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Government-supported hospitals. This group includes tax-supported hospitals for counties, towns, and cities with nonprot hospitals that are run by a board of citizen administrators who serve without pay. The main objective of this type of hospital is to provide health care for a community or geographic region. Additionally, many small hospitals were established by individual physicians who needed places to care for patients following surgery and other medical procedures.

Between and , the number of hospitals in the United States grew from just over to about 7, In fact, the establishment of hospitals at this time became a national movement. The U. Census Bureau in its surveys in and again in considered the development of hospitals as a public undertaking, providing a new kind of institution that was a model of technology, cleanliness, and efciency. The noise, dirt, smell of festering wounds, and unruly patients of an earlier era were gone.

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In their place, there were drugs for pain relief, a concerted effort at understanding and managing disease, an air of discipline and tightly controlled hygienic practices, and a real sense that illness could be controlled. Rosemary Stevens , who has written extensively on the history of American hospitals, describes the reaction of Henry James who had returned to America from Europe in Presbyterian Hospital in New York and Johns Hopkins Hospital in Baltimore were symbols of stillness, whiteness, poetry, manners, and tonenecessary values, he considered, amidst the violence, vulgar materialism, and hurly-burly of America.

As time passed, more and more people considered hospitals as safe places for treatment and recovery. A real indicator of public trust occurred when babies began to be born in them. In , less than 29 percent of all births took place in hospitals, but in that gure rose to 56 percent. Patients began to realize that hospitals were there for their benet. Mostly they were nurses who had absorbed administrative responsibilities into their clinical duties. But the rapid growth in hospitals required a broader set of competencies from these new administrators, and there arose a need to communicate with others who were endeavoring to develop as health managers.

By the s, the rst edgling group of administrators organized and formed their own association called the Association of Hospital Superintendents. This group later morphed into what is now the American Hospital Association. As hospitals became larger and more complex, the new norm was to run them like businesses, emphasizing a drive for efciency. Physicians, nurses, and the newly minted hospital administrators felt that hospitals as complex institutions should be run like Henry Fords well-functioning motorcar businesses. In the s and s, they would engage in what was in vogue at the time scientic management.

In this way of approaching hospital management, it was important to understand productivityemphasizing the roles of measurement, standardization, performance, coordination of operations, and motivation of workers. Hospitals were encouraged to standardize their medical record-keeping and their nancial reporting. As hospitals navigated a course toward better management, con icts inevitably arose and administrators found themselves in new roles such as keeping the peace among physicians, boards, and private and public donors.

Administrators felt keenly the need to separate their function from that of the physician- or nurse-administrator, the model from earlier times. So, they began to acquire discrete areas of function within hospital settings: They centered their operations on housekeeping, accounting, public relations, fund-raising, and human resources issues, leaving the majority of patient-care concerns in the hands of clinical staff. A quiet agreement existed between the clinical and the administrative staffs that neither area would con ict, but rather that they would work in concert for the greater good of the institution.

A Focus on Social Welfare In the early- to midth century, another shift took place in the distribution of health care. With the development of more institutions created to provide medical attention, payment for services in those institutions became an issue. When hospitals became places where people felt safe in taking their health issues, they were patronized by those who could pay for the services out-of-pocketessentially the rich and near-rich.

However, when the Great Depression occurred in the s, the federal government began to take a more active role in providing programs for all classes of citizens. Along with programs to get people back to work and to provide for the indigent, the government began to consider national health programs and ways to improve public health. Frances Perkins, Secretary of Labor. There were a string of government interventions that set the stage for the more equitable distribution of care.

Beaufort Longest and Kurt Darr , who write extensively on health policy issues, suggest that the following initiatives in the midth century were key:. Medicare pays for medical services provided to persons who have disabilities or are age 65 or over. Medicaid is run by the states and is subsidized by the federal government. It offers a range of health services to participants who qualifyusually on an income basis. In exchange for this assistance, health organizations had to provide services for those unable to pay for varying lengths of time.

