Hospital Administration in the Early 1900s: Visions for the Future and the Reality of Daily...

Margarete Arndt, D.B.A., professor of management, Clark University Graduate School of Management, Worcester, Massachusetts, and Barbara Bigelow, Ph.D., professor of management, Clark University Graduate School of Management

EXECUTIVE SUMMARY

This article explores the first vision of modern

hospital management as it was advanced by the American Hospital Association in the early 1900s and compares it with the reality of daily practice at the time. The findings show a wide gap between vision and reality. They also show that many of the issues faced by hospital administrators a hundred years ago remain relevant today. They include the tension between adoption of new technology and the cost of hospital care, advocacy for business practices from the private sector, and the administrator's responsibility in the area of quality of care.

The number of hospitals in the United States grew from 149 in 1873 to 6,665 in 1913 (Ochsner 1913; Modem Hospital 1913a). The vast majority were small. Almost 70 percent had no more than 50 beds, and fewer than 200 had more than 200 beds (McClure 1918; Modem Hospital 1914a). To attract patients accustomed to medical care in the home, hospitals had to overcome the traditional image of the hospital as an unclean house of death or a refuge for the poor and had to transform into "a work place for the production of health" based on scientific principles (Starr 1982, 146; Hornsby 1913; Hurd 1913).

The extant literature has described eloquently the social and symbolic role of hospitals in their communities and the influence of science and the professionalization of medicine and nursing on the hospital's role and development (Starr 1982; Stevens 1986; Reverby 1987; Melosh 1982; Freidson 1970). Much less is known about the actual work of hospital superintendents (as administrators were then called) in the early 190Os or about the emergence of hospital management as a distinct occupation (Neuhauser 1995). This article addresses these gaps. First, we show that a vision of the modern hospital administrator as a business leader emerged along with a vision of the modern hospital as a scientific institution. The conceptualization of these new roles developed under the aegis of the American Hospital Association (AHA), the professional association for hospital administrators at the time. Second, we describe the actual work of hospital officials during those early years and compare it to the emerging view. The article closes with a discussion of the links between our findings and hospital management today.

DATA SOURCES

The primary data source for this article is the journal Modem Hospital. Founded in 1913, Modern Hospital was the only journal in the early 190Os to focus entirely on hospital management, advising superintendents on "the most intimate details of hospital administration" (Modern Hospital 1913b, 185). The journal's editorial board was composed mostly of AHA officers, and its editorial content reflected the opinions of the AHA (Amdt and Bigelow 2005).

Our study covers the years 1913 through 1920, when the hospital administration occupation first received attention. For the analysis of practitioners' actual work, we drew on the column "Queries and Answers," a regular feature in Modem Hospital addressing questions from readers. Through the use of an inductive coding scheme, inquiries were assigned to categories that represented specific management areas (Miles and Huberman 1994). If an inquiry addressed multiple topics, each was assigned to its respective category. We did not approach the reading with an a priori list of topics because that would have reflected today's notions about the nature of hospital administration. Instead, we let the topics emerge inductively through the reading. Similar to the constant comparative method, categories were created, split, abolished, or subsumed as the reading progressed (Glaser and Strauss 1967). Appendix I shows an abbreviated set of categories and samples of inquiries in each. To access the complete appendix, go to www.ache.org/pubs/jhmsub.cfm.

THE EARLY 190Os VISION OF MODERN HOSPITAL ADMINISTRATION

The early years of the twentieth century were characterized by "the expanding work of the modern hospital and the responsibilities of its administrators" (Washburn 1913, 127). Although a "theory of hospital administration . . . still lack[ed] definition," management in the private sector provided a model (Goldwater 1920, 275-76). Keppel (1916, 304-305) wrote about "the modern hospital as a health factory," arguing that "the hospital is to all intents and purposes a manufacturing plant, and any scheme looking towards its successful management must be similar to the schemes used in other manufacturing establishments of equal size and grade." Consistent with this view of the hospital as akin to manufacturing plants, the AHA, as reflected in its editorial control of Modem Hospital, advocated a model of modern hospital administration that focused on business practices and on the hospital as a scientific institution.

First, administrative work was to resemble management in the private sector. It would span all hospital departments (Edsall 1915; Valentine 1916; Lyons 1919; Goldwater 1920), and like the businessman in the private sector, the administrator would sit at the top of a hierarchy and provide direction (Waldheim 1920; Edsall 1915; Wilson 1915; Tipping 1914). The board's role would have to change accordingly (Tipping 1914; Walsh 1915). Trustees provided important expertise in law, accounting, and other business matters, but they often used their position to engage in the hospital's daily affairs. Such "dominating and domineering" conduct was now deemed inappropriate (Modern Hospital 1916a, 426), and articles called on trustees to let the superintendent have "direct executive authority over all the departments of the hospital" (Babcock 1920, 178).

