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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. 


■-.  . 


• 


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.     .          ......  r 

in   ti  .".... 

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o  _ .  . .    i  n  support 

service  d    ..us 

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. .    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 
Row  Publ ishers,  1957. 

.   Integrating  the  Individual  and  the  Organization.   New  York: 

John  Wiley  and  Sons,  Inc.,  1964. 

Barnard,  Chester  I.   The  Functions  of  the  Executive.   Cambridge,  Mass.: 
Harvard  University  Press,  1938. 

.   Organization  and  Management.   Cambridge,  Mass.:  Harvard 

University  Press,  19^8. 

Bell,  Gerald  D.   Organizations  and  Human  Behavior.   Englewood  Cliffs, 
N.J.:  Prentice-Hall,  Inc.,  1967. 

Bennis,  Warren  G.   Changing  Organizations.   New  York:  McGraw-Hill  Book 
Co.,  1966. 

Berelson,  Bernard  and  Gary  A.  Steiner.   Human  Behavior:  Shorter  Edition. 
New  York:  Harcourt,  Brace,  and  World,  Inc.,  1967. 

Blau,  Peter  M.  and  W.  Richard  Scott.   Formal  Organizations.   San  Francisco: 
Chandler  Publishing  Co.,  1962. 

Bloom,  Samuel  W.   The  Doctor  and  His  Patient.   New  York:  The  Free  Press, 
1963. 

Brown,  Esther  Lucile.   Newer  Dimensions  of  Patient  Care:  Part  2;    Improv- 
ing Staff  Motivation  and  Competence  in  the  General  Hospital. 
New  York:  Russell  Sage  Foundation,  1962. 

Burling,  Temple,  Edith  M.  Lentz,  and  Robert  N.  Wilson.   The  Give  and  Take 
in  Hospitals.   New  York:  G.  P.  Putnam's  Sons,  1956. 


264 


265 


Caplow,  Theodore.   The  Sociology  of  Work.   New  York:  McGraw-Hill  Book 
Co.,  1954. 

Carzo,  Rocco,  Jr.  and  John  N.  Yanouzas.   Formal  Organizations:  A  Sys- 
tems Approach.   Homewood ,  111.:  Richard  D.  Irwin,  Inc.,  I967. 

Cyert,  Richard  M.  and  James  G.  March.   A  Behavioral  Theory  of  the  Firm. 
Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1963. 

Dale,  Ernest.   Management  Theory  and  Practice.   New  York:  McGraw-Hill 
Book  Co.,  1965. 

.   Organi  zat ions  .   New  York:  American  Management  Association, 

1967. 

Davis,  Keith.   Human  Relations  at  V/ork.   3rd  ed .  revised.   New  York: 
McGraw-Hill  Book  Co.,  I967. 

Davis,  Ralph  Currier.   The  Fundamentals  of  Top  Management.   New  York: 
Harper  and  Row,  Publishers,  1951. 

Dubin,  Robert.   Human  Relations  in  Administration.   Englewood  Cliffs, 
N.J.:  Prentice-Hall,  Inc.,  1961. 

Etzioni,  Amitai.   A  Comparative  Analysis  of  Complex  Organizations.   New 
York:  The  Free  Press,  I96I. 

.   Modern  Organizations.   Englewood  Cliffs,  N.J.:  Prentice- 

Hall,  Inc.,  1964. 

Fayol ,  Henri.   General  and  Industrial  Management.   London:  Sir  Isaac 
Pitman  and  Sons,  Ltd.,  1949. 

Fox,  Willi  am  Mc  Nair.   The  Management  Process.   Homewood ,  111.:  Ri  chard 
D .  I rwi  n,  I nc.  ,  1 963 . 

Galbraith,  John  Kenneth.   The  New  Industrial  State.   Boston:  Houghton 
Mifflin,  Co.,  1967. 

Gilb,  Corinne  L.   Hidden  Hierarchies.   New  York:  Harper  and  Row,  Pub- 
lishers, 1966. 

