Measuring Hospital Medical Staff Organizational Structure Stephen M. Shorteli and Thomas E. Getzen Based on organization theory and the work of Roemer and Friedman, seven dimensions of hospital medical staff organization structure are proposed and examined. The data are based on a 1973 nationwide survey of hospital medical staffs conducted by the American Hospital Association. Factor analysis yielded six relatively independent dimensions supporting a multidimensional view of medical staff organization structure. The six dimensions include 1) Resource Capability, 2) Generalist Physician Contractual Orientation, 3) Communication/Control, 4) Local Staff Orientation, 5) Participation in Decision Making, and 6) Hospital-Based Physician Contractual Orientation. It is suggested that these dimensions can be used to develop an empirical typology of hospital medical staff organization structure and to investigate the relationship between medical staff organization and public policy issues related to cost containment and quality assurance.
I NCREASED regulation and demands for greater accountability are increasing the responsibilities and transforming the roles of hospital medical staffs. This is reflected in the following comments of one practicing physician [1]: Do you remember the day when most of the medical staff decisions were made in the coffee shop or the golf course or when hospital accreditation was based on hastily written minutes covering the previous two years, or when policies were established by force of personality without considering the total hospital structure? Do you remember those good old days when no one was accountable to
anyone, and when financial angels bailed out hospitals in distress? Those days are gone with the $3 office call and $5 house call. Also gone is the medical staff organization, as we have known it,....
Formerly, a gentleman's professional organization, the medical staff now must be an expert in data collection, summarization, and evaluation; in public relations; in corporate finances; in cost effectiveness; and we must have a legal sensitivity rivalling that of a lawyer.
Given this situation it is surprising how little is currently known about
This research was supported in part by Grant No. HS 01978 from the National Center for Health Services Research, DHEW, Washington, DC and in part by a second grant from the Center for Health Services Research, University of Washington. Address communications and requests for reprints to Stephen M. Shortell, Professor and Director of the Center for Health Services Research, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195. Prof. Shortell also holds an adjunct appointment as Professor in the Department of Sociology at the University of Washington. Thomas E. Getzen is a doctoral student in the Department of Economics and a research assistant with the Center for Health Services Research, University of Washington. 001 7-9124/79/1402-097/$02.50/0
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ization, and centralization have been refined. These and related concepts have been used extensively in organizational studies of hospitals [21] but, as previously noted, have found little application in the study of medical staff organization structure. The major exception to the above is the work of Roemer and Friedman who suggested seven dimensions of medical staff organization structure: 1) staff composition, 2) appointment process, 3) commitment, 4) departmentalization, 5) control committees, 6) documentation, and 7) informal dynamics [9]. Weights based on investigator's judgments were then assigned and an overall index developed to reflect the relative tightness of medical staff organization structure. Their data, with the exception of those related to commitment, are based on an exploratory study of ten California hospitals. The present investigation extends their work by examining the degree to which many of their dimensions exist empirically based on data collected from over 4,000 U.S. general hospitals. The Australian typology on medical staff organization structure is based primarily on clinical department organization [13]. Hospital medical staffs were grouped according to whether or not they worked independently, in teams, or were also a part of sections, departments, or divisions. Further work is beConceptualizing Medical Staff ing conducted to investigate other diOrganization Structure mensions of medical staff organization structure in that country. a Organization structure has been Based largely on current organization subject of considerable interest to sociand the work of Roemer and theory ologists since Weber's early work on seven major dimensions of Friedman, has bureaucracy [14]. A major issue structure are postulated: organization been the degree to which empirical 2) FormalizaResource Capability, 1) studies of organizations have yielded Commitment, Centralization, 4) 3) tion, results supportive of Weber's unidi6) ParticiCommunication/Control, 5) mensional view of bureaucratic strucand 7) Decision in Making, ture [15-17] versus a multidimensional pation individThe Orientation. Care Primary view [18-20]. In the process, such concepts as role specialization, formal- ual measures of these predicted dimen-
medical staff organization structure in general and, in particular, about the relationship between structure and staff performance in regard to cost and quality of care. Data on individual characteristics of hospital medical staffs exist [2-4] as do some preliminary investigations relating these characteristics to hospital performance [5-12]. Nevertheless, with the exception of Roemer and Friedman [9] and a recent Australian report on patterns of medical staff organization [13], there has been no attempt to systematically examine dimensions of hospital medical staff organization structure. The purpose of this paper is to propose seven major dimensions of hospital medical staff organization structure and to test these empirically using data obtained from the American Hospital Association's 1973 nationwide survey of medical staff organization. In the following section, the major dimensions of medical staff organization structure are described along with their empirical referents. Subsequent sections describe the factor analytical methods used, results, future measurement issues, and suggestions for testing relationships between medical staff organization structure and performance indicators.
Staff Organization Structure sions are shown in Table 1. Departmentalization was not included as a separate dimension in the present study because of the existence of only a single individual measure; however, its relationship to the other dimensions is examined. As indicated in Table 1, Resource Capability includes a number of measures related to size, teaching, and support services provided by hospitals to their medical staffs. Size has long been recognized as an important structural variable [22,23] (or as a contextual variable related to structure) while Pugh et al. [18] have also identified "supportive components" as an important dimension of structure. Formalization refers to the degree to which rules, procedures, policies, and instructions are set in writing and is similar to Roemer and Friedman's concept of "documentation." Again, Pugh et al. [18], Reiman [20], and others have established formalization as a key dimension of organization structure. Centralization refers to the level at which various decisions are made in an organization. It has also been established as a key variable in studies of organization structure [18,20]. In the present context, it is assumed that higher centralization exists where department chiefs and committee members are appointed rather than elected by their own members. Commitment to Hospital is based primarily on Roemer and Friedman's work pertaining to percentage of physicians on contract. From an organization theory viewpoint, it may be seen as a related indicator of formalization in that placing freestanding professionals under written contracts specifying responsibilities and obligations suggests a more formalized structure of professional activities. Communication/Control is also similar to Roemer and Friedman's notion
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and from an organization structure perspective has been studied by Van de Ven and Koenig [24], Shortell, Becker, and Neuhauser [12], and Scott, Forrest, and Brown. [11]. Participation in Decision Making is a widely studied organizational variable [25,26]. Flood and Scott have directly examined its implications for the quality of surgical care in hospitals [27]. While decision making is typically thought of as an organizational process rather than an aspect of structure, the emphasis here is on structural indicators of participation such as whether medical staff bylaws allow medical staff members to vote on the hospital governing board. Finally, Primary Care Orientation is suggested as a seventh dimension reflecting the concept of role specialization developed and studied by Pugh et al. [18,28] and other investigators of organization structure. Given the apparent growing interest of hospitals in primary care activities, it was felt that investigation of this dimension was particularly pertinent. Measures pertaining to appointment processes are not included because they are viewed as being process measures of medical staff activities as opposed to measures of staff organization structure. Measures of informal dynamics are not available from the data but would be excluded in any event as being measures of process and not structure. Data for the variables shown in Table 1 were obtained from the American Hospital Association's 1973 nationwide survey of medical staff organization. Questionnaires were sent to all U.S. short-term general hospitals with an 81 percent completion rate (n = 4,212). Preliminary findings and additional background material on the survey are available in previous AHA staff publications [2-4].
