaches. Because of the desire to typify the hospital as a proto-
type for study, the relationship between this form of organization and
others which match the title of formal, or complex, organizations is
essential. It has therefore been necessary to consider the organization
as resident in an evolving culture which extends its influence in vary-
ing degrees upon all organizations depending upon the organization's
link with the society and the culture. The objective of the organization
has been accepted as this link for it appears to be the major determinant
of structure. The format of this approach, and many of the concepts
utilized, should then be classified as an institutional method. However,
the level at which the analysis takes place and the dynamic processes
which are employed in this essay are both below and beyond the descriptive
method which is usually associated with this approach.
Static analysis can be categorized as a descriptive and comparative
technique of analysis. The interest in those cases where these methods
are employed is toward an outline of the design of differences between
particular organizations. It has been the method in this study to critique
250
those static analyses which describe salient differences between the
hospital organization and the modal organization. The question is
asked each time whether these marked differences are unique to the
hospital organization or whether there are factors involved in these
differences which are present in all organizations to some degree but
are of insufficient magnitude to produce a similar structural phenomenon,
The question is then posed as to whether an increase in magnitude of
the particular phenomenon in the modal organization would produce a
similar structural arrangement as that occurring in the hospital organiz-
ation. The course of change is traced through the mechanism of the
organizational process suggested by those authorities which adhere to
the concept of the existence of a management process--loosely that
which Koontz and O'Donnell suggest as the operational school of manage-
10
merit.
Adherents to the management process approach of organizational
analysis are willing to acknowledge the contribution of related disci-
plines to the sum of knowledge of management theorists. The present
work does not disparage the contribution provided by the static analysis
in establishing descriptions of organizations in comparative form.
Without these conclusions it would have been impossible to perform the
process analysis required to establish a continuum along which a dynamic
,0lbid.
251
process is carrying many organizations. Litchfield has noted that
most of the new thought on administration has come from the fields of
mathematics, engineering, anthropology, sociology, or some one of the
emerging behavioral sciences,1' However, he also notes that these
contributions have only been concerned with selected parts of adminis-
tration and not with the whole; for the most part, the contributions
from these other disciplines have been incidental to some other
1 2
purpose. Mee remarks in a similar manner that: "Management thought
has always had its identifiable channels, but it has always been fed by
1 3
tributaries of thought streams from related disciplines." But, in
turn he sees these contributions and the disciplines from which they
come as being a challenge to the rightful place held by management
thought as expressed in the management process.^ It is hoped that
this study has performed the twofold responsibility implied in these
comments: that is has accepted the challenge of those disciplines which
Edward H. Litchfield, "Notes on a General Theory of Administra-
tion," Administrative Sciences Quarterly, I (June, 1956), ^.
12lbid.
3john F. Mee, Management Thought in a Dynamic Economy (New York:
New York University Press, 1963) , p. 1 10.
Ibid. , pp. xx-xxi .
252
reject the applicability of the management process in the hospital
environment because of the dissimilarity of structural process between
hospitals and those enterprises within which much of management thought
has been developed, and that it has furthered the process of incorpora-
tion of new data from other disciplines into the body of management knowl
edge .
The management process approach in its present form is basically
an amalgam of what have sometimes been referred to as the Formal and
Informal schools of management thought. Basic to each of these separate
schools of thought is a way of looking at the organizational structure
which provides support to the management theories themselves. As the
concept of a management process has fused the two approaches to manage-
ment, so too, the theories of organization which underlie them have come
together to provide the necessary support. Simon, in describing the
influence of these separate theories upon his developed decision theory
of organization which must be considered as adjunct to the model of
organization provided in the management process theory, concluded that
the contribution of the Formal theory of organization was structure or
anatomy, while the Informal school of organization provided process or
physiology. ' Etzioni, from a sociological approach, refers to the
synthesis of the Formal and Informal theories as a structuralist concept
^Herbert A. Simon, Administrative Behavior (2nd ed.; New York:
The Free Press, 1957), p. 220.
