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Managing the medical enterprise

Material Information

Title:
Managing the medical enterprise a study of physician managers
Series Title:
Research for business decisions ;
Alternate title:
Physician managers
Creator:
Betson, Carol L ( Carol Lane ), 1942-
Place of Publication:
Ann Arbor, Mich
Publisher:
UMI Research Press
Publication Date:
Language:
English
Physical Description:
xiv, 191 pages : ; 24 cm.

Subjects

Subjects / Keywords:
Health services administration ( lcsh )
Hospitals -- Administration ( lcsh )
Group medical practice -- Management ( lcsh )
Health maintenance organizations -- Management ( lcsh )
Delivery of Health Care -- organization & administration -- United States ( mesh )
Health Maintenance Organizations -- organization & administration -- United States ( mesh )
Hospital Administration -- United States ( mesh )
Physicians -- United States ( mesh )
Practice Management, Medical -- United States ( mesh )
Hôpitaux -- Administration ( rvm )
Santé, Services de -- Administration ( rvm )
Médecine de groupe -- Gestion ( rvm )
Assurance-maladie à prépaiement -- Gestion ( rvm )
Group medical practice -- Management ( fast )
Health maintenance organizations -- Management ( fast )
Health services administration ( fast )
Hospitals -- Administration ( fast )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (pages 177-185) and index.
General Note:
Revision of the author's thesis (D.P.A.)--University of Colorado, 1984.
General Note:
School of Public Affairs
Statement of Responsibility:
by Carol L. Betson.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
13096116 ( OCLC )
85031834 ( LCCN )
0835717356 ( ISBN )
ocm13096116
Classification:
R728 .B445 1986 ( lcc )
362.1/068 ( ddc )
W 84 AA1 B5m 1986 ( nlm )
44.10 ( bcl )
85.05 ( bcl )

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Full Text
MANAGING THE MEDICAL ENTERPRISE:
A STUDY OF PHYSICIAN MANAGERS
by
Carol Lane Betson
B.S., Adelphl University, 1964
M.A., Columbia University, 1970
M.S., The University of Colorado, 1979
A thesis submitted to the
Faculty of the Graduate School of Public Affairs of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Public Administration,
Graduate School of Public Affairs
1984


This thesis for the Doctor of Public Administration
degree by
Carol.Lane Betson
has been approved for the
Graduate School
of Public Affairs
by
Mim Orleans
Date
g,


Betson, Carol Lane (D.P.A., Public Administration)
Managing the Medical Enterprise: A Study of
Physician Managers
Thesis directed by Assistant Professor Eileen Tynan.
The work that managers do has long been of
interest to students of both the public and private
sector. This study describes the jobs of physician
managers in hospitals, medical group practices, and
prepaid health plans. A task inventory consisting of
86 items was developed to analyze these jobs. Organ-
izational and personal characteristics are identified
which influence the jobs (or responsibilities) that
physicians managers have.
The empirical portion of this study is based
on.a self-administered survey mailed to the 893 mem-
bers of the American Academy of Medical Directors
(AAMD). The task inventory was developed in accord-
ance with the form and language of job analysis tech-
niques. The tasks are grouped according to manage-
ment functions developed in a previous study: policy
management, program management, and resource manage-
ment. The survey also contains questions about organ-
ization affiliations, work arrangements, experience,
and education. There was a response rate of 56 per-
cent .


iv
Key findings indicate that physician managers
are primarily responsible for policy management tasks.
The majority of these tasks involve issues specific to
physician relations. In addition, the tasks for which
most physician managers are responsible deal with
coordinating, managing conflict, and organization
decision making. All of these processes are known to
be associated with improvements in the effectiveness
and efficiency of health care organizations.
Another important finding is that organiza-
tional characteristics are associated with task re-
sponsibility more often than the personal characteris-
tics of physician managers. For example, a line as
opposed to a staff position is significantly asso-
ciated with responsibility for certain tasks more
often than experience or education. However, of the
personal characteristics, experience is associated
with physician manager responsibility more often than
education.
One conclusion of this study is that physician
managers are responsible for tasks that contribute to
efficiency and effectiveness in health care organiza-
tions. It is likely that increasing numbers of physi-
cian will become part of management teams in these
organizations. Therefore, it seems reasonable to


V
expect that health care institutions will strive to
structure jobs that use the skills of physician man-
agers to further the goals of the organization.
The form and content of this abstract are approved.
I recommend its publication.
Signed


ACKNOWLEDGEMENTS
There can be no full accounting of my debt to
all those who contributed to this research effort.
However, there are some individuals who must be recog-
nized for their essential participation in either the
development or improvement of the manuscript, their
social/emotional support or a miraculous combination
of both.
Eileen Tynan, my thesis advisor, contrib-
uted significantly to this study and to my intellec-
tual growth. Her commitment to excellence along with
her pragmatic nature, guided me through this process
and clearly made the difference between success and
failure. Miriam Orleans, Michael Guthrie, Janelle
Krueger and James Null, all superbly talented people,
helped by providing important suggestions and criti-
cisms throughout.
The subject of the study is the job of physi-
cian managers, and it would not have been possible
without the support of Roger Schenke, the executive
director of the American Academy of Medical Directors.
I hope he will find this work a good return on his
investment.


vii
Phil Burgess deserves special acknowledgement
for being dependable, from the beginning, as a source
of inspiration and for his guidance throughout my
years in the doctoral program. Leland Kaiser and
Floyd Mann were also important in this regard.
I am especially grateful to Kyle Davis. Much
of the data processing would have taken weeks longer
if he had not lent his expertise to this project.
Sandy Schwarz and Mary Sue Burgess also assisted with
the data analysis, but more importantly, Mary Sue
deserves credit for reading the manuscript in draft
form and making the necessary editorial corrections.
I am exceptionally fortunate to have a core
group of close friends who tried to provide a balance
in my life during this period of time. This was an
extremely difficult task because I have evidently
been obsessed with my work. Elizabeth Acinapura
always reminded me that laughter was still possible,
and Lily Appelman managed to keep me in touch with
the real world. At one point I doubted that I would
ever complete my work. Ann Carey and Virginia Lucero
got me through that by cutting and alphabetizing 893
labels! A special thanks needs to go to my friend,
teacher and role model, Tina Kurowski. Her unflag-
ging support and encouragement at critical times kept


viii
me on track and convinced that this was a viable
project.
It is evidently a well-known fact that fam-
ilies suffer during the dissertation process. Mine
was no exception. Immense gratitude, which is diffi-
cult to put into words, goes to Raymond Betson, with-
out whom none of this would have been possible.
Jennifer and Deborah, my two children, have endured my
long hours of work, and demonstrated understanding
beyond their years. I hope they are able to forgive
me for the chunks of their lives that I have missed.
Finally, it is clear that my mother, Lillian
Katzman, was indispensable in helping me accomplish
this piece of work. In addition to being a source of
personal strength, her unending hours at the word
processor translated my thoughts into a reality. She
demonstrated incredible determination to ensure that
the margins, tables, etc., meet the necessary require-
ments. This woman is an amazement to everyone, in-
cluding herself


CONTENTS
CHAPTER I
INTRODUCTION......................................1
Purpose of the Study............................1
The Health Care Delivery System ............... 3
Historical Developments .................... 3
The Current System...........................8
People.....................................8
Providers................................. 9
Institutions and Organizations.............9
Financing.................................10
Government................................11
Problems Facing the Health Care System. ... 11
Costs........................................1^
Structure of Health Care Financing. ... 14
High Provider Fees.........................15
Physician Control ........................ 15
Physician Training.........................15
Advances in Medical Technology.............16
Higher Demands and Expectations .......... 16
Labor Intensity of Health Industry. ... 17
Increased Litigation.......................17
Quality......................................18


X
Regulation...................................21
Summary........................................27
Notes..........................................29
CHAPTER II
RATIONALE FOR STUDY OF PHYSICIAN MANAGERS . 30
The Nature of Managerial Work..................30
Distinguishing Aspects of the
Health Care System...........................34
Management in Health Care Organizations ... 42
Role Studies of Health Care Managers. ... 43
Studies of Cost and Quality..................46
Regulation...................................51
Physicians as Managers. ...................... 53
Tension Between Physicians and
Managers...................................53
Physicians in Management Positions. ... 57
Research on Physician Managers. .... 57
Issues Relevant to Physician
Managers...............................60
Physician Managers in Hospitals .... 64
Physician Managers in Physician
Organizations ........................ 67
Summary........................................69
Notes..........................................71
CHAPTER III
THE STUDY APPROACH AND METHODOLOGY...............75
Study Purpose
. 75


xi
Conceptual Framework...........................76
Review of Job Analysis Techniques ............ 77
Time Studies.................................77
Motion Studies...............................78
Ratio Delay and Work Sampling................79
Critical Incident .......................... 81
Functional Job Analysis .................... 82
Task Inventories.............................84
Summary........................................87
Method Selected for Studying the
Job of Physician Managers....................88
Dependent Variables .......................... 89
Independent Variables '......................91
Organizational Characteristics...............91
Type of Organization.......................93
Size. .....................................94
Title . ............................... 95
Job Description, the People
Preceding in the Position, and
Full or Part Time Position...............96
Line or Staff Position.....................97
Personal Characteristics.....................97
Education .................................97
Experience.................................98
Data Collection................................98
Choice of Population.........................98


xii
Development of Survey Instrument...........100
Validity and Reliability.................103
Steps in Developing the Survey...........109
Mechanics of Administering the
Survey..................................111
Description of Survey .....................111
Data Analysis.................................115
Analysis of Physician Manager
Responsibility...........................118
Analysis of Frequency of
Task Performance.........................119
Notes.........................................121
CHAPTER IV
FINDINGS....................................... 123
Characteristics of Physician Manager
Members of AAMD............................123
Experiences Found Helpful ................ 125
Work Arrangements..................*. . 127
Tasks......................................135
Physician Managers in Hospitals and
Physician Organizations .................. 136
Physician Managers in Hospitals .......... 138
Responsibilities....................... 141
Frequency of Occurrence ................ 143
Physician Managers in Physician
Organizations .......................... 149
Responsibilities.........................151
Frequency of Occurrence ................ 156


xiii
Comparison of Physician Managers
in Hospitals and Physician
Organizations ........................... 158
Summary of Physician Manager
Responsibilities and Frequency
of Task Performance.........................163
Chi Square Analysis...........................164
Policy Management Tasks ................... 167
Task #5, Deciding Which Programs
and Medical Services the
Organization Offers .................. 167
Task #6, Deciding the Size of
Programs and Medical
Services. .............................170
Task #33, Promoting the Organ-
ization . ............................172
Program Management Tasks....................175
Task #40, Ensuring that a System
for Review and Evaluation
of Medical Staff Competency
Operates Effectively. . .............. 175
Task #60, Designing Mew or Modi-
fying Existing Risk
Management Functions...................177
Resource Management Tasks ............... 179
Task #51, Monitoring and Report-
ing on Data from Systems
Designed to Obtain Infor-
mation About Medical Care ...... 179
Task #55, Designing Ways to Im-
prove Efficiency of Pro-
fessional Departments.....................181
Task #68, Designing Contracts for
Physicians
183


xiv
Task #82, Advising Physicians on
Career or Professional
Issues.................................186
Summary of Findings........................188
Notes....................................19^
CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS FOR
FURTHER STUDY .... I.........................197
Conclusions from Analysis of
Physician Managers in Hospitals
and Physician Organizations .............. 197
Conclusions from Chi Square
Analysis...................................206
Summary of Conclusions.......................212
Suggestions for Further Research.............213
Research on the Job of Physician
Managers.................................214
Research on Physician Managers and
the Efficiency/Effectiveness
of Organizations. .......................215
Notes.................................... 219
BIBLIOGRAPHY......................................220
APPENDICES........................................236
A. The Survey Instrument.......................237
B. The Survey Instrument:
Descriptive Statistics .................. 250
C. Lists of "Others" from Survey...............271


TABLES
TABLE
1.1 National Health Expenditures by Type of
Care, U.S., Fiscal Year 1982............... 12
3.1 Independent Variables ........................ 92
3.2 Major Issues Addressed in each Section
of Survey Instrument.......................112
4.1 Characteristics of Survey Respondents . 123
4.2 Experiences Found Helpful in Prepara-
tion for Current Position ............... 126
4.3 Organizational Affiliations of Survey
Respondents..............................128
4.4 Job Titles Reported by Survey
Respondents................................132
4.5 Summary Financial Profile of Survey
Respondents................................134
4.6 Tasks for which Survey Respondents Are
Most and Least Responsible.................137
4.7 Characteristics of Survey Respondents
in Hospitals...............................139
4.8 Tasks for which Physician Managers in
Hospitals are Most and Least
Responsible................................142
4.9 Tasks for which More Than 75% of
Physicians are Responsible in
Hospitals (Policy Management) ............ 144
4.10 Tasks for which More Than 75t of
Physicians are Responsible in
Hospitals (Program Management).............145


xvi
Tables (continued)
4.11 Tasks for which More than 75% of
Physicians are Responsible in
Hospitals (Resource Management) ......... 146
4.12 Tasks Physician Managers Perform Most
and Least Often in Hospitals...............148
4.13 Characteristics of Survey Respondents
in Physician Organizations.................150
4.14 Tasks for which Physician Managers in
Physician Organizations are
Most and Least Responsible.................152
4.15 Tasks for which More Than 75% of
Physicians are Responsible in
Physician Organizations
(Policy Management) ...................... 153
4.16 Tasks for which More Than 75% of
Physicians are Responsible in
Physician Organizations
(Program Management).......................154
4.17 Tasks for which More Than 75% of
Physicians are Responsible in
Physician Organizations
(Resource Management) ................... 155
4.18 Tasks Physician Managers Perform Most
and Least Often in Physician
Organizations ............................ 157
4.19 Comparison of Ten Tasks for which the.
Highest Percentage of Physicians
Have Responsibility in Hospitals
and Physician Organizations .............. 159
4.20 Comparison of Ten Tasks which the
Highest Percentage of Physicians
Perform Often in Hospitals and
Physician Organizations .................. 162
4.21 Representative Tasks Selected for Chi
Square Analysis .......................... 165


xvii
Tables (continued)
4.22 Independent Variables and Tasks with
Significant Association ................ 166
4.23 Extent of Association Between Inde-
pendent Variables arad Physician
Responsibility for Task #5..............168
4.24 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #6..............171
4.25 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #33.............173
4.26 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #40............. 176
4.27 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #60..............178
4.28 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #51..............180
4.29 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #55...............182
4.30 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #68..............184
4.31 Extent of Association Between Inde-
pendent Variables and Physician
Responsibility for Task #82..............187
4.32 Association Between Physician Manager
Responsibility for Tasks and
Independent Variables ................... 189
5.1 Tasks for which Most Physician Managers
are Responsible
198


xviii
5.2 Comparison of Physician Manager Tasks
with Effectiveness and
Efficiency Actions .......................
202
i.


xix
FIGURES
FIGURE
1.1 Health Care Industry Regulation ............ 23
1.2 A Typology of Regulatory Instruments
and Examples from the Health
Services Industry.........................26


CHAPTER I
INTRODUCTION
Purpose of the Study
A disturbing paradox exists in the health care
delivery system. On the one hand, the practice of
medicine with its technological advances is often
described as being the best available in the world.
On the other hand, it is riddled with controversy
regarding escalating costs, inappropriate care, and
poor management. Obviously, there is a distinction
between the individual practice of medicine and the
general delivery of medical care.
One approach .to this dilemma is an effort to
improve the management of health care organizations by
increasing physician involvement. Physicians, skilled
in the technologies of medicine, who in addition de-
velop management skills, are in the unique position to
integrate the two and help to improve the health care
system. A physician manager has been defined as:
any physician with full or part time manager-
ial roles, i.e., medical directors, department
chairs, chiefs of service, presidents of medi-
cal staffs, clinical directors, directors of
medical affairs, etc. (Schenke, 1980, p. xiii)


2
Although there is general agreement on a theo-
retical level about the potential benefits of physi-
cians in management, this group of professionals has
1
undergone little systematic study. This is unfortu-
nate, as knowledge about physician managers could aid
greatly in the formulation of a thoughtful approach
toward the role of physicians as managers in the
health care system. It is to this end that this study
was undertaken.
In short, the purpose of this study is to
describe the job of physicians who are in management
positions, and where possible, identify organizational
and personal characteristics that might influence the
performance of their jobs. The study also provides a
vehicle for looking at the skills physician managers
need if they are to be more effective. Finally, the
study highlights the need for additional research on
physician managers, their jobs and their potential for
a meaningful management role in the health care
system.
The study is undertaken with the recognition
that a complex set of issues underlies any study of
physician managers. One of them is the nature of the
health care delivery system. This section, therefore,
provides an overview of the environment in which phys-
ician managers operate. Chapter II discusses some of


3
the more specific issues relating to physician man-
agers.
The Health Care Delivery System
The health care delivery system in the United
States is both large and complex. The numerous prob-
lems of the system, such as escalating costs, are well
publicized. To better understand the problems in-
volved, a brief historical review of the American
health care system is presented. Then, the current
system is described. Finally, two urgent problems
that face health professionals, policy makers, and the
public, (1) escalating costs, and (2) quality of care,
will be discussed.
Historical Developments
While there are varied approaches to examining
the historical evolution of the American health care
system, Torrens (1980) presents a clear, concise frame
work. He divides this evolution into four periods:
(1) institutionalization of health care, (2) introduc-
tion of the scientific method into medicine, (3) a
growing interest in the social and organized structure
of health care, and (4) the current period of limited
resources, restriction of growth, and reorganization
of methods of financing and delivering care.


4
Torrens suggests that the first period,
institutionalization of health care, began around the
middle of the 19th century and was symbolized by the
establishment of large hospitals such as Bellevue
Hospital in New York City and Massachusetts General
Hospital in Boston. These hospitals provided "visible
institutions around which health care services could
be organized." (Torrens, 1980, p. 4).
Before the establishment of these institu-
tions, almshouses (poorhouses) existed to provide food
and shelter for the homeless poor. They incidentally
housed the chronically and mentally ill as well as
others too old or disabled to care for themselves
(Dowling, 1980). Pesthouses were also common at this
time and served as isolation or quarantine facilities
for people contaminated with diseases such as smallpox
or typhus. Medical care was strictly a secondary
function of these institutions, with the protection of
the community as the primary goal. Most commonly,
anyone able remained home and was cared for by family
or friends (Garrison, 1929)*
Community and voluntary hospitals began to be
established during the late 1700s and early 1800s
(Dowling, 1980). These facilities were built because
physicians and surgeons needed a place to practice
their craft, and medical students needed a place for


5
their preceptorships. These hospitals accepted both
charity and paying patients as long as they did not
have a contagious disease. Despite the improved accom-
modations, most people who became ill continued to
remain at home. It was not until the late 1800's or
early 1900's that hospitals began to be accepted as a
place to receive medical care, and this was a result
of scientific advances.
Torrens suggests that the second important
period in the historic development of the health care
system was marked by the introduction of the scienti-
fic method into medicine. Prior to this time, medi-
cine was viewed as "... a rather informal collec-
tion of unproved generalities and good intentions."
(Torrens, 1980, p. 4). Although Torrens dates this
period as occurring around the turn of the century, it
probably began in 1860 with the critical discovery
that a bacillus caused a disease called anthrax
(Garrison, 1929).
Subsequently, the notion that diseases were
caused by specific organisms became firmly estab-
lished. Major discoveries by Pasteur, Koch, and
others followed, resulting in cures for diseases that
had previously plagued mankind. These discoveries,
together with dramatic surgical successes made possi-
ble by the developments of anesthesia and asepsis,


6
lead to a qualitative break with the past and the
beginning of the scientific era of medicine (Freidson
1970; Starr, 1982).
During this period the Johns Hopkins medical
school, which opened in 1893* became an important in-
fluence in defining medicine and medical care. This
school is credited with making the most radical change
from the old ways to the new scientific orientation
(Torrens, 1984). John Hopkins was the first school to
establish a four year program of medical study with
the unprecedented requirement that all students have
college degrees. In addition, this institution be-
lieved medical education should be rooted in the basic
sciences and in hospital medicine. Therefore, scien-
tific research and clinical instruction were hand in
hand, and a hospital was built in connection with the
school. This approach to medicine soon dominated
medical education in the United States and abroad.
Graduates of Hopkins became esteemed practitioners,
professors at other schools, and scientists, and
played a major role in shaping the character of medi-
cine in the 20th century (Starr, 1982).
The third historical phase in the development
of the health care delivery system is characterized by
Torrens as a period of growing interest in the social
and organizational structure of health care.


7
Beginning with World War II and continuing to the
early 1980s, major scientific and clinical advances
continued to occur. However, at the same time, there
was a prevailing concern about financing health care
and the government's role in the delivery of health
care. These concerns resulted in the proliferation of
health insurance plans, including government programs
such as Medicare and Medicaid.
It is important to emphasize that the tremen-
dous growth of third party payors, e.g., private or
government sponsored health insurance plans, that
occurred during this third phase, inexorably altered
the way in which medical care was delivered. For
example, individuals covered by health insurance no
longer had to be concerned about the cost of care.
This resulted in an increased demand for medical ser-
vices. In addition, third party payors provided funds
that made the tremendous expansion of health care
facilities possible.
The current period is said to have begun in
the early 1980s. It is described by Torrens as:
". . an era of limited resources, restriction of
growth, and reorganization of the methods of financing
and delivering care" (Torrens, 1980, p. 4). These
issues translate into several major problems now fac-
ing the health care delivery system, including cost


8
and quality. These will be discussed further in a
later section of this chapter.
The current system
In order to describe America's health care
delivery system, the major components of the system
need to be identified. These are: (1) the people for
whom the system provides care, (2) the providers of
care, (3) the institutions and organizations within
which they work, (4) the financing mechanisms, and (5)
the government under which the system functions.
People. In 1981 the United States had a popu-
lation of 226,504,825. Numerous ethnic and national
groups are represented, and there is a wide range of
social classes and incomes. The infant mortality rate
in 1981, often "used as a general measure of the health
2
of a population, was 43 per 1000 live births (Sta-
tistical Abstract of the U.S., 1982-1983). In 1982,
the major cause of death in the United States was
heart disease, accounting for about one-third of all
deaths in that year. Life expectancy in 1982, at 74.5
years, was at its highest point ever. Women (78.2
years) continued to live longer than men (70.8 years)
(Department of Health and Human Services 1984).


9
Providers. The health care delivery system,
as discussed later in this chapter, is one of the
countrys major employers. The largest categories
consist of nurses, clerical staff, hospital manual
workers, physicians, dentists, pharmacists, and tech-
nicians. Physicians are the dominant group and are
generally acknowledged as having the most power and
control over the system (Berger, 1983).
Institutions and Organizations. The principal
mode of physician organization is still private, solo
practice, although the proportion of physicians prac-
ticing in groups and/or salaried by hospitals is in-
creasing steadily (Starr, 1982). Ambulatory care is
the most frequently used type of care. Typically, it
is provided in doctors offices, ambulatory care cen-
ters, or neighborhood health centers (Jonas, 1977).
There are two major types of institutions that
provide beds for inpatients. These are hospitals and
nursing homes. Hospitals are the most numerous. In
1980, there were 7,051 hospitals in the United States
with more than 1,365,000 beds (Statistical Abstract
of the United States, 1982-1983). Hospitals are usu-
ally categorized either by ownership, size, function,
or average length of stay. The principal types of
ownership and the number of hospitals represented in


10
each category in 1980 are as follows: government
(federal, state, or local) 2,562, private, not-for-
profit (voluntary or community) 3.547, and private,
for-profit (proprietary) 942 (U.S. Bureau of Census,
1982-1983).
According to the American Hospital Associa-
tion, hospital size is classified according to the
number of beds, as follows: 6-24 beds; 25-49 beds;
50-99 beds; 100-199 beds; 200-299 beds; 300-399 beds;
400-499 beds; and over 500 beds (American Hospital
Association, 1983). Hospital function is generally
categorized as: general, tuberculosis, psychiatric,
and other special. There are only two length of stay
categories: long (average length of stay 30 days or
more), or short (average length of stay less than 30
days) (U.S. Bureau of Census, 1982-1983).
Financing. Between 1970 and 1981, the percent-
age of the Gross National Product (GNP) devoted to
health and medical care increased from 7.6 percent to
9.8 percent (Statistical Abstract of the United
States, 1982-1983). In 1982, it rose to over 10 per-
cent, translating to a total of $322 billion, or
$1,354 per person (Department of Health and Human
Services, 1984). These amounts included monies spent
for hospital care, physician and dentist services,


11
pharmaceuticals, research, hospital construction and
administrative costs.
Table 1.1 illustrates the distribution of
these expenditures by type of care. The largest
single category of expenditure is for hospital care
(425), followed by physician services (19.2%). The
remaining expenditures are distributed among dental
services (6.0%), drugs (6.9%), nursing home care
(8.5%), other personal health care (6.3%) and other
health spending (11.1%).
Government. The United States government
does not operate the health-care delivery system.
Actually, the government is less involved in health
care than the governments of most other countries
(Jonas, 1977). However, the role government does play
is enormous and expanding rapidly. For example, the
government collects and disseminates information;
trains personnel; operates institutions; provides
services, finances services; supports and carries out
research; plans; evaluates; and regulates.
P.roblems Facing the Health Care System
Almost all Americans are aware of at least
some of the problems that plague the health care
delivery system today. Unfortunately, neither the
problems nor concern about them is new; they have just


12
i
\
TABLE 1.1
NATIONAL HEALTH EXPENDITURES BY TYPE OF CARE
UNITED STATES, FISCAL YEAR 1982
TYPE OF CARE PERCENTAGE
Hospital care 42.0
Physician services 19.2
Dentist services 6.0
Drugs and drug sundries 6.9
Nursing home care 8.5
Other personal health care 6.3
Other health spending 11.1
Total 100.0
: !
. (
! I
!
r
i i
Source: R. M. Gibson, D.R. Waldo, and K.R.
Levit. "National Health Expenditures." Health Care
Financing Review. 4, no. 5, 1983.
* j
) I
: I
; i
> \
; 5
2


13
gradually increased in magnitude. To illustrate, the
following is a summary of a study on health care de-
livery service released in 1932:
The problem of providing satisfactory medi-
cal service to all the people of the United
States at costs which they can meet is a
pressing one. At the present time, many
persons do not receive service which is
adequate either in quantity or quality,
and the costs of service are inequitably
distributed. The result is a tremendous
amount of preventable physical pain and
mental anguish, needless deaths, economic
inefficiency and social waste. Furthermore,
these conditions are, as the following pages
will show, largely unnecessary. The United
States has the economic resources, the organiz-
ing ability, and the technical expertise to
solve this problem. (Committee on the Costs of
Medical Care, 1932, p.2>
This statement was made by a committee appointed in
1928 by President Hoover to investigate the problems
of health care delivery. It is disturbingly relevant
today.
In actuality, the problems of the health care
system are so interrelated that an attempt to deal
with one without regard for the others would be fu-
tile. However, for the purposes of this discussion, a
review of two of the major problems facing the health
care system, cost and quality, will be presented.
These are selected because they are relevant to issues
of physician managers. Subsequently, the issue of
regulation is described. Regulation is recognized to
be a response to cost, quality and other problems;


14
however, it is also a problem in itself and is dis-
cussed here because of the influence it has had on
physicians in management.
Costs
Constantly rising expenditures have character-
ized the health care system since 1929, when data were
first collected (McCarthy, 1977). The most commonly
cited reasons for these rising costs are as follows.
Structure of health care financing. The
cost-based third-party payment system of health care
financing is a primary cause of high health care cost
(Summers, 1981). The involvement of third party pay-
ors (government and private insurance), means little
or no out-of-pocket costs to consumers. This system
insulates consumers and to some extent providers from
the true cost of treatment decisions.
Further, reimbursement by third-party payors
has up until now been on a fee-for-service basis.
This means the more service provided, the more money
collected. Medicare and Medicaid followed this model,
making large amounts of money available for services.
These programs were originally designed to address
another problem of the health care system, that of
access. It was intended that through this program the
elderly and poor would be able to receive needed care.


As a result of the payment system, there has been a
sharp increase in requests for service, skyrocketing
costs, and little or no incentive to weigh costs
against benefits (Fuchs, 1974; Summers, 1981; Starr,
1982) .
High provider fees. The problem of high pro-
vider fees is related to the structure of health care
financing. Medicare/Medicaid and other insurance
plans typically pay physicians according to their
"customary" or "reasonable" fees. This has built-in
bias toward high cost. In addition, reimbursement
systems have paid most for hospital-based care, further
encouraging physicians to provide care in a more cost-
ly environment (Starr, 1982).
Physician control. Physicians make the deci-
sions that determine the type and amount of services
provided. For example, physicians determine whether a
patient needs to be admitted to a hospital, the length
of stay once admitted, etc. However, research has
shown that many physicians have not been aware of
costs such as diagnostic procedures, laboratory tests,
or the cost of a hospital room (Moore, 1983; Berger,
1983; Weisbord and Stoelwirder, 1979).
Physician training. Physicians a>"e trained
to practice medicine at the highest level of their


16
technical ability without regard to costs (Friedson,
1970). In addition, there are no limits placed on the
number or variety of medical specialists trained in
this country. Specialists do more complicated proce-
dures, use the hospital more often, and charge higher
fees.
Advances in medical technology. New proce-
dures, equipment, and techniques flourished after World
War II and continue to do so today. It has been said
that the health care industry has been "captured" by
3
technological developments (Torrens, 1980, p.8).
Although these technical advances have been credited
with making a substantial improvement in the quality
of medical care, they usually involve complex and
costly equipment, procedures, and/or facilities.
Recent examples of these developments include computer-
ized axialtomography (CAT) scanners, lasers, ultra-
sonography, coronary artery bypass surgery, microsur-
gery, artificial organs, intensive care units, neo-
natal units, advanced pharmacies, etc.
Higher demands and expectations. The in-
crease in demand for services is associated with at
least three factors: (1) belief that health care is
now a "right", (2) the growth of health care insurance
plans including Medicaid/Medicare, and (3) advances in


17
technology (Fuchs, 1974; Summers, 1981; Starr, 1982).
The increase in expectations means simply that consu-
mers want the best medical services available. When
confronted with situations involving personal or fam-
ily illnesses, people want to disregard cost and get
all the care they need and/or desire (Mechanic, 1978).
Labor intensity of the health industry.
There has been a dramatic growth in the number and
type of personnel employed in the health care indus-
try. It is now one of the largest employers in the
country and, in 1980, employed over 7 million persons
(United States Department of Health and Human Ser-
vices, PHS., 1981).
Recently new categories of health care person-
nel have appeared. These include physicians assis-
tants, nurse practitioners, dental hygienists, special
ized laboratory and radiology technicians, home health
aids, nutritionists, etc. These personnel, some of
whom received many years of professional training,
demand salaries commensurate with their level of
skill.
Increased litigation. As the number of
malpractice suits brought against physicians has in-
creased, so have malpractice insurance premiums.
These higher rates add to the overall cost of medical


18
care in at least two ways. First, physicians pass
most of these costs on to patients; and second, in
trying to avoid any possible suits physicians practice
"defensive" medicine. This means that in order to
document their diagnosis or a specific treatment,
physicians order more tests or perform more procedures
than they would otherwise. This documentation has
proved to be a powerful weapon in defending against
malpractice suits (Eisenberg, 1978; Summers, 1981).
It has been said that the "crisis" in Ameri-
ca's health care system is a crisis of money (Starr,
1982, p. 381). In other words, if costs (limited
resources) were not an issue there would be no crisis.
While the problems facing today's health care system
involve more than just costs, it is clear that the
nation probably cannot afford to pay for the quantity
and quality of care desired. This brief and undoubt-
edly incomplete list of factors which contribute to
health care costs is intended to provide some insight
into the magnitude of the problem.
Quality
Concurrent with concern over escalating health
care costs are concerns about the quality of health
care. Although there is no universally accepted def-
inition of "quality", it can be thought of simply as


19
"the degree of excellence or confirmation to stan-
dards" (LoGerfo and Brook, 1980, p.403). Concern
about quality of care is not new. As early as 1918
the American College of Surgeons stated that:
. . the medical staff [should] review and
analyze at regular intervals their clinical
experience in the various departments of the
hospital such as medicine, surgery, obstet
rics, and other specialties. The medical
records of patients, free and pay, to be the
basis for such review and analysis.
(American College of Surgeons, 1918, p.1)
Assessments of the quality of care are under-
taken for a variety of reasons. For example, there
may be a substantive concern about existing problems
in quality of care, or an assessment may be made to
satisfy the requirements of a regulatory agency. The
focus of quality studies is generally specific provi-
ders, e.g., physicians; specific conditions, e.g.,
review of patients with acute myocardial infarctions;
or care received by selected groups of patients, e.g.,
on a particular unit of a hospital (LoGerfo and Brook,
1980) .
The type of quality review originally sugges-
ted by the American College of Surgeons became insti-
tutionalized as the Morbidity and Mortality Conference
(M & M's). This has occurred at most hospitals with
training programs for over 50 years and continues
today. In addition, the medical staff in most


20
hospitals have made efforts to ensure quality through
activities such as, credentialling, medical record
review, tissue review, utilization review, etc.
(Vanagunas, Egelston, Hopkins and Walczak, 1981).
More recently a legal impetus for quality
assurance and quality assurance programs has come from
Title XIX of the Amended Social Security Act (Medi-
caid) which linked reimbursement to specific stan-
dards of care. As a result, formal quality assurance
programs have become part of several accrediting organ-
izations, including the Joint Commission on Accredita-
tion of Hospitals (JCAH). In 1976, JCAH added a qual-
ity of professional service section, part of which
states:
There shall be evidence of a well-defined,
organized program designed to enhance pa-
tient care through the ongoing objective
assessment of important aspects of patient
care and the correction of identified prob-
lems. (JCAH, 1981. pp. 151-54)
To ensure meeting accreditation requirements,
hospitals have been required to have formalized assur-
ance programs. These programs involve, among other
activities, conducting medical audits. These in turn
are to be conducted in accordance with an audit method-
ology developed by JCAH for this purpose. Other qual-
ity assurance activities often involve the traditional
M&M conferences, credentialling, medical records,


21
tissue review, and utilization review, but in addition
are being directed at infection control, antibiotic
usage, drug utilization, etc. (Vanugdunas, et. al.,
1981).
Quality assurance activities have been studied
and criticized as having "little documented impact in
terms of improving patient health or reducing care
costs" (Williamson, 1978, p.631). Williamson (1978)
attributes this to the lack of an appropriate decision
process for selecting priority areas where target
outcomes will most likely be achieved. Nonetheless,
there are no signs that the-plethora of quality assur-
ance programs and activities are decreasing, which may
be due to demands of regulatory agencies. Nor does it
appear that a more accurate selection process is being
employed.
Regulation
As previously mentioned, increased regulation
in the health care industry has been in response to
other problems. However, regulation in and of itself
has become an issue that affects the job of physician
managers. In the broadest sense, regulation encompas-
ses :
. . the entire panoply of laws, rules
and ethical precepts, public and private,
which govern the conduct of the health


22
industry and health professionals. (Levin,
1980, p. 1)
Virtually every aspect of the health care
industry is subject to some type of regulation. The
training and education of health professionals, the
construction of health facilities, the introduction of
new medical treatment, and the financing and operation
of health care institutions. All this results in the
health care industry being called "the most heavily
regulated industry in the United States." (Levin,
1980, p.1).
Whatever the specific regulation, laws enacted
in the area of health care have two things in common.
First, they are intended to remedy or alleviate per-
ceived social problems, e.g., the uneven quality of
health care or containing escalating health care
costs. Second, laws require detailed and often exten-
sive administrative regulations in order to be imple-
mented (Morgan, 1980).
Figure 1.1, prepared by Wolper and Hopkins
(1977). illustrates the major health care regulations
on both federal and state levels from 1930 to 1977.
Although this table is several years old, it dramati-
cally depicts the changes in regulatory activity since
1965. In addition, it shows that the majority of
federal regulations have revolved around controlling


FIGURE 1.1
HEALTH CARE INDUSTRY REGULATION
NA1IONAI
HIAIIH
INSURAHCI
| runic Diicioiuii

I lAtl MVIIW MOSMCIIVI SUDOIIIHO

I CAfllAl KnNDIIUII CONIIOl! /
Source: 'Lawrence F. Wolper
'Prospering in a Regulated
Progress 58, no. 9 (1977).
and Wallard
Environment."
G. Hopkins
Hospital
ro
U)


24
rising health care costs by either planning, stimula-
ting growth of alternative delivery systems (HMOs), or
utilization review. On a state level, attempts have
been made .at prospective budgeting and reimbursement
systems and rate review since the late sixties.
Wolper and Hopkins categorize health care
regulations into four areas:
1. Planning. States are required to have
state health plans, and institutional providers are
required to consider the service demands of the commu-
nity .
2. Development and distribution of services.
Some regulations are intended to control demand by
limiting supply. Such regulations focus on new and
expensive services.
3. Utilization controls. Cloaked in the lan-
guage of quality care, utilization controls focus
primarily on controlling "misuse (overuse) of patient
care services.
4. Financial controls. Aimed directly at
controlling health care expenditures made by pur-
chasers such as the federal government, financial
control regulations lean towards being punitive as
well as incentive oriented.
Bice (1984) categorizes the types of
regulatory instruments in the health industry.


25
| Figure 1.2 shows.that these are either (1) subsidies,
| (2) entry controls, (3) rate or price settings, or (4)
i quality controls. Subsidies are considered the most
|
j traditional and widely used means of regulating the
| supply and demand for health services. Entry controls
i
j such as licensure and certification are used to ensure
j that persons offering goods or services are at least
| minimally qualified to do so. Rate or price setting
I is usually assumed by governments for a number of
j i
jj reasons, but most often in health services to protect
j
II the public from high costs of needed services. Qual-
t
; l
;! ity controls include a wide-variety of regulatory
; I
I
jj mechanisms aimed at reducing risks and generally apply
: I
: i
i
jj to all designated suppliers.
! i
ii Despite the enormous number of regulations
!
j! within which the health care industry currently func-
i )
; j
ii tions, additional efforts to control cost are likely
{ i
ii to result in even more. For example, because of huge
jj deficits in the Medicare program, regulations that
; i
i j
ij base government reimbursement on a Diagnosis Related
; i
ij Group (DRG) are becoming a reality.
ii
; The DRG is a culmination of a number of ef-
: | forts which have as their ultimate goal a precise
1 i
ij description of various kinds of health care products
ij (Studnicki, 1983). Using this concept, Congress has


Regulatory Instruments
FIGURE 1.2
A TYPOLOGY OF REGULATORY INSTRUMENTS AND
EXAMPLES FROM THE HEALTH SERVICES INDUSTRY
Objects of Regulation
Subsidies
Entry
Restrictions
Rate
Controls
Quality
Controls
Source: Thomas W. Dice. "Health Servioes Planning
and Regulation." In Introduction to Health Services.
2nd ed. Eds. Stephen J. Williams and Paul R. Torrens.
New York: John Wiley & Sons, 198*1, p. 390.
Individuals Institutions
Supply Training grants Demand Medicare/Medicaid Tax exemptions Supply Construction grants, loans, loan guarantees Tax exemptions Demand Tax exemptions to employers
Personnel licensure Facilities licensure
Capital expenditures controls
Fee schedules under Rate setting commissions
Medicaid & the Economic Medicare and Medicaid
Stabilization Program reimbursement limits
Professional Standards Certilicatlon for
Review Organization . Medicare and Medicaid


27
approved a single fee system, with specific fees for
268 different groups of illnesses requiring hospital
care. To date, this system includes only costs billed
directly by the hospital to Medicare. The Department
of Health and Human Services is studying how this
system could be extended to cover bills from physi-
cians for hospitalized Medicare patients. It is too
early to document positive or negative results of
reimbursement based on DRGs. However, concern over
regulatory devices using DRGs seems focused on the
potential "for providing financial incentives for
distorting the legitimate practice of medical art and
science" (Studnicki, 1983, p. 110).
Summary ,
This chapter highlighted some of the complex
issues facing the health care delivery system today.
A brief historical review and a description of the
current system were presented, because the importance
of environment to organizations, and therefore man-
agers, is well recognized. The issues of cost, qual-
ity, and regulation have been discussed, because
clearly they have implications for health care man-
agers. These will be described more fully in Chapter
II.
The dissertation is organized in five


28
chapters. Chapter II presents the rationale for the
study, and a review of the relevant literature on
physician managers. Chapter III contains the meth-
odology. Chapter IV presents the findings of the
study, and Chapter V discusses the implications and a
general summary.


29
NOTES CHAPTER I
1. The literature relevant to physician
ment in the management of health care organiz
reviewed in Chapter II.
2. Infant morta
widely used indicator
fant mortality, the r
births can be compare
ized countries. For
tality in Sweden was
compared with 43 per
United States in 1981
expectancy for men in
women (World Almanac,
lity and life expectancy
s of general health stat
ate of infant deaths per
d with that of other ind
example, in 1978 the inf
7.7 per thousand live bi
thousand live births in
. Further, in 1979 the
Sweden was 72.5 and 78.
1983) .
3. This argument is similar to one made
public administration by Sayre (1948), when h
that personnel specialists had become obsesse
techniques at the expense of purpose. Sayre
fundamental examination of both ends and mean
system of personnel administration.
s' involve-
ations is
are
us. In-
live
ustrial-
ant mor-
rths,
the
life
7 for
about
e observed
d with
urged
s in the


CHAPTER II
RATIONALE FOR STUDY OF PHYSICIAN MANAGERS
As mentioned previously, the primary purpose
of this study is to describe the job of physician
managers, and to identify personal or organizational
characteristics that might influence the performance
of this job. In order to better understand the work
of physician managers, this chapter reviews some pre-
vious studies of managerial work. Next, aspects of
the health care delivery system that may substantially
affect managerial work are discussed. Finally, the
relevant literature on physician managers is pre-
sented .
The Nature of Managerial Work
The work that managers do has long been of
interest to students of both the private and public
sector. Fayol (1949) and Gulich (1937) defined man-
agement activity in terms of a number of functions for
which managers were responsible. Fayol, credited with
developing the first comprehensive theory of management,
identified 14 different principles of management.
These include: division of work, authority,


31
discipline, unity of command, centralization, and
scalar chain (line of authority). Gulick, (1937) also
viewed management in terms of functions for which
managers were responsible. He proposed seven major
management functions: planning, organizing, staffing,
directing, coordinating, reporting and budgeting.
Known collectively as POSDORB, this approach to man-
agement has influenced management theory for forty
years.
Barnard (1938) emphasized what managers should
be doing for the organization to survive. He argued
that the most important managerial functions should
parallel the organization's needs. These include hav-
ing a common goal toward which members of the organ-
ization could work, members who are willing to con-
tribute, and members who have basic communication
skills.
More recently, Mahoney, Jerdee, and Carroll
(1965) obtained estimates from managers on the amount
of time they spent on several management functions:
planning, investigating, coordinating, evaluating,
supervising, staffing, negotiating, and representing.
Mintzberg (1973) distinguished eight major schools of
thought on the managerial job. These are: classical,
great man, entrepreneurship, decision theory, leader


32
effectiveness, leader power, leader behavior, and work
activity. Mintzberg's own work belonged to the last
category, which seeks to find out what managers
actually do.
Mintzberg (1975) sought to determine how man-
agers spend their time and how they perform their
jobs. From his research and the research of others
who have studied managers with the same focus,
Mintzberg concluded that managers fill ten roles. He
grouped these roles into three major categories.
These are:
A. Interpersonal roles.
1. The figurehead role (performing cere-
monial and social duties as the organizations repre-
sentative) .
2. The leader role.
3. The liaison role (particularly with
outsiders).
B. Informational roles.
4. The recipient role (receiving informa-
tion about the operation of an enterprise).
5. The disseminator role (passing informa-
tion to subordinates).
6. The spokesperson role (transmitting
information outside the organization).
C. Decision roles.