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Table 1: Predicted Dimensions of Hospital Medical Staff Organization Structure Mean or Dimension Resource Capability
Formalization
Centralization
Commitment to Hospital
Communication/Control
Participation in Decision Making
Measur Percent of Active Staff Board Certified Percent of Active Staff Pathologists and Radiologists Number of Active Staff Members per Bed Existence of a Director of Medical Education Percent of Active Staff Funded for Research Number of Services and Benefits Provided to Active Medical Staffe.g., In-Hospital Clinical Office Space, Bookkeeping Services, etc. Number of Interns and Residents per Bed Hospital Bed Size
Standard
Percent Deviation
.34
27.0 14.0 .37
20.0%
40.0
5.0%
21.3
41.0% 14.0%
1.87 0.18 167
2.63 0.06 171
1.2
0.8
12.0%
32.1
45.0%
45.1
49.7%
46.1
58.0%
40.0
5.9%
23.5
Percent Nonactive Staff Physicians Percent of Active Staff on Contract Percent of Contract Staff on Salary President of Medical Staff on Contract Percent of Department Chiefs on Contract Percent of Contract Active Staff Holding Committee Assignments* Percent of Noncontract Physicians with Major Professional Activity in Your Hospital
36.0% 20.0% 23.0% 4.0% 28.2%
27.0 22.0 35.0 20.0 31.6
Number of Committees per Logarithm of Bed Size Number of Meetings per Committee Number of Members per Committee
4.3 11.1 6.5
Number of Staff Requirements-e.g., Board Certification, County Medical Society Membership, etc. Whether or not the Proportion of Maximum or Minimum Medical Staff Members Appointed to Board is Specified Percent of Committees with a Quorum Requirement Percent of Departmental Chiefs Appointed instead of Elected Percent of Committees for which Members are Appointed instead of Elected Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed
Medical Director Votes on Governing Board Director of Medical Education Votes on Governing Board President of Medical Staff is on Governing Board Other Medical Staff Officers are on Governing Board Active Staff are on Governing Board Physicians are on Executive Committee of Governing Board Percent of Medical Staff Committees With Nonphysician Voting
49.0%
83.0%
0.49
28.0 1.8 5.1
3.8
3.0%
17.2
0.5% 39.2%
7.3 48.8
19.0% 42.0%
39.0 49.0
25.7%
43.7
37.0%
31.0
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Table 1 (cont.): Predicted Dimensions of Hospital Medical Staff Organization Structure Measures
Dimension Primary Care Orientation
Ratio of Outpatient Visits per Bed Percent of Active Staff in Generalist Care (FP, GP, Pediatricians)t Percent of Generalist Care Physicians on Contract Number of Activities Involved in Cooperation with Outside HMOs-e.g., Emergency Care, Education, Peer Review, etc.
Mean or Standard Percent Deviation
145
38.0% 5.0% 0.68
186 27.0 18.6 1.21
*The Percentage of Contract Active Staff Holding Committee Assignments rather than all staff was used due to data problems in the latter measure. tThe term "generalist care" is used rather than "primary care" because there is as yet no widely accepted common definition of primary care nor is it known how much primary care is actually delivered by family practitioners, general practitioners, and pediatricians. Internists and obstetrician-gynecologists were excluded in order to arrive at what was felt to be a closer approximation to generalist as opposed to specialist care.
Methods
The predicted dimensions and individual measures shown in Table 1 are based on previous research noted earlier and on face validity. The measures involving Resource Capability are straightforward and indicate the increasing ability of a hospital medical staff to deliver high quality services. The Formalization measures are also straightforward and involve staff requirements and specifications. In regard to Centralization, the assumption is made that appointment of departmental chiefs and committee members by hospital administration or medical staff hierarchy represents greater centralization of authority than where such individuals are elected by the staff at large. Commitment to Hospital is measured not only by physicians on contract, but also by the percentage of noncontract physicians having their major professional activity (e.g., admission of patients) at the hospital. From a structural perspective, Communication/Control is measured by the number, frequency, and size of committees since committee interaction is one of
the primary means of information exchange and feedback in complex organizations. The Participation in Decision Making measures are straightforward and involve various types of physician participation in hospital governing board activities. Ideally, it would also be important to include physician involvement in hospital administration decision making bodies, but such data were not available. The Primary Care Orientation dimension is the most problematic but, given the data available, is best represented by percent of generalist care physicians, volume of outpatient activity, and involvement with health maintenance organization (HMO) activities. The data were examined using factor analysis, which takes the variance defined by intercorrelations among a set of measures, and attempts to allocate it in terms of fewer underlying hypothetical or, in this case, predicted variables or dimensions [29,30]. Trivially, the variance can be totally (100 percent) explained by setting the number of factors equal to the number of variables. Typically, however, most of the variance can be explained by a much
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smaller set which can then be interpreted in a theoretically meaningful manner. For example, a set of data on various physical, social, and psychological variables could be analyzed to reveal three dominant underlying clusters which might be identified by the researcher as "genetic," "nutritional," and "environmental" factors. In the present analysis, those factors which explain more of the variance than a single arbitrary variable (eigenvalue < 1.0) are retained. Thus, if there were ten variables, only those factors explaining more than 10 percent of the total variance would be retained. It is assumed that each variable is explained in part by the underlying factors, but also has a residual random variance. The "principal factor solution" obtained is not unique and may not be the most meaningful theoretically. A simpler factor structure can be obtained by rotating the axis, i.e., by choosing one of an infinite number of linear combinations of the principal factors, which meets the mathematical maximization conditions. Furthermore, we allow for the possibility that some of the underlying factors may be correlated with each other by using an "oblimin" or nonorthogonal rotation. Results Table 2 summarizes the result of the oblimin rotated factor matrix reducing the original 32 variables to 9 principal factors explaining 53 percent of total variation. The first factor accounted for 15.3 percent of the total variance and 37.2 percent of the total explained variation. Each of the variables with a loading of .30 or greater is discussed in order of decreasing value in relation to the originally predicted dimensions. As shown, the first factor is composed of the following variables: 1) number of interns and residents per bed (+); 2) bed size (+); 3) number of
services and benefits provided (+); 4) committee size (+); 5) existence of a Director of Medical Education (+); 6) percent generalist care physicians (-); 7) percent of contract staff on salary (+); 8) percent of active staff board certified (+); 9) percent of department chiefs appointed (+); and 10) number of active staff physicians per bed (+). Since this factor contains six of the seven originally predicted dimensions, it seems appropriate to label it "resource capability" although it might be just as appropriately labeled "sizeteaching capability" because of the dominant influence of number of interns and residents per bed and bed size itself. Factor II is comprised of 1) percentage of generalist care physicians on contract (+); 2) percentage of active staff on contract (+); 3) president of medical staff on contract (+); 4) number of services and benefits provided (+); 5) number of interns and residents per bed (+); and 6) percent of contract staff on salary (+). The three highest loadings each involve contractual relationships but it should also be noted that the variable "percent of noncontract physicians with major professional activity in your hospital" actually loads negatively (-.21) on this factor. Thus, it appears that this factor is really measuring more of a "generalist physician contractual orientation" than Commitment to Hospital, per se. In brief, the percentage of physicians on contract, particularly generalist care physicians, does not appear to be a valid indicator of medical staff commitment to the hospital. As shown, the third factor consists of 1) the number of committees per logarithm of bed size (+); 2) percent of committees with members elected by the medical staff (+); 3) percent of committees with nonphysician voting (+); 4) number of meetings per commit-
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Table 2: Factor Structure Matrix* Factor: Hospital Bed Size Number of Interns and Residents per Bed Existence of a Director of Medical Education Number of Services and Benefits Provided to Active Staff Number of Staff Requirements Percent of Contract Staff on Salary Percent of Active Staff on Contract President of Medical Staff on Contract Percent of Generalist Care Physicians on Contract Percent of Active Staff Board Certified Number of Active Staff Members per Bed Ratio of Outpatient Visits per Bed Percent of Noncontract Physicians with Major Professional Activity in Your Hospital Percent Nonactive Staff Physicians Percent of Active Staff Radiologists and Pathologists Percent of Active Staff in Generalist Care Percent of Medical Staff Committees with Nonphysician Voting Number of Meetings per Committee Number of Members per Committee Percent of Contract Active Staff Holding Committee Assignments Percent of Committees with a Quorum Requirement Number of Committees per Logarithm of Bed Size Percent of Committees for which Members are Appointed Percent of Departmental Chiefs Appointed Departments per Bed President of Medical Staff is on Governing Board Other Medical Staff Officers are on Governing Board Active Medical Staff are on Governing Board Physicians are on Executive Committee of Governing Board Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed Percent of Active Staff Funded for Research Number of Activities Involved with Outside HMOs *
I
I
III
IV
V
0.68 0.72
0.32
VI
VII
0.77
0.22
0.56
0.30
0.32
0.25
-0.22
0.37
-0.25 0.63
0.21
0.66 0.46 0.36
0.63 0.23 0.27 0.91 0.20
-0.28
0.23
0.37
-0.21
0.21
0.30 0.72 0.43 0.91
0.82
0.31 0.30 0.26
IX Commuality
-0.25 -0.58 0.45 0.40
0.42 0.55 0.20 0.34
VII
0.63
0.22
0.42
0.29
0.51 0.16
-0.66
0.27 -0.21
0.51 0.30
0.33 0.16 0.76
0.85 -0.35
0.21
0.52
-0.66 -0.30
-0.30 0.37 -0.22
0.43 0.51 0.34 -0.23 0.20 -0.26 -0.34 0.48 0.33 0.32
0.21
0.24
0.65 0.56
0.31
0.25 0.73
-0.22 0.26
0.21 0.26 0.52 0.13 0.08
0.28
0.22
0.64
0.48 0.35
0.38
0.25
0.20 0.55
0.41
0.19
0.48
0.24
0.62
0.40
0.42
0.19
0.36
0.13 0.06
0.09
The following variables, which were shown in Table 1, are deleted from Table 2 because they had a one to one correspondence with an individual value of another variable included in the analysis: Whether or not the Proportion of Maximum or Minimum Medical Staff Members Appointed to the Board is Specified, Percent of Department Chiefs on Contract, Medical Director Votes on Governing Board, and Director of Medical Education Votes on Governing Board. For example, Percent of Department Chiefs on Contract overlapped fully with Percent of Active Staff on Contract since all department chiefs are members of the active staff.