In addition to a hierarchical structure, other business practices to be adopted from the private sector included cost accounting and bookkeeping (Carter and Porter 1918; Mann 1914; Warner 1916; Wechsler 1914), budgeting and cash control (Hurd 1916; Loder 1915), purchasing and inventory practices (Greener 1914a), and formal admission procedures and billing policies (Greener 1914b; Poll 1916; Van Norman 1914). Internal control systems would rationalize and improve operations and facilitate comparisons across hospitals (Modem Hospital 1916b; Warner 1916; Wilson 1915). This, in turn, would help hospitals contain their costs, a challenge that was deemed "one of the most insistent and difficult problems before the hospital people" (Modem Hospital 1916c, 355). Costs were of particular importance because hospitals' major source of revenue was private patients, and high charges made it difficult to attract self-paying patients, especially from members of the middle class, who were more likely to receive care in the home.

Second, if the hospital were to attract private patients, it had to be seen as a preferred place of care, so the hospital's emergence as a scientific facility was important. New facilities and technology would create this modern scientific institution. Modern Hospital presented information on how to plan and construct facilities (Hornsby 1916a; Hubbard 1917; Modem Hospital 1914b, 1915b, 1916d); how wards, kitchens, and administrative offices should be laid out and furnished; and what equipment to buy and how to use it (Hannaford 1914; Hornsby 1916b; Hornsby et al. 1917; Mixter and Kellogg 1917). Prescriptions could be extremely detailed, including, for example, "two blackboards for a play room" for a children's hospital (Burgess 1914, 236) or potato mashers for the hospital kitchen (Modern Hospital 1915a). Administrators' attention was also drawn to the placement of patients with infectious diseases (Richardson 1913; Burby 1916) and to fire safety (Hollinger 1916; Porter 1915, 1917; Modem Hospital 192Oa; Hejda, 1914). Attention to the former was critical if hospitals wanted to shed their image as unclean, and attention to the latter was the result of hospital fires (Trained Nurse and Hospital Review 192Oa). Many older hospitals were not fireproof, and even in newly constructed buildings the term "fireproof" was considered "at best a relative one" (Modem Hospital 1914c, 365).

It was the superintendent's responsibility to provide physicians with facilities and opportunities "no matter what it costs for installation and operation" (Warner 1915, 413; Townsend 1914, 234), and cooperation with the medical staff was an important aspect of a modern hospital's management (Golightly 1916; Modern Hospital 1919a, 1913c). Physicians were eager to make use of the hospital's technology and support staff for the care of their private patients, and the hospital depended on such admissions. Thus, the hospital was to "carry out the orders of doctors" (Modem Hospital 1915c, 386), and "lack of consideration and respect for the physician's rights and privileges . . . brought discredit to the superintendent and disrepute to the hospital" (Golightly 1916, 179). If need be, physicians could use "pitiless publicity" to get hospital superintendents to install new technology (Modern Hospital 1919b, 46).

Ancillary clinical personnel played an important role in the framing of the hospital as a scientific institution. Nursing was the single most important service and had the greatest influence on "making or marring the reputation of the hospital" (Trained Nurse and Hospital Review 1913, 232). Modern Hospital contained much advice on how to organize a nursing department (Lawler 1914; Greener 1914c), the skills and education of nurses (Nutting 1914; Hornsby 1914b; Watson 1915), and the proper role of nurses on the patient care team (Hornsby 1917a; Beers 1914; Walsh 1916). Despite the importance of nursing, administrators were advised to view other areas as equally important (e.g., a formal dietary department with trained dietitians and a social service department with trained social service workers). The "scientific feeding of the sick" (Homsby 1914a; Modem Hospital 1918a; Eckman 1918) held the promise of "displacing drugs by foods" (Modem Hospital 1918a, 33), while social service would take its place "squarely by the side of the other departments" because it would increase the hospital's efficiency (Warner 1913, 155).

THE REALITY OF DAILY PRACTICE IN THE EARLY 1900s

Most hospitals in the early twentieth century did not yet fulfill the vision of the hospital as a modern scientific institution. They still used blocks of ice for cooling and coal stoves for cooking and heating, and many still made soap, did laundry, mended linen, rolled gauze, and manufactured "syrups, essences, tinctures and elixirs" (Bacon 1918, 431). Medical records, refrigerators, vacuum cleaners, laboratory and sterilization equipment, and even furnishings and vegetable peelers all represented new technology. Similarly, packaged or prepared food, commercial laundries, and commercial supplies for patient care were new to the industry.

Hospitals employed only small numbers of trained nurses. Most of the care was provided by nursing students (McKenzie 1914; Reverby 1987). Very few hospitals had introduced a social service department or a dietary department with formally trained staff (Beckley 1933; Modern Hospital 192Ob, 306; Hornsby 1917b; Atwood 1914). The majority of hospitals would not have had the resources for either service. Menu planning was often the responsibility of the superintendent, the job of cooking for patients and staff was sometimes combined with the functions of the housekeeper (Coleman 1915), and the superintendent may even have helped with the cooking (Gladwin 1907; Modem Hospital 1918b).

