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UBC Theses and Dissertations

Strategic planning in a small community health care setting Hatlevik, Norman M. 1983

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STRATEGIC PLANNING-IN A SMALL COMMUNITY HEALTH CARE SETTING By NORMAN M. HATLEVIK B . A . Commerce and E c o n o m i c s , H o n o r s Simon F r a s e r U n i v e r s i t y , 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF MEDICINE (Depar tment o f H e a l t h C a r e and E p i d e m i o l o g y ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d . D r . V a n c e M i t c h e l l D r . C . J . G . M a c K e n z i e M r . L . F. D e t w i l l e r THE UNIVERSITY OF BRIT ISH COLUMBIA May, 1983 ® Norman M. H a t l e v i k , 1983 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of H e a l t h Ca re & E p i d e m i o l o g y The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 D a t e September 16 , 198? DE-6 (3/81) ABSTRACT T h i s s t u d y p r o v i d e s an o v e r v i e w o f t h e s t r a t e g i c p l a n n i n g p r o c e s s and p r e s e n t s t h e h y p o t h e s i s t h a t s t r a t e g i c p l a n n i n g i s n o t o n l y a p p l i c a b l e t o a s m a l l , communi ty h e a l t h s e t t i n g b u t e s s e n t i a l . The p a p e r d i s c u s s e s t h e p r e s e n t s i t u a t i o n w h i c h h o s p i t a l s , e s p e c i a l l y s m a l l communi ty h o s p i t a l s , f i n d t h e m -s e l v e s i n and a t t e m p t s t o d e t e r m i n e i f t h e s t r a t e g i c p l a n n i n g p r o c e s s c a n o f f e r a d v o c a c y p r e s c r i p t i o n s and a f o r m a t f o r s u r v i v a l . I t i s a i m e d a e n c o u r a g i n g a p r a c t i c a l i n t e r e s t i n t h e t h e o r e t i c a l s t r a t e g i c p l a n n i n g p r o c e s s . W h i l e t h i s i s n o t a " m o d e l - b u i l d i n g " e x e r c i s e , t h e i s s u e s d i s c u s s e d a r e o f c o n c e r n t o b o t h t h e t h e o r y b u i l d e r and t h e p r a c t i t i o n e r . An a t t e m p t i s made t o go beyond t h e e x i s t i n g l i t e r a t u r e on s t r a t e g i c p l a n n i n g t o a d i s c u s s i o n o f t h e i n t r i n s i c , i n d i r e c t o r " i n v i s i b l e " f a c t o r s p e c u l i a r t o t h e p r o c e s s and t o h o s p i t a l s , f a c t o r s w h i c h a r e c r i t i c a l and r e q u i r e t h e a t t e n t i o n o f b o a r d s and a d m i n i s t r a t o r s . W h i l e t h e s t u d y attempts t o s i m p l i f y t h e s t r a t e g i c p l a n n i n g p r o c e s s , t h e a d d i t i o n a l d i s c u s s i o n and e m p h a s i s on t h e s e " i n d i r e c t " f a c t o r s may a p p e a r t o make t h e a t t e m p t e d t r a n s i t i o n f r o m t h e o r y t o p r a c t i c e more f o r e b o d i n g a p r o c e s s t h a n i t i s . T h i s s t u d y i s d e v e l o p e d by way o f a l i t e r a t u r e r e v i e w and c a s e s t u d y a n a l y s i s . The Case S t u d y d e s c r i b e s how one s m a l l communi ty h o s p i t a l became c o n c e r n e d a b o u t t h e i r c a p a b i l i t i e s - i i i - -v o f d e a l i n g w i t h t h e p o l i t i c a l and e c o n o m i c f o r c e s t h a t wou ld a f f e c t t h e f u t u r e o f t h e i r f a c i l i t y and how t h e y d e v e l o p e d a s t r a t e g i c p l a n n i n g a p p r o a c h d e s i g n e d t o e n s u r e t h e s u r v i v a l o f t h e i r comm-u n i t y o r g a n i z a t i o n . The d o m i n a n t r o l e f o r b o t h t h e B o a r d and A d m i n i s t r a t i o n became one o f s t r a t e g i c p l a n n e r s . P a r t One p r o v i d e s an o v e r v i e w o f t h e h e a l t h c a r e s y s t e m and t h e c u r r e n t i s s u e s t h a t a r e c o n f r o n t i n g t h e s y s t e m . P a r t Two b r i e f l y d e s c r i b e s t h e h o s p i t a l i n d u s t r y and d i s c u s s e s t h e c o m p l e x i t y o f h o s p i t a l s . P a r t T h r e e d e s c r i b e s t h e c h a r a c t e r i s t i c s o f s m a l l communi ty h o s p i t a l s . P a r t Fou r d i s c u s s e s t h e " s t a t e o f t h e a r t " o f p l a n n i n g i n t h e h o s p i t a l i n d u s t r y . P a r t F i v e p r o v i d e s a d e f i n i t i o n o f s t r a t e g i c p l a n n i n g and d e s c r i b e s s p e c i a l c o n s i d -e r a t i o n s . The r e a d e r i s t a k e n t h r o u g h t h e s t r a t e g i c p l a n n i n g p r o c e s s i n a s t e p - b y - s t e p manner. I t i s i n t h i s s e c t i o n d u r i n g d i s c u s s i o n o f t h e r o l e s o f t h e main p l a y e r s t h a t t h e many " i n v i s i b l e " f a c t o r s a r e i l l u m i n a t e d . P a r t Seven p r e s e n t s t h e Case S tudy and a t t e m p t s t o a p p l y t h e o r y t o p r a c t i c e . P a r t E i g h t p r o v i d e s c o n c l u d i n g comments on t h e a p p l i c a t i o n o f t h e s t r a t e g i c p l a n n i n g p r o c e s s i n a s m a l l , communi ty h o s p i t a l . . The main h y p o t h e s i s o f t h i s s t u d y i s t h a t t h e o r e t i c a l s t r a t e g i c p l a n n i n g i s i n d e e d a p p l i c a b l e and i m p l e m e n t a b l e i n a s m a l l , cbmm-u n i t y h e a l t h c a r e s e t t i n g . I t was p r o p o s e d and found t h a t t h e o -r e t i c a l s t r a t e g i c p l a n n i n g c a n and d o e s a l l o w an o r g a n i z a t i o n t o p r e d i c t and i n f l u e n c e i t s f u t u r e . S i g n e d D r . V a n c e M i t c h e l l , P r o f e s s o r - i v ' - -TABLE OF CONTENTS PART PAGE A b s t r a c t i i T a b l e o f C o n t e n t s - ±v One H e a l t h C a r e i n Canada 1 O v e r v i e w and t h e I s s u e s Two The H o s p i t a l I n d u s t r y 5 - A C u r s o r y O v e r v i e w and t h e I s s u e s T h r e e S m a l l Community H o s p i t a l s 13 - D e f i n i t i o n , D e s c r i p t i o n , R o l e and P r o b l e m s F o u r H o s p i t a l P l a n n i n g 22 - D e f i n i t i o n , O v e r v i e w , S t a t e o f t h e A r t F i v e S t r a t e g i c P l a n n i n g - D e f i n i t i o n and P r o c e s s 32 - R o l e o f t h e C . E . O . 102 - R o l e o f t h e B o a r d o f D i r e c t o r s 1 1 6 - R o l e o f P h y s i c i a n s 126 - R o l e o f t h e C o n s u l t a n t 134 - R o l e o f P o l i t i c s 137 - R o l e o f I n v i s i b l e F a c t o r s 1 4 4 S i x C a s e S t u d y A n a l y s i s 153 Seven C o n c l u s i o n s 179 A p p e n d i c e s 186 F o o t n o t e s 22 3 B i b l i o g r a p h y 2 2 6 - 1 -Health Care i n Canada As the health care system i n Canada has improved the services offered are viewed as a r i g h t , not a p r i v i l e g e . This expect-a t i o n has re s u l t e d i n increased demands on the system that often exceed the a b i l i t y to d e l i v e r . The economic s i t u a t i o n of our country continues to d e t e r i o r a t e and a rev e r s a l does not seem imminent. The economic r e a l i t i e s are not leaving the health care system unscathed. Health care budgets, s p e c i f i c a l l y those of i n s t i t u t i o n s , are being cut throughout the country. One thing that can be said f o r sure i s that tomorrow and next year, things w i l l never be the same again i n the health care system. Governments are i n great f i n a n c i a l d i f f i c u l t i e s . The mag-nitude of government d e f i c i t s i s becoming unmanageable. The capacity of governments to levy more taxes has reached a l i m i t and governments are faced with extremely d i f f i c u l t p r i o r i t y dec-i s i o n s . While Federal and P r o v i n c i a l governments have come under public pressure f o r the current s i t u a t i o n , so too has i t become commonplace to c r i t i c i z e h o s p i t a l governments - the boards of d i r e c t o r s and h o s p i t a l managements - the senior administrative group. Health care costs are sending clear messages i n d i c a t i n g the need for lower cost health care a l t e r n a t i v e s and higher p r o d u c t i v i t y . - 2 -Combined w i t h t he d e m a n d / s u p p l y i s t h e f a c t a new e r a o f h e a l t h c a r e i s upon u s . The p o t e n t i a l i m p l i c a t i o n s o f t h e r i s i n g o v e r 65 p o p u l a t i o n , w h i c h i s p r o j e c t e d t o be a t 20% by t h e y e a r 2030, may i n d i c a t e an emergence o f c h r o n i c d i s e a s e as t h e d o m i n a n t p a t t e r n o f m o r b i d i t y . Our c o n v e n t i a l i n f e c t i o u s d i s e a s e t e c h -n o l o g i e s may be i l l - s u i t e d t o cope w i t h t h i s s h i f t . T h i s w i l l c r e a t e a g r e a t e r need f o r l o n g t e r m c a r e f a c i l i t i e s and a p p r o a c h e s , and more emphas is on g e r i a t r i c s . T h i s p r o b l e m w i l l be e x a c e r -b a t e d by t h e s h r i n k i n g o f t h e n u c l e a r f a m i l y and t h e i n c r e a s e i n l o b b y i n g p o t e n t i a l o f t h i s g r o u p . A l s o i n t h i s new e r a i s a s h i f t i n emphas is f rom c u r a t i v e c a r e t o p r e v e n t a t i v e c a r e and f r o m i n p a t i e n t c a r e t o o u t p a t i e n t c a r e w h i c h has c r e a t e d a g r o w i n g demand f o r home h e a l t h s e r v i c e s and t o h e l p p e o p l e s t a y out o f h o s p i t a l whenever p o s s i b l e and as l o n g as p o s s i b l e . The t r a d i t i o n a l r e l i a n c e on h i g h c o s t t e c h n o l o g y may c o n t i n u e u n a b a t e d even though t h e r e s u l t s o f s c i e n t i f i c a d v a n c e s may be d i m i n i s h i n g . That i s , many h e a l t h a u t h o r i t i e s b e l i e v e t h a t more d o c t o r s and more h o s p i t a l s w i l l have no more e f f e c t on good h e a l t h o v e r a l l t h a n t h e way p e o p l e l i v e , t h e i r l i f e s t y l e . The n e x t m a j o r a d v a n c e i n h e a l t h may r e s u l t o n l y f rom what e a c h i n d i v i d u a l p e r s o n i s w i l l i n g t o do t o a v o i d d e l e t e r i o u s p r a c t i c e s s u c h as s m o k i n g , e x c e s s i v e d r i n k i n g , e t c . T h i s b e l i e f i s d e s c r i b e d as t h e H e a l t h F i e l d C o n c e p t i n Marc L a l o n d e ' s (1974) "A New P e r s p e c t i v e on t h e H e a l t h o f C a n a d i a n s " , and i s s u p p o r t e d by D r . Thomas McKeown's (1975) m a s s i v e h i s t o r i c a l s t u d y o f t h e l e v e l s o f h e a l t h i n E n g l a n d and W a l e s . T h i s i n d i v i d u a l h e a l t h c o n s c i o u s n e s s may be - 3 -be brought i n t o play by economic default sooner than by p o l i t i c a l planning and s o c i a l change. With the economic pressures and changing needs, health care organizations, and ho s p i t a l s i n p a r t i c u l a r , have been coming under increasing s c r u t i n y to ensure that they are aimed i n sound d i r e c t i o n s . P r o v i n c i a l governments, i n l e g i s l a t i n g the health f i e l d , have undertaken the major and important r e s p o n s i b i l i t y of adequately funding the health care system and i n c r e a s i n g l y , these funding sources are demanding s t r i c t e r a c c o u n t a b i l i t y from health care organizations. A problem a r i s e s when a p r o v i n c i a l M i n i s t r y a r t i c u l a t e s i t s goals as increasing the e f f i c i e n c y and eff e c t i v e n e s s of the health system but does not have the management c a p a b i l i t i e s nor data bases to provide the means whereby these goals can be r e a l i z e d . The emphasis then becomes focused on ensuring that costs are contained (which i s not n e c e s s a r i l y the same as e i t h e r e f fectiveness or e f f i c i e n c y ) . The funding agencies paying f o r health care costs are assuming a more act i v e r o l e i n attempting to contain health care costs. These agencies, which are extensively involved i n paying, have watched demand soar and are now paying as much a t t -ention to costs as ensuring communities have an optimal mix of healt h care service a v a i l a b l e . They are beginning to r a i s e penetrating questions such as: what r e s u l t s have been achieved; and even i s there a r e a l need f o r the services provided by the organization? In addition, business, industry, and labour are becoming i n c r e a s i n g l y concerned about the costs of health-related - 1 -employee fringe b e n e f i t s . These pressures have created a rate of change i n the h e a l t h care industry which i s greater and accelerating at a more r a p i d pace than at any time i n recent h i s t o r y . They have combined to create a period of d i s c o n t i n u i t y i n the health care system and i n d i c a t e there are major problems ahead i n dealing with the environmental forces, forces that may a f f e c t the very nature of the health care system. The need to plan to s t a b i l i z e these environmental forces i s obvious. In past years, many "opportunities" to deal with these pressures and forces have been missed. By missed opportunities I r e f e r to the f a c t that a l l i n s t i t u t i o n s and h o s p i t a l s i n p a r t i c u l a r do not change focus or d i r e c t i o n when things are going w e l l . Planning does not r e a d i l y occur i n times of t r a n q u i l i t y . Change generally emerges from problems and c r i s e s . With the c r i s i s comes the opportunity to plan or to once again be missed out by assuming that we have muddled through so many s i m i l a r problems f o r so long that we cannot recognize that the c r i s i s i s r e a l . This type of coping i s no longer adequate nor appropriate. - 5 -The Hospital Industry "Every organization much achieve some primary goal, other-wise s o c i e t y w i l l not, i n the long run, support the organization. A l l organizations are chartered by society to perform an economic mission: to produce some good or service which i s wanted by people "outside", and to produce at a l e v e l of e f f i c i e n c y and e f f e c t -iveness that i s acceptable externally. Internal e f f i c i e n c y , as important as i t may seem, i s simply a means to a larger end -s o c i a l p r o d u c t i v i t y . This i s p a r t i c u l a r l y true of a h o s p i t a l which must render q u a l i t y patient care at a l e v e l of e f f i c i e n c y s a t i s f a c t o r y to patients and governing boards." ( 1 ) Hospitals, as organizations, can be characterized as extremely unique i n having a very p o l i t i c a l environment. It has often been said that h o s p i t a l s are labour or people intensive but that they are also very ego-intensive. With the types of i n d i v i d u a l s found i n the organization: administration, profess-i o n a l s t a f f and boards of d i r e c t o r s , a l l of whom are convinced that they a l l have the proper answers, the tendency f o r j u r i s -d i c t i o n a l disputes are almost everywhere. Besides the inherent aspects of the life-and-death struggles that go on i n h o s p i t a l s , i t i s also a place where s t a f f ' s emotions are subject to str e s s at a l l times. - 6 -A hospital's milieu i s unique and so are the variety of problems faced by employees. The following issues either occur more frequently or uniquely i n the health care industry compared to other industry: 1. Psycho-medical reactions: hypertension, "burn-out", depress-ion, psychosomatic illness and abuse of chemicals, specific-a l l y sedatives, barbiturates, opiates, and stimulants. 2. Rotating shift work. 3. Organizational change due to funding, technology, and programs. 4 . Social conflict as a product of stress among patients and staff. 5. Women's issues: working mothers, sexual harassment, struggles in career management and professional development. 6. Potential for violence as part of job: emergency department, psychiatric and chemical related i l l n e s s . 7. Death and illness as normal factors. ( 2 ) A hospital i s a d i f f i c u l t place to work, an almost impossible place to get consensus, and a tough place to manage and maintain direction. (3) Hospitals, by virtue of their mission; their uniqueness as organizations; the largest, most expensive and most visible segment of the health system* a r e open to considerable scrutiny, and are most susceptible to change. This i s understandable also as hospitals consume the largest part of the health care budget and they are the single greatest item i n v i r t u a l l y a l l provincial budgets, In B.C., from 1971 to 1981, the annual expenditure i n he a l t h has grown from $337 m i l l i o n to $2 b i l l i o n , an increase of 600%. H o s p i t a l s and physician s e r v i c e s account f o r 85 percent of t h i s budget. For decades they have been the centrepiece of the h e a l t h care system, and now t h e i r p o s i t i o n i s threatened as " t r a d i t i o n a l " ways of dealing with problems, both f i s c a l and s e r v i c e , are not l i k e l y to work and are often inappropriate. H o s p i t a l administrators and t r u s t e e s are being charged d a i l y , r e l e n t l e s s l y , and with malice to do more with l e s s , to do b e t t e r f o r l i t t l e economic or s o c i a l r e t u r n, to a point where they r e g u l a r l y apologize f o r actions taken i n the best i n t e r e s t s of the communities they serve. The concerns and e f f o r t s by boards and a d m i n i s t r a t i o n to reduce high cost i n p a t i e n t s e r v i c e s and to deal with dwindling u t i l i z a t i o n r a t e s have r e s u l t e d i n confusion about these t r a d i t i o n a l h o s p i t a l r o l e s . This confusion may simply be the f i n a l blow se a l i n g a f a t e that was predestined by improper s t r a t e g i c p o s i -t i o n i n g or r e p o s i t i o n i n g i n the 1950's, 60's, or 70's, a period when there was s t i l l growth and time to manoeuver. In the 1950's the s t r a t e g i c problem f o r many h o s p i t a l s was simply to r e a f f i r m that they were i n the acute care h o s p i t a l business and from time to time assess t h e i r weaknesses. Changes i n the environment were quite p r e d i c t a b l e , and those that d i d occur impacted on a c t i v i t i e s which management and board had always been concerned with such as: r a i s i n g money f o r c a p i t a l expend-i t u r e s , developing new programs, and attempting expansion. The - 8 -management too l s that were used for dealing with these environ-mental changes were not p a r t i c u l a r l y d i f f e r e n t from those they had always had. However, i n the 1960's and 1970's the changes that began to take place were often t o t a l l y unexpected, and the time to react to them was short. No one can predict with c e r t a i n t y what i s going to happen i n the 