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tee (+); 5) number of members per committee (+); and 6) percent generalist care physicians (-). These results support the originally predicted Communication/Control dimension of staff structure built around committees. The negative loading of percent generalist care physicians (-.30) suggests less formally organized communication and control in hospitals with a higher percentage of generalist care physicians. The fourth factor is comprised of 1) number of active staff physicians per bed (-); 2) percent of noncontract physicians with major professional activity at the hospital (+); 3) percent generalist care physicians (+); and 4) percentage of physicians not on the active medical staff (+). This factor is difficult to label but the results suggest that a lower ratio of active staff physicians per bed is associated with a higher percentage of noncontract physicians having their major professional activity at the hospitals, with a higher percentage of generalist care physicians, and with a higher absolute percentage of nonactive physicians. Taken together, this factor would appear to be measuring a "local orientation" of medical staff in that, while active staff size per bed is low, it is comprised primarily of generalists who focus most of their activity at the one hospital. Factor V consists of 1) active medical staff members on the hospital governing board (+); 2) medical staff officers on the hospital governing board (+); 3) medical staff members on the executive committee of the governing board (+); 4) president of the medical staff on the governing board (+); and 5) physician governing board members elected by the medical staff (+). These findings support the predicted dimension of Participation in Decision Making. Factor VI is composed of 1) ratio of radiologists and pathologists to other active staff physicians (+); and 2) per-
centage of active staff on contract (+). These findings suggest a more "hospitalbased specialist contractual orientation" in contrast to the "generalist orientation" of Factor II. Factors VII, VIII, and IX are composed of many of the same items as are Factors I and II, and reflect nonlinearities and random variation in the data. For these reasons, they are excluded from further discussion.
Discussion Table 3 summarizes the empirically derived factors. The results support a mutidimensional view of medical staff structure consistent with the results found in the general organizational literature by Pugh et al. [18], Hage and Aiken [26], and Reimann [20]. Comparison of Table 3 with Table 1 predictions indicates support for some of the originally hypothesized dimensions, further elaboration of others, and no support for still others. Factors related to "resource capability," "communication/control," and "participation in decision making," are supported, although the resource capability factor could be labeled "sizeteaching capability." There is no support for separate formalization, centralization, or primary care orientation dimensions. Neither do the items comprising formalization or centralization load strongly or consistently on any of the derived factors, although there is some suggestion that centralization is associated with resource capability (sizeteaching) and with communication/ control. In regard to primary care orientation, the percentage of generalist care physicians on contract loads strongly on Factor II but such other aspects as HMO involvement are not related to this factor and, in fact, do not load strongly on any factor. Of particular importance is the lack
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Table 3: Summary of Empirically Derived Factors of Hospital Medical Staff Organization Structure Factors
Resource (Size-Teaching) Capability
Generalist Physician Contractual Orientation
Communication/Control
Local Staff Orientation
Participation in Decision
Making
Hospital-Based Specialist Contractual Orientation
Variables
Number of Interns and Residents per Bed Hospital Bed Size Number of Services and Benefits Provided to Active Staff Number of Members per Committee Existence of a Director of Medical Education Percent of Active Staff in Generalist Care Percent of Contract Staff on Salary Percent of Active Staff Board Certified Percent of Departmental Chiefs Appointed Number of Active Staff Members per Bed Percent of Generalist Care Physicians on Contract Percent of Active Staff on Contract President of Medical Staff on Contract Number of Services and Benefits Provided to Active Staff Number of Interns and Residents per Bed Percent of Contract Staff on Salary
Committees per Logarithm of Bed Size Percent of Committees for which Members are Appointed Number of Meetings per Committee Percent of Medical Staff Committees with Nonphysician Voting Number of Members per Committee Percent of Active Staff in Generalist Care
Number of Active Staff Members per Bed Percent of Noncontract Physicians with Major Professional Activity in Your Hospital Percent of Active Staff in Generalist Care Percent of Nonactive Staff Physicians
Factor Loading 0.72 0.68
0.55 0.52 0.42 -0.35 0.34 0.31 0.31 0.30 0.91 0.72 0.43
0.37 0.32 0.30 0.65 0.56 0.51
0.43 0.34 -0.30 -0.66 0.51 0.37 0.30
Active Staff are on Governing Board Other Medical Staff Officers are on Governing Board Physicians are on Executive Committee of Governing Board President of Medical Staff is on Governing Board Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed
0.62 0.48
Percent of Active Staff Radiologists and Pathologists Percent of Active Staff on Contract
0.85 0.63
0.42 0.41 0.36
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of a single factor that might be termed "hospital commitment." Roemer and Friedman's measure of the "percentage of physicians on contract" does not appear to be related to the notion of hospital commitment since, in Factor II, such measures as the "percentage of noncontract physicians with major professional activity in your hospital" actually load negatively on the factor for which "percentage of contract physicians" is positively loaded. There are, however, strong interrelationships among the contractual physician measures themselves suggesting that they represent a* separate dimension of medical staff organization structure in their own right. In fact, the present results suggest that it is important to distinguish between two dimensions: the first (Factor II) related to "generalist physician contractual orientation," and the second (Factor VI) related to "hospital-based specialist contractual orientation." While "percentage of physicians on contract" may not be a valid measure of hospital commitment, this does not imply that contracts have no influence on physician behavior. For example, contracts which offer physicians a percentage of gross departmental revenue offer an incentive to provide more overall services. Contracts involving a percentage of net revenue offer some incentive for physicians to contain costs and to select those procedures and services which maximize the difference between marginal revenue and marginal costs. Physicians under straight salary arrangements have neither an incentive to increase services rendered, nor an economic incentive to control costs. In addition to these revenue-producing and cost containment considerations, it might be argued that hospitals can more legitimately claim time to serve on various committees from contract physi-
cians than from medical staff members not under contract. None of the above, however, suggest that "percentage of contract physicians" is a measure of hospital staff commitment. A better overall behavioral indicator of commitment is the percentage of physicians who actually admit most of their patients to a given hospital. Further insight into the factor structure was obtained by examining the correlations among the factors. The factors were essentially uncorrelated with each other; the highest correlation was that of "resource capability" with "generalist physician contractual orientation" (r = .29). In brief, the results suggest six relatively separate factors of medical staff organization structure. Resource capability is the dominant factor. There is no support for a structural dimension of hospital commitment. Contractual orientation did emerge but in two separate although somewhat related factors: a "generalist physician contractual orientation" and a "hospital-based specialist contractual orientation." Distinct factors also emerge for "communication/control" and "participation in decision making." In contrast to much of the existing organizational literature, there was no support for separate dimensions of formalization or centralization. This may be due to the limited measures of these dimensions available from the data. Suggestions for further analysis and potential uses of the above dimensions are discussed below. Future Research and Potential Policy Significance The data examined here represent the only comprehensive set of data available on medical staff organization. As such, they are uniquely valuable for conducting comparative research on nearly all U.S. hospitals. If updated and supplemented from time to time, they