Hospital superintendents were identified in hospital bylaws as the institution's executive head. For example, the rules and regulations of Memorial Hospital in Worcester, Massachusetts, noted that "the Superintendent. . . under the direction of the Trustees, shall have the management of both the Hospital and the Dispensary, including the control of all subordinates, employees, domestics, nurses and patientsand the care of the grounds, buildings, and appurtenances" (Memorial Hospital 1912, 2). Bylaws also enumerated specific areas of responsibility for the superintendent, such as the appointment, control, and discharge of employees; maintenance of permanent patient records; acting on applications from patients for admission to the hospital; keeping records of monies and gifts received, bills incurred, and inventories; purchase of provisions and supplies; oversight of housekeeping; and preparation of budgets and reports to the board (Memorial Hospital 1912; Milford Hospital 1913; Sturdy Memorial Hospital 1914).

These functions were conceptually consistent with the AHA's vision of hospital administration. In actual practice, however, most superintendents did not give direction from the apex of a formal hierarchy but were personally involved in the daily work of hospital departments (Homer 1917; Modern Hospital 1918b). Milford Hospital required that "at least once a day she shall visit and inspect wards, kitchen, laundry, and all other departments of the hospital" (Milford Hospital 1915, 29). An editorial in Modem Hospital (1918b, 387) described the superintendent of a 30-bed hospital who "was bookkeeper, office girl, dietitian, teacher, housekeeper, and buyer, did all the radiography for that county . . . and sometimes fired the furnace on Sunday afternoon when the janitor was out."

The superintendents of hospitals usually were nurses (Parnall 1920; Redwine 1917; Riddle 1912). Their duties could include direct supervision of the nursing staff (Milford Hospital 1915; Sturdy Memorial Hospital 1914) and personal involvement in nursing care (Hertzler 1916; Modem Hospital 1918b). The following excerpt from an article in the American Journal of Nursing (Gladwin 1907, 622-623) illustrates the scope of superintendents' work:

She goes to a hospital of say twenty-five beds, ten nurses, and five servants. Sometimes she has a housekeeper. . . . Her assistant is often a recent [nursing] graduate.. . . The management of the storeroom, kitchen, and laundry is. . . arduous in the extreme. . . . There are eight or ten physicians on the staff, all of whom must be pleased and met with such tact as she can summon to her aid. The superintendent assigns patients to their beds, sees their friends, and is at the mercy of anyone who chooses to call for her at the door or over the telephone. She keeps the books, makes out the bills, collects money, pays the nurses and servants and is on call at all times, day or night, for obstetric cases, accidents, or emergencies; often helps in the operating room, gives ether. . . has been known to cook the dinner when the cook "gave notice" suddenly. . . [and] orders all the hospital supplies with such economy as she can master while she is trying to make an inquiring public understand why she has not taught graduate nurses not to put hot things on polished surfaces, and why she hasn't provided them with better table manners.

If the hospital had a nursing school, the hospital superintendent participated in the instruction of its pupils and often was head of the school as well (Beers 1914; Hornsby 1914b; Trained Nurse and Hospital Review 1916; Milford Hospital 1915).

The column "Queries and Answers" in Modem Hospital provides further insight into actual hospital work in the early twentieth century. During the years covered by our study, 344 questions from hospital officials (e.g., hospital administrators, trustees, or superintendents of nurses) were printed. One hundred forty (41 percent) pertained to patient care (see Table 1). The largest number of these (55) addressed clinical topics, including sterilization/infection. The emphasis on patient care is consistent with the notion that patient services-infection control in particular-were key to making the hospital a desirable place for care. Questions were also asked about personnel management, which included the training and support of nursing staff. Questions concerning medical staff included several from writers seeking help with difficult physicians.

Eighty-three letters (24 percent) dealt with hospital facilities. They ranged from questions as broad as how to found and build a new hospital to those as specific as what window blinds to use. The frequency and range of inquiries illustrate the growing interest in establishing and upgrading hospitals and offering new technology.

Not a single question pertained to social service, one of the support services actively promoted by the AHA. The number of inquiries about the dietary department was small as well, with inquiries focusing on kitchen utensils. These findings may reflect the minute number of hospitals (and they were among the largest ones) that had introduced a social service or dietary department with formally trained staff.

Judging by the questions in the category of business practices, the writers were not aware that the hospital was to be seen as a "business." The word itself was not used, and few questions concerned formal organizational structure or hierarchical relationships. A few questions addressed organizational structure indirectly through complaints about an intrusive visiting committee or board member in connection with purchasing or personnel management. These inquiries were consistent with the vision that boards should accord the superintendent full authority for managing the institution, but the questions also show that the separation of functions had not yet occurred.

The letters suggest that hospital officials were conscious of the cost of care and charges to patients, reflecting a general concern about cost, but very few questions pertained to formal internal control systems, such as inventory management or purchasing. Many of these controls originated in the few large hospitals; the majority of hospitals might not have seen a need for such systems or might have lacked the resources to implement them. In many hospitals the superintendent could be the purchasing agent, cash manager, bookkeeper, and bill payer at the same time.