33
7. The entrepreneurial role.
8. The disturbance-handler role.
9. The resource allocation role.
10. The negotiator role.
Additionally, one of Mintzberg's major findings.is
that rather than being systematic, reflective plan-
ners, managers simply respond to the pressures of
their jobs. He suggests that managerial work is char-
acterized by "...brevity, variety and discontinuity."
(Mintzberg, 1975, p. 50).
Mintzbergs work has been criticized on sever-
al counts, e.g., insufficient sample size, and failure
to include non-managerial work performed by all man-
agers (Koontz, O'Donnell, and Weihrich, 1982). How-
ever, McCall and Segrist (1980) tested Mintzberg's ;
framework using a questionnaire based on the roles.
They asked managers to rate the importance of the role
to their own supervisory performance. They concluded
that the construct validity of six of the roles was
supported. In addition, they stated:
Managers' perceptions of relative role impor-
tance across levels and functions were suffi-
ciently similar to support Mintzberg's conten-
tion that managerial jobs are essentially alike.
(McCall and Segrist, 1980, p. 47)
That management is generic is a widely held
assumption (Drucker, 1973; Sheldon, 1975; Caplow,
1976). According to this viewpoint, organizations


34
resemble each other to such a great extent that much of
what is learned by managing one organization can be
applied to managing any other organization. According
to Sheldon (1975), despite minor differences of degree
in organizations "there is not that much difference
between a manager in the health field, whether he be a
physician or not, and a manager in industry."
(Sheldon, 1975, p.1). Drucker (1973) discussing es-
sential management functions, suggests that management
faces the same problems everywhere:
. . it has to organize work for productiv-
ity and achievement. It is responsible for
the social impact of its enterprise. Above
all, it is responsible for producing the re-
sults, whether economic performance, stu-
dent training or patient care for the sake
of which each institution exists. (Drucker,
1973, P- 17)
While it is not the intent of this study to
argue whether or not management is generic, it is rel-
evant to examine the research that addresses some char-
acteristics of the health care delivery system which
affect the work of health care managers.
Distinguishing Aspects of the Health Care System
The health care delivery system is considered
by many to be different from other systems. Austin
(1974) identifies five characteristics that he sug-
gests make the health care industry "unique". He
emphasizes that other industries may share one or more


35
of these characteristics but in no other field do all
of these factors converge as they do in health care:
1. Delivery of individualized services. Whe-
ther in a large, complex setting or a small, intimate
one, the health care industry delivers a service that
must be individualized to a grerater extent than those
of any other service industry. Personal health or
medical care cannot be mass producerd, and even ser-
vices delivered to groups must be tailored to the
needs of the individuals.
2. Professionalism. The health care delivery
is ". . the most highy professionalized industry in
our society" (Austin, 1974, p. 308). Members of numer-
ous different professions work both as providers of
service and as directors of institutions, agencies,
and programs. However, all those involved in direct
patient care are responsive and responsible to the
physician.
3. Extreme complexity. Complexity has been a
generally accepted fact about the health care system
because the systems three major components (users,
providers, and mechanisms for bringing users and pro-
viders together) interact in extremely complex ways.
Factors contributing to this complexity include: the
pluralistic nature of the mechanism involved; the
interface of public service objectives; private


36
interests and obligations within the industry; the
financing structure, which depends largely on third
party sources; and the complicated internal and exter-
nal relationships, which must be developed and main-
tained .
4. The wide range of delivery facilities.
Service delivery settings range from large academic
health centers providing comprehensive care, to small,
single service units. Between these two extremes, a
wide variety of organizations exists that are fre-
quently fragmented and uncoordinated. Such variety
requires "... a diversity of administrative
approaches unequaled in other specialty fields"
(Austin, 1974, p. 310).
5. Financial reimbursement arrangements. The
variety of.payment sources and the proportion of third
party payors involvement upsets classical supply and
demand market conditions and creates layers between
provision of service and payment.
Austin argues that all these factors result in
". . a complexity of professional and administrative
relationships unrivaled by most other industries"
and therefore, the need for an exceptionally high
degree of coordination between units of the system
(Austin, 1974, p. 310).
The differences between hospitals and other


37
organizations in our society have been the subject of
extensive study. Considerably less attention has been
paid to physician organizations, (e.g., group prac-
tices or pre-paid health plans) at least in a compara-
tive sense. Burling, Lentz, and Wilson (1956), and
Georgopolous and Mann (1962), were among the first to
describe the structure and functions of a hospital.
Burling's work, a case study approach to six community
general hospitals, was conducted from 1949 to 1954 and
served to "map" the territory.
Burling's study was probably the first to
recognize what has become a recurrent theme in the
literature: that unlike most other organizations,
three separate power bases exist within the hospital.
The Board of Trustees considers policy; the adminis-
tration oversees the daily operations of the organiza-
tion; and the physicians manage and control the clini-
cal services. Burling observed that no one person or
group has complete authority to dictate change. Each
of these forces has its own separate interests, and
its behavior serves to protect these interests
(Burling, Lentz and Wilson, 1956).
Georgopolous and Mann (1962) in their study of
twelve Michigan hospitals, examined the concept of
three power bases or lines of authority within the
1
hospital in more detail. These authors identified the


38
physicians as the major power group and noted that
they are socialized as professionals, assume a
cosmopolitan role, are autonomous and independent, and
may or may not be committed to the goals of the organ-
ization. In addition, physicians may play several
roles in the hospital, which results in role conflict
(Georgopolous and Mann, 1962).
These authors argued that because of the three
power groups, coordination becomes a crucial manage-
ment issue. Georgopo-lous and Mann concluded that:
(1) good coordination is essential to the effective-
ness of community general hospitals, and (2) that an
increase in the quality of nursing care and total
patient care accompanies increased coordination.
These observations have been confirmed. The
professional model in which physicians are socialized
places a high value on autonomy. This in turn results
in managerial problems for hospitals (Hage, 1974; and
Rubin and Beckhard, 1978). Perrow (1965), after ac-
knowledging the unique position of physicians in the
hospital, .suggested that role conflict occurs because,
depending on the situation, doctors are staff, line
managers, or guests in the organization.
Freidson, (1970) and Nadler (1978) noted that
while physicians were crucial to the survival and
f -nctioning of the hospital, they may not be committed


39
to organizational goals and objectives. This situ-
ation is in contrast to that existing in most other
organizations, where role conflict is rarely toler-
ated. The primary power base is fully committed to
the goals of the organization and interdependence
between members is expected and acknowledged.
Additional differences among hospitals and
other types of organizations have been identified.
The most important distinguishing factor of the hos-
pital is the character of the product. Health or
medical care is largely immeasurable and unquantifi-
able. This results in vague and ambiguous goals that
make effective management difficult. The service is
variable, diverse, and subject to little standardiza-
tion. At the same, time, quality of the hospital
product is considered more important than in an indus-
trial setting (Georgopolous and Mann, 1962; Drucker,
1973; and Bennett, 1978).
Other characteristics thought to contribute to
the uniqueness of hospitals are as follows; Hospitals
are considered vitally important to society and likely
to remain so, while other organizations may or may not
be considered important. Hospitals are extremely
complex, highly differentiated, quasi-bureaucratic
organizations while other organizations may be simple
or complex. The hospital is dependent upon and


40
responsive to the surrounding community, and its work
is more integrated with the needs and demands of its
customers. The hospital has less control over its
environment and services than other businesses
(Georgopolous and Mann, 1962; Bennett, 1978).
Medical centers are even more complex than
hospitals. Weisbord (1978), who has worked with sev-
eral academic medical care centers, with the American
Association of Medical Colleges, and other medical care
groups, collaborated with Lawrence and Lorsch to con-
ceptualize a model analyzing how parts of a medical
center fit together. Instead of being one organiza-
tion, Weisbord said, an academic medical center is
actually (1) a medical school and one or more teach-
ing hospitals, (2) other professional schools, and (3)
a university with different departments. This struc-
ture requires professionals to play more than one role
or "wear more than one hat" at a time, which leads to
role conflict and organizational problems.
Although individual differences among hospi-
tals exist due to geographical location, local environ-
ment, size, mission, and goals, one overriding simi-
larity has been established: they all differ in sig-
nificant ways from other complex organizations and
social systems. The hospital is heavily dependent
upon human energy and knowledge and sophisticated


1} 1
technical facilities, as well as effective coordina-
tion of both elements (Georgopolous, 1972; Rakich,
Longert, and O'Donovan, 1977).
More recently Shorten and Kaluzny (1983)
summarized and listed nine ways that hospitals may be
considered different from industrial organizations;
1. Defining and measuring output are difficult.
2. The work involved is more highly variable
and complex than in other organizations.
3. More of the work is of an emergency and
non-deferrable nature.
4. The work permits little tolerance for ambi-
guity or error.
5. The work activities are highly interdepen-
dent, requiring a high degree of coordination among
diverse professional groups.
6. The work involves an extremely high degree
of specialization.
7. Organizational participants are highly
professionalized, and their primary loyalty belongs to
the profession, rather than to the organization.
8. There exists little effective organization-
al or managerial control over the group most respons-
ible for generating work and expenditures: physicians.
9. In many health care organizations,
particularly hospitals, there exists dual lines of


42
authority, which creates problems of coordination and
accountability and confusion of roles (Shorten and
Kaluzny, 1983. pp. 13-14).
While these authors acknowledged that the
"uniqueness" of health care organizations can be over-
stated, they seem to agree with those that say "the
field [of health services management] is different as
a whole and not by its parts" (Brown, 1973). It is
"the confluence of professional, technical and task
attributes that make the management of health care
organizatons particularly challenging" (Shortell and
Kaluzny, 1983. p. 14).
Management in Health Care Organizations
It is clear that the health care system is
complex, and it is evident that a significant body of
literature argues in favor of the health care industry
being substantially different from other industries.
From the studies on the work of managers, much is
known about the general functions managers perform and
the various roles managers fill. The question now
becomes, how do all these factors affect the work of
managers in health care settings?
There appears to be a paucity of research
addressing this question, either directly or in any
breadth. However, there are fragmented strains of


43
research that address subsets of the question. A
number of studies have been done on the role of
health service managers. These provide information
about how non-physician health care managers spend
their time, the forms of communication they use, and
what activities they undertake and consider important
(Munson and Zuckerman, 1983).
Other studies, conducted for the most part in
hospitals, focus on the cost and quality problems of
the health care field and stress implications for
managers. Although related to cost and quality prob-
lems, regulation is often discussed as a separate
issue and cited as a reason for the increase in physi-
cian managers. Therefore, a brief review of regulation
is also presented.
Role Studies of Health Care Managers
The available literature on the role of health
care managers has focused on the following dimensions:
(1) time spent on various activities, (2) forms of
communication, and (3) activities. Allison (1975)
studied the role of 24 health administrators in four
different types of organizations: hospitals, long-
term care facilities, multi-specialty group practice
clinics, and health maintenance organizations. He
developed 46 items that described specific management
functions and asked respondents to indicate level of


44
involvement, time spent, and degree of importance of
each.
Kuhl (1977) used Allisons work to develop her
questionnaire, which was mailed to a national sample of
chief executives in hospitals and prepaid group prac-
tice health plans. The content of executive work was
the dependent variable, measured in two ways. First,
executives were asked to indicate in their own words
four aspects of their work that were most important.
Second, executives were asked to indicate the nature
of their involvement in 114 distinct activities, the
time devoted to activities in which they were involved,
and the importance attached to those activities.
In order to analyze the data, Kuhl used con-
tent analysis, which produced 23 groupings. These
were then placed in four broad areas that represented
components of the executive role. These areas were
(1) internal management (all activities that relate to
the general purpose of managing the internal opera-
tions of the organization), (2) organizational develop-
ment (activity oriented toward changing or developing
the organization), (3) external relations (activities
relevant to maintaining contact with people or organi-
zations pertinent to the organizations present or
future operations), and (4) environmental surveillance
(monitoring or surveying the environment for the


45
purpose of interpreting how changes in the environment
may affect the organization).
Kuhl found that the majority of activities
fell into the internal management area, which was in
turn subdivided into organizational design, personnel
management, financial management, logistical manage-
ment, service delivery, and legal work. She concluded
that the role of these executives closely conformed to
the traditional administrative model in that these
executives are primarily concerned with maintaining
the ongoing operations of the organization. Their
major responsibilities include assuring conformity
with organizational objectives, allocating organiza-
tional resources, promoting efficiency, and providing
for organizational growth.
Munson and Zuckerman (1983) reviewed several
other role studies of health care administrators and
concluded that the general findings support the univer
salist model of the managers role. In other words,
most of the studies reviewed by these authors, includ-
ing the two presented here, document that management
activities such as planning, organizing, etc., and
organization-building human relations activities com-
prise most of the work of health care managers.


46
Studies of Cost and Quality
As discussed earlier, Georgopolous and Mann
(1962) concluded that because of the three power
groups that existed simultaneously in hospitals, coor-
dination was the pivotal element in ensuring both
organizational effectiveness and quality of care. For
example, management practices such as asking subordin-
ates for their ideas about various work related prob-
lems were associated with increased coordination. In
addition, Georgopolous and Mann found quality of care
to be associated with situations where there was less
tension between doctors and nurses and greater under-
standing of each other's roles.
More than ten years later. Shorten, Becker,
and Neuhauser (1976) examined 42 Massachusetts hospi-
tals and came to similar conclusions. In this study,
quality of care was measured by the rate of post
operative complications and the medical-surgical
mortality rate (controlling for case mix and sever-
ity) These authors found that the number of regu-
larly scheduled meetings between radiology, laboratory
and nursing service to facilitate coordination was
associated with lower costs and higher quality of
care. The extent to which physicians perceived they
influenced decisions involving the purchase of hospi-
tal equipment was also associated with lower costs.


47
Most important was the conclusion that these and other
managerial practices explained more of the variance in
cost than differences in case mix or the quality of
care provided.
It is becoming increasingly evident that
health managers can improve organizational performance
through their influence on the composition of the
medical staff and medical staff organization. Roemer
and Friedman (1971) studied the relationship between
hospital performance, physicians on contract, and
medical staff organization. They found positive rela-
tionships between a high proportion of contractual
physicians and several measures of hospital perform-
2
ance. They also found a positive association between
organizational performance and hospitals with a tightly
structured medical staff.
Sloan and Becker (1981) examined the relation-
ship between costs and characteristics of the medical
staff organization in 228 hospitals. They found sev-
eral management factors to be associated with lower
costs per admission: the percentage of hospital-based
physicians on contract, incentive contracts for physi-
cians who were not hospital based, and the presence of
physicians on the executive committee of the governing
board.
In a study involving 15 short term general


48
1
i
' i
* i
hospitals. Flood and Scott (1978) examined the effect
of several selected structural characteristics on
medical outcome. Specifically, these characteristics
included the distribution of power among professional
role groups, and the power exercised by the surgical
staff over its own members. They found the extent of
control exercised by the surgical staff over individu-
al surgeons to be associated with the quality of care.
However, they also found that when the hospital admin-
istrator had more power, it was the factor most
strongly associated with quality of surgical care.
(Flood and Scott, 1978)
Shorten and LoGerfo (1981) examined the rela-
tionship of hospitals, physicians, and medical staff
characteristics to quality of care for two conditions,
acute myocardial infarction (AMI) and appendicitis.
For the conditions and hospitals studied, they found
that structural characteristics of the hospital (e.g.,
bed size, degree of teaching involvement) and individ-
ual physician characteristics (e.g., specialty compo-
sition) were not strongly related to better perform-
ance. Instead, medical staff characteristics such as
degree of physician participation in hospital decision-
making, frequency of committee meetings, concentration
of activity in one hospital, and percentage of physi-
cians on contract were strongly associated with


49
superior performance. The authors concluded that a key
factor in improving the quality of hospital care may
be activities aimed at changing medical staff organi-
zation and ensuring its involvement with the overall
hospital organization.
In summary, it is clear from these representa-
tive studies that the problems of cost and quality
(referred to as efficiency and effectiveness in several
studies) can be significantly affected by management
3
practices. For example, all managers can influence
the number of regularly scheduled meetings that facil-
itate coordination, a key variable in insuring effect-
iveness. Managers can also influence the composition
and organization of the medical staff and provide
physicians with a variety of opportunities to have
input on organizational decisions.
The complexity of the system and differences
cited earlier certainly do not make it easy for health
managers to have a positive influence irr their organi-
zation. One of the most obvious difficulties and
recurring themes is the lack of control managers have
on physicians and their behavior (Austin, 1974;
(Friedson, 1975; Summers, 1982). Building on
Mintzberg's conceptualization of management roles
reviewed earlier in this chapter, Scott and Shorten
suggested that health care managers are able to exert


50
a positive influence on the efficiency and effective-
ness of their organizations by working through three
major roles. These are (1) the interpersonal role
(direct attempts to influence others), (2) the infor-
mation gathering role (monitoring of environment and
organizational activities), and (3) the decision-
making role (entrepreneurial activities determining
allocation of resources).
However, these authors also warned that "in
executing these roles, health care managers, perhaps
more than their counterparts in industry, are called
upon to make use of their expert and referent power
rather than their legitimate or coercive power" (Scott
and Shorten, 1983, p. 443). Scott and Shortell sug-
gested a number of specific actions managers can take
to affect their organizations. Some of these are as
follows:
1. Emphasizing structural and process control,
rather than outcome control. This translates into
carefully selecting employees and professional staff
members and developing good interpersonal relation-
ships and making procedural suggestions to profes-
sional staff.
2. Creating substitutes for formal leadership
by developing cohesive work groups, organizational
development, and training programs.


51
3. Helping to enact reality for people by
articulating shared concerns, attitudes, values, and
capabilities of staff members and by directing the
flow of information. Examples include deciding what
issues to place on agendas and whom to appoint to
various committees.
Regulation
It was noted earlier that regulation in the
health care delivery system is directed most often at
either controlling costs or ensuring quality. In
essence, the number of regulations in the health care
field have been an outgrowth of the cost and quality
issues. While much of this regulation is reported to
have had little or no effect on health care costs,
there is some evidence to suggest that they may have
prevented some hospitals from acquiring certain equip-
ment or providing expensive services, thus controlling
"misuse amd increasing quality of care (Bice, 1980;
Sloan and Steinwald, 1980; Goldsmith, 1980).
Whether or not any given regulation is or is
not effective, it is generally agreed that regulatory
policies have significantly complicated the work of
health care managers. Goldsmith (1980) outlines four
types of regulations thought to have the most profound
effect on managers:


52
i \
i i
! I
1. Certificate of need. This law requires
health facilities of all types to obtain approval from
state health departments prior to proceeding with
building programs, and in some cases with purchasing
equipment. In addition, there are often target occu-
pancy rates which, if not met, would be cause for
facilities to be denied permission to renovate or even
replace equipment. These restrictions have created
incentives for managers to compete with other health
care facilities for patients, services, etc.
2. Health manpower policy. Based oh the be-
lief that there is now an over-supply of health profes-
sionals, the health professions Educational Associa-
tion Act of 1976 restricts entry of foreign-trained
physicians. The eventual reduction in the total num-
ber of new physicians will create problems for health
care managers in areas that even now have low ratios
of physicians to population.
3. Federal Trade Commission (FTC). Believing
that there may be a cost benefit to price competition
among physicians, the FTC has acted to lift the medi-
cal society ban on advertising for physicians. Evi-
dently this has also occurred for institutional
providers.
4. Cost containment. There are numerous new
regulatory approaches to cost containment, especially


53
for hospitals. This has caused health care managers
to focus on increasing or maintaining levels of use
and on expanding their market share. It is predicted
that the 1980s will see the use of the corporate
enterprise in health services, which is already having
a profound impact on the politics of medical care, its
institutions, and its managers (Starr, 1982).
Physicians as Managers
An increasing number of physicians are assum-
ing management positions within their organizations
(Schenke, 1980). This trend is occurring despite the
presumption that physicians view management as a less
prestigious kind of work and may not be enthusiastic
supporters of formal organizational methods (Thompson,
1979). In fact, tension between physicians and health
care managers, specifically hospital administrators,
is a frequently cited problem in the literature.
Therefore, a discussion of this issue will be pre-
sented. This is followed by a review of studies
focusing on physicians as managers in hospitals and
physician organizations.
Tension between Physicians and Managers
Tension between professionals or clinicians
and managers or administrators is not limited to the


54
health care field. Simon (1945) described tensions
between practitioner-oriented faculty and discipline-
oriented faculty in a university setting. Whether in
a business school, engineering school, or school of
education, Simon warned that efforts must be made to
lower barriers that impede communication between these
two factions. Without communication, he said, deleter-
ious developments occur, such as the members of each
discipline in the professional school demanding in-
creased autonomy so that they can pursue the goals
defined by their discipline without regard to the
"irrelevant professional school goals" (Simon, 1945,
p. 250).
Perrow (1972) asked why conflict always seems
to exist between groups such as faculty and adminis-
tration in colleges, doctors and nurses and adminis-
trators in hospitals, and social workers and psychia-
trists. He suggests that the answer lies in the
never-ending struggle for values dear to the partici-
pants (e.g., security, power, autonomy, and a host of
rewards):
Because organizations do not consist of people
sharing the same goals, since the members bring
with them all sorts of needs and interests, and
because control is far from complete, people will
struggle for these kinds of values. (Perrow,
1972, p. 154)
Before discussing the conflict between physi-
cians and health care managers further, it must be


55
emphasized that this seems to be a more prevalent
issue in hospitals than in physician organizations.
This may be explained by the small size of the group
vs. the larger, more bureaucratic hospital and the
need for physicians in a group to take quick correct-
ive action (Shorten and Kaluzny, 1983).
Simon (1945) and Perrow (1972) argued that the
issues of diverse goals and needs associated with
power and autonomy are at the root of tension or
conflict between groups. While there may be addi-
tional factors involved, the literature reviewed sup-
ports this view of conflict,as it pertains to physi-
cians and health care managers. Freidson, (1970);
Austin, (1974); Starr, (1982), and others have recog-
nized that physicians tend to identify more closely
with professional goals than with those of the organi-
zation. Their relative autonomy stems from their
control over clinical matters and allows them to pur-
sue goals defined by their professional training
(e.g., patient care) without regard for the major
problems of the health care system or their organiza-
tion (e.g., cost control).
Fry (1980) argued that a major obstacle of
innovative growth and development in the health
delivery system is the inability of physicians and
their professional and administrative counterparts to


56
agree on problem definitions and priorities for
change, and to coordinate with each other to implement
a collective strategy. The result of these difficul-
ties is conflict between physicians and managers.
An alternate view on the reasons for tension
between physicians and managers is the difference in
risk-taking behavior. Stone (1976) found hospital
administrators to be risk avoiders, especially with
regard to investment decisions. This is different
from physicians, who are risk takers. The ability of
physicians to take risks was attributed to their train-
ing and need to evaluate risks but not avoid them. In
the situation described by Stone, the risk-taking doc-
tors would recommend solutions that the risk-avoiding
administrators would be unwilling to implement, result-
ing in conflict.
Although the reasons may vary, tension between
physicians and health care managers occurs frequently.
At the same time, studies reviewed earlier in this
chapter show that increased physician participation in
organizational decision-making and policy decisions
results in a higher quality of care and a greater
ability to control costs. The question now becomes
how can tension or conflict be managed while organiza-
tion effectiveness is maximized?
One theme repeatedly stressed in the


57
literature is the need for integration of administra-
tive and clinical-decision making. This is viewed as
an attempt to merge the power possessed by the physi-
cians by virtue of his clinicl expertise with a legi-
timately defined organization role (Shorten, 1974).
Practically, this can result in arrangements such as
interdisciplinary management teams, physicians being
appointed to governing boards, and physicians assuming
a variety of full-time managerial positions (e.g.,
medical director, vice president of medical affairs,
etc.).
Physicians in Management Positions
The literature discussed thus far suggests that
the increasing involvement of physicians in the manage-
ment process is both inevitable and highly desirable.
However, there is a dearth of empirical research on the
physician in management. After describing what little
research is available, the literature that discusses
issues relevant to physician managers in general will
be reviewed.
Research on Physician Managers. Slater
(1980c) conducted a study that explored the roles of
physician managers. Using a task list previously
developed by Kuhl (1977) he surveyed the membership of
the American Academy of Medical Directors (AAMD).


58
Basic and expanded roles were identified. A basic
role was defined "by identifying those task items for
which 70 percent or more of the respondents claimed
involvement" (Slater, 1980c, p. 61). Slater identi-
fied eight basic role tasks, six of which related to
what was termed internal management, one to external
relations, and one to quality assurance.
Expanded role tasks were defined as, "those
tasks accounting for the differences among physician
managers" (Slater, 1980c, p. 65). These were analyzed
and grouped to identify common sets of tasks, such as
physician personnel administration, service delivery,
external organization and maintenance, external rela-
tions, interorganizational arrangements, environmental
surveillance, and quality assurance. According to
Slater, these expanded role tasks moved the physician
toward a managerial role in which physicians are invol-
ved in the planning, organizing, staffing, directing
and controlling, but not the budgeting activities re-
lated to the delivery of medical care in their organi-
zations.
In another study of physician-managers, Kurtz
(1980) used three different self-assessment feedback
instruments: (1) Firo B, (2) Styles of Leadership
Survey, and (3) Lifo to examine patterns of behavior
of physician managers who attended an AAMD-sponsored


59
physician-in-management seminar. Further, he assessed
the effects of these behavior patterns on the role of
organization-leader and physician-manager. His find-
ings revealed the following:
1. That these individuals were very selective
in the groups they joined and, in general, had low
inclusion needs. This, Kurtz reasoned, is fine for
solo practitioners but potentially difficult for physi
cians assuming managerial positions.
2. There was a high need to take control among
these individuals, which might also be inconsistent
with a managerial role.
3* This group of individuals had low affection
needs, typical of physicians socialized to suppress
emotional involvement.
Lloyd and Shalowitz (1980) surveyed large non-
government, not-for-profit hospitals in order to find
out what type of hospitals were most likely to have
physician managers with the title of "medical director
and what, in general, medical directors did in these
hospitals. They constructed a profile of hospitals
employing medical directors, and a profile of the indi
viduals serving in those capacities. Their survey
revealed that one third of the total number of
hospitals responding, (109/323), had medical direc-
tors, and these were in the larger hospitals (average


60
bed size of 498). These hospitals were also three
times as likely to be teaching hospitals. Most of the
demographic information on the medical directors was
consistent with Slater's findings.
Lloyd and Shalowitz described the functions
most often associated with the position of medical
director. Their survey revealed the numerous commit-
tee meetings attended by medical directors, as well as
the percentage of respondents engaged in other areas
such as medical staff, nursing service, medical educa-
tion, Joint Commission on the Accreditation of Hospi-
tals (JCAH), Professional Standards Review Organiza-
tion (PSRO), pharmacy, physician recruitment, labora-
tory, x-ray, research, marketing, risk management, and
program development.
Issues Relevant to Physician Managers. Physi-
cians have the potential for becoming managers. They
have intelligence, discipline, motivation to organize,
and altruism (Torrens, 1980). Based on their clinical
background, they are able to communicate well with
their peers. This, combined with their understanding
of the field, helps them articulate needs within their
organization and within the health care delivery ser-
vice (Slater, 1980b). They also have a demonstrated
ability in didactic learning and broad exposure to
analytic thinking (Hejna and Gutmann, 1983).


61
Despite these attributes, physicians do not
receive training or even exposure to management skills
4
while in medical school (Yanda, 1977; Herzlinger,
1978; Long, 1980; Phillips, 1981). Therefore, as
physicians have increasingly been assuming managerial
roles, the majority of the literature has been norma-
tive describing the management skills physicians need
to develop.
Kralewski (1980) emphasized the leadership role
of physician managers in the development of public poli-
cies affecting health services. Therefore, he argues,
a policy perspective and the accompanying policy analy-
sis skills are important for physician managers to
develop. Further, Kralewski argues that it is espec-
ially important for physician managers to learn to
subordinate their professional self-interests to public
needs and resources. The degree to which physician
managers are able to accomplish this will quite likely
determine the future nature of the health care delivery
system.
Rubin (1980c) proposed that the singular and
unique responsibility of physician managers is, "to
make a difference in the lives of the people who
report to you" (Rubin, 1980c, p. 45). Rubin argued
that since this is done through the conscious and
active exercise of power and influence, physician


62
managers must be aware of the style of power and
influence and the need for style flexibility, and must
develop a broad range of power and experience skills.
Delbecq (1980b) agreed with Rubin and maintains
that in order to make a difference in an organization,
the physician manager needs to be skilled at making
strategic decisions. He summarized strategic decisions
considered important for the physician manager to ac-
tuate. These include decisions regarding domain, deci-
sions regarding environmental challenge, decisions
regarding organizational strengths and weaknesses, and
decisions to test and implement innovations.
The need for physician managers to obtain
skills in the area of financial management is well
documented. Long (1980), discussing the need for im-
proved financial management in the health care indus-
try, suggested that the need is particularly acute
among the smaller physician dominated health and medi-
cal care organizations. Herzlinger (1978) and others
argued it is most acute in hospitals where physicians
skilled in aspects of financial management could help
make difficult choices (Stoelwirder, 1979; Berger,
1983)
According to Kurtz (1980b) one explicit need of
the physician manager is an awareness and understanding
of the psycho-sociology of organizations and the people


63
i
i
j!
!!
: f
i i
! i
! t
! i
! !
I j
who work in them. In other words, physician managers
need to be familiar with the field of organizational
behavior. Kurtz argued that the application of organi-
zational concepts may make the difference between suc-
cess or failure for the physician manager. Delberq
(1980a) in a more specific discussion, emphasized the
need for physicians to develop skills in dealing with
deviant behavior. He suggested the use of a protocol
where, in the absence of a personal relationship, the
potential for dysfunctional consequences are minimized.
Kaiser, stressing the importance of the inter-
face role, suggested the greatest problem faced by
physician managers is that of maintaining joint account-
ability, i.e., to management and the practicing physi-
cian (Kaiser, 1980). The issue of a dual role, that
of clinician and manager, is one that is well-addres-
sed in the literature. Slater (1980a), epitomized the
position that physician managers should continue to
practice. He stated that "the continued respect of
his colleagues depends on his continuing to be an
effective clinician" (Slater, 1980a, p. 75).
Royer, while acknowledging that physician
managers have many reasons for continuing to practice,
including credibility, discussed some problems faced
by those choosing to maintain a practice. These in-
clude maintaining continuity of patient care and


64
limited clinical exposure. Royer stressed that credi-
bility accrues from the quality of decisions made by
the manager. His position is that physicians in man-
agement positions do not have to maintain a medical
practice. Rubin (1980a), addressing the issue of dual
roles and role conflict, agreed with Royer that main-
taining a clinical practice may not be the best ap-
proach. His view was that trying to be in two camps
simultaneously (clinician and manager) results in
never being fully in either camp. Physician managers,
Rubin suggested, need to develop a new reference
group.
Physician Managers in Hospitals. The litera-
ture on physician managers in hospitals seems devoted
to elaborations on the need for physician managers.
There are also numerous references to tasks and roles
that should be performed. These are basically the
same as those previously discussed for physician man-
agers in general, but the references to specific organ
izational issues will be discussed.
Reasons behind the need for physician man-
agers, some of which have been covered previously,
include problems with the medical staff, problems
with patients, regulatory and judicial calls for moni-
toring physician performance, increased urgency for
professional coordination of contract and salaried


65
physicians, cost containment efforts, the need for
integrating clinical and managerial goals, developing
medical technology, and unrealistic time requirements
of voluntary positions (Harvey, 1970; Ashley, 1972;
Cohn, 1975; Fifer, 1979; Johnson, 1979; Rogatz, 1979;
and Blanton, 1980).
Mastrangelo (1980) reported on a case in which
a segment of the hospital administration decided that
the organization needed a medical director but could
not muster the necessary support. The recommendation
originated from the past-president of the medical
staff and was studied by an ad hoc committee of the
medical executive committee, which acted as the joint
conference committee (JCC). This committee assembled
the available literature and information regarding the
role and function of a hospital medical director.
On site visits to hospitals that had medical
directors were also conducted. In addition, medical
directors from other institutions were invited to talk
with the committee. Despite the recommendations of
the ad hoc committee that the hospital hire a medical
director, the JCC voted against creating this position
for two reasons, the hospital ad hoc committee did not
fully explain the reasons for supporting the position
of medical director, and the physicians objected to
the proposed job description on the grounds that the


66
medical director would have too much power.
There are other references to physicians feel-
ing threatened or resistant to physician managers.
Harvey (1970) suggested that many doctors and adminis-
trators feel a full time physician manager would pose a
threat to their clinical freedom. Blanton (1980) sug-
gested that in many hospitals, the case for the full-
time physician manager is being seriously considered,
despite the usual resistance of the medical staff.
Rogatz (1979) explained resistance to the establish-
ment of the position by the medical staff as forcing
recognition of the fact that the staff is not as
autonomous as it would like to be, and perceiving the
physician manager as a threat to the balance of power
among the governing board. 1
Finally, the question of where a physician man-
ager fits in the organizational hierarchy is addressed
The consensus seems to be that a line position is
5
best. Cohn (1975) argued that the medical director
should report in direct line to the hospital adminis-
trator but also should be assured direct input to the
board of trustees. Marcarelli (1976) quite clearly
stated, "In my opinion, a medical director must func-
tion in a line or managerial position capacity if he
is to properly discharge his responsibilities"
(Marcarelli, 1976, p. 5). While Snyder (1977)


67
presented the pros and cons of each arrangement, he
seemed predisposed to the line position. Fifer (1979)
suggested that the physician manager report to either
the CEO or board of trustees, but serve in a line
capacity.
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Physician Managers in Physician Organizations.
For purposes of this study, physician organizations
have been defined to include group practices, pre-paid
health plans, and individual practice associations.
Therefore, the literature on physician managers in
both types of organizations are reviewed together. In
addition, physician managers in Health Maintenance
Organizations (HMOs) and group practices most often
have the title of medical director, and in this sec-
tion the terms will be used interchangeably.
Studies of HMOs have focused primarily on
organizational performance, rather than on the physi-
cian manager. However, because medical directors have
historically been a part of HMOs, the literature does
occasionally address the role. For example, Phillips
and Dorsey (1980) studied some aspects of structure
and function in a survey of 40 prepaid group practice
HMOs, including issues related to the role and status
of the medical director and the relationship between
the medical and executive directors.


68
Analysis of the data seemed to indicate that
in "staff" model plans, medical directors are selected
by and report to health plan managers rather than
6
their professional peer group. In the "group" model
plans, medical directors more often are selected by
and report to members of the physician group. The
authors concluded that with regard to HMOs, medical
directors seem to have more delegated authority in the
group model than their staff model counterparts. A
more general conclusion was that there is a trend
toward more physician involvement in medical services
administration.
There are more similarities than differences
between the literature on physician managers in hospi-
tals and physician organizations, especially with re-
gard to the need for medical directors. This need is
again suggested to be a result of cost containment
efforts, the need for coordination between departments
and people, quality control, complicated staffing
requirements, and patient relations (Rodenbaugh, 1973;
Gray, 1975; Pollard, 1976; and Waterhouse, 1981).
This list is almost identical to that reported for
hospitals.
One difference between physician managers in
physician organizations and in hospitals is that medi-
cal directors of physician organizations are expected


69
to participate in personnel functions, such as physi-
cian recruitment and physician evaluation, more often
as part of their primary responsibilities (Pollard,
1976; and Waterhouse, 1981). Another difference be-
tween physician managers in the two groups is that in
the literature on physician organizations, there is
little attention paid to resistance or tension between
the medical director and other physicians or to issues
such as whether the position is line or staff.
Summary
This chapter reviewed literature relevant to
the study of physician managers. First, literature
suggesting that managerial principles can be applied
in a generic way was presented. Next there was a
discussion of various aspects of health care organiza-
tions that differentiate them from other types of
organizations. Studies of management in health care
settings were then described. These were primarily
role studies or studies dealing with specific problems
such as cost and quality.
The studies on the role of health care man-
agers concluded that this role closely conforms to
that of the traditional, generic manager. For ex-
ample, the activities performed reflected the primary
concern to be maintaining the ongoing operations of


70
the organization. Other studies of health care man-
agers focused on issues of cost and quality. It is
clear from this work that managers in health care
settings can improve the efficiency and effectiveness
of their organization in a variety of ways. The most
important ways are facilitating coordination, influ-
encing the composition and organization of the medical
staff, and ensuring physician participation in organi-
zational decision-making.
Finally, this chapter reviewed the literature
on physicians as managers. Included here was a de-
scription of the tension between physicians and man-
agers. Regardless of the specific reasons for the
tension, the need for integration of administrative
and clinical decision-making is well recognized. With
few exceptions, the literature dealing with physician
managers focused on documenting the need for physician
managers, the skills required by physician managers,
and the problems faced by physician managers. Little
is known about the work of physicians who hold manage-
ment positions


71
NOTES CHAPTER II
1. The phenomenon of multiple decision-makers
in hospitals remains an important theme in the litera-
ture. Two general models of physician/hospital rela-
tionships, the dual authority model and the shared
authority model are currently being examined in the
light of pressures towards cost containment and con-
cerns about quality. According to Shorten (1983).
the more traditional dual authority model suggests
that physicians determine the nature of hospital oper-
ations and the hospital administration (management)
provides the equipment, supplies, and facilities for
the physicians. The shared authority model has evol-
ved as a result of legal, economic, and social forces
and emphasizes shared decision-making on most organiza-
tional issues. Evidence regarding the association of
more shared decision-making between administrators and
physicians and increased integration of clinical and
administrative information suggests that this results
in both lower costs and higher quality of care
(Shorten, 1983).
2. Historically, physicians and their trade
organizations have opposed "contract practices," e.g.,
pay on a capitation basis rather than by visit, or
physician practicing within a corporate structure as
opposed to solo practice. However, the profession no
longer seems as opposed to either arrangement, and an
increasing number of physicians accept a variety of
contractual arrangements with prepaid hospital plans,
hospitals, and other corporations. Currently, about 26
percent of physicians have contractual relationships
with hospitals on salary (Starr, 1982). These physi-
cians are then employees of the organization, and their
presence has obvious implications for managers.
3. Effectiveness is the degree to which goals
and objectives are succesfully met. Efficiency refers
to the ratio of outputs to inputs: the number of
products and/or services provided by a given supply of
resources (Scott and Shorten, 1983. 420-42.1).
4. Of the 125 medical schools in 1981, three
offered formal practice management courses and 11
offered courses in cost containment (AAMC Curriculum
Directory, 1980-1981) .
5. A line position is managerial with dele-
gated authority to make certain organizational deci-
sions. A staff position is defined as advisory, not


72
usually requiring final decision-making activity
(Snyder, 1977; Cohn, 1975).
6. Definition of Staff and Group Model HMOs,
and IPA's.
Group Model
There are two kinds of group model HMOs:
a. The first type of group model is one in
which medical services are delivered in the
HMO-owned health center or satellite clinic
by physicians who belong to a specially
formed but legally separate medical group
that only serves the HMO. A Kaiser Perman-
ente Medical Group is the best example of
this model. The group is paid a negotiated
monthly capitation by the HMO (Kaiser Found-
ation Health Plan), and the physicians in
turn are salaried and generally prohibited
from carrying on any fee-for-service prac-
tice. For the purposes of the monograph,
this type of group model is called a PPD-
only group model HMO.
b. In the second type of group model, the
HMO contracts with an existing, independent
group of physicians to deliver medical care.
Usually, an existing multispecialty group
practice adds a prepaid component to its
fee-for-service mode, becomes an FFS/PPD
medical group, and affiliates with or forms
an HMO. Both fee-for-service and prepaid
medical services are delivered at the
group's clinic facilities. The group may
contract with more than one HMO. This type
of group model is referred to in the mono-
graph as FFS/PPD group model HMO.
The group is paid a monthly capitation by
the HMO(s), based on a negotiated rate for
each HMO enrollee. The group in turn will
distribute the capitation income to physi-
cians according to an established procedure.
Any one of a number of procedures can be
used for such distribution: regular fee-for
service equivalent for HMO patients actually
served; fee-for-service, less a discount;
equal shares of the HMO capitation revenue
to all physicians, regardless of how many
prepaid patients they individually served


73
during the month; or a combination of the
above methods.
A hybrid of this form of group model HMO is
one in which several independent group prac-
tices with a prepaid component "network"
together as the physician supply. HMO
Colorado, sponsored by Blue Cross, is an
example of a model. Five independent
FFS/PPD medical groups, located in different
parts of the Denver metropolitan area, are
affiliated with the HMO.
The two kinds of group models are also known
as prepaid or capitated group practice
models.
Staff Model
The staff model consists of a group of physi-
cians who are either;
a. salaried employees of a specially formed
professional group practice that is an in-
tegral part of the HMO plan (Genesee Valley
Group Health Association, Rochester, Mew
York, is an example of this model), or
b. salaried employees of the HMO. An ex-
ample of this model is Group Health Plan of
Puget Sound, Seattle, Washington.
Medical services in staff models are delivered
at HMO-owned health centers and only to HMO
plan enrollees. The physicians in either form
of staff model are usually limited in carrying
on any fee-for-service activities.
Individual Practice Association (IPA) Model
The IPA model HMO has a central administrative
core that contracts directly with individual
physicians who continue to practice in solo
settings in their own offices serving both FFS
and PPD patients. They usually are reimbursed
on a discounted fee-for-service basis, and
ancillary services are usually performed at
local hospitals. Some IPAs include a separ-
ate, specially formed corporation that repre-
sents the solo practitioners. A hybrid of the
IPA model is formed when one or more FFS/PPD


74
group practices are included with participa-
ting solo practitioners. The Comprecare HMO
in Denver which contracts with solo and group
physicians through the Columbine Medical Group
is a good illustration of this type of hybrid.
(Neal, 1983).


CHAPTER III
THE STUDY APPROACH AND METHODOLOGY
This chapter first reviews the purpose of this
study and the conceptual framework used to address the
study objectives. Next, a review of the methods used,
to study jobs is presented. This is followed by a
discussion of the specific method selected for use in
this study and a description of the dependent and
independent variables. Then, issues involving the
study sample and data collection techniques are ad-
dressed. The chapter closes with a description of the.
approaches used to analyze the data.
Study Purpose
As discussed earlier, the purpose of this study
is twofold:' first, to describe the job of physician
managers, and second, to identify organizational and
personal characteristics that might influence the
performance of this job. Two questions are addressed:
1. Does the job of the physician manager vary
among organizational types?
2. What are the organizational and/or personal


76
characteristics associated with the performance of
specific tasks by physician managers?
Conceptual Framework
The conceptual framework used for this study
was adapted from earlier work that identified and cat
gorized managerial functions. Burgess (1975) catego
ization dividing management functions into three area
Policy Management, Program Management, and Resource
Management was used to group tasks for analysis.
According to Burgess, policy management is a process
involving the strategic functions of guidance and
leadership. Specifically, it refers to the capacity
to perform the needs assessment, goal setting, and
evaluation functions; the ability to establish priori
ties and mobilize and allocate resources; and the
ability to guide relations with the community.
Program management encompasses administrative
functions and tactical requirements of executing poli
cy. Planning and overseeing programs and services,
identifying opportunities for improving efficiency,
and developing cost-effectiveness measures and other
evaluation criteria are examples of program manage-
ment. Finally, resource management refers to the
capacity to carry out and manage the administrative
and organizational support functions. These


77
activities constitute an organization's basic capabil-
ities and bottom-line assets. Like policy management,
resource management cross-cuts functional departments.
It includes personnel administration (e.g., recruit-
ment, labor relations, etc.), property management,
information management, and financial management.
Review of Job Analysis Techniques
Although the question of what people do in
their jobs can be studied in a variety of ways, there
are two phases common to all approaches. First, there
is a need to collect and record the information about
the job under study. Second, the data must be an-
alyzed in order to discover aspects of the job that
are important to the purpose of the analysis (Livy,
1975). The specific methods used to collect and an-
alyze this information vary according to the purpose
of the analysis and the preference of the analyst.
Time Studies
Various efforts at gathering information on
the general nature of work, specific jobs, worker
qualification, and the interaction between them date
back to the late 1800's. Frederick Taylor, the father
of the scientific management movement, is generally
acknowledged as the originator of work time studies in


78
1881 at the Midvale Steel Company (Larkin, 1969).
Taylor used an observer to determine the amount of
time a job took under various conditions, and then
used this information to establish time standards, or
the amount of time a job should take (Taylor, 1912).
Taylor believed that there was "one best way"
of accomplishing any given task. His mission was to
discover the fastest, most efficient, and least fa-
tiguing way to do a job which, he reasoned, would
result in an increased output for the organization.
Therefore, one of the basic tenets of Taylor's scien-
tific management movement was to scientifically inves-
tigate all aspects of the job. Based on this informa-
tion, fundamental rules, laws, and formulas governing
the best working raeithods could ;be developed. In addi-
tion, compensation for a fair day's work could be
established.
Motion Studies
At about the same time Taylor was developing
time studies, Frank B. and Lillian Gilbreth were work-
ing on motion studies. The Gilbreths, concerned with
eliminating wastefulness resulting from ill-directed
and inefficient motions, focused on the physiological
and psychological capabilities of the individual work-
er (Larkin, 1969). They took a "systems" approach
and examined the job within the context of the


79
work-place (Barnes, 1937). The Gilbreths investigated
several fields of work, including health care. They
filmed and then analyzed the activities of a team of
doctors in the operating room. This resulted in a
decision by the surgeons to decrease by fifteen per-
cent the amount of time patients were given anesthesia
(Smalley and Freeman, 1966).
Thus, motion and time studies represent the
marriage of Taylor and Gilbreths* works. Used since
the early 1900s, they still exist as an accepted
methodological approach to job analysis. Barnes of-
fers one of the most precise definitions of motion and
time studies:
Motion and time study is the systematic study of
work systems with the purpose of 1) Developing
a preferred system and method, i.e., at the low-
est cost, 2) Standardizing systems and methods
of work, 3) Determining the time required by
good individuals working at a normal pace to do
the task at hand, and U) Assisting in training
workers in appropriate methods. (Barnes, 1937,
p. 1)
Ratio Delay and Work Sampling
Through the 1920s and 1930s, motion and time
studies, considered part of scientific management,
represented the accepted method for studying work in
the United States. However, in England, L.H.C.
Trippett was using a new technique called ratio delay
to study the jobs of workers in the textile industry
(Barnes, 1937).


80
Ratio delay, and what is now called work sam-
pling, are similar in that they are both based on the
laws of probability, inferential statistics, random
and instantaneous observation, and the use of the
binomial distribution to establish sample size and
confidence levels (Torgersen, 1956). However, ratio
delay is traditionally used when the concern is with
the down time of machines, while work sampling focuses
on human activity. Although introduced into the
United States during the 1940s, neither technique was
widely accepted until the 1950s (Connor, 1961).
In contrast to the continuous observation re-
quired for motion/time studies, work sampling consists
of making observations of workers or machines at ran-
dom intervals, and noting whether the worker is active
or idle. The focus is on investigating the proportion
of total time devoted to the numerous activities that
comprise a job. Statistically, the number of times an
activity is observed to be performed has been found to
be closely correlated to the total length of time
spent on its performance (Barnes and Trinca, 1978).
Introduction of the work sampling technique represen-
ted a significant advance for job analysis because it
was found to provide accurate information at a lower
cost and with less time than continuous observation
required of motion/time studies (Torgersen, 1956;


81
: 3
3
Connor, 1961; Cercone, 1978).
Critical Incident
Another important contribution to job analyis
techniques occurred in 1949 with the introduction of
the critical incident method. Flannagan (1949) devel-
oped this approach because he was concerned that most
attempts to analyze jobs were too general to be useful
for either evaluation or training. He proposed that
observing incidents of extreme behavior, either good
or bad, and evaluating, classifying, and recording
these incidents, could result in establishing the
critical requirements for a job.
Critical incident studies have been used to
describe an important job-related event where deci-
sions have to be made promptly and correctly. They
usually examine interpersonal relations 'or judgment.
Recordings of critical incidents can be made by super-
visors, job incumbents, observers as the behavior
occurs, or by recall. Critical incidents records
typically include: (1) what led up to the incident;
(2) exactly what the employee did that was so effec-
tive or ineffective; (3) perceived consequences of the
behavior; and (4) whether the consequences were within
the control of the employee (McCormic, 1979).
The critical incident technique has come to be


Full Text

PAGE 1

MANAGING THE MEDICAL ENTERPRISE: A STUDY OF PHYSICIAN MANAGERS by Carol Lane Betson B.S., Adelphi University, 1964 M.A., Columbia University, 1970 M.S., The University of Colorado, 1979 A thesis submitted to the Faculty of the Graduate School of Public Affairs of the University of Colorado in partial fulfillment of the for the degree of Doctor of Public Administration, Graduate School of Public Affairs 1984

PAGE 2

i i i I This thesis for the Doctor of Public Administration degree by Carol.Lane Betson has been approved for the Graduate School of Public Affairs by Date 11,-J / '1 !? 7-'

PAGE 3

Betson, Carol Lane (D.P.A., Public Administration) Managing the Medical A Study of Physician Managers Thesis directed by Assistant Professor Eileen Tynan. The work that managers do has long been of interest to students of both the public and private sector. This study describes the jobs of physician managers in hospitals, medical group practices, and prepaid health plans. A task inventory consisting of 86 items was developed to analyze these jobs. Organ izational and personal characteristics are identified which influence the jobs (or responsibilities) that physicians managers have. The empirical portion of this study is based on.a self-administered survey mailed to the 893 members of the American Academy of Medical Directors (AAMD). The task inventory was developed in accordance with the form and language of job analysis techniques. The tasks are grouped according to management functions developed in a previous study: policy management, program management, and resource management. The survey also contains questions about organization affiliations, work arrangements, experience, and education. There was a response rate of 56 percent.

PAGE 4

iv Key findings indicate that physician managers are primarily responsible for policy management tasks. The majority of these tasks involve issues specific to physician relations. In addition, the tasks for which most physician managers are responsible deal with coordinating, managing conflict, and organization decision making. All of these processes are known to be associated with improvements in the effectiveness and efficiency of health care organizations. Another important finding is that organiza-tional characteristics are associated with task responsibility more often than the personal characteris-tics of physician managers. For example, a line as opposed to a staff position is significantly asso-ciated with responsibility for certain tasks more often than experience or education. However, of the personal characteristics, is associated with physician manager responsibility more often than education. One conclusion of this study is that physician managers are responsible for tasks that contribute to efficiency and effectiveness in health care organiza-tions. It is likely that increasing numbers of physi-cian will become part of management teams in these organizations. Therefore, it seems reasonable to

PAGE 5

v expect that health care institutions will strive to structure jobs that use the skills of physician managers to further the goals of the organization. The form and content of this abstract are approved. I recommend its publication. Signed Faculty Hember Charge of Thesis i.