253
or organization theory. Again, Etzioni, sees this combination as
a synthesis of structure and process but in the static sense of com-
parative description rather than as a prescriptive tool of management
or a method of dynamic analysis. It is his endeavor to use this
1 8
method to encompass all formal organizations in a comparative scheme.
The incorporat i ve powers of the management process approach to
organization theory may be demonstrated by the activity of a group
of organizational theorists from various disciplines to describe a
1 9
Modern Organization theory in 1958. This work was described by the
editor as the ragged, leading edge of developments in the various fields
of organization theory. Even at the time of that writing one of the
contributors was willing to admit in a separate work that many of the
conclusions reached were encompassed by a synthesis of the Formal and
21
Informal schools of thought. And, later this same author was willing
Amitai Etzioni, Modern Organizations (Englewood Cliffs, N.J.:
Prentice-Hall, Inc., 1964) , p. 20. Note: Etzioni, p. 4, identifies
the Formal school as the Classical approach and the Informal school as
the Human Relationist. Etzioni, p. 25, also provides for a Neo-Cl assical
school, which carries on the Classical tradition of formal analysis but
includes an empirical element in the search for more effective organi-
zations.
17lbid., p. 47.
18
Ibid., p. 48.
l9Haire.
Ibid., p. 1 .
Chris Argyris, Personality and Organization (New York: Harper
and Row Publishers, 1957) , p. 239.
25**
to admit that many of the direct criticisms which he had expressed
in earlier statements in regard to the pyramidal structure of organi-
zation described by the process school in adaptation of the Formal
theory and basic to this underlying theory of management were without
22
substantial foundation. In large part this attempt to synthesize
advanced organizational ramifications of such concepts as game theory
and decision theory, information therory and communication theory,
group theory, and motivation theory into a "new" theory of organization'
merely provided a convenient consolidation of newer concepts which made
them amenable to assimilation into the larger frame of reference pro-
vided by the management process school. It will, probably, always be
possible to describe a new theory of organization which is acting as a
way station, where newer concepts will be consolidated awaiting evalua-
tion, reconstruction, and incorporation into the mainstream of manage-
ment thought.
It is too soon to evaluate the most current of these concepts which
23
has arrived on the scene. It is difficult to apprise whether systems
theory is entirely a new concept, or whether it is an expression designed
^Chris Argyris, Integrating the Individual and the Organization
(New York: John Wiley and Sons, Inc., 1964), p. 196.
23
Scott, in Organization Theory: A Behavioral Analysis, pp. 122
and 135, refers to the systems concepts as modern organization theory
insofar as they refer to human organizations.
255
to connotate the whole of organization theory as it presently exists.
Scott maintains that the aim of general systems theory is the creation
of a science of organizational universals . Johnson, et al . refer to
general systems theory as providing an overall framework with which
varied disciplines including management may relate specific findings
and concepts of their own to those provided by other disciplines. '
A more specific benefit according to these authors is that general
systems theory if applied as a concept within organizations will prevent
managers from making decisions which will have untoward consequences
for the system as a whole for emphasis will be focused on overall per"
formance.
However, beyond these broad generalities there are some specific
questions which must be asked about the so called -- systems theories
of organization. Starting at the level of General Systems Theory as
described by Boulding we discover nine levels at which systems charac-
teristics can be discerned. ' These nine levels span man's knowledge
of the universe, that is, knowledge which is extant may be categorized
24 I b I d . , pp. 120.
-'Richard A. Johnson, Fremont E. Kast, and James E. Rosenzweig,
The Theory and Management of Systems (New York: McGraw-Hill Book Co.,
Inc., 1963), p. 10.
26lbid., p. 5.
2'Kenneth Boulding, "General Systems Theory — The Skeleton of
Science," Management Science, II (April, 1956), 197"208.
256
within one of the various levels in regard to the level of SOphiStiCa-
tion of the system. The goal of the general systems theorist would
be the classification of this knowledge at each level into a scheme of
input, through-put and output. " It would therefore be possible for
members of those disciplines which work in areas located at one level
of system to relate their work to that of another discipline working
at a different level of the hierarchy of systems. In essence, the
general systems schema allows for the interrelationship of all knowledge.