The National Institutes of Health, which traces its roots back to , began an aggressive program of research, especially on cancer. In the s, federal programs were established to train more physicians, nurses, technicians, and managers. Veterans Administration hospitals were built and institutions for health services were established for groups such as inmates in federal prisons, American Indian and Alaskan natives, and activeduty and retired military personnel and their dependents. Over the years, federal legislators have continued to legislate in favor of both containing costs and improving servicestwo goals that are sometimes in con ict with one another.

Health care costs have increased dramatically as compared to costs for other services in the rest of the economy, and that has created a need for more efcient delivery. A Struggle Ensues to Establish a New Field As the 20th century progressed, health administrators not only adapted to the ever-widening context that was being created for their services, but also innovated by creating systems, institutions, policies, and best practices.

But it was not easy. Turf issues and con icts over setting standards soon took over. An interesting turf issue is the one that occurred between the sexes. In , graduate nurses made up half the membership of the American Hospital Association. In addition to nurses, a hospital superintendent could also be a physician, a layperson, or a Catholic sister. Eventually, women got pushed aside as this new niche was gradually occupied by men who perceived an opportunity in which they could be successful in the burgeoning economy of the early 20th century.

With the growth of health institutions taking place at such a rapid pace, administrators were running to catch up in terms of staf ng and training. Added to that, there was little agreement over standards for the eld. Large and small hospitals had different agendas and constituencies and were run accordingly. Also, those administrators who saw hospital care as an outgrowth of a vigorous public health agenda were rarely supported by their trustees. There were exceptions: for example, when the head of the Boston Dispensary with the support of the board and administrators started a pay clinic for middle-income workers in that supported personal and public health awareness.

However, administrators in most settings lacked a common purpose and a sense of unity, which in those very early days inhibited the creation of a national organization for hospital administrators. Development of the First Professional Organization and University Programs Two areas of activity ourished during the 20th century that were critical in establishing the eld.

First, professional organizations began to be established to represent the people employed in the eld and to set standards. Second, educational programs were developed to educate potential health care administrators. These initiatives helped to formulate the health care management infrastructure that exists today. In , a group of practicing administrators came together to form the American College of Hospital Administrators now the American.

The emphasis of the new group was on the lay administrator. Of the charter fellows of the new association, 16 were women and 32 were physicians. Then in , the University of Chicago established its rst graduate program in hospital administration. Published in , Daviss book proposed a two-year graduate degree curriculum in hospital administration that would cover the following subjects in the rst year: accounting, statistics, management, economics and the social sciences, and the history of hospitals and the health professions.

In the second year, there would be mostly practice work and some coursework in business policy, public health, and labor relations. Davis was ultimately named head of the new program in Chicago, which closely followed the model he proposed in the book. What is signicant about these two events is that hospital administration was nally becoming a eld in its own right. This was recognized in at a meeting of the Committee on the Costs of Medical Care, where hospitals were de ned as large, complex medical, social, and business institutions that needed to be directed by administrators who received high-level training in university programs or in institutes of hospital administration.

It was a call for talented individuals who would regard hospital administration as a worthy and ful lling career. A Although the rst program in health economics was establishe lished in at Columbia Teachers College for graduate nurses, it was quite a while before a formal degree-granting program in hospital administration was created. Father Moulinier of the Catholic Hospital Association developed one at Marquette University in Wisconsin, but by it had closed with only two women having received degrees. After the Chicago program opened, eight new programs in hospital administration were established in the s, nine more in the s, and 15 more in the s.

These programs called their degree programs hospital administration, but later the degree came to be titled health care administration. This change reected that students were anticipating working in a wider range of organizations and not just hospitals. As the decades passed, the eld of health care administration came to encompass such settings as ambulatory care facilities, consulting rms, health care associations, home health agencies, hospices, hospitals and hospital systems, integrated delivery systems, long-term care facilities, managed care organizations such as HMOs and PPOs , medical group practices, mental health organizations, public health departments, university or research institutions, and military health facilities.