From today's vantage point, many of the questions seem unsophisticated and minor. At the time, however, they addressed issues that were new and often controversial. The advice on facilities, technology, and services exposed practitioners to new methods and approaches. Hospital officials whose institutions still processed most of their food and produced many of their patient care supplies would have had questions about commercial products. The appearance of new instruments; furnishings for operating rooms or patient rooms; and new techniques for laboratory work, sterilization, anesthesia, or medical records left hospital officials searching for information about their appropriateness and use. At the same time, the questions reveal the complexity of the early hospitals. However small they may have been, they had a board of trustees, provided nursing and medical care, had operating rooms and laboratories, maintained medical records, had housekeeping personnel, bought supplies, fed patients and staff, often trained nursing pupils, and engaged with patients' families and the community. In other words, even the smallest hospital was a complex organization that called for a great variety of tasks and knowledge.

Our study of the inquiries to Modern Hospital has limitations. First, the contributions were selected by the journal editors, and we do not know what criteria they used to select letters for print. If editorial policy influenced the selection, we would expect that the editors would have been more likely to publish letters that were consistent with the emerging vision of hospital administration that was supported by the journal. Such selection bias would only increase the strength of our findings with respect to the low volume of inquiries in the areas of dietary, social service, and business practices. Second, we do not know whether the letters are representative of hospital officials' expertise in general. We do know, however, that during the years covered by our study a knowledge base had not yet been established (Goldwater 1920; Neuhauser 1995), and trustees and administrators explored their institution's functions and organization as well as their own role while they were running the hospital (Milford Hospital 1913; Trained Nurse and Hospital Review 1920b).

DISCUSSION

In the early 1900s the hospital was not yet the scientific institution it was envisioned to be, the superintendents' work in most hospitals still encompassed clinical work, and the idea of the hospital as a business had not begun to take hold. Yet a model for modern hospital administration emerged at this time under the aegis of the AHA. It did not see the superintendent as someone who "[was] expected to know all the details of hospital work" (Neuhauser 1995, 2). Rather, the administrator was viewed as a business leader, elevated above others, giving orders, and monitoring the organization from the hierarchical apex through an elaborate organizational structure and internal control processes. The journal's response to one inquiry reflects this vision of the administrator: it admonishes the reader to "refrain from doing any piece of work that is likely to lower your dignity" (Modem Hospital 1915c, 386).

These findings link directly to issues faced by hospital managers today. First, the conflict between the adoption of new technology and the concern over the cost of hospital care is as acute today as it was 100 years ago. Second, hospital administrators continue to be urged to adopt management practices from the private sector (Arndt and Bigelow 2000), even though differences between the two types of industries persist. For example, there is a distinct difference between the role of management in the private sector and the role of hospital administrators. Private-sector managers control what the organization does, how it does it, and who does it, while hospital administrators control neither the institution's medical work nor the clinical credentialing of practitioners. Similarly, it is taken for granted that firms in the private sector will vigorously pursue payment for goods or services rendered, but the public is less accepting of this business practice when hospitals apply it (Lagnado 2003; Kowalczyk 2004, 2005). In addition, firms in the private sector are expected to eliminate unprofitable product lines, but this business practice is less accepted when hospitals try to close a service (Barnard 2000). The differences in the organizations' internal structures and the acceptable range of conduct continue to make it difficult for hospital administrators to adopt management practices from the private sector.

Third, concern for patient care is as pressing for hospital administrators today as it was in the early twentieth century. The difference lies in how the concern is realized. The great majority of hospital administrators used to be nurses who were expected to be familiar with all aspects of the hospital's clinical work and even participate in direct patient care. This expectation ended in the second half of the twentieth century. Except in teaching hospitals headed by a physician, management is now the responsibility of individuals who have no clinical background and who identify with the management profession (Neuhauser 1995). Nevertheless, although hospital administrators are now personally disassociated from clinical work, they continue to be held responsible for it. For example, when total quality management fails to yield the anticipated benefits, responsibility is laid on management (Arndt and Bigelow 1995; Melum and Sinioris 1992; Nerenz 1997; Goldmann 1997).

More recently the focus has shifted to patient-centered care, which is anticipated to result both in efficiency and in individualized attention for patients through "mass customization" (McLaughlin and Kaluzny 2000, 75). As in the case with total quality management, the introduction and nurturing of patient-centered care is management's responsibility, yet hospital administrators as business executives have little or no clinical input, let alone control over clinicians. They have to rely on indirect means to elicit clinicians' cooperation, which may or may not be granted. Strains between administrators and physicians began to appear in the early twentieth century, and the relationship remains strained today (Rundall et al. 2004). Management's ability to influence clinical behavior will receive even more attention as pay for performance is widely adopted.

Our study compared the actual work of practitioners and the AHA's vision for modern hospital administration during the early 1900s. The comparison shows how far the occupation had to travel before it became a profession with modern management practices, but it also shows surprising continuity between the issues that hospital administrators faced back then and the issues they face today. The reputation of a hospital within its community still rests on the breadth and quality of its patient care, but there is continued pressure on hospitals to see themselves as a business. It remains very much the responsibility of hospital managers to bridge some stakeholders' calls for clinical efficiency and cost control with other stakeholders' view that the hospital must provide important healthcare services and communal structure.

Acknowledgment

The authors thank Duncan Neuhauser and the reviewers of the Health Care Division in the Academy of Management for their helpful comments on earlier versions of this article.

For more information on the concepts in this article, please contact Dr. Arndt at marndt@clarku.edu.