Staff Organization Structure can serve as a useful barometer of changing medical staff organization structure and its relationship to costeffective patient care practices in response to such factors as Professional Standards Review Organizations (PSROs), multiunit hospital systems, continued vertical integration of hospital services, changing standards of patient care, legal decisions, and continued advances in technology. The data base also has the advantage that it contains structural measures similar to those used by previous investigators, and the present analysis has added further knowledge concerning the validity of those measures with suggestions for further elaboration as well as some new leads. The data base, of course, does not contain all of the measures one would necessarily use to measure medical staff organization structure nor are physician perceptions of staff structure included. Present analysis clearly indicates the need for further work in measuring centralization and formalization. But given the cost, time, and related problems in collecting such information, the present data are sufficiently comprehensive to be useful in a number of ways. First, an empirical typology of hospital medical staff organization structures might be developed based on the dimensions which emerged from the present analysis. Of particular interest would be the delineation of the different types of medical staff organization structure by hospital ownership (federal, state, local, voluntary, for profit, etc.) and region of the country. For example, large regional differences in average length of patient stay exist between the east and west coasts. Differences in physician education and training apparently do not explain such differences. There is some suggestion that they may be partially related to occupancy rates [31]. But the question
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might also be raised as to whether or not some of the differences might be due to medical staff organization structures differing between regions. The impact of medical staff organization structure on hospital costs and quality of care is an important area for investigation, particularly given the continued implementation of PSROs. For example, hospitals with medical staffs scoring high on the resource capability dimension may have both higher costs and higher quality. Generalist physician contractual orientation may be associated with lower costs, and also may be an indicator of growing hospital involvement in ambulatory and hospital sponsored primary care. Based on previous research [6] there is some suggestion that the coordination and control dimensions might be associated with lower costs and higher quality. Local staff orientation may be associated with both lower costs and lower quality along with a possible tendency to be less innovative in adoption of new technology and patient care practices. Previous research [12] also suggests that physician participation in decision making may be associated with lower costs. Finally, hospitalbased contractual orientation may be associated with higher costs as suggested by a recent study indicating that hospital-based remuneration represents a significant portion of total direct costs in radiology and pathology departments [351. With few exceptions, little is known about any of these suggested relationships. Classification of hospital medical staff organization structures could also be useful in evaluating prospective reimbursement experiments and related cost containment strategies. Do hospitals placed in different categories for purposes of prospective reimbursement exhibit different medical staff organization structures? What is the
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relationship between medical staff organization structure and case mix? These are important questions from a practitioner and policy viewpoint because all the dimensions identified contain variables under the control of hospital governing boards, medical staffs, and administrators, and can be changed to improve performance. Individual measures of the hospital medical staff organization dimensions are also of interest. For example, what are the third party reimbursement and cost implications of adding more salaried physicians? In regard to hospitalbased contract physicians, a recent court ruling has indicated the right of state rate review commissions to review hospital-based doctors [32]. Further, preliminary evidence suggests that for the same diagnosis and set of patient characteristics, charges per case are lower if the attending surgical specialist is board certified than if he is not
[33].
Still another set of considerations is related to a recent Institute of Medicine report examining the specialty mix, specialty ratios, number of foreign medical graduates, and methods of payment in teaching hospitals [34]. How is medical staff organization structure affected by
these considerations and, in turn, what is the relationship to educational activities and patient care practices? It is increasingly clear that physician behavior, particularly within the context of the hospital, is being subjected to external controls. A fundamental issue in American health care delivery is the degree to which a satisfactory level of institutionalization and bureaucratization of medical practice can be attained with regard to access, cost, quality, continuity, and both patient and provider satisfaction. Medical staff organization is a central aspect of this issue and the dimensions developed in the present analysis provide conceptual and empirical referents for further investigations.
ACKNOWLEDGEMENTS. Appreciation is expressed to the Vice President's Office of the American Hospital Association for providing the data on which this analysis is based. The conclusions and judgments expressed are the sole responsibility of the authors. Appreciation is also expressed to Vandan M. Trivedi, Ph.D., and George Bugbee for their comments on an earlier draft of this paper.
REFERENCES 1. Conner, A.E. Medical staff organization-A change is needed. Virginia Medical Monthly 102 (4):292, Apr. 1975. 2. Kessler, M.S. Doctors on boards: Survey tracks a growing trend. The Hospital Medical Staff 5(6):10, June 1976. 3. Kessler, M.S. Physician compensation: Survey shows marked increase in contractual arrangements. The Hospital Medical Staff 5(7):19, July 1976. 4. Kessler, M.S. Survey compares medical staff organization in teaching and nonteaching hospitals. The Hospital Medical Staff 5(8):18, Aug. 1976. 5. Georgopoulos, B.S. and F.C. Mann. The Community General Hospital. New York: Mac-
millan Company, 1962. 6. Longest, B. Relationships between coordination, efficiency, and quality of care in general hospitals. Hospital Administration 19(4):65, Fall 1974. 7. Morse, E.V., G. Gordon and M. Moch. Hospital costs and quality of care: An organization perspective. Milbank Memorial Fund Quarterly 52(3):315, Summer 1974.
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8. Becker, S. and D. Neuhauser. The Efficient Organization. New York: El Sevier Press, 1975. 9. Roemer, M.I. and J. Friedman. Doctors in Hospitals: Medical Staff Organization and Hospital Performance. Baltimore: Johns Hopkins Press, 1971. 10. Schultz, R. Physicians on boards: Survey examines level, extent of participation. Hospitals 46(24):51, Dec. 16, 1972. 11. Scott, W.R., W.H. Forrest, Jr. and B.W. Brown, Jr. Hospital Structure and Post Operative Mortality and Morbidity. In S.M. Shortell and M. Brown (eds.), Organizational Research in Hospitals, pp. 72-89. Chicago: Blue Cross Association, 1976. 12. Shortell, S.M., S. Becker and D. Neuhauser. The Effects of Management Practices on Hospital Efficiency and Quality of Care. In S.M. Shortell and M. Brown (eds.), Organizational Research in Hospitals, pp. 90-107. Chicago: Blue Cross Association, 1976. 13. Medical Administrative Teaching and Research Advisory Group. Patterns of medical staff organization. The School of Health Administration, The University of New South Wales, Australia, June 1975. 14. Weber, M. The Theory of Social and Economic Organization. Translated by A.M. Henderson and T. Parsons. New York: The Free Press, 1946. 15. Blau, P. The hierarchy of authority in organizations. American Journal of Sociology 73
(4):453, 1967. 16. Hall, R. Intra-organizational structural variation: Application of the bureaucratic model. Administrative Science Quarterly 7(2):295, 1962. 17. Child, J. Organization structure and strategies of control: A replication of the Aston studies. Administrative Science Quarterly 17(2):163, 1972. 18. Pugh, D.S., D.J. Hickson, C.R. Hinings et al. Dimensions of organization structure. Administrative Science Quarterly 13(1):65, 1968. 19. Samuel, Y. and B.F. Mannheim. A multi-dimensional approach toward a typology of bureaucracy. Administrative Science Quarterly 15(2):216, 1970. 20. Reimann, B. On the dimensions of bureaucratic structure: An empirical reappraisal. Administrative Science Quarterly 18(4):462, 1973. 21. Shortell, S.M. Organization Theory and Health Services Delivery. In S.M. Shortell and M. Brown (eds.), Organizational Research in Hospitals, pp. 1-12. Chicago: Blue Cross Association, 1976. 22. Anderson, T. and S. Warkov. Organizational size and functional complexity. American Sociological Review 26(1):23, Feb. 1961. 23. Blau, P. and R.A. Shoenherr. The Structure of Organizations. New York: Basic Books, 1971. 24. Van de Ven, A. and R. Koenig. Determinants of coordination modes within organizations. American Sociological Review 41(2):322, 1976. 25. Hall, R. Leadership and Decision-Making. In Organizations: Structure and Process, pp. 243-268. Englewood Cliffs, NJ: Prentice-Hall Inc., 1972. 26. Hage, J. and M. Aiken. Relationship of centralization to other structural properties. Administrative Science Quarterly 12(1):72, 1967. 27. Flood, A. and W.R. Scott. Professional power and professional effectiveness: The power of the surgical staff and the quality of surgical care in hospitals. Journal of Health and Social Behavior 19(3):240, Sept. 1978. 28. Pugh, D.S., D.J. Hickson, C.R. Hinings et al. The context of organization structures. Administrative Science Quarterly 14(1):91, Mar. 1969. 29. Williams, F. Factor Analysis. In Reasoning With Statistics, pp.151-166. New York: Holt, Rinehart, and Winston, Inc., 1968. 30. Harman, H. Modern Factor Analysis. Chicago: University of Chicago Press, 1960. 31. Watts, C. and R. Hartman. The Determination of Average Length of Stay: An Economic Approach. Health Policy Research Series, Discussion Paper #8, Center for Health Ser-
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32. 33. 34. 35.