It will therefore be possible to discover both the universal characteris-
tics of all levels and that knowledge contained at one level which by
analogy can be imputed to another level.
The first stumbling block to the feasibility of this approach is
the requirement that existing knowledge be converted into a form amenable
to general systems structure. Secondly, the simple structure now provided
of input, transformation, and output must be amplified to accommodate the
mass of data below the most generalized level of expression. This ampl i-
I
fied structure must conform at each level of the hierarchy if meaningful
transference is to take place.
The long-range possibilities of such a scheme of order are beyond
imagination. Problems of construction, cataloging, and education are
28 Ibid. , p. 5.
■'Daniel Katz and Robert L. Kahn, The Social Psychology of Organizations
(New York: John Wiley and Sons, Inc., 1966), p. 8.
257
perhaps surmountable. The resistance of many time honored areas of
professional specialization could be overcome through the benefits to
be obtained. However, if this point were reached it would be necessary
to face up to the problem of the gaps in knowledge which existed. In
many cases these gaps might be irrelevant to the scientist working at
a particular level of the hierarchy where the gap exists. The knowl-
edge may be complete to the tasks at hand at that particular level;
however, the requirements for transfer of existing findings from that
level to another level may necessitate more extensive data for the
original findings to be of any use. Working hypotheses of one disci-
pline may be essential factual data in another. Undoubtedly, an expanded
scientific population could overcome this obstacle in time > — what might
appear to be trivia to members of a particular discipline at the present
time may hold attraction as a life-work for new members of that discipline
in the future. Alternatively, members of a discipline normally found
working at one level of the hierarchy of systems, say a sociologist, could
invade the territory of a discipline at another level, say entomology,
and research the necessary information required to transfer other scienti-
fic findings, say race predjudice of infant ants as a function of insect
terri tory.
At our present level of attainment it is difficult to appreciate
what benefits general systems theory may hold for the future. The degree
of transferability presently being accomplished to the level of social
258
organization are not of large magnitude. The most active work has
taken place in the area of communications and cybernetic theory, but
it appears that these systems networks will require a great deal more
elaboration to contain the rich body of data which has been accumulated
through the years in regard to human organizations. To characterize
human communications and control in terms of these systems concepts is
quite valid, but is is often accomplished at the expense of the nuances
of insight suggested by the larger body of data which defies categori-
zation under the general systems schema at the present time. Scott
reminds us that care should be taken in using analogies which bridge
systems levels that are mere literary devices: "For systems to be
analogous, they must exhibit inherent structural similarities or impl Ic-
30
itly identical operational principles." The work of Mason Ha ire is
perhaps typical of the analogies which attempt to transfer physical and
biological laws to factors associated with the growth patterns of human
organizations.-* In spite of the potential prospects which these attempt
might suggest to the computer scientist interested in constructing models
of organization, it is unlikely that this method of approach will sup-
plant the existing expositions on organizational growth which provide
considerable insight to the operating executive with their infinite
30
Scott, Organization Theory: A Behavioral Analysis, p. 122.
3lMason Haire, "Biological Models and Empirical Histories of the
Growth of Organizations," Modern Organization Theory, ed. Mason Haire
(New York: John Wiley and Sons, Inc., 1959), pp. 272-306.
259
number of variables.
Open-systems concepts have become much employed at the social
organization level of the General Systems hierarchy. Those of interest
employ the figurative relationship of input, process, and output pre-
scribed by the general theory. One of the most comprehensive of these
systems is that reported by Katz and Kahn.^ This particular model is
of particular importance both in that it encompasses the entirety of
social organization as well as providing for a management process as a
subsystem both of society and the separate component organizat ions.-^
Their model provides that society is made up of institutions which can
be categorized into production or technical subsystems, supportive sub-
systems, maintenance subsystems, adaptive subsystems, and managerial
subsystems.-' In like manner, each of the organization which comprise
the formal portions of the society can be described as containing these
subsystems. ^->
The advantages proclaimed for the open-systems approach over more
traditional methods of organization theory is its avoidance of goal
directed models concentrating upon closed-systems which fail to recognize
the interrelationship among organizations in a society.-' Systems models
32
Katz and Kahn.