1980's and 1990's, but i t i s a reasonable hypothesis that changes i n the environment are going to occur, p a r t i c u l a r l y p o l i t i c a l and economic changes. In the 1980's we w i l l continue to see the trend that started i n 1970 with h o s p i t a l costs s t e a d i l y increasing and occupancy rates across Canada s t e a d i l y d e c l i n i n g . This condition of low u t i l i z a t i o n or "death beds" i s c r i p p l i n g some h o s i t a l s more than others and for small community hospitals too many empty beds for too long can si g n a l t h e i r doom. This declining census does not always r e f l e c t f a i l i n g health care for the problem may l i e i n t i r e d and out-dated h o s p i t a l p o l i c i e s and poor communication with employees, with doctors, with i t s community, and with the Mi n i s t r i e s of Health. Professional l i t e r a t u r e and the mass media are constant with t h e i r c r i t i c i s m s of health care's lack of a system to respond to changing s o c i e t a l needs. Most medical health f a c i l i t i e s seem to react to changes rather than to anticipate trends or the future. Too many decisions are apparently made without thorough analysis of the long-term impact of those decisions, causing a pre v a i l i n g posture of playing "catch-up" a l l the time. There are charges and counter-charges about the excess of h o s p i t a l beds, about dup-l i c a t i o n of expensive equipment, about unnecessary tests and surg-- 9 -i c a l procedures, about excessive lengths of stay, and about how a l l of these contribute to questionable patient care and the un-questionable s p i r a l i n g of costs. In turn, health care administrators, boards of trustees, and health associations describe t h e i r r o l e as one of putting out one f i r e a f t e r another, not quite sure what to expect from any of them. Often, we end up with a plethora of new programs, many of which are introduced simply to keep up with other health providers i n the industry. Hospitals often respond by resigning themselves to f a t e , and predict large numbers of unemployed, unserved health needs and economic r u i n . It becomes an easy out to blame the government, blame the union movement, blame the schools for turning out poor professionals - blame everything except where the blame properly should r e s t : i n themselves f o r lacking the s k i l l s of s t r a t e g i c planning. Hospitals can adopt a "seige" mentality and a strategy of consolidation, retrenchment, and preservation of " b a s i c s " as the f i r s t p r i o r i t y . One could say that h o s p i t a l s are programmed for stalemate. Their attempt to keep the demand f o r service at high l e v e l may not be appropriate when a l l l o g i c t e l l s us that e f f e c t i v e health care ought to reduce demand. Survival and growth, even for those who are strong and mature, cannot be taken f o r granted. Even the most dynamic organizations i n terms of d e l i v e r i n g today's services can q u i c k l y f i n d themselves ou* of business i f they neglect the s k i l l s of assessing and responding to the changing needs of t h e i r service areas. If h o s p i t a l s are to escape becoming the next v i c t i m of - 10 -" m a r k e t i n g m y o p i a " t h e y must d e v e l o p management r e s p o n s e s t h a t w i l l be new and d i f f e r e n t f r o m t h o s e u s e d i n t h e p a s t . I n d e e d , by t h e m id 1 9 8 0 ' s i t may become a p p a r e n t t h a t a m a j o r t a s k o f b o a r d s and management f o r t h e r e m a i n d e r o f t h e 1 9 8 0 ' s i s g o i n g t o be t o d e f e n d t h e l e g i t i m a c y o f t h e h o s p i t a l as t h e p r i n c i p a l s u p p l i e r f c r h e a l t h c a r e s e r v i c e s t o s o c i e t y . I t may w e l l be t h a t b o a r d s and management have t o d e v e l o p s t r a t e g i e s f o r s u r v i v a l o f t h e i r own h o s p i t a l s d e a l i n g w i t h t h e e c o n o m i c , s o c i a l and p o l i t i c a l e n v i r o n m e n t s t h a t a r e q u i t e d i f f e r e n t f rom any u s e d b e f o r e . C h o o s i n g t h e a p p r o p r i a t e s t r a t e g i e s t o d e a l w i t h government and o t h e r p a r t s o f t h e e n v i r o n m e n t i s t r u l y one o f t h e g r e a t e s t c h a l l e n g e s f o r management i n t h e n e x t d e c a d e . T h i s a p p r o a c h c a l l s f o r a d i f f e r e n t r e s p o n s e , one w h i c h i s p r o a c t i v e and l e s s e m o t i o n a l and a s k s how t o combat t h e s e c h a n g i n g c o n d i t i o n s . H o s p i t a l s must s t r a t e g i c a l l y p o s i t i o n t h e m s e l v e s t o adapt t o c h a n g i n g needs i n t h e i r community o r p a t i e n t m a r k e t and become c a t a l y s t s r e s p o n s i b l e f o r a l t e r n a t i v e d e l i v e r y s y s t e m s r a t h e r t h a n j u s t a p l a c e p e o p l e go t o d i e . H o s p i t a l s must be more a g g r e s s i v e i n t r y i n g t o c a p t u r e t h e o p i n i o n s o f t h e v a r i o u s p u b l i c s w i t h w h i c h t h e y d e a l . They c a n be t h e v e c t o r o r t h e v i c t i m o f s l o w p r o d u c t i v i t y , c o m p e t i t i o n , and r e g u l a t i o n . I t a l l depends upon t h e i r knowledge o f t h e needs o f t h e i r p a t i e n t m a r k e t and t h e i r w i l l i n g n e s s , d e s i r e and c a p a b i l i t y t o r e s p o n d t o t h e s e n e e d s . I n summary, h o s p i t a l s a l w a y s s u b j e c t t o a m i x t u r e t e c h n o l o g i c a l f o r c e s . Such a r e comp lex and dynamic s y s t e m s ; o f p o l i t i c a l , e c o n o m i c , s o c i a l and s y s t e m s do n o t r u n by t h e m s e l v e s , - 11 -t h e y must be u n d e r s t o o d , d e s i g n e d , i m p r o v e d , a d m i n i s t e r e d , and c o n t r o l l e d . I t r e q u i r e s p l a n n i n g , e i t h e r f o r m a l , o r i n f o r m a l , b u t a l w a y s c o n s c i o u s and d e l i b e r a t e . The c r i s i s f a c i n g them i s b a s i c a l l y a c o m b i n a t i o n o f : a p r o l o n g e d , p e r h a p s p e r m a n e n t , p e r i o d i n w h i c h r e s o u r c e s a r e d e c r e a s i n g ; f u n d i n g agency a l l o -c a t i o n d e c i s i o n s w i t h r e s p e c t t o t h e s e r e s o u r c e s a r e not s h i f t i n g t o w a r d h o s p i t a l b a s e d a c t i v i t i e s ; changes i n m e d i c a l p r a c t i c e ; e x p a n s i o n o f a l l i e d h e a l t h p r o f e s s i o n a l s ; changes i n t e c h n o l o g y ; c h a n g e s i n p o p u l a t i o n c o m p o s i t i o n ; and i n f l a t i o n . The way ou t o f t h e c r i s i s and a r o u n d t h e f i r s t r e p s o n s e o f t h e d e f e n s i v e p o s i t i o n i s t o t a k e t h e o f f e n s i v e and l e a d t h e way i n d e v e l o p i n g s t r a t e g i e s t o i n c r e a s e e f f i c i e n c y , e f f e c t -i v e n e s s and p r o d u c t i v i t y , no t s i m p l y o f h o s p i t a l s , bu t o f t h e e n t i r e h e a l t h c a r e s y s t e m . W i l l and can h o s p i t a l s r e s p o n d t o t h e c h a n g i n g h e a l t h c a r e needs o f an a g i n g p o p u l a t i o n , i n c r e a s i n g l y c h a r a c t e r i z e d by c h r o n i c d i s e a s e and d i s a b i l i t y and t h e a b s e n c e o f t r a d i t i o n a l f a m i l y s u p p o r t s , and t o t h e need f o r a p p r o p r i a t e p r e v e n t a t i v e s e r v i c e s and l o n g t e r m c a r e i n a c o m b i n a t i o n o f m e d i c a l and s o c i a l s e r v i c e s , a l l i n t h e f a c e o f d w i n d l i n g r e s o u r c e s ? Or w i l l t h e g r o u p r e q u i r i n g c a r e be c o n t i n u a l l y f o r c e d i n t o t h e i n c r e a s i n g l y i n a p p r o p r i a t e and u n n e c e s s a r i l y e x p e n s i v e a c u t e c a r e sys tem? - 12 -H o s p i t a l s must s e r i o u s l y c o n s i d e r t h e i r r o l e and t h i s can o n l y be done t h r o u g h s t r a t e g i c p l a n n i n g . W h i l e l a r g e , more matu re h o s p i t a l s may be a b l e t o cope and a d a p t , t h e i m p a c t w i l l be g r e a t e s t on t h e s m a l l communi ty h o s p i t a l . - 13 -SMALL COMMUNITY HOSPITALS A small, p u b l i c , community h o s p i t a l , for the purposes of t h i s study, i s defined as having 50 beds or l e s s ; approx-imately 5000 bed days per year; and i s situated within 50 miles of a larger treatment f a c i l i t y . These small f a c i l i t i e s provide an i n t e g r a l l i n k and are an e s s e n t i a l and valuable component i n the Canadian health care system. They represent 421 f a c i l i t i e s or 56% of Canada's t o t a l ; and 10,120 beds or 9% of the t o t a l of 115,388 beds a v a i l a b l e . In B.C., small public community h o s p i t a l s represent 51 i n s t -i t u t i o n s or 49% and 1195 beds or 8%. Such hospit a l s are often characterized by the following aspects: (in no order of frequency or p r i o r i t y ) a long, proud h i s t o r y which i s supported by considerable comm-unity emotion - board attendance i s usually between 50 - 60% no review of th e i r r o l e i n t o t a l i t y but rather have watched and reacted to de c l i n i n g population downward trend i n - acute patient days - % occupancy - inpatient E.C.G., Lab, X-Ray, Surgery - often upward trend i n - length of stay due to long term care patients - out-patient services - number of part-time s t a f f - 14 -t h e b o a r d h a s d i r e c t a n d / o r p e r c e i v e d i n v o l v e m e n t i n d a y - t o -day o p e r a t i o n r a t h e r t h a n a d h e r i n g t o a p o l i c y - m a k i n g r o l e . They o f t e n h a n d l e p r a i s e and c r i t i c i s m r a t h e r t h a n r e d i r e c t i n g t o t h e a d m i n i s t r a t i o n . p o o r a d m i n i s t r a t i v e s t r u c t u r e . Depa r tment h e a d s a r e n o t g i v e n a u t h o r i t y and r e s p o n s i b i l i t y f o r d e p a r t m e n t s . T h e r e i s l i t t l e o r p o o r d e l e g a t i o n . D e p a r t m e n t h e a d s o b t a i n no b u d g e t i n f o r m -a t i o n and have no c o n t r o l o v e r t h e i r c o s t c e n t r e s . - many f a m i l y - r e l a t e d s t a f f and o f t e n b o a r d members have r e l a t i v e s w o r k i n g a l s o - p e r f o r m a n c e e v a l u a t i o n s a r e n o t i n p l a c e o r a r e n o t up t o d a t e , p a r t i c u l a r l y f o r t h e C . E . O . no s p e c i f i c g o a l s o r o b j e c t i v e s s t a t e d - p o l i c y manua ls a r e i n a d e q u a t e and t h e r e i s a l a c k o f w r i t t e n p o l i c i e s , p r o c e d u r e s and j o b d e s c r i p t i o n s - o l d e r s t a f f a t t o p o f p a y s c a l e and b e n e f i t s many i t e m s o f r e p o r t i n g and r e c o r d i n g done by r o t e r a t h e r t h a n f rom u n d e r s t a n d i n g - m e d i c a l s t a f f may have m i x e d f e e l i n g s t o w a r d s t h e h o s p i t a l b u t a g r e e i t o p e r a t e s t h e way t h e y d e s i r e s t r a n g e l y enough , t h e r e may be a p a t t e r n o f s u r p l u s , p o s s i b l y due t o p a s t f u n d i n g mechan ism r a t h e r t h a n u t i l i z a t i o n and management. T h i s may i n d i c a t e c e r t a i n a r e a s a r e b e i n g n e g l e c t e d . - h i g h l y a c t i v e a u x i l i a r y - c o n c e n t r a t i o n o f l o c a l p a t i e n t s r e f e r r a l p a t t e r n s and e s p e c i a l l y r e l a t i o n s h i p s w i t h n e a r e s t ma jo r h e a l t h f a c i l i t y a r e n o t t o t a l l y c o - o p e r a t i v e - 15 -- a t m i d d l e o r l o w e r end o f r e g i o n a l o r p r o v i n c i a l s t a t i s t i c a l c o m p a r i s o n s . The c o m m u n i t i e s t h e s e h o s p i t a l s a r e l o c a t e d i n a r e g e n e r a l l y c h a r a c t e r i z e d by t h e f o l l o w i n g t r a i t s : - s l o w o r n e g a t i v e g r o w t h w i t h p o p u l a t i o n p r o j e c t i o n s t h a t a r e l o w o r n e g a t i v e a l s o - s l o w o r s t a t i c b i r t h r a t e and i n c r e a s e d d e a t h r a t e - d e c l i n e i n s c h o o l age c h i l d r e n - d e c l i n e i n l a b o u r f o r c e - i n c r e a s e i n 65+ p o p u l a t i o n - d e c l i n e i n number o f h o u s e h o l d s and s i z e o f h o u s e h o l d s - d e c l i n e i n f a m i l y s i z e - f a c i l i t y u s u a l l y p l a y s a s i g n i f i c a n t employment r o l e - r e g i o n a l h o s p i t a l d i s t r i c t d o e s n o t p l a y an a c t i v e r o l e i n h e a l t h c a r e p l a n n i n g . They o f t e n s e e t h e p r o v i n c i a l g o v e r n -ment a s t h e s o l e p l a n n i n g and f u n d i n g body . T h i s r e s u l t s i n a p e r c e i v e d c e n t r a l i z e d c o n t r o l a t t h e p r o v i n c i a l l e v e l . The s m a l l h o s p i t a l s a r e p o t e n t i a l l y a t g r e a t e r s u r v i v a l r i s k t h a n o t h e r communi ty o r u r b a n h o s p i t a l s b e c a u s e o f t h e i r s i z e and management d e p t h and b e c a u s e o f t e n p r o v i n c i a l g o v e r n m e n t s do n o t t a k e t h e i r s p e c i a l c o n d i t i o n s i n t o a c c o u n t . The p r o b l e m s f a c i n g s m a l l h o s p i t a l a d m i n i s t r a t o r s when s o r t i n g o u t t h e f u t u r e o f t h e i r i n s t i t u t i o n s a r e q u i t e e x t e n s i v e . The s m a l l h o s p i t a l must t y p i c a l l y meet t h e n e e d s o f an a r e a t h a t i s u n d e r s e r v e d , o r c o n v e r s e l y , may be e x p e r i e n c i n g o v e r u t i l i z a t i o n b e c a u s e o f - 16 -a g i n g p o p u l a t i o n a s i t may s e r v i c e an e v e r - g r e a t e r p r o p o r -t i o n o f o l d e r p e r s o n s ; h a v e a s t a f f o f o l d e r p h y s i c i a n s and a l i m i t e d number o f s k i l l e d p e r s o n n e l ; i t must come t o g r i p s w i t h e x t e r n a l r e g u l a t o r y p r e s s u r e s ( gove rnment , u n i o n s ) t h a t a r e r e m o v i n g management p r e r o g a t i v e s . S m a l l h o s p i t a l s p r o v i d e t h e communi ty w i t h t h e f i r s t and o f t e n t h e o n l y c o n t a c t w i t h t h e h e a l t h s y s t e m . W h i l e t h e y have s p e c i a l p r o b l e m s o f g e o g r a p h y and s i z e r e s t r i c t i o n s , t h e y a r e a s r e s p o n s i b l e a s any f o r p r o v -i d i n g a c u t e c a r e , i n p a t i e n t and a m b u l a t o r y c a r e and s h o u l d n o t be e x p o s e d t o s u b s t a n t i a l l y more r i s k t h a n t h e h o s p i t a l i n an u r b a n e n v i r o n m e n t . H e a l t h c a r e and t h e s e r v i c e s p r o v i d e d by t h e s m a l l communi ty h o s p i t a l s a r e no e x c e p t i o n a s t h e y s t r u g g l e a g a i n s t t h e l i m i t a t i o n s e x p e r i e n c e d by i n s t i t u t i o n s o f e v e r y s i z e . The f o l l o w i n g a r e s p e c i a l p r o b l e m s t h a t i m p a c t upon t h e s m a l l h o s p i t a l : i n c r e a s i n g q u a n t i t i e s o f l e g i s l a t i o n and r e g u l a t i o n by g o v e r n -ment and t h e p r o f e s s i o n a l a s s o c i a t i o n s t h a t i n c r e a s e t h e demands f o r h i g h e r s t a n d a r d s i n f a c i l i t i e s and p e r s o n n e l emp loyed a l o n g w i t h l a b o u r demands f o r h i g h e r s t a n d a r d s h a v e come t h e h i g h c o s t o f s a l a r i e s and b e n e f i t s and i n p a t i e n t c a r e t h e age o f s p e c i a l i z a t i o n w i l l make i t e c o n o m i c a l l y d i f f i c u l t and u n f e a s i b l e f o r t h e s m a l l h o s p i t a l s t o r e t a i n a f u l l r a n g e o f s p e c i a l i s t s . A t t h e same t i m e , d i f f i c u l t i e s i n r e c r u i t i n g s p e c i a l i s t s w i l l be compounded by t h e i n a b i l i t y o f t h e s e f a c i l i t i e s t o p r o v i d e ample a c c e s s t o h i g h e r e d u c a t i o n . S p e c -i a l i s t s w i l l r e g a r d t h e s m a l l , r u r a l a r e a a s a d e a d - e n d i n t h e i r - 17 -c a r e e r p a t h - b e c a u s e o f t h e s p i l l o v e r f rom t h e U n i t e d S t a t e s c o u r t c a s e s , C a n a d i a n d o c t o r s w i l l want t o p r o t e c t t h e m s e l v e s w i t h t e s t s and p r o c e d u r e s w h i c h p u t a n o f t e n u n n e c e s s a r y b u r d e n o n t h e f i n a n c e s o f t h e s m a l l h o s p i t a l - p h y s i c i a n s t r a i n e d w i t h modem m e d i c a l p r o c e d u r e s and s o p h -i s t i c a t e d e q u i p m e n t w i l l want t h e t e c h n i c a l s u p p o r t , p e r s o n n e l and f a c i l i t i e s o f t h e l a r g e , u r b a n h o s p i t a l r a t h e r t h a n t h e s m a l l f a c i l i t y - s m a l l h o s p i t a l s d e s p e r a t e l y need b a c k - u p and s o p h i s t i c a t e d management s e r v i c e s , b u t when s e e k i n g a f f i l i a t i o n s o r r e l a t -i o n s h i p s w i t h r e g i o n a l h o s p i t a l s d i s c u s s i o n s t o o o f t e n c e n t r e a r o u n d a c o m p l e t e t a k e - o v e r o r t h e d e v e l o p m e n t o f a c l i n i c a l s e r v i c e . S h a r e d management s e r v i c e s o r s u p p o r t c a n be a ma jo r f a c t o r i n s u r v i v a l w h i l e a t t h e same t i m e s u c h s e r v i c e s c a n b u i l d t h e r e g i o n a l i z e d s y s t e m t h a t i s n e c e s s a r y f o r c o s t -e f f e c t i v e a r e a w i d e h e a l t h s e r v i c e d e l i v e r y . - t h e s m a l l h o s p i t a l must h a v e a commitment t o o v e r c o m i n g b o t h t r a d i t i o n a l i s m and p r o v i n c i a l i s m by e x p o s i n g t h e i r s t a f f s and t h e i r communi ty l e a d e r s h i p t o new i d e a s , new c o n c e p t s , and new methods f o r d e a l i n g w i t h t h e p r o b l e m s t h a t o c c u r w i t h t h e i m p o s i t i o n o f l i m i t s - t h e r e must be a p a i n f u l b u t r e a l i s t i c s e l f - a p p r a i s a l . Does t h e h o s p i t a l t r u l y need t o e x i s t a s a s e p a r a t e e n t i t y o r s h o u l d i t be p a r t o f a l a r g e r s y s t e m o r merge w i t h n e i g h -- 18 -b o u r i n g f a c i l i t i e s ? M u l t i - h o s p i t a l s y s t e m s a r e p r o v i n g , i n many c a s e s , t h a t t h e r e a r e c o s t b e n e f i t s and p a t i e n t s e r v i c e b e n e f i t s i n p o o l i n g r e s o u r c e s f o r t h e p r o v i s i o n o f h e a l t h s e r v i c e s t h e s m a l l h o s p i t a l c o u l d w e l l r e p r e s e n t t h e f a c i l i t y w i t h t h e g r e a t e s t i n v e s t m e n t o f money