Minorities and Women Enter the Field and Establish Professional Organizations Although the rst program in health economics was established in at Columbia Teachers College for graduate nurses, it was quite a while before a formal degree-granting program in hospital administration was created. Women and minorities began to enter the eld in the late s when it became a separate career option distinct from the clinical side.

As they came into the eld in increasing numbers, their focus was often on the distinct needs of their identity groups. Eventually, women and minorities began to establish separate professional groups that would represent their views. After several changes in leadership, the Conferences activities were limited to one informal meeting held in conjunction with the annual AHA meeting.

In , NAHSE was formed for the purpose of promoting the advancement and development of African-American health care leaders, elevating the quality of health care services rendered to minority and underserved. But implementing the goal of providing a cult culturally competent and diverse workforce can be difcult without good planning. One major hospital system reached its diversity goals by instituting something called a circuit breaker wherein the incentive programs of all senior leaders relied on the completion of a three-year diversity and inclusion plan.

If any part of the organization failed to develop a plan, no one in the management structure would have received his or her at-risk performance incentive pay. There was percent participation. An organization called Women in Healthcare Management WHCM was founded in Boston, Massachusetts, to provide a forum for professional women to meet peers, network, share information, and stay informed on issues affecting the health care eld. Its members are managers in settings and organizations spanning the wide range of the health care industry.

WHCM services include two large group meetings annually, periodic networking meetings, a job bank, inclusion in the annual member directory, and the opportunity to form small groups for more frequent and informal networking. The Association of Hispanic Health care Executives AHHE was founded in as a national voluntary organization seeking to foster programs and policies to increase the presence of Hispanics in health administration professions.

AHHE is the rst organization devoted exclusively to Hispanic health care executives and to the education of the health care industry about the Hispanic health care marketplace.

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The Asian Health Care Leaders Association ASHCLA is a membership and leadership organization devoted to increasing the representation and professional development of Asian-Americans in health care executive management, policy, and administration. The organization has programs in mentoring, networking, lifelong learning, and career development that are designed to serve individuals and organizations at all levels and across all disciplines of the health care eld and serves as a networking point for AsianAmericans in clinical elds who may be interested in moving into leadership roles.

Administrators and Physicians: Two Different Perspectives Hospital administrators began to assert themselves, especially in the large, urban hospital systems, and ultimately physicians came to see them as potential threats. Although administrators did not possess medical degrees, they became forces to be reckoned with in the American Hospital Association and it became evident that their agendas were departing from those that traditionally focused on physicians. Established in , the founders were intent that this organization be separate from the American Hospital Association and serve the professional interests of both non-medical as well as physician administrators.

Some physician administrators saw the establishment of this organization as an attempt to take hospital administration duties away from physician managers and give them to non-physician managers. However, the new college for administrators was successful despite criticism from traditionalists, and it provided an important setting for identication and bonding for administrators. Over time physicians came to see that rather than being competitors for power, administrators provided important business and administrative functions that freed doctors to concentrate on medical issues, which, after all, were their primary concern.

Professional Organizations: A Big Umbrella The rst health care managers were hospital administrators. But as the population increased, and health institutions grew with the population, other occupations began to be de ned under the umbrella. Group practice administrators, marketing and public relations professionals, academicians in public health or policy issues, nursing home and long-term care administrators, consultants, insurance professionals, professional and trade group executives, social workers, and others are all now considered health care administrators. A good way to see how some of these groups joined underneath the umbrella of hospital administrators is to look at the development of their professional organizations, which now exert a great deal of inuence on health policy and practices.

MGMA is the nations principal voice for the medical group management profession. The mission of MGMA is to continually improve the performance of medical group practice professionals and the organizations they represent. MGMA serves 22, members who lead and manage more than 13, organizations in which almost , physicians practice. Its diverse membership comprises administrators, CEOs, physicians in management, board members, ofce managers, and many other management professionals.