PAGE 6

ACKNOWLEDGEMENTS There can be no full accounting of my debt to all those who contributed to this research effort. However, there are some individuals who must be recognized for their essential participation in either the development or improvement of the manuscript, their social/emotional support or a miraculous combination or both. Eileen Tynan, my thesis advisor, contributed significantly to this study and to my tual growth. Her commitment to excellence along with her pragmatic nature, guided me through this process and clearly made the difference between success and failure. Miriam Orleans, Michael Guthrie, Janelle Krueger and James Null, all superbly talented people, helped by providing important suggestions and criticisms throughout. The subject of the study is the job of physician managers, and it would not have been possible without the support of Roger Schenke, the executive director of the American Academy of !iedical Directors. I hope he will find this work a good return on his investment.

PAGE 7

. vii Phil Burgess deserves special acknowledgement for being from the beginning, as a source of inspiration and for his guidance throughout my years in the doctoral program. Leland Kaiser and Floyd Mann were also important in this regard. I am especially grateful to Kyle Davis. Much of the data processing would have taken weeks longer if he had not lent his expertise to this project. Sandy Schwarz and Mary Sue Burgess also assisted with the data analysis, but more importantly, nary Sue deserves credit for reading the manuscript in draft form and making the necessary editorial corrections. I am exceptionally fortunate to have a core group of close friends who tried to provide a balance in my life during this period of time. This was an extremely difficult task because I have evidently been obsessed with my work. Elizabeth Acinapura always reminded me that laughter was still possible, and Lily Appelman managed to keep me in touch with the real world. At one point I doubted that I would ever complete my work. Ann Carey and Virginia Lucero got me through that by cutting and alphabetizing 893 labels! A special thanks needs to go to my friend, teacher and role model, Tina Kurowski. Her unflagging support and encouragement at critical times kept

PAGE 8

I' i I viii me on track and convinced that this was a viable project. It is evidently a well-known fact that ram-ilies suffer during the dissertation process. Mine was no exception. Immense gratitude, which is diffi-cult to put into words, goes to Raymond Betson, with-out whom none of this would have been possible. Jennifer and Deborah, my two children, have endured my long hours of work, and demonstrated understanding beyond their years. I hope they are able to forgive me for the chunks of their lives that I have missed. Finally, it is clear that my mother, Lillian Katzman, was indispensable in helping me accomplish this piece of work. In addition to being a source of personal strength, her unending hours at the word processor translated my thoughts into a reality. She demonstrated incredible determination to ensure that the margins, tables, etc., meet the necessary require-. ments. This woman is an amazement to everyone, in-eluding herself.

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CONTENTS CHAPTER I INTRODUCTION. . . . . . . . 1 1 Purpose of the Study. . . . . . The Health Care Delivery System Historical The Current System. . . . 3 3 8 8 9 9 . People . . . . . Providers . ... . . Institutions and Organizations. . . 10 Financing Government . . 11 Problems Facing the Health Care System 11 Costs . . . . . . 14 Structure of Health Care Financing 14 High Provider Fees. 15 Physician Control . . . 15 Physician Training Advances in Medical Technology. Higher Demands and Expectations Labor Intensity of Health Industry. Increased Litigation. Quality . . . 15 16 16 17 17 18

PAGE 10

X Regulation. . . . 21 Summary . . . . . . 27 Notes . . . . . . . . 29 CHAPTER II RATIONALE FOR STUDY OF PHYSICIAN MANAGERS 30 The Nature of Managerial Work . . 30 Distinguishing Aspects of the Health Care System . . 34 .Management in Health Care Organizations 42 Role Studies of Health Care Managers 43 Studies of Cost and Quality . . 46 Regulation. . . . . 51 Physicians as Managers . . . . 53 Tension Between Physicians and Managers . . 53 Physicians in Management Positions. 57 Research on Physician Managers; 57 Issues Relevant to Physician Managers. . . 60 Physician Managers in Hospitals 64 Physician Managers in Physician Organizations 67 Summary . . . . 6 9 Notes . . . 71 CHAPTER III THE STUDY APPROACH AND METHODOLOGY. 75 Study Purpose . 75

PAGE 11

Xi Conceptual Framework . . 76 Review of Job Analysis Techniques . . 77 Time Studies . . . . . . 77 Hotion Studies. . . . . 78 Ratio Delay and Work Sampling . . 79 Critical Incident Functional Job Analysis . Task Inventories . . Summary . Method Selected for Studying the Job of Physician Managers Dependent Variables . . . Independent Variables . Organizational Characteristics Type of Organization. . . Size. . . . Title . . . . . Job Description, the People Preceding in the Position, and Full or Part Time Position. . . 81 . . 82 . . 84 . . 87 . . 88 . 89 . . 91 . . 91 . . 93 . . 94 95 96 Line or Staff Position. . . . 97 97 Personal Characteristics . Education . 97 Experience . . . . . 98 98 Data Collection . Choice of Population 98

PAGE 12

xii of Survey Instrument. . 100 Validity and Reliability. 103 Steps in Developing the Survey. . Mechanics of Administering the Survey Description of Survey . Data Analysis . . . Analysis of Physician Hanager Responsibility . . . Analysis of Frequency of Task Performance Notes . . . . . CHAPTER IV . . . FINDINGS. . . . . . . . Characteristics of Physician Manager . 109 1 1 1 1 1 1 115 118 119 121 123 Members of AAMD 123 Found Helpful 125 Work Arrangements . . . 127 Tasks . . . . . 135 Physician Managers in Hospitals and Physician Organizations 136 Physician Managers in Hospitals 138 Responsibilities Frequency of Occurrence Physician Managers in Physician Organizations Responsibilities. . . . . . . Frequency of Occurrence . . 1 4 1 143 149 151 156

PAGE 13

'' l: I xiii Comparison of Physician Managers in Hospitals and Physician Organizations Summary of Physician Manager Responsibilities and Frequency . . of Task Performance . Chi Square Analysis . . Policy Management Tasks . Task 05, Deciding Which Programs and Medical Services the Organization Offers Task 16, Deciding the Size of Programs and Medical . . . Services . . . . Task 133, Promoting the Organization ..... . . . Program Management Taiks . . . Task #40, Ensuring that a System for Review and Evaluation of Medical Staff Competency Operates Effectively . Task #60, Designing New or Modi fying Existing Risk Management Functions . . . Resource Management Tasks . . . Task 051, Monitoring and Reporting on Data from Systems Designed to Obtain Information About Medical Care Task #55, Designing Ways to Improve Efficiency of Professional Departments . . . . Task #68, Designing Contracts for Physicians 158 163 164 167 167 170 172 175 175 177 179 179 181 183

PAGE 14

Task 182, Advising Physicians on Career or Professional Issues . . Summary of Findings . . Notes . . . . . . CHAPTER V xiv . . . . . . CONCLUSIONS AND RECOMMENDATIONS FOR FURTHER STUDY . . Conclusions from Analysis of Physician Managers in Hospitals and Physician Organizations . . Conclusions from Chi Square Analysis Summary of Conclusions. . . Suggestions for Further Research Research on the Job of Physician . . . . Managers Research on Physician Managers and the Efficiency/Effectiveness of Organizations. . Notes . BIBLIOGRAPHY . . . . . . . APPENDICES. . . . A. The Survey Instrument . . B. The Survey Instrument: Descriptive Statistics . . . C. Lists of "Others" from Survey. . 186 188 194 197 197 206 212 213 214 215 219 220 236 237 250 271

PAGE 15

TABLE 1 1 3.1 TABLES National Health E:yenditures by Type cf Care, U.S., Fiscal Year 1982 Independent Variables . . . 3.2 Major Issues Addressed in each Section . 12 92 of Survey Instrument 112 4.1 Characteristics of Survey Respondents 123 4.2 Experiences Found Helpful in Preparation for Current Position 126 4.3 Organizational Affiliations of Survey Respondents 128 4.4 Job Titles Reported by Survey Respondents . 132 4.5 Summary Financial Profile of Survey Respondents 4.6 Tasks for which Survey Respondents Are 134 Most and Least Responsible 137 4.7 Characteristics of Survey Respondents in Hospitals 139 4.8 Tasks for which Physician Managers in Hospitals are Most and Least Responsible 142 4.9 Tasks for which More Than of Physicians are Responsible in Hospitals (Policy Management) 144 4.10 Tasks for which More Than 75% of Physicians are Responsible in Hospitals (Program Management) .. 145

PAGE 16

Tables (continued) 4.11 Tasks for which More than of Physicians are Responsible in Hospitals (Resource Management) . 4.12 Tasks Physician Managers Perform Most xvi 146 and Least Often in Hospitals. 148 4.13 Characteristics of Survey Respondents in Physician Organizations. 15 0 4.14 Tasks for which Physician Managers in Physician Organizations are Most and Least Responsible. 152 4.15 Tasks for which More Than of Physicians are Responsible in Physician Organizations (Policy Management) 153 4.16 Tasks for which More Than of Physicians are Responsible in Physician Organizations (Program Management) 154 4.17 Tasks for which More Than 75S of Physicians are Responsible in Physician Organizations (Resource 4.18 Tasks Physician Managers Perform Most and Least Often in Physician . 155 Organizations . . . . 157 4.19 Comparison of Ten Tasks for which the. Highest Percentage of Physicians Have Responsibility in Hospitals and Physician Organizations 159 4.20 Comparison of Ten Tasks which the Highest Percentage of Physicians Perform Often in Hospitals and Physician Organizations 162 4.21 Representative Tasks Selected for Chi Square Analysis 165

PAGE 17

xvii Tables (continued) 4.22 Independent Variables and with Significant Association 166 4.23 Extent of Association Between Inde-pendent Variables amd Physician for Task 15 168 4.24 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task f6 171 4.25 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 133 173 4.26 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 140 176 4.27 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 160 178 4.28 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 151 180 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 155 182 4.30 Extent of Association Between Independent Variables and Physician Responsibility for Task 868 184 4.31 Extent of Association Between Inde-pendent Variables and Physician Responsibility for Task 182 187 4.32 Association Between Physician Manager Responsibility for Tasks and Independent Variables 189 5.1 Tasks for which r-tost Physician aanagers are Responsible . 198

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5.2 Comparison of Physician Manager Tasks with Effectiveness and xviii Efficiency Actions 202 i

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xix FIGURES FIGURE 1.1 Health Care Industry Regulation 23 1.2 A Typology of Regulatory Instruments and Examples from the Health Services Industry 26

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. i I CHAPTER I INTRODUCTION Purpose of the Study A disturbing paradox exists in the health care delivery system. On the one hand, the practice of medicine with its technological advances is often described as being the best available in the world. On the other hand, it is riddled with controversy regarding escalating costs, inappropriate care, and poor management. Obviouly, is a distinction between the individual practice of medicine and the general delivery of medical care. One approach.to this dilemma is an effort to improve the management of health care organizations by increasing physician involvement. Physicians, skilled in the technologies of medicine, who in addition de-velop management skills, are in the unique position to integrate the two and help to improve the health care system. A physician manager has been defined as: any physician with full or part time managerial roles, i.e., medical directors, department chairs, chiefs of service, presidents of medical staffs, clinical directors, directors of medical affairs, etc. (Schenke, 1980, p. xiii)

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2 Although there is general agreement on a theo-retical level about the potential benefits of physi-cians in management, this group of professionals has 1 undergone little systematic study. This is unfortu-nate, as knowledge about physician managers could aid greatly in the formulation of a thoughtful approach toward the role.of physicians as managers in the health care system. It is to this end that this study was undertaken. In short, the purpose of this study is to describe the job of physicians who are in management positions, and where 6rganizational and personal that might influence the performance of their jobs. The study also provides a vehicle for looking at the skills physician managers need if they are to be more effective. Finally, the study highlights the need for additional research on physician managers, their jobs and their potential for a meaningful management role in the health care system. The study is undertaken with the recognition that a complex set of issues underlies any study of physician managers. One of them is the nature of the health care delivery system. This section, therefore, provides an overview or the environment in which phys-ician managers operate. Chapter II discusses some of

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I: I 3 the more specific issues relating to physician man-agers. The Health Care Delivery s1stem The health care delivery system in the United States is both large and complex. The prob-lems of the system, such as escalating costs, are well publicized. To better understand the problems in-volved, a brief historical review of the American health care system is presented. Then, the current system is described. Finally, two urgent problems that face health policy makers, and the public, (1) escalating costs, and (2) quality of care, will be discussed. Historical Developments While there are varied approaches to examining the historical evolution of the American health care system, Torrens (i980) presents a clear, concise frame-work. He divides this evolution into four periods: (1) institutionalization of health care, (2) introduc-tion of the scientific method into medicine, (3) a growing interest in the social and organized structure of health care, and (4) the current period of limited resources, restriction of growth, and reorganization of methods of financing and delivering care.

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i l I 4 Torrens suggests that the first period, institutionalization of health care, began around the middle of the 19th century and was symbolized by the establishment of large hospitals such as Bellevue Hospital in New York City and Massachusetts General Hospital in Boston. These hospitals provided "visible institutions around which health care services could be organized." (Torrens, 1980, p. 4). Before the establishment of these institutions, almshouses (poorhouses) existed to provide food and shelter for the homeless poor. They incidentally housed the chronically and ill as well as others too old or disabled to care for themselves (Dowling, 1980). Pesthouses were also common at this time and served as isolation or quarantine facilities-for people contaminated with diseases such as smallpox or typhus. Medical care was strictly a secondary function of these institutions. with the protection of the community as the primary goal. Most commonly. anyone able remained home and was cared for by family or friends (Garrison, 1929). Community and voluntary hospitals began to be established during the late 1700s and early 1800s (Dowling. 1980). These facilities were built because physicians and surgeons needed a place to practice their craft. and medical students needed a place for

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i: I' l t I I I, i I I I i I i I q I I I I I I I i l I : j I : ; i : j l I l I l I I l < I l i 1 l I : i i! 'j l I l ; l '! ; i I : i :I ; I I ; l : I ; 1 I : i : i ; I ; I : I i : I ; l : l : I ; i 'I I ' : i : l : : 1 ; 5 their preceptorships. These hospitals accepted both charity and paying patients as long as they did not have a contagious disease. Despite the improved accom-modations, most people who became ill continued to remain at home. It was not until the late 1800's or early 1900's that hospitals began to be accepted as a place to receive medical care, and this was a result of advances. Torrens suggests that the second important period in the historic development of the health care system was marked by the introduction of the scienti-fie method into medicine. Prior to this time, medi-cine was viewed as a rather informal collec-tion of unproved generalities and good intentions." (Torrens, 1980, p. 4). Although Torrens dates this period as occurring around the turn of the century, it probably began in 1860 with the critical discovery that a bacillus caused a disease called anthrax (Garrison, 1929). Subsequently, the notion that diseases were caused by specific became firmly estab-lished. Major discoveries by Pasteur, Koch, and others followed, resulting in cures for diseases that had previously plagued mankind. These discoveries, together with dramatic surgical successes made possi-ble by the developments of anesthesia and asepsis,

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I I I I :I I I !! : I : I ; I ; I :I ! ; I ; i 'I I : l ; I ; i :! j : i : : j :! i l ; 6 lead to a qualitative break with the past and the beginning of the scientific era of medicine (Freidson 1970; Starr, 1982). During this period the Johns Hopkins medical school, wtich opened in 1893. became an important in-fluence in defining medicine and medical care. This school is credited with making the most radical change from the old ways to the new scientific orientation (Torrens, 1984). John Hopkins was the first school to establish a four year program of medical study with the unprecedented requirement that all students have college degrees. In this institution be-lieved medical education should be rooted in the basic sciences and in hospital medicine. Therefore, scien-tific research and clinical instruction were hand in hand, and a hospital was built in connection with the school. This approach to medicine soon dominated medical education in the United States and abroad. Graduates of Hopkins became esteemed practitioners, professors at other schools, and scientists, and played a major role in shaping the character of medi-cine in the 20th century (Starr, 1982). The third historical phase in the development of the health care delivery system is characterized by Torrens as a period of growing interest in the social and organizational structure of health care.

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I I I i I I I I ; I i I I I i I ; I l : . ' I j I I 1 1 l l I I I I : I I I i i I 7 Beginning with World War II and continuing to the early 1980s, major scientific and clinical advances continued to occur. However, at the same time, there was a prevailing concern about financing health care and the government's role in the delivery of health care. These concerns resulted in the proliferation of health insurance plans, including government programs such as Medicare and Medicaid. It is important to emphasize that the tremen-dous growth of third party payors, e.g., private or government sponsored health insurance plans, that occurred during this third inexorably altered the way in which medical care was delivered. For example, individuals covered by health insurance no longer had to be concerned about the cost of care. This resulted in an increased demand for medical ser-vices. In addition, third party payors provided funds that made the tremendous expansion of health care facilities possible. The current period is said to have begun in the early 1980s. It is described by Torrens as: n an era of limited resources, restriction of growth, and reorganization of the methods of financing and delivering care" (Torrens, 1980, p. 4). These issues translate into several major problems now fac-ing the health care delivery system. including cost

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: I q i I : I 8 and quality. These will be discussed further in a later section of this chapter. The current system In order to describe America's health care delivery system, the major components of the system need to be identified. These are: (1) the people for whom the system provides care, (2} the providers of care, (3) the institutions and organizations within which they work, (4) the financing mechanisms, and (5) the government under which the system functions. People. In 1981 United States had a popu-lation of 226,504,825. Numerous ethnic and national groups are represented, and there is a wide range of social classes and incomes. The infant mortality rate in 1981, often used as a general measure of the health 2 of a population, was 43 per 1000 live births (Sta-tistical Abstract of the U.S., 1982-1983). In 1982, the major cause of death in the United States was heart disease, accounting for about one-third of all deaths in that year. Life expectancy in 1982, at 74.5 years, was at its highest point ever. Women (78.2 years) continued to live longer than men (70.8 years) (Department of Health and Human Services 1984).

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. i : l 1 9 Providers. The health care delivery system, as discussed later in this chapter, is one of the country's major employers. The largest categories consist of nurses, clerical staff, hospital manual workers, physicians, dentists, pharmacists, and tech-nicians. Physicians are the dominant group and are generally acknowledged as having the most power and control over the system (Berger, 1983). Institutions and Organizations. The principal mode of physician organization is still private, solo practice, although the proportion of physicians prac-tieing in groups and/or by hospitals is in-creasing steadily (Starr, 1982). Ambulatory care is the most frequently used type of care. Typically, it is provided in doctors' offices, ambulatory care cen-ters, or neighborhood health centers (Jonas, 1977). There are two major types of institutions that provide beds for inpatients. These are hospitals and nursing homes. Hospitals are the most numerous. In 1980, there were 7,051 hospitals in the United States with more than 1,365,000 beds (Statistical Abstract of the United States, 1982-1983). Hospitals are usu-ally categorized either by ownership, size, function, or average length of stay. The principal types of ownership and the number of hospitals represented in

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I : I : I :I : I :I I : l : j I : I I I 1 10 each category in 1980 are as follows: government (federal, state, or local) 2,562, private, not-for-profit (voluntary or community) 3,547, and private, for-profit (proprietary) 942 (U.S. Bureau of Census, 1982-1983). According to the American Hospital Association, hospital size is classified according to the number of beds, as follows: 6-24 beds; 25-49 beds; 50-99 beds; 100-199 beds; 200-299 beds; 300-399 beds; 400-499 beds; and over 500 beds (American Hospital Association, 1983). Hospital function is generally categorized as: general, psychiatric, and other special. There are only two length of stay categories: long (average length of stay 30 days or m_ore), or short (average length of stay less than 30 days) (U.S. Bureau of .Census, 1982-1983). Financing. Between 1970 and 1981, the percent-age of the Gross National Product (GNP) devoted to health and medical care increased from 7.6 percent to 9.8 percent (Statistical Abstract of the United States, 1982-1983). In 1982, it rose to over 10 per-cent, translating to a total of $322 billion, or $1,354 per person (Department of Health and Human Services, 1984). These amounts included monies spent for hospital care, physician and dentist services,

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j i I i I : i ; i : I : I I i .. i 1 1 pharmaceuticals, research, hospital construction and costs. Table 1.1 illustrates the distribution of expenditures by type of care. The largest single category of expenditure is for hospital care (42S), followed by physician services (19.2S). The remaining expenditures are distributed among dental services (6.0S), drugs (6.9S), nursing home care (8.5S), other personal health care (6.3S) and other health spending (11.1%). Government. The United States government does not operate the health-care delivery system. Actually, the government is less involved in health care than the governments of most other countries (Jonas, 1977). However, the role government does play is enormous and expanding rapidly. For example, the government collects and disseminates information; trains personnel; operates institutions; provides services, finances services; supports and carries out research; plans; evaluates; and regulates. Facing the Health Care System Almost all Americans are aware of at least some of the problems that plague the health care delivery system today. Unfortunately, neither the problems nor concern about them is new; they have just

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TABLE 1.1 NATIONAL HEALTH EXPENDITURES BY TYPE OF CARE UNITED STATES, FISCAL YEAR 1982 TYPE OF CARE Hospital care Physician services Dentist services Drugs and drug sundries Nursing home care Other personal health care Other health spending Total PERCENTAGE 42.0 19.2 6.0 6.9 8.5 6.3 11. 1 100.0 12 Source: R. M. Gibson, D.R. Waldo, and K.R. Levit. "National Health Expenditures." Health Care Financing Review. 4, no. 5, 1983 ..... -.. --

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13 gradually increased in magnitude. To illustrate, the following is a summary of a study on health care de-livery service released in 1932: The problem of providing satisfactory medi-cal service to all the people of the United States at costs which they can meet is a pressing one. At the present time, many persons do not receive service which is adequate either in quantity or quality, and the costs of service are inequitably distributed. The result is a tremendous amount of preventable physical pain and mental anguish, needless deaths, economic inefficiency and social waste. Furthermore, these conditions are, as the following pages will unnecessary. The United States has the economic resources, the organizing ability, and the technical expertise to solve this problem. (Committee on the Costs of Medical Care, 1932, p.2} This statement was made by a committee appointed in 1928 by President Hoover to investigate the problems of health care delivery. It is disturbingly relevant today. In actuality, the problems of the health care system are so interrelated that an attempt to deal with one without regard for the others would be fu-tile. However, for the purposes of this discussion, a review of two of the major problems facing the health care system, cost and quality, be These are selected because they are relevant to issues of physician managers. Subsequently, the issue of regulation is described. Regulation is recognized to be a response to cost, quality and other problems;

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i i I i i 1 4 however, it is also a problem in itself and is dis-cussed here because of the influence it has had on physicians in management. Costs Constantly rising expenditures have character-ized the health care system since 1929, when data were first collected (McCarthy, 1977). The most commonly cited reasons for these rising costs are as follows. Structure of health care financing. The cost-based third-party payment system of health care financing is a primary cause of high health care cost (Summers, 1981). The involvement of third party pay-ors (government private insurance), means little or no out-of-pocket costs to consumers. This system insulates consumers and to some extent providers from the true cost of treatment decisions. Further, reimbursement by third-party payors has up until now been on a fee-for-service basis. This means the more service provided, the more money collected. Medicare and Medicaid followed this model, making large amounts of money available for services. These programs were originally designed to address another problem of the health care system, that of c:ccess. It was intended that through this program the elderly and poor would be able to receive needed care.

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i i i I I ! !l r I I i I I . ; I I 1 1 I I I' ,, I II I I I I I I ! j i I 15 As a result of the payment system, there has been a sharp increase in requests for skyrocketing costs, and little or no incentive to weigh costs against benefits (Fuchs, 1974; Summers, 1981; Starr, 1982). High provider fees. The problem of high pro-vider fees is related to the structure of health care financing. Medicare/Medicaid and other insurance plans typically pay physicians according to their "customary" or "reasonable" fees. This has built-in bias toward high cost. In addition, reimbursement systems have paid most for hospital-based care, further encouraging physicians to provide care in a more cost-ly environment (Starr, 1982). Physician control. Physicians make the deci-sions that determine the type and amount of services provided. For example, physicians determine whether a patient needs to be admitted to a hospital, the length of stay once admitted, etc. However, research has shown that many physicians have not been aware of costs such as diagnostic procedures, tests, or the cost of a hospital room 1983; Berger, 1983; Weisbord and Stoelwirder, 1979). Physician training. Physicians are trained to practice medicine at the highest level of their

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: 1 6 technical ability without regard to costs (Friedson, 1970). In addition, there are no limits placed on the number or variety of medical specialists trained in this country. Specialists do more complicated proce-dures, use the hospital more often, and charge higher fees. Advances in medical technology. New proce-dures, equipment, and techniques flourished after World War II and continue to do so today. It has been said that the health care industry has been "captured" by 3 technological developments (Torrens, 1980, p.8). Although these technical advances have been credited with making a substantial improvement in the quality of medical care, they usually involve compiex and costly equipment, procedures, and/or facilities. Recent examples of these developments include computer-ized axialtomography (CAT) scanners, lasers, ultra-sonography, coronary artery bypass surgery, microsur-gery, artificial organs, intensive care units, neo-natal units, advanced pharmacies, etc. Higher demands and expectations. The in-crease in demand for services is associated with at least three factors: (1) belief that health care is now a "right", (2) the growth of health care insurance plans including Medicaid/Medicare, and (3) advances in

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17 technology (Fuchs, 1974; Summers, 1981; Starr, 1982). The increase in expectations means simply that consu-mers want the best medical services available. When confronted with situations involving personal or fam-ily illnesses, people want to disregard cost and get all the care they need and/or desire (Mechanic, 1978). Labor intensity of the health industry. There has been a dramatic growth in the number and type of personnel employed in the health care iadustry. It is now one of the largest employers in the country and, in 1980, employed over 7 million persons (United States Department of Health and Human Services, PHS., 198i). Recently new categories of health care person-nel have appeared. These include physicians' assis-tants, nurse practitioners, dental hygienists, special-ized laboratory and radiology technicians, home health aids, nutritionists, etc. These personnel, some of whom received many years of professional training, demand salaries commensurate with their level of skill. Increased litigation. As the number of malpractice suits brought against physicians has in-creased, so have malpractice insurance premiums. These higher rates add to the overall cost of medical

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18 care in at least two ways, First, physicians pass most of these costs on to patients; and second, in trying to avoid any possible suits physicians practice "defensive" medicine. This means that in order to document their diagnosis or a specific treatment, physicians order more tests or perform more procedures than they would otherwise. This documentation has proved to be a powerful weapon in defending against malpractice suits (Eisenberg, 1978; Summers, 1981). It has been said that the "crisis" in America's health care system is a crisis of money (Starr, 1982, p. 381). In other if costs (limited resources) were not an issue there would be no crisis. While the problems facing today's health care system involve more than just costs, it is clear that the nation probably cannot afford to pay for the quantity and quality of care desired. This brief and undoubtedly incomplete list of factors which contribute to health care costs is intended to provide some insight into the magnitude of the problem. Quality Concurrent with concern over escalating health care costs are concerns about the quality of health care. Although there is no universally accepted definition of "quality", it can be thought of simply as

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I I l I ; I 1 j I l I ; i I I I :I I :I ; I I :I I : i l I I : I ; l I i i : i ; I : ; i i l : I 'I : : I : i 19 "the degree of excellence or confirmation to stan-dards" (LoGerfo and Brook, 1980, p.403). Concern about quality of care is not new. As early as 1918 the American College of Surgeons stated that: the medical staff [should] review and analyze at regular intervals their clinical experience in the various departments of the hospital such as medicine, surgery, obstet rics, and other specialties. The medical records of patients, free and pay, to be the basis for such review and analysis. (American College of Surgeons, 1918, p.1) Assessments of the quality of care are under-taken for a variety of reasons. For example, there may be a substantive concern about existing problems in quality of care, or an assessment may be made to satisfy the requirements of a regulatory agency. The focus of quality studies is generally specific provi-ders, e.g., physicians; specific conditions, e.g., review of patients with acute myocardial infarctions; or care received by selected groups of patients, e.g., on a particular unit of a hospital (LoGerfo and Brook, 1980). The type of quality review originally sugges-ted by the American College of Surgeons became insti-tutionalized as the Morbidity and Mortality Conference (M & M's). This has occurred at most hospitals with training programs for over 50 years and continues today. In addition, the medical staff in most

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' ; 20 hospitals have made efforts to ensure quality through activities such as, credentialling, medical record review, tissue review, utilization review, etc. (Vanagunas, Egelston, Hopkins and Walczak, 1981). More recently a legal impetus for quality assurance and quality assurance programs has come from Title XIX of the Amended Social Security Act (Hedi-caid), which linked reimbursement to specific stan-dards of care. As a result, formal quality assurance programs have become part of several accrediting organ-izations, including the Joint Commission on Accredita-tion of Hospitals (JCAH). In 1976, JCAH added a qual-ity of professional service section, part of which states: There shall be evidence of a well-defined, organized program designed to enhance patient care through the ongoing objective assessment of important aspects of patient care and the correction of identified problems. (JCAH, i981. pp. 151-54) To ensure meeting accreditation requirements, hospitals have been required to have formalized assur-ance programs. These programs involve, among other activities, conducting medical audits. These in turn are to be conducted in accordance with an audit method-ology developed by JCAH for this purpose. Other qual-ity assurance activities often involve the traditional M&M conferences, credentialling, medical records,

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. ; I I I j i I I l I I I I I I I I i I i i i 1 1 ! 21 tissue review, and utilization review, but in addition are being directed at infection control, antibiotic usage, drug utilization, etc. (Vanugdunas, et. al., 1981). Quality assurance activities have been studied and criticized as having "little documented impact in terms of improving patient health or reducing care costs" (Williamson, 1978, p.631). Williamson (1978) attributes this to the lack of an appropriate decision process for selecting priority areas where target outcomes will most likely be achieved. Nonetheless, there are no signs that the-plethora of quality assur-ance programs and activities are decreasing, which may be due to demands of regulatory agencies. Nor does it appear that a more accurate selection process is being l employed. I I Regulation As previously mentioned, increased regulation in the health care. industry has been in response to other problems. However, regulation in and of itself has become an issue that affects the job of physician managers. In the broadest sense, regulation encompas-ses: the entire panoply of laws, and ethical precepts, public and private, which govern the conduct of the health

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; : I i i I i I , I I I I i I I I I i I i I i I i I i I l l! I I i i i i I j I I i ! i i ; i I I il I i i I l industry and health (Levin, 1980, p. 1) 22 Virtually every aspect of the health care industry is subject to some type of regulation. The training and education of health professionals, the construction of health facilities, the introduction of new medical treatment, and the financing and operation of health care institutions. All this results in the health care industry being called "the most heavily regulated industry in the United States." (Levin, 1980, p.1). Whatever the specific regulation, laws enacted in the area of health care have two things in common. First, they are intended to remedy or alleviate per-ceived social problems, e.g., the uneven quality of health care or containing escalating health care costs. Second, laws require detailed and often exten-sive administrative regulations in order to be imple-mented (Horgan, 1980). Figure 1.1, prepared by Wolper and Hopkins (1977), illustrates tbe major health care regulations on both federal and state levels from 1930 to 1977. Although this table is several years old, it dramati-cally depicts the changes in regulatory activity since 1965. In addition, it shows that the majority of federal regulations have revolved around controlling

PAGE 42

. ,,.,_ ... -.. --------.. IUO FIGURE 1. 1 IIEALrn CARE INDUSTRY REGULATION .J' .. rr ,y ,ttd'" J u f' ,f .. ,. 413 c;/1 I 1 !1 I j .. ., ... I I c; J' l I .. {' #'"' .. "'"' !1 .. !.I I ,..,. .. I :!1 (j *'I '* .tl .to I 3(t ., c; 1 # l .t" 4' if H t 1 1 1 1111 11 l J I I I I I 1 I I I I I '"' " 10 n n 74 .n ,. 77 Y I PUIIIC OIIClOSUU I (u11 .. vttw a PIOIPICUVI euoGIIINO / 1 C:irnAl lllf'INonuu coNrlols 1 Source: 'Lawrence F. Wolper, and Wallard "Prospering in a Regulated Environment." 58, no. 9 (1977). G. Uopkins. llosp!!!!! NAtiONAl HIAUH INSUIANCI N w

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24 rising health care costs by either planning, stimula-ting growth of alternative delivery systems (HMOs), or utilization review. On a state level, attempts have been made .at prospective budgeting and reimbursement systems and rate review since the late sixties. Wolper and Hopkins categorize health care regulations into four areas: 1. Planning. States are required to have state health plans, and institutional providers are required to consider the service demands of the commu-nity. 2. Development and distribution of services. Some regulations are intended to control demand by limiting supply. Such regulations focus on new and expensive services. 3. Utilization controls. Cloaked in the lan-guage of quality care, utilization controls focus primarily on controlling "misuse" (overuse) of patient care services. 4. Financial controls. Aimed directly at controlling health care expenditures made by pur-chasers such as the federal government, financial control regulations lean towards being punitive as well as incentive oriented. Bice (1984) categorizes the types of regulatory instruments in the health industry.

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25 Figure 1.2 shows.that these are either (1) subsidies, (2) entry controls, (3) rate or price settings, or (4) quality controls. Subsidies are considered the most traditional and widely used means of regulating the supply and demand for health services. Entry controls such as licensure and certification are used to ensure that persons offering goods or services are at least minimally qualified to do so. Rate or price setting is usually assumed by governments for a number of reasons, but most often in health services to protect the public from high costs of needed services. Quality controls include a of regulatory mechanisms aimed at reducing risks and generally apply to all designated suppliers. Despite the enormous number of regulations within which the health care industry currently func-tions, additional efforts to control cost are likely to result in even more. For example, because of huge deficits in the Medicare program, regulations that base government reimbursement on a Diagnosis Related Group (DRG) are becoming a The ORG is a culmination of a number of ef-forts which have as their ultimate goal a precise description of various kinds of health care products (Studnicki, 1983). Using this concept, Congress has I

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---------..... ---____ ________ _ .......... ----.. -------------. n i E ::J .. "3 2' a: ---------------------FIGURE 1.2 A TYPOLOGY OF REGULATORY INSTRUHENTS AND E X A 11 P L E S F R 0 11 T II E II E A L T H S E R V I C E S I N DUST R Y ObJects of Regulation Individuals lnslilullons Supply Supply Training grants Construction grants, loans, loan guarantees Subsidies Tax exemptions Demand Demand Medicare I Medicaid Tax exemptions to Tax ex.empllons em plovers Entry Personnel licensure Facilities licensure Restrictions Capital expendilures con!rols Rate Controls Feo schedules under Rate selling commissions I Medicaid the Economic Medicare and Medicaid I Stabilization Program relmbursemenlllmlls Quail IV Conlrols Professional Standards Cerllllcallon for Aovlew Organization Medicare and Medicaid So u r c e : 'f hom a s \L 0 1 c e II e a 1 t h S e r v 1 o e s P 1 an n J. n g and Regulation." In Introduction to llcalth Services. 2nd ed. Eds. Stephen --r:--wfiiT ams and-PaulR-.-Torrens. New York: John Wiley. & Sons, 1984, p. 390. f\) "'

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i I l ! I I j I I l I I l i I i i I i :I i i I I I I I I I il I t I : I : I j I i i : i i I l 27 approved a single fee system, with specific fees for 268 different groups of illnesses requiring hospital care. To date, this system includes only costs billed directly by the hospital to Medicare. The Department of Health and Human Services is studying how this system could be extended to cover bills from physi-cians for hospitalized Medicare patients. It is too early to document positive or negative results of reimbursement based on DRGs. However, concern over regulatory devices using DRGs seems focused on the potential "for providing financial incentives for distorting the legitimate practice of medical art and science" (Studnicki, 1983, p. 110). Summary This chapter highlighted some of the complex issues facing the health care delivery system today. A brief historical review and a description of the current system were presented, because the importance of environment to organizations, and therefore man-agers, is well recognized. The issues of cost, qual. ity, and regulation have been discussed, because clearly they have implications for health care man-agers. These will be described more fully in Chapter II. The dissertation is organized in five

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! I i i I I I I I i I I I I : i : I l l l l ; I I ; I :I :; '' : i i j ; I 'I ; i ; i I ii : t :! l i ; :I ; l ; ; i j i 'i : I ; I i i I I : ; : I :I i : i I 28 chapters. Chapter II presents the rationale for the study, and a review of the relevant literature on physician managers. Chapter III contains the meth-odology. Chapter IV presents the findings of the study, and Chapter V discusses the implications and a general summary.

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' I I I I I j I I d I : I i i i I i I I ; I I ' I ; i I i i I ; i ; i : ' I : i i i I ; d ; 29 NOTES CHAPTER I 1. The literature relevant to physicians' involvement in the management of health care organizations is reviewed in Chapter II. 2. Infant mortality and life expectancy are widely used indicators of general health status. Infant mortality, the rate of infant deaths per live births can be compared with that of other industrialized countries. For example, in 1978 the infant mortality in Sweden was 7.7 per thousand live births, compared with 43 per thousand live births in the United States in 1981. Further, in 1979 the life expectancy for men in Sweden was 72.5 and 78.7 for women (World Almanac, 1983). 3. This argument is similar to one made about public administration by Sayre (1948), when he observed that personnel specialists had become obsessed with techniques at the expense of purpose. Sayre urged fundamental examination of both ends and means in the system of personnel administration.

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: i : I I I I i I I j I i I I CHAPTER II RATIONALE FOR STUDY OF PHYSICIAN MANAGERS As mentipned previously, the primary purpose of this study is to describe the job of physician managers, and to identify personal or organizational characteristics that might influence the performance of this job. In order to better understand the work of physician managers, this chapter reviews some pre-vious studies of managerial work. Next, aspects of the health care delivery system that may substantially affect managerial work are discussed. the relevant literature on physician managers is pre-sented. The Nature of Managerial Work The work that managers do has long been of interest to students of both the private and public sector. Fayol (1949) and Gulich (1937) defined man-agement activity in terms of a number of functions for which managers were responsible. Fayol, credited with developing the first comprehensive theory of management, identified 14 different principles of management. These include: division of work, authority,

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; ; l 1 !I I i i I ! I i I i l l ; i i i I I l I I ; I : I : I I ; I : I I : I I 31 discipline, unity of command, centralization, and scalar chain (line of authority). Gulick, (1937) also viewed management in terms of functions for which managers were responsible. He proposed seven major management functions: planning, organizing, staffing, directing, coordinating, reporting and budgeting. Known collectively as POSDORB, this approach to man-agement has influenced management theory for forty years. Barnard (1938) emphasized what managers should be doing for the organization to survive. He argued that the most important functions should parallel the organization's needs. These include hav-ing a goal toward which members of the organ-ization could worK, members who are willing to con-tribute, and members who have basic communication skills. More recently, Mahoney, Jerdee, and Carroll (1965) obtained estimates from managers on the amount of time they spent on several management functions: planning, coordinating, evaluating, supervising, staffing, negotiating, and representing. Mintzberg (1973) distinguished eight schools of thought on the managerial job. These are: classical, great man, entrepreneurship, decision theory, leader

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. i I 32 effectiveness, leader power, leader behavior, and work activity. Mintzberg's own work belonged to the last category, which seeks to find out what managers actually do. Mintzberg (1975) sought to determine how man-agers spend their time and how they perform their jobs. From his research and the research of others who have studied managers with the same focus, Hintzberg concluded that managers fill ten roles. He grouped these roles into three major categories. These are: A. Interpersonal ro+es. 1. The figurehead role (performing cere-monial and social duties as the organization's repre-sentative). 2. The leader role. 3. The liaison role (particularly with outsiders). B. Informational roles. 4. The recipient role (receiving informa-tion about the operation of an enterprise). 5. The disseminator role (passing informa-tion to subordinates). 6. The spokesperson role (transmitting information outside the organization). C. Decision roles.

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l i I I I I I 33 7. The entrepreneurial role. 8. The disturbance-handler role. 9. The resource allocation role. 10. The negotiator role. Additionally, one of Mintzberg's major findings.is that rather than being systematic, reflective planners, managers simply respond to the pressures of their jobs. Me suggests that managerial work is characterized by brevity, variety and discontinuity." (Mintzberg, 1975, p. 50). Mintzberg's work has been criticized on sever-al counts, e.g., sample size, and failure to include non-managerial work performed by all managers (Koontz, O'Donnell, and Weihrich, T982). How-ever, McCall and Segrist (1980) tested framework using a questionnaire based on the roles. They asked managers to rate the importance of the role to their own supervisory performance. They concluded that the construct validity of six of the roles was supported. In addition, they stated: Managers' perceptions of relative role importance across levels and functions were sufficiently similar to support Mintzberg's contention that managerial jobs are essentially alike. (McCall and Segrist, 1980, p. 47) That management is generic is a widely held assumption (Drucker, 1973; Sheldon, 1975; Caplow, 1976). According to this viewpoint, organizations

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. ; 34 resemble each other to such a great extent that much of what is learned by managing one organization can be applied to managing any other organization. According to Sheldon (1975), despite minor differences of degree in organizations "there is not that much difference between a manager in the health field, whether he be a physician or not, and a manager in industry." (Sheldon, 1975, p.1). Drucker (1973) discussiflg es-sential management functions, suggests that management faces the same problems everywhere: it has to organize work for productivity and achievement. It is responsible for the social impact of enterprise. Above all, it is responsible for producing the results, --whether economic performance, student training or patient care --for the sake of which each institution exists. (Drucker, 1973, p. 17) While it is not the intent of this study to argue whether or not management is generic, it is rel-evant to examine the that addresses some char-acteristics of the health care delivery system which affect the work of health care managers Distinguishing Aspects of the Health Care System The health care delivery system is considered by many to be different from other systems. Austin (1974) identifies five characteristics that he sug-gests make the health care industry "unique". He emphasizes that other industries may share one or more

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! :I ; I 35 of these characteristics but in no other field do all of these factors converge as they do in health care: 1. Delivery of individualized services. Whe-ther in a large, complex setting 01 a small, intimate one, the health care industry delivers a service that must be individualized to a grerater extent than those of any other service industry. Personal health or medical care cannot be mass producerd, and even ser-vices delivered to groups must be tailored to the needs of the individuals. 2. Professionalism. The health care delivery is the most highy professionalized industry in our society" (Austin, 1974, p. 308). Members of numer\ ous different professions work both as providers of I ; service and as directors of institutions, agencies, and programs. However, all those involved in direct patient care are responsive and responsible to the physician. 3. Extreme complexity. Complexity has been a generally accepted fact about the health care system because the system's three major components (users, providers, and mechanisms for bringing users and pro-viders together) interact in extremely complex ways. Factors contributing to this complexity include: the pluralistic nature of the mechanism involved; the interface of public service objectives; private

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i I I II I ! l i l i i I i i 1 I I I l l ; I ., I i i l i i l i I :I I I l I : l I I ; ll ; i i i ' I I : i ': ! : I j l i I I ; l i I l ; : l i ' ; 'I l I 'i ; : I i ' : . ; '! 36 interests and obligations within the industry; the financing structure, which depends largely on third party sources; and the complicated internal and exter-nal relationships, which must be developed and main-tained. 4. The wide range of delivery facilities. Service delivery settings range from large academic health centers providing comprehensive care, to small, single service units. Between these two extremes, a wide variety of organizations exists that are fre-quently fragmented and uncoordinated. Such variety requires a diversity.of administrative approaches unequaled in other specialty fields" (Austin, 1974, p. 310). 5. Financial reimbursement arrangements. The variety of.payment sources and the proportion of third party payors involvement upsets classical supply and demand market conditions and creates layers between provision of service and payment. Austin argues that all these factors result in a complexity of professional and administrative . relationships unrivaled by most _other industries" and therefore, the need for an exceptionally high degree of coordination between units of the system (Austin, 1974, p. 310) ihe differences between hospitals and other

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37 organizations in our society have been the subject of extensive study. Considerably less attention has been paid to physician organizations, (e.g., group prac-tices or pre-paid health plans) at least in a compara-tive sense. Burling, Lentz, and Wilson (1956), and Georgopolous and Mann (1962), were among the first to describe the structure and functions of a hospital. Burling's work, a case study approach to six community general hospitals, was conducted from 1949 to 1954 and served to "map" the territory. Burling's study was probably the first to recognize what has become a recurrent theme in the literature: that unlike most other organizations, l three separate bases exist within the hospital. 'I The Board of Trustees considers policy; the adminis: I il tration oversees the daily operations of the organiza: I I i! tion; and the physicians manage and control the clini-; i l ,; cal services. Burling observed that no one person or f! group has complete authority to dictate change. Each I of these forces has its own separate interests, and its behavior serves to protect these interests (Burling, Lentz and Wilson, 1956). Georgopolous and Mann (1962) in their study of twelve Michigan hospitals, examined the concept of three power bases or lines of authority within the 1 hospital in more detail. These authors identified the

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; i l l I I ! i i I i f i I I II II I, :I I I' ; I q I I I 1 38 physicians as the major power group and noted that they are socialized as professionals, assume a cosmopolitan role, are autonomous and independent, and may or may not be committed to the goals of the organ-ization. In addition, physicians may play several roles in the hospital, which results in role conflict (Georgopolous and Mann, 1962). These authors argued that because of the three power groups, coordination becomes a crucial manage-ment issue. and Mann concluded that: (1) good coordination is to the effective-ness of community general and (2) that an increase in the quality of nursing care and total patient care accompanies increased coordination. These observations have been confirmed. The professional model in which physicians are socialized places a high value on autonomy. This in turn results in managerial problems for hospitals (Hage, 1974; and Rubin and Beckhard, 1978). Perrow (1965), after ac-knowledging the unique position of physicians in the hospital, .suggested that role conflict occurs because, depending on the situation, doctors are staff, line managers, or guests in the organization. Freidson, (1970) and Nadler (1978) noted that while physicians were crucial to the survival and of the hospital, they may not be committed

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39 to organizational goals and objectives. This situation is in contrast to that existing in most other organizations, where role conflict is rarely tolerated. The primary power base is fully committed to the goals of the organization and interdependence between members is expected and acknowledged. Additional differences among hospitals and other types of organizations have been identified. The most important distinguishing factor of the hospital is the character of the product. Health or medical care is largely immeasurable and unquantifiable. This results in and ambiguous goals that make effective management difficult. The service is variable, diverse, and subject to little standardization. At the same. time, quality of the hospital product is considered more important than in an industrial setting (Georgopolous and Mann, 1962; Drucker, 1973; and Bennett, 1978). Other characteristics thought to contribute to the uniqueness of hospitals are as follows: Hospitals are considered vitally important to society and likely to remain so, while other organizations may or may not be considered important. Hospitals are extremely complex, highly differentiated, quasi-bureaucratic organizations while other organizations may be simple or complex. The hospital is dependent upon and

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I i I i I i il i I i I 40 responsive to thesurrounding community, and its work is more integrated with the needs and demands of its customers. The hospital has less control over its environment and services than other businesses (Georgopolous and Mann, 1962; Bennett, 1978). Medical centers are even more complex than hospitals. Weisbord (1978), who has worked with sev-eral academic medical care centers, with the American Association of Medical Colleges, and other medical care groups, collaborated with Lawrence and Lorsch to con-ceptualize a model analyzing how parts of a medical center fit together. Instead of being one organiza-tion, Weisbord said, an academic medical center is actually (1) a medical school and one or more teach-i n g h o s p r t a 1 s ( 2 ) 0 the r p r 0 _f e s s i 0 n a 1 s c h 0 0 1 s and ( 3 ) a university with different departments. This struc-ture requires professionals to play more than one role or "wear more than one hat" at a time, which leads to role conflict and organizational problems. Although individual differences among tals exist due to geographical location, local environ-ment, size, mission, and goals, one overriding simi-larity has been established: they all differ in sig-nificant ways from other complex organizations and social systems. The hospital is heavily dependent upon human energy and knowledge and sophisticated

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' ' j l I I I l I. i i i II i! I 41 technical facilities, as well as effective coordina-tion of both elements (Georgopolous, 1972; Rakich, Longert, and O'Donovan, 1977). More recently Shortell and Kaluzny (1983) summarized and listed nine ways that hospitals may be considered different from industrial organizations: 1. Defining and measuring output are difficult. 2. The work involved is more highly variable and complex than in other organizations. 3. More of the work is of an emergency and non-deferrable nature. 4. The work permits little for ambi-guity or error. 5. The work activities are highly interdepen-dent, requiring a high degree of coordination among diverse professional groups. 6. The work involves an extremely high degree of specialization. 7. Orgariizational participants are highly professionalized, and their primary loyalty belongs to the profession, rather than to the organization. 8. There exists little effective organization-al or managerial control over the group most respons-ible for generating work and expenditures: physicians. 9. In many health care organizations, particularly hospitals, there exists dual lines of

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42 authority, which creates problems of coordination and accountability and confusion of roles (Shortell and Kaluzny, 1983, pp. 13-14). While these authors acknowledged that the "uniqueness" of health care organizations can be over-stated, they seem to agree with those say "the field [of health services management] is different as a whole and not by its parts" (Brown, 1973). It is "the confluence of professional, technical and task attributes that make the management of health care organizatons particularly challenging" (Shortell and Kaluzny, 1983, p. 14). Management in Health Care Organizations It is clear that the health care is complex, and it is evident that a significant body of literature argues in favor of the health care industry being substantially different from other industries. From the studies on the work of managers, much is known about the general functions managers perform and the various roles managers fill. The question now becomes, how do all these factors affect the work of managers in health care settings? There appears to be a paucity of research addressing this question, either directly or in any breadth. However, there are fragmented strains of : : ;

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; i : ; I I I i I I i I I I i I I ) i : i i i ! i ; ) i I : i I I 'I l l l : i l i i ; ; ; i! '' : ; : 'I I I ' 43 research that address subsets of the question. A number of studies have been done on the role of health service managers. These provide information about how non-physician health care spend their time, the forms of communication they use, and what activities they undertake and consider important (Munson and Zuckerman, 1983). Other studies, conducted for the most part in hospitals, focus on the cost and quality problems of the health care field and stress implications for managers. Although related to cost and quality problems, regulation is often as a separate issue and cited as a reason for the increase in physi-cian managers. Therefore, a brief review of regulation is also presented. Role Studies of Health Care Managers The available literature on the role of health care managers has focused on the following dimensions: (1) time spent on various activities, (2) forms of communication, and (3) activities. Allison (1975) studied the role of 24 health administrators in four different types of organizations: hospitals, long-term care facilities, multi-specialty group practice clinics, and health maintenance organizations. He developed 46 items that described specific management functions and asked respondents to indicate level of

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44 involvement, time spent, and degree of importance of each. Kuhl (1977) used Allison's work to develop her questionnaire, which was mailed to a national sample of chief executives in hospitals and prepaid group practice health plans. The content of executive work was the dependent variable, measured in two ways. First, executives were asked to indicate in their own words four aspects of their work that were most important. Second, executives were asked to indicate the nature of their involvement in 114 distinct activities, the time devoted to activities which they were involved, and the importance attached to those activities. In order to analyze the data, Kuhl used con-tent analysis, which produced 23 groupings. These were then placed in four broad areas that represented components of the executive role. These areas were (1) internal management (all activities that relate to the general purpose of managing the internal opera-tions of the organization), (2) organizational develop-ment (activity oriented toward changing or developing the organization), (3) external relations (activities relevant to maintaining contact with people or organi-zations pertinent to the present or future operations), and (4) environmental surveillance (monitoring or surveying the environment for the

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45 purpose of interpreting how changes in the environment may affect the organization). Kuhl found that the majority of activities fell into the internal management area, which was in turn subdivided into design, personnel management, financial management, logistical management, service delivery, and legal work. She concluded that the role of these executives closely conformed to the traditional administrative model in that these executives are primarily concerned with maintaining the ongoing operations of the organization. Their major responsibilities assuring conformity with organizational objectives, allocating organizational resources, promoting efficiency, and providing for organizational growth. Munson and Zuckerman (1983) reviewed several other role studies of health care administrators and concluded that the general findings support the universalist model of the manager's role. In other words, most of the studies reviewed by these authors, including the two presented here, document that management activities such as planning, organizing, etc., and organization-building human relations activities comprise most of the work of health care managers.

