Lesson 11
Health Care Managers
INTRODUCTION: THE NEED FOR PROFESSIONAL MANAGEMENT
Effective management of health care organizations and of the considerable resources at their disposal requires competent managers. Like their counterparts in any organization, health services managers are responsible for facilities, services, finances, and relations with other organizations.
The job of managing a health facility has become highly complex due to the many advances in medical technology and the emergence of dozens of specialty health professions, together with significant changes in consumer expectations, business practices, and health care financing. As a result, the need for professional managers continues to grow.
Contributing to the need for professional management is the extensive oversight and scrutiny to which health facilities are subject. Both past performance and plans for the future are subject to review by a variety of groups and organizations, including consumer groups, government agencies, professional oversight bodies, insurance companies, and other third-party payers, business coalitions, and even the courts. Preparing for inspection visits by observers from regulatory bodies and submitting appropriate records and documentation can be time-consuming as well as technically demanding.
WORK DESCRIPTION OF HEALTH SERVICE MANAGERS
Health service manager is an inclusive term for individuals in many different positions who plan, organize, and coordinate the delivery of health care. Hospitals provide more than half the jobs in this field. Other places that employ health services managers include medical group practices, outpatient clinics, HMOs, nursing homes, hospices, home health agencies, rehabilitation centers, community mental health centers, emergency care centers, diagnostic imaging centers, and offices of doctors, dentists, and other health practitioners.
Three functional levels of administration are found in hospitals and other large facilities--executive, internal management, and specialized staff. The Executive Director provides overall management direction, but is concerned with community outreach, planning, policymaking, response to government agencies and regulations. The job often includes speaking before a civic group, promoting public participation in health programs, and coordinating the activities of the organization with those of government or community agencies. Institutional planning is an increasingly important responsibility of chief administrators who must assess the need for services, personnel, facilities, and equipment and recommend such changes as shutting down a maternity ward, for example, or opening an outpatient clinic.
Chief administrators need ability as well as technical skills in order to respond effectively to community requirements for health care while at the same time satisfying demand for financial viability, cost containment, and public and professional accountability. Within a single institution such as a community hospital the health care administrator is directly responsible to a board of trustees, and community leaders who are voted into office to determine broad policies and objectives for the hospital.
Day-to-day management, particularly in large facilities, may be the responsibility of one or more associate or assistant administrators, who work with service unit managers and staff specialists. Depending on the size of the facility, associate or assistant administrators may be responsible for budget and finance; human resources, including personnel administration, education, and in-service training; information management; and direction of the medical, nursing, ancillary services, housekeeping, physical plant, and other operating departments. As the health care system becomes more specialized, skills in financial management, systems analysis, and labor relations are needed as well.
Hospital and nursing home administration differ in important aspects. Hospitals are complex organizations, housing as many as 30 highly specialized departments such as admissions, surgery, clinical laboratory, therapy, emergency medicine, nursing, physical plant, medical records, accounting, and so on. The hospital administrator works with the administering board in establishing general policies and operating philosophy and provides direction to assistant administrators (or vice-presidents, as they may be called) and department heads who carry out those policies. The administrator coordinates the activities of the assistant administrators and department heads to ensure that the hospital runs efficiently, provides high-quality medical care, and recovers adequate revenue to remain solvent or make a profit.
Administrators represent the health institution to the community and the State. Nationally, they participate in association memberships such as the American Hospital Association, the American Public Health Association, and the Association of Mental Health Administrators.
Nursing home administrators need many of the same management skills. However, administrative staffs in nursing homes are typically much smaller than those in hospitals. Nursing home administrators often have only one or two assistants, sometimes none. As a result, nursing home administrators are involved in detailed management decisions much more than hospital administrators in all but the smallest hospitals. They wear various hats--personnel director, director of finance, director of facilities, admissions' director, for example--analyzing data and then making daily management decisions in all of these areas. In addition, because many nursing home residents are long-term, staying for months or even years, administrators must try to create an environment that nourishes residents' psychological, social, and spiritual well-being, as well as tending to their health care needs.
In the growing field of group practice management, managers need to be able to work effectively with the physicians who own the practice. Specific job duties vary according to the size of practice. While an office manager handles the business side in very small medical groups, leaving policy decisions to the physicians themselves, larger groups generally employ a full-time administrator to advise on business strategies and coordinate the day-to-day management of the practice.
A group of 10 or 15 physicians might employ a single administrator to oversee personnel matters, billing and collection, budgeting, planning, equipment outlays, advertising, and patient flow, whereas a practice of 40 or 50 physicians would require a chief administrator and several assistants, each responsible for a different area of management. In addition to providing overall management direction, the chief administrator is responsible for ensuring that the practice maintains or strengthens its competitive position. This is no small task, given the rapidly changing nature of the health care environment. Ensuring competitiveness might entail market research to analyze the services the practice currently offers and those it might offer, negotiating contracts with hospitals or other health care providers to gain access to specialized facilities and equipment, or entering joint ventures for the purchase of an expensive piece of medical equipment such as a magnetic resonance imager.
Managers in HMOs perform all the functions of those in large medical group practices, and one additional function--that of an insurance company. HMO subscribers pay an annual fee that covers almost all care. HMO managers must establish a comprehensive medical benefit package with enrollment fees low enough to attract adequate enrollments but high enough to operate successfully.
WORKING CONDITIONS
Health services managers often work long hours. Facilities such as nursing homes and hospitals operate around the clock, and administrators and managers may be called at all hours to deal with emergencies. The job may include travel to attend meetings or to inspect health care facilities.