They work in medical practices and ambulatory care organizations of all sizes and types, including integrated systems and hospital- and medical school-af liated practices. Health Care Consulting Health care institutions often hire outside consultants to advise them in areas of expertise that they do not have on-site. Recommendations in areas such as strategy, nance, marketing, governance, executive development, and more are frequently delivered by consultants.

In , it was recognized that a professional membership organization was needed to apply standards and credentialing for consultants so that health care institutions could rely on quality advice. The American Association of Healthcare Consultants AAHC was founded to provide these services and to further the education and networking opportunities for members. With over 35, members, it is the nations leading membership organization for health care nancial management executives and leaders.

Their purpose is to de ne, realize, and advance the nancial management of health care by helping members and others improve the business performance of organizations operating in or serving the health care eld. Their members range from CFOs to controllers to accountants and members can be found in all areas of the health care system, including hospitals, managed care organizations, physician practices, accounting rms, and insurance companies. Marketing and Public Relations Large hospital centers and even group practices found it necessary to adopt business marketing and public relations practices in order to get the message out for their services and to bring the community into their delivery environment.

With the complexities of aligning with community needs, speaking for a health institutions successes and sometimes failures , sorting through the tangle of ever-changing legislative guidelines, and generally upholding the reputation of the institution, marketing and public relations professionals became critical to the function of these organizations. This type of health care professional is here to stay. Historically, these professionals have not been in the health care environment for very long. It appears that about 40 years ago, the movement to establish marketing and public relations departments in health facilities began to gear up as these facilities became more complex.

Their professional organizations are largely regional, and they function to bring together professionals who serve in the capacity of public relations and marketing professionals in the health care industry. It is located in Southern California and primarily addresses the needs of marketing and public relations in that area. Their goal was to create a forum to foster professional growth and regular interaction among colleagues within the eld. Health Information Systems Health care technology is more important than ever, with new advances being made in both equipment and information.

Focused on providing global leadership for the optimal use of health care information technology IT and management systems for the betterment of health care, this membership organization represents more than 20, individual members. Additionally, there are over corporate members, including many international organizations.

Human Resources Health care organizations are governed by unique regulatory and compliance laws and issues, and there are unions that represent various segments of health care workers. With more than 3, members, the organization seeks to establish best practices in the delivery of human resource services in a health care setting.

Health Care Facilities: Standardization and Accreditation Attempts had been made to standardize hospital care as far back as , but things got serious in when a consortium of health organizations established the Joint Commission on Accreditation of Hospitals JCAH a nonprot organization designed to provide standards for voluntary accreditation.

Over the years, the commission has developed a rigorous set of standards that are now used to evaluate the compliance of 16, institutions. The evaluation process helps these institutions improve their systems, which results in better patient care. For instance, critical care units of hospitals are. Another important initiative by the Joint Commission is to institute measurement systems that evaluate performance standards. Activities in health care institutions that do not conform to the performance standards are monitored until improvement is achieved.

Now, the accreditation process has extended beyond hospitals to long-term care facilities, psychiatric facilities, ambulatory care centers, laboratories, and other facilities. The organization changed its name to reect its broader mission to the Joint Commission on Accreditation of Healthcare Organizations, but it is now known simply as the Joint Commission. Educational Programs: Support and Accreditation With the development of many educational programs in the 20th century, it became necessaryif the eld was to be taken seriously and seen as a viable occupational optionto devise ways to evaluate the health care administration programs and to accredit the worthy ones.

Two organizations were formed that addressed these needs. The Association of University Programs in Health Administration AUPHA is a non-prot membership organization comprised of university-based educational programs, faculty, practitioners, and provider organizations. Its purpose is to serve as a kind of clearinghouse where quality programs can be supported and acknowledged in service of promoting excellence in health care management education. They do this through providing opportunities for networking and through providing tools, research, conferences, and forums. In , the Joint Commission on Education for Hospital Administration, which was established by the foundation, presented a report that called for the expansion of university graduate programs in health care administration and provided guidelines for their content.