References

Arndt, M., and B. Bigelow. 2005. 'Professionalizing and Masculinizing a Female Occupation: The Reconceptualization of Hospital Administration in the Early 1900s." Administrative Science Quarterly 50: 233-61.

_____. 2000. The Transfer of Business Practices into Hospitals: History and Implications." Advances in Health Care Management 1: 339-68.

_____. 1995. The Implementation of Total Quality Management in Hospitals: How Good Is the Fit?" Health Care Management Review 20: 7-14.

Atwood, A. T. 1914. The Dietary Department of the Johns Hopkins Hospital." Modem Hospital 2: 280-84.

Babcock, W. L. 1920. "Duties and Responsibilities of Boards of Trustees." Modem Hospital 15: 178-81.

Bacon, A. S. 1918. "A Cooperative Economy Campaign in All Departments of the Hospital." Modem Hospital 11: 430-33.

Barnard, A. 2000. "State Requires Notice Before Hospital Cuts." Boston Globe (December 20): B5.

Beckley, H. 1933. "American Association of Hospital Social Workers" In American and Canadian Hospitals, edited by ). C. Fifield, 61-63. Minneapolis, MN: Midwest Publishers Company.

Beers, A. 1914. "How Nurses May Contribute Toward a Hospital's Success." Modem Hospital 2: 302-3.

Burby, N. 1916. The Contagious Building, Memorial Hospital, New London, Conn." Modem Hospital 2: 306-7.

Burgess, E. 1914. "Complete Equipment of a 100-Bed Children's Hospital." Modem Hospital 1: 236-38.

Carter, H. K., and C. A. Porter. 1918. "Bookkeeping for Small Hospitals and Allied Institutions." Modem Hospital 10: 182-89.

Coleman, L. E. 1915. "What Should Hospital Dieticians or Dietician-Housekeepers Be Taught, and How Should They Be Trained?" Modern Hospital 5: 199-201.

Eckman, R. S. 1918. The Standardization of the Work and Training of the Dietitian." Modem Hospital 10: 52-53.

Edsall, D. L 1915. "Relation of the Staff to the Administration of the Hospital." Modem Hospital 4: 184-88.

Freidson, E. 1970. Professional Dominance. New York: Atherton Press.

Gladwin, M. E. 1907. "Superintendents of Small Hospitals." American loumal of Nursing 7: 622-23.

Glaser, B., and A. Strauss. 1967. The Discovery of Grounded Theory. New York: Aldine de Gruyter.

Goldmann, D. A. 1997. "Sustaining CQL." International loumal for Quality in Health Care 9: 7-9.

Goldwater, S. S. 1920. The Training of Superintendents." Modem Hospital 14: 275-77.

Golightly, B. 1916. "A Few Problems of Small Hospital Management." Modem Hospital 6: 178-79.

Greener, E. A. 1914a. "Purchasing and Dispensing of Hospital Supplies and Drugs." Modem Hospital 2: 352-55.

_____. 1914b. "Admission of Patients in a Small General Hospital." Modem Hospital 2: 19-24.

_____. 1914c. "Organization and Administration of the Nursing Department." Modem Hospital 2: 163-68.

Hannaford, H. E. 1914. "Architecture and Equipment of the New Cincinnati General Hospital." Modem Hospital 2: 1-8.

Hejda, C. W. 1914. "Fire Protection and Fire Drills for Hospitals." Modem Hospital 2: 292-95.

Hertzler, E. 1916. "Suggestions to Would-Be Superintendents." Trained Nurse and Hospital Review 57: 146-47.

Hollinger, B. 1916. TheTechnic |sic| of Practical Routine Fire Drill in Hospitals." Modem Hospital 6: 26-27.

Horner, M. 1917. "Office Work in the Small Hospital." Trained Nurse and Hospital Review 58: 139-41.

Hornsby, J. A. 1913. "Proposed Inspection and Standardization of Hospital." Modem Hospital 1: 98-100.

_____. 1914a. "The Items in Hospital Efficiency." Modem Hospital 3: 25-27.

_____. 1914b. "Items in Hospital Efficiency-Nursing of Patients." Modem Hospital 3: 161-64.

_____. 1916a. The Small Community Hospital-Its Creation." Modem Hospital 6: 415-20.

_____. 1916b. "The Small Community Hospital-The Interior Arrangement." Modem Hospital 7: 388-92.

_____. 1917a. "Standardization of Hospitals-Class IV. Small Semipublic Hospitals." Modem Hospital 9: 253-61.

_____. 1917b. The Hospital Problem of Today-What Is It?" Modem Hospital 9: 322-28.

Hornsby, J. A., M. Wheeler, S. Strouse, R. S. Eckman, et al. 1917. "Standardization of Hospitals-Class V. Small Semipublic Community Hospitals." Modem Hospital 9: 341-49.

Hubbard, F. J. 1917. "A Complete Suburban Hospital-The Muhlenberg." Modem Hospital 8: 1-12.

Hurd, H. M. 1913. The Hospital as a Factor in Modern Society." Modern Hospital 1: 33.

_____. 1916. "Advantages of the Budget System." Modem Hospital 6: 186.

Keppel, F. D. 1916. The Modern Hospital as a Health Factory." Modem Hospital 7: 303-6.

