The structural characteristics of health care organizations have received considerable attention since the early 1960s when Perrow (1961; 1965) and Gordon (1961; 1962) wrote about the relationships among the top management triangle. Despite dramatic changes in the industry since that time, the basic structure has changed little. Power is still more likely to be shared among administrators, medical staff and board members than concentrated in a managerial hierarchy (Morlock & Nathanson, 1983). Objectives held by each of these three groups still tend to be diverse and conflicting rather than congruent.
This combination of diverse goals and shared power suggests that decision making in these organizations may be more akin to the process observed in political and community settings than to the hierarchically determined process attributed to most types of organizations. That is, administrators in health care organizations may be constrained in their choice of actions by the preferences of other groups (Young & Saltman, 1985), and by the dominance of values that may act to the benefit of medical interests.
Get full access to this article
View all access options for this article.
References
1.
AllisonG. T. (1971). Essence of Decision: Explaining the Cuban Missile Crisis. Boston, MA: Little, Brown and Co.
2.
AltmanS.WeinerS. (1978). Regulation as a second best. In GreenburgW., ed., Competition in the Health Care Sector. Germantown, MD: Aspen.
3.
BacharachS. B.LawlerE. J. (1981). Bargaining: Power, Tactics, and Outcomes. San Francisco, CA: Jossey-Bass Publishers.
4.
BachrachP.BaratzM. S. (1962). ‘Two faces of power’, The American Political Science Review56 (4): 947–952.
5.
BachrachP.BaratzM. S. (1970). Power and Poverty. New York: Oxford University Press.
6.
BaldridgeJ. V. (1971). Power and Conflict in the University. New York: John Wiley.
7.
BauerK. G. (1977). ‘Hospital rate setting — this way to salvation?’ Milbank Memorial Fund Quarterly55 (1): 117–157.
8.
CyertR. M.MarchJ. G.1963. A Behavioral Theory of the Firm. Englewood Cliffs, NJ: Prentice-Hall.
9.
EmersonR. M. (1962), ‘Power-dependence relations’, American Sociological Review27: 31–41
10.
EnthovenA. (1983). As quoted in The Blue Sheet — Health Policy and Biomedical Research News of the Week26 (2): 4.
11.
FreidsonE. (1970). Professional Dominance: The Social Structure of Medical Care. Chicago, IL: Aldine Publishing Co.
12.
GamsonW. (1968). Power and Discontent. Homewood, IL: Dorsey.
13.
GordonP. J. (1961). ‘The top management triangle in voluntary hospitals (I)’, Journal of the Academy of Management4 (3): 205–214.
14.
GordonP. J. (1962). ‘The top management triangle in voluntary hospitals (II)’, Journal of the Academy of Management5 (1): 66–75
15.
GossM. E. W. (1963). ‘Patterns of bureaucracy among hospital staff physicians’, in FreidsonE. (ed), The Hospital in Modern Society. London: The Free Press of Glencoe.
16.
HarrisJ. E. (1977). ‘The internal organization of hospitals: some economic implications’, Bell Journal of Economics8: 467–482.
17.
HollisterR. M.KramerB. M.BellinS. S. (eds), Neighborhood Health Centers. Lexington, MA: Lexington Books.
18.
The Johns Hopkins Health Services Research and Development Center. (1981). ‘Decision-making patterns and hospital performance.’ Bulletin4: 1–3
19.
JohnsonR. L. (1979). ‘Revisiting the “wobbly three-legged stool”’, Health Care Management Review4 (3): 15–22.
20.
LukesS. (1974). Power: A Radical View. New York: Macmillan Press Ltd.
21.
MarchJ. G. (1966). ‘The power of power’, in EastonD. (ed). Varieties of Political Theory. Englewood Cliffs, NJ: Prentice-Hall.
22.
MarchJ. G.SimonH. A. (1958). Organizations: New York: John Wiley.
23.
MayJ. T.DurhamM. L.NewP. K. (1980). ‘Professional control and innovation: the neighborhood health center experience.’ In RothJ. A. (ed), Research in the Sociology of Health Care, Volume I. Greenwich, CT: JAI Press.
24.
MintzbergH. (1979). The Structuring of Organizations. Englewood, NJ: Prentice-Hall.
25.
MorlockL. L.NathansonC. A. ‘Power and influence’, in ShortellS. M.KaluznyA. D. (eds), Health Care Management. New York: John Wiley & Sons.
26.
MunsonF. C.HancockW. M. (1972). ‘Problems of implementing change in two hospital settings’, AIEE Transactions4 (4): 258–266.
27.
PerrowC. (1961). ‘The analysis of goals in complex organizations’, American Sociological Review26: 854–866.
28.
PerrowC. (1965). Hospitals, technology, structure and goals. In MarchJ. G. (ed). Handbook of Organizations. Chicago, IL: Rand McNally and Co.
29.
PettigrewA. M. (1973). The Politics of Organizational Decision-Making. London: Tavistock.
30.
PfefferJ. (1981). Power in Organizations. Marshfield, MA: Pitman Publishing Inc.
31.
SaltmanR. B.YoungD. S. (1981). ‘The hospital power equilibrium: an alternative view of the cost containment dilemma’. Journal of Health Politics, Policy and Law6 (3): 391–418.
32.
SchattschneiderE. E. (1960). The Semi-Sovereign People: A Realist's View of Democracy in America. New York: Holt, Rinehart & Winston.
33.
ScottW. R.1972. Professionals in hospitals: technology and the organization of work. In GeorgopoulosB. S. (ed), Organization Research in Health Institutions. Ann Arbor, MI: The Institute for Social Research.
34.
StraussA. (1978). Negotiations: Varieties, Contexts, Processes and Social Order. San Francisco. Jossey-Bass Publishers.
35.
StraussA.SchatzmanL.EhrlichD.BucherR.SabshinM. (1963). ‘The hospital and its negotiated order’, in FreidsonE. (ed), The Hospital in Modern Society. New York: The Free Press.
36.
ThompsonJ. D. (1967). Organizations in Action. New York: McGraw-Hill Co.
37.
WeinerS. L.MaxwellJ. H.SapolskyH. M.DunnD. L.HsiaoW. C. (1987). ‘Economic incentives and organizational regularities: Managing hospitals under DRGs’, The Milbank Quarterly65 (4): 463–487.
38.
WeisbordM. R. (1976). ‘Why organization development hasn't worked (so far) in medical centers’, Health Care Management Review1 (2): 17–28.
39.
YoungD. W.SaltmanR. B. (1985). The Hospital Power Equilibrium: Physician Behavior and Cost Control. Baltimore: The Johns Hopkins University Press.