i n equ ipment and f a c i l i t i e s and t h e l a r g e s t e m p l o y e r . I t t h e n h a s t h e r e s p o n s i b i l i t y t o t a k e a l e a d e r s h i p r o l e i n n o t o n l y s e r v i n g t h e communi ty i n t h e p u r s u i t o f h e a l t h s t a t u s b a t a l s o l e a d e r s h i p i n t h e s o c i o e c o n o m i c s e n s e o f q u a l i t y o f l i f e , d i v e r s i t y o f s e r v i c e and t h e o p t i m a l u s e o f r e s o u r c e s . One o f t h e most c r i t i c a l n e e d s o f s m a l l h o s p i t a l s i s t o h i r e o r have a c c e s s t o c o m p e t e n t f i n a n c i a l managers who a r e f a m i l i a r w i t h t h e s p e c i a l p r o b l e m s o f t h e s e h o s p i t a l s . The f i s c a l manager p r o b a b l y s h o u l d be c o n s i d e r e d t h e main s u p p o r t p e r s o n t o t h e p l a n n i n g team. U n l e s s a s m a l l h o s p i t a l has s t r o n g f i s c a l management and s t r o n g f i s c a l p l a n n i n g , i t p r o b -a b l y w i l l n o t do w e l l i n s t r a t e g i c p l a n n i n g . C o n s i d e r a t i o n s h o u l d be g i v e n t o u s i n g f i s c a l c o n s u l t a n t s and d a t a s e r v i c e s o r seek t o s h a r e t h e s k i l l s o f a f i n a n c i a l manager o r t o p u r c h a s e them t h r o u g h m u l t i - o r g a n i z a t i o n a l a r r a n g e m e n t s t o h e l p u p g r a d e f i s c a l management methods i f t h e y a r e l a c k i n g i n t h e o r g a n i z a t i o n . The a c c o u n t a n t i s t h e n e w e s t s p e c i a l i s t o n t h e communi ty h o s p i t a l s t a f f . A s a d i a g n o s t i c i a n t h e y a r e a s s e s s e d on t h e b a s i s o f t h e i r r e p o r t i n g , r a t h e r t h a n on t h e i r r e c o r d i n g . They must t h e r e f o r e be more c o n c e r n e d w i t h i n t e r p r e t i n g t h a n w i t h t h e mere a c c u m u l a t i o n o f h i s t o r i c a l d a t a . A h o s p i t a l i s more t h a n an i n s t i t u t i o n i n w h i c h m e d i c a l c a r e i s g i v e n ; i t i s a l s o a s i g n i f i c a n t b u s i n e s s o r g a n i z a t i o n a f f e c t i n g t h e e n t i r e comm-u n i t y . A s a n o n - p r o f i t b u s i n e s s , i t o f f e r s no c o c o o n t o t h e a c c o u n t a n t w i t h a ' p e n c i l - p u s h i n g ' m e n t a l i t y . A s t h e c a t a l y s t on t h e a d m i n i s t r a t i o n team t h e a c c o u n t a n t must be imbued w i t h a s e n s e o f t h e i r management r e s p o n s i b i l i t y . A t h o r o u g h u n d e r s t a n d i n g o f h o s p i t a l f i n a n c e and t r e n d s and t h e c r e a t i v e a b i l i t y t o u s e f i s c a l o p p o r t u n i t i e s t o t h e b e n e f i t o f o r g a n i z a t i o n a l i n t e r e s t s a r e n e c e s s a r y e l e m e n t s o f s u c c e s s f u l s t r a t e g i c p l a n n i n g . No l o n g e r c a n t h e h o s p i t a l t r u s t e e s e x p e c t t h e c h i e f e x e c u t i v e o f f i c e r s , o f f i c e m a n a g e r s , o r l o c a l a c c o u n t a n t s t o r e l y on t h e i r own s k i l l s i n h a n d l i n g h i g h l y t e c h n i c a l and s o p h i s t i c a t e d f i n a n c i a l o p e r a t i o n s . Many s m a l l h o s p i t a l s w i l l f a c e t h e need t o spend i n c r e a s i n g amounts o f money on t h e i r p h y s i c a l p l a n t s and on c a p i t a l e q u i p m e n t . A l l o c a t i n g t h e s e e x p e n d i t u r e s w i l l become i n c r e a s i n g l y c o m p l e x , so s m a l l h o s p i t a l s w i l l have t o become i n c r e a s i n g l y s o p h i s t i c a t e d i n f i n a n c i a l management. I t must be c a u t i o n e d t h a t a h o s p i t a l c a n have t h e b e s t f i n a n c i a l s y s t e m s i n p l a c e and s t i l l be headed f o r d i s a s t e r . I t i s i m p o r t a n t t o remember t h a t p r o p e r o p e r a t i o n s must f e e d p r o p e r f i n a n c i a l s y s t e m s b u t t h e r e v e r s e i s n o t n e c e s s a r i l y t r u e . Becoming o b s e s s e d w i t h p e r f e c t i n g t h e f i n a n c i a l r e p o r t i n g s y s t e m e a r l y on r a t h e r t h a n s t r e s s i n g t h e needs f o r a c c u r a t e o p e r a t i n g d a t a , c a n be a m i s t a k e . B e s i d e s h a v i n g s p e c i a l p r o b l e m s , t h e r e a r e o t h e r o b s t a c l e s t h a t s t a n d i n t h e way o f s t r a t e g i c p l a n n i n g i n s m a l l communi ty h o s p i t a l s - t h e y g e n e r a l l y do n o t have t h e e x p e r t i s e t o t a c k l e t h e p l a n n i n g p r o c e s s by t h e m s e l v e s , o r t h e y a r e u n a b l e t o a f f o r d e x p e n s i v e o u t s i d e h e l p - t h e h o m o g e n e i t y o f b o a r d members i s l i k e l y t o d i s c o u r a g e e f f e c t i v e p l a n n i n g . A s t u d y o f b o a r d c o m p o s i t i o n h a s i n d i -c a t e d t h a t t h e more homogeneous t h e b o a r d i s , t h e l e s s i n n o v a t i v e i t w i l l b e . (4) - p a r t l y b e c a u s e o f t h e c o n s e r v a t i v e n a t u r e o f s m a l l c o m m u n i t i e s and p a r t l y b e c a u s e o f t h e age o f most b o a r d members, commun i ty h o s p i t a l s t e n d t o r e s i s t change o r a t l e a s t n o t p l a n f o r i t - t h e members o f t h e m e d i c a l s t a f f c a n be a ma jo r i m p e d i m e n t t o s t r a t e g i c p l a n n i n g . P h y s i c i a n s may be l e e r y o f c o m p e t i t i o n , t e m p t e d t o p l a c e t h e i r own i n t e r e s t s above t h e h o s p i t a l ' s , and a r e i n e x p e r i e n c e d i n l o n g - r a n g e p l a n n i n g . Y e t when i t comes t o t h e t o u g h d e c i s i o n s , b o a r d members o f t e n d e f e r t o p h y s i c i a n s b e c a u s e o f t h e i r m e d i c a l k n o w l e d g e . I t i s o b v i o u s t h a t t h e s m a l l community h o s p i t a l , w h i c h i n c l u d e s more t h a n h a l f o f t h e h o s p i t a l s i n C a n a d a , may n o t s u r v i v e i t s p r e s e n t r o l e , l o c a t i o n , o r s e r v i c e c o n f i g u r a t i o n , d e s p i t e i t s i m p o r t a n c e t o i t s c o m m u n i t y , u n l e s s p l a n n i n g i s i m m e d i a t e l y a d o p t e d a s a m a j o r management f u n c t i o n . - 21 -I t i s i r o n i c t h a t t h e s m a l l h o s p i t a l , w h i c h h a s f e w e r r e s o u r c e s t h a n i t s l a r g e r u r b a n c o u n t e r p a r t , s h o u l d be f a c e d w i t h t h e i m p e r a t i v e o f i m p l e m e n t i n g a p l a n n i n g p r o c e s s when i n f a c t v e r y few h o s p i t a l s o f any s i z e have c o m p l e t e l y m a s t e r e d t h e s k i l l o f s t r a t e g i c p l a n n i n g . - 22 -HOSPITAL PLANNING The p h i l o s o p h i c a l b a s e o f p l a n n i n g l i e s i n t h e c o n c e p t i o n t h a t any o r g a n i z a t i o n , be i t f a m i l y , b u s i n e s s , m i l i t a r y , g o v e r n -ment , o r a h o s p i t a l , c a n more e f f e c t i v e l y o b t a i n i t s o b j e c t i v e s i f i t engages i n s y s t e m a t i c p l a n n i n g . " P l a n n i n g p h i l o s o p h y p r e s u p p o s e s t h a t man must i n f l u e n c e h i s f u t u r e t o some d e g r e e by p r e s e n t a c t i o n s t o s u r v i v e . T h i s p l a n n i n g e f f o r t i s c o n s i d -e r e d e t h i c a l l y d e s i r a b l e and p r e s u m e s t h e e x i s t a n c e o f g o a l s s u f f i c i e n t l y d e f i n i t e f o r p l a n n i n g . " (5) A s w e l l a c c e p t e d a s t h e n o t i o n o f p l a n n i n g i s t h e t e r m i t s e l f w h i c h h a s many m e a n i n g s , d e p e n d i n g on such f a c t o r s a s who i s i n v o l v e d , how p l a n n i n g i s c a r r i e d o u t , and what i t i s t o a c c o m p l i s h . The t e r m " p l a n n i n g " c o v e r s a w i d e v a r i e t y o f a c t i v i t i e s r a n g i n g f rom t h e s i m p l e t o t h e c o m p l e x , f r o m t h e s o l u t i o n o f c u r r e n t p r o b l e m s f a c i n g management t o d e t e r m i n a t i o n o f a c t i o n t h a t an o r g a n i z a t i o n must c o n s i d e r i n c o p i n g w i t h an u n c e r t a i n f u t u r e . The f o l l o w i n g a r e some o f t h e d e f i n i t i o n s found i n t h e l i t e r a t u r e t h a t have been a p p l i e d t o t h e a c t i v i t y o f p l a n n i n g : p r o v i d i n g some t y p e o f s t r u c t u r e d d i r e c t i o n and g u i d a n c e t o a h e a l t h c a r e p r o v i d e r r e g a r d i n g i t s f u t u r e d i r e c t i o n s and v i a b i l i t y b a s e d on an a n a l y s i s o f i t s c u r r e n t and a n t i c i p a t e d s i t u a t i o n -- d e c i d i n g . i n a d v a n c e what i s t o be d o n e . B a s i c a l l y an i n t e l l e c t u a l - 23 -p r o c e s s w h i c h i n v o l v e s d e c i s i o n - m a k i n g and r e q u i r i n g m e n t a l p r e d i s p o s i t i o n t o t h i n k b e f o r e a c t i n g . To a c t i n t h e l i g h t o f f a c t s r a t h e r t h a n on g u e s s e s and g e n e r a l l y s e e k i n g t o do t h i n g s i n an o r d e r l y f a s h i o n - s e n s i n g t h a t s o m e t h i n g n e e d s t o be done and d e c i d i n g f i r m l y who d o e s w h a t , w h e n ; a n a c t i v i t y much b r o a d e r t h a n c o m p i l i n g and a n a l y z i n g i n f o r m a t i o n o r d r e a m i n g up i d e a s a b o u t what m i g h t be d o n e . I t i s more t h a n l o g i c o r i m a g i n a t i o n o r j u d g e -ment . I t i s a c o m b i n a t i o n o f a l l t h e s e t h a t c u l m i n a t e s i n t o a d e c i s i o n , a d e c i s i o n a b o u t what must be d o n e . The common theme i n t h e s e d e f i n i t i o n s i s t h a t p l a n n i n g h a s a l w a y s been an a c t i v i t y i n w h i c h t h e r e i s a need f o r d e c i s i o n s w h i c h d e t e r m i n e c o u r s e s o f f u t u r e a c t i o n . These c a n be immed-i a t e o r f a r - r e a c h i n g i n t h e i r c o n s e q u e n c e s . A l s o , r e g a r d l e s s o f t h e e m p h a s i s , p l a n n i n g i s g e n e r a l l y r e c o g n i z e d a s t h e d e c i s i o n -mak ing p r o c e s s t h a t e n a b l e s an o r g a n i z a t i o n t o a c t i v a t e and p r o d u c e r e s u l t s a t some f u t u r e d a t e . The p l a n n i n g p r o c e s s s h o u l d i d e a l l y embody t h e f o l l o w i n g a s p e c t s : - be p u r p o s e f u l , and a l w a y s s t a r t w i t h a s t a t e m e n t o f g o a l s and o b j e c t i v e s - a c o n t i n u o u s p r o c e s s c o n s i s t i n g o f a s e r i e s o f i n t e r r e l a t e d s t e p s o r p h a s e s , n o t a s i n g l e a c t - an i n t e g r a l p a r t o f t h e p r o c e s s o f managing - be h i e r a r c h a l i n n a t u r e and c o n s i s t o f a s y s t e m o f p l a n s , r a t h e r t h a n an i n d i v i d u a l p l a n - h a v e an o r g a n i z a t i o n a l i d e n t i f i c a t i o n . I n o t h e r w o r d s , p l a n s a r e c a u s e d by and made f o r c e r t a i n p a r t s o f an o r g a n i z a t i o n . - a l l o w f o r t h e s o c i o - p o l i t i c a l e n v i r o n m e n t o f t h e o r g a n i z a t i o n - s h o u l d be d e l i b e r a t e , r a t i o n a l , and o b j e c t i v e . An i m p o r t a n t p o i n t o f r e f e r e n c e f o r p l a n n i n g i s t h e c u r r e n t o r o r g a n i -z a t i o n a l p r o f i l e and c a p a b i l i t y - d e a l w i t h t h e f u t u r e , and a s s u c h , r e q u i r e s an i n p u t o f f o r e c a s t s o r t r e n d s - s t a t e s t a n d a r d s w h i c h become t h e b a s i s o f t h e m o n i t o r i n g s y s t e m - e l e m e n t s o f f l e x i b i l i t y must be b u i l t i n t o t h e d e s i g n o f a p l a n s i n c e i n t e r n a l r e q u i r e m e n t s and e x t e r n a l i n f l u e n c e s c a n c h a n g e o v e r t i m e - p e r v a s i v e and t a k e p l a c e a t a l l l e v e l s and i n each p a r t o f t h e o r g a n i z a t i o n - a t o p management f u n c t i o n a s t h e u l t i m a t e r e s p o n s i b i l i t y f o r p l a n n i n g r e s t s a t t h i s l e v e l - be c r e a t i v e p r o b l e m s o l v i n g a l t h o u g h t h i s i s d i f f i c u l t b e c a u s e t h e r e a r e n o t n e c e s s a r i l y s t a n d a r d s o l u t i o n s and a n s w e r s - a b l e n d o f a r t and s c i e n c e - p r o v i d e t h e b a s i s f o r i n f o r m e d and i m p r o v e d d e c i s i o n - m a k i n g - i n v o l v e t h e t a s k s o f e d u c a t i n g and c o m p r o m i s i n g t o r e a c h ag reement and u n d e r s t a n d i n g - r e q u i r e an i n t e g r a t i o n o f t h e p r o g r a m m a t i c , o r g a n i z a t i o n a l , p h y s i c a l , f i n a n c i a l , and e n v i r o n m e n t a l d y n a m i c s o f an i n s t i t u t i o n . P l a n n i n g i s no more t h a n a c o n s c i o u s , r a t i o n a l p r o c e s s o f d e c i d i n g upon a d e s i r e d f u t u r e s t a t e and c o m m i t t i n g r e s o u r c e s t o a c h i e v e i t t o a v o i d a l w a y s r e a c t i n g t o i m m e d i a t e p r o b l e m s . N o r m a l l y , by t h e t i m e t h e p r o b l e m i s i m m e d i a t e , t h e s o l u t i o n i s a l r e a d y l o n g o v e r d u e . P l a n n i n g a l l o w s t h e i d e n t i f i c a t i o n o f t h e p r o b l e m b e f o r e i t becomes a c r i s i s and a l l o w s t h e d e v e l o p m e n t o f an e f f e c t i v e c o u r s e o f a c t i o n t o p r o v i d e an o n - g o i n g s o l u t i o n i n s t e a d o f s t o p p i n g f o r t e m p o r a r y f i x e s , o r f r o m " m u d d l i n g -t h r o u g h " . When s p e a k i n g a b o u t p l a n n i n g we c a n make s e v e r a l d i f f e r e n t i a t i o n s . One d i s t i n c t i o n i s be tween i n f o r m a l p l a n n i n g , w h i c h e v e r y o n e d o e s , and f o r m a l p l a n n i n g . Even t h e most u n s o p h -i s t i c a t e d manager g a t h e r s and o r g a n i z e s d a t a , makes a s s u m p t i o n s a b o u t t h e s p e c i f i c s i t u a t i o n , e s t a b l i s h e s g o a l s and o b j e c t i v e s , and s e t s p r i o r i t i e s f o r a c t i v i t i e s . T h i s i s u s u a l l y e x t e m p o r -a n e o u s and c a r r i e d o u t w i t h l i t t l e a t t e m p t t o be s y s t e m a t i c o r o r d e r l y . Most p e o p l e and most o r g a n i z a t i o n s n e i t h e r a n a l y z e t h e c o n t e n t s n o r t h e e f f e c t i v e n e s s o f t h i s t y p e o f p l a n n i n g p r o c e s s . I n f o r m a l p l a n n i n g d i f f e r s f r o m f o r m a l p l a n n i n g i n t h a t i n t h e f o r m e r , t h e manager makes t h e d e c i s i o n s a l o n e , t h e a c t ( r a t h e r t h a n t h e p r o c e s s ) l a c k s a m u l t i d i s c i p l i n a r y p e r s p e c t -i v e , and h a s no r i g o r o u s m e t h o d o l o g y . F o r m a l p l a n n i n g i s t h e r e c i p r o c a l o f t h i s a c t i v i t y . A n o t h e r d i s t i n c t i o n i s between i n c r e m e n t a l p l a n n i n g ( t r o u b l e s h o o t i n g ) and d e v e l o p m e n t a l . I n c r e m e n t a l i s when a p r o b l e m i s i d e n t i f i e d , e v a l u a t e d , r e s p o n s e s a r e c o - o r d i n a t e d and e n d e a v o u r s made t o c o n t r o l t h e s i t u a t i o n . D e v e l o p m e n t a l b e g i n s by r e s e a r c h i n g c h o i c e s and c h a n g e s and e v a l u a t i n g f e e d b a c k . (6) A n o t h e r d i s t i n c t i o n h a s been made a t t h e macro and m i c r o l e v e l s . A t t h e macro l e v e l , t h e ma jo r o b j e c t i v e o f h e a l t h c a r e p l a n n i n g i s t o p r o d u c e a c o m p r e h e n s i v e and c o -o r d i n a t e d n e t w o r k o f a l l h e a l t h p r o v i d e r s r e s u l t i n g i n t h e - 26 -o r g a n i z a t i o n and d e l i v e r y o f opt imum h e a l t h . T h i s i s n e c e s s a r y a s a s i n g l e h o s p i t a l o r p r o v i d e r c a n n o t be e x p e c t e d t o p r o v i d e t h e e n t i r e s p e c t r u m . A t t h e m i c r o l e v e l , t h e o b j e c t i v e i s t o b e t t e r manage t h e i n t e r n a l w o r k i n g s o f h e a l t h c a r e f a c i l i t i e s . P l a n n i n g i s n o t an a d j u n c t t o n o r m a l h o s p i t a l o p e r a t i o n s , n o r c a n i t be done i n i s o l a t i o n f r o m t h e l i f e o f t h e f a c i l i t y . I t i s n o t t h e d u s t - c o v e r e d Master P l a n d e v e l o p e d y e a r s ago b y a c o n s u l t a n t o r management and n e v e r i m p l e m e n t e d . I t i s an i n t e g r a l f u n c t i o n o f h o s p i t a l management and a n e c e s s a r y t o o l f o r s u r v i v a l t h a t s h o u l d s i g n i f i c a n t l y c o n t r i b u t e t o t h e f o l l o w i n g r e s u l t s : - more p r o d u c t i v e commitment of o r g a n i z a t i o n r e s o u r c e s t o a r e a s t h a t m a x i m i z e s t r e n g t h s and o p p o r t u n i t i e s and t h a t meet n e e d s . - a v a i l a b i l i t y o f f u t u r e o p t i o n s . - i n c r e a s e d o r g a n i z a t i o n a l i n t e g r a t i o n and s u p p o r t t h r o u g h b e t t e r c o n f l i c t r e s o l u t i o n , d e c i s i o n - s t a g i n g and s e n s e o f m i s s i o n . - i m p r o v e d p o s i t i o n i n g o f t h e o r g a n i z a t i o n f o r f u t u r e g a i n s i n r e l a t i o n t o e x t e r n a l demands , such a s t h o s e p o s e d by r e g u l a t o r y a g e n c i e s and c o m p e t i t o r s - o n g o i n g o r g a n i z a t i o n a l e v a l u a t i o n arid g r o w t h . The e v o l u t i o n o f h o s p i t a l p l a n n i n g a p p e a r s t o have t h r e e g e n e r a t i o n s . The f i r s t g e n e r a t i o n o f h o s p i t a l p l a n n i n g i s c o n s i d e r e d a s f a c i l i t y p l a n n i n g . T h i s was h e a v i l y o r i e n t -a t e d t o d e s i g n and c o n s t r u c t i o n o f p h y s i c a l f a c i l i t i e s . The f o c u s on f a c i l i t i e s o c c u r r e d i n p e r i o d s o f h o s p i t a l g r o w t h , c h a r a c t e r i z e d by c a p a c i t y s h o r t a g e s , u n i o n i z a t i o n , and t e c h n o -l o g i c a l e x p a n s i o n . Government f u n d i n g i n i t i a t i v e s s u c h a s t h e N a t i o n a l H e a l t h G r a n t P r o g r a m and H o s p i t a l C o n s t r u c t i o n G r a n t s were i n t r o d u c e d . A r c h i t e c t s and e n g i n e e r s were k e y p a r t i c i p a n t s . The s e c o n d g e n e r a t i o n o f h o s p i t a l p l a n n i n g w o u l d be i n s t i t u t i o n a l  p l a n n i n g . T h