Kowalczyk, L. 2005. "Hospital Softens Collection Tactics." Boston Globe (lanuary 27): C1.

_____. 2004. "Hospital Using liens to Collect from Patients." Boston Globe (October 17): A1.

Lagnado, 2003. "Hospitals Try Extreme Measures to Collect Their Overdue Debts." Wall Street loumal (October 30): A1.

Lawler, E. M. 1914. "Organization of the Nursing Department of lohns Hopkins Hospital." Modern Hospital 2: 148-51.

Loder, C. 1915. "Operating a Hospital Under the Budget System." Modem Hospital 4: 411-12.

Lyons, B. W. 1919. "Maintaining Balance in Hospital Administration." Modem Hospital 13: 166-68.

Mann, W. O. 1914. "Efficient Methods in Cost Accounting and Hospital Finance." Modern Hospital 2: 37-40.

McClure, H. T. 1918. The Hospital Field in Figure-A Survey of Conditions as They Actually Exist." Modem Hospital 10: 169-70.

McKenzie, M. 1914. "Are Our Nurse Training Schools Educative?" Modem Hospital 3: 341-42.

McLaughlin, C. P., and A. D. Kaluzny. 2000. "Building Client Centered Systems of Care: Choosing a Process Direction for the Next Century." Health Care Management Review 25: 73-82.

Melosh, B. 1982. The Physician's Hand: Work Culture and Conflict in American Nursing. Philadelphia: Temple University Press.

Melum, M. M., and M. K. Sinioris. 1992. Total Quality Management: The Health Care Pioneers. Chicago: American Hospital Association.

Memorial Hospital. 1912. "Rules and Regulations." Worcester, MA: Memorial Hospital.

Miles, M. B., and A. M. Huberman. 1994. Qualitative Data Analysis, 2d ed. Thousand Oaks, CA: Sage.

Milford Hospital. 1913. Report of the Managing Board of the Milford Hospital. Milford, MA.

_____. 1915. "Rules and Regulations of the Milford Hospital." Report of the Milford Hospital for the Year Ending May 31, 1915. Milford, MA.

Mixter, C. G., and H. F. Kellogg. 1917. "Architecture and Equipment of the Jordan Hospital, Plymouth, Mass." Modem Hospital 13: 258-64.

Modern Hospital. 1913a. "Salutatory." 1: 32-33.

_____. 1913b. "Announcement of Valuable Papers." 1 : 185-86.

_____. 1913c. "The Doctor's Part in Hospital Management." 1: 184-85.

_____. 1914a. "Are Small Hospitals Slighted?"2: 297-98.

_____. 1914b. "Architecture and Equipment of the New Cincinnati General Hospital." 2: 1-8.

_____. 1914c. "Fire Protection in Hospitals." 2: 365.

_____. 1915a. "The Hospital Kitchen." 4: 220-23.

_____. 1915b. "Mont St. Mary's Hospital at Niagara Falls, NY." 5: 1-5.

_____. 1915c. "Hints for Hospital Superintendents." 5: 386.

_____. 1916a. "The Hospital Trustee." 6: 426-427.

_____. 1916b. "Figures for Standardization." 7: 396.

_____. 1916c. The Per Capita Cost." 7: 355.

_____. 1916d. "Chapin Memorial Pavilion, Springfield (Mass) Hospital." 6: 176-78.

_____. 1918a. "Standards for Hospital Dieticians." 10: 33.

_____. 1918b. "The Training and the Rewards of the Woman Hospital Superintendent." 11. 387-88.

_____. 1919a. "How to Prevent a Fuss." 13: 293.

_____. 1919b. "The Importance of the Laboratory in the Hospital." 13: 46-47.

_____. 1920a. "Check Up on Your Fire Hazards." 15: 188.

_____. 1920b. "Rockefeller Foundation Summons Hospital Social Service Workers." 14: 306-7.

Nerenz, D. R. 1997. "CQI in Health Care: Some Comments on Can It Really

Work?" International loumal for Quality in Health Care 9: 3-4.

Neuhauser, D. 1995. Coming of Age. Chicago: Health Administration Press.

Nutting, A. 1914. "Hospital Trustees and the Training School." Modern Hospital 3: 57-59.

Ochsner, A. |. 1913. "Hospital Growth Marks Dawn of a New Ear." Modem Hospital 1: 1-3.

Parnall, C. G. 1920. "Selection of the Hospital Personnel." Modem Hospital 14: 416-18.

Poll, D. 1916. "The Admitting Department of a Large Hospital." Modem Hospital 6: 109-10.

Porter, H. F. 1915. "Safety from Fire to the Helpless in Hospitals." Modem Hospital 2: 23-25.

_____. 1917. "Reducing the Hazard to Life in Non-Fire Proof Hospital Buildings." Modem Hospital 9: 333-36.

Redwine, E. M. 1917. "Management of the Small Hospital* American Journal of Nursing 18: 197-202.

Reverby, S. 1987. Ordered to Care: The Dilemma of American Nursing, 1850-1945. New York: Cambridge University Press.