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46 Studies of Cost and Quality As discussed earlier, Georgopolous and Mann (1962) concluded that because of the three power groups that simultaneously in hospitals, coordination was the pivotal element in ensuring both organizational effectiveness and quality of care. For example, management practices such as asking subordinates for their ideas about various work related problems were associated with increased coordination. In addition, Georgopolous and Mann found quality of care to be associated with situations where there was less tension between doctors and nurses and greater understanding of each other's roles. More than ten years later, Shortell, and Neuhauser (1976) examined 42 Massachusetts hospi tals and came to similar conclusions. In this study, quality of care was measured by the rate of post operative complications and the medical-surgical mortality rate (controlling for case mix and severity). These authors found that the number of regu larly scheduled meetings between radiology, laboratory and nursing service to facilitate coordination was associated with lower costs and higher quality of care. The extent to which physicians perceived they influenced decisions involving the purchase of hospital equipment was also associated with lower costs.

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'! 47 Most important was the conclusion that these and other managerial practices explained more of the variance in cost than differences in case mix or the quality of care provided. It is becoming increasingly evident that health managers can improve organizational performance through their influence on the composition of the medical staff and medical staff organization. Roemer and Friedman (1971) studied the relationship between hospital performance, physicians on contract, and medical staff organization. They found positive rela-tionships between a high of contractual physicians and several measures of hospital perform-2 ance. They also found a positive association between organizational performance and hospitals with a tightly structured medical staff. Sloan and Becker (1981) examined the relation-ship between and characteristics of the medical staff organization in 228 hospitals. They found sev-eral management factors to be associated with lower costs per admission: the percentage of hospital-based physicians on contract, incentive contracts for physi-cians who were not hospital based, and the presence of physicians on the executive committee of the governing board. In a study involving 15 short term general

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i i I I 48 hospitals, Flood and Scott (1978) examined the effect of several selected structural characteristics on medical outcome. Specifically, these characteristics included the distribution of power among professional role groups, and the power exercised by the surgical staff over its own members. They found the extent of control exercised by the surgical staff over individu-al surgeons to be associated with the quality of care. they also found that when the hospital admin-istrator had more power, it was the factor most strongly associated with quality of surgical care. (Flood and Scott, 1978) Shortell and LoGerfo (1981) examined the rela-tionship of hospitals, physicians, and medical staff characteristics to quality of care for two conditions, acute myocardial infarction (AMI) and appendicitis. For the conditions and hospitals studied, they found that structural characteristics of the hospital (e.g., bed size, degree of teaching involvement) and individ-ual physician characteristics (e.g., specialty compo-sition) were not strongly related to better perform-ance. Instead, medical staff characteristics such as degree of physician participation in hospital decision-making, frequency of committee meetings, concentration of activity in one hospital, and percentage of physi-cians on contract were strongly associated with

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: ', ; ; '' :I I I I I I I I I I I i I I I I I I i i 49 superior performance. The authors concluded that a key factor in improving the quality of hospital care may be activities aimed at changing medical staff organi-zation and ensuring its involvement with the overall hospital organization. In summary, it is clear from these tive studies that the problems of cost and quality (referred to as efficiency and effectiveness in several studies) can be significantly affected by management 3 practices. For example, all managers can influence the number of regularly scheduled meetings that facil-itate coordination, a key in insuring effect-iveness. Managers can also influence the composition and organization of the medical staff and provide physicians with a variety of to have input on organizational decisions. The complexity of the system and differences cited earlier certainly do not make it easy for health managers to have a positive influence irr their organi-zation. One of the most obvious difficulties and recurring themes is the lack of control managers have on physicians and their behavior 1974; (Friedson, 1975; Summers, 1982). Building on Mintzberg's conceptualization of management roles reviewed earlier in this chapter, Scott and Shortell suggested that health care managers are able to exert

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50 a positive influence on the efficiency and effective-ness of their organizations by working through three major roles. These are (1) the interpersonal role (direct attempts to influence others), (2) the infor-mation gathering role (monitoring of environment and organizational activities), and (3) the decision-making role (entrepreneurial activities determining allocation of resources). However, these authors also warned that "in executing these roles, health care managers, perhaps more than their counterparts in industry, are called upon to make use of their and referent power rather than their legitimate or coercive power" (Scott and Shortell, 1983, p. 443). Scott and Shortell sug-gested.a number of specific actions managers can take to affect their organizations. Some of these are as follows: 1. Emphasizing structural and process control, rather than outcome control. This translates into carefully selecting employees and professional staff members and developing good interpersonal relation-ships and making procedural suggestions to profes1 sional staff. I I .i 2. Creating substitutes for formal leadership : r f I "i by developing cohesive work groups, organizational i development, and training programs . 1

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! II I II I i i I I I I :I 'I :I 'I i 'I I I I I I I I ; I : i i' c, t :I I i i I :I : l I i i ; i I :! i : I : 51 3. Helping to enact reality for people by articulating shared concerns, attitudes, values, and capabilities of staff members and by directing the flow of information. Examples include deciding what issues to place on agendas and whom to appoint to various committees. Regulation It was noted earlier that regulation in the health care delivery system is directed most often at either controlling costs or ensuring quality. In essence, the number of regulations in the health care field have been an outgrowth cf the cost and quality issues. While much of this regulation is reported to have had little or no effect on health care costs, there is some evidence to suggest that they may have prevented some hospitals from acquiring certain equip-ment or providing expensive services, thus controlling "misuse" amd increasing quality of care (Bice, 1980; Sloanand Steinwald, 1980; Goldsmith, 1980). Whether or not any given regulation is or is not effective, it is generally agreed that regulatory policies have significantly complicated the work of health care managers. Goldsmith (1980) outlines four types of regulations thought to have the most profound effect on managers:

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. i : I i ; i j : I : i : I : i l : I :I :I I :I i i ; i I l I : i : l ; i I I : i i I 52 1. Certificate of need. This law requires health facilities of all types to obtain approval from state health departments prior to proceeding with building programs, and in cases with purchasing equipment. In addition, there are often target occu-pancy rates which, if not met, would be cause for facilities to be denied permission to renovate or even replace equipment. These restrictions have created incentives for managers to compete with other health care facilities for patients, services, etc. 2. Health manpower policy. Based on the be-lief that there is now an oyer-supply of health profes-sionals, the health profession's Educational Associa-tion Act of 1976 restricts entry of foreign-trained physicians. The eventual reduction in the total num-ber of new physicians will create problems for health care managers in areas that even now have low ratios of physicians to population 3. Federal Trade Commission (FTC). Believing that there may be a cost benefit to price competition among physicians, the FTC has acted to lift the medi-cal society ban on advertising for physicians. Evi-dently this has also occurred for institutional providers. 4. Cost containment. There are numerous new regulatory approaches to cost containment, especially

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I I I I I ! : I ; I ; : I i I I i i l I I : i : I < : ; I '! : : I 53 for hospitals. This has caused health care managers to focus on increasing or maintaining levels of use and on expanding their market share. It is predicted that the 1980s will see the use of the corporate enterprise in health services, which is already having a profound impact on the politics of medical care, its institutions, and its managers (Starr, 1982). Physicians as Managers An increasing number physicians are assum-ing management positions within their organizations (Schenke, 1980). This trend is occurring despite the presumption that physicians view management as a less prestigious kind of work and may not be enthusiastic of organizational (Thompson, 1979). In fact, tension between physicians and health care managers, specifically hospital administrators, is a frequently cited problem in the literature. Therefore, a discussion of this issue will be pre-sented. This is followed by a review of studies focusing on physicians as managers in hospitals and physician organizations. Tension between Physicians and Managers Tension between professionals or clinicians and managers or administrators is not limited to the

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: I !I I I I : l i I : I I 1 I !I : i : I I I ; ; : ! 54 health care field. Simon (1945) described tensions between practitioner-oriented faculty and discipline-oriented faculty in a university setting. Whether in a business school, engineering school, or school of education, Simon warned that efforts must be made to lower barriers that impede communication between these two factions. Without-communication, he said, deleter-ious developments occur, such as the members of each discipline in the professional school demanding in-creased autonomy so that they can pursue the goals defined by their discipline without regard to the "irrelevant professional school goals" 1.945, p. 250). Perrow (1972) asked why conflict always seems to exist between groups such as faculty and adminis-tration in colleges, doctors and nurses and adminis-trators in hospitals, and social workers and psychia-trists. He suggests that the answer lies in the never-ending struggle foi values dear to the partici-pants (e.g., security, power, autonomy, and a host of rewards): Because organizations do not consist of people sharing the same goals, since the members bring with them all sorts of needs and interests, and because control is far from complete, people will struggle for these kinds of values. (Perrow, 1972, p. 154) Before discussing the conflict between physi-cians and health care managers further, it must be

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55 I emphasized that this seems to be a more prevalent ! I issue in hospitals than in physician organizations. This may be explained by the small size of the group vs. the larger, more bureaucratic hospital and the need for physicians in a group to take quick correct-ive action (Shortell and Kaluzny, 1983). Simon (1945) and Perrow (1972) argued that the issues of diverse goals and needs associated with power and autonomy are at the root of. tension or conflict between groups. While there may be addi-tional factors involved, the literature reviewed sup-ports this view of conflict_as it pertains to physi-cians and health care managers. Freidson, (1970); Austin, (1974); Starr, (1982), and others have recog-nized that physicians tend to identify more closely with professional goals than with those of the organi-zation. Their relative autonomy stems from their control over clinical matters and allows them to pur-sue goals defined by their professional training (e.g., patient care) without regard for the major problems of the health care system or their organiza-tion (e.g., cost control). Fry (1980) argued that a major obstacle of innovative growth and development in the health delivery system is the inability of physicians and their professional and administrative counterparts to

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1! I I :I l :I j I I ; I :I i' :I ll I I I :I : j I ' 56 agree on problem definitions and priorities for change, and to coordinate with each other to implement a collective strategy. The result of these difficul-ties is conflict between physicians and managers. An alternate view on the reasons for tension between physicians and managers is the difference in risk-taking behavior. Stone found hospital administrators to be risk avoiders, especially with regard to investment decisions. This is different from physicians, who are risk takers. The ability of physicians to take risks was attributed to their train-ing and need to evaluate risks but not avoid them. In the situation described by Stone, the risk-taking doc-tors would recommend solutions that the risk-avoiding administrators would be unwilling to implement, result-ing in conflict. Although the reasons may vary, tension between physicians and health care managers occurs frequently. At the same time, studies reviewed earlier in this chapter show that increased physician participation in organizational decision-making and policy decisions results in a higher quality of care and a greater ability to control costs. The question now becomes how can tension or conflict be managed while organiza-tion effectiveness is maximized? One theme repeatedly stressed in the

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57 literature is the need for integration of administra-tive and clinical-decision making. This is viewed as an attempt to merge the power possessed by the physi-cians by virtue of his clinicl expertise with a legi-timately defined organization role (Shortell, 1974). Practically, this can result in arrangements such as interdisciplinary management teams, physicians being appointed to governing boards, and physicians assuming a variety of full-time managerial positions (e.g., medical director, vice president of medical affairs, etc.). Physicians in Management Positions The literature discussed thus far suggests that the increasing involvement of physicians in the manage-ment process is both inevitable and highly desirable. However, there is a dearth of empirical research on the physician in management. After describing what little research is available, the literature that discusses issues relevant to physician managers in general will be reviewed. Research on Physician Managers. Slater (1980c) conducted a study that explored the roles of physician managers. Using a task list previously developed by Kuhl (1977) he surveyed the membership of the American Academy of Medical Directors (AAMD)

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' 58 Basic and expanded roles were identified. A basic role was defined "by identifying those task items for which 70 percent or more of the respondents claimed involvement" (Slater, 1980c, p. 61). Slater identi-fied eight basic role tasks, six of which related to what was termed internal management, one to external relations, and one to quality assurance. Expanded role tasks were defined as, "those tasks accounting for the differences among physician managers" (Slater, 1980c, p. 65). These were analyzed and grouped to identify common sets of tasks, such as physician personnel service delivery, external organization and maintenance, external relations, interorganizational arrangements, environmental surveillance, and quality assurance. According to Slater, these expanded role tasks moved the physician toward a managerial role in which physicians are invol-ved in planning, organizing, staffing, directing and controlling, but not the budgeting activities re-lated to the delivery of medical care in their organi-zations. In another study of physician-managers, Kurtz (1980) used three different self-assessment feedback instruments: (1) Firo B, (2) Styles of Leadership I Survey, and (3) Lifo to examine patterns of behavior I i 1 of physician managers who attended an AAMD-sponsored i I l

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1 I il I I I ; I ; I 1 I ; I I : I : I i :! :I j : I :I I i I :I I I : i ; l I I ; I i I : I : I 'I I i : I : i I i i 59 physician-in-management seminar. Further, he assessed the effects of these behavior patterns on the role of organization-leader and physician-manager. His find-ings revealed the following: 1. That these individuals were very selective in the groups they joined and, in general, had low inclusion needs. This, Kurtz reasoned, is fine for solo practitioners but potentially difficult for physi-cians assuming managerial positions. 2. There was a high need to take control among these individuals, which might also be inconsistent with a managerial role. 3. This group of individuals had low affection needs, typical of physicians socialized to suppress emotional involvement. Lloyd and Shalowitz (1980) surveyed large non-government, not-for-profit hospitals in order to find out what type of hospitals were most likely to have physician managers with the title of "medical director" and what, in general, medical directors did in these hospitals. They constructed a profile of hospitals employing medical directors, and a profile of the indi-viduals serving in those capacities. Their survey revealed that one third of the total number of hospitals responding, (109/323), had medical direc-tors, and these were in the larger hospitals (average

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; : : I l I I I I I I I I I I I I I ; l :! : i I I I i I i :I ; I : I i : i 'I 'I i i ; : '' i I : i I; I l ; . 60 bed size of 498). These hospitals were also three times as likely to be teaching hospitals. Most of the demographic information on the medical directors was consistent with Slater's findings. Lloyd and Shalowitz described the functions most often associated with the position of medical director. Their survey revealed the numerous commit-tee meetings attended by medical directors. as well as the percentage of respondents engaged in other areas such as medical staff. nursing service. medical educa-tion. Joint Commission on the Accreditation of Hospi-tals (JCAH). Professional Review Organiza-tion (PSRO). pharmacy. physician recruitment. labora-tory. x-ray. research. marketing. risk management, and program development. Issues Relevant to Physician Managers. Physi-cians have the potential for becoming managers. They have intelligence. discipline, motivation to organize, and altruism (Torrens. 1980). Based on their clinical background, they are able to communicate well with their peers. This. combined with their understanding of the field, helps them articulate needs within their organization and within the health care delivery ser-vice (Slater, 1980b). They also have a demonstrated ability in didactic learning and broad exposure to analytic thinking (Hejna and Gutmann, 1983).

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61 Despite these attributes, physicians do not receive training or even exposure to management skills 4 while in medical school (Yanda, 1977; Herzlinger, 1978; Long, 1980; Phillips, 1981). Therefore, as physicians have increasingly been assuming managerial roles, the majority of the literature has been norma-tive describing the management skills physicians need to develop. Kralewski (1980) emphasized the leadership role of physician managers in the development of public poli-cies affecting health services. Therefore, he argues, a perspective and the accompanying policy analy-sis skills are important for physician managers to develop. Further, Kralewski argues that it is espec-ially important for physician managers to learn to subordinate their professional self-interests to public needs and resources. The degree to which physician managers are able to accomplish this will quite likely determine the future nature of the health care delivery system. Rubin proposed that the singular and unique responsibility of physician managers is, "to make a difference in the lives of the people who report to you" (Rubin, 1980c, p. 45). Rubin argued that since this is done through the conscious and active exercise of power and influence, physician

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62 managers must be aware of the style of power and influence and the need for style flexibility, and must develop a broad range of power and experience skills. Delbecq (1980b) agreed with Rubin and maintains that in order to make a difference in an organization, the physician manager needs to be skilled at making strategic decisions. He summarized strategic decisions considered important for the physician manager to ac-tuate. These include decisions regarding domain, deci-sions regarding environmental challenge, decisions regarding organizational strengths and weaknesses, and decisions to test and innovations. The need for physician managers to obtain skills in the area of financial management is well documented. Long (1980), discussing the for im-proved financial management in the health care indus-try, suggested that the need is particularly acute among the smaller physician dominated health and medi-cal care organizations. Herzlinger (1978) and others argued it is most acute in hospitals where physicians skilled in aspects of financial management could help make difficult choices (Stoelwirder, 1979; Berger, 1983). According to Kurtz (1980b) one explicit need of the physician manager is an awareness and understanding of the psycho-sociology of organizations and the people

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63 who work in them. In other words, physician managers need to be familiar with the field of organizational behavior. Kurtz argued that the application of organizational concepts may make the difference between success or failure for the physician manager. Delberq (1980a) in a more specific discussion, emphasized the need for physicians to develop skills in dealing with deviant behavior. He suggested the use of a protocol where, in the absence of a personal relationship, the potential for dysfunctional consequences are minimized. Kaiser, stressing the importance of the interface role, suggested the problem faced by physician managers is that of maintaining joint accountability, i.e., to management and the practicing physician (Kaiser, 1980). The issue of a dual role, that of clinician and manager, is one that is well-addressed in the literature. Slater (1980a), epitomized the position that physician managers should continue to practice. He stated that "the continued respect of his colleagues depends on his continuing to be an effective clinician" (Slater, 1980a, p. 75). Royer! while acknowledging that physician managers have many reasons for continuing to practice, including credibility, discussed some problems faced by those choosing to maintain a practice. These include maintaining continuity of patient care and

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; i : I i I l i l il l l I I i I i ! i :! i f i i I I i i I : I ; i : I c I d : I ; I :! ; . ; l j; ; i ; i : i ! i; i ; I 'J ; ; :I : \ l I I i i i :! : i 'I :I ; . I l . ; 64 limited clinical exposure. Royer stressed that credi-bility accrues from the quality of decisions made by the manager. His position is that physicians in man-agement positions do not have to maintain a medical practice. Rubin (1980a), addressing the issue of dual roles and role conflict, agreed with Royer that main-taining a clinical practice may not be the best ap-proach. His view was that trying to be in two camps simultaneously (clinician and manager) results in never being fully in either camp. Physician managers, Rubin suggested, need to develop a new reference group. Managers in Hospitals. The litera-ture on physician managers in hospitals seems devoted to elaborations on the need for physician managers. There are also numerous references to tasks and roles that should be performed. These are basically the same as those previously discussed for physician man-agers in general, but the references to specific organ-izational issues will be discussed. Reasons behind the need for physician managers, some of which have been covered previously, include problems with the medical staff, problems with patients, regulatory and judicial calls for moni-toring physician performance, increased urgency for professional coordination of contract and salaried

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i : 65 physicians, cost containment efforts, the need for integrating clinical and managerial goals, developing medical technology, and unrealistic time requirements of voluntary positions (Harvey, 1970; Ashley, 1972; Cohn, 1975; Fifer, 1979; Johnson, 1979; Rogatz, 1979; and Blanton, 1980). Mastrangelo (1980) reported on a case in which a segment of the hospital administration decided that the organization needed a medical director but could not muster the necessary support. The recommendation originated from the past-president of the medical staff and was studied by an_ad hoc committee of the medical executive committee, which acted as the joint conference committee (JCC). This committee assembled the available literature and information regarding the role and function of a hospital medical director. On site visits to hospitals that had medical directors were also conducted. In addition, medical directors from other institutions were invited to talk with the committee. Despite the recommendations of the ad hoc committee that the hospital hire a medical director, the JCC voted against creating this position for two reasons, the hospital ad hoc committee did not fully explain the reasons for supporting the position of medical director, and the physicians objected to the proposed job description on the grounds that the

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I i i I I I I j I I 1 I I : I i I I I I i i ! 1 j :! 66 medical director would have too much power. There are other references to physicians feel-ing threatened or resistant to physician managers. Harvey (1970) suggested that many doctors and adminis-trators feel a full time physician manager would pose a threat to their clinical freedom. Blanton (1980) sug-gested that in many hospitals, the case for the full-time physician manager is being seriously considered, despite the usual resistance of the medical starr. Rogatz (1979) explained resistance to the establish-ment of the position by the medical staff as forcing recognition of the fact that the staff is not as autonomous as it would like to be, and perceiving the physician manager as a threat to the balance of power among the i Finally, the question of where a physician man-ager fits in the organizational hierarchy is addressed The consensus seems to be that a line position is 5 best. Cohn (1975) argued that the medical director should report in direct line to the hospital adminis-trator but also should be assured direct input to the board of trustees. Marcarelli (1976) quite clearly stated, "In my opinion, a medical director must func-tion in a line or managerial position capacity if he is to properly discharge his responsibilities" (Marcarelli, 1976, p. 5). While Snyder (1977)

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' I I j :I i i j '. i i II : :! .. .. : i i i '' 67 presented the pros and cons of each arrangement, he seemed predisposed to the line position. Fifer (1979) suggested that the physician manager report to either the CEO or board of trustees, but serve in a line capacity. Physician Managers in Physician Organizations. For purposes of this study, physician organizations have been defined to include group practices, pre-paid health plans, and individual practice associations. Therefore, the literature on physician managers in both types of organizations are reviewed together. In addition, physician managers in Health Maintenance Organizations (HMOs) and group practices most often have the title of medical director, and in this sec-tion the terms will beused interchangeably. Studies of HMOs have focused primarily on organizational performance, rather than on the physi-cian manager. However, because directors have historically been a part of HMOs, the literature does occasionally address the role. For example, Phillips and Dorsey (1980) studied some aspects of structure and function in a survey of 40 prepaid group practice HMOs, including issues related to the role and status of the medical director and the relationship between the medical and executive directors

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68 Analysis of the data seemed to indicate that in "staff" model plans, medical directors are selected by and report to health plan managers rather than 6 their professional peer group. In the "group" model plans, medical directors more often are selected by and report to members of the physician group. The authors concluded that with regard to HMOs, medical directors seem to have more delegated authority in the group model than their staff model counterparts. A more general conclusion was that there is a trend toward more physician involvement in medical services administration. There are more similarities than differences between the literature on physician managers in hospi-tals and physician organizations, especially with re-gard to the need for medical directors. This need is again suggested to be a result of cost containment efforts, the need for coordination between departments and people, quality control, complicated staffing requirements, and patient relations (Rodenbaugh, 1973; Gray, 1975; Pollard, 1976; and Waterhouse, 1981). This list is almost identical to that reported for hospitals. One difference between physician managers in physician organizations and in hospitals is that medi-cal directors of physician organizations are expected

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; i I l I I I I I I 1 I I I I I I I I I i I I I I i I l i I I i I I i I I I i l i i I I i 69 to participate in personnel functions, such as physi-cian recruitment and physician evaluation, more often as part of their primary responsibilities (Pollard, 1976; and Waterhouse, 1981). Another difference be-tween physician managers in the two groups is that in the literature on physician organizations, there is little attention paid to resistance or tension between the medical director and other physicians or to issues such as whether the position is line or staff. Summary This chapter reviewed literature relevant to the study of physician managers. First, literature suggesting that managerial principles can be applied in a generic way was presented. Next there was a discussion of various aspects of health care organiza-tions that differentiate them from other types of organizations. Studies of management in health care settings were then described. These were primarily role studies or studies dealing with specific problems such as cost and quality. The studies on the role of health care man-agers concluded that this role closely conforms to that of the traditional, generic manager. For ex-ample, the activities performed reflected the primary concern to be maintaining the ongoing operations of

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I I I I I I i I I i I I i 'l '! l I I I :I :I 1 j i 'i j j I 'I : I :I :' I I I : i : i i i i 70 the organization. Other studies of health care man-agers focused on issues of cost and quality. It is clear from this work that managers in health care settings can improve the efficiency and effectiveness of their organization in a variety of ways. The most important ways are facilitating coordination, influ-encing the composition and organization of the medical staff, and ensuring physician participation in organi-zational decision-making. Finally, this chapter reviewed the literature on physicians as managers. Included here was a de-scription of the tension physicians and man-agers. Regardless of the specific reasons for the tension, the need for integration.of administrative and clinical decision-making is well recogniz'ed. With few exceptions, the literature dealing with physician managers focused on documenting the need for physician managers, the skills required by physician managers, and the problems faced by physician managers. Little is known about the work of physicians who hold manage-ment positions.

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, I I : I l j 1i i I i l I ' i I i d I 'I I I i I I I : I ; I i i I I i l ! : j I I 'I : I ; I I : I ; : : ; 71 NOTES CHAPTER II 1. The phenomenon of multiple decision-makers in hospitals remains an important theme in the literature. Two general models of physician/hospital relationships, the dual authority model and the shared authority model are currently being examined in the light of pressures towards cost containment and cop cerns about quality. According to Shortell (1983), the more traditional dual authority model suggests that physicians determine the nature of hospital operations and the hospital administration (management) provides the equipment, supplies, and facilities for the physicians. The shared authority model has evolved as a result of legal, economic, and social forces and emphasizes shared decision-making on most organizational issues. Evidence regarding the association of more shared decision-making between administrators and physicians and increased integration of clinical and administrative information suggests that this results in botb lower costs and higher quality of care (Shortell, 1983). 2. Historically, physicians and their trade organizations have opposed "contract practices," e.g., pay on a capitation basis rather than by visit, or physician practicing within a corporate structure as opposed to solo practice. However, the profession no longer seems as opposed to either arrangement, and an increasing number of physicians accept a variety of contractual arrangements with prepaid hospital plans, hospitals, and other corporations. Currently, about 26 percent of physicians have contractual relationships with hospitals on salary (Starr, 1982). These physi cians are then employees of the organization, and their presence has obvious implications for managers. 3. Effectiveness is the degree to which goals and objectives are succesfully met. Efficiency refers to the ratio of outputs to inputs: the number of products and/or services provided by a given supply of resources (Scott and Shortell, 1983, 420-421). 4. Of the 125 medical schools in 1981, three offered formal practice management courses and 11 offered courses in cost containment Curriculum Directory, 1980-1981) 5. A line position is managerial with delegated authority to make certain organizational decisions. A staff position is defined as advisory, not

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usually requiring final decision-making activity (Snyder, 1977; Cohn, 1975). 72 6. Definition of Staff and Group Model HMOs, and IPA's. Group Model There are two kinds of group model HMOs: a. The first type of group model is one in which medical services are delivered in the HMO-owned health center or satellite clinic by physicians who belong to a specially formed but legally separate medical group that only serves the HMO. A Kaiser Permanente Medical Group is the best example of this model. The group is paid a negotiated monthly capitation by the HMO (Kaiser Foundation Health Plan), and the physicians in turn are salaried and generally prohibited carrying on any fee-for-service prac tice. For the purposes of the monograph, this type of group mqdel is called a PPDonly group model HMO. b. In the second type of group model, the HMO contracts with an existing, independent group of physicians to deliver medical care. Usually, an existing multispecialty group practice adds a prepaid component to its fee-for-service mode, becomes an FFS/PPD medical group, and with or forms an HMO. Both fee-for-service and prepaid medical services are delivered at the group's clinic facilities. The group may contract with more than one HMO. This type of group model is referred to in the monograph as FFS/PPD group model HMO. The group is paid a monthly capitation by the HMO(s), based on a negotiated rate for each HMO enrollee. The group in turn will distribute the capitation income to physicians according to an established procedure. Any one of a number of procedures can be used for such distribution: regular fee-for service equivalent for HMO patients actually served; fee-for-service, less a discount; equal shares of the HMO capitation revenue to all physicians, regardless of how many prepaid patients they individually served

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i I I i I I I l I I I l l I I I I I I ' ; I ; : i i 1 ; : '' l : l :I ; i : : i : i i ; I :1 during the month; or a combination of the above methods. 73 A hybrid of this form of group model HMO is one in which several independent group practices with a prepaid component "network" together as the physician supply. HMO Colorado, sponsored by Blue Cross, is an example of a model. Five independent FFS/PPD medical groups, located in different parts of the Denver metropolitan area, are affiliated with the HMO. The two kinds of group models are also known as prepaid or capitated group practice models. Staff Model The starr model consists of a group of physicians who are either: a. salaried of a specially formed professional group practice that is an integral part of the HMO plan (Genesee Valley Group Health Association, Rochester, New York, is an example of this model), or b. salaried employees of the HMO. An example of this model is qroup Health Plan of Puget Sound, Seattle, Washington. Medical services in staff models are delivered at HMO-owned health centers only to HMO plan enrollees. The physicians in either form of staff model are usually limited in carrying on any fee-for-service activities. Individual Practice Association (IPA) Model The IPA model HMO has a central administrative core that contracts directly with individual physicians who continue to practice in solo settings in their own offices serving both FFS and PPD patients. They usually are reimbursed on a fee-for-service basis, and ancillary services are usually performed at local hospitals. Some IPAs include a separate, specially formed corporation that represents the solo practitioners. A hybrid of the IPA model is formed when one or more FFS/PPD

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group practices are included with participating solo The Comprecare HMO in Denver which contracts with solo and group physicians through the Columbine Medical Group is a good illustration of this type of hybrid. (Neal, 1983). 74

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CHAPTER III THE STUDY APPROACH AND METHODOLOGY This chapter first reviews the purpose of this study and the conceptual framework used to address the study objectives. Next, a review of the methods used to study jobs is presented. This is followed by a discussion of the specific method selected for use in this study and a description of the dependent and independent variables. Then, issues involving the study sample and data collection techniques addressed. The chapter closes with a description of the approaches used to analyze the data. Study Purpose As discussed earlier, the purpose of this study is twofold: first, to describe the job of physician managers, and second, to identify organizational and personal characteristics that might influence the performance of this job. Two questions are addressed: 1. Does the job of the physician manager vary among organizational types? 2. What are the organizational and/or personal

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I I I I I I I I ll i I I l I I ; i I i i '' f '' i i : I 'l : i : I ; l I : i 'I I j I 76 characteristics associated with the performance of specific tasks by physician managers? Conceptual Framework The conceptual framework used for this study was adapted from earlier work that identified and cate-gorized managerial functions. Burgess' (1975) categor-ization dividing management functions into three areas: Policy Management, Program Management, and Resource Management was used to group tasks for analysis. According to Burgess, policy management is a process involving the strategic functions of guidance and leadership. Specifically, it refers to the capacity to perform the needs assessment, goal setting, and evaluation functions; the ability to establish priori-ties and mobilize and allocate resources; and the ability to guide relations with the community. Program management encompasses administrative functions and tactical requirements of executing poli-cy. Planning and overseeing programs and services, identifying opportunities for improving efficiency, and developing cost-effectiveness measures and other evaluation criteria are examples of program manage-ment. Finally, resource management refers to the capacity to carry out and manage the administrative and organizational support functions. These

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i i lj II ! 1 I I i I I l I I '. i i I '. :I j i i I :I I i I I ll i I I I I ; i I :' i ll l! : I I ll \ I I I I I ; I :I : l :I : j l! : i I :! i :! 77 activities constitute an organization's basic capabil-ities and bottom-line assets. Like policy management, resource management cross-cuts functional departments. It includes personnel administration (e.g., recruit-ment, labor relations, etc.), property management, information management, and financial management. Review of Job Analysis Techniques Although the question of what people do in their jobs can be studied in a variety of ways, there are two phases common to all approaches. First, there is a need to collect and record the information about the job under study. Second, the data must be analyzed in order to discover aspects of the job that are important to the purpose of the analysis (Livy, 1975). The specific methods used to collect and an-alyze this information vary according to the purpose of the analysis and the preference of the analyst. Time Studies Various efforts at gathering information on the general nature of work, specific jobs, worker qualification, and the interaction between them date back to the late 1800's. Frederick Taylor, the father of the scientific management movement, is generally acknowledged as the originator of work time studies in

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t i l I I I I : I I I I i I I i i I i I i I l i I I I I : I j I i I I 'I '! II ll i I ' : I ; i ' 1 j i : ; i :I 78 1881 at the Midvale Steel Company (Larkin, 1969). Taylor used an observer to determine the amount of time a job took under various conditions, and then used this information to establish time standards, or the amount of time a job should take (Taylor, 1912). Taylor believed that there was "one best way" of accomplishing any given task. His mission was to discover the fastest, most efficient, and least fa-tiguing way to do a job which, he reasoned, would result in an increased output for the organization. Therefore, one of the basic tenets of Taylor's scien-tific management movement was to scientifically inves-tigate all aspects of the job. Based on this informa-tion, fundamental rules, laws, and formulas governing the best working could developed. In addi-tion, compensation for a fair day's work could be established. Motion Studies At about the same time Taylor was developing time studies, Frank B. and Lillian Gilbreth were work-ing on motion studies. The Gilbreths, concerned with eliminating wastefulness resulting from ill-directed and inefficient motions, focused on the physiological and psychological capabilities of the individual work-er (Larkin, 1969). They took a "systems" approach and examined the job within the context of the

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l i J I ; i : : l ; I I il l I ; I i i I I I ; I ! : j i i i I ; I 1 i : :! 1 i 79 work-place (Barnes, 1937). The Gilbreths investigated several fields of work, including health care. They filmed and then analyzed the activities of a team of doctors in the operating room. This resulted in a decision by the surgeons to decrease by fifteen per-cent the amount of time patients were given anesthesia (Smalley and Freeman, 1966). Thus, motion and time studies represent the marriage of Taylor and Gilbreths' works. Used since the early 1900s, they still exist as an accepted methodological approach to job analysis. Barnes of-fers one of the most definitions of motion and time studies: Motion and time study is the systematic study of work systems with the purpose of 1) Developing a preferred system and method, i.e., at the lowest cost, 2) Standardizing systems and methods of work, 3) Determining the time required by good individuals working at a normal pace to do the task at hand, and 4) Assisting in training workers in appropriate methods. (Barnes, 1937, p. 1) Ratio Delay and Work Sampling Through the 1920s and 1930s, motion and time studies, considered part of scientific management, represented the accepted method for studying work in the United States. However, in England, L.H.C Trippett was using a new technique called ratio delay to study the jobs of workers in the textile industry (Barnes, 1937).

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80 Ratio delay, and what is now called work sam-pling, are similar in that they are both based on the laws of probability, inferential statistics, random and instantaneous observation, and the use of the binomial distribution to establish sample size and confidence levels (Torgersen, 1956). However, ratio delay is traditionally used when the concern is with the down time of machines, while work sampling focuses on human activity. Although introduced into the United States during the 1940s, neither technique was widely accepted until the 1950s (Connor, 1961). In contrast to the continuous observation re-quired for motion/time studies, work sampling consists of making observations of workers or machines at random intervals, and noting whether the worker is active or idle. The focus is on investigating the proportion of total time devoted to the numerous activities that comprise a job. Statistically, the number of times an activity is observed to be performed has been found to be closely correlated to the total length of time spent on its performance (Barnes and Trinca, 1978). Introduction of the work sampling technique represen-ted a significant advance for job analysis because it was found to provide accurate information at a lower cost and with less time than continuous observation required of motion/time studies (Torgersen, 1956;

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81 Connor, 1961; Cercone, 1978). Critical Incident Another important contribution to job analyis techniques occurred in 1949 with the introduction of the critical incident method. Flannagan (1949) devel-oped this approach because he was concerned that most attempts to analyze jobs were too general to be useful for either evaluation or training. He proposed that observing incidents of extreme behavior, either good or bad, and evaluating, classifying, and recording these incidents, could result in establishing the critical requirements for a job. Critical incident studies have been used to describe an important job-related event where deci-sions have to be made promptly and correctly. They usually examine interpersonal relations or judgment. Recordings of critical incidents can be made by super-visors, job incumbents, observers as the behavior occurs, or by recall. Critical incidents records typically include: (1) what led up to the incident; (2) exactly what the employee did that was so effec-tive or ineffective; (3) perceived consequences of the behavior; and (4) whether the consequences were within the control of the employee (McCormic, 1979). The critical incident technique has come to be

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; I I i I 82 used increasingly for performance appraisal. However, aggregated data on incidents about a given job from multiple incumbents can still be a useful job analysis technique. Functional Job Analysis Functional job analysis (FJA) represents yet another important method for obtaining information about jobs. The fundamental concepts of FJA were developed during the early 1950s, when the United States Employment Service was producing the 1965 edi-tion of the Dictionary of Occupational Titles and a new job classification system (McCormic, 1979). AlFine (1971), who was involved in the develop-ment of originally proposed its use as an ap-proach to manpower planning, this technique has been used extensively for job analysis (Fine and Wiley, 1971). FJA has been characterized by Fine and Wiley as both a conceptual system for defining the dimensions of worker activity and a useful way of measuring this activity. Some of the primary premises of the rJA system are paraphrased as follows: 1. A fundamental distinction must be made between what gets done and what workers do to get things done.

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I I I I I I I i I j : I I : I I I I i I I I 83 2. All jobs involve the worker to some extent with either data, people, or things. 3. Workers function in unique ways in any one of these three areas. For example, when a worker's task is involved with equipment (things), certain physical resources are required. When the task in-volves the use of ideas (data), mental resources are required. When the task involves customers and co-workers (people), interpersonal resources are re-quired. 4._ Although there may be an infinite number of ways of describing the performed, there are only a few patterns of behavior (functions) which describe how workers use themselves in relation to information, people, and things. Those functions have been defined by Fine in worker-function These make up the primary tools of FJA, providing a standardized, con-trolled language to describe worker activity over a range of varying conditions and difficulty. For exam-ple, in relation to information, a worker functions to compare, compile, compute, or analyze. 5. The functions appropriate to each area (in-formation, people, and things) are hierarchical and ordinal, moving from simple to complex. In summary, Fine argued that in order to design jobs, a base of accurate and comparable information

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I I I I I I I I I ! I l l i l I l i I i l I i 84 describing the job is essential. In order to develop this information, he proposes the use of two fundamen-tal techniques: 1. Defining the fundamental unit of work and jobs using task statements written according to a specific form and structure in order to express what workers do and what is accomplished. 2. Describing worker functions using hier-archies (simple to complex) related to data, people, and things (Fine and Wiley, 1971). Task Inventories Task inventories been used over a period of many years, but the United States Air Force is credited with developing and refining this method specifically for use as a job analysis approach. The armed services have a long history of being interested in job analysis. Their stated objective has been to clearly identify tasks performed for various jobs in order to plan adequate training (Ammerman, 1965). Prior to the 1960s, a variety of methods for examining jobs had been tried. However, most had significant limitations, such as reliance on an expert job an-alyst, high cost, incompleteness, non-quantifiability of data, and small sample size. The Air Force viewed task inventories as

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f II 1 j l I i I ; l i I I i I I I i i I I j l I I !I I j i i I i I li I I I I I I .I I I i I i I I I i I i I l I l i :I i 85 promising because they could be administered to a large number of people, were relatively inexpensive, and were quantifiable. Research that included rigor-ous reliability and validity testing was sponsored. Subsequently, this approach to job analysis has been used extensively and enjoys widespread acceptance in the military as well as in many other organizations (Nelson, Jacobs, and Breer, 1975). Typically, a task inventory appears in the form of a questionnaire that job incumbents, supervisors, or analysts use to provide information about the incumbent's involvement with each task. Two features characterize a task inventory: (1) a list of tasks for the occupational field under study, and (2) some type response scale. Usually the scale elicits an indication of the respondent's involvement in the task, but may also request an opinion about the task (McCormic, 1979). The list of tasks that comprise the task inven-tory should include as many of the tasks performed by the incumbent as possible. Statements describing the tasks are usually grouped into broad categories but focus on what is done, not on how or why it is done. McCormic presents the following steps for construction and use of task inventories: 1. Define scope or breadth of the occupational

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l i i ; I I j : l I :I I I L I I I I I I i i I i : i I : I :1 i i : I : i : i . '. : i 86 area to be covered. 2. Locate written sources of activity state-ments. This usually means reviewing any available literature that may describe the occupat.onal area. 3. Develop preliminary inventory. There are two approaches to a preliminary inventory. One involves the analyst developing the preliminary inventory based on the source material. This can be done by developing the task statements and then cate-gorizing them into duty groupings or by beginning with a duty outline and then developing task statements within this The second approach is for the job analyst to ask a sample of job incumbents or experts to list the activities performed in the occu-pational area. The analyst then consolidates and edits the statements. 4. Review preliminary inventory. The prelim-inary inventory should be reviewed by several techni-cal advisors. 5. Prepare revised draft of inventory. This inventory should be redrafted by several technical advisors. 6. Select scales to be used. 7. Administer pilot test of inventory. 8. Print inventory 9. Administer inventory. Some task

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:' 87 I i I i I I II inventories are mailed and others are administered I lj within an organization. Sample selection must be I II II I I I II II I I I! 'j f 'I I i I i l i I II ll l i 1 ll I! ,, 'I : l l i! i I il I' I; :! : i i i l i; I I : l l! I l i l I! :! ; 'I I$ I! \ l I' 'I : i 'I '. j i : i carefully considered. Once task inventory data are obtained, any number of statistical analyses can be carried out, depending on purpose and projected uses. Summary Numerous methods are used to perform job an-alyses. However, a national survey conducted in 1968 by the Bureau of Business Research to determine the current uses, methods, and practices of job analysis showed continuous observations, questionnaires, inter-views, task inventories, and written narratives to be the methods most commonly used (Jones and DeCotris, 1969). survey, which consisted of 1805 mailed questionnaires. disti-nguished between job analyses done for workers paid hourly and those paid a salary. When designed for salaried workers the analysis tended to focus on functional relationships between the work-er and data, individuals, social skills, company poli-cies, and the relationship to other jobs in the organ-ization. When designed for workers paid by the hour, the analysis focused on the environment and physical working conditions.