University undergraduate programs seeking full membership are accredited through the AUPHA, and today there are over graduate and undergraduate programs in North America. This organization sets criteria for quality graduate programs in health care management education and accredits programs that meet those criteria. CAHME performs a public service by maintaining quality in such programs and disseminating information about the appropriate programs to students and early careerists.

Programs accredited by CAHME are housed in different settings within the university including schools of business, medicine, public health, public administration, allied health sciences, and graduate studies. Where We Are Today The eld of health care administration has changed dramatically. Cynthia Haddock and her colleagues state that there are three primary objectives that concern health care administrators today.

First, they are responsible for the business and nancial aspects of hospitals, clinics, and other health services organization. As such, they are focused on increasing efciency and nancial stability. Their roles include human resources management, nancial management, cost accounting, data collection and analysis, strategic planning, marketing, and the various maintenance functions of the organization.

Second, health care administrators are responsible for providing care to dependent people at the most vulnerable times of their lives. Third, administrators are responsible for maintaining the moral and social order of their organizations, serving as advocates for patients, arbitrators in situations where there are competing values, and intermediaries for the various professional groups that practice within the organization.

Oscar Aylor r. How did you get into the health care administration industry? While I was at the University of Virginia, I wanted to be a doctor one year and the next year I did not. I did not have a long-term focus, even though I was intrigued by medicine because I had a grandfather who was a country doctor and I used to follow him around on his house calls. Just as I was graduating, a fraternity brother who had the same interests asked me if I had ever heard of hospital administration. I looked into it and it appealed to me, so I applied to a few graduate programs right out of college.

I did not get accepted because they said I needed some experience rst and to come back later. So, I got some experience at my hometown hospital doing a variety of things from helping the credit manager and personnel director to doing EKGs. What do you think are some of the issues in the eld now? We have a lot of problems. One is that we have to get better care to the growing immigrant population. Another is that too many people are experiencing a loss of insurance coverage. Also, there are too many people that experience access problems to existing health care resources.

There are frustrating issues of cost and quality. When these things happen, it does not just affect the individuals, it affects the whole community. What are some of the highlights of the history of the eld, and what trends emerged as a result of it? The modern hospital began in the late s. Harvard and then Johns Hopkins began introducing science into the curriculum, had research programs, and established medical schools and residency programs. Physicians were resistant to science in those days. That is, they believed that patient care and science were not connected in important enough ways to affect their relationships with patients.

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That all changed with the Flexner Report, which was issued in Abraham Flexner was commissioned by the Carnegie Foundation to evaluate the quality of medical education. Flexner made appointments with medical school deans, who thought he was going to award them funds from the foundation. But what he did was nd that only about 75 percent of the medical schools existing then needed to survive, and the rest really could not justify their existence. That report put a lot of medical schools out of business and consolidated others. The number of schools quickly went from to 95 within a few years. After that, medical education along with hospitals became more sophisticated and complex.

Doctors did not have time to run them. They were much more interested in doing surgery, using the new technology, and making money. It was about that time that the health care administration eld began to thrive because of the need for business rigor in the hospitals. How would you characterize the relationship between medical professionals and health care administrators? This varies from institution to institution. If an administrator is skilled at coordinating efforts to bring these groups together, it is reected in the success of the institution.

The turnover rate of administrators tells the story. If there is too much turnover, then the relationships have not been worked out adequately. It requires better than sufcient interpersonal skills on the part of the administrator. There is still a strain in some quarters.

But with the younger generation coming along, relationships between clinical staff and administrators are getting better. Both sides are beginning to think more alike. Technology has bridged a lot of that. With both working on EMR [electronic medical records], patient safety issues, and other technological issues, we are more comfortable sitting at the same table than we used to be. What are the trends in public health that have affected administrators? Hospitals became more interested in treatment and surgery, and public health professionals pushed prevention.