Richardson, D. L. 1913. "Disinfection as Part of the Hospital Administration." Modem Hospital 1: 76-80.

Riddle, M. M. 1912. "Hospital and Training School Administration." American tournai of Nursing 13. 54-55.

Rundall, T. G., H. |. Kaiser, H. T. O. Davies, and C. Hodges. 2004. "Doctor-Manager Relationships in the United States and the United Kingdom." Journal of Healthcare Management 49: 251-70.

Stair, P. 1982. The Social Transformation of Medicine. New York: Basic Books.

Stevens, R. 1986. "The Changing Hospital." In Applications of Social Science to Clinical Medicine and Health Policy, edited by L. H. Aiken and D. Mechanic. New Brunswick, N): Rutgers University Press.

Sturdy Memorial Hospital. 1914. "Rules and Regulations." Attleboro, MA.

Tipping, A. B. 1914. "Qualifications of the Modem Hospital Superintendent." Modem Hospital 2: 98-99.

Townsend, F. C. 1914. "Vast Difference Between Hospital Needs and Necessities of Commercial Organizations." Modem Hospital 3: 233-44.

Trained Nurse and Hospital Review. 1913. "Hospitals and the Nursing Question." 51: 231-32.

_____. 1916. "Vocational Opportunities for Nurses." 56: 82-86.

_____. 1920a. "Fire Hazards in Hospitals." 64: 40.

_____. 1920b. "Baltimore, Md" 64: 335.

Valentine, R. G. 1916. "Application of Principles of Organizations to Hospital Service." Modem Hospital 6: 26267.

Van Norman, K. H. 1914. "Admission of Patients, History Taking, and Subsequent Care." Modem Hospital 2: 81-84.

Waldheim, A. 1920. "Increasing the Efficiency of Hospital Administration." Modern Hospital 14: 298-99.

Walsh, A. M. 1916. "What a Nurse Should Contribute to Team-Work" Modern Hospital 7: 171-73.

Walsh, W. H. 1915. "The Hospital Superintendent-Past, Present, and Future." Modem Hospital 4: 19-23.

Warner, A. R. 1913. "The Place of Social Service in a Medical Institution." Modem Hospital 1: 155-57.

_____. 1915. "The Hospital Management and the Surgical Division." Modem Hospital 4: 412-13.

_____. 1916. "Hospital Accounting and Finances." Modem Hospital 7: 481-83.

Washburn, F. A. 1913. "President's Address." Modem Hospital 1: 125-27.

Watson, S. A. 1915. "A Modified Course of Bacteriology for the Small School." Modern Hospital 4: 271-73.

Wechsler, H. M. 1914."Hospital Organization and Accounting System." Modem Hospital 3: 148-50.

Wilson, R. J. 1915. "Little Things That Are Big Things in Hospital Management." Modern Hospital 5: 29-32.

APPENDIX I

Source: Modern Hospital's "Queries and Answers" Column, 1913-1920.

1. General Management (121 inquiries)

Cost/Charges

What is the correct method for determining the cost per capita per day? (1916)

Kindly give the names of several hospitals that make a regular charge for laboratory work. (1920)

Controls

What is your opinion in regards to hospital inventories? One hears so many arguments for and against them.. . . (1918)

Purchasing

I have been buying for our hospital. . . sometimes in quantity and sometimes on contract when I thought 1 could save something. Some members of the board think we should buy altogether on contract.... All of us would like to know what The Modern Hospital thinks about this. (1914)

Personnel Management

Nearly all our nurses lose weight during night service and become pale, and I am quite sure that it is due to their failure to obtain proper rest in the day time. What can we do about it? (1914)

What allowance of time is granted a nurse who resigns or is dismissed from a school of nursing and is admitted to another school? (1920)

Legal Matters

Should a patient be sued for non-payment of a hospital account? (1920)

Fund Raising

I would appreciate it very much if you would give me information regarding the use of moving picture films or slides in campaigns for funds... . (1920)

Public Relations

I am interested to know what saith (sic) "the law and the prophets" about the advertising of hospitals in the lay press or newspapers. (1917)

Medical Records

Would you please advise us of the best place to keep patients' records while the patients are still in the house? (1915)

Training School/Medical School

I would be greatly obliged to you if you would give me the benefit of your opinion concerning the proper organization of a training school for nurses in a manner to preserve its distinctiveness as one of the units of the general organization of the hospital of which it is a part. (1914)

Job Content/Reporting Relationships

Should the board of trustees of a hospital invite the superintendent to attend meetings? (1920)

Miscellaneous

I saw somewhere a form for a "condition book" for the use of the hospital office, so that the telephone girl could answer inquiries without having to call the nurse on the floor each time. Can you tell me something about the form of this book? (1914)

2. Facilities (83 inquiries)

Design/Layout/Size

We are to build, and are thinking about automatic elevators, as our institution is a small one.. . . We want to know whether they are safe.... (1914)

What toilet accommodations should be provided for patients and nurses in the hospital? (1920)

Cost of Construction/Equipment

Will you please tell me what proportion of the cost of construction of an average hospital should be allowed for equipment? Does equipment include laundry machinery, lighting fixtures, steam sterilizing apparatus, and cooking apparatus? (1915)