EMPLOYMENT OPPORTUNITIES
Health services managers hold 300,000 jobs. More than half of all jobs are in hospitals, as the following shows:
Hospitals 52%
Nursing homes 18%
Offices of physicians 10%
Outpatient facilities 7%
Offices of dentists 2%
Medical and dental laboratories 2%
Offices of other health practitioners 2%
Other 4%
EDUCATION, OTHER QUALIFICATIONS, AND ADVANCEMENT
As is generally true with managerial jobs, most entrants transfer from other occupations. Knowledge of management principles and practices is the essential requirement for a position in this field, and such knowledge often is gained through work experience. Nonetheless, formal educational preparation is important, especially for those who wish to advance in the profession. For many positions, a graduate degree in health services administration, nursing administration, or business administration is a decided asset. For others, a degree in finance, personnel administration, or public administration provides an appropriate background. Some employers want applicants who have had clinical experience, like nurses and therapists, as well as academic preparation in business or health services administration.
Many hospitals are setting up separate ventures such as outpatient surgical centers, alcoholism treatment centers, and home health care services. When they operate at a profit, separate companies such as these can funnel needed revenue to the hospital. To operate and manage these subsidiary companies, hospitals, or the corporations that run them, are looking outside the health industry for managers with well-established skills in profit-and-loss analysis, marketing, and finance. Nonetheless, graduate education in health services administration remains a prerequisite for many upper-level positions in hospitals and their subsidies.
Academic programs in health administration, leading to a bachelor's, master's, or doctoral degree, are offered by colleges, universities, and schools of public health, allied health, and business administration. The various degree programs provide different levels of career preparation. The master's degree in hospital administration, health administration, or public health, is regarded as the standard credential for many positions in this field. Educational requirements vary with the size of the organizations and the amount of responsibility involved. Generally, larger organizations require more specialized academic preparation than smaller ones do.
Many colleges and universities offer bachelors' degree programs in health services administration. About 70 schools have programs leading to the master's degree in hospital or health services administration; 11 of these programs are in schools of public health, some schools offer joint degree programs leading to a master's in business administration.
To enter graduate programs, applicants must have a bachelor's degree, with courses in natural sciences, psychology, sociology, statistics, accounting, and economics. Competition for entry to these programs is keen, and applicants need above-average grades to gain admission. The programs generally last between two and three years. They include up to one year of supervised administrative experience, undertaken after completion of coursework in such areas as hospital organization and management, accounting and budget control, personnel administration, strategic planning, and management of health information systems.
New graduates with masters' degrees in health or hospital administration may be hired by hospitals as assistant administrators or, more often, as department heads or project directors. Postgraduate residencies and fellowships are offered by hospitals and other health facilities; these are normally staff jobs.
Growing numbers of graduates from masters' degree programs are taking jobs in HMOs, large group medical practices, multi facility nursing home corporations, and clinics. Students should be aware, however, that mid-level job transfers from one setting to another might be difficult. Employers place a high value on experience in similar settings because some of the management skills are unique to each setting.
Relatively few masters' degree recipients take administrative positions in nursing homes of life-care communities, although graduates of a small number of long-term care administration programs generally do so. Many nursing home administrators pursue graduate education while employed.
New recipients of bachelors' degrees in health administration usually begin their careers as administrative assistants or assistant department heads in larger hospitals, or department heads or assistant administrators in small hospitals or nursing homes.
The Ph.D. is usually required for a position in teaching, consulting, or research. Nursing services administrators are usually chosen from among supervisory registered nurses with administrative abilities and advanced education.
Licensor is not required in most areas of health services management, except for a nursing home or long-term care administration. Sixteen States currently require two years of college and an associate degree for licensor, while 25 require a bachelor's degree. All States and the District of Columbia require these administrators to pass a licensing examination, and most students prepare for it by completing a special course of study. These preparatory courses, usually consisting of 100 to 200 hours of study in long-term care administration, are available through some colleges, universities, and home study programs. The licensing examination covers principles of administration; management of a long-term care unit; environmental health and safety; and medical, psychological, and social aspects of patient care. More than half the States require applicants to complete an internship known as an administrator-in-training program before taking the licensor examination. The internship generally lasts one year and is supervised by a licensed administrator. Since requirements vary from State to State, persons considering a career in long-term care administration should investigate licensing requirements where they wish to work.
Health services managers are often responsible for millions of dollars' worth of facilities and equipment and hundreds of employees. To make effective decisions, they need to be open to different opinions and good at sifting through contradictory information. To motivate subordinates to implement those decisions, they need strong leadership qualities. Interpersonal skills are important in all settings, but nowhere more so than in medical groups where success depends on developing a good working relationship with the physicians-owners. Tact, diplomacy, and communication skills are essential.
Like their counterparts in other kinds of organizations, health service managers need to be self-starters. In order to create an atmosphere favorable to good patient care, they must like people, enjoy working with them, and be able to deal effectively with them. They should be good at public speaking.
Health services managers may advance by moving into more responsible and high-paying positions within their own institution, or by shifting to another health care facility or organization. Advancement occurs with promotion to successively more responsible jobs such as an assistant or associate administrator, and, finally, chief executive officer (CEO). Health services managers sometimes begin their careers in small hospitals in positions with broad responsibilities, such as an assistant administrator.
Outside the more traditional avenues of advancement, many managers take staff positions with the Veterans Administration, U.S. Public Health Service, or State or local public health departments. Others find positions with voluntary health agencies such as the American Cancer Society or with trade and professional associations in the health care field. A growing number of jobs are available with firms that provide health management services on a contract basis. Jobs are available in health planning agencies and professional review organizations. Individuals with academic training/experience in health administration are well suited for such positions.
JOB OUTLOOK