i s was and i s c h a r a c t e r i z e d by a b r o a d e r f o c u s on p l a n n i n g t h e p r o g r a m s and d e p a r t m e n t s o f t h e h o s p i t a l . A n n u a l o r l o n g - t e r m o b j e c t i v e s f o r t h e m a j o r e x i s t i n g p r o g r a m s a r e s e t . To v a r y i n g d e g r e e s , h o s p i t a l s t i e b u d g e t i n g t o t h e s e o b j e c t i v e s and e x p l o r e new t y p e s o f r e l a t e d h e a l t h c a r e s e r v i c e s t h a t t h e h o s p i t a l c o u l d p r o v i d e . T h i s i n s t i t u t i o n a l p l a n n i n g i s o f t e n o r i e n t e d t o r e s p o n d i n g t o e x t e r n a l i n i t i a t i v e s a s r e s o u r c e c o n s t r a i n t s began t o be f e l t . I t was d u r i n g t h i s g e n e r a t i o n t h a t many h o s p i t a l s h i r e d d i r e c t o r s o f p l a n n i n g t o d e a l w i t h t h e e x t e r n a l f o r c e s and t o d e v e l o p h o s p i t a l m a s t e r p l a n s . The h o s p i t a l i n d u s t r y , w i t h few e x c e p t i o n s , i s c u r r e n t l y t o t t e r i n g between t h e s e c o n d and t h i r d g e n e r a t i o n s o f h o s p i t a l p l a n n i n g . T h i s i s i n between i n s t i t u t i o n a l and s t r a t e g i c p l a n n i n g . S u c c e s s f u l e v o l u t i o n i n t o t h i r d - g e n e r a t i o n p l a n n i n g w i l l be j u d g e d by a h o s p i t a l ' s a b i l i t y t o do more w i t h l e s s and t o f i n d o p p o r t u n i t i e s w i t h i n t h e c o n s t r a i n t s . A c c o r d i n g t o some o b s e r v e r s t h e e f f e c t i v e n e s s o f p l a n n i n g e f f o r t s i n t h e h e a l t h c a r e f i e l d i n a l l g e n e r a t i o n s h a s i n t h e p a s t and p e r h a p s i n t h e f u t u r e been c o n s t r a i n e d by t h e l a c k o f a c o n s c i o u s , d e f -i n i t i v e m e t h o d o l o g y t o g u i d e e f f o r t s . P l a n n i n g was o f t e n a c c o m p l i s h e d on a s p o r a d i c o r p e r i o d i c b a s i s f o l l o w i n g an i n f o r m a l c o n s e n s u s t h a t f a c i l i t i e s must be e x p a n d e d , new e q u i p -ment n e e d e d , o r new s e r v i c e s s h o u l d be p r o v i d e d . T h i s p l a n n i n g was o n l y c o n c e r n e d w i t h t h e d e t a i l s o f c o - o r d i n a t i n g t h e c o n s t -- 28 -r u c t i o n p r o j e c t . The l a c k o f p l a n n i n g e m p h a s i s h a s a l s o been c o n s t r a i n e d by t h e f a c t t h e r e i s l i t t l e p r e s s u r e o r i n c e n t i v e t o p l a n , t h e c o m p l e x i t y i n v o l v e d due t o many " i m m e a s u r a b l e s " , c o m p r e h e n s i v e n e s s and d i v e r s i t y , and w i t h an i n s a t i a b l e demand f o r s e r v i c e s t h e r e were r a r e l y any q u e s t i o n s a s t o an i n s t -i t u t i o n ' s v i a b i l i t y . Some h o s p i t a l s u s e few i f any q u a n t i t a t i v e t o o l s w i t h w h i c h t o s t e e r t h e i r a c t i v i e s . W i t h t h e e x c e p t i o n o f s t a t u t o r y o r g o v e r n m e n t r e q u i r e m e n t s , many o f t h e s m a l l o r g a n i z a t i o n s do n o t even p r e p a r e a n n u a l s t a t e m e n t s o r o t h e r r e p o r t s . M o r e o v e r , t h e y s e l d o m u s e q u a n t i t a t i v e methods t o measure t h e i r a c h i e v e -ments o r t o t r a c k t h e i r p r o g r e s s t o w a r d s p e c i f i c g o a l s . T h i s may be due t o t h e f a c t t h a t t h e h e a l t h c a r e f i e l d i s marked by p e o p l e who a r e , by n a t u r e , d o e r s and who a r e u n d e r d a y - t o - d a y p r e s s u r e s t o g e t t h i n g s d o n e . A more d e t a i l e d d i s c u s s i o n w i l l be g i v e n i n t h e n e x t s e c t i o n a s t o why h o s p i t a l s h a v e n o t made t h e f u l l t r a n s i t i o n i n t o t h e t h i r d g e n e r a t i o n o f s t r a t e g i c p l a n n i n g . H o s p i t a l s a r e o b l i g a t e d , m o r a l l y and l e g a l l y , t o s t r a t -e g i c a l l y p l a n . They d o n ' t r e a l l y h a v e a c h o i c e . They c a n p l a n f o r and a n t i c i p a t e t h e p r o b l e m s o r t h e y c a n s i t back and r e a c t , w a i t i n g f o r o t h e r s t o c o n t r o l t h e i r d e s t i n y . The o p t i o n o f n o t p l a n n i n g i s n o t open t o most h o s p i t a l s and a l l s h o u l d r e a l i z e t h a t . P l a n n i n g i s e s s e n t i a l i f g o v e r n i n g b o a r d s a r e t o e x e r c i s e c o n t r o l o v e r t h e d e s t i n y and d e v e l o p m e n t o f t h e i r o r g a n i z a t i o n s , p a r t i c -u l a r l y i n t h e s e t i m e s o f u n p r e c e d e n t e d c h a n g e . F o r t u n a t e l y , we a r e l e a r n i n g t h a t t h e p o t e n t i a l o f p l a n n i n g _ i s much g r e a t e r and t h a t p l a n n i n g i s a p r o c e s s - t h a t - 29 -describes a human interaction which produces a commitment to a course of action that requires many people to change at the same time. Hospitals, with their traditional lack of strategic planning, actually rely considerably on a collective approach to change, partly because of the complex nature of the hospital, partly because of the social emphasis which characterizes much of their endeavours, and partly because of the professional background of the leading participants. In a hospital or medical care setting, planning i s a process of questions raised and answers sought, of ideas exchanged and debated, of support received and withheld, conflict and resolution of issues, persuasion and compromise of solutions accepted, a l l involving people of varied interests and backgrounds and a l l who share a commitment to the hospital's goals. In summary, the structure, accountability and governance of hospitals have come under close scrutiny, with the dual goal of improving delivery and cutting the cost of services. Increasing competition for limited resources by a growing variety of prov-iders, and confusing, changing government structures have sparked an interest in strategic planning as a key tool for hospitals to survive and to thrive. Even with these incentives observers are particularly c r i t i c a l of the lack of policy and planning in hospitals. Generally, hospitals don't do planning usually because they don't know how to do i t or i t i s not an all-out effort. For instance, a U.S. nation-wide survey of 614 acute general hospitals revealed that although 96% claimed to have engaged in - 30 -comprehensive planning, about one-third of these efforts were one-time exercises and not part of an on-going, iterative process. (7) While this was in the U.S. setting, the results could be generalized to the Canadian health industry. Not only have hospitals failed to reach the strategic management stage of development of the third generation, but many of them have failed to reach even the strategic planning stages that for-profit enterprises initiated 15 to 20 years ago. The arena in which the hospital must now compete and survive can be equally demanding as the environment in which i t s profit-seeking counterpart operates. The task of survival i s perhaps even more d i f f i c u l t since management of an organization dependent upon government funding i s often without the benefit of even the most basic equipment in i t s arsenal of strategic and tactical weaponry. More and more, however, the tools applied by the profit-oriented manager in climbing his way over the "return on investment" hurdle and winding his way through rarkets jammed with utterly differentiated products are becoming available and being applied by the non-profit organization manager. Since the management technology has evolved in response to the necessity of decision-making in the face of uncertainty, competition and scarce resources, conditions prevalent in both spheres of operation, the hospital should find that this technology i s easily tranferable and readily applicable. Some areas of management technology have been more readily assimilated by managers in non-profit organizations I - 31 -t h a n o t h e r s . F o r t h e most p a r t , t h a t w h i c h h a s been a d o p t e d a p p e a r s t o c o n c e r n i t s e l f w i t h t h e management o f t h e i n t e r n a l o r g a n i z a t i o n . T h i s i n t e r n a l f o c u s o n management r e s u l t s i n a n o t h e r a r e a o f e q u a l i m p o r t a n c e b e i n g n e g l e c t e d . F a c e d w i t h t h e r a p i d l y c h a n g i n g e n v i r o n m e n t w h i c h c h a r a c t e r i z e s t h e p e r i o d o f t i m e i n w h i c h b o t h t h e p r o f i t and n o n - p r o f i t s e c t o r s f i n d t h e m s e l v e s o p e r a t i n g , t h e e x t e r n a l e n v i r o n m e n t i s r e q u i r i n g more and more a t t e n t i o n . Many f a c t o r s i n t h e u n c o n t r o l l a b l e e n v i r o n m e n t o f t h e n o n - p r o f i t o r g a n i z a t i o n a r e c h a n g i n g , a l l c a l l i n g f o r c o r r e s p o n d i n g c h a n g e s i n t h e ways w i t h w h i c h t h e o r g a n i z a t i o n d e a l s w i t h c h a n g e s . The i d e a s o f b u s i n e s s p l a n n i n g a r e a s r e l e v a n t t o h e a l t h c a r e o r g a n i z a t i o n s a s t h e y a r e t o c o r p o r a t i o n s . The c o n c e p t s o f s t r a t e g y , e x p a n s i o n , d i v e r s i f i c a t i o n , m e r g e r s , a c q u i s i t i o n s - t h e w h o l e r a n g e o f t e r m s , t e c h n i q u e s , and t o o l s - c a n and s h o u l d be b r o u g h t t o b e a r i n a c o n s c i o u s manner i n t h e manage-ment o f h e a l t h c a r e f a c i l i t i e s . One c o u l d s p e c u l a t e t h a t an i m p o r t a n t f a c t o r i n r i s i n g h e a l t h c o s t s d u r i n g t h e l a s t d e c a d e h a s been a l a c k o f i m p l e m e n t a t i o n o f s t r a t e g i c p l a n n i n g i d e a s and t o o l s . - 32 -STRATEGIC PLANNING F o r t h e b e t t e r p a r t o f a d e c a d e , s t r a t e g y and s t r a t e g i c p l a n n i n g have been s o l e l y t h e b u s i n e s s b u z z - w o r d s o f c o m p e t i t i v e i n d u s t r i e s a s t h e y l a y o u t s t r a t e g i e s f o r t h e f u t u r e . S t r a t e g i c p l a n n i n g h a s been a d o p t e d by c o r p o r a t e management f o r two ma jo r r e a s o n s . F i r s t , t h e c o n c e p t i s s t r a i g h t f o r w a r d and e a s i l y u n d e r s t o o d . S e c o n d , i t a l l o w s managers t o assume more c o n t r o l o v e r t h e f u t u r e s o f t h e i r o r g a n i z a t i o n s . (8) Now h o s p i t a l s must a l s o a d o p t t h i s t y p e o f t h i n k i n g f o r t h e r e i s an o b v i o u s need t o accommodate t h e e c o n o m i c , p o l i t i c a l and s o c i a l f o r c e s t h a t a r e s t i m u l a t i n g q u e s t i o n s and r e s o u r c e a l l o c a t i o n c o n c e r n s i n t h e h e a l t h c a r e i n d u s t r y . W i t h o u t i t t h e y w i l l behave l i k e any l a r g e , u n w i e l d y b u r e a u c r a c y when t h e y c n u l d be n i m b l y m e e t i n g communi ty n e e d s . B o a r d s o f d i r e c t o r s , when t h e y d i s c u s s c o r p o r a t e s t r a t e g y , must have some common i d e a o f what i s meant by t h e t e r m . A s s u g g e s t e d b e f o r e , i t c a n be c o n s i d e r e d t h e e v o l v i n g p a t t e r n o f d e c i s i o n s t h a t b o t h d e t e r m i n e s and makes c l e a r what a h o s p i t a l ' s p u r p o s e s , g o a l s , and p r i n c i p l e p o l i c i e s a r e . A p p r o a c h e s t o h o s p i t a l s t r a t e g i c p l a n n i n g a r e a s v a r i e d a s t h e number o f i n s t i t u t i o n a l p l a n n e r s , c o n s u l t a n t s and a c a d e m i c s engaged i n t h e p r o c e s s . E v e n w i t h t h e d i f f e r e n c e s i n a p p r o a c h e s c e r t a i n e l e m e n t s a r e common t o e v e r y a p p r o a c h , s u c h a s d e f i n i t i o n and e v a l u a t i o n o f t h e o r g a n i z a t i o n ' s " l i n e o f b u s i n e s s " , a s s e s s -ment o f t h e e n v i r o n m e n t , e x a m i n a t i o n o f t h e i n s t i t u t i o n ' s m i s s i o n and r o l e , and i d e n t i f i c a t i o n and a n a l y s i s o f s t r a t e g i c o p t i o n s . - 33 -S t r a t e g i c p l a n n i n g i s an e s s e n t i a l component o f e f f e c t i v e h o s p i t a l management. I t i n v o l v e s a l l l e v e l s o f management , m e d i c a l s t a f f l e a d e r s h i p , t h e b o a r d and v a r i o u s e x t e r n a l p u b l i c s i n a s s e s s i n g t h e communi ty n e e d . I t a s s i s t s u s i n d e t e r m i n i n g t h e c u r r e n t and f u t u r e h e a l t h s e r v i c e and r e l a t e d n e e d s o f t h e c o m m u n i t y , i n r e l a t i o n b o t h t o t h e o r g a n i z a t i o n ' s s t r e n g t h s and w e a k n e s s e s and t o t h e p r o g r a m s o f o t h e r l o c a l h e a l t h s e r v i c e o r g a n i z a t i o n s . S t r a t e g y i n t e g r a t e s an o r g a n i z a t i o n ' s m a j o r g o a l s , p o l i c i e s , and a c t i o n s i n t o a c o h e s i v e w h o l e . A t t h e same t i m e , i t h e l p s a l l o c a t e t h e o r g a n i z a t i o n ' s s c a r c e r e s o u r c e s b a s e d on i t s c o m p e t e n c i e s and s h o r t c o m i n g s , a n t i c i p a t e d c h a n g e s i n t h e e n v i r o n m e n t , and c o n t i n g e n t moves by i t s r e g u l a t o r s and c o m p e t i t o r s . S t r a t e g i c management l i n k s t h e r i g o r o f f o r m a l p l a n n i n g t o v i g o r o u s o p e r a t i o n a l e x e c u t i o n . The h e a r t o f t h e s t r a t e g i c p r o c e s s i s t h e g e n e r a t i o n o f a l t e r n a t i v e s - c o m b i n i n g i n new ways o p p o r t u n i t i e s , communi ty needs and h o s p i t a l c a p a b i l i t i e s . I n o r d e r f o r s t r a t e g i c p l a n n i n g t o t a k e p l a c e , t h e r e must be a p l a n n i n g p r o c e s s t h a t s t i m u l a t e s e n t r e p r e n e u r i a l t y p e t h i n k i n g and an o r g a n i z a t i o n a l v a l u e s y s t e m t h a t r e i n f o r c e s b o a r d and management ' s commitment t o t h e h o s p i t a l . s t r a t e g y . The v a l u e s y s t e m t h a t t h e h o s p i t a l must a d o p t s h o u l d c o n s i d e r f o u r common themes : 1. The v a l u e o f teamwork w h i c h l e a d s t o t a s k - o r i e n t e d o r g a n -i z a t i o n a l f l e x i b i l i t y . - 3 4 -2. E n t r e p r e n e u r i a l t y p e d r i v e o r t h e commitment t o making t h i n g s h a p p e n . 3. Open c o m m u n i c a t i o n r a t h e r t h a n t h e p r e s e r v a t i o n o f c o n f i d e n -i a l i t y . By open c o m m u n i c a t i o n , i t i s n o t n e c e s s a r y f o r s e n i o r management t o d i v u l g e e v e r y t h i n g , b u t a s a minimum a l l s t a f f i n t h e h o s p i t a l s h o u l d know t h e s t r a t e g y p u r p o s e s t h a t t h e i r a c t i o n s s e r v e . 4 . A s h a r e d b e l i e f t h a t t h e e n t e r p r i s e c a n l a r g e l y c r e a t e i t s own f u t u r e r a t h e r t h a n be b u f f e t e d i n t o a p r e d e t e r m i n e d c o r n e r by t h e w i n d s o f e n v i r o n m e n t a l c h a n g e . A s t r a t e g y t h a t meets t h e s e s p e c i f i c a t i o n s i s a l w a y s t h e p r o p e r s u b j e c t o f d i s c u s s i o n by t h e management and b o a r d , f o r s t r a t e g y i n a c h a n g i n g w o r l d o f h o s p i t a l s s h o u l d a l w a y s be e v o l v i n g w i t h e x p e r i m e n t a l o f f s h o o t s and i n f o r m a t i v e f o r a y s . P l e n t y o f room e x i s t s i n t h e c o u r s e o f t h e s e d e t e r m i n a t i o n s f o r i n c r e m e n t a l p r o c e s s e s and i n t u i t i v e j udgement . What b o a r d members must r e a l i z e i s t h a t s i g n i f i c a n t s t r a t e g i c s h i f t s i n l a r g e o r g a n i z a t i o n s t a k e y e a r s , i f n o t d e c a d e s , t o a c c o m p l i s h . C o n s e q u e n t l y , i t i s r a r e f o r a s i n g l e p e r s o n t o m a s t e r m i n d a c o m p l e t e change i n a ma jo r o r g a n i z a t i o n ' s t o t a l s t r a t e g y - a l t h o u g h t h i s c a n o c c u r i n a t i m e o f c r i s i s o r when an i n d i v i d u a l ' s t e n u r e i s e x c e p t i o n a l l y l o n g . What one s e e s i n t h e s h o r t r u n a s an i m p o r t a n t s t r a t e g i c s h i f t v e r y o f t e n t u r n s o u t u n d e r i n v e s t i g a t i o n t o be p a r t o f a much l o n g e r c o n t i n -u i t y t h a t h a s been b u i l d i n g f o r some y e a r s and w i l l l a t e r g e n t l y m u t a t e and e v o l v e i n t o q u i t e a d i f f e r e n t fo rm t h a n i t now p o s s -- 35 -e s s e s . T h o s e who w i s h t o shape s t r a t e g y i n l a r g e o r g a n i z a t i o n s must l e a r n t o l i v e w i t h and manage t h i s c o n t i n u o u s l y e v o l v i n g , s o m e t i m e s a m b i g u o u s , c o n s e n s u s - c r e a t i n g s y s t e m a t i c u s e o f p l a n -n i n g a s a management t o o l t o b e s t p o s i t i o n t h e c o r p o r a t i o n t o s e t and meet i t s g o a l s i n b o t h t h e s h o r t and l o n g t e r m . One o f i t s most i m p o r t a n t t r a i t s i s a d e e p - r o o t e d r e o r i e n t a t i o n i n t h i n k i n g t h r o u g h o u t t h e o r g a n i z a t i o n t o w a r d s t r a t e g i c management i a s a s o c i a l l y o r i e n t e d b u s i n e s s . The u n d e r s t a n d i n g and c o m m i t -ment o f t h e C . E . O . , b o a r d o f d i r e c t o r s , a n d , i n a h o s p i t a l s e t t i n g , o f t h e t o p p h y s i c i a n s , a r e c r i t i c a l i n g r e d i e n t s i n s t r a t e g i c p l a n n i n g . C o n t r a r y t o t h e o p i n i o n v o i c e d b y w r i t e r s , and o t h e r s , s t r a t e g i c p lanning d o e s n o t i n v o l v e i t s e l f i n any way w i t h t h e s e t t i n g o f o b j e c t i v e s , even l o n g - r a n g e o n e s . S t r a t e g i c p l a n n i n g and l o n g - r a n g e p l a n n i n g a r e n o t t h e same t h i n g . The ma jo r d i f f -e r e n c e s be tween t h e s e two t y p e s o f p l a n n i n g a r e b o t h d r a m a t i c and f a r - r e a c h i n g , e s p e c i a l l y i n h e a l t h c a r e o r g a n i z a t i o n s . L o n g -r a n g e o b j e c t i v e s c a n n o t and s h o u l d n o t be s e t u n t i l s t r a t e g i c p l a n n i n g h a s been c o m p l e t e d . The examp le o f t e n c i t e d i s t h a t you f i r s t d e c i d e on y o u r v a c a t i o n d e s t i n a t i o n b e f o r e commencing y o u r p l a n n i n g on how t o t r a v e l o r what t o t a k e . S t r a t e g i c p l a n n i n g c o n c e r n s i t s e l f w i t h e s t a b l i s h i n g t h e m a j o r d i r e c t i o n s o f t h e o r g a n i z a t i o n , e g . what i s i l s p u r p o s e / m i s s i o n , m a j o r c l i e n t s t o s e r v e , m a j o r p r o g r a m s t o p u r s u e , m a j o r g e o g r a p h i c a l a r e a , and m a j o r d e l i v e r y a p p r o a c h e s . I t i s b r o a d and c o n c e r n s i t s e l f w i t h b o t h ends and means. U n t i l t h e s e d i r e c t i o n s have been - 36 -c a r e f u l l y t h o u g h t t h r o u g h and d e c i d e d u p o n , i t i s f o o l h a r d y f o r an o r g a n i z a t i o n t o d e t e r m i n e what i t i s g o i n g t o d o . B a s i c a l l y , s t r a t e g i c p l a n n i n g i s d i s t i n g u i s h e d f r o m t r a d -i t i o n a l p l a n n i n g by t h r e e c h a r a c t e r i s t i c s : 1. S t r a t e g i c p l a n n i n g e x a m i n e s t h e o r g a n i z a t i o n i n t h e c o n t e x t o f i t s e n v i r o n m e n t . A s h o s p i t a l s f a c e i n c r e a s i n g c o m p e t i t i o n f rom e a c h o t h e r and f r o m new t y p e s o f p r o v i d e r s , t h i s a p p r o a c h i s e s s e n t i a l i n i d e n t i f y i n g o p t i o n s f o r t h e f u t u r e . 