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i I i I I I I I I :I II i I 'I 'I !. I! I I 'i It : i I i I! I' I ! I i : i i i I i ; i : ': ' i Method Selected for Studying the Job of Physician Managers 88 The method selected for this study was a self-administered, mailed questionnaire containing a task inventory. Tasks were presented in accordance with the form and language suggested by Fine use with the functional job analysis technique. Eighty-six tasks were included in this survey. Questions about personal and organizational characteristics were asked in order to explore factors that might influ-ence the tasks for which physician managers were re-sponsible and which they performed. This approach reflected considerations of economy and time while permitting the standardization necessary in research. However, this method.also has limitations. Continuous observation and work sampling have been shown to be more effective methods of job analysis than the mailed survey (Nelson, 1975). Nonetheless, with the population of interest, physician managers, spread across the nation, and with limited resources, a compromise in the methodology of choice was neces-sary. An additional limitation involves the recogni-tion that a list of tasks simply can not capture all the cognitive, judgmental, and unobservable processes which are components of the job (Goddard, 1953; Melia,

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' I ; ll I I I I I I i I' II l I, i! i I i! '' q 1. d I' I I l! I I i I. 1 I 'I i i I l : i -II !j i I I II ; u i I :I ! I' I' l I i! i l' i: I i II I: i i I! i i I I I I '! l l : i j, I i : I I l !l l 89 1979). In developing this instrument, an attempt was made to capture both job content and specific oper-ating conditions or constraints in the organization which result in differences in the physician manager's job. However, certain important variables may have been omitted. Unfortunately, this will most likely go unnoticed, and it is therefore assumed a priori that complete accuracy will not be achieved. Dependent Variables The primary dependent variables in this study are the eighty-six tasks comprising the task list section of the questionnaire. According to the United States Training and Employment Service, a task is defined as follows: It is a distinct activity that constitutes a logical and necessary step in the performance of work by the worker. A task is created whenever individual effort, physical or mental, is exerted to accomplish a specific purpose. (United States Training and Employment Service, p. 1) Fine stipulates a task be defined in terms of a controlled language, a controlled metho9 of formula-tion and in relation to a systems context (Fine, 1974). According to Fine, the definition of a task is as follows: A Task is an action or action sequence grouped through time designed to contribute a specified end result to the accomplishment of

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90 an objective and for which functional levels and orientation can be reliably assigned. The task action or action sequence may be primar ily physical, such as operating an electric typewriter, or primarily mental, such as analyzing data, and/or primarily interpersonal, such as consulting with another person (Fine, 1974, .P 4). The tasks for this study were composed to reflect Fine's concern about the proper way in which to articulate the work. Each task statement begins with the action the physician is expected to perform and includes the result expected of the action. For example, task nine is: writing new or modifying existing criteria for the responsibilities of physicians. "Writing" is the word in the task statement that describes the action or activity to be performed. "Criteria for the responsibility of physi-cians" is the phrase in the task statement that de-scribes the expected outcome or what gets done as a result of the action. The list of tasks was developed in the follow-ing manner: First, a review of the literature on physician managers provided some descriptions of what the job of physician managers should be (Phillips, 1979; Rogatz, 1979; Mastrangelo, 1980). These descrip-tions were subjected to content analysis, expressed as tasks, and placed in the policy, program, and resource management function categories discussed earlier.

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91 Second, the activities enumerated in Slater's survey of physician managers discussed earlier were reviewed and incorporated into the task list as appropriate. (Slater, 1980c). Third, personal interviews with physicians in managerial positions served both to expand the task list and confirm the accuracy of tasks already listed. (See Bibliography for identities of physicians interviewed). Independent Variables Although the major area of concern in this study is discovering what physician managers do, it is also important to identify the personal or organizational characteristics which may affect job performance. As shown in Table 3.r, the variables are grouped under two headings: organizational characteristics and personal characteristics. Organizational Characteristics The organizational characteristics selected for this study include two categories: The first relates to the organization and are as follows: (1) type of organization (e.g., hospital or physician organization), (2) ownership of the organization, and (3) size of the organization. The second category relates to the position (of physician manager) within

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l 1 i I I I I II I I I I I l 1 i i I i i l i I i I II I ! I i I I I I I I I I ) I l! I ; i : I '! 92 TABLE 3.1 INDEPENDENT VARIABLES Organizational Personal Characteristics Characteristics A. Variables Relating to Organization 1. Type a. Hospital b. Physician Organization 2. Ownership a. For Profit b. Non Profit Non govt. c. Government d. Other 3. Size a. Number of beds b. Number of physician full time empl.oyees B. Variables relating to position 1. Title 2. Job Description 3. Line/Staff 4. Full/part time 5. Number of people preceding in position A. Education 1. Training in Management 2. Masters Degree 3. Graduate Courses 4. Continuing Ed. courses B. Experience 1 Years in practice 2. Years in paid management position 3. Years in other paid job 4. Year:s in armed services 5. Years in voluntary management experience 6. Years in current job 7. Work in organization be-fore current job ----------------

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I I I I I i i i I i I i I I I I I I I I I I i! : i i :I 'I I ' ; l ; 1 : i I 93 the organization. These include (1) title, (2) whe-ther or not there is a job description, (3) whether the position is line or staff, (4) whether the posi-tion is full or part time, and (5) the number of people who preceded the incumbent in the position. Type of Organization. The American Hospital Associa-tion (AHA) defines a hospital as: a health care institution with an organized medical and professional staff, and with permanent facilities that include inpatient beds, medical, nursing and other health related services to patients. (AHA, 1984, p. 17) Although all hospitals have in common certain unique qualities that differentiate them from other organizations, there are individual differences among hospitals. These differences include ownership, geographical location, local environment, overall mission, and specific goals (Rohrer, 1962). These differences are reflected in some of the items on the questionnaire and in the independent variables selec-ted. For example, whether the hospital is established as a proprietary, or federally owned in-stitution. The term "physician covers a wide variety of meanings in regard to organizational arrangement. However, in this study, the term is used specifically to mean any group medical practice or

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94 health plan. The American Medical Association (AMA) Council on medical service defines a group prac-tice as follows: Group medical practice is the application of medical services by three or more physicians, formally organized to provide medical care, consultation, diagnosis and/or treatment through the joint use of equipment and personnel, and with income from medical practice distributed in accordance with methods previously determined by members of the group. (Goodman, Bennett, and Odem, 1976, p. 2) A prepaid health plan is defined as: A legal entity which provides directly, or arranges for the provision of comprehensive health care services to an enrolled population; the services to be delivered through a multi-specialty medical group or groups; the enrolled population comes substantially from employer groups. (Kuhl, 1977, p. 5) Size. Size is often considered the single most impor-tant factor influencing and explaining the character-istics of organizational structure (Pugh, Hicksorr and Hinings, 1969). For example, large organizations are usually more formalized and tend to distinguish be-tween specialized groups which then require systematic coordination (Mintzberg. 1979). In addition. employ-ees of a large organization often view the organiza-tion as offering more potential and being more effi-cient than a smaller organization, but also more auth-oritarian (Handy, 1976). Alpander emphasized the importance of size as

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i i :; ; : ; j 95 a variable that influences the internal complexity of hospitals (Alpander, 1982). He believes that a posi-tive association exists between larger hospitals and complexity. Kuhl included size as an independent variable when exploring the roles of health adminis-trators. She found size to be "positively related to a policy-making role in most areas of responsibility, and negatively related to executives personally per-forming activities in most areas of responsibility" (Kuhl. 1977. p. 57). Scott, Flood, and Ewy (1979), focusing on the structural features of organizations, addressed size as a variable, and Shortell and Getzen (1979) incorporated size in a discussion of the resource capability of In this study hospital size is measured by the number of beds, while the size of physician organizations is measured by the number of full-time physician employ-ees. Title. Titles create expectations and implies rank and responsibility (Drucker, 1973). Physicians assuming managerial roles are known to have a wide variety of titles, such as Medical Director, Chief Executive Officer (CEO), Department Chair, Vice Presi-dent of Medical Affairs, etc. (Schenke, 1980). Be-cause of this variety, it is appropriate to examine

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! I I I I I I II ll I I I I I ll I j ; l : I I i I' I I I II I I I I l I I I i i i I I I i I I I ! 96 the influence of Title on the physician manager's responsibility for the tasks. Job Description, the People Preceding in the Position, and Full-or Part-Time Position. Job descrip-tions serve to specify the responsibility and obliga-tions of a position (Shafritz, 1980). The number of people preceding an individual in a job may influence the behavioral expectations of the job. Thus, these aspects of a job can be seen as related to character-istics of an organization, specifically, organiza--tional structure (Shortell and Getzen, 1979). Whether or not a position is full or part time may affect several aspects of the job. For example, the individ-ual's ability to participate in decision making, the degree of commitment to the organization, and the degree of control/communication possible. Therefore, this characteristic is included as an independent variable. Line or Staff Position. The distinction be-tween line and staff positions has long been accepted as a fundamental tenet of organizational theory. Line positions are generally considered to be those with the formal authority to make decisions, while those in staff positions advise (Mintzberg, 1979). This dis-tinction may be oversimplified, may not consider the

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l I I I I I I : I I l l i I I I I I I i I I' I I i I I i I i I I I I l I I I i I I i i j ;I 1 I 97 various types of staff work, and may not be relevant to all types of organizations (Sherman, 1966; Handy, 1976; Mintzberg, 1979). Nonetheless, it is included as an independent variable in this study because of its widespread acceptance as a way to differentiate between types of positions within organizations. Personal Characteristics Organizations are often discussed as if they operate independently of the people who work in them. However, people constitute the essential ingredient in organizations (Sherman, 1966). In an attempt to cap-ture the impact of certain personal characteristics on the tasks for which physician managers are responsible educational preparation and experience have been in-eluded as independent variables in this study. Education. Education, especially for profes-sionals, is often linked to age and is typically considered a demographic characteristic. However, it is important to emphasize that in addition, education plays a powerful role in determining performance (Freidson, 1975). In this study, all respondents had a basic medical education. What is of more specific interest is what effect additional education in the field of management may have on the tasks for which physicians managers assume responsibility.

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I I I I I t I I I i l i I I I I i I l I I I i : j 98 Experience. Experience is included as an independent variable in this study for at least two reasons. First, it has been suggested that the work environment is even more important than education in explaining some important elements of professional performance (Friedson, 1975). Second, physicians generally have experienced the traditional techniques for acquiring knowledge, such as lectures, seminars, etc. However, management is a complex activity, re-quiring more communication, coordination, and coopera-tion than physicians may be used to. Further, the methods of learning to create and support behavior and attitude changes necessary to become a manager are dramatically different from those required for knowledge (Rubin, 1980b). Therefore, experiences, the actual performance of managerial tasks, may be the most powerful factor influencing physician manager responsibility for task performance. Data Collection Choice of Population As previously mentioned, physician managers have a variety of titles, ranging from Medical Direc-tor to CEO. In addition, they are employed or asso-ciated with a potpourri of organizations, such as hos-pitals, nursing homes, pharmaceutical companies, and

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99 group practices. Despite the decision to limit the focus of this study to physician managers in hospitals and physician organizations, the random selection of organizations was impractical. Instead, the entire population of an organization, The American Academy of Medical Directors (AAMD), whose membership consists .largely of physicians in management positions, was surveyed. The membership of AAMD was selected as the appropriate population for two reasons. First, AAHD is a well recognized organization, established in 1975 and accredited by the Medical Association (AHA) in 1976. Second, its members are physicians who are either in management positions or have an interest in management. The membership is self-selected and open to "any licensed physician with an interest or with full or part-time administrative or management responsibilities" (AAMD Bulletin, 1983). Further, AAMD states its purpose as "the national professional and educational association of physicians with leadership, management, or administration responsibilities in hospitals, specialty practices, HMOs, industry, nursing homes and government" (AAMD Bulletin, 1983). However, the decision to focus on only members of AAMD who are affiliated with a hospital or physician organization is also a limitation of the study.

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' :' 100 First, the generalizability of the findings is limited to physician managers within AAMD. Second, little is learned about physician managers in health care or-ganizations other than hospitals and physician organ-izations. Development of Survey Instrument A review of the literature and search for an already developed instrument revealed only two pre-vious surveys of physician managers. One, conducted by Lloyd and Shalowitz (1980), concentrated on physi-cian managers with the title of Medical Director work-ing in large non-government: non-profit hospitals. The aim of this survey was to construct a profile of hospitals employing medical directors, and a descrip-tion of the individuals in those capacities. Their instrument was clearly different from the one required for this study, since it did not focus on tasks and limited the study to physician managers with the title of Medical Director. The second survey, conducted by Slater (1980a), studied AAMD members and was reviewed care-fully as a possible model for this study. Slater incorporated a task list previously used in a study of non-physician health care administrators in hospitals and HMOs. The study focused on the roles of physician

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; I l I i II 'I l I 101 managers. Despite the apparent similarities. there are at least three intrinsic characteristics of the in-strument used in Slater's survey that made it unsuit-able for use in this study. First. although there was a list of tasks in the instrument. other dimensions of interest. such as responsibility for the task and frequency of performance. were not addressed. These dimensions will be discussed in more depth in a subse-quent section of this chapter. Second. Slater used the terms role and role tasks and this study is about the job of physician managers. This is not a semantic issue. The two terms have quite different meanings. There are numerous definitions of role. Linton's classical distinction between position and role is as follows: A status. as distinct from the individual who may occupy it, is simply a collection of rights and duties A role represents the dynamic aspect of a status. The individual is socially assigned to a status and occupies it with relation to other statuses. When he puts the rights and duties which constitute the status into effect, he is performing a role There are no roles without statuses or statuses without roles. Just as in the case of status, the term role is used with a double significance. Every individual has a series of roles deriving from the various patterns in which he participates and at the same time a role, general, which represents the sum total of these roles and determines what he does for his society and

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I j : I i l I I I '! i ; i 'I 'I l : I :I i l i 1 : l I :! : ; what he can expect from it. (Linton, 1936, 113-114) 102 More recently, Katz and Kahn, who emphasized the importance of roles in their theory of organiza-tions state that a role is "a set of expected activi-ties associated with the occupancy of a given posi-tion" (Katz and Kahn, 1978, p. 200). Further, Katz and Kahn define role behavior as "the recurring action of an individual, appropriately interrelated with the repetitive activities of others so as to yield a predictable outcome" (Katz and Kahn, 1978, p. 189). In contrast to a role, a job is a relatively simple concept. A job is viewed as: a group of positions which are identical with respect to their major or significant tasks and sufficiently alike to justify their being covered by a single analysis. One or more people can have the same job. (United States Department of Labor, 1972, p. 1) Clearly, it can be seen that the terms role and job have different meanings. Job is position, and role is the expected behavior associated with that position. Therefore, it is inappropriate to use an instrument using the term role for a study which focused on the job. The thiid characteristic of Slater's survey that posed problems for this study was the use of a task list developed for non-physician health care administrators. This, it seems, does not acknowledge

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I I I I i j I j i I I I I I I I II I 103 1 the uniqueness of physician managers. Slater's finding that none or the tasks in the physician man-ager's basic role overlapped those of the health care administrator emphasizes this concern. In summary, it appeared that there was no existing instrument suitable for use in this study. Therefore, despite the difficulties of developing a new survey instrument, it was both necessary and ap-propriate. The issue of validity and reliability will be discussed next. Validity and Reliability. Concern with reliability and validity stems from the necessity for research to be believable. To be useful, the data collected, analyzed, and ultimately reported during a research effort must be both relevant to the research questions and correct. Validity and reliability are two crucial aspects or correctness. Ideally, research instruments should be reliable, valid, relevant, and sensitive. However, in the social sciences, few re-searchers are able to meet all of these criteria (Selltiz, Wrightman, and Cook, 1976). Synonyms for reliability include consistency, dependability, stability, and predictability (Kerlinger, 1964; Henerson, Morris, and Fitz-Gibbon, 1978). Basically, an instrument (or procedure) is

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. I I I I I I l I I I I I I I I I ! i I I i i : ! i : i i 1 : I ; i i I t : I : I :I i : I i i I : I ! I : i I ; r : i I : : l 104 reliable if it repeatedly yields similar results. Several factors often classified as either constant or random errors are known to influence reliability (Selltiz, Wrightsman, and Cook, 1976). According to Selltiz, a constant error is "one introduced into the measurement by some factor that systematically affects the characteristic being measured or the process or measurement". (Selltiz et. al., 1976, p. 168). For example, in this study, the well known "social desir-ability" influence, which is the tendency to present a favorable picture of oneself, might result in physi-cians indicating for an exaggerated number of tasks. A random error is one resulting from a tran-sient aspect of the person's views, procedures (Selltiz, 1976). These are likely to vary from one act of measurement to another, despite stabi-lity of the characteristic of interest. Feeling ill, excessively stressed, or angry are examples of situa-tions that result in a random error. Specifically, this survey attempted to estab-lish reliability in the following manner. The ques-tions were written as unambiguously as possible. All respondents received the instrument the same way (via mail), and the same detailed instructions approved on all surveys. The survey asks questions dealing with

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i ; i : ; 105 either personal factual information or information about the work place. According to the literature, this type of information is highly reliable (Blalock, 1972; Selltiz et. al., 1976; Henerson et. al., 1978). The validity of an instrument is a more com-plex concept than reliability. It is defined as "the extent to which differences in scores on it [the instru-ment] reflect true differences among individuals on the characteristics that we seek to measure, rather than constant or random errors." (Selltiz et. al, 1976, p. 169). The concept is epitomized by asking: are we measuring what we think we are measuring? (Kerlinger, 1964). In this study, the question is: are we measuring physician managers' responsibility for specific tasks? There are numerous classifications of validity, but traditionally three are discussed: content, criterion-related, and construct. Content validity addresses whether or not the the instrument provides an adequate representation of the kind of behavior with which it is concerned (Kerlinger, 1964; Isaac, 1978). It requires "careful consideration of exactly what the behavior is that one wishes to measure and of the variety of ways in which it might be measured" (Selltiz, 1976, p. 179). It seems generally accepted that judgment

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i I I I I I I l i I I i 1 l j i l l l I 1 !I I I :I II 'I I ll :I i I i I l i I I i I I i \ l ; :! 106 plays a key role in establishing content validity. That is, each item on a test instrument must be judged by competent judges for its presumed relevance to the pr?perty being measured (Kerlinger, 1964). Criterion-related validity focuses on the is-sue of predictability. Interest is not on what the test measures but how well the instrument compares with external variables that are considered to be direct measures of the characteristic or behavior in question (Isaac, 1978). Therefore, it follows that to achieve criterion-related validity, it would be neces-sary to compare test scores_with one or more criteria known to measure the attribute of interest. One exam-ple of the importance of establishing criterion-rela-ted validity is the use of tests as predictors of some specific behavior, such as the likelihood of appli-cants to succeed in certain jobs. Since physician managers are not generally subjected to testing prior to being offered their jobs, criterion-related valid-ity is not of concern in this study. Construct validity addresses the question "to what extent do certain exploratory concepts or quali-ties account for performance on a test (Isaac, 1978, p. 82). Construct validity is needed when the investigator is interested in using the test perform-ance as, "a basis for iriferring the degree to which

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i; I ; l I I I I l i I I I 107 the individual possesses some characteristic or trait. presumed to be reflected in the test perfor-mance". (Selltiz, 1976, p. 173). These traits are abstractions or constructs, such as intelligence or j1 attitude toward war, not specific behavior. The meth: l II I II i I :I II ; I : I 1 i I I I : i i I I i l ll I I I I ; I : I I i 1 i i l j ; I ; l : i i : ! ; ; : :: ; i i od used for validating this kind of instrumet involves setting up hypotheses regarding the behavior of per-sons with high or low test scores and then testing the hypothesis in another research situation (Isaac, 1978). Although all research efforts require that reliability and validity be addressed, it is generally agreed that the intended use of a test should deter-mine what kind of evidence is required. It is this distinction, between intended use and the nature of a test, that is pivotal for this study. The intention here is not to predict future behavior, to classify persons according to personality traits, or to account for test results. Instead; the focus is on finding out more about the nature of the job held by a group of physician managers. Therefore, establishing con-tent validity seems to be the most reasonable demand on the study. To ensure content validity, a panel of experts who are physician managers and members of AAMD re-viewed each item on the survey. These experts

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i i 'l 'I ll 11 I i II I i : i i j i \j i! :I ; I i I ; i : i l i ; 1 : l ; l ; j I '! ; \ :1 :\ 108 determined that no important questions were omitted and that the survey reflected a balanced picture of the physician manager's job. Further, the survey provided the respondents with an opportunity to add any work done that was not included in the task list. In addition, validity was considered in the manner in which the data were analyzed and reported. Inferences or descriptions of associations are made only about the physician managers in the surveyed population. No predictions about individuals are made. In short, measures considered to be appropriate for this study were taken in order to minimize error and maximize both reliability and validity. In general, survey research may have unique advantages with respect to reliability and validity. First, it has been shown that the reliabil-ity of test items dealing with personal factual infor-mation is high (Henerson, et. al, 1978). Second, although the reliability of attitudes is more diffi-cult to determine, the reliability of average re-sponses is higher than that of individual responses. Third, the use of survey research can permit the researcher to check the validity of the survey data with repeated interviews of the respondents and/or with outside criteria (Kerlinger, 1964; Isaac, 1978; Henerson et. al., 1978).

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. i i) j j i i I i i ! i i II I I i i i I I l i I ; I :I i I 'I I I I I I .; I 1! I I :I :I i i I I :I '' :I I : i : i :! l :; : l 109 For example, it would be possible to ask a physician manager if he/she is responsible for a specific task, such as reviewing the budget for the organization. Others in the organization could then be asked if the physician manager is responsible for that task. Finally, during the process of construct-ing the survey instrument, questions can be examined by any number of experts or judges to ensure content validity. Steps in Developing the Survey. In order to describe the job of physician managers, it was neces-sary to have a survey instrument which would 1) pre-sent the choice of tasks for physician managers, 2) assess the respondent's responsibility for the task, 3) measure the frequency with which the task was performed, and 4) measure the respondent's perception of the tasks important to the organization. Having responsibility for a task is different from performing that task. Therefore, for each task, responsibility and frequency of task performance were treated as separate dimensions. Asking about the perception of the task's importance to the organiza-tion was suggested by work on organizational effect-iveness. Goodman and Rennings (1979) proposed that to maximize effectiveness, organizations need to specify

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.I i I ll : I 1 I : I :I i l l i i I :1 I I ; I : I : I : I : I I ; I :I : I ; I :I f 1 : I i l ' ' ; 110 tasks performed and then decide, among other things, the relative importance of those tasks to the overall objectives of the organization. The specific steps in the development of the survey instrument included: 1. The development of the task list and other questions on organizational and personal characteris-tics. 2. Consultation with experts. 3. Pre-test of initial instrument. 4. Revisions as a result of the pre-test. The development of the task list (dependent variables) and other questions on organization and personal characteristics (independent variables) have already been described. After drafting the survey instrument, a meet-ing was held with the executive directors of AAMD. These physicians, all of whom are managers, first completed the instrument and subsequently reviewed and discussed each question. A second draft of the survey was then prepared and pre-tested among sixty-five members of AAMD. The pre-test was administered per-sonally by the executive director of AAMD during a physician-in-management seminar. Of those who re-ceived it, 42 (64%) completed and returned the survey. Based on the responses and suggestions

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I I : i I I i I 1 1 1 received from the pre-test, several minor changes were made. For example, the average amount of time required for completion of a each section was included in the directions presented before each section. Other modifications included enlarging the print and attaching a cover letter to each survey. Mechanics of Administering the Survey. The final survey instrument accompanied by a cover letter from the executive director was mailed to the entire 893 membership of AAMD during May, 1983. (See Appen-dix A for the complete instrument). In June, with a response rate of 46 percent, a follow-up letter from the executive director was mailed. By July, when the data collection deadline was reached, a total of 502 surveys had been received, representing a response rate of 56 percent. Description of Survey The final survey instrument contains four sections, each with a distinct focus. Table 3.2 il-lustrates the major issues addressed. Part One asked questions about personal background and training, including the following: (1) area of clinical specialty, (2) status on the medical staff, (3) education in management, (4) general experience, (5) helpfulness

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I I I i I i l1 ll I i ! i! I! I i i! l ; I 1 I; i 1 j l : i ' < I; l I, i; i I i t I I < i j I '! '' il jl i i I I J i ; : i l /l 11 ; i I :1 :I '; l ; ; j i I : '' TABLE 3.2 MAJOR ISSUES ADDRESSED IN EACH SECTION OF SURVEY INSTRUMENT SECTION ONE PERSONAL CHARACTERISTICS 1. General demographic information (age, sex). 2. Area of clinical specialty 112 3. Status on medical staff (e.g., active, inactive, courtesy, etc.) 4. in Management 5. General Experience 6. Helpfulness of education and/or experience 1. Current position (years in, method of selection, full/part time, etc.) 8. Arrangement between physician and organization with regard to contract, job description and evaluation. 9. Professional committments (e.g., private practice). 10. Job satisfaction SECTION TWO: ORGANIZATIONAL VARIABLES 1. Title 2. Type of Organization 3. Formal and informal reporting/communiction arrange-ments 4. Line/Staff 5. Authority/influence 6. Organizational size SECTION THREE: COMPENSATION 1. Time devoted to management 2. Salary 3. Bonuses and benefits 4. Time off 5. Total compensation

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' ' 1! I I I i I I I j I I i I I, II I I. i I II II ll I' I i I I ! I j i I Table 3.2 (continued) MAJOR ISSUES ADDRESSED IN EACH SECTION OF SURVEY INSTRUMENT SECTION FOUR: TASK LIST For each task the respondent was asked three questions: 113 1. Whether or not he/she had responsibility for the task as part of the job 2. How often he/she performed the task. 3. How important he/she perceived the task to be to the overall effectiveness of the organization. The tasks were grouped under the following categories: a. Policy management tasks inside organization b. Policy management tasks outside organization c. Program management (1) Quality assurance (2) Education (3) Risk management d. Resource management tasks (1) Data management (2) Financial management (3) General management (4) Resource management

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: ! i 11 4 of education and experience, (6) years in current position, (7) method of selection, (8) full or part time, (9) arrangements between physicians and organi-zations with regard to contracts, (10) job descrip-tions and evaluations, (11) professional commitments, and finally, (12) job satisfaction. Part Two asked questions about the organization, such as: (1) title, (2) type of organization, (3) formal and informal reporting/communication ar-rangements, (4) line/staff designation, (5) amount of authority/influence, and (6) organization size. Section Three on compensation and asks the physician about (1) the amount of time devoted to management, (2) salary, (3) bonuses, (4) benefits, (5) 2 time off, and (6) tota.l compensation. Section Four contains 86 tasks grouped under the following categories: (1) policy management tasks inside the organization, (2) policy management tasks outside the organization, (3) program management and (4) resource management tasks. As previously mentioned, three dimensions were investigated for each task listed: 1. Responsibility: Respondents were asked if they had responsibility for the task in their organ-ization. The response choices were Yes, No, or Not Appiicable (N/A). Instructions on the survey

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! I ; I I I I .I 'i '' ; i i l' :! :I i I :! ; l i i ( j 1 i i l ; : I ; 115 indicated N/A was the appropriate answer if the task did not apply to the respondent's work situation. If the rospondent shared responsibility for the task, he/she was instructed to mark Yes. 2. Frequency of occurrence: This was separ-ated from responsibility because managers may in fact perform tasks for which they are not formally responsible or vice-versa. Response choices for frequency were: Rarely, Occasionally9 Frequently, and Very Frequently. 3. Importance to the organization: This last dimension was developed to insight into how phys-ician managers perceived the importance of the various tasks for w.hich they were responsible. Choices were: not very important, somewhat important, very impor-tant. Data Analysis In non-experimental research, such as this study, there are a number of approaches to analyzing the data. A positivist approach was selected, which suggests that when data are qualitative, they can be refined and quantified and/or categorized (Selltiz, 1976). This approach implies the use of a variety of techniques and statistical methods, which order and summarize findings to perform statistical analysis.

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i i I I i I l l L i 1 1 6 As the questionnaires were received, several steps were taken: (1) they were examined for com-pleteness, (2) any additional comments by respondents were recorded, (3) responses were subjected to prelim-inary editing, and (4) they were coded for keypunch-ing. Inspection of the raw data was instructive. For example, early in the study, the issue of importance was considered. However, for a variety of reasons, this was rejected and further analysis was limited to responsibility and frequency. In addition, on several questions the respondents were instructed to select only one answer answer only one group of questions which related to the type of organization in which they worked. Despite these instructions, ap-proximately 17 percent of the physicians answered more than one group of questions. This fact required sub-jective judgements and influenced the way in which questions were coded. Finally, the comments and additional tasks that were added to the Task List were of interest from a phenomenological perspective. For example, notes of encouragement with positive feedback were common, as were requests for copies of the summarized results and detailed explanations of various answers. Once the initial editing was completed, data from the entire population were examined. As

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117 mentioned earlier, AAMD members are affiliated with a wide variety of organizations. A general profile of the repondents' affiliations was developed. Next, three organizational categories were defined: hospital, physician organization, and "other". Respondents who indicated that their primary affiliation was in one of the following settings were included: general hospitals (university-based), gen-eral hospitals (non-university-based), specialty hos-pitals (university-based), specialty hospitals (non-university-based. Only respondents from long-term care hospitals (.8 S) were excluded from analysis. The physician organization group was obtained in the same manner. Respondents who indicated their primary affiliation was in any of the following were included: single-specialty group practice, single-specialty group practice with over 50 percent asso-ciated with a health plan, multi-specialty group practice, multi-specialty group practice with over 50 percent associated with a health plan, multi-specialty with less than 50 percent associated with a health plan, staff (or group) model prepaid health plan (PPHP), or independent practice association (IPA). Respondents from any other type of organiza-tion were grouped in a third or "other" category, consisting of such organizations as: long-term care

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' i l I ! I' I '' 1 i l ! I I' ; 118 hospitals, nursing homes, industrial organizations, pharmaceutical companies, government agencies, mili-tary services, and community health centers. Analysis of Physician Manager Responsibility This study employs univariate analyses to examine the tasks for which physician managers are responsible. Within each type of organization physi-cian manager responsibility for the tasks was analyzed in the following ways: First, the percentage of phys-icians within hospitals and physician organizations who are responsible for each of the 86 tasks was calculated. Second, the tasks were ranked according to this percentage of responsibility. Third, the ranked tasks were examined within the management func-tion Policy Management, Program Management and Resource Management. Fourth, comparisons were then made between the hospitals and physician organi-zations. Fifth, in order to examine how responsibil-ity for the tasks differed, a Spearman's rank correla-tion coefficient was computed. This measured the degree of relationship between the two sets of rank-ordered items for task responsibility. Analysis using chi-square was then performed in order to assess the extent of association between the independent and dependent variables. Core tasks

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I 'i II I i! I l II I I ! II i f I I i! II I i I. l I i I i i I : 1 1 9 were selected from among all of the 86 tasks as being most representative of the tasks for which physician managers are responsible. A factor analysis was used 3 to select this subset of ten tasks. Crosstabulations were then done on the ten tasks by each of the inde-pendent variables. Analysis of Frequency of Task Performance Prior to analyzing the frequency dimension, the responses Frequently and Very Frequently were col-lapsed into one category. This was done in order to provide a more general sense of how often physician managers performed the tasks. This new category is termed Often in the following discussion. The responses of physicians answering either "Yes" or "No" for responsibility were included in the frequency analyses, since responsibility and perform-ance are separate variables. Physicians responding "No" to the responsibility question were included, because there were some tasks where some physicians answered that they performed the task "often" despite their "No" response. People responding "MIA" on the responsibility variable were not included in the anal-ysis. Within each type of organization, frequency of performance was analyzed in a manner similar to

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' j 1 120 responsibility. The proportion of physicians perform-ing each task often was calculated. Tasks were then ranked the management function categories. A Spearman's correlation coefficient was then com-puted to measure the degree of relationship, within each type of between responsibility and frequency.

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1 i I I l I I I I i I I ' i 1 I 'I I I I' 1 I I I I I I i I I I I I i I I 1 I j j I i I I I I i ! l I I 121 NOTES CHAPTER III 1. Physicians are generally recognized as occupying positions of cultural authority, economic power, and political influence. No group has ever held a more dominant position in our society. Unlike the other classical professions, law and the clergy, the medical profession maintains close bonds with modern science, which also enjoys privileged status. In addition to the association with scientific knowledge, physicians come into direct and intimate contact with people, are present at critical transitional moments of life, and serve as intermediaries between the world of science and private experience (Starr, 1982). 2. This study did not address the compensation aspect of the job of physician manager. The questionnaire included it at the request of AAMD. 3. A Q-type factor analysis was used to select a core group of representative tasks. An orthogonal solution was and the ten tasks with the highest loadings were selected. Categorized by management function these are as follows: Policy Management 15, Deciding which programs and medical services the organization, department/service, or agency offers. 06, Deciding the size of programs and medical services. 113, Monitoring and reporting on issues of interest of administration to medical staff. fl33, Promoting the organization, ment/service, or agency. Program Management Tasks 040, Ensuring that a system for review and evaluation of medical staff competency operates effectively. 060, Designing new or modifying existing risk management functions and/or programs.

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! I 122 Resource Management Tasks 051, Monitoring and reporting on data from systems designed to obtain information about medical care. 055, Designing ways to improve efficiency of professional departments within the organization or agency. 068, Designing contracts for physicians. 082, Advising and/or counseling physicians on career or professional issues.

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I i ! ) ) CHAPTER IV FINDINGS This chapter presents the findings of the study, beginning with a description of the 502 physi-1 cian respondents. Next, results of the analysis per-taining to physicians in hospitals, physicians in physician organizations, and comparisons between the two groups are presented. Finally, findings from the chi-square analysis are discussed. Characteristics of Physician Manager Members of AAHD Characteristics of a typical member of the American Academy of !1edical Directors (AAllD) are illustrated in Table 4.1. The most typical physician manager is a 53-year-old, Board-certified, male in-2 ternist. He has in practice over 16 years, and in his current full-time managerial position for over five years. Before being selected for this position, more than half of the respondents were already em-ployed by the organization. After assuming his cur-rent position, he is not likely to maintain a private medical practice. On the average, fewer than two

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I I I i 124 TABLE 4.1 CHARACTERISTICS OF SURVEY RESPONDENTS (N:502) n Sex: ilale n=Z179 Age: Average = 53 years Clinical Specialties: Internal Hedicine Family Practice Pediatrics Other1 General Surgery Ob/gyn Psychiatry 29. a 7.0S 5.2S Preventive Medicine Female n=20 (Range: 31-76 years) Physical tied. & Rehab. Anesthesiology Radiology Emergency Medicine Orthopedics Pathology Otolaryngology Urology 1. 1 8 c;; 1. 6: 1. q;, 1. 2:0: 1 1. o..: !199 lJ87 502 Board certification in area of specialization: 502 Number of years in medical practice: average 16.7 years (Range 0-!12 years) 485 Number of years in current position: average 5.lJ years (Range 0-35 years) 489 were working for the organization before assuming current position. 502 consider jobs full time. 30S consider job part time. 502 maintain a private medical practice. are either somewhat satisfied or very satisfied with their job. Uote: Respondents include physicians in all types of organizations. For list of nothersn see Appendix c. p.272 lJ93

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125 persons preceded him in the job. The vast majority of respondents reported being satisfied with their jobs. Experiences Found Helpful As can be seen in Table 4.2, almost all respon-dents had both an internship and residency. In addition, the vast majority had experience in a medical practice, and most felt this experience was helpful in preparing them for their current positions. Although about 83 percent of the physicians had some management education, only about 61 percent of them felt this had been helpful in preparing them for their positions. The majority of the physicians served in the armed forces, (65$), but only 40 percent found this experience to be helpful. Focusing on the respondents with formal mana-gerial training, 78 percent participated in continuing 3 education programs. These seminars, courses, or workshops, were sponsored by a variety of groups and organizations, including AA:to, the military, and the American Hospital Association (AHA). Other types of managerial training included the following: graduate courses in a university-based management or business program, !laster's in Public Health, !1aster's in Ousiness Administration, Haster's in Health Administration,

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126 TABLE 4.2 EXPERIENCES FOUND HELPFUL IN PREPARATION FOR CURRENT POSITION (N:502) EXPERIENCE PERCE!iT WITH EXPERIENCE PERCENT WITH EX p E R IE N C E 1-IH 0 FOUND IT HELPFUL1 Clinical experience of internship and residency Organizational or super visory experience of internship/residency Clinical aspects of medical practice ttanagerial aspects of medical practice Formal education Voluntary management experience On-job training Armed services Paid fuanagement experiences (other than practice) experience 2 Other paid organization work 99.4 99.4 95.4 95.4 -82.8 81.8 8 j. 3 65.2 63.0 35.2 1 9. 4 62.4 59.8 82.6 81 1 60.7 75.5 75.5 39.6 55.2 38.2 22.9 For this Table, the responses nHelpful" and "Very Helpful" were combined. 2 Formal management education included the following: Undergraduate degrees in man agement or administration in Public Health il..=sters in Business A-dmin istration Masters in Health Graduate courses in university based mgmt. Continuing ed. in mgmt. Other

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127 and undergraduate degree in management or administra-tion. Work Arrangements An examination of the various managerial ar-rangements between this group of physicians and their organizations reveal that about 64 percent have writ-ten contracts or memoranda of uderstanding with the 4 organization. Approximately 77 percent have a writ-ten job description. which the majority wrote themselves. The chief executive officer wrote 41 percent, and the board of trustees wrote 20 percent. Formal evaluations of job performance occur for more than half of the survey respondents. and the majority (87$) of these are annual. The type of organization within which AAMD members most frequently work is the non-university-based general hospital. As can be see in Table 4.3, this type of hospital accounted for almost 38 percent of the affiliations reported. Other types of hospi-tals, specialized hospitals. and long-term care hos-pitals, accounted for over 16 percent of the respon'1 dents affiliations. Over 54 percent of the respon. j dents reported some type of hospital to be their : I primary organizational affiliation. I : i I :

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! i l I I I i I I I I i i I i i ! I I I i : I I ; I i I i I 1 i TABLE 4.3 ORGANIZATIONAL AFFILIATION OF SURVEY RESPONDENTS (n:498) 128 TYPE OF ORGANIZATION PERCEll! HOSPITALS (n:270) General hospital (non-university based) General hospital (university based) Specialty hospital {non-university based) Specialty hospital {university based) Long-term care hospital PHYSICIAN ORGANIZATIONS (n:122). 37.8 6.8 6.6 2.2 0.8 Multi-specialty group practice 7.0 Staff (or group) model pre-paid health plan Multi-specialty group practice with less than associated with a health plan Multi-specialty group practice with over associated with a health plan Single specialty group practice Independent practice association Single specialty group practice with over associated with a health plan OTHER (n:106) 1 6.4 s.o 2.8 2.2 0.8 0.2 Other 8.6 Government agency 4.0 Military 3.8 Industrial organization 2.2 Pharmaceutical company 1 0 Nursing home 0.8 Community health center o.a 1For List of "others" See Appendix C, p. 27d

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129 Less than half (41%) of the hospitals within which physicians worked had a national or regional affiliation. Of those who did report an affiliation, 74 percent were affiliated with Catholic hospitals and 24 percent with the military, thus accounting for 98 percent of the affiliations. The average number of physicians on the medi-5 cal staff of hospitals was reported to be 332. The average number of full-time physicians employed by the organization was 40, and the average number of full-6 time physicians on contract was 13. The average num-ber of licensed beds was 424 and the average number of ICU beds was 31. Physician organizations accounted for about 26 percent of respondents' affiliations. These include I I multi-specialty group practices with or without a pre-paid health plan association, representing almost 15 percent of the total response; staff or group model prepaid health plan accounted for 6 percent; singlei l specialty group practices, representing less than 2.5 percent; and Individual Practice Associations (IPAs) . I ' I I I accounting for less than 1 percent of affiliations. No respondents reported being affiliated with a sin-gle-specialty group practice with less than 50 percent association with a prepaid health plan. The average number of full-time physicians in group practice was

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; : i I i i i I I I I I I I l I d I I l : i j : I : j I I I : 130 56, with 10 as the average number of part-time physi7,8 cians in the group. The average number of full time non-physician employees in the group was reported 9 as 325. Of the organizations with any type of prepaid health plan, 57 percent had no national or regional affiliation. Of the 43 percent that did claim an affiliation, there was no large grouping in categories 10 as there was for hospitals. Those organizations with a staff model prepaid health plan had an average of 33 full-time physicians, 67 part-time physicians, 202 non-physician full-time employees. Of the 0.8 percent of the total AAMD respondents reporting their primary organization asso-ciation to be an IPA, the average number of participa-ting physicians was 102. Other types of health care organizations in-elude nursing homes, industrial organizations, pharma-ceutical companies, government agencies, military community, health centers, and miscellaneous types. Here the average number of 1 1 full-time physicians was 82. 12 25 The average number of part-time physicians was and the average number of non-physician full-time 1 3 employees was 532. It is important to emphasize that despite a choice of nineteen different types of health care

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. I i I 1 3 1 organizations, a relatively large percentage of re-spondents (8.6$) felt the organization in which they worked did not fit into any of the established cate-gories. In actual count, this represents 32 "other" 14 types of organizations. The job titles held by AAMD members who re-sponded to the survey are presented in Table 4.4. i1edical directors of organizations represented over 34 percent of the respondents and were the largest single group reported. The remaining titles ranged from vice president of medical affairs, at 13 percent, to assis-tant medical director, at 2_percent. The "other" category for title, while smaller than for organiza-tion type, was still considerable, at over 5 percent. (See Appendix C, p. 277). Whether a physician manager holds a line or staff position is an organizational issue addressed in the survey. When "line" and "mostly line" categories are combined, over 70 percent of the survey respond-ents.held line positions within their organizations. Further, almost 80 percent felt their positions should be line. This issue will be discussed further in Chapter V. When responses to the questions on authority and influence are compared, it is clear that these physicians perceive themselves to have much more

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TABLE 4.4 JOB TITLES REPORTED BY SURVEY RESPONDENTS TITLE director of an ?rganization Vice president of medical or professional affairs Chief executive officer Medical director of a service, department or program Director of medical affairs Chairman or chief of department or service Chief of staff Clinical director of department, or program Director of medical education Assistant medical director 1 Other PE:RCEN'i." OF RESPONDENTS 34.5 12.8 12.0 10.0 8.2 7.2 3.4 2.2 2.2 2.0 5.4 For list of "others" see Appendix C, p. 277 132 (n=499) 172 64 60 50 1 1 36 1 7 1 1 1 1 0 27

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i i i I I I i i ; i I I I i ll I. ; I ; i I : I l : l I I ; 133 1 5 influence than authority. While 57 percent of them said they felt they had a great deal of formal ity. 72 percent said they felt they had a great deal 16 of influence. Further, while 2 percent claimed to have almost no formal authority, only 0.2 percent claimed to have almost no influence. Other data from the survey support these findings. Less than 30 per-cent of the respondents reported having a vote on the governing board. Slightly more (37%) were board members, while a much higher number (73%) attended Board meetings but had no vote. Therefore, it may be that the presence and presumed at board meetings of respondents resulted in their influence being greater than their authority. This issue is discussed further in Chapter V. Although compensation and benefits for physi-cian managers is not a major focus of this study, in-formation regarding these issues was obtained at the request of the sponsoring organization. Table 4.5 presents a summary of the financial profile for AAilD members who responded to the survey. The average 17 salary for 1982 was $80,561. The average bonus from the organization was $5,628. The average share of profits or dividends was $2,540, and the average an-nual pension and retirement was $8,742. The sum of

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I I I I 134 Table 4.5 1 SUI111ARY FINANCIAL PROFILE OF SURVEY RESPONDENTS TYPE OF COMPENSATION Annual salary Amount received in bonuses from organization Total share of profits or dividends Annual amount of pension and retirement pay contributed by organization Average total compensation n Average amount 482 $80,561 465 $ 5,628 448 $ 2,540 448 $ 8,742 383 $97,471 1All responses are based on 1982

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' ' 1 1 135 I I l these figures result in an average total compensation I l I of $97, 471. In addition, respondent's organizations paid for the following extra benefits: malpractice insur-ance, health insurance, life insurance and disability insurance. Other benefits reported included an aver-age of three and one-half weeks of paid vacation, and nine days of paid educational leave per year. The average number of hours per week devoted to management activities was about 35 hours. Tasks The task list, as presented to respondents, appeared to be relatively complete. Respondents were given the opportunity to add any tasks they performed that they perceived to be omitted from the list. Relatively few tasks were added (n=27), and those that were seemed to be uniquely associated with the organi-zation and/or position held by the physician. For example, one respondent was required to fly four hours 18 per month. The frequencies with which respondents are responsible for each task are presented in Appendix B. There were no tasks unchecked, suggesting that all the tasks are relevant to the job of some physician man-agers. The range of response was from 94 percent

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136 (preparing new or modifying existing policies or pro-cedures) to 8 percent (negotiating with unions). The 10 tasks for which the highest percentage of physicians are responsible is shown on Table 4.6. For purposes of comparison, the 10 tasks for which the fewest percentage of physicians are responsible is presented in the same table. Nine of the 10 tasks for which the highest percentage of physicians are respon-sible are considered policy management functions. One task is considered a resource management function. There is more variation among the tasks reported with low frequency. Three are P?licy management, three are program management, and four are resource management tasks. Physician Managers in Hospitals and Physician Organizations After the initial analysis of responses for all physicians who returned the survey, data from phys-icians in "other" types of organizations were ex-eluded. This left data from physician managers in hospitals and physician organizations for further analysis. As discussed in Chapter III, the hospital group included: general university-based and non-university-based hospitals. The physician organiza-tion group included: single specialty group practices alone, with, and without a 50 percent association with

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i j j I I i I I : i i : I ;! : i i I I : ; 137 TABLE 4.6 TASKS FOR WHICH SURVEY RESPONDENTS ARE HOST AND LEAST RESPONSIBLE (n:502) l IOST TASK PERCENT POLICY Preparing policies or procedures Designing or reviewing 93.6 new programs 91.4 Communicating info. to med. staff and governing body of organization 88.3 Preparing goals and ob objectives for the org. 87.7 Monitoring and reporting to admininistration issues of interest to med. staff 87.6 Monitoring and reporting to med. staff issues of in terest to administration Attending medical staff committees Attending admininistration committees Deciding on programs and med. services RESOURCE MANAGEMENT !tediating conflict among physicians 84.3 83.7 80.9 80.5 78.6 LEAST TASK PERCENT POLICY KAUAGEMEUT Representing org. to third-party payors 31.2 Lobbying regulatory agencies 26.5 Chairing board comm. 18.1 PROGRAH t1ANAGE!IENT Teaching CE pgms. to non-physicians 30.7 Designing CE pgms. for non-physicians 27.1 Designing general educational pgms. RESOURCE MANAGEMENT Supervising construc1 5. 3 tion projects 25.2 Designing contracts for non-physicians 18.3 Designing wage/benefit schedules for non:.physicians Negotiating with unions 1 2. 9 8.0

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138 a health plan; multi-specialty group practices alone, with, and without a 50% percent association with a health plan; staff (or group) model prepaid health plan; and IPAs. The findings for physicians in hospitals and physician organizations are presented separately. First, descriptive findings for each of the two groups with regard to personal characteristics are discussed. Next, analysis of task responsibility and frequency of performance is described. Finally, comparisons between the two groups are presented. Physician Managers in Hospiials As shown in Table.4.7, physician managers in hospitals are more likely to be male. than female This finding corresponds to that for all physician respondents, 96 percent of whom were male, and 4 percent of whom were female. The average age for these physicians is 54 years. The percentage of physicians in the various specialties is similar to those shown for all survey respondents. Internal medicine is the predominant specialty This may be compared to the national proportion of 15 percent of all practicing physicians listed as as specialists in internal medicine in 1980 (Bureau of Census. 1980). The reasons why internal

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j j i I I I I I I I I I I I I I i I I I j I I I i i I I I I : 1 I i I I I 139 TABLE 4.7 CHARACTERISTICS OF SURVEY RESPONDENTS IN HOSPITALS Sex: ;tale n:255 ( 95. a) Age: Average = 54 years Clinical specialties: Internal medicine Family practice Pediatrics Other General surgery Psychiatry Ob/gyn Physical medicine 6.4S 4.9S Female n=13 (Range: 34-74 years) Anesthesiology Emergency medicine Orthopedics Pathology Radiology Urology Preventive med. 1. 1. 1 certirication in area or specialization: 81S Number or years in medical practice: Average 17 years n 268 261 265 258 (Range 0-41 years) 263 of years in current position: Average 6 years (Range 0-30 years) 263 45.7S were working for the before assuming current 267 74.5) consider job rull time. 25S consider job part time. 267 45.7S maintain a private medical practice. 267 85.8S are either somewhat satisfied or very satisfied with their job. 267

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: j i I I I I I I I I I i I I I i i l i I I I I 140 medicine being the predominant specialty in this group of physician managers were not explored in this 19 study. Boards represent the highest level of creden-tial for specialists. The vast majority of physician managers in hospitals have passed the boards in their area of specialization. This finding is consistent with what the literature suggests about physician managers in general, that they are most often selected because they are good clinicians, not because they have demonstrated skills (Schenke, 1976; Wood, Another indication of the importance of their continuing in clinical prac-tice is the finding that although 75 percent of these physicians consider job to be full time, about 47 percent continue to maintain a private medical practice. Physician managers in hospitals have been in medical practice an average of 17 years, and in their current position for an average of six years. While this survey did not ask what these physicians were doing prior to assuming their current job, it is likely that they were engaged in some form of medical prac-tice. The majority of these physician managers have written contracts with the hospital (69.0%) and have written job descriptions (83%). A smaller number

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' 'I j I I ! 1 4 1 (56$) have formal job evaluations. Most of these physicians reported being either somewhat satis-fied or very satisfied with their jobs. Responsibilities. There are no tasks for which 100 percent of physician managers working in hospitals are responsible. Neither are there any tasks for which zero percent are responsible. For all of the tasks, "No" was selected as a response more 20 frequently than N/A. Table 4.8 shows the 10 tasks for which the highest and lowest percentage of physicians have re-sponsibility. These tasks are grouped by management function category. Of the tasks reported with the highest frequency, eight of the 10 are considered . policy management and two program management. An analysis of these tasks revealed that one-half deal directly with the medical staff. While the language of the remaining one-half does not specify "medical staff," an association is likely. For example, physi-cian managers who are responsible for assuring ac-creditation with JCAH are likely to be performing functions associated with physician activity. Yhen physician managers are preparing policies or proce-dures, these are probably dealing with medical care or physicians.