Gouldner,  Alvin  W.  Patterns  of  Industrial  Bureaucracy.   New  York:  The 
Free  Press  of  Glencoe,  1954. 

Henderson,  Virginia.   The  Nature  of  Nursing.   New  York:  The  Macmillan 
Co.,  1966. 


266 


Herzberg,  Frederick,  Bernard  Mausner,  and  Barbara  Bloch  Snyderman. 

The  Motivation  to  Work.   2nd  edition.   New  York:  John  Wiley 
and  Sons,  Inc. ,  1959. 

.   Work  and  the  Nature  of  Man.   Cleveland,  Ohio:  The  World 

Publ i  shi  ng  Co. ,  1 966. 

Horty,  John  F.,  Nathan  Hershey,  Eric  W.  Springer,  and  Donald  M.  Stocks. 
Student's  Guide  to  Hospital  Law;  2nd  Editions.   Pittsburgh, 
Pa.:  Health  Law  Center,  Graduate  School  of  Public  Health, 
University  of  Pittsburgh,  1962. 

Hutchinson,  John  G.   Organizations:  Theory  and  Classical  Concepts. 
New  York:  Holt,  Rinehart  and  Winston,  1967. 

Johnson,  Richard  A.,  Fremont  E.  Kast,  and  James  E.  Rosenzweig.  The 
Theory  and  Management  of  Systems.  New  York:  Mc  Graw-Hill 
Book  Co. ,  i  nc. ,  1963. 

Katz,  Daniel  and  Robert  L.  Kahn.   The  Social  Psychology  of  Organizations. 
New  York:  John  Wiley  and  Sons,  Inc.,  1966. 

Koontz,  Harold  and  Cyril  O'Donnell.   Principles  of  Management.   3rd  Edition. 
New  York:  McGraw-Hill  Book  Co.,  1964. 

Kron,  Thora.   Nursing  Team  Leadership.   Philadelphia,  Pa.:  W.  B.  Saunders 
Co.,  1961. 

Likert,  Rensis.   New  Patterns  of  Management.    New  York:  McGraw-Hill  Book 
Co.,  Inc.,  1961. 

Litterer,  Joseph  A.   The  Analysis  of  Organizations.   New  York:  John  Wiley 
and  Sons ,  I nc. ,  1965 . 

MacEachern,  Malcolm  T.   Hospital  Organization  and  Management.   Berwyn, 
111.:  Physicians'  Record  Co.,  1962. 

March,  James  G.  and  Herbert  A.  Simon.   Orqani  zat  ions .   New  York:  John 
Wiley  and  Sons,  Inc.,  1958. 

Marshall,  Alfred.   Principles  of  Economics.   8th  Edition.   London:  Mac- 
mi  1  Ian  and  Co. ,  Ltd. ,  1920. 

Maslow,  Abraham  H.  Toward  a  Psychology  of  Being.  Princeton,  N.J.: 
D.  Van  Nostrand  Co.,  Inc.,  1962. 


267 


.   Eupsychian  Management:  A  Journal.   Homewood,  111:  Richard 

D.  Irwin,  Inc.,  and  the  Dorsey  Press,  1 965  - 

McGregor,  Douglas.   The  Human  Side  of  Enterprise.   New  York:  McGraw- 
::i  1  1  Book  Co.  ,  I  nc.  ,  1 960. 

.   The  Professional  Manager.   Edited  by  C.  McGregor  and  W.  G. 

Bennis.   New  York:  McGraw-Hill  Book  Co.,  Inc.,  1 967 . 

Mc  Guire,  Joseph  W.   Theories  of  Business  Behavior.   Englewood  Cliffs, 
N.J.:  Prentice-Hall,  Inc.,  1 964. 

McLuhan,  Marshall.   Understanding  Media:  The  Extensions  of  Man.   New 
York:  The  New  American  Library,  1964. 

Mee,  John  F.   Management  Thought  in  a  Dynamic  Economy.   New  York:  New 
York  University  Press,  1963. 