2. S t r a t e g i c p l a n n i n g r e c o g n i z e s t h a t b u s i n e s s o r g a n i z a t i o n s a r e made up o f a number o f s u b - u n i t s , o r l i n e s o f b u s i n e s s , e a c h o f w h i c h may p l a y a d i f f e r e n t r o l e i n c o n t r i b u t i n g t o t h e a c h i e v e m e n t o f o v e r a l l c o r p o r a t e g o a l s . T h i s c o n c e p t i s p a r t i c u l a r l y a p p r o p r i a t e t o h o s p i t a l s , whose r o l e s a r e becoming i n c r e a s i n g l y d i v e r s i f i e d . 3. S t r a t e g i c p l a n n i n g e m p h a s i z e s t h a t r e s o u r c e s a r e l i m i t e d . An a c h i e v a b l e s t r a t e g i c p l a n must a s s i g n p r i o r i t i e s t o e a c h l i n e o f b u s i n e s s . I n o r g a n i z a t i o n s one m a j o r g o a l i s a imed a t b r i n g i n g a b o u t o r g a n i z a t i o n a l o r b e h a v i o u r a l change i n one fo rm o r a n o t h e r . O b -v i o u s l y t h i s t y p e o f c h a n g e d o e s n o t o c c u r o v e r n i g h t . The l o n g e r t h e p e r i o d o f t i m e i t t a k e s t o a c c o m p l i s h , t h e g r e a t e r becomes t h e i m p o r t a n c e o f s t r a t e g i c p l a n n i n g t o h e l p e n s u r e t h a t t h e o r g a n i z a t i o n i s a imed i n t h e p r o p e r d i r e c t i o n o r d i r e c t i o n s . T h i s i s t h e p r i m a r y r o l e o f s t r a t e g i c p l a n n i n g . The f o l l o w i n g i s a b r i e f and common l i s t o f c h a r a c t e r i s t i c s o f s t r a t e g y . I t must be u n d e r s t o o d t h a t n o t a l l t h e s e c h a r a c t -- 37 -e r i s t i c s w i l l be found i n e v e r y s t r a t e g i c d e c i s i o n b u t many o f them w i l l bs. These c h a r a c t e r i s t i c s i n c l u d e : 1. Tends t o change t h e n a t u r e o f t h e o r g a n i z a t i o n ( i t s p u r p o s e o r d i r e c t i o n ) 2. I n v o l v e s u n u s u a l r i s k i n t h e e v e n t o f f a i l u r e 3. I n v o l v e s u n u s u a l b e n e f i t s i n t h e e v e n t o f s u c c e s s 4. I n v o l v e s u n u s u a l commitment ( t i m e , money, e f f o r t f o r p r o l o n g e d p e r i o d o f t i m e ) » 5. I n v o l v e s h i g h - l e v e l a p p r o a c h 6. U s u a l l y i n v o l v e s a s e r i e s o f d e c i s i o n s 7. F r e q u e n t l y h a n d l e d by a s e n i o r c o m m i t t e e o r t a s k f o r c e 8. Once s e t i n m o t i o n t h e y c a n n o t be e a s i l y r e v e r s e d . S t r a t e g i c p l a n n i n g i s more o f an a r t t h a n a s c i e n c e . N o t e v e r y o n e c a n do i t and t h e e d u c a t i o n a l p r o c e s s c a n be f r u s t r a t i n g . The p r o c e s s o f s t r a t e g i c p l a n n i n g i s what i s i n t e r e s t i n g . W h i l e t h e t e r m i s n o t u s e d , one c o u l d n o t h e l p b u t i m a g i n e a " z e r o b a s e d p l a n n i n g " m o d e l , where b e f o r e l o o k i n g i n w a r d t o d e t e r m i n e "where t o f r o m h e r e ? " and p r i o r i t i e s , we must l o o k t o o u r e x t e r n a l e n v i r o n m e n t t o d e t e r m i n e what i s n e e d e d . S t r a t e g y i s a l i v i n g c o n c e p t , w i t h c e r t a i n f u n d a m e n t a l c h a r a c t e r - d e t e r m i n i n g p u r p o s e s r e m a i n i n g e s s e n t i a l l y u n c h a n g e d . I n a d d i t i o n , i t i s i m p o r t a n t t o c o n s i d e r t h a t s t r a t e g i c p l a n n i n g , l i k e a l l p l a n n i n g , must c e a s e t o be a management e x e r c i s e w h i c h one c o m m i s s i o n s e v e r y t h r e e t o f i v e y e a r s . T h e r e i s a need f o r d a y - t o - d a y a w a r e n e s s o f t h e l i m i t i n g e f f e c t o f t o d a y ' s d e c i s i o n s on an o r g a n i z a t i o n ' s l o n g - t e r m o p t i o n s . - 38 -The q u e s t i o n h a s o f t e n a r i s e n a s t o w h e t h e r one c a n c r e a t e a p l a n n i n g p r o c e s s and be p l a n n i n g w i t h o u t p r o d u c i n g a p l a n . (8) And a l s o , how e x p l i c i t t h i s p l a n s h o u l d be s t a t e d . Too o f t e n , i n a l l g e n e r a t i o n s o f p l a n n i n g , we have f a l l e n i n t o t h e t r a p o f c o n s i d e r i n g p l a n n i n g t o be a s o p h i s t i c a t e d q u a n t i t a t i v e m e t h o d , a w r i t t e n d o c u m e n t , o r a s e t o f r e g u l a t o r y r e q u i r e m e n t s . T h i s a p p a r e n t d i c h o t o m y between p l a n n i n g p r o c e s s e s and w r i t t e n p l a n s show t h a t s t r a t e g i c p l a n n i n g i s on a s p e c t r u m . A t t h e one end you h a v e h o s p i t a l s t h a t a r e p r o c e s s - o r i e n t e d where p l a n n i n g p r o c e s s e s a r e i n h e r e n t t h r o u g h o u t b o a r d and a d m i n i s t r a t i v e s t r u c t u r e s and a c t i v i t i e s . The p r o c e s s p l a n n e r k e e p s h i m s e l f i n f o r m e d a b o u t a w i d e r a n g e o f o p e r a t i n g d e c i s i o n s b e i n g made a t d i f f e r e n t l e v e l s i n t h e h o s p i t a l . The p r o c e s s i n v o l v e s a s e r i e s o f a c t i v i t i e s w h i c h c r e a t e c o l l e c t i v e l y a s t r a t e g i c g u i d a n c e s y s t e m t o move t h e f a c i l i t y t o w a r d s i t s f u t u r e . The c r e a t i o n o f a " p l a n " i s n o t s t r e s s e d . C a r r i e d t o an e x t r e m e we f i n d b o a r d s and managements t h a t save t h e i r e n e r g y f o r t h o s e few i s s u e s , d e c i s i o n s , o r p r o b l e m s t o w h i c h t h e y s h o u l d g i v e t h e i r p e r s o n a l a t t e n t i o n . They a r e s e n s i t i v e t o t h e power s t r u c t u r e i n t h e i r o r g a n i z a t i o n , work t h r o u g h p e o p l e i n d i f f e r e n t p a r t s o f t h e o r g a n i z a t i o n who have i d e a s t h e y l i k e , and d e v e l o p a h a z y s e t o f g o a l s , a h a z y t i m e t a b l e , and a h a z i e r n o t i o n o f how t h e y c a n r e a c h t h e s e g o a l s and f i n d ways t o b y p a s s o p p o s i t i o n . T h i s t y p e c f p l a n n e r must know how t o s a t i s f y t h e o r g a n i z a t i o n t h a t i t h a s a s e n s e o f d i r e c t i o n w i t h o u t e v e r g e t t i n g h i m s e l f c o m m i t t e d p u b l i c l y t o a s p e c i f i c s e t o f o b j e c t i v e s . P r a c t i s i n g t h e a r t o f i m p r e c i s i o n , t h e y commun ica te o b j e c t i v e s o v e r t i m e by p r o m o t i n g a c o n s i s t e n c y o r p a t t e r n i n o p e r a t i n g d e c i s i o n s and - 3 9 -a v o i d s management by o b j e c t i v e s and o t h e r p o l i c y s t r a i g h t -j a c k e t s . T h i s method assumes a f u t i l i t y i n t r y i n g t o push t o t a l p a c k a g e s o f p u r p o s e s and p o l i c i e s t h r o u g h an o r g a n i z a t i o n . A t t h e o t h e r end o f t h e s p e c t r u m a r e h o s p i t a l s w h i c h a r e p l a n - o r i e n t e d , where t h e f o c u s i s on t h e p r e p a r a t i o n o f a comp-r e h e n s i v e l o n g - r a n g e p l a n a s t h e n e c e s s a r y document f o r t h a t i n s t i t u t i o n ' s d e c i s i o n a m a k e r s . The i n s t i t u t i o n w h i c h i s p l a n -o r i e n t e d r e f l e c t s t h e b e l i e f t h a t a c o m p r e h e n s i v e l o n g - r a n g e p l a n i s a n e c e s s a r y t o o l t o h e l p management keep t h e i n s t i t u t i o n c o g n i z a n t o f i t s m i s s i o n and g o a l s , t h r o u g h t h e a n a l y s i s and d o c u m e n t a t i o n o f t h e i n s t i t u t i o n ' s e n v i r o n m e n t , s e r v i c e a r e a s , f a c i l i t i e s and p r o g r a m s , u t i l i z a t i o n e x p e r i e n c e , e t c . The p l a n - o r i e n t e d p l a n n e r p r o d u c e s h i g h l y f o r m a l i z e d s t r a t e g i c p l a n s , a p r o c e s s w h i c h may be v i e w e d a s s t e r i l e , b u t one w h i c h i s p r o m o t e d by p r o f e s s i o n a l p l a n n e r s . I n r e c e n t y e a r s , t h e r e h a s been an i n c r e a s i n g c h o r u s o f d i s c o n t e n t c o n c e r n i n g t h i s t y p e o f s t r a t e g i c p l a n n i n g . Many managers a r e c o n c e r n e d t h a t d e s p i t e e l a b o r a t e s t r a t e g i c p l a n s and p l a n n i n g s y s t e m , c o s t l y s t a f f s f o r t h i s p u r p o s e , and ma jo r commitments o f t h e i r own t i m e , t h e i r most e l a b o r a t e s t r a t e g i e s n e v e r g e t i m p l e m e n t e d . These e x e c u t i v e s and t h e i r b o a r d s have g e n e r a l l y f a l l e n i n t o t h e c l a s s i c t r a p o f t h i n k i n g o f s t r a t e g y f o r m u l a t i o n and i m p l e m e n t a t i o n a s s e p a r a t e s e q u e n t i a l p r o c e s s e s . They have r e l i e d on t h e awesome r a t i o n a l i t y o f t h e i r f o r m a l l y d e r i v e d s t r a t e g i e s and t h e i n h e r e n t power o f t h e i r p o s i t i o n s t o c a u s e t h e i r o r g a n i z a t i o n s t o r e s p o n d . When t h i s d o e s n o t o c c u r , t h e y become b e w i l d e r e d , i f n o t f r u s t r a t e d and a n g r y . - HO -Somewhere i n t h e m i d d l e o f t h i s s p e c t r u m i s an a l t e r n a t i v e mode l o f s t r a t e g i c p l a n n i n g i n w h i c h b o t h p r o c e s s o r i e n t a t i o n and t h e p l a n o r i e n t a t i o n a r e r e p r e s e n t e d and where t h e o r g a n i z a t i o n s c a n a p p a r e n t l y b e n e f i t f r om t h e b e s t o f b o t h w o r l d s . T h i s a p p r o a c h a l l o w s t h e managers who o p e r a t e w i t h a c e r t a i n amount o f l o g i c a l  i n c r e m e n t a l i s m t o b u i l d t h e seeds o f u n d e r s t a n d i n g , i d e n t i t y , and commitment i n t o t h e v e r y p r o c e s s e s t h a t c r e a t e d t h e i r s t r a t e g i e s . By t h e t i m e t h e s t r a t e g y b e g i n s t o c r y s t a l i z e i n f o c u s , p i e c e s o f i t a r e a l r e a d y b e i n g i m p l e m e n t e d . Th rough t h e i r s t r a t e g i c f o r m -u l a t i o n p r o c e s s e s , t h e y have b u i l t a momentum and p s y c h o l o g i c a l commitment t o t h e s t r a t e g y , w h i c h c a u s e s i t t o f l o w t o w a r d f l e x i b l e i m p l e m e n t a t i o n . C o n s t a n t l y i n t e g r a t i n g t h e s i m u l t -aneous i n c r e m e n t a l p r o c e s s e s o f s t r a t e g y f o r m u l a t i o n and i m p l e m e n t -a t i o n i s t h e c e n t r a l a r t o f e f f e c t i v e s t r a t e g i c management. A s t u t e managers combine and r e s t r u c t u r e t h e s e p a r a t e p r o p o s a l s b e f o r e them t o move p a r t w a y t o w a r d t h e i r o b j e c t i v e s . They i d e n t i f y o p p o r t u n i t i e s and r e l a t i o n s h i p s i n t h e s t r e a m o f o p e r a t i n g p r o b l e m s and d e c i s i o n s . Qu inn (1980) f i n d s t h a t managements " a r r i v e a t t h e i r s t r a t e g i c g o a l s t h r o u g h h i g h l y i n c r e m e n t a l p r o c e s s e s , r a t h e r t h a n t h r o u g h t h e k i n d s o f s t r u c t u r e d a n a l y s i s o f t e n p r e s c r i b e d o r ' r e q u i r e d ' a c c o r d i n g t o management dogma." T h i s p o i n t o f v i e w has w i d e s u p p o r t , e s p e c i a l l y among s t u d e n t s o f o r g a n i z a t i o n a l b e h a v i o u r . Henry M i n t z b e r g , a u t h o r o f "The N a t u r e o f M a n a g e r i a l Work" ( 1 9 7 3 ) , and o f t h r e e HBR a r t i c l e s , b e l i e v e s t h a t s t r a t e g y i s a p a t t e r n i n a s t r e a m o f d e c i s i o n s and c a n be q u i t e d i v o r c e d f r o m i n t e n t . S t r a t e g y emerges f rom b e h a v i o u r a n d , i f a r t i c u l a t e d , may so c o n s t r a i n c r e a t i v e members o f t h e o r g a n i z a t i o n t h a t t h e s t r e a m o f i n n o v a t i o n w i l l d r y u p . How e x p l i c i t and a r t i c u l a t e s h o u l d be t h e p a t t e r n o f p u r p o s e s and p o l i c i e s t h a t f l o w f rom t h i s i n c r e m e n t a l p r o c e s s t h a t d e f i n e s t h e b u s i n e s s o f a h o s p i t a l and t h e k i n d o f h o s p i t a l i t i s and s h o u l d become? The u s e s o f a m b i g u i t y a r e s e n s e d by e v e r y p o l i t i c a l l y w i s e a d m i n i s t r a t o r , who by d e f i n i t i o n i s s e n s i t i v e t o t h e ways i n w h i c h t h e p u r p o s e s and p e r c e p t i o n s o f i n d i v i d u a l s d i v e r t o r even d i s r u p t c o - o p e r a t i v e a c t i o n . B u t u n l e s s a b o a r d o f d i r e c t o r s knows what t h e p u r p o s e s and p o l i c i e s o f t h e h o s p i t a l a r e , i t c a n h a r d l y r e v i e w o r t a k e p a r t i n t h e s u b t l e p r o c e s s e s t h a t p r o d u c e t h e m , a p p r o v e t h e o u t c o m e , o r have c o n f i d e n c e i n t h e w isdom o f t h e r i s k s b e i n g u n d e r t a k e n . F o r a b o a r d t h e o p p o r t u n i t y t o c o n s i d e r an a r t i c u l a t e d s t r a t e g y , w h a t e v e r shape i t i s i n o r w h a t e v e r u n c e r t a i n t y i t s t i l l h a s n o t a d d r e s s e d , c a n be a p r o d -u c t i v e way t o p e r f o r m i t s t w i n f u n c t i o n s o f s u p p o r t i n g and e v a l -u a t i n g t h e p e r f o r m a n c e o f i t s C . E . O . and h i s i m m e d i a t e s e n i o r a s s o c i a t e s . The m a i n r e a s o n f o r a t t e m p t i n g t o make s t r a t e g y e x p l i c i t i s t o i d e n t i f y a r e a s o f i n d e c i s i o n and e x p o s e i n d e c i s -i v e n e s s t o r e a s o n a b l e d i s c i p l i n e . "The m a s t e r who knows b u t w o n ' t t e l l i s no w o r t h i e r t h a n t h e p r e t e n d e r who d o e s n ' t know and t h e r e f o r e c a n ' t t e l l . " N e i t h e r g e t s t h e b e n e f i t o f c o u n s e l f r o m h i s a s s o c i a t e s i n management o r on t h e b o a r d . O p p o s i t i o n i s s o m e t i m e s b e t t e r f a c e d i n open argument t h a n m a n i p u l a t e d i n a c c o r d a n c e w i t h a h i d d e n and p e r h a p s c o n f u s e d a g e n d a . Candor i s becoming r e c o g n i z e d more and more w i d e l y a s a d m i n i s t r a t i v e l y u s e f u l and a l s o i n f o r m a t i v e . (9 ) I f t h e g o a l s o f t h e o r g a n i z a t i o n and t h e p r i n c i p a l means f o r g e t t i n g t h e r e c a n be c o m m u n i c a t e d , t h e n p e o p l e o f l i k e m i n d , a t t r a c t e d and h e l d t o a h o s p i t a l b e c a u s e o f what i t s e e k s t o b e , c a n commit t h e i r e n e r g y and c r e a t i v i t y t o i t w i t h o u t f o r e v e r b e i n g t o l d o r h a v i n g t o i m p r o v i s e what t o d o . I t h a s been s a i d f o r s t r a t e g i c p l a n n i n g t o be s u c c e s s f u l , h o s p i t a l s must i n v o l v e a p p r o p r i a t e power b a s e s i n t h e p r o c e s s . These g r o u p s i n c l u d e t r u s t e e s and p h y s i c i a n s , s t a f f , b u s i n e s s , l a b o u r , p a t i e n t s , communi ty g r o u p s , l e g i s l a t o r s , and many o t h e r s . The a p p r o p r i a t e power b a s e s v a r y among h o s p i t a l s so e a c h h o s p i t a l must i d e n t i f y t h e most i m p o r t a n t o n e s i n i t s own s p e c i f i c s i t u a t i o n . I f t h e a p p r o p r i a t e power b a s e s a f f e c t e d by t h e c h a n g e h a v e an o p p o r t u n i t y t o p a r t i c i p a t e i n t h e p r o c e s s a s e a r l y a s p o s s i b l e , a r e aware o f t h e p r o c e s s , and f u l l y k n o w l e d g e a b l e o f t h e end r e s u l t , s u c c e s s i s more l i k e l y t o be a c h i e v e d . I n t h i s p r o c e s s t h e f i n a n c i a l , t e c h n i c a l , m a t e r i a l and human r e s o u r c e s c a n be p l a n n e d f o r and s o u g h t o u t i n a d v a n c e and t h e o r g a n i z a t i o n a l s t r u c t u r e s and s y s t e m s w i l l t h e n be d o m i n a t e d by t h e h o s p i t a l ' s g e n e r a l p u r p o s e r a t h e r t h a n by t h e s p e c i a l p u r p o s e s o f a f e w . I f t h e s t r a t e g y i s c h a l l e n g i n g , members o f t h e o r g a n i z a t i o n c a n be s t i m u l a t e d t o r e s p o n d w i t h more t h a n r o u t i n e p e r f o r m a n c e , w i t h new ways o f r e a c h i n g g o a l s , 1 and w i t h s o l u t i o n s t o p r o b l e m s e n c o u n t e r e d on t h e t r a c k . A band o f p e o p l e c a s u a l l y g a t h e r e d t o work f o r a l i v e l i h o o d c a n be made i n t o an i n s t i t u t i o n embody ing v a l u e s , c r e a t i n g l o y a l t y , and p r o v i d i n g n o n - m a t e r i a l r e w a r d s , t o say n o t h i n g o f p r o f i t i n g f r o m e f f i c i e n t o r f i r s t - c l a s s p e r f o r m -a n c e . I f t h e s t r a t e g y i s known, r a t h e r t h a n o b s c u r e d i n i n c r e -- 43 -mental wandering or muddling-through, where only the leader (and often not even he) knows what i s really going on, then i t s evolution cannot really be monitored. A changing organ-ization w i l l have untold d i f f i c u l t y in coming to terms with a changing environment. Successful "strategic planning" in health care w i l l depend on our a b i l i t y to overcome the natural tendency to begin the process with old assumptions and beliefs which tend to limit objective and meaningful assessment. They also depend on a purpose-ful move towards a leadership position. Given the apparent importance of strategic planning for hospitals, why has i t not been utilized? Ironically, most obstacles are self-imposed. They arise either because the purpose of planning i s poorly understood, or because the participant's organizational mission (mythologies) about what their health care institution should be do not mesh with market (demand) re a l i t i e s . Too often, hospital planning has been supply-driven rather than based on patient demand. This i s a backward approach to planning. In l i s t i n g these obstacles i t appears the most prevalent are: 1. Lack of acceptance of strategic planning as a necessary gover-nance and management tool. This requires bringing together the divergent needs of p r o f i t a b i l i t y and an even cash flow with the traditional strong sense of community responsibility. Often the latter outweighs an appreciation of f i s c a l realities. 