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. I : I I I I I I I I 142 TABLE 4.8 TASKS FOR WHICH PHYSICIAN MANAGERS IN HOSPITALS ARE MOST AND LEAST RESPONSIBLE nosT !..EAST TASK PERCENT TASK PERCENT POLICY HAtlAGEIIENT medical staff committees 95.1 and repor ting to administration issues of interest to medical staff 93.7 Preparing policies or procedures Communicating infor mation to medical staff and governing body Designing or review ing new programs Monitoring and report ing to med. staff issues of to 93-3 9 2. 1 9 0. 1 istration 89.8 Attending administra tive committees Preparing goals and objectives PROGRAM Ensuring accreditation Ensuring system for and evaluation of med. staff competency exists 87.8 85.6 88.4 85.7 POLICY 1 1ANAGE;1ENT Deciding prices for services Lobbying regulatory agencies Chairing board comm. PROGRAM MANAGEMENT Designing CE pgms. for non-physicians Designing general educational pgms. RESOURCE iAN AG E:1ENT Obtaining consulting services Supervising construc tion projects Designing wage/benefit schedules for non-physicians Designing contracts for non-physicians Negotiating with unions 26.4 24.2 9.3 25.4 1 2. 0 27.2 20.3 1 3. 0 1 2. 6 6.8

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' I 'I j I l I i I i I II I I j : l 'l I : i :! : i :I I : I i I i I I 'i : I :I :I i i i 143 An examination of the tasks for which the low-est percentage of physician managers are responsible reveals three tasks considered policy management, two program management and five resource management. An analysis of these tasks shows that none deals with the medical staff or physicians. Half of these do involve financial aspects of management (e.g., deci-ding pricing for services) and two tasks relate to designing educational programs for non-physicians. Tables 4.9 through 4.11 illustrate the tasks for which 75 percent or more of physicians in hospi-tals are responsible. As these three tables show, 11 of the 21 tasks represented are policy manage-ment, six are program management, and four are resource management tasks. An of these tasks reveals that 15 out of the 21 tasks deal with physician-related activities. There are only two tasks for which less than 10 percent of physician managers are responsible. Neither deals with physicians One, (9%) chairing board committees is a policy management task. The other, negotiating with unions (0.8%) is a resource management task. Frequency of Occurrence. Similar to responsibility. all of the tasks were performed by some

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I j ,, I I I 144 TABLE 4.9 POLICY MANAGEMENT TASKS FOR WHICH MORE THAN 75$ OF PHYSICIANS ARE RESPONSIBLE IN HOSPITALS TASK Attend medical staff committees Monitoring and reporting on issues of medical staff to Preparing policies or procedures Communicating information to medical staff and governing body of organization Designing or reviewing new programs Honitoring and reporting to medical staff issues of interest to administration Attending administrative committees Preparing goals and objectives for organization Preparing agenda items for medical staff meetings Ensuring standards of care are written and disseminated Deciding on programs and medical services for 6rganization OF PHYSICIANS RESPONSIBLE 95.1 93.7 93-3 92. 1 90.1 89.8 87.8 85.6 80.9 76.8 7 6 0 1

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, I : I I I l 1 145 TABLE 4.10 PROGRAM MANAGEMENT TASKS FOR WHICH MORE THAN 75% OF PHYSICIANS ARE RESPONSIBLE IN HOSPITALS TASK Ensuring accreditation Ensuring system for review and evaluation of medical staff competency exists Ensuring system for review and evaluation of medical staff competency operates effectively Designing programs to compare physicians' behavior to established standards of care in organization Ensuring system for review and evaluation of credentials for new physicians exists Ensuring data to medical care issues are used appropriately % OF PHYSICIANS RESPONSIBLE 88.4 85.7 83.4 82.8 82.6 80.0

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: I i I I 146 TABLE 4.11 RESOURCE MANAGEMENT TASKS FOR WHICH MORE THAN OF PHYSICIANS ARE RESPONSIBLE IN HOSPITALS Of PHYSICIANS TASK RESPONSIBLE Mediating conflict among physicians 84.3 conflict among physicians and non-physician personnel 83.5 Mediating conflict among physicians and administration or governing body 78.4 Reviewing budget Cor part) 75.2

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'I I I I I I 147 physicians. Conversely, there were no tasks performed by 100 percent of the physicians. In addition, every task is performed by some physicians, even when not officially responsible for the task. As previously discussed, the choices "frequently" and "very fre-quently" were combined for this analysis and are called "often" in their combined form. The data indicate that only seven of the 86 tasks are not performed "often" by at least some of the physicians, despite their not being responsible for the task. In other words, even when "No" is selected as a response to responsibility question 92 percent of the tasks are performed "often" by some physicians. However, when "N/A" was selected, only 25 percent of the tasks were performed often. The 10 tasks physicians perform most and least often are shown in Table 4.12. Of the tasks performed most often, seven are policy management and three are program management. Of those performed least, one is policy management, three are program management, and six are resource management functions. A Spearman's correlation coefficient was cal-culated to measure the association between tasks for which physicians in hospitals are responsible and those they perform often. A coefficient of .6456 was obtained, indicating a positive relationship. That

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I I. I i I i I 148 TABLE 4.12 TASKS PHYSICIAN MANAGERS PERFORM AND LEAST OFTEN IN HOSPITALS :-tOST TASK PERCENT TASK PERCENT POLICY MANAGEMENT Attending medical staff committees 86.0 Monitoring & report ing to administration issues of interest to medical staff 81.5 Communicating infor mation to med. staff and governing body 80.8 Monitoring & report ing to medical staff of interest to administration Preparing agenda for medical staff 75.9 73.5 Attend admin. comm. 69.1 Prepare policies or procedures PROGRAM MANAGEMENT Ensure system for re-. view and evaluation 66.3 of new physicians 75.1 Ensuring accredi-69.0 tat ion Ensuring system for review and evaluation of medical staff competency 66.8 POLICY 11/t!lAGEHENT Chairing bd. committees 14.3 PROGRAii ilANAGEI-tENT Teaching CE programs non-physicians 16.9 Designing general ed-ucational programs 13.6 Monitoring risk man-agement programs 12.2 RESOURCE MANAGEMENT Designing wage/benefit schedules for physicians 15.1 physicians on professional issues Designing contracts for physicians Obtain/buy consulting services for org. Identifying need for outside consulting service Ensuring grievance procedure for non-physicians is followed 15.0 11.7 1 1 0 8.4 8. 1

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149 is, in general, if physicians are held responsible for a task, they are likely to perform it often. Physician !tanagers in Physician Organizations As shown in Table 4.13, over 98 percent of the physician managers in physician organizations are men. This is higher than the distribution for either all survey respondents or physician managers in hospitals. The average age for these physicians is 52 years. With regard to clinical specialty, Table 4.13 shows that internal medicine remains the predominant specialty (40%). The majority of physician managers in physician organizations (78%) have passed their boards in their area of specialization. The discus-sion about clinical specialty and Boards for physician managers in hospitals also applies here. These physicians have been in medical practice an average of 15 years. They have been in their current positions an average of six years. Three fourths (75%) of these physician manager worked for the organization before assuming their current posiI tion. Less than half (43%) consider their job full time, and 64 percent maintain a private Slightly more than half of these physicians (53%) have written contracts with their organizations but 65 percent have written job descriptions. Less than half

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TABLE 4.13 CHARACTERISTICS OF SURVEY RESPONDENTS IN PHYSICIAN ORGANIZATIONS Sex: Hale n:119 Age: Average = s2 years Clinical specialties: Internal med. Pediatrics Family practice Other General surgery Ob/gyn Psychiatry 39.7S 11.6S 10.7S 6.6S 5.8S '-'. 1 & Female n=2 (1.7S) (Range: 31-71 yrs.) Radiology Urology Preventive med. Emergency med. Anesthesiology Pathology 2.5S 1. 0.8S Board certification in area of specialization: of years in medical practice: Average 15 years 150 n 1 21 120 1 21 1 21 (Range 0-42 years) 121 of years in current position: Average 6 years (Range 0-35 years) 121 74.8: were working for the organization before assuming current position. 121 consider job full time. 56.7: consider job part time. 121 maintain a private medical practice. are somewhat satisfied or very satisfied with their job. 1 2 1 1 2 1

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15 1 have formal job evaluation. The vast majority of these physicians (88%) also report being either somewhat satisfied or very satisfied with their jobs. Responsibilities. As with the hospital group, there are no tasks for which all physicians in physician organizations either are or are not respon-sible. There were four tasks for which the "N/A" response was higher than the "No" response. ; I i Table 4.14 shows the ten tasks for which the highest and lowest percentage of physicians in this group are responsible. Of those with the highest frequency, nine are policy management and one is a resource management task. An of these tasks show that seven relate directly to physician .ties. Of those with the lowest frequency, two refer to policy management, three to program management and five to resource management. A review of the content of these tasks reveals that one task, designing coneducation programs for physicians, deals with : 1 physicians. I :j :J Tables 4.15 through 4.17 illustrate the tasks : j for which 75 percent or more of the physicians in ij physician organizations are responsible. As these : i !I tables show, 12 (57%) of the 21 tasks relate to pol-: i :I :1 icy, three (14%) to program management, and six I i

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I ; I 152 TABLE 4.14 TASKS FOR WHICH PHYSICIAN MANAGERS IN PHYSICIAN ORGANIZATIONS ARE MOST AND LEAST RESPONSIBLE HOST TASK PERCENT POI.ICY Preparing policies or procedures Designing or reviewing new programs Communicating information to med. and governing body Preparing goals and objectives Preparing agenda for physician meetings Deciding number and type of phys. that practice in org. Deciding on pgms. 9 4. 1 93.3 88.5 88.5 86.5 86.0 and med. services 85.7 Monitoring and report ing to med. staff issues of interest to administration 83.6 and report ing to administration issues of interest to medical staff 83.4 RESOURCE MANAGEMENT Mediating conflicts among physicians 85.1 I. EAST TASK PERCENT POI.ICY MANAGEMENT Deciding on research activity 36.4 Lobbying regulatory agencies 26.4 PROGRAI1 11ANAGE:ENT Designing CE programs for physicians 33.6 Teaching CE pgms. to non-physicians 29.6 Designing CE pgms. for non-physicians 24.5 RESOURCE r!ANAGEIIENT Ensuring a grievance procedure for non-physicians is followed Designing wage/benefit schedules for non-phys. Supervising construc tion projects Designing contracts for non-physicians Negotiating with unions 36.3 33.5 31.9 25.8 8.2

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! I I i l I r I I : I : i I I I I i i I i l j 153 TABLE 4.15 POL ICY l!AN AGErtENT TASKS FOR WHICH UOR E THAN 75% OF PHYSICIANS ARE RESPONSIBLE IN PHYSICIAN ORGANIZATIONS TASK Preparing policy or procedures Designing or reviewing new programs Communicating information to medical staff and governing body Preparing goals and objectives for the organization Preparing agenda for physician meetings Deciding number and type of-physicians that practices in organization Deciding on programs and medical services for organization Monitoring and reporting to medical staff issues of interest to administration Monitoring andreporting to administration issues of interest to medical staff Attending medical staff committees Deciding size of programs and medical services Deciding patient care equipment needs % PHYSICIANS RESPOUSIBLE 94.1 93.3 88.5 88.5 86.5 86.0 85.7 83.6 83.4 7 9. 1 76.2 75.2

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I I I I : I I I I I i 1 j TABLE 4.16 PROGRAM MANAGEMENT TASKS FOR WHICH MORE THAN OF PHYSICIANS ARE RESPONSIBLE IN PHYSICIAN ORGANIZATIONS TASK Ensuring system for review and evaluation of credentials of new physicians Ensuring system for review and evaluation of medical staff competency operates effectively Ensuring system for review and evaluation of medical staff competency exists PHYSICIANS RESPONSIBLE 79.5 76.2 76.2 154

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': i i i I I i I i I I I j I I I i i I ! I i l : f : i ; I 1 I : I I ; ; j : :; ; i I i l i I I 'l I i i 155 TABLE 4.17 RESOURCE MANAGEMENT TASKS FOR WHICH MORE THAN 75% OF PHYSICIANS ARE RESPONSIBLE IN PHYSICIAN ORGANIZATIONS TASK RESOURCE MANAGEMENT Mediating conflicts among physicians Ensuring physician recruiting program operates as needed Mediating conflicts among physicians and non-physicians Reviewing budget (or part) Hiring physicians Hediating conflicts among physicians and administration or governing body % PHYSICIANS RESPONSIBLE 85. 1 79.3 78.5 77. 1 76.8 75.0

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156 (29$) are resource management tasks. An analysis of these tasks reveal that 17 (81$) deal with physicians or medical care. Examining the tasks for which fewer than 10 percent of physicians are responsible shows only one, negotiating with unions (8%), which is a resource management task. Frequency of Occurrence. As with the respon-sibility dimension for physicians in physician organi-zations, all tasks are performed by some physicians, and no tasks for which physicians are responsible are performed by 100 percent of the physicians. When these physicians indicated no responsibility, 88 per-cent of the tasks are nonetheless performed often by some physicians. In one case, that of reviewing the budget for the organization, 100 percent of the physi-cian managers not responsible for the task performed it "often". The 10 tasks physician managers in physician organizations perform most and least often are presen-ted in Table 4.18. Of the tasks performed most often, seven are policy management and three are resource management. Of those performed least often, four are policy management, four are program management, and two are resource management tasks. The Spearman's correlation coefficient between tasks for which

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'i I I I I i I I I I i I i i I I I TABLE 4.18 TASKS PHYSICIAN !tANAGERS PERFORI 1 I10ST AND LEAST OFTEN IN PHYSICIAN ORGANIZATIONS MOST TASK PE:RCENT POLICY MAHAGEHENT Prepare agenda for med. staff meetings 74.4 Monitor & report to admin. on issues of interest to med. staff 73.4 Attend med. staff committees Communicate info. to both med. staff and governing body Deciding number/type of phys. to practice in organi:z:ation Prepare new or modify policies/procedures Monitor & report to med. staff issues of interest to admin. Rt:SOURCE UANAGE!1ENT Review financial per73.4 71.8 69. 1 58. 1 58.0 formance of org. 83.9 Design incentive pgms. to increase physician productivity 76.8 Design wage/benefit schedules. for non physicians 70.3 LEAST TASK POLICY HAUAGEMENT Lobbying regulatory agencies Write new or modify privileges of physicians Deciding research activities Prepare new or modify by-laws PROGRAH HANAGEHENT Evaluate ed. programs Design CE pgms. for non-physicians Design general educational programs reaching CE pgms. to non-physicians RESOURCE r1ANAGEHE!n conflicts among phys. & admin./gov. body Ensure grievance procedure for non-physicians is followed 157 PERCENT' 22.0 17.7 17.5 8.6 18.9 11.5 7.7 6.4 16.7 5.0

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158 physicians in physician organizations are responsible and those they perform often was positive at .4658. While this is positive, it is not as high as in hospi-tals, indicating less association between responsi-bility and frequency of performance than in hospitals. Comparison of Physician Managers in Hospitals and Physician Organizations These findings indicate that physician man-agers in physician organizations are more likely to have been selected for their current from within the organization than their counterparts in hospitals. In addition, are more apt to work part time and to maintain a private medical practice. On the other hand, physician. managers in hospitals are more likely to have written contracts with their or-ganizations, have written job descriptions, and have a formal job evaluation than physicians in physician organizations. There are both differences and similarities between the tasks for which physician managers in these two organizations are responsible and perform often. Table 4.19 presents a comparison of the 10 common tasks for which most physicians in hospitals and physician organizations have responsibility. Of these tasks, six are shared by the two groups. All shared tasks are policy management functions.

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' I I :1 : I I I I : I :I I ! 159 TABLE 4.19 COMPARISON OF 10 TASKS FOR WHICH THE HIGHEST PERCENT OF PHYSICIANS HAVE RESPONSIBILITY IN HOSPITALS AND PHYSICIAN ORGANIZATIONS TASK PC:RCEN! IN HOSPITALS !ASK PERCENT IN PHYSICIAN ORGS. 21 12 2 14 4 13 23 3 42 39 2 3 4 5 8 12 3 14 21 23 26 39 42 84 POLICY HANAGEHENT 95.0 93-7 93-3 92.1 90. 1 89.8 87.8 85.6 PROGRAH HANAGEHEMT 88.4 85.7 2 4 14 3 26 8 5 13 12 8 4 corresponds with task POLICY MANAGEMENT 94.1 93-3 88.5 88.5 86.5 86.0 85.7 83.6 83.4 RESOURCE MANAGEMENT 85. 1 Preparing new or modifying existing policies and procedures Preparing goals and objectives for the organization Designing or reviewing new Deciding which programs and medical services organization offers Deciding the number and type of physicians that practice in organization and reporting to administration issues of interest to medical staff Honitoring and reporting to medical staff issues of interest to administration Communicating information to both the medical staff and governing body Attending meciical staff committees Attending administrative committees Preparing agenda for medical staff or physicians' meetings Ensuring that a system for review and evaluation of medical staff competency exists Ensuring accreditation with JCAH, AAAHC, or other accrediting bodies Mediating conflict among physicians

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160 An examination of the tasks for which 75 per-cent or more of the physicians in hospitals and physi-cian organizations are responsible shows that 16 out of 21 of the tasks, are common to both groups. Of these, nine are policy management, three are program management, and four resource management. All of the resource management tasks for which 75 percent or more of the physician managers i I were responsible were common to both groups. When examining tasks common to both groups for which 10 percent or fewer physicians were responsible, only one task, negotiating with appeared. Of the tasks for which both groups have re-sponsibility, 57 percent deal directly with physician aspects of management. It could be argued that sev-eral tasks where "medical or "physician" is not articulated in the task statement nonetheless relate to physician aspects of management. For example, when physician managers prepare policies and procedures, a task shared by the two groups, these policies and procedures most likely to deal with physicians. A Spearman's correlation coefficient to meas-ure the association between the ranked tasks for which physician managers were responsible in hospitals and physician organizations wzs positive and hat .8071. In other words, there is a high degree of association

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: i 1 I I i I I I ; l I I I I j 1 I I I I : I i I I I I l j j i l I l I 1 6 1 between the most frequently occurring tasks in the hospital group and the physician organization group. As illustrated by Table 4.20, 60 percent of the tasks performed often by physicians in the two groups are shared and are also all policy management tasks. Of these, all but one relate to medical staff or physician activities. A Spearman's correlation coefficient to measure the association between tasks for which physician managers in hospitals and physician organizations perform "often" was positive at .6749. Clearly, the data reviewed indicate that phys-ician managers in both hospitals and physician organi-zations are responsible and perform many of the same tasks. Further, findings indicate that these tasks are likely to be policy management tasks that relate di-rectly or indirectly to medical staff or physicians in general. An analysis of the tasks for which few physicians are responsible perform often uncover no obvious patterns. However, negotiating with unions, a resource function, is a task for which physicians are consistently not responsible and do not perform often. Differences between hospitals and physician organizations become evident when the tasks are ana-lyzed by policy management, program management, and resource management categories. For 23 of the 36

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I I I I I I I i l 162 TABLE 4.20 COMPARISON OF 10 TASKS WHICH THE HIGHEST PERCENTAGE OF PHYSICIANS PERFORM OFTEN IN HOSPITALS AND PHYSICIAN ORGANIZATIONS PHYSICIANS PERFORI-1 MOST TASK PHYSICIANS PERFORl1 HOST OFTEN IN HOSPS. TASK OFTEN IN PHYS. ORGS. 21 12 14 13 26 23 2 38 42 40 POLICY 86.0 81.5 80.8 75.9 73.5 69. 1 66.3 PROGRAH MANAGEMENT '-. 75. 1 69.0 66.8 26 12 21 14 8 2 13 58 65 71 -POLICY HANAGEMENT 7!1.4 73.4 73.4 71.8 69.1 68. 1 68.0 RESOURCE MANAGEMENT 83.9 76.8 70.3 Number corresponds with task 2 8 12 1 3 1!1 21 23 26 38 40 !12 58 65 71 ?reparingnew or modifying existing policies and procedures Deciding the number and type of physicians that practice in organization :tonitoring and reporting to administration issues interest to medical staff Monitoring and reporting to medical staff issues of interest to administration Communicating information to the medical staff and governing body of organization Attending medical staff committees Attending administrative committees Preparing agenda for medical staff or physicians' meetings Ensuring a system for review and evaluation of credentials of new physicians Ensuring that a system for review and evaluation of medical staff competency operates efficiently Ensuring accreditation with JCAH, AAAHC, or other accrediting bodies Reviewing the financial performance of the organization Designing incentive to increase physician productivity Designing wage/benefit schedules for non-physicians

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! 1 I 163 policy management tasks, physicians in physician or-ganizations had a higher percentage of responsibility than physicians in hospitals. For 28 of the 36 re-source management tasks, physicians in physician or-ganizations also had a higher percentage of responsi-bility. Hpwever, for 13 of the 14 program management tasks, physicians in hospitals had a higher percentage of responsibility than physicians in physician organ-izations. For 21 of the 36 policy management tasks, a higher percentage of physicians in hospitals performed the tasks often. For all the 14 program management tasks, a higher percentage of physicians in hospitals performed the tasks often. However, for 26 of the 36 resource management tasks, a higher percentage of physicians in physician organizations performed the task often. Summary of Physician l1anager Responsibilities and Frequency of Task Performance In the analysis of the tasks for which most physician managers are responsible in hospitals and in physician organizations, the data indicate that there is a core group of tasks common to both groups. These are predominantly policy management tasks relating to the medical staff or to physicians in general. When the 10 tasks for which physicians in hospitals and

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i i I l I i I I I I I j I I l I I I i i I i I l 164 physician organizations are most and least responsible are examined, tasks dealing with the financial aspects of management are those for which physician managers are least responsible. Similar findings are evident with the 10 tasks performed most and least "often" by physician managers in both groups. The major difference betweem hospital and physician organizations as to tasks for which physi-cian managers are reponsible and perform is that phys-icians in hospitals are generally more involved with program management, and physicians in physician organ-izations are more involved in resource management tasks. Chi Square Analysis Crosstabulations were done on 10 representa-23 tive tasks by each of the 21 independent variables. Table 4.21 lists the 10 tasks. Table 4.22 shows the independent variables grouped by personal and organi-zational characteristics and the tasks for which there 22 was a p value of .05 or less. Only task #13 showed no significant association with any of the independent variables. Clearly, although there are a greater number of personal characteristic variables, organiza-tional characteristics account for task responsibility in many more of the tasks. These associations are

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TASK # 5 6 13 33 40 51 55 60 68 82 I I I TABLE 4.21 REPRESENTATIVE TASKS SELECTED FOR CHI SQUARE ANALYSIS TASK 165 Deciding which programs and medical services the organization offers. Deciding the size of programs and medical services. Monitoring and reporting to medical staff issues of interest to administration. Promoting the organization. Ensuring that a system for review and evaluation of medical staff competency oper_ ates. Monitoring and on data from systems designed to obtain information about medical care. Designing ways to improve efficiency of professional departments within the organization. Designing new or modifying existing risk management programs. Designing contracts for physicians. Advising and/or counseling physicians on career or professional issues.

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TABLE 4.22 INDEPENDENT VARIABLES AND TASKS WITH SIGNIFICANT ASSOCIATION INDEPENDENT VARIABLES TASKS WITH p <.05 ORGANIZATIONAL CHARACTERISTICS Type of organization Job description 6f licensed beds Physician org. size Ownership 6, 55, 5 33, 40, 51 6' 68 5, 40, 60 5 166 Line or staff Full time/part time 5, 6, 33, 55, 68, 82 55, 60, 82 PERSONAL CHARACTERISTICS Education Training in management Masters public health :tasters business admin. Hasters health admin. Graduate courses Continuing education Experience Yrs. in med. practice Yrs. in paid management Yrs. in other work Yrs. in Armed Service Voluntary mgmt. exp. Yrs. in job Work for org. before 55 82' 60 33 51 68 68. 33

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167 discussed below. Policy Management Tasks Task 05: Deciding which programs and medical services the organization offers. As shown in Table 4.23, four independent variables are significantly associated with physician manager responsibility for this task. All are considered organization charac-teristics. Type of organization is the first variable considered. Of physician managers whose organization is a hospital, 79 percent have responsibility for this task. Of physician managers whose organization is a physician organization, 88 percent have responsibility for this task. The size of the physician organization is the second factor significantly associated with this iask. Of physician managers in organizations with zero to five full-time physician employees (FTEs), 79 percent have responsibility for the task. Of physicians in organizations with six to 20 physician FTEs, 100 per-cent have responsibility for the task, and of physi-cian managers in organizations with 21 or more FTEs, 86 percent have responsibility for the task. This is the only task where ownership of the : organization or the form of governance is signifi1 cantly associated with physician responsibility. I I

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i I I I I I I I I j I I I I l I l I I I I I I i i :1 168 TABLE 4.23 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 05, DE CIDING WHICH PROGRAMS AND MEDICAL SERVICES THE ORGANIZATION OFFERS INDEPENDENT x2 VARIABLE YES tlO n d.o.f. p ORGANIZATION CHARACTERISTICS Type 364 3.955 1 .0467 Hospital 195 53 (21.4S) Physician 102 14 organization < 12. U> Size of phys. org. 364 6.994 2 .0303 o-s phys. 199 FTEs (21.3S) 6-20 phys. 20 0 FTEs < 100S) 21+ phys. 78 1 3 FTEs (14.3S) Owner-ship 364 14.899 5 .0108 For--pr-ofit 78 1 1 (87.6S) tJon-pro fit 187 49 (79.2S) F'ed. govt. 4 0 (100S) State govt. 2 4 i.ocal govt. 15 1

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I I i f 169 Table 4.23 (continued) EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK #5, DECIDING WHICH PROGRAMS AND MEDICAL SERVICES THE ORGANIZATION OFFERS INDEPENDENT VARIABLE YES n x2 d.o.f. p Other 1 1 2 Line 225 37 CH.a> 363 10.745 .0010 Staff 71 30 I C70.3S) C29.7S)

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I j I l i 170 As Table 4.23 shows, the number of physician managers in federal government organizations is small. How-ever, of these, 100 percent have responsibility for this task. In contrast, of physician managers in organizations owned by state governments, only 33 percent have responsibility for the task. An addi-tional finding regarding ownership is that more physi-cian managers in for-profit organizations have respon-sibility for this task than physician managers in non-profit organizations. Having a line in the organization is the last factor that has a association with responsibility for this task. Of physician man-agers with line positions, 86 percent have responsi-b1lity. In contrast, 70 percent of physicians with staff positions are responsible. Task #6, deciding the size of programs and medical services. Table 4.24 shows the three organ-izational variables that are significantly associated with physician manager responsibility for deciding the size of programs and medical services. Of physician managers in hospitals, 74 percent have responsibility for this task. Of physician managers in physician organizations, 85 percent have responsibility. The number of licensed beds is the size

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; I i 1 7 1 TABLE 4.24 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK #6, DECIDING THE SIZE OF PROGRAMS AND MEDICAL SERVICES INDEPENDEiiT x2 VARIABLE YES NO n d.o.f. p ORGANIZATION CHARACTERISTICS Type 4.221 1 .0399 Hospital 173 61 (26.U> Physician 93 17 organization (15.5S> of lieen.sed beds -344 5.964 2 .0507 50 or fewer 99 19 c16.1!> 51 to 199 31 7 (18.4S) 200+ 136 52 (72.3S> {27.7S) Line 207 41 344 17.887 1 .0000 C83.5S> (16.5S) Staff 59 37 (61.5S)

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: I i j i I I I : I I i I i I I i i : 172 variable associated with physician manager responsi-bility for this task. Of physician managers who work in hospitals with 50 or fewer beds, 84 percent have responsibility. In hospitals with 51-199 beds, 82 percent have responsibility, and in hospitals with 200 or more beds. 72 percent have responsibility. The last variable significantly associated with this task is line position. Of physician man-agers with line position, 84 percent have responsibil-ity for the task. Of physician managers with staff position, 62 percent have responsibility for the task. Task 033, promoting the organization. As illustrated in Table 4.25, two organizational charac-teristics and two personal .characteristics are signi-ficantly associated with physician manager responsi-bility for promoting the organization. Of physician managers with a written job description, 74 percent have responsibility for the task. Of physician man-agers without a job description, 62 percent have re-sponsibility for the task. Having a line position is significantly and positively associated with physician responsibility for promoting the organization. Of physician managers with line positions, 75 percent have responsibility,

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'' : l i i i I I I i I I I I i : i I I . 173 TABLE 4.25 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK #33, PROMOTING THE ORGANIZATION INDEPENDENT x2 VARIABLE YES NO. n d.o.f. p ORGANIZATIONAL CHARACTERISTICS Written job description 342 3.958 1 .0466 Yes 200 69 C74.3S) (25.7S) No 45 28 C61.6S) C38.4S) Line 183 60 340 5. 5 11 1 .0189 C75.3S) (24.7S) Staff 60 37 (61.9S) < 38. a> PERSONAL CHA;RACTERISTICS Experience Years in paid canagement 345 6. 124 2 .0468 0-4 166 52 C76.a> 5-10 58 34 C63.0S) (37.0) 11 + 23 12 C65.7S) C34.3S)

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:1 I 174 Table 4.25 (continued) EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK D33, PRO!tOTING THE ORGANIZATION INDEPENDErfT ){2 VARIABLE YES n d.o.f. Yeal"s in p CUl"l"ent job 339 5. 8 32 2 .0328 0-4 1 1 8 55 i <32.2S.) 5-10 91 37 (71. U> 11+ 33 4 C89.2S) (10.8S)

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175 while 62 percent of physician managers with staff positions have responsibility for the task. The years spent in a paid management position prior to accepting the current job is a personal characteristic variable significantly associated with this task. More physician managers zero to four years of experience have responsibility for this task than physician managers with five to 10 years or 11 or more years The reverse is found when the association between this task and the number of years in the current position is examined. Of physician managers with zero to four years of experience, 68 percent had responsibility for the task. This is less than physician managers with five to 10 years or those with 11 or more years Program Management Tasks Task 940, ensuring that a system for review and evaluation of medical staff competency operates effectively. As shown in Table 4.26, two variables, both organizational characteristics. are significantly associated with the task of ensuring that a system for review and evaluation of medical staff competency operates effectively. Of physician managers with a job description, 91 percent have responsibility for

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! j I j i I I I I I I I l I i l I i i I I I I ! 176 TABLE 4.26 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 140, ENSUR ING THAT A SYSTEM FOR REVIEW AND EVALUATION OF MEDICAL STAFF COMPETENCY OPERATES IN DEPEND x2 VARIABLE YES rw n d.o.f. ORGANIZATIONAL CHARACTERISTICS Written job p description 353 15.036 1 .0001 Yes 253 25 No 55 20 Size of physi-cian organization 356 6.306 2 .0427 -0-5 phys. 223 27 F'fEs 6-20 phys. 17 1 FTEs 21+ phys. 70 18 FTEs

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177 this task, and of physician managers without a job description, 73 percent have responsibility for this task. The size of a physician organization also influences physician manager responsibility for this task. Of physician managers in organizations with zero to five FTEs, 89 percent have responsibility. This increases to 94 percent when the organization has six to 20 FTEs. Of physician managers in organiza-tions with 21 or more FTEs, 80 percent have responsi-bility for this task. Task 060, designing new or modifying existing risk management functions. As shown on Table 4.27, two organizational characteristics and one personal charac-teristic are significantly associated with responsibil-ity for designing new or modifying existing risk man-agement functions. Physician organization size af-fects responsibility as follows: of physician man-agers who work in organizations with zero to five FTEs, 58 percent have responsibility. This increases l j to 88 percent with six to 20 FTEs, and drops to 44 i l percent with 21 or more full-time physician employees. The other organizational characteristic asso-ciated with this task is whether or not the position is full time. Of physician managers with full time

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; I I : I l 178 TABLE 4.27 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK #60, DESIGNING NE\i OR 110DIFYING EXISTING RISK !1ANAGEr1ENT PROGRAMS I N D E P E N D E !JT I x2 VARIABLE YES n d.o.f. p : ORGANIZATIONAL l CHARACTERISTICS Size of I phys. or g. l 254 6.516 2 .0385 0-5 phys. 1 14 82 FTEs 6-20 phys. 7 1 FTEs 21+ phys. 22 28 F!Es Full time 105 67 (61 Part time 37 44 PERSONAL CHARACTER IST.ICS Experience 254 7.945 2 I .o1a8 Yrs. in med. I practice 0-10 47 3 1 I 1 1-20 43 52 (45.3S) 21+ 53 28

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. ' i I 179 positions, 61 percent have responsibiity for the task, while only 46 percent have responsibility when the position is part time. The personal characteristics associated with this task is the number of years of experience in medical practice. Of physicians with zero to 10 years in practice, 60 percent have responsibility. Of those with 11-20 years, only 45 percent have responsibility. Of those with 21 or more years, 65 percent have respon-sibility for this task. Resource Management Tasks Task 351J monitoring and reporting on data from systems designed to obtain information about medical care. The task of monitoring and reporting on data from systems designed to obtain information about I medical care is significantly influenced by two inded pendent variables. These are job description, an organizational characteristic, and the number of years in the armed services, a personal characteristic re-lated to experience. As shown in Table 4.28, of physician managers with a job description, 77 percent have responsibility, and without a job description, 59 percent have responsibility for this task With regard to years in the armed services, I I of physician managers with zero to three years I I I !

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: I I I I I I I 180 TABLE 4.28 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 051, MONITOR ING AND ON DATA FROI1 SYSTEI1S DESIGNED TO OBTAIN INFORMATION ABOUT MEDICAL CARE ffiEPENDEN! VARIABLE YES IJO n x:2 d.o.f. ORGANIZATIONAL I CHARACTERISTICS I I Written job I p description 340 9.027 l 0027 I Yes 204 61 tlo 44 31 PERSONAL I CHARACTERISTICS I Experience I I Years in armed I services 340 6.599 2 .0369 0-3 196 66 4-10 35 23 (39.7%) 11 + 17 3 ( 15 ..

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' I I I I I i i 1 8 1 experience, 75 percent have responsibility for this task. This drops to 60 percent with four to 10 years of experience, and of physician managers with 11 or more years of experience, 85 percent have responsibility. Task #55, designing ways to improve efficiency of professional departments. As shown in Table 4.29, the task of designing ways to improve efficiency of professional departments is significantly associated with five factors. Three are organizational charac-teristics: organizational type, line position, and full or part-time position. One is a personal char-acteristic: graduate courses. Of physician managers in hospitals, 62 percent have responsibility for this task. Of physician man-agers in physician organizations, 75 percent are re-sponsible. Line or staff position is associated with this task as follows. Of physician managers with line positions, 75 percent have responsibility. When the position is considered staff, 47 percent have respon-sibility. The significant association between full-time positions and this task is as follows: Of physi-cian managers with full-time positions, 71 percent have responsibility. If the job is part-time, 58

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I I I i I 182 TABLE 4.29 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 155, DESIGN ING WAYS TO IMPROVE EffiCIENCY OF PROFESSIONAL DEPARTMENTS IN DEPEI1DENT I x2 VARIABLE '!ES NO n d.o.f. p ORGA:liZAT IOrJAL CHARACTERISTICS Type 331 5.378 1 .0204 Hospital 137 85 i I Physician 82 27 organization Line 174 61 326 19.967 1 .0000 I Staff 43 48 Full time 153 64 330 5.023 1 .0250 Part time 65 48 (42.5S) Education Grad. courses 331 3.721 1 .0537 Yes 48 14 I No 17 1 98

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183 percent have responsibility. This task is the only one of the 10 representative tasks significantly associated with an education variable. Physicians with graduate courses in a university setting have higher rates of responsibility for this task. Of physician managers with graduate courses, 77 percent have responsibility, and without graduate courses 64 percent have responsibility. Task 68, designing contracts for physicians. Four independent variables are significantly associated with the task of designing contracts for physicians. Two are the number of licensed beds, and line staff position. Two are personal characteristics that have do with experience, voluntary management experience, and the number of years in the current position. As shown in Table 4.30, of physician managers who work in hospitals with 50 or fewer licensed beds, 66 percent have responsibility for the task. This drops to 46 percent in organizations with 51-199 beds, and increases to 57 percent in organizations with 200 or more beds. Of physicians with line positions, 64 percent have responsibility. This contrasts to the 45 percent of those who have staff positions. The personal characteristics variables

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: I ; I ; I I I : I I I i 1 I I I I 1 184 TABLE 4.30 EXTENT OF ASSOCIATION BETWEEH INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 068, DESIGNING CONTRACTS FOR PHYSICIANS x2 VARIABLE YES NO n j.o.f. p CHARACTERISTICS Number of licensed beds 321 5.084 2 .0549 SO or fewer 81 41 (66.4S) 51-199 18 21 (46.2S) (53.8S) I 200+ 94 72 I (43.4S) Line 147 82 3221 9. 1 1 1 1 .0025 (64.2S) C35;8S) Staff 42 51 (54.8S> PERSONAL CHARACTERISTICS Experience Voluntary I management 327 5.923 1 .0149 Yes 150 1 1 9 (5"5.8S) (44.2S) No 43 15 (74.U) I

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. .. i l I i I I 185 Table 4.30 (continued) EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK #68, DESIGNING CONTRACTS FOR PHYSICIANS INDEPENDENT x2 VARIABLE YES rlo n d.o.f. I Years in p current job 322 7.832 2 I .0199 79 (51.5S) 5-10 78 46 11+ 26 9 (74.3:!) (25.7S>

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186 associated with responsibility for this task are as follows: Of physician managers with voluntary management experience, 56 percent have responsibility for the task. Of physician managers without this experience, .74 percent have responsibility. The other experience variable is the number of years in the current position. Of physician managers in this position zero to 4 years, 52 percent have responsibility for the task. This increases to 63 percent with five to 10 years on the job, and to 74 percent with 11 or more years. Task 082, advising Physicians on career or professional issues. As shown in Table 4.31, three factors are significantly associated with the task of advising physicians on career or professional issues. Two are organizational characteristics. These are and full-time position. Of physician managers with line positions, 76 percent have responsibility for this task, while 64 percent of physician managers with staff ositions have responsibility. Of full-time physician managers 81 percent have responsibility, while 57 percent of those with part-time positions have responsibility. The personal characteristic associated with this task is the number of years in medical practice.

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' I I 187 TABLE 4.31 EXTENT OF ASSOCIATION BETWEEN INDEPENDENT VARIABLES AND PHYSICIAN RESPONSIBILITY FOR TASK 082, ADVIS ING PHYSICIANS ON CAREER OR PROFESSIONAL ISSUES r:lDEPEMDENT VARIABLE YES r1o n x2 d.o.f. ORGANIZATIONAL I CHARACTERISTICS I Line 189 60 345 4.705 1 Staff 61 35 Full time 184 43 347 22.278 1 C81.a> Part time 68 52 I PERSONAL -I CHARACTERISTICS I I Experience I I Years in med. 351 6.454 2 practice 0-10 80 38 1,-20 102 24 (81 21+ 74 33 p .0301 .0353 .0397

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188 Of physician managers with zero to 10 years in medical practice, 68 percent have responsibility for this task. This increases to 81 percent with 11 to 20 years of medical practice, and decreases to 69 percent with over 21 years of experience. Summary of Findings The most important finding from the chi-square analysis is that organizational characteristics are significantly associated with more of the representa-tive tasks than are personal characteristics. Nine of the 10 tasks are associated with at least one of the 21 independent variables. Bowever, as shown in Table 4.32, none of the tasks was associated with more than five of these factors. Beginning with organizational characteristics, a line as opposed to a staff position was found to be associated with six of the 10 tasks. These are: #5, #6, 033, 055, 068 and #82 (see Table 4.22). Consis-tently, physician managers with line positions have higher rates of responsibility than those with staff positions. The type of organization, hospital or physi-cian organization, was found to be significantly asso-ciated with three tasks, #5, 06, and #55. In each case, physician managers in physician organizations

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i I i l I I i I l I i j I i I i I I 189 TABLE 4.32 ASSOCIATION BETWEEN PHYSICIAN MANAGER RESPONSIBILITY FOR TASKS AND INDEPENDENT VARIABLES TASK 15 Deciding which programs and medical services the organization, or agency offers 16 Deciding the size of programs and medical services 113 Monitoring and reporting to medical staff issues of interest to administration 133 Promoting the organization, department/service or agency #40 Ensuring that a system for review and evaluation of medical staff competency operates efficiently 151 Honitoring and reporting on data from systems designed to obtain information about medical care INDEPENDENT VARIABLE WITH p <.OS ORG. CHARACTERISTICS Type of organization Physician org. size Line position Ownership ORG. CHARACTERISTICS Type of organization Number of licensed beds Line position NONE ORG. CHARACTEliSTICS Job description Line position PERSONAL CHARACTERISTICS Yrs. in paid management Yrs. in current job ORG. CHARACTERISTICS Job description Phys. org. size ORG. CHARACTERISTICS Job description PERSONAL Yrs. in armed service

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. ! I I i j I I i I I I I I I i I 190 Table 4.32 (continued) ASSOCIATION BETWEEN PHYSICIAN RESPONSIBILITY FOR TASKS AND INDEPENDENT VARIABLES TASK #55 Designing ways to improve efficiency of professional departments within the organization or agency 060 Designing new or modifying existing risk management functions and/or programs 168 Designing contracts for physicians 182 Advising and/or counseling physicians on career or professional issues INDEPENDENT VARIAABLES WITH p <.05 ORG. CHARACTERISTICS Type Line position Full-time position PERSONAL CHARACTERISTICS Graduate courses ORG. CHARACTERISTICS Phys. org. size Full-time position PERSONAL CHARACTERISTICS Yrs. in med. practice ORG. CHARACTERISTICS Number of licensed beds Line position PERSONAL CHARACTERISTICS Voluntary Qanagement experience Yrs. in current job ORG. CHARACTERISTICS Line position Full-time position PERSONAL CHARACTERISTICS Years in med. practice

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; I i I I I I I I I I I i l i i 1 9 1 have higher rates of responsibility. The size of the physician organization is also associated with three tasks. Only task #5 is common to both the type and the size variable. The other two tasks are #40 and 060. In each case, physician managers who work in physician organizations with six to 20 physician FTEs (as opposed to zero to five, or 21 or more) have the highest rates of responsibility. Having a job description is significantly associated with three tasks. These are: #33, #40 and #51. In each case, physician managers with a written job description have higher_rates of responsibility for the task than those without a job description. Working full time is also associated with three tasks. These are, #55, #60 and #82. For all three, physician managers with full time positions have higher rates of responsibility than those with part-time positions. The number of licensed beds, which is one way to measure hospital size, was significantly associated with responsibility for two tasks. These are #6 and #68. In both cases, physician managers who worked in hospitals with 50 or fewer beds have the highest rates of responsibility. With task #6, physician managers in hospitals with between 51-199 beds had higher rates of responsibility than those working in organizations i with over 200 beds. However, with task /168, more

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:I i I : j : I ij : i I : l I 192 physician managers in the larger institution have responsibility for the task. The last organizational characteristic ex-amined in this study is ownership. or the form of governance. This characteristic is associated with only one task, #5. Here, more physician managers in or run by the federal government have responsibility for the task, while fewest have responsibility in state-run hospitals. Another find-ing regarding ownership is that physician managers in for-profit organizations have higher rates of respon-sibility than those working in non-profit organiza-tions. With regard to personal characteristics, it was found that various types of experience is asso-ciated with responsibility for several tasks. Educa-tion, on the other hand, is associated with responsi-bility for only one task. Factors such as training in management. a Master's degree, and continuing education, were not found to be associated with respons-ibility for any of the 10 tasks. Only graduate course work in a university setting is associated with physi-cian responsibility, and this occurs in task #55. More physician managers with graduate courses have responsibility for this task than do those without graduate courses.

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193 The years of experience in medical practice, the years spent in the current position, and the number of years in the armed services are all asso-ciated with physician manager responsibility. In each case, the longer the experience, the more physician managers have responsibility for the task. The number of years in medical practice is associated with re-sponsibility for tasks #60 and #82. The years in current position is associated for tasks 033 and #68. The number of years in the armed services is asso-ciated with task #51. A negative association is found between physi-cian managers with voluntary management experience and responsibility. Fewer physician managers with volun-tary management experience have responsibility for task 1168 than th"ose without this ex.perience. The same is true for the number of years in paid management. Physician managers.with zero to four years of exper-ience had higher rates of responsibility than those with more years of paid management experience. The number of years in other work before assum-ing the current position, and working for the organi-zation prior to accepting the current position, were not found to be significantly associated with respon-sibility for any of the 10 tasks.