Flooring Material

Would you kindly advise me what you consider the most satisfactory flooring for use in hospital kitchens? Also give a second and third choice. (1914)

Utilities

Can you tell us something about the relative merits of steam versus hot water for heating purposes in the hospital? (1913)

Miscellaneous

Which is better, oil pump or hydraulic movement for utensil and instrument sterilizer lids? (1913)

3. Patient Care (140 inquiries)

Sterilization/Infection Control

Are hospital gauze and cotton sterile as we buy them? (1913)

Is there any excuse for hospital wounds becoming infected, and if not, what can we do about it? Where is the trouble? We try to observe all the rules of aseptic surgery and keep as clean as we can. (1915)

Miscellaneous Patient Care Topics

To what extent is gas-oxygen anesthesia replacing ether, and what are the essentials for its use? (1913)

Please let me know if anything has recently been published on the subject of the treatment and prevention of bed sores. (1916)

Kitchen Supplies

We have been thinking for a long time about adding some fireless cookers to our kitchen equipment. . . but we would like to know just exactly what they do to food. (1914)

Diets

Kindly look over the accompanying menus and comment on them. (1920)

Cleaning Materials/Techniques/Soaps

It seems this matter of soap is a very technical question ... A salesman recently told me that "suds" had nothing to do with the value of soap. Is this true, and what is the real test of good soap? (1914)

Pest Control

We are overrun with cockroaches; we have used the advertised "roach remedies" without effect. What are we to do? (1915)

Laundry

Can you tell me how I can take blood stains out of the hospital linen? (1916)

Maintenance/Aesthetics

So many of our patients complain of the monotony of the walls and ceilings of our private rooms . . . Can't we do something in the way of decoration to overcome the everlasting sameness of the walls and ceilings? (1915)

Interns

We have four interns, and there are constant wrangles about who shall do what.. . . how can we arrange things so these frictions and misunderstandings will cease? (1913)

Compensation of Physicians

What is the most satisfactory arrangement for paying roentgenologists in hospitals? (a) straight salary, (b) percentage basis, (c) part salary and part percentage? (1920)

Miscellaneous

We have a man on our staff who is objectionable to everybody. . . But he is so strong socially and in a business way - and professionally, too - because he is a good doctor, that the board is afraid to drop him or even to call him down, even for his brutality to the nurses. Is there any we can get rid of this man? (1914)

PRACTITIONER APPLICATION

Linda Shyavitz, CHE, president and chief executive officer, Sturdy Memorial Hospital, Attleboro, Massachusetts

This article is a welcome reminder of the essentials in successful management of the contemporary hospital. The fact that these management themes that emerged about 100 years ago are still being discussed today is a testimony to their relevance.

The superintendents writing to Modern Hospital in the early twentieth century appeared more often concerned with the details of operations than with grand strategies. Apparently, they understood that all the vision in the world was meaningless if the basic operation did not run properly. After all, what does a patient today (and then) care about the brilliant strategic vision of the hospital chief executive officer (CEO) if the bathroom is dirty? Those of us managing hospitals too often forget that our institutions founder if we lose control over the details.

Relatedly, if the queries are representative, these superintendents appear highly focused on the essence of their business-patient care-as 41 percent of the questions related to patient care services. Perhaps, had hospital administrators as a group continued to stay focused on patient care, we would not be scrambling today to assure the public that our hospitals deliver safe, optimum quality care. Nonclinician administrators can and should have enough clinical know-how to be able to provide leadership on quality and safety issues. Learning about clinical and patient care areas is not that difficult, and we should not be in the business of patient care if we are ignorant about it.

The breadth of interest of these superintendents is comparable to the range of concerns of the contemporary CEO. All of the topics identified in Table 1 are likely to come up in any given year of a CEO's stewardship. A nimble CEO must still move from expense management to public relations to facilities design to physician recruitment to technology acquisition, and often in the same morning.

I was struck by an interesting distinction between these early twentieth century superintendents and contemporary executives. Despite these superintendents' apparent focus on the smallest details, they were, in a way, more visionary than hospital executives today. They were there in the beginning and had to figure out what a hospital should be and how it should run, and this is apparent in their queries that reflect the fundamental issues they needed to address. There were few guidelines, blueprints, or models, and each administrator essentially developed a hospital from "scratch." It is quite wonderful that they found ways to seek advice, compare approaches, find facts, and solicit feedback. They were true leaders.

I suspect that many of these early leaders, because they were nurses, were women and that the members of hospital boards were certainly predominantly men. The early twentieth century vision of the AHA of a hospital administrator that this article describes probably is not realistic given the cultural and social values at that time. It is hard to imagine local manufacturers on the board of my hospital in Attleboro, Massachusetts, in 1920 viewing the female superintendent as a "business leader, elevated above others, giving orders and monitoring the organization . . . through an elaborate organizational structure and internal control processes." Yet, despite how the community likely saw this administrator, she and others like her founded the healthcare management field. This article gives us insights into how these early administrators went about doing just that. The work was not glamorous. It entailed endless details and problems to solve that had no obvious solutions.

Visionary work is often mundane. But wasn't Microsoft founded in a garage?