Mills,  C.  Wright.  White  Collar:  The  American  Middle  Class.   New  York: 
Oxford  University  Press,  1956. 

Mooney,  James  D.   The  Principles  of  Organization.   Revised  Edition.  New 
York:  Harper  and  Brothers,  Publishers,  1947. 

Newman,  William  H.,  Charles  E.  Summer,  and  E.  Kirby  Warren.   The  Process 
of  Management,  2nd  ed .  revised.   Englewood  Cliffs,  N.J.: 
Prentice-Hall,  Inc.,  1 967 . 

Parsons,  Talcott.   The  Social  System.   New  York:  The  Free  Press,  1951. 

,  and  Neil  J.  Smelser.   Economy  and  Society.   New  York:  The 

Free  Press,  1956. 

Pfiffner,  John  M.  and  Frank  P.  Sherwood.   Administrative  Organization. 
Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  I960. 

Rayack,  Elton.   Professional  Power  and  American  Medicine:   The  Economics 
of  the  American  Medical  Association.   Cleveland:  The  World 
Publ ishing  Co. ,  1 967  - 

Scott,  William  G.   Organization  Theory:  A  Behavioral  Analysis  for  Manage- 
ment .   Homewood,  111.:  Richard  D.  Irwin,  Co.,  1967. 

Simon,  Herbert  A.   Administrative  Behavior.   2nd  Edition.   New  York: 
The  Free  Press,  1957. 

Sloan,  Raymond,  P.   Today's  Hospi  tal  .   New  York:  Harper  and  Row,  Pub- 
lishers, 1966. 


268 


Somers,  Herman  Miles  and  Anne  Ramse;  Somers.   Medicare  and  the  Hospitals; 
Issues  and  Prospects.   Wasnington,  D.C.:  The  Brookings  Insti- 
tute, 1967.  ' 

Terry,  George  R.   Principles  of  Management.   5th  ed .  rev.  Homewood ,  111.: 
Richard  D.  I rwin,  Inc. ,  1968. 

Tunley,  Rou 1 .   The  American  Health  Scandal.   New  York:  Dell  Publishing 
Co.,  1966. 

Urwick,  L.   The  Elements  of  Administration.   New  York:  Harper  and  Row, 
Publishers,  19^3. 

Vollmer,  Howard  M.  and  Donald  L.  Mills,  (eds.).   Professional ization. 
Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1966. 

Woodward,  Joan.   Industrial  Organization:  Theory  and  Practice.   London: 
Oxford  University  Press,  1965. 


Articles  and  Periodicals 


Bakke,  E.  Wight.   "Concept  of  the  Social  Organization,"  in  Modern 

Organization  Theory,  ed .  Mason  Haire  (New  York:  John  Wiley 
and  Sons,  Inc.,  1959),  pp.  16-75. 

Becker,  Howard  S.   "The  Professional  Dance  Musician  and  His  Audience," 
in  Profess ional ization.  eds.  Howard  M.  Vollmer  and  Donald  L. 
Mills  (Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1966), 
pp.  212-216. 

Bennis,  Warren  G.   "Organizational  Developments  and  the  Fate  of 

Bureaucracy,"  Industrial  Management  Review  (Spring,  1966), 
pp.  M-55. 

Bernstein,  Arthur  H.   "Medical  Staff  Appointments,  Pro  and  Con," 
Hospitals,  ILI1  (May  1,  1968),  99. 

Blai,  Boris,  Jr.   "Job  Satisfaction  Predictor,"  Personnel  Journal 
(October,  1963),  pp.  453-^56. 

Blumer,  Herbert.   "Preface,"  in  Professional ization,  eds.  Howard  M. 

Vollmer  and  Donald  L.  Mills  (Englewood  C 1 i  f f s ,  N.J.:  Prentice- 
Hall  ,  Inc. ,  1966),  p.  xi . 

Boulding,  Kenneth.   "General  Systems  Theory--The  Skeleton  of  Science," 

Management  Sciences, I  I  (April,  1956),  197-208. 