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. I 194 NOTES CHAPTER IV 1. A comparison of job titles among respondents and non-respondents suggests that the physician managers who responded to the survey are representative of the total population of physician members of AAMD. 2. Since so few women (n=20) were involved, sex was not used as an independent variable. 3. Not all findings are presented in tabular form. See Appendix B, p. 251 for data. 4. See Appendix B, p. 253 for data. 5. Many averages reported in this section were calculated without the responses of physicians whose reported values were so high that they skewed the averages. For this particular average, three outliers were excluded. When included, this average is 375. 6. For this particuiar average, six outliers were excluded. When included, the average is 19.8. 7. For this particular average, four outliers were excluded. When included, the average is 91.8. 8. For this particular average, one outlier was excluded. When included, the average is 18.6. 9. For this particular average, five outliers were excluded. When included, the average is 651. An example of one outlier was the medical director of a large group in southern California who included multiple facilities in his responses. 10. For a list of specific affiliations see Appendix B, p. 256. 11. For this particular average, two outliers were excluded. When included, the average is 208. 12. For this particular average, three outlers were excluded. When included, the average is 66. 13. For this particular average, two outliers were excluded. When included, the average is 2665. 14. For list of "other" types of organizations see Appendix C, p. 278.

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195 15. Definitions of influence and authority were not provided in the survey. However, authority is generally defined as the power associated with a position in the organization (Katz and Kahn, 1978). Influence is "the process whereby A modifies the attitudes or behavior of B. Power is that which enables him to do it." (Handy, 1976, p. 111). 16. See Appendix B, p. 258 for data. 17.This figure is lower than the average phys-icians' income in the United States for 1982, which was reported to be $99,500 (Rich, 1984). 18. Tasks added by respondents are listed in Appendix C, p. 284. 19. In a study of behavior and leadership styles of physician manager members of AAHD, Kurtz (1980) found that internists differed significantly from the total group. Using self-assessment feedback instruments, internists reported not experiencing a high degree of discomfort in conflict settings. In these situations they into authority stances in order tc centro! the situation. Kurtz speculated that the low discomfort levels might indicate a higher tolerance for stress and conflict than other specialty groups. 20. It is important to distinguish between responses of "No" and that of "Not Applicable (N/A)". "Ho" was intended to mean the respondent did not have responsibility for the task. However, a "No" response does not preclude the possibility that the task was the responsibility of someone else in the organization. "N/A" is more complex. As the instructions implied, it was intended to mean that in perception of the respondent, the task is irrelevant to the type of organization within which she/he works and hence, the task may not be anyone's responsibility. However, "N/A" might also mean that the respondent clearly. knew the task was someone else's responsibility and therefore not applicable to him or herself. 21. As discussed in Chapter III, a factor analysis was used to select a subset of 10 representative tasks. 22. Title was treated as an independent variable and found to be statistically significant in eight of the 10 representative tasks. However, there

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!I ; l : i i : I : I I : I j j i I i l 196 were 11 categories of titles and no way in which they could be collapsed. It is probable that the significance was due to the large number of categories, and therefore title has been removed from further analysis.

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' ; ' j! : 1 I I. I i I I I I I I I I l l CHAPTER V CONCLUSIONS AND RECOMMENDATIONS FOR FURTHER STUDY This chapter presents the conclusions from the study, beginning with the analysis of physician managers in hospitals and physician organizations. Next, conclusions from the chi-square analysis are discussed. The chapter ends with several recommenda-tions for further study. Conclusions from Analysis of Physician Hanagers in and Physician Organizations The first most significant conclusion of this study is that, regardless of organizational affilia-tion, physician managers have responsibility for and perform tasks that are appropriate. In essence, phys-ician managers are doing what the literature on this topic suggests they ought to do in order to maximize their influence on the efficiency and effectiveness of their organizationss. Table 5.1 lists the tasks by management func-tions that are common to both groups of physician managers and for which more than 75 percent of physi-cians have responsibility. Unlike managers in other

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198 TABLE 5.1 TASKS FOR WHICH !10RE THAN 75S OF PHYSICIAN MANAGERS ARE RESPONSIBLE IN HOSPITALS AHD PHYSICIAN ORGANIZATIONS TASK POLICY MANAGEMENT Attend med. staff committees Monitoring and reporting to administration issues of in terest to med. staff Preparing policies or procedures Communicating information to med. staff and governing body of org. Designing or reviewing new pgms. rtonitoring and reporting on issues of admin. to med. staff Preparing goals and objectives for organization Preparing agenda items for med. staff meetings Deciding on pgms. and med. services for organization PROGRAM HANAGEHEWT Ensuring system for review and evaluation of med. staff competency exists Ensuring system for and evaluation of credentials of new physicians exists ORGANIZATIONAL ACTIVITY org. decision making Coordination Org. decision caking Coordinating Org. decision making, cost/quality assurance Coordinating Org. decision making, cost/quality assurance Coordinating Org. decision making, cost/quality assurance Org. decision-making, cost/quality assurance, regulation decision making

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; i I I I I l i j I i i I I i I II ll I i l : I i i I I i I :l I i I 'I 1 I : I i I ; j i : I I :' .I : I ; i l : . 199 Table 5.1 (continued) TASKS FOR WHICH MORE THAN 75% OF PHYSICIAN MANAGERS ARE RESPONSIBLE IN HOSPITALS AND PHYSICIAN ORGANIZATIONS TASK RESOURCE HANAGEHENT Mediating conflicts among physicians conflicts among physician and non-physician personnel Reviewing budget (or part) conflicts among physi-. cians and administration or governing body ORGAtiiZATIONAL ACTIVITY Reducing tension, leading to coord ination Reducing tension Reducing tension Reducing tension

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i i I I I f, d lj II I ; I i I I lj j, i 11 i! II I I I ll ll i I I' !I I i '! 1 i ; i I' i l I' II i I I i J ; l I I: ! '' I. I: ; t i I i ; .I i i: i I I i ; ; ; ; ; I I : 200 organizations, physician managers have taken on signi-ficant policy management responsibilities (Burgess, 1984). According to Burgess, this is most appro-priate. It seems that when managers in non-health care organizations, especially in public institutions, are faced with the challenge of having to increase efficiency and effectiveness, they inappropriately focus on resource management functions. Although this may result in short-term benefits, only a focus on policy management functions promotes the processes of policy analysis, diagnosis, and evaluation. This, in turn, facilitates invention of remedial alternatives that promote the long-term efficiency and effective-ness of the organization (Burgess, 1975; Burgess, 1984). Table 5.1 also illustrates the tasks that re-late to the medical staff and to three activities known to be important to the efficiency and effective-ness of health care organizations. The majority of tasks common to physician managers are related to the medical staff and deal with either coordination, con-flict management, and/or organizational decision making. There is additional support for the conclusion that physician managers are responsible for appro-priate tasks. As discussed in Chapter II, when

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I l I I i 201 physicians participate in organizational decision-making, it results in a higher quality of care and decreased costs (Shortell and LoGerfo, 1981; Sloan and Becker, 1981). Scott and Shortell (1983) suggest a number of specific actions for health care managers to take in order to increase the efficiency and effec-tiveness of their organizations. These are: (1) emphasize structural and process control vs. outcome control, (2) create substitutes for formal leadership by developing cohesive work groups, and (3) help to enact reality for people by articulating shared con-cerns, attitudes, values, of staff members and by directing the flow of information. Table 5.2 compares the tasks common to physi-cian managers with the actions suggested by Scott and Shortell. Clearly, every task listed can be matched with one-of these activities. For example, mediating conflict will help create cohesive work groups; at-tending meetings and communicating information is directing the flow of information; and preparing pol-icy and procedures, and/or goals and is emphasizing structural vs. outcome control. That physician are doing what the literature suggests they should, is thus established. What can be implied by this conclusion is that physi-cians take a broad view of their management

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; j ; 202 TABLE 5.2 COMPARISON OF PHYSICIAN MANAGER TASKS WITH SPECIFIC EFFICIENCY AND EFFECTIVENESS ACTIONS ACTION: Emphasize structural and process control vs. outcome control. TASKS: Preparing policies and procedures Designing or reviewing new programs Preparing goals and objectives. Deciding on programs and medical services for organization Ensuring system for review and evaluation of medical staff competency exists Reviewing budget ACTION: Create substitutes for formal leadership by developing cohesive work groups TASKS: conflict among physicians liediating conflict among physicians and non-physician personnel conflict among physicians and administration or body ACTIOU: Help to enact reality for people by articulating shared concerns, attitudes, values, and capabilities of staff members and by directing the flow of information. TASKS: Attending medical staff committees t1onitoring and reporting to medical staff issues of interest to administration Communicating information to medical staff and governing body of organization Monitoring and reporting on issues of administration to medical staff Preparing agenda items for medical staff meetings

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. I ' i : : ; 203 responsibilities, take these responsibilities ser-iously, and are effective managers. Conventional wisdom says that those educated and trained in generic management should run health care organizations (Drucker, 1973). Evidently, what is occurring is that non-physician managers can not do it alone. Physi-cians must and have a meaningful management role in the health care system. The second conclusion of this study stems from the finding about the major difference between the tasks for which physician managers in hospitals and physician organizations are_responsible. In hospi-tals, more physicians are responsible for program management functions, and in physician organizations, more are responsible for resource management func-tions. The conclusion, supported by the literature, is that these task differences result from differences in the organizational of hospitals and phys-ician organizations. This is not surprising and essentially reinforces what is known about the two types of organizations. Hospitals are generally formal, bureaucratic organizations. They are more likely to have a variety of programs, such as quality assurance and risk man-agement, in which physician managers would be in-volved. In addition, as bureaucratic structures,

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204 hospitals create a division of labor, (Katz and Kahn, 1978). For example, most have personnel departments that are responsible for many tasks considered to be 1 resource management functions. Therefore it follows 1 that resource management tasks would not be the re-sponsibility of physician managers. On the other hand, physician organizations are likely to be smaller than hospitals and singularly dedicated to service. They generally provide minimal professional support to physicians in terms of organ-ized programs. Physician organizations rely on more of a decentralized self-administered system versus the more centralized bureaucratically administered system 1 of the hospital. Additional explanations for physician managers in physician organizations being responsible for resource management tasks include: an incentive to conserve resources by performing these tasks them-selves; a desire to deal directly with their personnel, with contracts with physicians, etc.; and a de-sire to obtain or maintain direct control of their organizational environments. For example, these phys-icians can hire individuals (receptionists, nurses, and other physicians), that will mesh with their pa-tient population and their own personalities. Finally, because they are smaller, physician

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205 organizations would most likely be severely affected by internal conflict and tension. This might explain why mediating conflict among physicians is among the tasks for which the vast majority of physicians in physician orginizations are responsible. Another finding of this study is that physician managers are not generally involved with the financial aspects of management. However, no clear cut conclusions can be made about the reasons more physicians are not responsible for financial management tasks. Some authors suggest this may be due to inadequate knowledge of financial management on the part of physician. (Herzlinger, 1978). However, it may also be due to other factors such as a conscious choice on the part of the physician to participate, or the unwillingness of the board of directors to permit this type of participation. Nonetheless, physician involvement in this area must be increased if they are to reach their potential as managers. Physician managers in hospitals and physician organizations have different working arrangements with their organizations. Physicians in physician organizations are more likely than their counterparts to have been selected for their position from within the organization, work part time, and maintain a private medical practice. It appears that physician managers

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I I ; 206 in physician organizations agree with Slater (1980a), who argues that physicians need to continue private practices to maintain .their credibility. (This is consistent with the fact that more of these physician managers work part time). In contrast, physician managers in hospitals are more likely to have formal contracts with the organization, a written job de-scription, and regular job evaluations. Once again, it can be concluded that differ-ences in organizational structure account for differ-ences between physician managers. According to Katz and Kahn (1978), larger, more complex organizations need to develop formal control mechanisms to ensure conformity with organizational goals. Contracts, job descriptions, and evaluations are all considered con-trol mechanisms. It is probable that the smaller, more informal structure of physician organizations, is able to accommodate to the needs and/or desires of the organization and the individual, while the hospital can not. Conclusions from Chi-Square Analysis The most important conclusion resulting from the chi-square analysis is that organizational charac-teristics are more influential in determining physi-cian manager responsibility for the 10 representataive

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I I I I I i i 1 I I I I l l! j i I: i : i ; l I f I i : i i i l j i i ; '' : 207 2 tasks than personal characteristics. Specifically, having a line as opposed to staff position is asso-ciated with responsibility for six of the 10 tasks. Type of organization, job description, size of the physician organization, and full versus part-time position are all significantly associated with respon-sibility for three tasks. The number of licensed beds is associated with responsibility for two tasks, and ownership with one task. The distinction between line and staff has long been accepted as a way to differentiate between types of positions within organizations. In this study, line positions are consistently associated with physician managers having higher rates of respon-sibility for the tasks. Recently the American Academy of Medical Directors (AAHD) has chosen to use a line position as a criterion for fellowship in the recently formed American College of Physician Executives. This reinforces the perceived importance of a line position to physician managers. With regard to job description and full versus part-time positions, the association with physician managers' responsibility is not surprising. More physician managers who work full time and who have written job descriptions have responsibility for cer-tain tasks. However, organizational type, size and

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. I ; I 208 ownership deserve additional comment. Organizational type, ownership, and size are often considered factors in explaining var-ious characteristics of organizational structure (Pugh et. al., 1969). These in turn are known to affect the role of health administrators (Kuhl, 1977). In this study, physician managers in physician organizations had higher rates of responsibility for three tasks. Two of these are considered policy management: #5, deciding which programs and medical services the organ-ization and 06, deciding the size of programs and medical services. If physician organizations are smaller, less formal organizations, it is intuitively appealing to assume that physician managers would have responsibility for these tasks. In act, there is likely to be no one else in the organization who could or would make these decisions. The same argument could be made regarding task #55, designing ways to improve efficiency of profes-sional departments. This is a resource management function and it has been previously established that physician managers in physician organizations have higher rates of responsibility for resource management tasks than their counterparts in hospitals. However, it is understandable that because physician organiza-tions are less bureaucratic, physician managers could

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i l I ; l ; i '; 'j : 209 be imaginative and inventive and might experiment with ways to improve efficiency. They are unencumbered by the massive red tape common to most bureaucratic or-ganizations. A specific pattern is evident when the asso-ciation between the size of a physician organization and responsibility is examined. Physician managers in medium-sized physician organizations (6-20 FTEs) have higher rates of responsibility than small (0-5 FTEs) or large organizations (21+). One explanation of this finding may be that in larger physician organizations, as with hospitals, a division of Labor results in specialists being hired to assume responsibility for tasks that were the responsibility of phys i ician managers (e.g., personnel, scheduling, etc.). In smaller physician organizations, certain tasks may not be appropriate to the organization. Therefore, physician managers are simply not responsible for these tasks. A dissimilar pattern emerges when examining the association between licensed beds (hospital size) and responsibility. In both cases, more physician managers in smaller hospitals (under 50 beds) have responsibility than in medium size (51-199 beds) or large hospitals (200+ beds). However, the explanation may be similar to the above discussion. That is,

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.. I ; '' i I 'I ,, II II II I I I j I I J. i i I I I I ; I ! I I i ll II I i I I I! I I ll J, :I I I: I! I I ', l i i: :I : I J I! 'I i I II I I I! :I I i I I' I l i i I! ; I i i :I I, ; I I ; : l : I i :1 210 smaller hospitals may have more in common with medium-sized physician organizations than they do with larger hospitals. There may .be less specialization and divi-sion of labor, resulting in more physician managers having responsibility for the tasks. Ownership is significantly associated with only one task: #5, deciding which programs and medi-cal services the organization offers. More managers working in organizations owned by the federal governrnent are found to have responsibility for this asso-ciation task. The meaning of this is not entirely clear. However, one explanation is that physician managers in highly structured organizations, such as veterans administration hospitals, are simply assigned responsibility for this task, while physician managers in other types of government-owned organizations or in non-governmental are not. The second major conclusion resulting from chi square analysis is that of the personal charac-teristics studied, experience has a more important influence on responsibility than education. Only one educational variable, graduate courses in a uni-versity setting, is significantly associated with physician manager responsibility for a task. On the other hand, five experience variables are associated with physician manager responsibility for seven tasks.

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, : ; I i I I I I I i I I 211 To illustrate this association, it was found that the longer physicians spent in their medical practices before assuming their current position, the higher rates of responsibility for two of the ten tasks: 860, designing new or modifying existing risk manage-ment programs; and #82, advising and/or counseling physicians on career or professional issues. This coincides with what the literature suggests about the physician's work environment. As discussed in Chapter III, Friedson (1975) argues that the work environment is more important than education in explaining impor-tant elements of professional performance. Although for the most part, more experience results in a higher rate of responsibility, this is not always the case. Voluntary management experience is si,gnificantly associated with physician manager responsibility for task 068, designing contracts for physicians. However, fewer physician managers with this type of experience have responsibility for this task. A similar situation is found with physician managers who have experience in paid management po-sitions. The longer the experience, the fewer physi-cians who have the responsibility for task #33, pro-moting the organization. The reason for this inverse associaton may be that experience (and education) are correlated with

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212 age. Although an increasing number of physicians are entering contractual relationships with health care organizations, and health care marketing (promoting the organization) is currently receiving considerable attention, these tasks are not traditionally part of health care management. It is possible that older physicians who most likely have voluntary management f II I 1 1 experience and/or experience in paid management posi-tions, are unfamiliar with either of these concepts. ; Therefore physician managers with this exper-ience may either choose not to assume responsibility or are not given responsibility for these tasks. Con-versely, the implication is that younger physician managers are the ones who are more likely to have additional non medical education andare therefore assuming responsibility for designing contracts and promoting the organization. Depending on the goals of the organization, this may or may not be a factor when hiring physician managers. Summary of Conclusions In summary, the important conclusions from this study are enumerated below: 1. Regardless of organizational type, physi-cian managers have responsibility for and perform tasks that are appropriate for their position in the

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' i I I I I i I 'I I t I I I I i I i l 213 organization. 2. The major differences between tasks for which physician in hospitals and physician organizations are responsible and perform often can most likely be explained by differences in the organi-zational structure of hospitals and physician organi-zations. 3. The differences in working arrangements between physician managers in hospitals and physician organizations are also likely to be a result of dif-ferences in organizational structure. 4. Organizational characteristics such as line position, or size, influence physician manager re-sponsibility more often than personal characteristics such as education or experience. 5. Of the personal characteristics, experience influences more often than education. Suggestions for future research There are two categories of work which are suggested as a result of this study. First are stud-ies that would enhance the ability to generalize about the job of physician managers. Second, comparative research is needed that would demonstrate the effect of physician managers on the effectiveness and effi-ciency in health care organizations.

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i I I I I I I I I I I I I I I I l i i i I I I I i i I I I i l i I I i i 214 Research on the Job of Physician Managers Since this research is limited to physician managers who are of the American Academy of Medical Directors (AAMD), it would be useful to study physician managers who are not members of AAHD. Alter-nately, the general population of physician managers without regard for AAMD membership could be studied. The difficulty in either of these studies lies in obtaining an appropriate population. Other than pro-fessional organizations, there is no clear way to identify which institutions employ physician managers. Nonetheless, the findings of such research could be compared with the findings of this study and in the ability to make meaningful generalizations about the work of all physician managers. Along the same line, this study was limited to physician managers in hospitals and physician organi-zations. Research on physicians in management posi-tions in other types of organizations, such as indus-trial organizations, nursing homes, and community health centers, needs to be done. This would also lead to an increased knowledge about the job of all physician managers. Previous research indicates that sex discrimin-ation against women occurs in most stages of the em-ployment and process (Terborg, 1977). In this study

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I I I I I I I j I I I I i i I I j i I l I i i I 215 the vast majority of_the population was male. A study of women physician managers might address a number of questions: (1) Are maleand female physicians respon-sible for and/or perform the same tasks? (2) Is the profile of women physician managers the same as that of males with regard to age, years in practice, spe-cialty, etc.? 3) Is sex an issue when physicians are hired in management positions? Research on Physician Managers and the Efficiency/ Effectiveness of Organizations Many of the studies reviewed in Chapter II demonstrated the benefits of coordination, conflict management, and physician participation in organiza-tion decision-making to the efficiency and effective-ness of health care organizations. This study ex-amined the job of physicians in management positions. As previously discussed, one way to view the tasks for which most physicians were found to be responsible is as coordinating tasks, conflict management tasks, and tasks dealing with organization decision-making. A logical continuation would be a study of health care organizations that employed physician managers and compare those to organizations without physician man-agers. Another approach would be a longitudinal study of the same organization before and after hiring a physician manager. For either approach specific

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216 criteria for measuring the efficiency/effectiveness would need to be defined and in the first design, organizations would need to be matched with regard to size, ownership, and other variables. Findings from this study indicate that few physician managers were responsible for financial aspects of management. Research reviewed previously suggests that when physicians are involved in the financial aspects of management, there are improve-ments in cost containment and quality of care. How-ever, little is known about the reasons physicians are not more involved in financial management of their organizations. Is it, as previously suggested (Herzlinger, 1978), because they do not have the necessary skills? Is it a function of personal prefer-ence, or is it that the organizations do not invite physician participation in financial management? If the answers to these questions were known, strategy to increase this type of physician involvement could be formulated. Issues of power, authority and influence have long been of interest to students of organizational behavior. As Katz and Kahn have stated, every organization faces the task of somehow reducing the variability, instability, and unpredictability of individual human acts" (Katz and Kahn, 1978, p. 196).

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; : 'i I I ; I I II II I I I I lj I i I 'I ll I I II I, ' ,, I i I I: ij I. 'I I I 11 ll I II I I I I I I i I l I i i j I I I; ! i II I i I ; I I i l I I I : ; I i i l1 l i j : ' 217 Kurtz (1980a) studied the behavior and leadership styles of physician managers, but to date, there have been no definitive studies describing the way in which physician managers use power, authority, or influence. Although authority and influence were not the focus of this study, the findings did indicate that physician managers perceive themselves to have more influence than authority (See survey, Appendix B, Part I). This issue provoked questions and should stimulate further research and investigation. This is important if organizations are to ensure that role requirements are carried out by each individual member, and if physician managers are to use power, authority, and influence in the most beneficial way for themselves and the organiiation. Studies such as these would be extremely use-ful on several counts. First, they would provide the information necessary to help health care organiza-tions decide whether or not to hire a physician manager. They would also highlight areas of need for skill development, e.g., use of power. Next, if phys-ician managers were found to be cost effective, e.g., assisting the organization in cost containment efforts while increasing quality of care, then incentives for organizations to hire physicians in management posi-tions might be designed by third party payors,

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' I ; I I I I I I i l l l l i i I i I I I I I I i i I I I I I ; i 1 1 : I ; I :I I I 218 especially the government. Finally, if more health care organizations began hiring physician managers, it would provide employment opportunities for physicians who now and will increasingly experience a surplus in their numbers.

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! ; i I I I I j l I l ,, I I 219 NOTES CHAPTER V 1. This may in part explain why services provided in physician organizations are less expensive than those provided in hospitals. 2. See Chapter III, p. 109.

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231 Sayre, Wallace s. "The Triumph of Techniques Over Pur pose." Public Administration Review 8, no. 2 (1948): 134-7. Schenke, Roger. "Job Descriptions: A Summary of Impressions." Medical Director 3, no. 1 (1978): 2. Schenke, Roger. Medical Director 1, no.2 (1976). Schenke, Roger. "The Medical Director: A New Profes sion." Medical Director 2, no. 3 (1977): 1. Schenke, Roger. "Need for Managers Pervades Medical World." Medical Director 4, no. 2 (1979): 4. Schenke, Roger, Ed. The Physician in Management. Falls Church, Va.: AAHD, 1980. Schulz, Rockwell, and Johnson, Alton C. Management of Hospitals. New York: McGraw-Hill, 1976. Scott, W. Richard; Flood, Ann Barry; and Ewy, Wayne. "Organizational Determinants of Services, Quality and Cost of Care in Hospitals." Hilbank Memorial Fund .Quarterly 57, no. 2 (Spring 1979): 234-64. Scott, W. Shortell, Stephen M. "Organiza tional Performance: Hanaging for Efficiency and Effectiveness." In Health Care Management: A Text in Organization Theory and Behavior. Eds. Stephen r-1. Shortell and ArnoldD. Kaluzny. New York: John Wiley & Sons, 1983. Selltiz, Claire; Wrightsman, Lawrence; and Cook, Stuart W. Research Methods in Social Relations. New York: Holt, Rinehart & Winston, 1976. Shafritz, Jay H. Dictionary of Personnel Hanagement and Labor Relations. Oak Park, Ill.: Moore Publishing, 1980. Sheldon, Alan. Organizational Issues in Health Care New York: Spectrum Publications, 1975. Sherman, Harvey. Depends. University, Ala.: The University of Alabama Press, 1966.

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232 Shortell, Stephen H. "Hospital Medical Staff Organ ization: Structure, Process and Outcome." Hospital Administration 19, (Spring, 1974): 96-107. Shortell, Stephen M. "Physician Involvement in Hospital Decision-Making". In The New Health Care for Profit: District Hospitals in Competitive Environment. Washington, D.C.: National Academy Press, Institute of Medicine, 1983. Shortell, Stephen H.; Becker, s. W.; and Neuhauser, D. "The Effects of Management Practices on Hospital Efficiency and Quality of Care." In Organizational Research in Hospitals. Eds. Stephen H. Shortell and H. Brown. Chicago, Ill.: Blue Cross Association, 1976. Shortell, Stephen M., and Getzen, Thomas E. "r1easuring Hospital Medical Staff Organizational Structure." Health Services Research 14, no.-2 (1979): 97-110. Shortell, Stephen M., and Kaluzny, Arnold D. Health Care Management: A in Organization Theory and Behavior. New York: John Wiley & Sons, 1983. Shortell, S.M. and LoGerfo, J. P. "Hospital Medical Staff Organization and Quality of Care: Results for Myocardial Infarction and Appendectomy." r1edical Care 19, no. 10 (1981): 1041-56. Simon, Herbert A. Administrative Behavior. London: The Free Press, 1945. Slater, Carl. "Challenges of the Physician Manager's Role." In The Physician in Hanagement. Ed. Roger Schenke. Falls Church, Va.: American Academy of Medical Directors (AAHD), 1980a. Slater, Carl. "The Physician Manager as an Integrative Professional." In The Physician in Management. Ed. Roger Schen ke. Fa 11 s Church-, -Va. : AAf.1D, 1980b. Slater, Carl. "The Physician Manager's Role: Results o f a Survey In The Ph y s i c i an i n :1 an age men t Ed. Roger Schenke. Falls Church, Va.: AAMD, 1980c.

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233 Sloan, F.A., and Steinwald, B. "Effects of Regulation on Hospital Costs and Input Use." Journal of Law and Economics 23, no. 2 (1980): 80-109-.Sloan, F., and Becker, E. "Internal Organization of Hospital Cost." Inquiry 18, no. 3 (1981): 224-40. Smalley, Harold, and Freeman, John. trial Engineering. New York: ing, 1966. Hospital IndusReinhold PublishSnyder, James D. "The Four Toughest Questions New Med ical Directors Ask." Group Practice 26, no. 4 (1977): 12-16. Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982. Stone, Gayle E. "Can Hospitals Be Managed?" In Issues in Health Care Hanagernent. Eds. Steven Spirn and David W. Benfer. Rockville, Md.: Aspen Publishers, 1982: 323-28. Studnicki, James. "Regulation by DRG: Policy or Perversion." Hospital and Health Services Administration 28, no.--1-(1983): 70-79. Summers, James W. "Hospital Administration and Medi cine at the Crossroads." Hospital and Health Services Administration 27, no. 3 TT982): 65-81. Summers, James W. "Money, Health and the Health Care Hospitals and Health Services Admin26, no. 1 'Winter 1981), 7-24. Industry." istration Taylor, Frederick. "Scientific Management." In Clas sics of Public Administration. Eds. J. H. ----Shafritz and Albert c. Hyde. Oak Park, Ill.: Moore Publishing, 1978. Terborg, J. R., and Ilgen, D. R. Theoretical Approach to Sex Discrimination in Traditionally Hasculine Occupations.11 Organizational Behavior and Human Performance 13, no. 3 (1975): 352-76. Thomas, Lewis. 110n the Science and Technology of Med icine." Daedalus 106, no. 1 (1977): 35-46.

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: i ; I . i I l i I 234 Torgersen, Paul E. "An Example of Work Sampling in the Hospital." Journal of Industrial Engineering 10, no. 3 (1956): 197-99. Torrens, Paul R. "Historical Evolution and Overview of Health Services in the United States." In Introduction to Health Services, 2nd ed. Eds. Stephen J. Williams and Paul R. Torrens. New York: John Wiley & Sons, 1984. Torrens, Paul. "Physicians' Perceptions of the Managerial Role." In The Physician in Management. Ed. Roger Church-,-Va.: American Academy of Medical Directors, 1980. U. S. Bureau of the Census. Statistical Abstract of the United 1982-1983, 103rd ed. Washington, D. c.: Government Printing Office, 1984. U.S. Bureau of the Census. Statistical Abstract of the United States 1980, 101st ed. Washington, D.C.: Government Printing Office, 1980. U.S. Dept. of Labor. Handbook ed. J. D. Hodgson, Secretary of Manpower Administration. Washingtn, D.C.: Government Printing Office, 1972. Vanagunas, Audrone, E.: Egelston, Martin; Hopkins, Julia; and Walczak, Regina H. "Principles of Quality Assurance." In Issues in Health Care aanagement. Eds. Steven Spirn and David W. Benfer. Rockville, Md., 1982: 233-236. Waterhousse, Blake E. "The Medical Director: The Group Practice Role." Group Practice Journal 30, no. 5 (1981): 25-26. Weisbord, Marvin R.; Lawrence, Paul R.; and Charns, Martin P. "Three Dilemmas of Academic Medical Centers." Journal of Applied Behavioral Science 14, no. 3 (1978): 284-304. W i 11 i am s K J "The R o 1 e o f the : 1 e d i c a 1 D i rector Hospital Progress 59, no. 6 (1978): 50-57. Wolper, Lawrence F., and Hopkins, Willard G. "Prospering in a Regulated Environment." Hospital Progress 58, no. 9 (1977): 70-79.

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235 Wood, Trevor J. "The Royal Australian College of Medical Administration: Evolution and Progress." The Medical Journal of Australia 261, no. 2 Ti980): 50-51. World Almanac. New York: Newspaper Enterprise Association, 1983. Yanda Roman H D Doctors 1'1 an age r s o f He a 1 t h Teams. New York: Amacom: A Division of American Management Association, 1977.

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I : I APPENDICES

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APPENDIX A THE SURVEY INSTRUHENT

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B.olc/Compcnsauo:a. Survey Conducted by the Amerian Aodemy of Mediol Directors in cooper2tion With the University of Colorado Resc::udler &=on 21s3 Scum Oavtcn Oenve:. Co!oado 80231 238

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'j i i i I I i i I I I I I I i l I i i I i l ; ! I 239 BACKGROUND The vital role of physician managers in our health care delivery system is well recognized. The American Academy of MedicaJ Directors (AAMD) is involved in a number of activities and research projects to better understand this group of physicians. The attached questionnaire represents one of these efforts. Medical directors and other physician managers from hospitals. Prepaid Health Plans (PPHP), Group Practices and other organizations are being surveyed in order to identity the tasks which are typicaJiy performed. Multiple consultations with a group of physician managers from AAMD have been extremely helpful in developing relevant questions for this survey. n addition, to ensure relevance and ease the process of completion, the survey has been pretested with 44 AAMD members. There are four parts to the survey. Part I asks questions about your personal background and training. It should take about eight minutes to complete. Part II asks questions about your Organization. Department/Service, or Agency. This section should take about nine minutes to complete. Part Ill asks questions about the compensation aspects of your job and should taJ
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: I I I : I I l 240 PART ONE INSnlUCTlONS 11-41 This section asxs questions acour your personal cac:xgound Please mane tne box next to tne most appropriate answer. Rememcer tnar ttlese questions relate to your managementtadmmistratJve position. INCMOUM.INI'OiliiAnON 1 s.. 2.. a.. o1 111r111 (moJCIIy/yr.J 3. QlniQI sc--r 1 0 Family ..,._ 2 0 -Mecliclne 3 0 co-. SurQety 20 Fnaae 7CRaGIOI09Y a C "-twe MediCine 9 c Pl!ysac:al MeGiane & ReNo. (5) (6-11) (12-13) 10COtnw (pi-SO
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12. w-you ror INa OrpliZallcln. or A9enCJ befor. you uaumea your c:urrwnt paaitlon? 1 eves 2 ONo 13. IMI1C 1M IMIIMICI UMCIIO Mlecl you lor your cunwnt IIOIIIIOn. 1 0 EII!Cllld (e.g. !)"( Meaocal Stalf Execuuve Commonee or Mea.ocal Stat!. anator ACimonostratoon or Organozauon or Group) 2 0 Selected
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, I I I I 242 PART TWO I NSTIIUCTIONS Thts sectton asks Questions acout ttte Orgamzatton. DeoartmenuServce or Agency wtttt wnicn you are assoctated. Please ;llace a marie tn tne oox next to ttte most approonate answer. Rememoer tnat tnese quesuons relate to your managemenUadmtntstrattve oosltlon. ORGANIZATIONAL T111e. Wllt!n you seleCt me most aoorocnate tO l!'IIS ot !ltiOUICI reftea tl'le QnfiClrH/ POSitJCn you nQICion your 0"1antzabon or ac;encv. rr your lime IS !ltlaNCIO-._ POSitiOnS. cnoose only one ariCI an-tne remaonQ.,. or me Quallon,..,. wun tnat on mond t 0 Onet EKecu:.ve ONiCar 2 0 V>a Meo1Ca1 or Profaaoonal Alfan ( 102CI:ll 0 MeCIIQI Oorectct ot an Orc;antzaiJOI'I 4 0 Oireaar ot Med1C31 Allarts s 0 Med!QI Ooreaor or a Semc:e. Oeoartrnent 6 0 AsslsQnl MeCIIQI 7 0 CliniQI Oireaor of C.OL. Setltoc8 or Proc;r2nl 8 0 Quet of Ceot. or SeMces 9 0 Cirector ot l\oledlal 10 0 Cl'loel of Srmt 2. Type Gl 01;& ( 104-105) PI-mvtt rne-tnat oesr your Orc;anozanon. 11 vou W0f11Wim more man one 0"1aruzaoon. c:noose me one mat" consiStent wom tl'le IItie vou -oo Quesoon One. I 0 General Haeclolll (Un.-srry 2 C General Haeclolll oaseCJI 3 0 $Qeclally Haeclo131 oaeCJI ol 0 SQecslny Mosclllll s c I..Cng-Ntm ear. Mosclllll 60 Gtoup 7 0 Sulgte Solcl8ny Grouo PraaiQ wolft -.s wom a ne .. m atan. 8 0 Single Soec81ry Groug Praax:e wom -t11an aaaocw:acs wolll nann aran. 90 Groug PrXIIC8 tO c Gmuo Pr8CitCe wom-.auoc:racwa Wllft a ne.nn a&an. t1 C Gtouo Pr8CitCe wom -''*' wom ne81m alan. 12 C Staff (or Gtouol Moa8l ...._."' Plan (PI'HP) 13 0 ll'ldeOII ... IC PraaiQ A8laclallon (IPA l 140 Home (01'-car. hle:lhty) IS C IIIIIUCNII 01'Q81IIDDOII 18 c "'*"-taa eo.no-, 180 MIJitrl li c c.-n.ry Hellllll c:.nw 3. I C 1' l)fOIIt 2 C Ncln profit, nan 9CM-SO Sla!8 Gowem,_r 8 C Local Gowwnmem (1061 3C Ncln cwoflt. 9CM-o&O F.-. Goownm.IC 70 Otner UOialtlt--------------------------'-Wllll:ft Gl-,...... ...-...-.. .,_ '-1 many u aoct!YI C Clliet ot me lotealal Stitt c s. a-.,a.Oozz 011 .-..-, ,_ 011 1a .--.. .... tCY 2CNo AIPCRTDIGICCMMIMC\11CII AARAw.liMIMTS a. To..._ dO,_ '-'111 me 01..........,. 011 A91fteY1 (Marlt a many as mey aQOiyl C Fewleleaecl -o1 CIOO'f (e.;. &c. Comm.l c c:,-. e-u..omc. 0 c..t C!laral1at C Weclcll Oilwclar 0 Ex.ecu-Of p.,.. c e-:uu.. Commouee Of MeCIIcal stalt c Mlcllcal Stilt CCMtotan 0 Cl'lief Of s-a 01 CeciL C!Wr 0 VIQ i'Aeaal or OIIW Vice Prelldent in tne 0"18nozab0n (ton (1081 (109) (110) ReccrQ 2 (1) (21 (3) (ol) (51 !el m { Q) (91 (10) (11) (13-tSl

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a In atiiiOtt to tile ,,. you INFORMAU. Y accountaOI to my-.,,. on tile Of9nzation or = fes ZC .. !J It yn.. zo whOm? r ,..,arK as many as apo1v 1 i:::: Meaacal 5tart = E .eoc. Comm ot Mea Start :'J Pres of Organtzatton =cc:o C Cr.aor ct Deot or Servoce !:l Boarc: Of Tru5tees 0 Otner lptease saecotyt 243 I, i) (191 201 i21l o221 12:3-241 d ti-WCIUid you dftctlbe 1J1e J)OSII.Ioft you nolcS wtlllln your 0'9U11Z31ion or A9M'C"f? ;>
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IF YOUR ORGAHIZAnON IS A GROUP PRACTICE. ANSWER QUE5nONS 23 THROUGH 27. IF NOT. SKIP TO QUE5n0N 2S. 23a. Ca. your -Ill :aft (e.g. nvolveCI wtn HMO. IPA, or own contract plam? 1 C Yes 20 No 24. -rneny In your Group?----25. -rneny In your Group?-----25. Wllat Ia tile teal numCIW Of full lime nofto11ftJIICIM ....,._ In your Group? ----ZT. Qa. your Group ll8ftldpale In a PNierred Pn:Mdlr 0r!18fa.lon (Pf>O} cw Exdu811e Pn:Mdlr OrganiDtlan (EPO}? 10Yes .2iJNo When you naw finiS/led t111s section. you may slcip to Part 3 244 (55) (63-66) (67-71) (72) IF YOUR ORGAHIZAnON IS A PREPAID HEALTH PLAN, ANSWER QUESTIONS 21 29. IF NOT, SKIP TO QUESnON 34. 28a. Qa. ycur IWW a naaanat cw reglonal alllllallaft (e.g. Kaiser. INA)? 10Yes 20No (73) 281:1.. II Y-...,.cty ---------------------------------(74-75) 29. "-IIWIY dcMa your OrgafliZallori '-1 ----IF YOUR ORGAHIZAnON IS A STAI'F IIODI!l. PREPAID HAI.TH PLAN. ANSWER QUESTIONS :J0.3Z.. IF NOT, SKIP TO QUESTION 33. 30. "-IIWIY full a.. In your facility? -----. 31. Ito......, pert a.. In your tadllly? ____ 32. "-IIWIY full lillie__,_-a.. In your tadflly? ____ W'-' you naw ccmpletiiCS tnis sactiOtl. you may slcop to Part 3. (84-88) (89-93) (94-98) IF YOUR ORGANIZAnON IPA 11001!1. PREPAID HEALTH PLAN. AHS\ftR QUESTION 33. IF NOT, YOU MAY SKIP TO PART 3. 33. "-IIWIY tile IPA? (99-103) Wl*l you cornpletiiCS tniS sac:tion, you may slcip to Part 3 IF YOUR OAGANIZAnON. CEPAR1111NTJSI!JMC2 OA GROUP DOES NOT FALl. INTO ANY OF THI! ASOVI! CA"nGOAIES, ANSWER OU!!STIONS 34 THROUGH 36. 34. "-IIWIY full lillie .,._._.In ycur 01!18flizllllllio cw ----35. "-IIWIY pert In yourOrpilzalicli, cw ----38. Ito...,., _,'IJ:oldui full lillie &npjoJ--a.. In ycur Agency?-----(10<1-108) (109-113) (114-118)

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I I l I ! 245 PART THREE INSTRUCTIONS This section asks Questions dealing with compensation aspects of your job. Again. piHaebflaaured that data will be reported in aggregate form onty Remember that these Questions relate to your management/administrative position. 1. 3. 4 Allllf'op_., -.,.._,...,.Of y-time do you tftlnl< Ia deolo-10 ac:IIYI-? Are you nn-.y conliMI""*d Kllwlllft? 1 C Yes 2 C No 3 C Sometr,_ WMI-llle 1 heel......,. -.ry tor rout poelllon In 1912 (notrncluding rncome from pnvate practice or second joe)? 6. wr.t-llle ...... _. 01 peMion and conii'IIIUIIMS lly your 0tlj8lilzallon 01 In 1il2? $, ______ 7. eo. 111e Ot\181 tlan 01 p.,-111e ..,.,.._.lot rout JMipr8cllce .,..._? 1 CYes 2CNo 6. Did rout 01\j8111;&a11UQ 01 A;.ncr ............ or pr'lfttde: 0 Heal11t IMUranCa C Lite Insurance C OisatJ&tity Insurance 9 How..., wexs 011*11 _.you aulftariZIId 10 ,....... tiiZ? ----10. How_.,OAYSOIJ*dpraf 1 111 .. 01 ... 11L nwtl .. oct. C0119W M '118 01 beMIIIII you -..c1 frolll .,_ Orp 'an 01 In tti:Z: C Memcennio cues tor Protaaoonai OrganiZations c MemCerslllo oua ror oaw 111an Protesaional OrganiUUona (e.g. =unuy dUCL allllelic dues) C AdCitlonal Ute lnsutanea c AcldiliOnal f3enefils (e.;.. dana! ;_,_, C Trawl to Proi8SIIONI Conlrca or eon-tiolaa (e.g. A.UAC seminatSI cear C Car indudlnQ main--. insuranc:elnd/or ga c Oilier om-ecsucatiOnal exoenaa (e.g. 1:10011s. joumaiL eu:.) 0 AOCIItlonal llme off CS!OckoptlOna 11b. ..,... do you ...... 1M dollar ...... to .. 01 8diiiiiDMI ...... ._... abcwlt? 12. ..._you ........ routcunwt Jo0, your 111*1 CCIIIICAI t 1: 1 C tnc:TIIIed t:1y totat 2 c o.cr.a.ct t:ly 011ota! compensation 3 c R4maineclllle -Record 4 (1 (3-51 (6) (7) (13-17) (18-22) (23-27) (28) (29) (30) (31) (32) (38) (37 (39) (.a) (41) (q) (43) (44) (451 (48) (47) (48) (49) (50) (51 (53-57) (58)

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i i iII 1 I i I I I I l I I I I l I I I i I I I r ! i I I I 1 i i i! ; l : ! : I : i i I ; I \ : J 246 PART FOUR Task List lnstrvc:tlonc For eacn task you arto oetng asked tnree Quesnons. Rrwt. do you na.., RESPONSIBIL.ITY tor tl'ltS ac:trvtty on your Organtzatton OeoanmenuS.rvoce or Agency. as pan of your 1011? Mark etrner: ves. No. or NJA. t1 r r.e ouesuon aoes not aoQiy ro your ....,rk sttuauon mark N/A ana oo on to tne neat Questron. rr you snare tnos resoonstOrltty worn otners. sucn as a Commrttee mark Yes. :nat you are resoonstble. ana address your own comoonent wnen matkrng tne omer rwo columns. Second. you are asaeo to mark tne FREQUENCY or now allen you ltnd yourself llandlrng tnts taale Mark ettller: Rarety. Occastonally. FreQuently or Very freQuently Please note: 11 s wetf recogntzeo tnat attnougn you arenottormally resQOnSIOiefordO tnq so as oanofyouqoo. you may ;::ctuauy nandle any of tne actNtttes ltsteo. If mts os tne caw. mart< NO undllf' tne RESPONSIBIL.ITY column. and tnen pt'OCI!IId to man< now treouently you nanale tne actrV1ty. Tltfrd. vou are -ng aslled to uatcate HOW IMPORTANT you_, eecn task to be to meOVERAU.. EFFECTIVENESS ofyourOrgantzauon. OeoanmenuSvoce or Agency Mano ettner: very moonant: Somewnat moonanr. or Not ""fV moonanL A. INSIDE THE ORGANIZATION, DEPARTMENT/SERVICE. OR AGENCY c'lc 1 Prepanng nor modifying existing bylaws. ....... c c 01 c c c c c (67-69) 2. Prepanng or modifying existrng policies cj and/or procedures. ........ c c c c c c c c c (70-72) 3. Pre1)81ing goals anc:t objectives lor the OrganiZatron. Depanmeni/Servrce ........ c c c c c c c c c c (13-75) 4. Designing or reviewing new .... c c c c c c c c c c (76-78) S. Deciding wllicn llrogtamS and medical services your Organization, D81)U!meni/Service or Agency otters. ............. c c c c c c c c c c (79-81) 6. Deciding the size of programs and medical services. .. c c c c c c c c c c (82-84) 7. Deciding patient C8re equipment needS. ......................... c c c c c c c c c c (85-87) a Deciding me number and type of physiCians that practice in your OrganiZation, or Agency c c c c c c c c c c (88-90) 9.Writlng n-or modifying criteria lor the of l)hysiCianL .................................. c c c c c c c c c c (91-93) 10. Wrftfng new or modifying existing criteria lor the pmrileges of physicians. ....................................... c c c c c 0 c c c c (94-96) 1 1. Deciding on PriCing tor serviceL ...................... .......... c c c c c c c c c c (97-99) 12. Monitoring and repottlng on isau of interest (and/or conam) of Medleal Staff to Administration or Staff. c c c iJ c c c c c c (100.102) 13. MonitOring and ntQOrting on issues of intanlst (and/or conce!'r!) of Adminis1ration or Business Staff to Medical Staff. c c c 0 0 c 0 c c c (103-105) 14. Communicating infcrmatlon to both the Medical Staff and Governing Body of the OrganiZation. Oepartmeni/Servica or Agency (e.g .. decisions made, new polleies, etc.). . c c c c c c c c c c (106-108) 15. Writing n-or modifying existing of medical care practice. ................................................. c c c t:i c c c c c c (109-111) 16. Ensuring tnat of care are written and dls3eminatecl. ................................................. c c c !C c c 01 c c c (112) 17. Writing n-or mOdifying existing administrative or I business (versua medical care) policies tor the Medical Staff (e.g. informed conant iDUe:s; way3 to estal)iish lc E.R. call list. etc.) .............................................. c c c c c c c c c (11S.117} 16. Ensuring administrative or business policies tor me Ia Medical Staff are written and disseminated c c c lc c c c c c (118-120)