33
Ibid.
34 1 b I d . , pp. 128-147.
35lbid., pp. 39-47.
^"Joseph A. Litterer, The Analysis of Organizations (New York:
John Wiley and Sons, Inc., 1965) , pp. 147-156.
260
of organization by avoiding goal limitations can be considered in
dynamic interaction with the environment of other organizations.^'
Argyris describes the systems concept as providing an effectiveness
model for a particular organization in its interrelationship with
other elements of the system. It is the system which has goals --
the organization itself is measured in its effectiveness in service of
these goals. " However, one of the earliest exponents of systems con-
cepts, Talcott Parsons, in describing his model of social organization
maintained that the basis of organization theory should rest with a
cul tural- insti tut ional point of view. in large part, then, it can be
maintained that the contribution of open~systems theory as a segment of
general systems theory is mainly an attempt to bring these various disci'
plines employing this approach into the scheme upon which the management
process and its dynamic analysis has always had its foundation.
The parts analyses of the earlier psychologists, sociologists,
-''Douglas McGregor, The Professional Manager, eds. Caroline Mc-
Gregor and Warren G. Bennis (New York: McGraw-Hill Book Co., 1967),
pp. kQ-k].
3"Chris Argyris, Integrating the Individual and the Organization
(New York: John Wiley and Sons, Inc., 1 96.4) , p. 124.
39|bid.
Talcott Parsons, "Suggestions for a Sociological Approach to
the Theory of Organizations -- I," Administrative Sciences Quarterly,
(September, 1956), 67.
261
and anthropologists has always been an unsatisfying experience to
the management theorists. The incorporation of the informal theories
of management into the formal theory providing the management process
was in reaction to the need to provide structure to the various role
and group theories of the Human Relationists . The early work of F. W.
Taylor in formulating a theory of management had many of these same
defects which result from a synthesis approach to theory rather than
an analytical approach. The real basis for management theory today
can be attributed to the work of Fayol , Mooney, and others of a
later period who also adhered to an analytical and institutional
approach to management and its underlying theory of organization. *
This same appreciation of the institutional aspects of organization
theory and the dynamic analysis which provides the basis for the univer-
sal concepts now being suggested by the exponents of General Systems
theory is carried on in management theory today from this tradition.
^'Henri Fayol , General and Industrial Management (London, Sir
Isaac Pitman and Sons,' Ltd. , 19^9) •
James D. Mooney, l he Principles of Organization (Revised Edition;
New York: Harper and Brothers, Publishers, 1947).
■^Ralph Currier Davis is perhaps representative of this core of
analysis in management theory, in his, The Fundamentals of Top Manage-
ment (New York: Harper and Row, Publ ishers, 1951) .
kk
Perhaps representative of this tradition, with appropriate in-
corporation of later concepts, are William McNair Fox, The Manage-
ment Process (Homewood, Illinois: Richard D. Irwin, lnc~ 1963) ,
and Koontz, and O'Donnell.
262
As was pointed out, the management process or operational
management school of thought has successfully incorporated into the
mainstream of management theory much of the valid contributions pro-
vided by other disciplines down through the years. The question remains
as to the impact of systems theory upon the management process school
of thought. Before it is predicted that incorporation will take place
in this case also, it must be reiterated that systems theory is organi-
zation theory if the richness of organization theory is reduced to its
essential elements. And, it is organization theory which provides
the foundation, or assumptions, of management theory as it is expressed
in the management process. It could therefore be suggested that systems
theory provides the basis for incorporation of management theory itself.