2. Resistance to the adoption of a strategic process and program. This can be overcome i f planning goals clearly are understood - 44 -and p a r t i c i p a t i o n i s e n c o u r a g e d i n p l a n d e v e l o p m e n t . 3. L a c k o f a d e q u a t e management i n f o r m a t i o n s y s t e m s . I n many s m a l l h o s p i t a l s t h i s i s n o t a f f o r d a b l e and a v i t a l s u p p o r t f o r d e c i s i o n s i s l o s t . 4. P o o r d e c i s i o n m a k e r s . The p l a n n i n g c o m m i t t e e must be a s e l e c t g r o u p o f i n d i v i d u a l s who have c o n s i s t e n t l y a d d r e s s e d p r o b l e m s and i s s u e s and have h a n d l e d them i n a s y s t e m a t i c and t h o u g h t f u l manner . 5 . P o o r demand f o r e c a s t s . S h i f t s i n demands and any e n v i r o n m e n t a l c h a n g e must be a n t i c i p a t e d and q u a n t i f i e d (whenever p o s s i b l e ) i n o r d e r t o match demands , g o a l s , and r e s o u r c e s . 6. L a c k o f r e a l i s t i c and m e a s u r a b l e p l a n n i n g o b j e c t i v e s . One o f t h e h a r d e s t t a s k s i s s t a y i n g on c o u r s e . P l a n n i n g o b j e c t i v e s s h o u l d be r e l a t e d t o a p r o g r a m w i t h a d e f i n e d t i m e t a b l e and a c a l e n d a r o f r e v i e w . 7. L a c k o f c a n d o r and o b j e c t i v i t y . Some p a r t i c i p a n t s may be t o o c l o s e t o a p r o g r a m t o v i e w i t s r e s u l t s o b j e c t i v e l y . 8 . L a c k o f f o l l o w - t h r o u g h and e v a l u a t i o n . U s u a l l y more e f f o r t and r e s o u r c e s a r e c o m m i t t e d t o d e v e l o p m e n t o f t h e s t r a t e g i c p l a n t h a n a r e i n v e s t e d i n i t s e v a l u a t i o n . A c c o u n t a b i l i t y and c o n t r o l r e s t s on t h e e a r l y d e v e l o p m e n t o f p e r f o r m a n c e m e a s u r e s , d e f i n i t i o n o f r e s p o n s i b i l i t i e s and s c h e d u l e d r e v i e w s . E q u a l l y i m p o r t a n t i s d e l i n e a t i o n o f a means o f amending t h e document i t s e l f . I t i s t h e s e s u c h o b s t a c l e s t h a t must be ove rcome and by i n d i c a t i n g t h e s t e p - b y - s t e p p r o c e d u r e o f s t r a t e g i c p l a n n i n g , t h e r e a d e r w i l l - H5 -see i t i s n o t a s f o r m i d a b l e a s t h o u g h t . A s s t r a t e g i c p l a n n i n g i s c o n t i n u o u s i n n a t u r e w i t h no n a t u r a l b e g i n n i n g o r e n d , i t i s l o g i c a l t o v i e w s t r a t e g i c p l a n n i n g a s a p r o c e s s o r c y c l e h a v i n g t h e f o l l o w i n g s t e p s o r p h a s e s : 1. R e c o g n i z e t h e need and make t h e commitment . 2 . O r g a n i z e f o r p l a n n i n g . 3 . D e t e r m i n e , c o l l e c t and a n a l y z e d a t a on o r g a n i z a t i o n and e n v i r o n -ment . T h i s i n v o l v e s mak ing f o r e c a s t s and p r e d i c t i n g t r e n d s and i n d i c a t e s where we a r e . 4 . D e t e r m i n e t h e o r g a n i z a t i o n ' s p u r p o s e - where we want t o b e . 5 . S t e p s 3 & 4 a r e c o m b i n e d t o d e t e r m i n e a " d i s t a n c e " between where we a r e and where we want t o b e . To c l o s e t h i s d i s t a n c e we must a n a l y z e o u r d a t a b a s e i n t e r m s o f w e a k n e s s , o p p o r t u n i t i e s , t h r e a t s and s t r e n g t h s . 6. G o a l s a r e a r t i c u l a t e d t o c l o s e t h e d i s t a n c e and o b j e c t i v e s a r e d e s i g n e d and s p e c i f i e d t o a c h i e v e t h e g o a l s . A t t h i s s t a g e a l t e r n a t i v e s a r e s e l e c t e d and c o u r s e s o f a c t i o n c h o s e n . 7. The p l a n i s m a r k e t e d and i m p l e m e n t e d . 8 . The p l a n and p r o c e s s i s m o n i t o r e d and e v a l u a t e d , (page 50) Depend ing upon w h i c h a r t i c l e i s f i r s t g r a s p e d , a d i f f e r e n t s e t o f t e r m i n o l o g y c a n be i d e n t i f i e d f o r each a p p r o a c h . Nowhere i s t h i s c o n f u s i o n more d e m o n s t r a t e d t h a n i n t h e m u l t i p l e and i n t e r c h a n g e a b l e u s a g e o f t h e common t e r m i n o l o g y s u c h a s m i s s i o n , p h i l o s o p h y , s t r a t e g y , g o a l s o r o b j e c t i v e s . A t t h i s p o i n t s p e c i f i c d e f i n i t i o n s f o r t h e s e c o n c e p t s a r e p r e s e n t e d i n o r d e r t h a t t h e i r d i f f e r e n c e (and i n t e r r e l a t e d n e s s ) i n . t h e p r o c e s s may be d e m o n s t r a t e d . - 46 -To e l i m i n a t e c o n f u s i o n and t o c r e a t e c o n s i s t e n c y I have d e p a r t e d f r o m t h e l i t e r a t u r e and s o u g h t a s y l u m i n t h e d i c t i o n a r y . PHILOSOPHY/PURPOSE/MISSION The d i c t i o n a r y s u g g e s t s t h a t t h e s e t e r m s may be and s h o u l d be u s e d i n t e r c h a n g e a b l y . I t s t a t e s t h a t a P h i l o s o p h y i s t h e g u i d i n g p r i n c i p l e s f o l l o w e d i n a p a r t i c u l a r a c t i v i t y o r f i e l d o f k n o w l e d g e . In t h i s c a s e - h e a l t h c a r e . P u r p o s e adds t o t h i s t h e i d e a s o f r e s o l u t i o n o r d e t e r m i n a t i o n t o c a r r y o u t what one p r o p o s e s . I t i s u s e d t o g u i d e b o a r d p o l i c i e s . I t i s o f t e n i d e a l i s t i c and q u i t e g e n e r a l i z e d . G o a l s s t a t e m e n t s a r e d e r i v e d f r o m t h e m i s s i o n o r p h i l -o s o p h y s t a t e m e n t o f t h e o r g a n i z a t i o n . W h i l e s t i l l i d e a l i s t i c and r e m o t e , t h e s e s t a t e m e n t s a r e more s p e c i f i c t h a n t h e s t a t e m e n t o f p u r p o s e . They a r e u s e d t o g u i d e i n d i v i d u a l p o l i c y i s s u e s o r t o make d e c i s i o n s . They a l l o w f o r d i s c r i m i n a t o r y d e c i s i o n - m a k i n g when a l t e r n a t i v e d e c i s i o n s o r p o l i c i e s a r e p r e s e n t e d t o t h e o r g a n i z a t i o n . S t r a t e g y s t a t e m e n t s a r e d e r i v e d f rom t h e p e r i o d i c a s s e s s -ment o f t h e o r g a n i z a t i o n and i t s e n v i r o n m e n t i n t e r m s o f i t s c u r r e n t p o s i t i o n , t h e t r e n d s w h i c h a r e mov ing i t f o r w a r d i n t o t h e f u t u r e , and t h e d e s i r e d p o s i t i o n t o w h i c h t h e o r g a n i z a t i o n w i s h e s i t t o e v o l v e i n t h e f u t u r e . These s t a t e m e n t s u s u a l l y i d e n t i f y , d e s c r i b e and a r t i c u l a t e t h e a r e a s o f t h e d e s i r e d f u t u r e . The making o f d e c i s i o n s o r t h e s e t t i n g o f p o l i c y i s g o v e r n e d by t h e s e s t a t e m e n t s , i . e . p o l i c y i s s e t o r d e c i s i o n s a r e made t o t h e e x t e n t t o w h i c h t h e y work t o w a r d t h e c o n t e n t o f t h e s e s t a t e m e n t s . - 47 -THE STRATEGIC PLANNING PROCESS COMMITMENT ORGANIZE DATA BASE DEVELOPMENT I n t e r n a l Assessment E x t e r n a l Assessment Trends PHILOSOPHY , ; — (& D e s c r i p t i o n ) -—• Present P o s i t i o n P l a n n i n g Gap Desired P o s i t i o n W.O.T.S. (Where i d e o l o g y i s tampered by r e a l i t y ) J GOALS & OBJECTIVES IMPLEMENTATION EVALUATION - 48 -" O b j e c t i v e s " r e f e r s t o an end o r g o a l w i t h t h e i m p l i c a t i o n t h a t i t c a n be r e a c h e d . The o b j e c t i v e s a r e a n n u a l i z e d s t a t e m e n t s o f m e a s u r a b l e and a t t a i n a b l e p r o g r a m s , s e r v i c e s o r p r o d u c e c h a n g e s w h i c h a r e s e l e c t e d f rom among a l t e r n a t i v e p r o g r a m s and s e r v i c e s i n a manner c o n s i s t e n t w i t h t h e g o a l s and s u p p o r t o f t h e movement o f t h e o r g a n i z a t i o n t o w a r d t h e a t t a i n m e n t o f one o r more g o a l s . A s m e n t i o n e d i n t h e p r e v i o u s s e c t i o n , s t r a t e g i c p l a n n i n g i s n o t a s i n g l e a c t . I t i s a p r o c e s s o f c y c l e s c o n s i s t i n g o f many i n t e r r e l a t e d and i n t e r d e p e n d e n t s t a g e s o r s t e p s . T h e r e i s no n a t u r a l b e g i n n i n g o r e n d . I t i s a w h o l e s e r i e s o f i n t e r r e l a t e d a c t i v i t i e s t h a t must be segmented i n t o r e l a t e d , w o r k a b l e c o m p o n e n t s . I t m a t t e r s l i t t l e how t h e s e a c t i v i t i e s a r e d i v i d e d , a s l o n g a s t h e components o f any p h a s e a r e i n t e r r e l a t e d and l e a d t o mak ing t h e n e x t p h a s e more p r o d u c t i v e . The t a s k o f t h e p l a n n i n g c o m m i t t e e i s t o manage t h e s e p h a s e s , t h e i r c o m p o n e n t s , and t h e d e c i s i o n - m a k i n g p r o c e s s so t h a t t h e o u t p u t s a r e r e l e v a n t and p r o d u c t i v e f o r f u t u r e d e c i s i o n - m a k i n g p h a s e s . R e g a r d l e s s o f t h e t y p e o r s c o p e o f s t r a t e g i c p l a n n i n g , t h e f o l l o w i n g s t e p s must be c o m p l e t e d : 1. S t r a t e g i c P l a n n i n g Commitment ( r e c o g n i t i o n o f t h e need) P l a n n i n g i t s e l f r e q u i r e s p l a n n i n g and good p l a n n i n g o c c u r s o n l y when management makes a c o n s c i o u s e f f o r t t o i n c o r p o r a t e i t a s an o n g o i n g p a r t o f a d m i n i s t r a t i o n . The f i r s t p r o b l e m i n s e i z i n g t h e o p p o r t u n i t y t o d e v e l o p s t r a t e g i e s i s f o r t h e key d e c i s i o n - m a k e r s t o make a commitment t o t h e b e l i e f t h a t p l a n n i n g i s w o r t h w h i l e . T h i s commitment s h o u l d be - 4 9 -i n t h e fo rm o f a f o r m a l p o l i c y s t a t e m e n t . Even i n t h o s e few h o s p i t a l s c u r r e n t l y d o i n g s t r a t e g i c p l a n n i n g , t h i s commitment s h o u l d be r e s t a t e d as o f t e n t h e o r i g i n s o f t h e need have been f o r g o t t e n . The i d e a l s i t u a t i o n i s f o r t h e C . E . O . and t h e b o a r d c h a i r m a n t o s t a t e a t t h e n e x t b o a r d m e e t i n g - "We a r e t o d a y g o i n g t o commit o u r s e l v e s t o t h e commencement o f s t r a t e g i c p l a n n i n g . " T h i s i s t h e e a s i e s t and l e a s t p a i n f u l b e g i n n i n g . U n f o r t u n a t e l y , t h e demands o f t h e f u t u r e p r e s s l e s s u r g e n t l y t h a n t h o s e o f t h e p a s t and p r e s e n t , so t h i s s t e p i s no t t a k e n i n t h i s manner . B o a r d and management t i m e and t a l e n t i s so f o c u s e d on d e l i v e r i n g c a r e t h a t p r e s e r v e s p r e s e n t needs t h a t p l a n n i n g f o r t h e f u t u r e i s o f t e n p o s t p o n e d . O f t e n t h i s r e c o g n i t i o n o f need comes a b o u t f r o m a c r i s i s s i t u a t i o n and u s u a l l y t h e t e l l t a l e s i g n s o f c r i s i s a r e e v e r y w h e r e . The i n i t i a l p r o b l e m , i d e n t i f i c a t i o n o f t h e s i t u a t i o n , i s t h e need f o r someone t o r e c o g n i z e t h e g e n e r a l and s p e c i f i c s i g n s i n d i c a t i n g t h a t a c r i s i s i s f a c i n g t h e o r g a n i z a t i o n and t o c r e a t e a r e a l u n d e r -s t a n d i n g o f t h e need t o do s o m e t h i n g about t h e c r i s i s . When an o r g a n i z a t i o n i s i n a c r i s i s and i s a b l e t o r e c o g -n i z e t h a t c r i s i s , t h e b o a r d ' s r o l e w i l l be t h a t o f a t t e m p t i n g a t u r n - a r o u n d o f t h e h o s p i t a l . The word c r i s i s i m p l i e s a s e r i o u s need f o r improvement i n any o r g a n i z a t i o n and a t u r n - a r o u n d i s n e e d e d . I t s u g g e s t s t h a t , f o r one r e a s o n o r a n o t h e r , a h o s p i t a l r e q u i r e s a one s h o t e f f o r t t o remove o r r e v e r s e c e r t a i n e n t r e n c h e d s i t u a t i o n s and p r a c t i c e w h i c h , i f p e r m i t t e d t o c o n t i n u e , w o u l d l e a d t o t h e e v e n t u a l f a i l u r e o f t h e o r g a n i z a t i o n . T h e r e a r e h o s p i t a l s i n s i t u a t i o n s w h i c h by n a t u r e a r e t e r m i n a l and t h e o n l y c u r e f o r them i s t o c l o s e o r do a c o m p l e t e r e v e r s a l . To d e c i d e w h e t h e r a t u r n -- 50 -a r o u n d i s f e a s i b l e , a s t r a t e g i c p l a n n i n g p r o c e s s must be i n i t i a t e d . Whatever s i t u a t i o n an o r g a n i z a t i o n i s i n , be i t a c r i s i s o r good t i m e s , w h i c h w i l l be f ewer i n t h e f u t u r e , t h e p r o p e r t i m e t o s t a r t on s t r a t e g i c p l a n n i n g i s t h e p r e s e n t . T h e r e i s o n l y one t i m e , and t h a t i s now. A s i m p e r f e c t and u n r e a d y and u n t r a i n e d a s a l l t h e p a r t i c i p a n t s may b e , t h e p e r f e c t t i m e t o s t a r t i s a t t h e p r e s e n t . (10) E c k s t e i n ( 1 9 5 6 ) o b s e r v e d t h a t however i m p e r f e c t t h e p l a n n i n g t e c h n i q u e s a r e , i t i s t h e w i l l t o p l a n t h a t m a t t e r s . O r g a n i z e f o r S t r a t e g i c P l a n n i n g ( E s t a b l i s h m e n t o f t h e C o m m i t t e e ) Once c o m m i t t e d , t h e h o s p i t a l ' s t r u s t e e s and management s h o u l d be w i l l i n g t o become i n v o l v e d i n a l l a p p r o p r i a t e p l a n n i n g a c t i v i t i e s . The f i r s t a s p e c t s h o u l d i n v o l v e a m e a s u r i n g o f t h e i r own ( the b o a r d ' s ) p e r f o r m a n c e o r e f f e c t i v e n e s s . B o a r d s need t o examine t h e m s e l v e s p e r i o d i c a l l y t o m a i n t a i n o r i m p r o v e e f f e c t -i v e n e s s . T h i s s e l f - e x a m i n a t i o n s h o u l d e n s u r e a l l members o f t h e B o a r d p a r t i c i p a t e . The s t a r t i n g p o i n t i s t o d e t e r m i n e what a r e t h e B o a r d ' s d u t i e s t h a t need t o be e v a l u a t e d . (Append ix 1 ) . T h i s e v a l u a t i o n i s a two s t e p p r o c e s s . The f i r s t s t e p i s t o a s s e s s p e r f o r m a n c e o r o b t a i n i n f o r m a t i o n on p e r f o r m a n c e . The s e c o n d i s t o p l a c e t h a t p e r f o r m a n c e a g a i n s t some s t a n d a r d t o d e t e r m i n e i t s a d e q u a c y . I t i s e x p e c t e d t h a t i n t h e e v a l u a t i o n o f any g r o u p o r i n d i v i d u a l , s t r e n g t h s and w e a k n e s s w i l l be i d e n t i f i e d . The p u r p o s e o f t h e e v a l u a t i o n i s t o p e r m i t and e n c o u r a g e t h o s e c o n c e r n e d , t o c a p i t a l i z e on t h e i r s t r e n g t h s and t o c o m p e n s a t e a s much a s p o s s i b l e f o r t h e i r w e a k n e s s e s . I n e v a l u a t i n g a b o a r d o f d i r e c t o r s , i t n e e d s t o be examined i n two p e r s p e c t i v e s . The f i r s t i s a c o l l e c t i v e , a g r o u p o f p e o p l e w i t h g i v e n g r o u p t a s k s . The second i s a c o l l e c t i o n - 51 -o f i n d i v i d u a l s , each w i t h g i v e n t a s k s . The c h a i r m a n i s an i n d i v -i d u a l w i t h an a d d i t i o n a l s e t o f t a s k s , who assumes t h e l e a d e r s h i p r o l e , so t h a t e v e r y a c t i s i n t e n d e d t o h e l p a c c o m p l i s h t h e t a s k s o f t h e b o a r d a s a g r o u p . The e v a l u a t i o n p r o c e s s s h o u l d i n c l u d e t h e f o l l o w i n g q u e s t i o n s : 1. How e f f e c t i v e i s t h e b o a r d ? T h i s w i l l be d e t e r m i n e d by t h e d e g r e e t o w h i c h t h e b o a r d a c h i e v e s i t s s t a t e d g o a l s . 2 . How e f f i c i e n t i s t h e b o a r d ? T h i s w i l l be b e s t a n s w e r e d by t h e B o a r d ' s u s e o f i t s r e s o u r c e s , m a t e r i a l s , manpower, f a c i l i t i e s , and e q u i p m e n t . 