Health Services Research vices Research, Department of Health Services, University of Washington, Seattle, WA, May 1978. Right Commission Wins Right to Review Fees of Hospital-Based Doctors. Action Kit for Hospital Law, Jan. 1978. Pauly, M.V. The effect of medical staff characteristics on hospital costs. Final report submitted to Social Security Administration, DHEW, June 1977. Institute of Medicine. Medicare-Medicaid Reimbursement Policies: Social Security Studies Final Report. Washington, DC: National Academy of Sciences, Mar. 1976. Mitchell, S., T. Shaffert and R. Schlenker. Study of Reimbursement and Practice Arrangements of Provider-Based Physicians, pp. 1-12. NTIS Pub. No. PB-281 125. Philadelphia, PA: Arthur Andersen and Co., Dec. 1977.
I NCREASED regulation and demands for greater accountability are increasing the responsibilities and transforming the roles of hospital medical staffs. This is reflected in the following comments of one practicing physician [1]: Do you remember the day when most of the medical staff decisions were made in the coffee shop or the golf course or when hospital accreditation was based on hastily written minutes covering the previous two years, or when policies were established by force of personality without considering the total hospital structure? Do you remember those good old days when no one was accountable to
anyone, and when financial angels bailed out hospitals in distress? Those days are gone with the $3 office call and $5 house call. Also gone is the medical staff organization, as we have known it,....
Formerly, a gentleman's professional organization, the medical staff now must be an expert in data collection, summarization, and evaluation; in public relations; in corporate finances; in cost effectiveness; and we must have a legal sensitivity rivalling that of a lawyer.
Given this situation it is surprising how little is currently known about
This research was supported in part by Grant No. HS 01978 from the National Center for Health Services Research, DHEW, Washington, DC and in part by a second grant from the Center for Health Services Research, University of Washington. Address communications and requests for reprints to Stephen M. Shortell, Professor and Director of the Center for Health Services Research, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195. Prof. Shortell also holds an adjunct appointment as Professor in the Department of Sociology at the University of Washington. Thomas E. Getzen is a doctoral student in the Department of Economics and a research assistant with the Center for Health Services Research, University of Washington. 001 7-9124/79/1402-097/$02.50/0
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ization, and centralization have been refined. These and related concepts have been used extensively in organizational studies of hospitals [21] but, as previously noted, have found little application in the study of medical staff organization structure. The major exception to the above is the work of Roemer and Friedman who suggested seven dimensions of medical staff organization structure: 1) staff composition, 2) appointment process, 3) commitment, 4) departmentalization, 5) control committees, 6) documentation, and 7) informal dynamics [9]. Weights based on investigator's judgments were then assigned and an overall index developed to reflect the relative tightness of medical staff organization structure. Their data, with the exception of those related to commitment, are based on an exploratory study of ten California hospitals. The present investigation extends their work by examining the degree to which many of their dimensions exist empirically based on data collected from over 4,000 U.S. general hospitals. The Australian typology on medical staff organization structure is based primarily on clinical department organization [13]. Hospital medical staffs were grouped according to whether or not they worked independently, in teams, or were also a part of sections, departments, or divisions. Further work is beConceptualizing Medical Staff ing conducted to investigate other diOrganization Structure mensions of medical staff organization structure in that country. a Organization structure has been Based largely on current organization subject of considerable interest to sociand the work of Roemer and theory ologists since Weber's early work on seven major dimensions of Friedman, has bureaucracy [14]. A major issue structure are postulated: organization been the degree to which empirical 2) FormalizaResource Capability, 1) studies of organizations have yielded Commitment, Centralization, 4) 3) tion, results supportive of Weber's unidi6) ParticiCommunication/Control, 5) mensional view of bureaucratic strucand 7) Decision in Making, ture [15-17] versus a multidimensional pation individThe Orientation. Care Primary view [18-20]. In the process, such concepts as role specialization, formal- ual measures of these predicted dimen-
medical staff organization structure in general and, in particular, about the relationship between structure and staff performance in regard to cost and quality of care. Data on individual characteristics of hospital medical staffs exist [2-4] as do some preliminary investigations relating these characteristics to hospital performance [5-12]. Nevertheless, with the exception of Roemer and Friedman [9] and a recent Australian report on patterns of medical staff organization [13], there has been no attempt to systematically examine dimensions of hospital medical staff organization structure. The purpose of this paper is to propose seven major dimensions of hospital medical staff organization structure and to test these empirically using data obtained from the American Hospital Association's 1973 nationwide survey of medical staff organization. In the following section, the major dimensions of medical staff organization structure are described along with their empirical referents. Subsequent sections describe the factor analytical methods used, results, future measurement issues, and suggestions for testing relationships between medical staff organization structure and performance indicators.
Staff Organization Structure sions are shown in Table 1. Departmentalization was not included as a separate dimension in the present study because of the existence of only a single individual measure; however, its relationship to the other dimensions is examined. As indicated in Table 1, Resource Capability includes a number of measures related to size, teaching, and support services provided by hospitals to their medical staffs. Size has long been recognized as an important structural variable [22,23] (or as a contextual variable related to structure) while Pugh et al. [18] have also identified "supportive components" as an important dimension of structure. Formalization refers to the degree to which rules, procedures, policies, and instructions are set in writing and is similar to Roemer and Friedman's concept of "documentation." Again, Pugh et al. [18], Reiman [20], and others have established formalization as a key dimension of organization structure. Centralization refers to the level at which various decisions are made in an organization. It has also been established as a key variable in studies of organization structure [18,20]. In the present context, it is assumed that higher centralization exists where department chiefs and committee members are appointed rather than elected by their own members. Commitment to Hospital is based primarily on Roemer and Friedman's work pertaining to percentage of physicians on contract. From an organization theory viewpoint, it may be seen as a related indicator of formalization in that placing freestanding professionals under written contracts specifying responsibilities and obligations suggests a more formalized structure of professional activities. Communication/Control is also similar to Roemer and Friedman's notion
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and from an organization structure perspective has been studied by Van de Ven and Koenig [24], Shortell, Becker, and Neuhauser [12], and Scott, Forrest, and Brown. [11]. Participation in Decision Making is a widely studied organizational variable [25,26]. Flood and Scott have directly examined its implications for the quality of surgical care in hospitals [27]. While decision making is typically thought of as an organizational process rather than an aspect of structure, the emphasis here is on structural indicators of participation such as whether medical staff bylaws allow medical staff members to vote on the hospital governing board. Finally, Primary Care Orientation is suggested as a seventh dimension reflecting the concept of role specialization developed and studied by Pugh et al. [18,28] and other investigators of organization structure. Given the apparent growing interest of hospitals in primary care activities, it was felt that investigation of this dimension was particularly pertinent. Measures pertaining to appointment processes are not included because they are viewed as being process measures of medical staff activities as opposed to measures of staff organization structure. Measures of informal dynamics are not available from the data but would be excluded in any event as being measures of process and not structure. Data for the variables shown in Table 1 were obtained from the American Hospital Association's 1973 nationwide survey of medical staff organization. Questionnaires were sent to all U.S. short-term general hospitals with an 81 percent completion rate (n = 4,212). Preliminary findings and additional background material on the survey are available in previous AHA staff publications [2-4].