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i I I I I I l I I I I I i I I I I I i :I I t j I I i i : i :! 0 i : ; l 19. Prepanng or modifying existing administrative I I I: ol I: o 1 ;o policies tor non.pnys1c1an neaun profes31ona1s. .............. 0 0 0: o 0 0 0 o i jo 0 c 20. Chamng Medical Staff Comm1ttees. 00 00 00 00 00 00 00 00 00 00 00 00 0 0 0 0 0 01 21. Attending Medical SlaH Committees 00 00 00 00 00 00 00 00 00 00 00 ... 0 0 o I io 0 0 o 1' o 0 ol I i 22.. Chamng Admin1strat1ve Committees ................ 0 0 0 0 0 0 0 i :o 0 Ol o 1 !o I 23. Attending Administrative Comm1ttees ................ 0 0 0 0 0 0 0 o! 24. Chairing Soard Committees 00 00 00 00 00 00 .. 00 00 00 00 00 00 00 00 00 00. 0 0 [J 0 0 0 0 lo I c [J 25. Attending Board Committees 00 00 00 00 00 00. 00 00 00 00 00 00 0 c Cl 0 0 c 0 ic c c I 26. Prel)anng agenda ilems tor Medical Stalf or I l I Physicians meetings. 00 00 00 .... 00 00 00. 00 00 00 00 00 00 ... 0 c Ci 0 0 0 0 o c c I i I 27 Prepanng agenda items for meet1ngs Wltn tne Admin1strat1ve or I I Staff or With me Administration I : I of tne Organ1zat1on (e.g manager or CEO ) . 0 c c 0 0 c c j o c o! 28. Preparing agenda 1tems tor meetings with the Governing BOdy .. 0 0 0 0 c c 01 c c c' I 29. Deciding on researcn actJv1t1es. 00 00 00 00 00 00 00 00 00 00 c c 0 0 c 0 Cj 0 0 o! B. OUTSIDE THE ORGANIZATION. OR AGENCY I 30. Monitonng and reporting on cnanges in the social envrrdnment (e.g.. hign concentratiOn ot elderly in setVice area). in tne economrc environment (e.g.. local unemployment rate). or in the political envirdnment (e.g. cuts in health care livery service) in order to identity issues to be acted upon by tne Organization. OeQartment/Service or Group c c 0 c c c 0 0 c 01 31. Lobbying Regulatory Agencies (e.g HSA"s. State Licensing Autnority) or Legislative Bodies (e.g.. Federal Government. State Legislature). c c c c c c c c c cj 32. Coordinating witn otner Health OrganiZations (e.g. aoout patient care issues. snared services) c c c c c c c c c 0 33. Promoting your OrganiZa!lon. Department/Servrce or Agency (e.g. to local industries or to tne general public) c c c c c c c c c c 34. Representing (being a spokesperson for) your OrganiZation. Department/Service or Agency to otner Medical or Health Cant OrganiZations (e.g.. local Medical Society) C c c c c c c c c 0 35. Representing (being a spokesperson for) your OrganiZation or Agency to tne general public (e.g... SQeak to local groups. meet tne press. etc.) 00 c c c c c c c c c c 38 your OrganiZation or Agency to tnird pany payers. c c c c c c c c c c C. QUALITY ASSURANC2! 37 Designing n-or mOdifying exi$ting programs that compare physicians' bel'lavior to establiShed standards of care in the Organization. OepartmenttService or Agency. 0 C C ecce ceo ZQ. Ensuring ti'i&l i systvm for riiY'iWW w .:u.::.O.-: c: :t-.:. credentials of npny,icians being admitted to the OrganiZation or Agency exists. 00. C C C C C 0 C 0 C C 39. Ensuring that a system for re'#iand evaluation of Medical Staff competency exists (e.g. identifying tne impaired physician) . c c c 1 ,o c c c c c c 40. Ensuring that a system for re'#iand evaluation of clio c lie Medical Stalf competancy operates effectively . c 0 0 c c c 247 Record 5 {1-3) (4-0) (7-9) (1D-12) (13) (16-18) (19-21) (22) (25-27) (28-30) (31-33) (34-36) (37-39) (40-42) (43-45) (46-48) (49-51) (52-54) (55-57) (58-60) (61-63) (64-06)

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248 41. Mon1tonng or rev1ew1ng the system for evaluating tne '. I' competency of non-pnys1c1an nealth profess1ona1s. ............ a a a! a a a a i !a a a (67-69) 42. Ensunng accreaitatlon With JCAH. AAAHC. or Other i '' accrechtmg oodles ............................................. 0 a 0 :c 0 0 a : a 0 0 (70-72) C. EDUCAnONAL AcnVmES 10 i i a I !c 43. Desgning. Continuing Education (CE) programs for pnyscans . 0 a 0 0 0 0 0 {73-75) I 44 CE programs non..pnys1cians ............ 0 0 0 lc 0 a 0 I iC 0 0 (76-78) I 45. general (non-clinical) education programs c do (e.g management courses) ................. . ................ 0 0 0::0 0 a 0 0 (79-811 46. Teacning ce programs to pllySI<:ia."lS. InCluding neuse ; staff if applicable .............................................. 0 0 0 ,a 0 0 0 ; 10 0 0 (82-84) : 47. Teacning ce programs to non-pnys1cian nealtn care !a ' professionals. Clients and/or their families. ...... 0 0 0 0 0 a : o a 0 {85-87) 46. Evaluating educatioto programs. ............................... 0 0 0 !c 0 0 c I !c 0 0 (88-90) :I I' E. DATA MANAGEMENT ; I II I 49. Enswlng systems dllllgned to obtain data necessary I' '' i to evaluate mediCal care ant dewtoped. ........................ 0 0 c! lo a 0 c I ;o 0 0 I (91-93) I I I 50. Ensuring SystemS designee: to otltain data necessary for c lie clio l general managemen1 decisions are (e.g., management infomwion system) .... 0 0 0 0 0 0 (94-96) I i ll I 51. Monitoring and reootting on data from systems designed c i lo to otltain information abOut modicaJ care .. 0 a 0 0 o lie 0 0 (97-99) 52. Monitoring and reootting on data from systems designed a lie I! I (1Q0-102) to otltain data for management decisions. ...................... 0 0 0 0 c i : o 0 0 I 53. Ensuring tnat data re1trvant to medical care issues ant ; : I used &l)propriately 0 0 0 i io 0 0 c 1 : c 0 0 (103-105) i 54. Ensuring tllat issues ant lie e lie U$8d appropriately ............................................. 0 0 0 0 0 0 0 (106-108) i F. RNAHQAL MANAGEMENT I l I i aile l 55. Designing ways to improw efficiency of professional I departments W1tllin your OrganiZation or Agency 0 0 0110 0 0 c 0 (109-111) l i 56. Developing tne budget or part of tl'le budget for tile 1 : OrganiZati_,, Ceparlment/SerYiee or Agency . 0 c 0: :o 0 0 C 1 0 c c (112-114) l 57 Reviewing tne budgllt or part of tne budget for tne ll c lie I c i lo I OrganiZation, OIII)Mtlnent/Setvice or Agency . 0 0 0 0 0 0 1 111s-117l i :I II I 58. Revi-ing tl'le financial perton11anee of tl'le Organization. I! Department/Service or Agency (e.g. management data II" o! ::; t:::;uGgiiit; .................................................... 0 0 0 a Cl 01 a 0 0 (116-120) G. RISK MANAGEMENT I 59. Does your Organization or Agency a risk II I Record 6 management program? OYes ONo II (1) If yes. amwer questions 60 & 61. If not. skip to question 62. o! jo ; I ; i I 1 ;! 60 Designing new or modifying existing risk management tunC1ions. 0 Cl 0 0 c : ![J 0 c (2-4) J! 61. Monitoring and/or managing e11isting risk management :I ll i I . i l functions and or programs. .................................... 0 a 0 lie 0 a c IIO c c (5-1} : ; ;

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H. GENERAL MANAGEMENT 62. raentifyrng the neea tor outs1ae consulting serv1ces ........... ... CJ CJ CJ CJ CJ CJ CJ l I CI CJ CJ 63. Obtarn1ngtbuy1ng consultrng serv1ces for the Orgamzat1on.. . . CJ CJ ::J CJ a a a 11a a a : i 64. Supervrsrng cap1tal construction prorects as needed . . . . . . C CJ C CJ CJ CJ a t l a CJ CJ I. RESOURCE MANAGEMENT ; 65. Designing rncentive programs to increase physiCian produCtiVIty 0 CJ CJ CJ : CJ CJ a Cl i CI Cl Cl I 66. Ensunng that a phySICian recru1!Jng program operates as needed. CJ CJ 0 ; Cl C1 a CJ i Cl Cl CJ 07. Deciding scope of pract1ce tor non-salaned phys1c1ans ....... CJ CJ CJ CJ CJ CJ CJ I C1 CJ CJ 68. Designrng contracts for phys1c1ans. . . . . . . CJ CJ CJ ; i CJ CJ CJ CJ 1 CJ Cl CJ 69. Design1ng contracts tor non-physicians.. . . . . . CJ Cl CJ ; Cl Cl CJ Cl 1 l CI Cl CJ 70. Designing wage/benefit scnedule for physicians. . . CJ CJ CJ : : CJ CJ CJ Cl I i CI CI CJ 71. Designing wage/benefit scnedule for non-Qhysrcians .. C CJ CJ ; CJ CJ i i CJ I 72. Hiring physicrans.. ............................................. CJ CJ ccclccc I c I CI 73. Hiring non-physician nearth care personnel ....... . C CI 74. Deciding expectations ot saran&d or contract physicians (e. g wnting a job d&SQiption) .. .. C CJ CJ CJ CI CI CI CI CI CI 75. Deciding organizational expectations of non-physicians. CI CI CI CI CI CI CI CI CI Cl 76. Supervising physicians (e g. for appropriateness of I 78. Ensuring a grievance procedure for physic:iaM is followed.. . CI C CJ CJ 79. Ensuring a grievance Procedure for non-Qhysicians is followed. CJ CJ CJ l CI 80. Negotiating w1th unions. CJ CJ CJ I CJ I 81. Advising and/or counseling pllysicians on personal issues. . a CJ CI j CJ 82. Advising and/or counseling physiCians on career or j professional issues. CI C CJ 1 CJ I' 83. Advising and/or counseling non-physician health care personnel. CJ CJ CJ 1 I CJ 1!4. Mediating conflict among physicians C CJ CI I CI 85. Mediating conflict among pl1ysiclanS and non-Qnysic:ian health i care personnel... C C C j : CI I 86. Mediating conflict among prtysicians and Administration or 1 ; 97. CJCJCI CCCI CI CI CI CI CI c CJ CJ CI CI CJ CJ CI CJ CCCI CICIC CI CJ CI CI CI CI CJ CJ CJ CI CI CI CI CJ CJ CI CI CI CI CI CI CI CI CI CCCI CICJCJ CCJCI CICJCJ 88. Please add any tas1ts tl'lat you perform not listed -------------------(9-10) (11-13) (14-16) (17-191 (2Q-22) (23-25) (26-28) (29-31) (32-34) (35-37) (:3&-40) (41-43) (44-46) (47-'9) (5o-52) (53-55) (56-58) (59-61) (62-Q4) (65-67} (68-70) (71-73) (74-76) (77-79) (8Q-82l (83-85) (86-88) (89-91) (92-94) (95-97) (98-100) I (101) (104-106) (107)

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APPENDIX B THE SURVEY INSTRUMENT: DESCRIPTIVE STATISTICS

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251 PART O!IE INDIVIDUAL 1. Sex !1ale 2. Uean Age 53 years 3. Clinical specialty Family Practice Internal Medicine General Surgery Psychiatry 5.2S Pediatrics 08/GYN 5.6S Orthopedics 1.4S Anesthesiology 1.8S Female Radiology Preventive Medicine Physical Hed. & Rehab. Urology Pathology Otolaryngology 1S Emergency :tedicine Other 1 4. Are you board certified in your area specialization? Yes No Sa. Is on your medical staff or Independent Practice Association (IPA) a requirement for your position? Yes No 13.5S 5b. If yes, what is your status? Active Courtesy Inactive Provisional Consultant Other Not applicable 6. nark the answel"(s) that describes your training in management or administration. Uone Undergraduate degree in :tngmt. or Admin i!asters in Public Health 7. U Masters in Bus. Adm. ilasters in Health Adm. Graduate courses in a university based mngmt. or bus.program 19.1% Continuing ed. in mgmt. (e.g. AAMD seminars) 77.81 Other *** 7. Before assuming your current position, please list: Years in medical practice: Average 16.7 Years in paid management position: Average 5.4 For "other" specialties see Appendix C, p. 272 ** For "other" category see Appendix C, p. 272 *** For "other" management training see c. p. 273

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) i : I i I t I I I I i I I I I I I i I I 1 1 I : I i 252 Years in other paid professional work relating to your current management position: 2.9 Years in armed services: Average 4.9 8. rfark which of the following work experiences you have had: Internship/residency Medical Practice 95.4S Voluntary experience (e.g., chief of service; chair of standing committee; board member) Paid management experience Other paia professional work (e.g. Public Health Ser vice; government programs) Armed Services Business experience (e.g. entrepreneural activities, real estate, investments. etc.) Academic Position None of the above Other 9. 11ark how helpful the following experiences have been in preparing you for your current position. -Clinical experience of Internship/Residency: Very helpful: Not very helpful: 20.7l Somewhat helpful: Not at all helpful: Organizational or supervisory experience of Internship/Residency (e.g., Chief Resident) Very helpful: 25.5S Not very helpful: Somewhat helpful: Not at all helpful: 11.6: Clinical aspects of Practice Very helpful: Not very helptul: Somewhat helpful: Not at all helpful: Managerial aspects of medical practice Very helpful: Hot very helpful: 10.6% Somewhat helpful: Not at all helpful: 1.81 Voluntary management experience Very helpful: Not very helpful: Somewhat helpful: Not at all helpful: 4S Paid management experience {other than practice) Very helpful: Not very helpful: 4.4S Somewhat helpful: Not at all helpful: lOS list of experiences see Appendix C, p. 273

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253 Other paid organizational work Very helpful: Hot very helpful: 10.8S Somewhat helpful: Not at all helpful: 13.1S On the job training Very helpful: Somewhat helpful: Armed Services Very helpful: Somewhat helpful: 20 . 3S Business experience Very helpful: 12.5$ Somewhat helpful: Formal education as noted on Very helpful: Somewhat helpful: 20.5S Other t Not very helpful: Not at all helpful: Not very helpful: Not at all helpful: Not very helpful: not at all helpful: Question 6 not very helpful: Not at all helpful: 10. How many years have you held your current position? Average: 5.4 years 11. How many people preceded you in your current position? Average: 1.6 12. Were you working for this Organization, Department/Service or Agency before you assumed your current position? Yes No 13. mark the method used to select you for your current position. Elected (e.g. by :1edical Staff, Executive Committee of Medical Staff, and/or Administration of Organization or Agency). 13.2% Selected (e.g. by rtedical Staff, Executive Committee of Medical Staff, Administrator, Dean, CEO, or search process) 78.9S Assigned (e.g. with military) Founder or son of founder 1S Other 1.8S ** 14. Do you now hold any paid administrative or management posi tion in ADDITION your current job? Yes 15.51 84.5S For List of "other" helpful experiences see Appendix C, p. 274 ** For "other" methods see Appendix C, p. 274

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15. Is your position considered full or part time? full time (35 hours a week or more) part time 254 16. Do you have a written contract or memorandum of understanding with your Organization or Agency? Yes No 17a. Is there a written job description for your position? Yes No 17b. rr yes, by whom was it written? Hark as many as apply. Self: Medical Director: CEO: 41. U Vice Pres. of Professional or Medical Affairs: Vice President of Organization: Medical staff (or Exec. Committee of Staff): Service or Department Chief: Personnel Director of Organization: External Consultants: Dean: Board of Trustees: Administrator: Dept. Armed Services: Other: 18a. Is there a formal evaluation of your job performance? Yes No 18b. If yes, who evaluates your performance? Self: 9.a Medical Director: CEO: 48.U Vice Pres. of Professional or f1edical Affairs: 7. 71. Vice Pres. of Organization: Medical Staff (or Exec. Committee of Medical Staff): Service or Department Chief:4.61. Personnel Director of Organization: External Consultants: Dean: 1.41. Board of Trustees: Other: ** For "others" who wrote job description see Appendix C, p. 275 ** For "others" who evaluate performance see Appendix C, p. 275

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'I 1 i I ; I l I I I I i I j 18c. If yes. how often does the evaluation occur?. Annually: 87.2S Occasionally: Every two years: Other: 19. Do you maintain a private medical practice? Yes 43.6S Mo 255 20. If yes. since assuming your current position. has the time spent in your practice: Substantially increased: 4.1S Somewhat increased: Not changed: 19.9S Somewhat decreased: 25.3S Substantially decreased: 46.1S 21. Do you feel your primary professional committment is: to your private medical practice: 19.2S to your management/administrative responsibilities: to other professional duties: 1.1S JOB SATISFACTION 22. Please mark the answer that best describes how you feel about your position. Very dissatisfied: 6.1S Somewhat dissatisfied 7.9S Somewhat satisfied: Very satisfied: For "other" category see Appendix c. p. 276

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. ' : I i i t 256 PART TWO ORGANIZATIOUAL CHARACTERISTICS 1. Title Chief Executive officer Vice President of Medical or Professional Affairs Director of an Organization Director of Medical Affairs :1edical Director of a Service. Department or Program lOS Assistant Medical Director Clinical Director of Dept.r Service or Program Chairman or Chief of Dept. or Services 7.2S Director of Medical Education Chief of Staff 3.4S Other 5.4S 2. Type of organization General Hospital (University based) 6.8S General Hospital based) Specialty Hospital (University based) Specialty Hospital (non-University based) Long-term Care Hospital .as Single Specialty Group Practice 2.2S Single Specialty Group Practice with over associated with a health plan Single Specialty Group Practice with less than associated with a health plan OS Multi-Specialty Group Practice 7S 11ulti-specialty Group Practice with over asso-. ciated with a plan Multi-specialty Group Practice with less than 50S associated with a health plan 5S Staff (or Group) llodel Prepaid Health Plan (PPHP) Independent Practice Association (IPA) .as Nursing Home (or extended care facility) .8% Industrial Organization 2.2S Pharmaceutical Company Government agency 4S Military Community Health Center Other 8.6s For list of "other" titles, see Appendix C, p. 277 For list of "other" organizational types see Appendix C, p. 278

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. j i 3. Ownership For Profit Profit, Non Govt. Non Profit Govt. sponsored Federal Government State Government Local Government Other 4. Which of the following positions does your Organizationor Agency have? 257 :1edical Director 84. U Chief of the Medical Staff Director of :1edical Educa tion 5. Does your Organization or Agency have or is it affiliated with a residencyprogram? Yes 56.4S rio REPORTING/CO!!fiUN ICATIOr: 6. To whom do you report in the Organization or Agency? Governing body as a whole Few selected members of the body Chief Executive Officer Dean or Chancellor 3.6S Medical Director Executive of Parent Org. 4.5S Vice President of ical Affairs or other Vice President in Org. Executive Committee of 11edical staff 12. lledical Staff Chief of staff 6.8S Chief of Service or Dept. Chair Vice President in Org. Other 8. u 7a. In addition to the above, are you INFOR!!ALLY accountable to -anyone else in the Organization or Agency? Yes llo 46. 2S 7b. If yes, to whom? Medical Staff 43.2S Board of Trustees 38.5S Exec. Comm. of Staff 31.2S CEO 24.4S Pres. of Organization Chair of Dept. or Serv. Other for list of "other" types of ownership see Appendix C, p. 273 For list of "other" reporting/communication arrangments see Appendix C, p. 279 *** For list of "others" informally accountable see Appendix c, p. 280

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! I I I I I 258 8. How would you describe the position you hold within your Organization or Agency? Line 45S Staff Mostly Line Staff 9. Do you think your position should be: Line Staff 5.9S Hostly Line 29.2S Mostly Staff 10. How much formal authority do you feel you have in your Organization or Agency? A great deal 57.2S Some Very little Almost none 11. How much influence do you feel you have in your organization or agency? A great deal Some 24.9S Very little Almost none .2S 12a. Do you generally attend Governing Board meetings? Yes 72.6S No 27.4S 12b. Are you a member of the Governing Board? Yes 36.9S No 63.1S 12c. Do you have a vote on the Governing Board? Yes Uo 70. U 13. Which of the following formal or infQrmal mechanism does your Organization, Agency or Group use to ensure communication between the Hedical Staff Organization or physicians, and the Administration or Business Staff? MECHA!HSllS Regularly scheduled staff meetings Regularly scheduled management/decision making Policy Committee meetings Regularly scheduled breakfast, lunch or dinner meetings 34.4S Assigned agenda time for reports, updates, announcements in Committee meetings Cross representation on Committees Informal on the job meetings Informal off the job meetings Off site retreats

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i! i I II ! II I I i I I I I I I I i i I I i i I I i I i i I l j i I i I Staff Memoranda 68.1' Administrative directives/guidelines Files of communications, messages, memos, etc. 49.7' Bulletin boards 41.5S Newsletters 60.1' Other 2.4S 259 IF YOUR ORGANIZATION IS A HOSPITAL, ANSWER QUESTIONS 14 7HROUGH 22 IF NOT, SKIP TO QUESTIOU 23 14a. Does your hospital have a national or regional affiliation Yes 41.2S No 58.8S 14b. If Yes, specify Catholic Hospitals 74.2S Military 15. How many physicians are there on your Medical Staff? Average 375.3 -16. How many full time physicians are employed by your Organization? Average 40.1 17. How many full time contract are there in your Organization? Average 19.8 18. What was the (approximate) number of in-patient days in 1982? Average 98916.7 19. How many licensed beds are there in your Organization? Average 424.3 20. How many ICU beds are there in your Organization? Average 31.7 21. Does your Organization participate in a Prepaid Health Plan (PPHP)? Yes No 77.9' 22. Does your organization participate in a Preferred Provider Organization (PPO) or an Exclusive Provider Organization (EPO)? Yes No For list of communication mechanisms see Appendix c. p. 280 For list of "other" affiliations see Appendix c. p. 281

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I I : I 260 Ir YOUR ORGANIZATION IS A GROUP PRACTICE ANSWER QUESTIONS 23 THROUGH 27. IF NOT, SKIP TO QUESTION 28 23a. Does your group provide prepaid health care Yes No 23b. If Yes, approximately what of your group's annual revenue is _derived from Prepaid Health Care arrangement? 45.6% 24. How many full time physicians are there in your Group? Average 91.8 25. How many part time physicians are there in your Group? Average 18.6 26. What is the total number of full time non-physician employees in your Group? Average 651 27. Does your Group participate in a Preferred Provider Organiza tion (PPO) or Exclusive Provider Organization (EPO)? Yes No IF YOUR ORGANIZATION IS ANY TYPE OF A PREPAID HEALTH PLAN, QUESTIONS 28 and 29. IF NOT, SKIP TO 30 28a. Does your Organization have a national or regional affiliation Yes No 28b. If Yes, specify 29. How many enrollees does your Organization have? Average 357,432 IF YOUR ORGANIZATION IS A STAFF MODEL PREPAID HEALTH PLAN ANSWER QUESTIONS 30 THROUGH 32 30. How many full time physicians are there in your facility? Average 61.4 31. How many part time physicians are there in your facility? Average 14.5 For list of specific national or regional affiliations, see C, p. 282

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261 32. How many physician full time employees are there in your facility? Average 435.3 IF YOUR ORGANIZATION IS AN IPA PREPAID HEALTH PLAN ANSWER QUESTION 33 33. How many physicians participate in the IPA? Average 101.8 IF YOUR ORGANIZATION, DEPARTMENT/SERVICE OR GROUP DOES NOT FALL INTO AUY OF THE ABOVE CATEGORIES, ANSWER QUESTIONS 34 THROUGH 36 34. How many full time physicians work in your Organization, Department/Service or Agency? Average 207.6 35. How many part tioe physicians work in your Organization, Department/Service or Agency? Average 65.8 36. How many non physician full time employees are there .. in your Organization, Department/Service or Agency? Average 2664.8

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: I I : I I I i 262 PART THREE 1. Approximately what percentage of your time do you think is devoted to management activities? Hours per week Average 34.9 Percentage Average 2. Are you financially compensated for management activities? Yes tlo Sometimes .as 3. What was the established annual salary for your position in 19a2? Average $80,560.9 4. What was the total amount you received in bonuses from your Organization or Agency for your management role in 1982? Average $5627.8 5. What was the share of profits or dividends you received from your Organization or Agency relating tc your management role in 1982? Average $2540.2 6. What was the annual dollar amount of pension and retirement pay contributed by your Organization or Agency in 1982? Average $8741.8 1. Does the Organization or pay the Premium for your malpractice insurance? Yes 74. U llo 25. a. Did your Organization or Agency pay the Premium or provide: 9. Health Insurance Life Insurance 87.6S How many WEEKS of paid in 1982? Average 3.5 vacation were Disability Insurance Other you authorized to receive 10. How many DAYS of paid professional or educational leave we:-e you authorized to receive in 1982? Average 9. 1 For list of type of insurance see Appendix C, p. 283

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:I ; I I I .I I 263 11a. Please mark all other compensations or benefits you received from your Organization or Agency in 1982: Travel and expenses to Professional Conferences or Conven-tions: Membership dues for Professional Organizations: Additional Health Care Benefits: Other private educational expenses: 41.6S Additional Life Insurance: Entertainment expenses: Car: 22.4S Car including maintenance, insurance and/or gas: Additional time off: 15.9S. Membership dues for other professional Organizations 14.51 Other: 6.9S* Stock options: 6.5S 11b. What do you estimate the dollar value to be of additional benefits marked above? Average $9185.10 12. When you assumed your current job, your total financial compensation: 44.2J of respondents an increase by an average of $18,579.60 representing 25.8S of total compensation. 21.2S of respondents r-eported a decrease by an average of $24,3118 representing 28.6S of total compensation. 34.6S of respondents reported no change in their income. However, it is important to note that more respondents reported an increase in their income than a decrease. Therefore the mean (average) compensation increase is $4,825 representing an average of 8.3S of total compensation. For list of "other" compensations see Appendix C, p. 283

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264 TASK LIST A. THE ORGANIZATION. DEPARTMENT/SERVICE OR AGENCY l. Preparing new or modifying existing bylaws. Yes 65.3S No 19.9S N/A 14.8S 2. Preparing new or modifying existing policies and/or proce dures. Yes 93.6S No 4.7S N/A 3. Preparing goals and objectives for the Organization. Department/Service Agency Yes 87.7S No N/A 3.5S 4. Designing or reviewing new programs. Yes 91.4S No 6.6S N/A 2.1S 5. Deciding which programs and medical services your Organiza tion. Department/Service or Agency offers. Yes 80.5S No 15S N/A 4.5S 6. Deciding size of programs and medical services. Yes 72.5S No 18.3S N/A 9.2S 1. Deciding patient care equipment needs. Yes No 19.1S N/A 10.4S 8. Deciding the number and type of physicians that practice in your Organization. Department/Service or Agency. Yes 69S Uo N/A 10.4S 9. Writing new or modifying existing criteria for the responsibilities of physicians. Yes 72S No 18.8S N/A 9.2S 10. Writing new or modifying existing criteria for the privileges of physicians. Yes No 28.6S N/A 15.8S 11. Deciding on pricing for services. Yes 34S No 46.1$ N/A 19.9S 12. Monitoring and reporting on issues of interest (and/or concern) of Medical Staff to Administration or Business Staff. Yes 87.6S No 5.8S N/A 6.6S 13. Monitoring and reporting on issues of interest (and/or concern) of Administration or Business Staff to the Medical Staff. Yes No N/A as

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265 14. Communicating information to the !1edical Staff and the Governing Body of the Organization, Department/Service or Agency (e.g decisions made. new policies, etc.) Yes 88.3S No 6.1S N/A 15. Writing new or modifying existing standards of Medical care practice. Yes 60:1S No N/A 12.2S 16. Ensuring that standards of care are written and disseminated. Yes 69.7S No 20.8S 9.5S 17. Writing new or modifying existing administrative or busi ness (versus medical care) policies for the Medical Staff (e.g. informed consent issues; ways to establish E.R. call list). Yes No 23.5S N/A 11.1S 18. Ensuring administrative or business policies for the l1edical Staff are written and disseminated. Yes 64.9S No 23S N/A 12.1S 19. Preparing or modifying existing administrative policies for non physician health professionals. Yes 52.1S No 35.4S N/A 12.5S 20. Chairing Staff Committees. Yes 51.2S No N/A 21. Attending Medical Staff Committees. Yes 83.7S No 8.2S N/A 8$ 22. Chairing Administrative Committees. Yes 50.1$ No 36.4$ N/A 23. Attending Administrative Committees. Yes No N/A 24. Chairing Board Committees. Yes No M/A 25. Attending Board Committees. Yes 66$ No 18.3$ H/A 15.6$ 26, Preparing agenda items for Staff or Physicians' Meetings. Yes 77.7% No 15.1$ N/A 27. Preparing agenda items f meetings with the Administrative or Business Staff or with the Administration of the Organi zation (e.g., Business Manager or CEO.) Yes 63.91 No 24.81 N/A 11.3$

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266 28. Preparing agenda items for meetings with the Governing Body. Yes No N/A 29. Deciding on research activities. Yes No 26.5S B. OUTSIDE THE ORGANIZATION 30. r1onitoring and reporting on changes in the social environment (e.g.high concentration of elderly in service area), io the economic environment (e.g.local unemployment rate), or in the political environment (e.g. cuts in health care delivery service), in order to identify issues to be acted upon by the Organization, Department/Service or Agency. Yes 53S No N/A 31. Lobbying Regulatory Agencies (e.g.,HSA's, State Licensing Authority) or Legislative Bodies (e.g Federal State Legislature). Yes 26.5S No N/A 32. Coordinating with other health Care Organizations (e.g. about patient care issues, shared services), Yes 60.7S Uo R/A 33. Promoting your Department/Service or Agency. (e.g. to local or to the general public). Yes 66.3S No 24.5S N/A 9.2S 34. Representing (being a spokesperson for) your Organization, Department/Service or Agency to other Hedical or Health Care Organizations (e.g. local Medical Society), Yes No 18.1S N/A 7.1S 35. Representing your Organization, Department/Service or Agency to the general public (e.g., speak to local groups, meet the press, etc.). Yes 69.1S No U/A 8.6S 36. Representing your Organization to third party payors. Yes 31.2S No N/A 21.1S C. QUALITY ASSURANCE 37. Designing new or modifying existing programs that physicians' behavior to established standards of care in the Yes No 16.6S N/A 8.8S 38. Ensuring that a system for review and evaluation of the credentials of new physicians being admitted to the Organi zation or Agency exists. Yes No 14.1S 9/A 9.8S

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267 39. Ensuring that a system for review and of !ledical Staff competency exists (e.g. identifying the impaired physician). Yes 77.6S No N/A 40. Ensuring that a system for review and evaluation of i1edical Staff competency operates effectively. Yes 76.6S No N/A 9S Monitoring or reviewing the system for evaluating the competency of non-physician health professionals. Yes No N/A Ensuring accreditation with JCAH. AAAHC. or other accrediting bodies. Yes No N/A D. EDUCATIONAL ACTIVITIES Designing Continuing Education (CE) programs for physicians Yes No N/A Designing CE programs for non-physicians. Yes 27.1S No 53.2S N/A 45. Designing general (non-clinical) educational programs (e.g management courses. Yes 15.3S No 22.1$ Teaching CE programs to physicians. (including house staff if applicable). Yes No N/A Teaching CE programs to non-physician health care professionals. (clients and their families). Yes 30.7S No 48.6S N/A 20.8S Evaluating education programs. Yes No 30.5S N/A E.DATA MANAGEMENT Ensuring systems designed to obtain data necessary to evaluate medical care are developed. Yes 58.71 No N/A 10.jS 50. Ensuring systems designed to obtain data necessary for general management decisions are developed (e.g management information system). Yes No 43.5S N/A 151

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. i i I i I i : 268 51. Monitoring and reporting on data from systems designed to obtain information about medical care. Yes 64.1S No 25.5S N/A 10.5S 52. Monitoring and reporting on data from systems designed to obtain data for management decisions. Yes 45.2S No H/A 53. Ensuring that data relevant to medical care issues are used appropriately. Yes 74.6S No 16.3S N/A 9.1S 54. Ensuring that data relevant to management issues are used appropriately. Yes 48.9S No 38.1S N/A 13S F. FINANCIAL MANAGEHENT 55. Designing ways to improve efficiency of professional departments within your Organization or Agency. Yes 60.2S No 27.3S N/A 12.5S 56. Developing the budget or a part of the budget for the Organization, Department/Service or Agency. Yes 70.5i Gc 21.3S N/A 8.2S 57. Reviewing the budget or a part of the budget for the Organization, Departments/Service or Agency. Yes 75.8S No 16.8S N/A 7.4S 58. Reviewing the financial performance of the Organization, Department/Service or Agency (e.g. management data exclusive of the budget). Yes No 27.3S N/A 10.3S G. RISK MANAGEMENT 59. Does your Organization or Agency have a risk management program function? Yes 66.9S No 33.1S If yes, answer next two questions: 60. Designing new or modifying existing risk management functions. Yes 53.1% No 39-51 M/A 7.4% 61. r1onitoring and managing existing risk management functions and/or programs. Yes 59.71 No 32.61 N/A 7.7%

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269 H HANAGEMENT 62. Identifying the need for outside consulting services. Yes No N/A 63. Obtaining/buying consulting services for the Organization. Yes No 43.0S N/A 14.8S 64. Supervising capital construction projects as needed. Yes 25.2S Uo 52.8S N/A 22.1S I HUMAN RESOURCE MANAGEMENT 65. Designing incentive programs to increase physician productivity. Yes No U/A 20.7S 66. Ensuring that a physician recruiting program operates as needed. Yes No N/A 67. Deciding scope of practice for non-salaried physicians. Yes 35S No N/A 68. Designing contracts for physicians. Yes 46.3S N/A 69. De5igning contracts for non-physicians. Yes No 55.9$ 70. Designing wage/b.enefi t Yes 38.9S No 71. Designing wage/benefit Yes No 55. a 72. Hiring physicians. Yes No 21.8S N/A schedule for physicians. N/A 22 . schedule for non-physicians. N/A N/A 73. Hiring non-physician health care personnel. Yes 37.6S No N/A 74. Deciding expectations of salaried or contract physicians (e.g., writing a job descriptiong). Yes No 27.4S M/A 75. Deciding organizational expectations of non-physicians. Yes No N/A 76. Supervising physicians (e.g. for appropriateness of hospitalization use). Yes Ho 23.61 N/A

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270 77. Supervising non-physicians. Yes 53.5S No 34.5S N/A 78. Ensuring a grievance procedure for physicians is followed. Yes 67.6S No 19.7S N/A 12.7S 79. Ensuring a grievance procedure for non-physicians is followed. Yes 35.5S No 45S N/A 19.5S 80. Negotiating with unions. Yes 8S No 56.9S N/A 35.2S 81. Advising and/or counselling physicians on personal issues. Yes 65.2S No 24.3S N/A 10.4S 82. Advising and/or counselling physicians on career or professional issues. Yes 65.1S No 23.3S N/A 11.6S 83. Advising and/or counselling non-physician health care personnel. Yes 46.5S No 39.5S N/A 14S 84. l1ediating confli'
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. i : I i I \ I I APPENDIX C LISTS OF "OTHERS" FROH SURVEY

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272 LIST OF "OTHER" SPECIALTIES QUESTION 3 PART ONE Nephrology Aerospace Medicine Industrial Medicine Plastic Surgery Cardiac Surgery Dermatology Neurosurgery Rheumatology Adolescent Medicine Neurology Allergy Thoracic Surgery Legal i1ed i cine Pediatric Surgery Pulmonary Medicine Immunohematology Endocrinology Public Health Cardiology Insurance Hedicine Radiation Oncology r-tedical Genetics Hedical Oncology Head and Neck Surgery Alcoholism Child Psychology Occupational Medicine Pharmacological Research Opthalmology LIST OF "OTHER" CATEGORIES OF STATUS ON MEDICAL STAFF QUESTION 5b PART ONE Emeritus No admission privileges Partner Member of medical group HMO medical director In addition to active, senior meritorious Administrative Honorary Associate

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LIST OF "OTHER" MANAGEMENT TRAINING QUESTION 6 PART ONE University based courses at undergraduate level M.S. in Community Health Masters in Management Fellowships or preceptorships of various types State government training courses 273 Advanced training at corporate management workshop Federal executive management short course Paid consultants Broad reading Grew up in business family Military management courses LIST OF "OTHER" WORK EXPERIENCES QUESTION 8 PART ONE Medical film maker Disability management Medical missionary Consulting School board member Research on medical computer system Academic experience Medical director of small multi-specialty group Founder of group

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' LIST OF "OTHER" EXPERIENCES FOUND HELPFUL QUESTION 9 PART ONE Self-directed study Teaching residents and boy scouts Continuing education Applied research Bureaucratic experience in state hospital Consulting City Planning Commission "OTHER" METHODS OF SELECTION QUESTION 13 PART ONE Promoted from within State testing Interviewed for clinical position administrative position Uegotiated Elected civilian contract Within military .Appointed by Governing Board but 274 offered

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LIST OF "OTHERS" WHO WROTE JOB DESCRIPTION QUESTION 17b PART ONE State personnel board Partnership board Board of governors National corporate headquarters Search committee Director of plans and resources Executive director of organization Assistant chancellor Attorney for commissioner Previous program director Previous CEO President of division AHA guidelines Medical staff rules and regulations Bylaws inclusion Management company contract An amalgam of Do not know LIST OF "OTHERS" WHO EVALUATE PERFORMANCE QUESTION 18b PART ONE Board of management Board of health Partnership board Agency director Deputy health commissioner Executive director of hospital Chief of staff Chancellor Senior general officer District administrator of HRS State bureaucrat Director of plans and resources Assistant vice president for ambulatory services Chief of department 275 Peer review committee with outside consultant Frequent meetings with administration and administra-tion committee Military hierarchy -Dept. of armed services Accreditation such as AACME Provision in medical staff bylaw to discharge me for Informal-unorganized

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' i ; i ; : I "OTHER" FREQUENCY OF EVALUATION QUESTION 18c PART ONE Informally Semi-annually 276 Every two years informally, every six years formally Quarterly Every fourteen months Every six months Every five years three years Never

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I I l 1 LIST OF "OTHER" TITLES QUESTION 1 PART TWO Associate Dean for Clinical Affairs Assistant Health Commissioner Executive Director Medical Staff Chief of Professional Services 277 Assistant Administrator for Professional Affairs Associate Medical Director, Family Practice Residency Program Executive Head of Regional Blood Services Consultant Chairman of Corporation Profit Sharing and Pension Plans Chair utilization Committee Director of Quality Assurance and/or Risk Management Serve as both Medical Director and Director of Medical Education Both Vice President and rtedical Director Hospital Commanding Officer, Director Base Uedical Service Medical Member Air Force Physician Evaluation Board Senior Medical Evaluation Officer Chief Medical Readiness United States Air Force Chief Operating Officer

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'I I i i LIST OF "OTHER" ORGANIZATIONS QUESTION 2 PART TWO Foundation for Medical Care Management Corporation Retirement Community Emergency Medicine Contract Group Evaluation Health Care Delivery Service Medical Association County Public Health Department State Institution for Mentally Retarded Hospital Based Health Center Telecommunications Company Regional Blood Services/Blood Center 278 Combination non-University general hospital, multispecialty group practice with less than associated with prepaid health plan and research foundation Regional Human Services Center Non-profit medical education foundation State operated intermediate care facility JCAH State run comprehensive health benefits plan Residency Programs Forprofit health care organization owned by insurance company Hospital malpractice insurance company Health Plan Division of insurance company Paramedical training program under medical association Insurance company Corporation that includes six hospitals and two groups Multi-institutional health system Private organization that designs, implements, manages and evaluates health care delivery services Research center LIST OF "OTHER" TYPES OF OWNERSHIP QUESTION 3 PART TWO Non-profit district hospital Partnership Joint township district "EDS" federal corporation Mutual company Hospital authority

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i I I l I 279 LIST OF "OTHER" FORMAL REPORTING/COMMUNICATION ARRANGErtENTS Agency Director General t-1anager QUESTION 6 PART TWO Administrator of Organization Vice President of Administration Assistant Administrator Associate Administrator Assistant Vice President Ambulatory Services President of University Medical School Hierarchy Military Hierarchy No one Corporate Hedical.Director Regional Vice President Comptroller Hedical Society Private Contractors DHE Non Medical Middle Hanager Health Officer Chief of Professional Services Trustee of Profit Sharing and Pension Plans Chi e f o f Po 1 i c e and f1.a yo r

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: 1 I : I I il I I I : I ' Partnership LIST OF "OTHERS" TO WHOM MEMBERS ARE INFORMALLY ACCOUNTABLE QUESTION 7b PART TWO Peers and Co-Workers Hanagement Board Board of Commissioners Executive Committee Board of Visitors Hospital Authority Executive of Parent Organization Director of the State Department (local) Medical Director of Health Sector Superintendent Medical Director Chief of Staff Medical Affairs Director Someone in Military Hierarchy Sisters that own hospital Commissioner of Health Quality Assurance Manager President of Foundation Manager of Employee Relations LIST OF "OTHER" COMMUNICATION MECHANISMS QUESTION 13 PART TWO Medical Director On site seminars Weekly grand rounds Circulate board Policy manuals and protocols Closed circuit TV Regulations One on one telephone calls Marketing brochures Staff assistance visits 280

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I :! 281 LIST OF "OTHER" NATIONAL OR REGIONAL AFFILIATIONS FOR (HOSPITALS) QUESTION 14b PART TW01 Appalachian Regional Hospitals Federal Government System State Government Hospital System Adventist Health System Alexian Brothers of America, Inc. American Medical International Charter Medical Corporation Evangelical Hospital Association Hospital Corporation of America Kaiser Foundation Hospitals Lutheran Hospitals Methodist Hospital National Medical Enterprises Presbyterian_ St. Lukes I1edical Center of America Raleigh Hills Hospital Samaritan Health Services Shriners Chidren's Hospital State Wide Multi-institutional organization United Health Services, Inc. Universal Health Services, Inc. 1 Abbreviations were omitted when they were unknown and/or did not correspond with any of the organizations listed in the American Hospital Association Guide to the Health Care Field.

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LIST OF OTHER NATIOMAL OR REGIONAL AFFILIATIONS FOR PREPAID HEALTH PLANS QUESTION 28b PART TWO iHlitary Blue Cross/Blue Shield FHP Inc. National BA Health America Union ACTWU Kaiser INA HMO of Pennsylvania Life Extension Institute. Comprehensive HS Prudential Heal Care Plan. Inc. Prucare GHAA Federal Government 282

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. j I I i i I i I i ' i ; I :1 : I I I I I LIST OF "OTHER" TYPE Of PROVIDED BY ORGANIZATION QUESTION 8 PART THREE Workmens Compensation Liability Insurance Travel Insurance Accident Insurance Supplement umbrella Malpractice and Liability Life and Dental Insurance Spouse and Dependents !1ilitary Benefits LIST OF "OTHER" COMPENSATION OR BENEFITS QUESTION 11a PART THREE Tax sheltered annuity Professional study time Educational stipend Savings plan Deferred payment plan Sick leave $50,000 annuity Housing Heals Profit sharing compensation and pension Gas credit card 283 Reimbursement for getting up professional corporation Sabbatical leave Commissary and other military privileges University tuition Free parking Use of condominium Consultations with other benefits Moving expenses Low interest loans Great amount of freedom Vacations redeemed for cash Portion off office rent Office, secretaries Incentive plan Supplemental malpractice

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LIST OF "OTHER" TASKS Miscellaneous Policy Management Activities Set the philosophical tone of the group. Establish and maintain corporate culture. Miscellaneous Program Management Activities 284 Hedical advisor.consultant or director of various specific programs or services not listed, (e.g., director of poison control information center). Develop and coordinate various programs not listed (e.g., safety programs; industrial hygiene programs; toxicology programs; industrial epidemiology programs; industrial relations programs. Monitoring of local occupational health hazards. Negotiating sale of dialysis service to nephrologists. Review flight programs for aero-medical significance Miscellaneous Resource Management Activities Supervise specific departments, divisions or services not listed, (e.g., medical records department, anesthesiology department, respiration therapy). Work with satellite/branch clinic. Investigate potential new satellite/branch sites. Deal with investment issues; e.g. retirement benefits. Terminate physicians and other health care personnel when necessary. Negotiate contracts for physician services. Contract for hospital, SNF, surgery center, at a favorable rate. Clinical Activities Caring for other physician's patients in emergency. Visiting other physicians' patients when they do not visit in prescribed time. Signing telephone orders for other physicians. Occasional medical provider 20 hours + per week in clinic plus responsibility for hospital's (federal) patients and after hours calls. Emergency room physician 24 hours per month. Employee health supervision Executive Physical Evaluation, e.g., pre-employment and reclassification/physical examination.

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285 List of "other" tasks (continued) Specific flilitary Activities Flying four hours a month. Ensure state of wartime medical readiness. Responsible for: public health; OSHA compliance -safety in maintenance shops; exercise of a disciplinary system over employees and members (patients). Reviewing medical examinations for entry into USAF flying training or continued flying status. Reviewing aircraft accident reports. Staff assistance visits to medical facilities. Attend social functions. Duty as medical officer of the day. Write letters of commendation. Administer punishment under the uniform code of military justice. Educational Activities Direct residency training program. Supervise curriculum of program. Responsible for undergraduate and /or graduate medical education . Review and screen all requests for admission to medical school. Monitoring non-physician health care with respect to education, certification. Author medical column for union newspaper. General ilarketing Activities Direct participation in marketing pre-paid plans to prospective employers and employees. Market programs to client hospitals.

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: I i I I I I : : 286 List of "other" tasks (continued) Quality Assurance and/or Risk Management Activities Liability Control. Safety review (products). Review malpractice suits against hospitals and physi-cians. Assist defense counsel on malpractice cases. Collect data on causes of suits. Handle all legal contact with corporation attorneys. List of "other" tasks (continued) Lecture on prevention of malpractice suits. Develop and assure systems to protect patient confidentiality. Primary responsibility for federal regulations review. Research Activities Design and conduct clinical research. Insure proper investigation and respond to product complaints. Search for new product ideas or market trends. Publish original articles and books. Seek grants. Coordinate and direct-worldwide clinical trials and research candidates of new pharmaceuticals. MisGellaneous Administrative Activities "Approval/Veto" decision making for some of the tasks in specifically in the areas of "design", "prepare" and "write". Academic chair functions of appointment, promotion, and tenure. Acting as CEO in his absence. Evaluate other agencies. Investigate other agencies. Completing Role/Compensation surveys

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287 List of "other" tasks (continued) Miscellaneous Committee or Board Activities Chair or attend various committees not specifically listed on Task List. Serving on boards of directors, policy making bodies, or task forces. Act as medical consultant to lay governing board of retirement community and availability of medical care. Liaison Activities Advocacy for the community and the patients. Mediate between patients and physicians. Attempt to sense developing problem and to correct the situation before serious rifts develop. Act as liaison between various committees, with community, with other and/or between organization and Trainer in group dynamics, group process, etc. Application of organizational development principles to public health Responsible for lease space as landlord.