3. How a c c e p t a b l e o r c r e d i t a b l e i s t h e b o a r d ? The r e s p o n s e t o t h e q u e s t i o n i s found i n a t t i t u d e s e x p r e s s e d by i n d i v i d u a l b o a r d members, h o s p i t a l s t a f f and members o f t h e c o m m u n i t y . C r e d i b i l i t y w o u l d a p p e a r t o be a d i r e c t f u n c t i o n o f t h e b o a r d ' s a b i l i t y t o i d e n t i f y p r o b l e m s and i s s u e s a f f e c t i n g t h e a t t a i n m e n t o f t h e s t a t e d g o a l s o f t h e h o s p i t a l , t o p l a n and i m p l e m e n t p r o g r a m s r e d u c i n g o r e l i m i n a t i n g p r o b l e m s , and i n g e n e r a l t o make d e c i s i o n s and a c t upon them. I f we want t h e b o a r d t o be e f f e c t i v e , e f f i c i e n t , and c r e d i b l e i n i t s w o r k , by i m p l i c a t i o n we e x p e c t i n d i v i d u a l b o a r d members t o meet t h e same c r i t e r i a . A b o a r d w i s h i n g t o examine i t s own work s h o u l d s e t a s i d e s e v e r a l d a y s on an a n n u a l b a s i s . W i t h a r e c o r d o f t h e p o l i c i e s , o b j e c t i v e s and g o a l s , i n f o r m a t i o n w o u l d be c o l l e c t e d t o e s t a b l i s h t h e s t r e n g t h s and w e a k n e s s e s w h i c h were p r e c e i v e d by s e v e r a l members o f t h e b o a r d . I n t h i s c a s e , s u b j e c t i v e i n f o r m a i t o n w i l l p l a y an i m p o r t a n t p a r t i n a s s e s s i n g t h e p e r f o r m a n c e o f t h e c o l l e c t i v e g r o u p . An a l t e r n a t i v e w o u l d be t o h i r e an e x t e r n a l c o n s u l t i n g f i r m w h i c h i s - 52 -f a m i l i a r w i t h t h e p r o c e s s o f e v a l u a t i o n , and w o u l d p r o c e e d t o c o n d u c t t h e needed s t u d i e s , t o c o l l a t e t h e i n f o r m a t i o n , and t o p r o v i d e a summary c o n c l u d i n g w i t h r e c o m m e n d a t i o n s f o r t h e b o a r d . New b o a r d a p p o i n t e e s s h o u l d know t h a t an e v a l u a t i o n p r o c e s s e x i s t s , and s h o u l d l o o k on i t as a p o s i t i v e p r o c e s s w h i c h a ims t o m a i n t a i n t h e h i g h e s t q u a l i t y o f s t a n d a r d s f o r t h e i n s t i t u t i o n . I have s u g g e s t e d t h a t b o a r d s o f t r u s t e e s s h o u l d be e v a l u a t e d on a r e g u l a r b a s i s i n c l u d i n g t h e c o l l e c t i v e and i n d i v i d u a l m e m b e r s h i p . I t i s e v i d e n t t h a t t h i s p a r t i c u l a r t o p i c has no t been e x p l o r e d i n any d e p t h o r t o any e x t e n t , as I f o u n d l i t t l e i n t h e l i t e r a t u r e t h a t d i s c u s s e d t h e i s s u e s o r d e s c r i b e d methods and a p p r o a c h e s t h a t m i g h t be c o n s i d e r e d . I f e e l t h i s i s due t o t h e f a c t t h a t c o n c e n t r a t i o n has been on t h e o p e r a t i o n a l a s p e c t s o f t h e i n s t i t u t i o n , w i t h v a r i o u s p r o f e s s i o n a l s and o r g a n i z a t i o n s w i t h i n t h e i n s t i t u t i o n h a v i n g h i g h p r i o r i t y , and l i t t l e t h o u g h t has been g i v e n t o t h e need t o a p p r a i s e and e v a l u a t e t h e b o a r d o f t r u s t e e s . However , one must a l w a y s be s e n s i t i v e t o t h e f a c t t h a t i n most c a s e s , t r u s t e e s a r e v o l u n t e e r s and c o n t r i b u t e t h e i r v a l u a b l e t i m e and e f f o r t w i t h l i t t l e , i f a n y , r e m u n e r a t i o n . One i n d i v i d u a l i n p a r t i c u l a r s h o u l d be e v a l u a t e d - t h e c h a i r p e r s o n o f t h e b o a r d . P e r h a p s one o f t h e key p o s i t i o n s i n t h e h o s p i t a l t o d a y i s t h a t o f t h e c h a i r m a n o f t h e b o a r d . I n t h e p a s t , t h e p o s i t i o n has o f t e n been an h o n o r a r y one t h a t d i d no t e n t a i l much i n t h e way o f t i m e o r d e t a i l e d i n v o l v e m e n t w i t h h o s p i t a l a c t i v i t y . The i n c r e a s i n g s c r u t i n y by t h e p u b l i c , , g e n e r a l l y t h r o u g h t h e m e d i a , o f p u b l i c i n s t i t u t i o n s now makes t h i s p o s i t i o n one o f g r e a t i m p o r t a n c e and r e s p o n s i b i l i t y . A s u s p i c i o n on t h e p a r t o f t h e p u b l i c t h a t many i n d i v i d u a l s emp loyed o r w o r k i n g i n t h e h o s p i t a l - 53 -have v e s t e d i n t e r e s t s t h a t p r e c l u d e t h e i r f a i r n e s s i n judgement and d e c i s i o n - m a k i n g , h a s made t h e p o s i t i o n o f c h a i r m a n o f t h e b o a r d o f i n c r e a s i n g i n p o r t a n c e . In e v a l u a t i n g t h e work o f t h e c h a i r m a n o f t h e b o a r d , we need t o assume t h a t he e x h i b i t s t h e s k i l l s and p e r f o r m s t h e t a s k s l i s t e d f o r i n d i v i d u a l b o a r d members and t h a t , i n a d d i t i o n , he s e r v e s a s c h a i r m a n on b e h a l f o f t h e b o a r d . The i n d i v i d -u a l i s t o t a l l y a c c o u n t a b l e t o t h e g r o u p , and h i s p e r f o r m a n c e s h o u l d t h e n be j u d g e d on h i s a b i l i t y , t o h e l p t h e b o a r d a c c o m -p l i s h i t s g o a l s . I n a d d i t i o n , t h e c h a i r m a n ' s c o m p e t e n c e i n t h e f o l l o w i n g r o l e s s h o u l d be e v a l u a t e d by t h e members o f t h e b o a r d , a s t h e y h a v e t h e c l e a r e s t and b r o a d e s t p e r s p e c t i v e o f t h e c h a i r m a n ' s a c t i v i t i e s : 1. A s a l e a d e r , i n d e v e l o p i n g g o a l s he must s t e e r t h e b o a r d t o w a r d s new c h a l l e n g e s , bu t away f rom s h o a l s and q u a g m i r e s ; 2. A s a c o m m u n i c a t o r , he w i l l need t o be d i r e c t w i t h o t h e r members o f t h e b o a r d , t h e h o s p i t a l a d m i n i s t r a t o r , and t h e c o n s t i t u e n c i e s t h e b o a r d r e p r e s e n t s ; 3 . A s an e v a l u a t o r , he w i l l a s s e s s t h e e f f e c t i v e n e s s o f i n d i v i d u a l b o a r d members; 4. He w i l l a c t a s a f a c i l i t a t o r and n e g o t i a t o r f o r members o f t h e b o a r d and on b e h a l f o f t h e b o a r d w i t h e x t e r n a l i n s t i t u t i o n s and a g e n c i e s ; and 5 . A s a c o u n s e l l o r f o r o t h e r b o a r d members, he w i l l o f f e r h i s p e r c e p t i o n s arid a d v i c e . The C . E . O . s h o u l d a l s o be e v a l u a t e d a t t h i s t i m e . H o w e v e r , t h i s w i l l be d i s c u s s e d under a s e p a r a t e s e c t i o n . S e l e c t i o n o f t h e s t r a t e g i c p l a n n i n g c o m m i t t e e may be t h e s i n g l e most i m p o r t a n t a c t i o n t h e b o a r d ' s c h a i r m a n c a n t a k e . COMMITTEE STRUCTURE: S i z e The l i t e r a t u r e v a r i e s on t h i s a s p e c t ; h o w e v e r , a r a n g e o f 7 - 1 2 a p p e a r s common and depends on what i s r e q u i r e d t o r e p r e s e n t a l l t h e e l e m e n t s o f t h e h i g h l y d i v e r s e c o n s t i t u e n t s . An a v e r a g e number may be 10. A common m i s t a k e i s t o make a c o m m i t t e e t o o l a r g e i n an a t t e m p t t o e n s u r e e v e r y v i e w p o i n t i s r e p r e s e n t e d . A l l ma jo r i n t e r e s t s s h o u l d be r e p r e s e n t e d b u t t h e c o m m i t t e e s h o u l d be s m a l l enough t o a l l o w f o r e x c h a n g e o f i d e a s . C o m p o s i t i o n A l l t h e key g r o u p s must be r e p r e s e n t e d : b o a r d , a d m i n i s t r a t i o n , m e d i c a l s t a f f , s e n i o r s t a f f , n u r s i n g , and t h e h o s p i t a l a u x i l i a r y . I t i s o n l y t h e i n c l u s i o n o f t h e l a s t g r o u p t h a t may r e q u i r e some e x p l a n a t i o n . The g o v e r n i n g b o a r d must a u t h o r i z e t h e a u x i l i a r y so i t c a n i d e n t i f y w i t h and f u n c t i o n on b e h a l f o f t h e h o s p i t a l . I f t h e h o s p i t a l i s u l t i m a t e l y r e s p o n s i b l e f o r t h e a c t i v i t i e s o f t h e a u x i l i a r y t h e n t h e y ( the h o s p i t a l ) must keep t h e a u x i l i a r y i n f o r m e d and i n v o l v e them i n p l a n n i n g . Whatever t h e a u x i l i a r y ' s r o l e ; be i t f u n d r a i s i n g o r v o l u n t e e r s e r v i c e s , i f t h e y a r e t o f u n c t i o n a s t r u s t e d members o f t h e o r g a n i z a t i o n a l team and t o f u n c t i o n w i t h e f f e c t i v e n e s s , t h e y need t o be a p p r i s e d o f c u r r e n t i s s u e s f a c i n g t h e f a c i l i t y , and t h e h e a l t h c a r e s y s t e m . They need t o be aware o f the f a c i l i t y ' s e x p e c t -a t i o n s and g o a l s and t o be i n v o l v e d i n s t r a t e g i c p l a n n i n g d i s c u s s i o n s . T h i s c a n be a c c o m p l i s h e d i n many w a y s : - 55 -t h e C . E . O . c a n a t t e n d a u x i l i a r y m e e t i n g s - a member o f t h e a u x i l i a r y c a n be a p p o i n t e d t o t h e b o a r d - a member o f t h e a u x i l i a r y c a n be a p p o i n t e d t o t h e b o a r d s t r a t e g i c p l a n n i n g c o m m i t t e e . The b e s t a p p r o a c h i s f o r a l l o f t h e above t o o c c u r . The l i t e r a t u r e i n d i c a t e s t h e need f o r communi ty r e p r e s e n t a t i o n w i t h a consumer p e r s p e c t i v e . T h i s i s s u b j e c t t o d i s c u s s i o n a s one c a n say a l l t h e b o a r d members a l r e a d y on t h e c o m m i t t e e " r e f l e c t " t h e needs o f a s m a l l commun i t y . They a r e a l r e a d y c o n s u m e r s . The consumer p e r s p e c t i v e c a n be o b t a i n e d t h r o u g h o t h e r i n p u t v e h i c l e s w i t h o u t c r e a t i n g a d d i t i o n a l members o f t h e s t r a t e g i c p l a n n i n g c o m m i t t e e . I t i s p r e f e r a b l e t o have more t h a n one m e d i c a l s t a f f r e p r e s e n t a t i v e . The m e d i c a l s t a f f w o u l d i n t u i t i v e l y i n c l u d e t h e c h i e f - o f - s t a f f , h o w e v e r , you s h o u l d t r y t o p i c k d o c t o r s who have a c o n s i d e r a b l e s t a k e i n t h e h o s p i t a l . A l l members must be a l l o w e d s u f f i c i e n t t i m e t o a b s o r b s u b j e c t m a t t e r and t o do t h e i r work p r o p e r l y . Time must be c o m m e n s u r a b l e w i t h t h e t a s k g i v e n them. C h a i r p e r s o n The c h a i r p e r s o n o f t h e c o m m i t t e e must be a member o f t h e b o a r d . L i t e r a t u r e i n d i c a t e s t h a t t h e c o m m i t t e e c h a i r m a n s h o u l d n o t be t h e c h a i r m a n o f t h e b o a r d b u t r a t h e r someone who i s i m p a r t i a l t o t h e p r o c e s s . I n a s m a l l , r u r a l h o s p i t a l , t o r e d u c e p r o l i f -e r a t i o n o f d i f f e r e n t c o m m i t t e e s and t o p l a c e i m p o r t a n c e on s t r a t e g i c p l a n n i n g and t o i n t e r n a l i z e i t , t h e c h a i r m a n o r v i c e -c h a i r m a n o f t h e b o a r d c o u l d be t h e c h a i r m a n o f t h i s p l a n n i n g c o m m i t t e e . He must be a strong-minded, knowledgeable p e r s o n - 56 -who i s c a p a b l e o f d i r e c t i n g , d e l i b e r a t i o n and a b l e t o d e v e l o p s u f f i c i e n t t i m e t o be w e l l - i n f o r m e d . He must work c l o s e l y w i t h t h e C . E . O . and s t a f f i n r e v i e w i n g m a t e r i a l s and p r e p a r i n g a g e n d a s . The c h a i r m a n o f t h e p l a n n i n g c o m m i t t e e s h o u l d be a p e r s o n who i s a f a c i l i t a t o r and a b l e t o l e a d t h e c o m m i t t e e t o a p l a n t h a t i s b e s t f o r t h e h o s p i t a l . They must p a r t i c i p a t e w h i l e m a i n t a i n i n g t r a d i t i o n a l n e u t r a l i t y . They must be a b l e t o p r o v o k e p r o d u c t -i v e d i s c u s s i o n s o r i d e n t i f y more d e b a t a b l e i s s u e s . C o n s u l t a n t s may be used on t h e c o m m i t t e e and a f u l l e r d i s c u s s i o n on t h i s w i l l be found i n a s e p a r a t e s e c t i o n . R o l e - t o make r e c o m m e n d a t i o n s f o r l o n g - t e r m o b j e c t i v e s t o s e r v e a s an a d v i s o r y c o m m i t t e e t o t h e b o a r d on t o p i c s c o n c e r n i n g f u t u r e d i r e c t i o n s - t o s e r v e a s a c o l l e c t i v e v o i c e o f t h e communi ty r e g a r d i n g h e a l t h n e e d s o f t h e p o p u l a t i o n Mandate The p u r p o s e o f t h i s c o m m i t t e e s h o u l d be w e l l - r e c o g n i z e d f rom t h e s t a r t . I t i s n o t t h e p r o d u c t i o n o f a t h i c k r e p o r t t i t l e d "The S t r a t e g i c P l a n " o r " F i v e - Y e a r P l a n " . The o b j e c t i v e o f t h i s c o m m i t t e e and o f a l l s t r a t e g i c p l a n n i n g i s a c t i o n . T h i s i s t h e r e s u l t y o u a r e a f t e r . Once a l l t h e ma jo r i s s u e s a r e i n t h e open and have been d i s c u s s e d and a c o n s e n s u s has been r e a c h e d , t h i n g s w i l l b e g i n t o happen and change w i l l become v i s i b l e . T h i s c o m m i t t e e , o n c e f o r m e d , must be g i v e n a c l e a r mandate t h a t s h o u l d be w r i t t e n and c i r c u l a t e d f o r a l l s t a f f t o s e e . w h a t i s g o i n g o n . An example - 57 -o f s u c h a mandate c a n be seen i n A p p e n d i x I I . The s t r a t e g i c p l a n n i n g c o m m i t t e e s h a l l make recommendat ions f o r l o n g - r a n g e g o a l s and o b j e c t i v e s f o r t h e h o s p i t a l . I t s h a l l a t t e m p t t o be aware o f a l l d e v e l o p m e n t s i n t h e h e a l t h c a r e f i e l d and t r e n d s i n s o c i e t y and t o i n t e r p r e t t h e e f f e c t o f t h e s e d e v e l o p m e n t s and t r e n d s on t h e h o s p i t a l . A p r i n c i p a l f u n c t i o n o f t h e c o m m i t t e e s h a l l be t h e d e v e l o p m e n t o f a w r i t t e n s t a t e m e n t d e s c r i b i n g t h e h o s p i t a l ' s s p e c i f i c r o l e i n t h e commun i ty i n r e l a t i o n t o a l l o t h e r h e a l t h c a r e f a c i l i t i e s . The mandate s h o u l d i n c l u d e a p l a n n i n g c a l e n d a r - A p p e n d i x I I I . S t r a t e g i c p l a n n i n g i s b e s t a c c o m p l i s h e d o v e r a r e l a t i v e l y s h o r t p e r i o d t o e n s u r e c o n t i n u i t y o f p u r p o s e and p a r t i c i p a n t s and t o m a i n t a i n t h e momentum t h a t t h e p l a n n i n g p r o c e s s g e n e r a t e s i n i t s e a r l y p h a s e s . No p l a n n i n g p r o g r a m s h o u l d e x c e e d 12 months i n d u r a t i o n b e f o r e a s t r a t e g i c p l a n i s d e v e l o p e d , a l t h o u g h t h e p l a n n i n g p r o c e s s i s c o n t i n u o u s and o n g o i n g . The amount o f t i m e and t h e number o f m e e t i n g s needed t o e v a l u a t e t h e v a r i o u s s e r v i c e s and p rog rams w i l l v a r y , d e p e n d i n g on t h e needs o f e a c h i n s t i t u t i o n . A d e g r e e o f f l e x i b i l i t y s h o u l d be m a i n t a i n e d t h r o u g h o u t t h e p r o j e c t , b u t a t i m e f rame s h o u l d be e s t a b l i s h e d a t t h e b e g i n n i n g . M o n t h l y m e e t i n g s o f a p p r o x i m a t e l y two h o u r s d u r a t i o n s h o u l d be s u f f i c i e n t t o a c c o m p l i s h t h e c o m m i t t e e ' s work p r o v i d e d a d e q u a t e p r e p a r a t i o n i s made, t h e c o m m i t t e e m e e t i n g s a r e w e l l - p l a n n e d and t h e t a s k s o f e a c h member a r e c l e a r t o a l l members. W h i l e t h e c o m m i t t e e h a s a mandate t h a t i n d i c a t e s a c t i o n , i t i s c r i t i c a l t o remember t h a t t h e c o m m i t t e e d e r i v e s i t s a u t h o r i t y f r o m t h e b o a r d o f t r u s t e e s and l i k e any o t h e r c o m m i t t e e i t i s r e s p o n s i b l e and r e p o r t s back t o t h e b o a r d . I t h a s no d e c i s i o n -making power o f i t s own. However , t h e c o m m i t t e e s h o u l d h a v e power t o d e l e g a t e work t o s t a f f f o r f a c t - f i n d i n g and d i g g i n g o u t o f s t a t i s t i c s . H a v i n g a d e q u a t e s u p p o r t t h a t p r o d u c e s good i n f o r m a t i o n k e e p s t h e c o m m i t t e e f rom d e a l i n g w i t h t r i v i a and o p i n i o n . The C . E . O . must a s s e s s t h e s t a f f f o r t h e n e c e s s -a r y t a l e n t t o a s s i s t t h e c h a i r m a n . The c o m m i t t e e ' s t i m e f rame i s e x p l i c i t l y l o n g - r a n g e . I t s h o u l d s t a y o u t o f c u r r e n t o p e r a t i o n s and a d m i n i s t r a t i o n s and o u t o f t h e way o f t h e o t h e r b o a r d c o m m i t t e e s , w h i c h a r e w o r k i n g on c u r r e n t b u s i n e s s most o f t h e t i m e . The c o m m i t t e e ' s j o b i s t o c o n s i d e r ma jo r i s s u e s o f a l l s o r t s , ma jo r p r o j e c t s , and p r i o r i t i e s , and t o make r e c o m m e n d a t i o n s t o t h e b o a r d . M a j o r e x p e n d i t u r e s s h o u l d u s u a l l y be c o n s i d e r e d f i r s t by t h i s c o m m i t t e e and n e x t by t h e f i n a n c e c o m m i t t e e . The mandate i m p l i e s t h a t t h e c o m m i t t e e h a s t h e f u r t h e r d u t i e s and o b l i g a t i o n s t o : 1. D e v e l o p a f ramework f o r o r d e r l y d e c i s i o n - m a k i n g , t h r o u g h a d e f i n e d community r o l e c a l l e d t h e " M i s s i o n S t a t e m e n t " , a s e t o f l o n g - t e r m g o a l s and o b j e c t i v e s , a s t r a t e g y f o r a c h i e v e m e n t , and a t i m e t a b l e f o r recommended p r o g r e s s . 2. E n s u r e t h a t a l l r e c o m m e n d a t i o n s coming f rom t h i s and o t h e r c o m m i t t e e s f i t w i t h i n t h e h o s p i t a l ' s d e f i n e d r o l e f a c i l -i t a t e a c h i e v e m e n t o f i t s g o a l s and o b j e c t i v e s , and f o l l o w t h e s t r a t e g i c p l a n . I t i s a c o n t i n u i n g o b l i g a t i o n o f t h e c o m m i t t e e t o keep t h e h o s p i t a l on c o u r s e w i t h i t s p l a n - 59 -( s t r a t e g y ) o r t o change t h e p l a n a s new f a c t s and c o n d i t i o n s d i c t a t e . 3. D e v e l o p a s e n s e o f p r i o r i t i e s i n i t s e x a m i n a t i o n o f i s s u e s and p r o j e c t s so t h a t t h e h o s p i t a l ' s l i m i t e d r e s o u r c e s o f t i m e and money a r e s p e n t on t h o s e p r o j e c t s t h a t t a k e i t t h e f u r t h e s t i n a c h i e v i n g i t s d e f i n e d r o l e i n t h e c o m m u n i t y . 