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Table 1: Predicted Dimensions of Hospital Medical Staff Organization Structure Mean or Dimension Resource Capability
Formalization
Centralization
Commitment to Hospital
Communication/Control
Participation in Decision Making
Measur Percent of Active Staff Board Certified Percent of Active Staff Pathologists and Radiologists Number of Active Staff Members per Bed Existence of a Director of Medical Education Percent of Active Staff Funded for Research Number of Services and Benefits Provided to Active Medical Staffe.g., In-Hospital Clinical Office Space, Bookkeeping Services, etc. Number of Interns and Residents per Bed Hospital Bed Size
Standard
Percent Deviation
.34
27.0 14.0 .37
20.0%
40.0
5.0%
21.3
41.0% 14.0%
1.87 0.18 167
2.63 0.06 171
1.2
0.8
12.0%
32.1
45.0%
45.1
49.7%
46.1
58.0%
40.0
5.9%
23.5
Percent Nonactive Staff Physicians Percent of Active Staff on Contract Percent of Contract Staff on Salary President of Medical Staff on Contract Percent of Department Chiefs on Contract Percent of Contract Active Staff Holding Committee Assignments* Percent of Noncontract Physicians with Major Professional Activity in Your Hospital
36.0% 20.0% 23.0% 4.0% 28.2%
27.0 22.0 35.0 20.0 31.6
Number of Committees per Logarithm of Bed Size Number of Meetings per Committee Number of Members per Committee
4.3 11.1 6.5
Number of Staff Requirements-e.g., Board Certification, County Medical Society Membership, etc. Whether or not the Proportion of Maximum or Minimum Medical Staff Members Appointed to Board is Specified Percent of Committees with a Quorum Requirement Percent of Departmental Chiefs Appointed instead of Elected Percent of Committees for which Members are Appointed instead of Elected Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed
Medical Director Votes on Governing Board Director of Medical Education Votes on Governing Board President of Medical Staff is on Governing Board Other Medical Staff Officers are on Governing Board Active Staff are on Governing Board Physicians are on Executive Committee of Governing Board Percent of Medical Staff Committees With Nonphysician Voting
49.0%
83.0%
0.49
28.0 1.8 5.1
3.8
3.0%
17.2
0.5% 39.2%
7.3 48.8
19.0% 42.0%
39.0 49.0
25.7%
43.7
37.0%
31.0
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Table 1 (cont.): Predicted Dimensions of Hospital Medical Staff Organization Structure Measures
Dimension Primary Care Orientation
Ratio of Outpatient Visits per Bed Percent of Active Staff in Generalist Care (FP, GP, Pediatricians)t Percent of Generalist Care Physicians on Contract Number of Activities Involved in Cooperation with Outside HMOs-e.g., Emergency Care, Education, Peer Review, etc.
Mean or Standard Percent Deviation
145
38.0% 5.0% 0.68
186 27.0 18.6 1.21
*The Percentage of Contract Active Staff Holding Committee Assignments rather than all staff was used due to data problems in the latter measure. tThe term "generalist care" is used rather than "primary care" because there is as yet no widely accepted common definition of primary care nor is it known how much primary care is actually delivered by family practitioners, general practitioners, and pediatricians. Internists and obstetrician-gynecologists were excluded in order to arrive at what was felt to be a closer approximation to generalist as opposed to specialist care.
Methods
The predicted dimensions and individual measures shown in Table 1 are based on previous research noted earlier and on face validity. The measures involving Resource Capability are straightforward and indicate the increasing ability of a hospital medical staff to deliver high quality services. The Formalization measures are also straightforward and involve staff requirements and specifications. In regard to Centralization, the assumption is made that appointment of departmental chiefs and committee members by hospital administration or medical staff hierarchy represents greater centralization of authority than where such individuals are elected by the staff at large. Commitment to Hospital is measured not only by physicians on contract, but also by the percentage of noncontract physicians having their major professional activity (e.g., admission of patients) at the hospital. From a structural perspective, Communication/Control is measured by the number, frequency, and size of committees since committee interaction is one of
the primary means of information exchange and feedback in complex organizations. The Participation in Decision Making measures are straightforward and involve various types of physician participation in hospital governing board activities. Ideally, it would also be important to include physician involvement in hospital administration decision making bodies, but such data were not available. The Primary Care Orientation dimension is the most problematic but, given the data available, is best represented by percent of generalist care physicians, volume of outpatient activity, and involvement with health maintenance organization (HMO) activities. The data were examined using factor analysis, which takes the variance defined by intercorrelations among a set of measures, and attempts to allocate it in terms of fewer underlying hypothetical or, in this case, predicted variables or dimensions [29,30]. Trivially, the variance can be totally (100 percent) explained by setting the number of factors equal to the number of variables. Typically, however, most of the variance can be explained by a much
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smaller set which can then be interpreted in a theoretically meaningful manner. For example, a set of data on various physical, social, and psychological variables could be analyzed to reveal three dominant underlying clusters which might be identified by the researcher as "genetic," "nutritional," and "environmental" factors. In the present analysis, those factors which explain more of the variance than a single arbitrary variable (eigenvalue < 1.0) are retained. Thus, if there were ten variables, only those factors explaining more than 10 percent of the total variance would be retained. It is assumed that each variable is explained in part by the underlying factors, but also has a residual random variance. The "principal factor solution" obtained is not unique and may not be the most meaningful theoretically. A simpler factor structure can be obtained by rotating the axis, i.e., by choosing one of an infinite number of linear combinations of the principal factors, which meets the mathematical maximization conditions. Furthermore, we allow for the possibility that some of the underlying factors may be correlated with each other by using an "oblimin" or nonorthogonal rotation. Results Table 2 summarizes the result of the oblimin rotated factor matrix reducing the original 32 variables to 9 principal factors explaining 53 percent of total variation. The first factor accounted for 15.3 percent of the total variance and 37.2 percent of the total explained variation. Each of the variables with a loading of .30 or greater is discussed in order of decreasing value in relation to the originally predicted dimensions. As shown, the first factor is composed of the following variables: 1) number of interns and residents per bed (+); 2) bed size (+); 3) number of
services and benefits provided (+); 4) committee size (+); 5) existence of a Director of Medical Education (+); 6) percent generalist care physicians (-); 7) percent of contract staff on salary (+); 8) percent of active staff board certified (+); 9) percent of department chiefs appointed (+); and 10) number of active staff physicians per bed (+). Since this factor contains six of the seven originally predicted dimensions, it seems appropriate to label it "resource capability" although it might be just as appropriately labeled "sizeteaching capability" because of the dominant influence of number of interns and residents per bed and bed size itself. Factor II is comprised of 1) percentage of generalist care physicians on contract (+); 2) percentage of active staff on contract (+); 3) president of medical staff on contract (+); 4) number of services and benefits provided (+); 5) number of interns and residents per bed (+); and 6) percent of contract staff on salary (+). The three highest loadings each involve contractual relationships but it should also be noted that the variable "percent of noncontract physicians with major professional activity in your hospital" actually loads negatively (-.21) on this factor. Thus, it appears that this factor is really measuring more of a "generalist physician contractual orientation" than Commitment to Hospital, per se. In brief, the percentage of physicians on contract, particularly generalist care physicians, does not appear to be a valid indicator of medical staff commitment to the hospital. As shown, the third factor consists of 1) the number of committees per logarithm of bed size (+); 2) percent of committees with members elected by the medical staff (+); 3) percent of committees with nonphysician voting (+); 4) number of meetings per commit-