Those two streams were on separate paths, and they were uncomfortable with one another. Physicians, for instance, who went into public health were marginalized. Administrators who worked for health departments were treated the same way. With my peers, it was like the light was turned on. We realized that we all live in a world of public health. We have to be concerned about security, safety, population health. The streams started to converge at that moment. We are all much more concerned with public health than we used to be, and we are all more comfortable with the idea of prevention.

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What do you think will happen to health care now? Not all the big, famous medical institutions in the United States can survive over the long haul. There is not enough money to reimburse overhead for all the beds that exist. Also, there will be a continuing emphasis on prevention, on more outpatient care, and on shorter inpatient stays. Some say the hospital of the future will consist of an ICU [intensive care unit] and an emergency room. If I were looking into the future, I would think we would have to emphasize prevention and legitimate research.

The focus on inpatient care is on the way out. We need to provide more and better care on an outpatient basis. We need to plan better, especially on a system wide basis. We need to look at the health care needs of the United States and compare them to what is happening in areas outside our country, continuing to look for best practices. We need to nd ways to coordinate the delivery of health services to a greater extent within our own institutions. From a rocky start, health care management has evolved into a major business in the 21st century, run like any other business with many of the same concerns.

A major difference, of course, is that those involved in this business have the end usersthe patient well-being as a primary focus. Although it appears that many of the early con icts and challenges have been worked throughestablishment of roles, con ict with physicians, creating funding mechanisms for their institutionsnew challenges arise every day.

Today members of the health care management eldat about , individualscomprise a critical mass with which to confront these challenges. Moreover, the over 30 professional organizations that. Some who have been professionals in health care for some time believe that the eld has gotten too large and there are too many separate groups within it, each with its own agenda.

Others say it is still a hidden career in some respects because many are puzzled about the roles and requirements of health care administrators. Nonetheless, after a little more than a hundred years of recent history the industry is well-established and geared to expand. A Brief Chronology B. He wrote the Hippocratic Oath that de nes to this day the scientic and ethical obligations of physicians. Middle Ages: Religious communities assume responsibility for the sick and build hospitals throughout Europe, but they were the last resort for the sick and dying.

U Until Johns Hopkins Medical School opened in , m most medical students were taught in trade schools whic which, because they were set up to turn a prot, often accepted high school graduates who would have had trouble getting into a liberal arts college. After two, at most three, years of attending typically repetitious lectures by part-time teachers, students were free to apprentice themselves to older doctors or simply hang out a shingle, even if they had never laid a hand on a patient.

End of 19th Century: There are hospitals in the United States with 35, beds. The Hill-Burton Act mandates four billion dollars of federal money for the building and improvement of hospitals. It requires employers to maintain a safe working environment for health care employees. Beginning of 21st Century: According to the Bureau of Labor Statistics, 96, health care managers are employed by hospitals, 23, by physician ofces, 17, in nursing care facilities, 13, in home health care, and 12, in outpatient care centers.

It protects employees from outside access to personal health information and limits employers ability to use employee health information under health insurance plans. Every industry has a set of indicators that de ne its current state and its relative health compared to other industries. They build identities through what is known about the industrys performance in the marketplace and the activities that consolidate its mission and function. Health care management is no exception. Statistics on numbers employed, wages, trendscurrent and futureimportant technology, conferences and industry events, industry forces, and issues of law and government all make up the personality of an industry.

With the help of some information from the Bureau of Labor Statistics, let us look at basic facts and then at a discussion of prospects, the future job outlook, and earnings. Employment Several indicators demonstrate that the eld is expanding and will continue to do so. The Bureau of Labor Statistics states that medical and health services managers held about , jobs in About 35 percent worked in hospitals, and another 22 percent worked in ofces of physicians or in nursing and residential care facilities. Most of the remainder worked in home health care services, federal government health care facilities, outpatient care centers, insurance carriers, and community care facilities for the elderly.

Health care settings range from small-town private physician practices who employ one medical assistant to large inner-city hospitals that provide thousands of diverse jobs. In , almost

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