Brown,  Esther  Lucile.   "The  Need  for  Differentiation  of  Nursing  Service,1 
in  Issues  in  Nursing,  ed .  Bonnie  Bui  lough  and  Vern  Bui  lough 
(New  York:  Springer  Publishing  Co.,  Inc.,  1966),  pp.  106-117. 

Burns,  Tom  and  G.  M.  Stalker.  "Mechanistic  and  Organic  Systems,"  in 
Readings  in  Management,  ed .  Ernest  Dale  (New  York:  McGraw- 
Hill  Book  Co.,  1965),  PP.  234-236. 

Carr-Saunders ,  A.  M.   "Professions:  Their  Organization  and  Place  in 

Society,"  in  Profess ional ization,  eds.  Howard  M.  Vollmer  and 
Donald  L.  Mills  (Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc., 
1966),  pp.  3-9. 

Christman,  Luther  P.  and  Richard  C.  Jelinek.   "Old  Patterns  Waste  Half 
the  Nursing  Hours."  Modern  Hospital,  CVI I  I  (January,  1967), 
78-81. 


269 


270 


Clark,  Burton  R.   "Faculty  Organization  and  Authority,"  in  Profess  ional i- 
zat ion,  eds.  Howard  M.  Vollmer  and  Donald  L.  Mills  (Engelwood 
Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1966),  pp.  283-291. 

Cogan,  Morris  L.   "Toward  a  Definition  of  Profession,"  Harvard  Educa- 
tional Review,  XXIII  (Winter,  1953),  49,  cited  by  Howard  M. 
Volmer  and  Donald  L.  Mills,  eds.,  Professional ization 
(Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1966). 

Corwin,  Ronald  G.   "Role  Conception  and  Career  Aspiration:  A  Study  of 

Identity  in  Nursing,"  Sociological  Quarterly,  II  (April,  196l), 
pp.  69-86. 

.   "The  Professional  Employee:  A  Study  of  Conflict  in  Nursing 

Roles,"  American  Journal  of  Sociology,  LXVI  (June,  1961), 
604-615. 

Etzioni,  Amitai.   "Administration  and  the  Consumer,"  Admi  n  i  strat  i  ve 
Sciences  Quarterly,  II   (September,  1958),  251-264. 

.   "Authority  Structure  and  Organizational  Effectiveness," 

Administrative  Sciences  Quarterly,  IV  (June,  1959),  43-67. 

.   "Dual  Leadership  in  Complex  Organizations,"  American  Socio- 
logical Review,  XXX  (October,  1 965) ,  688-698. 

Fichter,  Joseph  H.   "What  Determines  Success,"  in  Professional ization, 
eds.  Howard  M.  Vollmer  and  Donald  L.  Mills  (Englewood  Cliffs, 
N.J:  Prentice-Hall,  Inc.,  1966),  pp.  145-147. 

Flores,  Florence.   "Role  of  the  Graduate  Nurse  Today,"  The  New  England 
Journal  of  Medicine,  CCLX  II  (September  6,  1 962) ,  487-491 . 

Freidson,  Eliot.   "Client  Control  and  Medical  Practice,"  in  Med?  cal 

Care:  Readings  in  the  Sociology  of  Medical  Institutions,  eds. 
W.  Richard  Scott  and  Edmund  H.  Volkart  (New  York:  John  W i 1 ey 
and  Sons,  Inc.,  1966),  pp.  259-271. 

.   "Specialties  Without  Roots:  The  Utilization  of  New  Services," 

in  Medical  Care:  Readings  in  the  Sociology  of  Medical  I nsti - 
tutions,  eds.  W.  Richard  Scott  and  Edmund  H.  Volkart (New 
York:  John  Wiley  and  Sons,  Inc.,  1 966) ,  pp.  447-458. 

.   "Review  Essay:  Health  Factories,  The  New  Industrial  Soci- 
ology," SocialProblems,  XIV  (Spring,  1967),  493-500. 