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Table 2: Factor Structure Matrix* Factor: Hospital Bed Size Number of Interns and Residents per Bed Existence of a Director of Medical Education Number of Services and Benefits Provided to Active Staff Number of Staff Requirements Percent of Contract Staff on Salary Percent of Active Staff on Contract President of Medical Staff on Contract Percent of Generalist Care Physicians on Contract Percent of Active Staff Board Certified Number of Active Staff Members per Bed Ratio of Outpatient Visits per Bed Percent of Noncontract Physicians with Major Professional Activity in Your Hospital Percent Nonactive Staff Physicians Percent of Active Staff Radiologists and Pathologists Percent of Active Staff in Generalist Care Percent of Medical Staff Committees with Nonphysician Voting Number of Meetings per Committee Number of Members per Committee Percent of Contract Active Staff Holding Committee Assignments Percent of Committees with a Quorum Requirement Number of Committees per Logarithm of Bed Size Percent of Committees for which Members are Appointed Percent of Departmental Chiefs Appointed Departments per Bed President of Medical Staff is on Governing Board Other Medical Staff Officers are on Governing Board Active Medical Staff are on Governing Board Physicians are on Executive Committee of Governing Board Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed Percent of Active Staff Funded for Research Number of Activities Involved with Outside HMOs *
I
I
III
IV
V
0.68 0.72
0.32
VI
VII
0.77
0.22
0.56
0.30
0.32
0.25
-0.22
0.37
-0.25 0.63
0.21
0.66 0.46 0.36
0.63 0.23 0.27 0.91 0.20
-0.28
0.23
0.37
-0.21
0.21
0.30 0.72 0.43 0.91
0.82
0.31 0.30 0.26
IX Commuality
-0.25 -0.58 0.45 0.40
0.42 0.55 0.20 0.34
VII
0.63
0.22
0.42
0.29
0.51 0.16
-0.66
0.27 -0.21
0.51 0.30
0.33 0.16 0.76
0.85 -0.35
0.21
0.52
-0.66 -0.30
-0.30 0.37 -0.22
0.43 0.51 0.34 -0.23 0.20 -0.26 -0.34 0.48 0.33 0.32
0.21
0.24
0.65 0.56
0.31
0.25 0.73
-0.22 0.26
0.21 0.26 0.52 0.13 0.08
0.28
0.22
0.64
0.48 0.35
0.38
0.25
0.20 0.55
0.41
0.19
0.48
0.24
0.62
0.40
0.42
0.19
0.36
0.13 0.06
0.09
The following variables, which were shown in Table 1, are deleted from Table 2 because they had a one to one correspondence with an individual value of another variable included in the analysis: Whether or not the Proportion of Maximum or Minimum Medical Staff Members Appointed to the Board is Specified, Percent of Department Chiefs on Contract, Medical Director Votes on Governing Board, and Director of Medical Education Votes on Governing Board. For example, Percent of Department Chiefs on Contract overlapped fully with Percent of Active Staff on Contract since all department chiefs are members of the active staff.
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tee (+); 5) number of members per committee (+); and 6) percent generalist care physicians (-). These results support the originally predicted Communication/Control dimension of staff structure built around committees. The negative loading of percent generalist care physicians (-.30) suggests less formally organized communication and control in hospitals with a higher percentage of generalist care physicians. The fourth factor is comprised of 1) number of active staff physicians per bed (-); 2) percent of noncontract physicians with major professional activity at the hospital (+); 3) percent generalist care physicians (+); and 4) percentage of physicians not on the active medical staff (+). This factor is difficult to label but the results suggest that a lower ratio of active staff physicians per bed is associated with a higher percentage of noncontract physicians having their major professional activity at the hospitals, with a higher percentage of generalist care physicians, and with a higher absolute percentage of nonactive physicians. Taken together, this factor would appear to be measuring a "local orientation" of medical staff in that, while active staff size per bed is low, it is comprised primarily of generalists who focus most of their activity at the one hospital. Factor V consists of 1) active medical staff members on the hospital governing board (+); 2) medical staff officers on the hospital governing board (+); 3) medical staff members on the executive committee of the governing board (+); 4) president of the medical staff on the governing board (+); and 5) physician governing board members elected by the medical staff (+). These findings support the predicted dimension of Participation in Decision Making. Factor VI is composed of 1) ratio of radiologists and pathologists to other active staff physicians (+); and 2) per-
centage of active staff on contract (+). These findings suggest a more "hospitalbased specialist contractual orientation" in contrast to the "generalist orientation" of Factor II. Factors VII, VIII, and IX are composed of many of the same items as are Factors I and II, and reflect nonlinearities and random variation in the data. For these reasons, they are excluded from further discussion.
Discussion Table 3 summarizes the empirically derived factors. The results support a mutidimensional view of medical staff structure consistent with the results found in the general organizational literature by Pugh et al. [18], Hage and Aiken [26], and Reimann [20]. Comparison of Table 3 with Table 1 predictions indicates support for some of the originally hypothesized dimensions, further elaboration of others, and no support for still others. Factors related to "resource capability," "communication/control," and "participation in decision making," are supported, although the resource capability factor could be labeled "sizeteaching capability." There is no support for separate formalization, centralization, or primary care orientation dimensions. Neither do the items comprising formalization or centralization load strongly or consistently on any of the derived factors, although there is some suggestion that centralization is associated with resource capability (sizeteaching) and with communication/ control. In regard to primary care orientation, the percentage of generalist care physicians on contract loads strongly on Factor II but such other aspects as HMO involvement are not related to this factor and, in fact, do not load strongly on any factor. Of particular importance is the lack
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Table 3: Summary of Empirically Derived Factors of Hospital Medical Staff Organization Structure Factors
Resource (Size-Teaching) Capability
Generalist Physician Contractual Orientation
Communication/Control
Local Staff Orientation
Participation in Decision
Making
Hospital-Based Specialist Contractual Orientation
Variables
Number of Interns and Residents per Bed Hospital Bed Size Number of Services and Benefits Provided to Active Staff Number of Members per Committee Existence of a Director of Medical Education Percent of Active Staff in Generalist Care Percent of Contract Staff on Salary Percent of Active Staff Board Certified Percent of Departmental Chiefs Appointed Number of Active Staff Members per Bed Percent of Generalist Care Physicians on Contract Percent of Active Staff on Contract President of Medical Staff on Contract Number of Services and Benefits Provided to Active Staff Number of Interns and Residents per Bed Percent of Contract Staff on Salary
Committees per Logarithm of Bed Size Percent of Committees for which Members are Appointed Number of Meetings per Committee Percent of Medical Staff Committees with Nonphysician Voting Number of Members per Committee Percent of Active Staff in Generalist Care
Number of Active Staff Members per Bed Percent of Noncontract Physicians with Major Professional Activity in Your Hospital Percent of Active Staff in Generalist Care Percent of Nonactive Staff Physicians
Factor Loading 0.72 0.68
0.55 0.52 0.42 -0.35 0.34 0.31 0.31 0.30 0.91 0.72 0.43
0.37 0.32 0.30 0.65 0.56 0.51
0.43 0.34 -0.30 -0.66 0.51 0.37 0.30
Active Staff are on Governing Board Other Medical Staff Officers are on Governing Board Physicians are on Executive Committee of Governing Board President of Medical Staff is on Governing Board Physicians are Elected to the Governing Board by the Medical Staff rather than Appointed
0.62 0.48
Percent of Active Staff Radiologists and Pathologists Percent of Active Staff on Contract
0.85 0.63
0.42 0.41 0.36
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of a single factor that might be termed "hospital commitment." Roemer and Friedman's measure of the "percentage of physicians on contract" does not appear to be related to the notion of hospital commitment since, in Factor II, such measures as the "percentage of noncontract physicians with major professional activity in your hospital" actually load negatively on the factor for which "percentage of contract physicians" is positively loaded. There are, however, strong interrelationships among the contractual physician measures themselves suggesting that they represent a* separate dimension of medical staff organization structure in their own right. In fact, the present results suggest that it is important to distinguish between two dimensions: the first (Factor II) related to "generalist physician contractual orientation," and the second (Factor VI) related to "hospital-based specialist contractual orientation." While "percentage of physicians on contract" may not be a valid measure of hospital commitment, this does not imply that contracts have no influence on physician behavior. For example, contracts which offer physicians a percentage of gross departmental revenue offer an incentive to provide more overall services. Contracts involving a percentage of net revenue offer some incentive for physicians to contain costs and to select those procedures and services which maximize the difference between marginal revenue and marginal costs. Physicians under straight salary arrangements have neither an incentive to increase services rendered, nor an economic incentive to control costs. In addition to these revenue-producing and cost containment considerations, it might be argued that hospitals can more legitimately claim time to serve on various committees from contract physi-