As Katz and Kahn have indicated in their outline of open-systems
theory a necessary element within each organization and the society as
a whole are the elements which they refer to as the managerial sub-
system. 5 /\s they describe this subsystem it cuts through all of the
other subsystems and provides the control and decision-making aspects of
the organization, or society, and its parts. ° its functions within the
total system, as outlined by the authors, are: to coordinate the various
substructures; to resolve conflicts between hierarchical levels; and, to
^Katz and Kahn.
^6 Ibid. , p. 3k.
263
coordinate external requirements with organizational resources and
needs. ' For those readers familiar with the functions of management
provided by the management process school, of planning, organizing,
and controlling, the similarity is apparent. In most respects, where
the managerial subsystem described by Katz and Kahn receives any
detailed treatment the connection with process and principles provided
by management theory is apparent. In fact, the sound analytical basis
and institutional flavor provided by the management process indicates
that the managerial subsystem of open-systems theory and the management
process described in managerial theory are one and the same. General
Systems theory and the open-systems theory at the level of social
organizations therefore provides support for the long-held contention
that the principles of management and its underlying theory of organiza-
tion as encompassed by the management process are universal to all
organizations.
*7lbld.
BIBLIOGRAPHY
Books
Alexis, Marcus and Charles Z. Wilson. Organizational Decision Making.
Englewood Cliffs, N . J . : Prent i ce-Hal 1 , Inc., 1 967.
American Hospital Association. Uniform Chart of Accounts and Defi-
nitions for Hospitals. Chicago: American Hospital Associ-
ation, 1959.
American Nurses' Association. Facts About Nursing. New York: Ameri-
can Nurses' Association, 19&7-
Argyris, Chris. Personality and Organization. New York: Harper and
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j
BIOGRAPHICAL SKETCH
Alan Donald Bauerschmidt was born November 23, 1927, in Brooklyn,
New York. In January, 19^5, he was graduated from Baldwin High School,
Baldwin, New York, and enlisted in the United States Navy as a Hospital
Apprentice Second Class. After serving on board various ships and
stations both in the United States and abroad, he was commissioned as
an Ensign, Medical Service Corps, U.S.N. , in December, 1953. After his
commissioning he served as a fiscal and supply officer at the U.S. Naval
Hospital, St. Albans, New York; medical administrative officer aboard
the U.S.S. Lake Chaplain, an attack aircraft-carrier on foreign station;
commanding officer of a 100-bed field hospital attached to the 2nd
Marine Division; medical supply officer of the same Division; and, as
medical administrative assistant to the Force Surgeon, Fleet Marine
Force, Atlantic, performing medical logistic and personnel planning
functions .
During his commissioned service with the U.S. Navy he graduated
from the Naval School of Hospital Administration, and received the
Bachelor of Arts degree in 1964, from The George Washington University
with a major in business administration. He received the Master of Arts
degree in financial management from the University the same year. He
retired from the U.S. Navy as a Lieutenant Commander, Medical Service
Corps, in August, 1965, while serving as the Comptroller of the National
Naval Medical Center, Bethesda, Maryland.
Since retiring from the U.S. Navy he has worked as a research
276
277
assistant in the College of Health Related Professions and as an in-
structor in the Department of Management at the University of Florida
while completing his work toward the degree of Doctor of Philosophy
with major fields of study in management and economics.. His minor
field of study has been hospital and health care administration.
Alan Donald Bauerschmidt is married to the former Connally Crawford,
of Jacksonville, Florida, and they reside with their two sons in Columbia,
South Carolina where he is presently an assistant professor of manage-
ment at the University of South Carolina.
This dissertation was prepared under the direction of the chair-
man of the candidate's supervisory committee and has been approved by
all members of that committee. It was submitted to the Dean of the
College of Business Administration and to the Graduate Council, and
was approved as partial fulfillment of the requirements for the
Degree of Doctor of Philosophy.
August, 1968
Supervisory Committee:
W. V. Wilmot, Jr\ , Chairman
A. M. S ievers
M. R. Langham
.$/. M. Champion
Dean, College of Business
Administration
Dean, Graduate School
v!>
$0 1~