• 


271 


Georgopou 1 i s ,  Basil  S.  "Hospital  Organization  and  Administration: 
Prospects  and  Perspectives,"  Hospital  Administration,  IX 
(Summer,  1964),  23-35. 

.   "The  Hospital  System  and  Nursing:  Some  Basic  Problems  and 

I ssues,"  Nursing  Forum,  V,  3  (1966),  8-35. 

,  and  Floyd  C.  Mann.   "The  Hospital  as  an  Organization," 

Hospital  Administration,  VII  (Fall,  1962),  50-64. 

Goode,  William  J.   "Community  Within  a  Community:  The  Professions," 
American  Sociological  Review,  XXII  (April,  1957),  194-200. 

Gordon,  Paul  J.   "The  Top  Management  Triangle  in  Voluntary  Hospitals 
(l),"  Academy  of  Management  Journal,  IV  (December,  196l), 
205-214. 

.   "The  Top  Management  Triangle  in  Voluntary  Hospitals  (ll),"  ^ 

Academy  of  Management  Journal,  V  (April,  1962),  66-75. 

Goss,  Mary  E.  W.   "Patterns  of  Bureaucracy  among  Hospital  Staff  Physi- 
cians ,"  TjTe_JjosDJ_t_aJ_JjT_Jjo_dej2^^        ed.  Eliot  Freidson 
(New  York:  The  Free  Press  of  Glencoe,  1963),  pp.  170-194. 

Greenwood,  Ernest.   "Atrributes  of  a  Profession,"  in  Profess ional ization, 
eds.  Howard  M.  Vollmer  and  Donald  L.  Mills  (Englewood  Cliffs, 
N.J.:  Prentice-Hall,  Inc.,  I966),  pp.  10-19. 

Guzzardi,  Walter,  Jr.   "What  the  Doctor  Can't  Order — but  You  Can,"  in     J 
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.  529-543. 

Haire,  Mason.   "Introduction — Recurrent  Themes  and  General  Issues  in 

Organization  Theory,"  in  Modern  Organization  Theory,  ed .  Mason 
Haire  (New  York:  John  Wi ley  and  Sons ,  I nc. ,  1 959)  ,  pp .  1-15. 

.   "Biological  Models  and  Empirical  Histories  of  the  Growth  of 

Organizations,"  in  Modern  Organization  Theory,  ed.  Mason  Haire 
(New  York:  John  Wiley  and  Sons,  Inc.,  1959),  pp.  272-306. 

Hall,  Oswald.   "Some  Problems  in  the  Provision  of  Medical  Service," 
Canadian  Journal  of  Economics  and  Political  Science,  XX 
(1954),  456-466. 

"Hospital  Statistics,"  Hospitals:  Guide  Issue,  ILI,  2  (August   1,  1 967) , 
437-480. 


272 


Hughes,  Everett  C.   "The  Professions  in  Society,"  Canadian  Journal 

of  Economics  and  Political  Science,  XXVI  (February,  1 960) , 
5^-61. 

Jelinek,  Richard  C.  "A  Structural  Model  for  the  Patient  Care  Oper-   y 
ation,"  Health  Services  Research,  II  (Fall-Winter,  1 967) 
226-242. 

Johnson,  Everett  A.   "Nursing  Reorganization  Strengthens  Head  Nurse 

Role,  Provides  Special  Nursing  Consultants,"  Hospitals,  I  LI  I  I 
(June  16,  1968),  85-90. 

Johnson,  M.  M.  and  H.  W.  Martin.   "A  Sociological  Analysis  of  the  Nurse 
Role,"  in  Profess ional ization,  eds.  Howard  M.  Vollmer  and 
Donald  L.  Mills  (Englewood  Cliffs,  N.J.:  Prentice-Hall,  inc., 
1966),  pp.  206-21 1 . 

Kast,  Fremont  E.  and  James  E.  Rosenzweig.  "Hospital  Administration  and   / 
Systems  Concepts,"  Hospital  Administration,  XI  (Fall,  1966), 
17-33. 