cians than from medical staff members not under contract. None of the above, however, suggest that "percentage of contract physicians" is a measure of hospital staff commitment. A better overall behavioral indicator of commitment is the percentage of physicians who actually admit most of their patients to a given hospital. Further insight into the factor structure was obtained by examining the correlations among the factors. The factors were essentially uncorrelated with each other; the highest correlation was that of "resource capability" with "generalist physician contractual orientation" (r = .29). In brief, the results suggest six relatively separate factors of medical staff organization structure. Resource capability is the dominant factor. There is no support for a structural dimension of hospital commitment. Contractual orientation did emerge but in two separate although somewhat related factors: a "generalist physician contractual orientation" and a "hospital-based specialist contractual orientation." Distinct factors also emerge for "communication/control" and "participation in decision making." In contrast to much of the existing organizational literature, there was no support for separate dimensions of formalization or centralization. This may be due to the limited measures of these dimensions available from the data. Suggestions for further analysis and potential uses of the above dimensions are discussed below. Future Research and Potential Policy Significance The data examined here represent the only comprehensive set of data available on medical staff organization. As such, they are uniquely valuable for conducting comparative research on nearly all U.S. hospitals. If updated and supplemented from time to time, they
Staff Organization Structure can serve as a useful barometer of changing medical staff organization structure and its relationship to costeffective patient care practices in response to such factors as Professional Standards Review Organizations (PSROs), multiunit hospital systems, continued vertical integration of hospital services, changing standards of patient care, legal decisions, and continued advances in technology. The data base also has the advantage that it contains structural measures similar to those used by previous investigators, and the present analysis has added further knowledge concerning the validity of those measures with suggestions for further elaboration as well as some new leads. The data base, of course, does not contain all of the measures one would necessarily use to measure medical staff organization structure nor are physician perceptions of staff structure included. Present analysis clearly indicates the need for further work in measuring centralization and formalization. But given the cost, time, and related problems in collecting such information, the present data are sufficiently comprehensive to be useful in a number of ways. First, an empirical typology of hospital medical staff organization structures might be developed based on the dimensions which emerged from the present analysis. Of particular interest would be the delineation of the different types of medical staff organization structure by hospital ownership (federal, state, local, voluntary, for profit, etc.) and region of the country. For example, large regional differences in average length of patient stay exist between the east and west coasts. Differences in physician education and training apparently do not explain such differences. There is some suggestion that they may be partially related to occupancy rates [31]. But the question
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might also be raised as to whether or not some of the differences might be due to medical staff organization structures differing between regions. The impact of medical staff organization structure on hospital costs and quality of care is an important area for investigation, particularly given the continued implementation of PSROs. For example, hospitals with medical staffs scoring high on the resource capability dimension may have both higher costs and higher quality. Generalist physician contractual orientation may be associated with lower costs, and also may be an indicator of growing hospital involvement in ambulatory and hospital sponsored primary care. Based on previous research [6] there is some suggestion that the coordination and control dimensions might be associated with lower costs and higher quality. Local staff orientation may be associated with both lower costs and lower quality along with a possible tendency to be less innovative in adoption of new technology and patient care practices. Previous research [12] also suggests that physician participation in decision making may be associated with lower costs. Finally, hospitalbased contractual orientation may be associated with higher costs as suggested by a recent study indicating that hospital-based remuneration represents a significant portion of total direct costs in radiology and pathology departments [351. With few exceptions, little is known about any of these suggested relationships. Classification of hospital medical staff organization structures could also be useful in evaluating prospective reimbursement experiments and related cost containment strategies. Do hospitals placed in different categories for purposes of prospective reimbursement exhibit different medical staff organization structures? What is the
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relationship between medical staff organization structure and case mix? These are important questions from a practitioner and policy viewpoint because all the dimensions identified contain variables under the control of hospital governing boards, medical staffs, and administrators, and can be changed to improve performance. Individual measures of the hospital medical staff organization dimensions are also of interest. For example, what are the third party reimbursement and cost implications of adding more salaried physicians? In regard to hospitalbased contract physicians, a recent court ruling has indicated the right of state rate review commissions to review hospital-based doctors [32]. Further, preliminary evidence suggests that for the same diagnosis and set of patient characteristics, charges per case are lower if the attending surgical specialist is board certified than if he is not
[33].
Still another set of considerations is related to a recent Institute of Medicine report examining the specialty mix, specialty ratios, number of foreign medical graduates, and methods of payment in teaching hospitals [34]. How is medical staff organization structure affected by
these considerations and, in turn, what is the relationship to educational activities and patient care practices? It is increasingly clear that physician behavior, particularly within the context of the hospital, is being subjected to external controls. A fundamental issue in American health care delivery is the degree to which a satisfactory level of institutionalization and bureaucratization of medical practice can be attained with regard to access, cost, quality, continuity, and both patient and provider satisfaction. Medical staff organization is a central aspect of this issue and the dimensions developed in the present analysis provide conceptual and empirical referents for further investigations.
ACKNOWLEDGEMENTS. Appreciation is expressed to the Vice President's Office of the American Hospital Association for providing the data on which this analysis is based. The conclusions and judgments expressed are the sole responsibility of the authors. Appreciation is also expressed to Vandan M. Trivedi, Ph.D., and George Bugbee for their comments on an earlier draft of this paper.
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8. Becker, S. and D. Neuhauser. The Efficient Organization. New York: El Sevier Press, 1975. 9. Roemer, M.I. and J. Friedman. Doctors in Hospitals: Medical Staff Organization and Hospital Performance. Baltimore: Johns Hopkins Press, 1971. 10. Schultz, R. Physicians on boards: Survey examines level, extent of participation. Hospitals 46(24):51, Dec. 16, 1972. 11. Scott, W.R., W.H. Forrest, Jr. and B.W. Brown, Jr. Hospital Structure and Post Operative Mortality and Morbidity. In S.M. Shortell and M. Brown (eds.), Organizational Research in Hospitals, pp. 72-89. Chicago: Blue Cross Association, 1976. 12. Shortell, S.M., S. Becker and D. Neuhauser. The Effects of Management Practices on Hospital Efficiency and Quality of Care. In S.M. Shortell and M. Brown (eds.), Organizational Research in Hospitals, pp. 90-107. Chicago: Blue Cross Association, 1976. 13. Medical Administrative Teaching and Research Advisory Group. Patterns of medical staff organization. The School of Health Administration, The University of New South Wales, Australia, June 1975. 14. Weber, M. The Theory of Social and Economic Organization. Translated by A.M. Henderson and T. Parsons. New York: The Free Press, 1946. 15. Blau, P. The hierarchy of authority in organizations. American Journal of Sociology 73
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