Kornhauser,  William.  "Scientists  in  Industry:  Conflict  and  Accommodation," 
in  Profess ional ization,  eds.  Howard  M.  Vollmer  and  Donald  L. 
Mills  (Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1 966) , 
pp.  292-293. 

Lambertson,  Eleanor  C.   "Reorganize  Nursing  to  Re-Emphasize  Care," 
Modern  Hospital ,  CV1  I  I  (January,  19&7),  68-71  and  138. 

Lentz,  Edith  M.   "Hospital  Admi ni strat ion--0ne  of  a  Species,"  Admi  ni -  . 
strative  Sciences  Quarterly,  I  (March,  1957),  444-463. 

Likert,  Rensis.   "A  Motivational  Approach  to  a  Modified  Theory  of 

Organization  and  Management,"  in  Modern  Organization  Theory, 
ed .  Mason  Haire  (New  York:  John  Wiley  and  Sons,  Inc.,  1959), 
pp.  184-217. 

Litchfield,  Edward  H.   "Notes  on  a  General  Theory  of  Administration," 
Administrative  Sciences  Quarterly,  I  (June,  1956),  3-29. 

Marksch,  Hans  0.   "Nursing  Dilemmas  in  the  Organization  of  Patient  Care," 
Nursing  Outlook,  V  (January,  1957),  31-34. 

Maslow,  Abraham  H.   "Eupsychia — The  Good  Society,"  Journal  of  Humanistic 
Psychology,  I  (Fall,  196l),  1-11. 

.   "Notes  on  Being-Psychology,"  Journal  of  Humanistic  Psychology, 

I  I  (Fal 1  ,  1962),  47-71 . 


273 


.   "A  Theory  of  Metamot i vat  ion :   The  Biological  Rooting  of 

the  Value-Life,"  Journal  of  Humanistic  Psychology.  VII 
(Fall,  1967),  93-127. 

"Medical  Technology,"  in  Professional ization,  eds..  Howard  M.  Vollmer 
and  Donald  L.  Mills  (Englewood  Cliffs,  N.J.:  Prentice-Hall, 
Inc. ,  1966) ,  p.  20. 

Merton,  Robert  K.   "Bureaucratic  Structure  and  Personality,"  in  Complex 
Organi  zat ions:  A  Sociological  Reader,  ed .  Amitai  Etzioni 
(New  York:  Holt,  Rinehart  and  Winston,  1961),  pp.  48-61. 

Orzack,  Louis  H.   "Work  as  a  'Central  Life  Interest1  of  Professionals," 
Social  Problems,  VII  (Fall,  1959),  125-132. 

Parsons,  Talcott,  "The  Professions  and  Social  Structure,"  Social  Forces, 
XVI  I  (May,  1939),  457-467. 

.   "Suggestions  for  a  Sociological  Approach  to  the  Theory  of 

Organizations--!,"  Administrative  Sciences  Quarterly,  I 
(September,  1956),  63-85. 

.   "Suggestions  for  a  Sociological  Approach  to  the  Theory  of 

Organizations--! I ,"  Administrative  Sciences  Quarterly,  I 
(December,  1956),  225-239. 

Perrow,  Charles.   "Organizational  Prestige:  Some  Functions  and  Dysfunctions," 
i  n  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.  558-567. 

.   "The  Analysis  of  Goals  in  Complex  Organizations,"  in  Read  i  nqs 

in  Organization  Theory:  A  Behavioral  Approach,  ed .  Walter  A. 
Hill  and  Douglas  M.  Egan  (Boston:  Allyn  and  Bacon,  Inc.,  1966), 
pp.  129-144. 

Roethl i sberger ,  F.  J.   "The  Foreman:  Master  and  Victim  of  Double  Talk," 

Harvard  Business  Review,  I  LI  I  I  (September-October,  1965),  22-37. 

Rosenberger,  Donald  M.   "A  New  Look  at  Hospital  Organizations,"  Hospitals,  y 
XXXVI  (February  1,  1962),  42-46. 

Rourke,  Francis  E.   "Bureaucracy  in  Conflict:  Administrators  and  Pro- 
fessionals," Ethj_cs,  LXX  (April,  I960),  220-227. 


274 


Saunders,  Lyle.  "The  Changing  Role  of  Nurses,"  in  I ssues  in  Nursing, 
eds.  Bonnie  Bui  lough  and  Vern  Bui  lough  (New  York:  Springer' 
Publishing  Co.,  Inc.,  1966),  pp.  ] 1 8-1 27. 

Sayre,  Wallace  S.   "Principles  of  Administration,"  Hospitals  XXX  (Jan- 
uary 16  and  February  1,  1 956,  34,35,  and  92,  and  50-52. 

Scott,  William  G.   "Organization  Theory:  An  Overview  and  an  Appraisal," 
Journal  of  the  Academy  of  Management.  IV  (April,  196l),  7-26. 

Scott,  W.  Richard.   "Professionals  in  Bureaucraci es--Areas  of  Conflict," 
!n  Professional ization,  eds.  Howard  M.  Vollmer  and  Donald  L 
Kills  (Englewood  Cliffs,  N.J.:  Prentice-Hall,  I nc    1966) 
pp.  265-275. 

Seeman,  Melvin  and  John  W.  Evans.   "The  Objective  Criteria  of  Performance," 
in  Medical  Care:  Readings  in  the  Sociology  of  Medical  Insti- 
Urt_i_ons,  eds.  W.  Richard  Scott  and  Edmund  H.  Volkart  (New  York: 
John  Wiley  and  Sons,  Inc.,  1966),  pp.  488-501. 

Selznick,  Philip.   "Strengthening  Leadersh i p--Co-optat ion , "  Human  Rela- 
tions, i  n  Administration,  ed.  Robert  Dubin,  2nd  edition 
(Englewood  Cliffs,  N.J.:  Prentice-Hall,  Inc.,  1961),  pp.  360-362. 

Simmons,  Leo  W.  and  Harold  G.  Wolff,  "Hospital  Practice  in  Social  Science 
Perspective,"  in  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)   dd  *476- 
488.  HP' 

Smith,  Harvey  L.   "Two  Lines  of  Authority  are  One  Too  Many  "  Modern  Hospi-  J 
tal ,  LXXXIV  (March,  1955),  59-64;  

Starkweather,  David  B.   "The  Classicists  Revisited,"  Hospital  Admini- 
stration, XII  (Summer,  I967),  69-80. 

Strauss,  Anselm,  et  ah  "The  Hospital  and  Its  Negotiated  Order,"  in  The 
Hospital  in  Modern  Society,  ed.  Eliot  Freidson  (New  York-  The" 
Free  Press,  1963),  147-169. 

Thompson,  Victor  A.   "Bureaucracy  and  Innovation,"  Administrative  Sciences 
Quarterly,  X  (June,  I965),  1-20. 

Wesbury,  Stuart  A.,  Jr.   "Courses  in  Management  Needed  in  Professional 
Training,"  Hospital  Topics  (September,  1967),  68-70. 


275 


Wessen,  Albert  F.   "Hospital  Idiology  and  Communications  between  Ward 
Personnel,"  in  Patients.  Physicians  and  Illness,  ed.  E. 
Gartly  Jaco  (New  York:  The  Free  Press,  1958). 

Wilson,  Robert  N.   "The  Physician's  Changing  Hospiial  Role,"  Human 
Organization,  XVI 1  I  (Winter,  1959-60),  177-183. 

.   "The  Social  Structure  of  a  General  Hospital,"  Annals  of  the 

American  Academy  of  Political  and  Social  Sciences,  No.  }>k6 
(March,  1963),  67-76. 

Zalaznick,  Sheldon.   "The  M.3.A. :  the  Man,  the  Myth,  and  the  Method," 
Fortune,  LXXVI I  (May,  1968),  168-171,  200,  202,  and  206. 


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~