4 . A c t a s a d d i t i o n a l v e h i c l e f o r good c o m m u n i c a t i o n among t h e b o a r d , t h e m e d i c a l s t a f f , and t h e a d m i n i s t r a t i o n . L o n g - r a n g e p l a n n i n g c a n n o t be e f f e c t i v e i f i t i s t h e work o f a s i n g l e c h a i r m a n f o r he w i l l n o t be aware o f t h e h o s p i t a l ' s and t h e c o m m u n i t y ' s v a l u e s and c u l t u r e n o r have a f e e l f o r b o a r d members' a t t i t u d e s . I t i s a l s o h e l p f u l i f t r u s t e e s and manage -ment h o l d many o f t h e same v a l u e s . When s e l e c t i n g t r u s t e e s f o r t h e c o m m i t t e e , do n o t o v e r l o o k t h e power o f e c o n o m i c s , t h e power o f p r e s t i g e , and s e l f - e s t e e m a s m o t i v a t o r s f o r i n v o l v e m e n t . Remember, o f c o u r s e , t h a t you need a b a l a n c e o f s k i l l s and r e s o u r c e s f o r t h e b o a r d . The f o l l o w i n g a s p e c t s s h o u l d be k e p t i n mind when s e l e c t i n g t h e c o m m i t t e e members: - s e n s e o f d u t y ( d e d i c a t e d , f a i t h f u l ) - o v e r a l l i n t e r e s t ( b i g p i c t u r e ) - e n t h u s i a s m f o r f a c i l i t y - g e n e r a l s t r e n g t h s and s p e c i f i c a b i l i t i e s (mix and match) - i n f o r m them o f i m p o r t a n c e and w o r k l o a d o f f u n c t i o n - t h e b e n e f i t o f a s k e p t i c o r d o u b t e r on b o a r d . N o t i f y t r u s t e e s , p r e f e r a b l y i n w r i t i n g , a s t o t h e number o f h o u r s o r d a y s p e r month t h a t t h e y s h o u l d a l l o c a t e - 60 -t o t h e c o m m i t t e e , d e f i n i n g work and a c t i v i t i e s . L e t t r u s t e e s know you e x p e c t an h o n e s t commitment t o t i m e s c h e d u l e s and t h a t s t r a t e g i c p a r t i c i p a t i o n means more w o r k , more t i m e , more t h o u g h t , and p r o b a b l y a t t i m e s , more u n c e r t a i n t y , f r u s t r a t i o n and c o n c e r n . The s t r a t e g i c p l a n n i n g c o m m i t t e e ' s work s h o u l d be an i s s u e -and a c t i o n - o r i e n t e d e f f o r t t o e s t a b l i s h a s t r a t e g i c p l a n f o r t h e p a r t i c i p a t i o n o f p r o b l e m s and t h e i r r e s o l u t i o n . S t r a t e g i c p l a n n i n g a d d r e s s e s i s s u e s t h a t o f t e n a r e d i s c u s s e d i n p u b l i c , and t h e p l a n n i n g committee must o p e r a t e a s a s e e k e r o f t r u t h . Once t h e c o m m i t t e e h a s been f o r m e d , a d e f i n i t e e d u c a t i o n a l p r o c e s s must b e g i n . W h i l e t h i s i s f o c u s e d d i r e c t l y a t t h e c o m m i t t e e , t h e f u l l b o a r d s h o u l d be i n c l u d e d . T h i s i s an e d u c a t i o n a l e f f o r t t h a t w i l l be t e d i o u s and h a r d and must be d e v e l o p e d o v e r t i m e and s t a r t e d o f f s l o w l y . To h e l p move a r e c a l c i t r a n t b o a r d i n t h i s d i r e c t i o n , t h e b o a r d c h a i r m a n m i g h t even c o n s i d e r a d d i n g c a r e f u l l y s e l e c t e d new, a d d i t i o n a l members t o t h e b o a r d p r i o r t o f o r m i n g t h e s t r a t e g i c p l a n n i n g c o m m i t t e e . The e f f o r t must be p u r p o s e f u l l y d e s i g n e d t o h a v e a l l p l a y e r s ove rcome t h e hope t h a t e v e r y t h i n g w i l l r e t u r n t o n o r m a l . P a r t o f t h e e f f o r t must a l s o c l e a r l y i n d i c a t e t h a t w h i l e i t may be a c r i s i s s i t u a t i o n , i t i s a l s o a t i m e o f g r e a t and p r o b a b l y u n i q u e o p p o r t u n i t y . I t i s a t t h i s p r e c i s e moment i n a h o s p i t a l ' s h i s t o r y when s t r a t e g i c p l a n n i n g w i l l t r u l y p a y o f f . A p l a n n i n g c h e c k l i s t may h e l p i n i n d i c a t i n g t h e p r e s e n t s t a t e (or l a c k ) o f p l a n n i n g . A p p e n d i x I V . - 61 -T h i s r e s p o n s i b i l i t y b e l o n g s t o t h e h o s p i t a l a d m i n i s t r a t o r and an a p p o i n t e d b o a r d member who must d e t e r m i n e t h e most a p p r o -p r i a t e c o u r s e o f a c t i o n , d e p e n d i n g on t h e l e v e l o f t h e b o a r d ' s a w a r e n e s s , i n t e r e s t , and commitment t o p l a n n i n g . O r i e n t a t i o n and e d u c a t i o n s h o u l d i n c l u d e : 1. I n t r o d u c t i o n t o t h e s t r a t e g i c p l a n n i n g p r o c e s s , s t r e s s i n g p l a n n i n g a s t h e key t o a s s u r i n g a v i a b l e f u t u r e f o r t h e i n s t i t u t i o n w i t h i n t h e f ramework o f a r e a - w i d e p l a n s and t o a s s u r i n g t h e a p p r o p r i a t e a l l o c a t i o n o f a v a i l a b l e r e s o u r c e s . The C . E . O . o r b o a r d c h a i r m a n c a n d e v e l o p p a r t i c i p a t i o n and e n c o u r a g e b o a r d i n v o l v e m e n t i n s t r a t e g i e s t h r o u g h t r u s t e e e d u c a t i o n by way o f a s e r i e s o f p e r s u a s i v e c a s e h i s t o r i e s . C a s e s w i l l h e l p t o e x p r e s s t h e v e r y n a t u r e and f o r m o f s t r a t e g y and g i v e a b e t t e r a p p r e c i a t i o n . The C . E . O . o r t h e b o a r d m i g h t b r i n g an o u t s i d e c o n s u l t a n t i n t o e d u c a t e b o a r d members on t h e c o n c e p t and p r a c t i c e o f s t r a t e g i c p l a n n i n g . I f i t i s f e a s i b l e , t h e C . E . O . m i g h t e v e n c o n s i d e r a r e t r e a t f o r members o f t h e b o a r d and s e l e c t e d members o f t h e h o s p i t a l s t a f f d u r i n g w h i c h a c o n s u l t a n t w o u l d l e a d them t h r o u g h a p p r o p r i a t e g r o u p p r o c e s s t e c h n i q u e s t o h e i g h t e n t h e i r a w a r e n e s s o f p l a n n i n g and t o m o t i v a t e them t o g e t i n t o t h e p l a n n i n g f u n c t i o n . 2 . An o v e r v i e w o f n a t i o n a l t r e n d s a f f e c t i n g h e a l t h c a r e d e l i v e r y , w i t h e m p h a s i s on t h o s e t r e n d s s p e c i f i c a l l y a f f e c t i n g s m a l l f a c i l i t i e s . 3. An o v e r v i e w o f r e g i o n a l and a r e a - w i d e t r e n d s a f f e c t i n g t h e l o c a l c o m m u n i t i e s and t h e l o c a l f a c i l i t i e s . - 62 -4. I n h e r e n t i n t h i s e d u c a t i o n a l o r i e n t a t i o n a r e m o r a l and e t h i c a l  o b l i g a t i o n s f o r n o t o n l y c o m m i t t e e members b u t a l l t r u s t e e s . T h e s e o b l i g a t i o n s a r e : - t o be w e l l - i n f o r m e d a b o u t t h e e v e r - c h a n g i n g h e a l t h c a r e e n v i r o n m e n t - t o seek t h e t r u t h r e g a r d i n g p r e s e n t and f u t u r e needs and t o q u e s t i o n t h e r e l e v a n c y o f t h e p r o g r a m s , s e r v i c e s and o p e r a t i o n o f t h e f a c i l i t y - t o c h a l l e n g e s t a t e m e n t s a b o u t t h e f a c i l i t y ' s a c c o m p l i s h m e n t s and c a p a b i l i t i e s and t o ask t h e h a r d , o f t e n u n p l e a s a n t q u e s t i o n s a b o u t t h e f u t u r e o r s u r v i v a l o f t h e f a c i l i t y . T h i s e d u c a t i o n a l p r o c e s s i s c o n s i s t e n t w i t h p l a n n i n g i t s e l f a s p l a n n i n g i s a l e a r n i n g p r o c e s s ; a p r o c e s s i n w h i c h t h e l e a r n e r i s e n c o u r a g e d t o l e t h i s p e r c e p t i o n s o f t o d a y i n t e r a c t w i t h h i s i d e a s a b o u t t h e f u t u r e . Once t h e p r o c e s s i s s t a r t e d e a c h member o f t h e c o m m i t t e e w i l l g row . A s t h e p o e t Emerson w r o t e : "A mind • s t r e t c h e d by a new i d e a n e v e r r e t u r n s t o i t s o r i g i n a l s h a p e . " F i n a l l y , t h e c h a i r m a n must e n c o u r a g e a team s p i r i t among t r u s t e e s , t h e e x e c u t i v e d i r e c t o r and o t h e r p r o f e s s i o n a l s t a f f , and a l l v o l u n -t e e r s . H o s p i t a l s must have c o m m i t t e d p e o p l e a t a l l l e v e l s ; and p r o f e s s i o n a l s and v o l u n t e e r s a l i k e must be w e l l l e d t o m a x i m i z e t h e i r s u c c e s s . D u r i n g t h e c o m m i t t e e ' s e d u c a t i o n , t h e y must be made aware t h a t t h e r e a r e some u n i q u e a s p e c t s t o p r o b l e m and i s s u e r e c o g n i t i o n and s o l u t i o n . Some o f t h e o l d - t i m e c l i c h e s s h o u l d be d i s b a n d e d . 1. I f you c a n f i g u r e o u t t h e p r o b l e m , t h e n i t i s a l m o s t s o l v e d . T h i s i s n ' t a l w a y s , o r even v e r y o f t e n , t r u e . You c a n f i g u r e - 63 -o u t a p r o b l e m t h a t you a r e g o i n g t o be $ 9 0 , 0 0 0 i n a d e f i c i t p o s i t i o n by y e a r - e n d , b u t f i g u r i n g o u t t h e s o l u t i o n i s a n o t h e r m a t t e r . 2 . A l l p r o b l e m s have a s o l u t i o n . T h i s i s n ' t t r u e . You w i l l a v o i d a l o t o f work i f t h i s i s a c c e p t e d f rom t h e b e g i n n i n g . I t i s o f t e n h e l p f u l t o s e p a r a t e p r o b l e m s t h a t a r e s o l v a b l e and u n s o l v a b l e and a c c e p t t h e f a c t t h a t t h e r e a r e some p r o b l e m s we must l i v e w i t h i n r e a s o n a b l e c o m f o r t a s we c a n n o t s o l v e them. 3 . T h e r e a r e a l w a y s a n s w e r s . S o m e t i m e s , t h e r e a r e no a n s w e r s and t h e c o m m i t t e e must l e a r n t o l i v e w i t h a m b i g u i t y . I t h a s been s a i d t h e s u c c e s s i n s t r a t e g i c p l a n n i n g w i l l be i n d i r e c t p r o p o r t i o n t o t h e a b i l i t y t o h a n d l e t h e a m b i g u i t y t h a t e x i s t s i n h o s p i t a l s . The c l a s s i c example o f no answer and a m b i g u i t y i s when y o u a r e c o n f r o n t e d by a communi ty i n d i v i d u a l who i n s i s t s t h a t y o u keep c o s t s down but a l s o i n s i s t s t h a t you h a v e a l l t h e n e c e s s a r y equ ipment when h i s f a m i l y n e e d s i t . The outcome o f t h e d i s c u s s i o n o f some c l i c h e s i s t h a t we c a n n o t a l w a y s r e a c h c o n s e n s u s o r f o r c e c o n c l u s i o n s f r o m o u r p l a n n i n g p r o c e s s . We s h o u l d n o t push p r e m a t u r e l y f o r s o l u t i o n s t h a t w i l l o n l y g i v e u s t h e wrong a n s w e r . A n o t h e r a s p e c t t h e c o m m i t t e e must keep i n mind i s n o t t o r e - i n v e n t t h e w h e e l . I t i s f a i r l y common knowledge t h a t most o f t h e p r o b l e m s t h a t h o s p i t a l s have a r e w e l l - k n o w n and have a l r e a d y been d e a l t w i t h i n o t h e r h o s p i t a l s . The r o l e o f t h e c o m m i t t e e , t h e r e f o r e , i s t o c o r r e c t l y match t h e p r o b l e m and t h e s o l u t i o n , n o t t o i n v e n t i n n o v a t i v e s o l u t i o n s o r t o d i s c o v e r p r o b l e m s n e v e r known b e f o r e . A s t h e c o m m i t t e e w i l l be i n v o l v e d i n c o n s i d e r a b l e d i s c u s s i o n -64 -b e f o r e r e a c h i n g a c o n s e n s u s , t h e r e a r e s e v e r a l t e c h n i q u e s t o make t h i s p r o c e s s more c o m f o r t a b l e and p r o d u c t i v e . These a r e l i s t e d b e l o w and c a n be r e s e a r c h e d i n any o f s e v e r a l b o o k s on g r o u p s , m e e t i n g s , o r i n t e r v i e w i n g . (a) M e e t i n g i n t h e p r o p e r room w i t h a p p r o p r i a t e and c o m f o r t a b l e f u r n i t u r e . (b) A r r a n g e l e n g t h o f m e e t i n g . (c) M e e t i n g s s h o u l d i be c o n d u c t e d w i t h a c l e a r l y s t a t e d p u r p o s e f o r i t and t h e c o m m i t t e e s h o u l d n e v e r l e a v e w i t h o u t a r r i v i n g a t a c o n c l u s i o n t o t h e p r o b l e m under d i s c u s s i o n . A l w a y s l a y down a s y s t e m o.f c o n t r o l s t o a s s u r e t h a t t h o s e a s s i g n e d t o f o l l o w - u p on i t e m s a c t u a l l y do s o . (d) The m e e t i n g must be d e s i g n e d t o a s s u r e a l l members o f t h e c o m m i t t e e p a r t i c i p a t e i n t h e d i s c u s s i o n . (e) S t a f f r e p o r t s must be c a r e f u l l y r e a d w i t h d i s c u s s i o n f o c u s e d on i s s u e s t h a t need r e s o l v i n g . I n c l o s i n g , t h e f i r s t c o n s t r u c t i v e t h i n g t h a t t h e c o m m i t t e e must do i s t o s t o p b l a m i n g t h e government ( a l t h o u g h t h e r e i s no q u e s t i o n t h a t g o v e r n m e n t i n t e r f e r e n c e h a s become one more i m p e d i m e n t t o e f f i c i e n c y ) , t o s t o p b l a m i n g l a b o u r u n i o n s ( though v a l u a b l e t i m e and e n e r g y i s consumed i n b a r g a i n i n g , g r i e v a n c e s and a r b i t r a t i o n ) , b u t t o d e v o t e t h e t i m e t o i n v e s t i g a t e , a n a l y z e , and d e c i d e t h e k i n d o f h e a l t h c a r e t h e p e o p l e o f o u r c o m m u n i t i e s a r e g o i n g t o r e c e i v e i n t h e y e a r s a h e a d . D a t a B a s e Deve lopment ( g e t t i n g t h e f a c t s t o g e t h e r ) T h i s a l l - i m p o r t a n t f a c t - g a t h e r i n g p h a s e i s somet imes r e f e r e n c e d i n d i f f e r e n t t e r m i n o l o g y a s " m a r k e t r e s e a r c h " , " s i t u a t i o n a n a l y s i s " , " e n v i r o n m e n t a s s e s s m e n t " , and " o r g a n i z a t i o n a l a s s e s s m e n t " , t o name a f e w . E s s e n t i a l l y , t h e o b j e c t i v e o f t h i s p h a s e i s t h e p r e p a r a t i o n o f a c o m p l e t e a s s e s s m e n t o f a l l r e l e v a n t i n t e r n a l and e x t e r n a l f a c t s , i s s u e s and c o n s i d -e r a t i o n s b e a r i n g on t h e o r g a n i z a t i o n ' s c u r r e n t s t a t u s and f o r e c a s t i n g t r e n d s t h a t w i l l i m p a c t on i t s f u t u r e s t a t u s . Few c a n deny t h e i m p o r t a n c e o f i n f o r m a t i o n i n t h e p l a n n i n g p r o c e s s . Data a s u s e d i n p l a n n i n g a r e a s y n t h e s i s o f p a s t t r e n d s and c u r r e n t c o n d i t i o n s t h a t p r o v i d e a b a s i s on w h i c h t o p r e d i c t f u t u r e h a p p e n i n g s . The l e v e l and d e p t h o f d a t a n e c e s s a r y f o r a s p e c i f i c p l a n n i n g p r o c e s s d e p e n d s on many f a c t o r s - t h e most i m p o r t a n t o f w h i c h i s t h e i r p e r t i n e n c e t o a p a r t i c u l a r p r o b l e m . O t h e r f a c t o r s t o c o n s i d e r a r e t h e c o m m i t t e e ' s a b i l i t y t o a n a l y z e and u t i l i z e them; how t h e d a t a a r e c o l l e c t e d and t h e c o s t o f c o l l e c t i o n ; and t h e i r a c c u r a c y and p r e c i s e n e s s . I t i s pa ramount t o remember t h a t d a t a a r e m e r e l y an a i d t o d e c i s i o n - m a k i n g . They do n o t and c a n n o t , i n t h e m s e l v e s , p r o v i d e a s o l u t i o n . F o r t h e p u r p o s e s o f t h i s s t u d y , t h r e e b r o a d c a t e g o r i e s o f d a t a c a n be i d e n t i f i e d , and t h e c o m m i t t e e i s w i s e t o u s e a s p e c t s o f a l l t h r e e : - 66 -- r e c u r r i n g d a t a ( r e g u l a r l y g a t h e r e d on own o r g a n i z a t i o n ) - r e p e t i t i v e s t u d i e s ( p e r i o d i c a l l y u n d e r t a k e n w i t h i n a g i v e n t i m e f r a m e ) 1 - s p e c i a l s t u d i e s ( c o n d u c t e d on a o n e - t i m e b a s i s ) . The l i s t o f i n f o r m a t i o n t o be o b t a i n e d i s a s l o n g a s t h e c o m m i t t e e w i s h e s ; remember ing t h a t t o o much i n f o r m a t i o n i s a s d e t r i m e n t a l a s t o o l i t t l e . D u r i n g t h i s s t e p , t h e f o l l o w i n g " p r o f i l e s " s h o u l d be d e v e l o p e d : O r g a n i z a t i o n a l A s s e s s m e n t ( i n t e r n a l P r o f i l e s ) The t a s k a t t h i s s t a g e r e q u i r e s a s e l f - a p p r a i s a l t h a t s h o u l d r e a c h e v e r y l e v e l and p a r t o f t h e o r g a n i z a t i o n . i t i s c a u t i o n e d t h a t i t i s h e r e t h a t h e a l t h c a r e o r g a n i z a t i o n s s u f f e r f r o m t h e i r most s e r i o u s d i f f i c u l t i e s - t h e i r p r o d u c t o r o u t p u t i s d i f f i c u l t t o a s s e s s and measurement h a s l o n g been r e g a r d e d a s v i r t u a l l y i m p o s s i b l e . I t e m s t o be i n c l u d e d i n t h i s s e c t i o n c a n be f ound i n t h e a l r e a d y a v a i l a b l e documents s u c h a s : M i n i s t r y o f H e a l t h , B . C . HIA 35 A p p e n d i x #5 F e d e r a l Y e a r End R e p o r t HS 1 & 2 A p p e n d i x #6 & 7 Q u a r t e r l y F e d e r a l R e p o r t - S t a t i s t i c s Canada A p p e n d i x #8 C o m p a r a t i v e S t a t e m e n t s ( B . C . H . A ) A p p e n d i x #9 P e e r Group I n d i c a t o r s ( M i n i s t r y o f H e a l t h , B . C . ) A p p e n d i x #10 A c c r e d i t a t i o n Q u e s t i o n a i r e & S u r v e y R e s u l t s A p p e n d i x #11 - 67 -E n v i r o n m e n t A s s e s s m e n t ( E x t e r n a l P r o f i l e s ) I t i s u s u a l l y c o n s i d e r e d t h a t a s t a t i s t i c a l s u r v e y o f p a t i e n t o r i g i n i s t h e most i m p o r t a n t a s p e c t o f t h i s d a t a b a s e . T h i s i s g e n e r a l l y n o t so f o r a s m a l l communi ty h o s p i t a l , even i f t h e y have a h i g h l y s p e c i a l i z e d u n i t , f o r t h e c o s t o f t h e s u r v e y f a r o u t w e i g h s t h e r e s u l t s . The minimum t h a t s h o u l d be c o n s i d e r e d h e r e i s : an u n d e r s t a n d i n g must be g a i n e d o f y o u r s e r v i c e a r e a , o r p u t i n c o m m e r c i a l t e r m s " t h e consumer b a s e " . You must l o o k a t t h e community n e e d s and who you a r e s e r v i n g t o f i n d o u t what i s g o i n g on and what i s l i k e l y t o happen i n t h e f u t u r e . T h i s i n f o r m a t i o n r e l a t e s d i r e c t l y t o t h e m a r k e t i n g o f y o u r p l a n . I t i s q u i t e h e l p f u l a t t h i s p o i n t i n t h e p r o c e s s t o r e v i e w a map o f y o u r a r e a and t o g a i n c e n s u s t r a c t i n f o r m a t i o n f r o m p r o v i n c i a l and f e d e r a l g o v e r n m e n t s . A r e v i e w o f any n a t u r a l b a r r i e r s i s a l s o h e l p f u l . A t t h i s p o i n t , t h e c o m m i t t e e s h o u l d be a s k i n g t h e c r i t i c a l q u e s t i o n s , s u c h a s " w i l l o u r s e r v i c e a r e a s h r i n k o r g r o w ; w i l l t h i s p o p u l a t i o n g e t younger o r o l d e r ; w i l l t h e p o p u l a t i o n change e t h n i c a l l y ; w i l l new b a r r i e r s o r a c c e s s , l i k e h i g h w a y s , be i n t r o d u c e d and s i g n i f -i c a n t l y change t r a f f i c p a t t e r n s ? What do r e c e n t v i t a l s t a t i s t i c s show f o r b i r t h s , d e a t h s , m o r t a l i t y r a t e s , d i s e a s e p a t t e r n s ? What a r e t h e s o c i a l i n d i c a t o r s , such a s human r e s o u r c e r a t e s , h o u s i n g c o n d i t i o n s , c r i m e and d e l i n q u e n c y r a t e s ? " I n a l l a s p e c t s o f p l a n n i n g , n o t h i n g i s a s b a s i c t o t h e p r o c e s s a s t h e s e r v i c e a r e a and the s e r v i c e a r e a ' s p o p u l a t i o n . P o t e n t i a l i n - p a t i e n t p o p u l a t i o n s must be d e f i n e d and a c k n o w l e d g e d t h e y can be d i f f e r e n t i n o r i g i n than an o u t - p a t i e n t o r emergency p o p u l a t i o n , d e p e n d i n g on o u r s e r v i c e s a v a i l a b l e and t h e a d m i s s i o n p r a c t i c e s . The C o m m i t t e e must become " t u n e d i n t o " t h e c o m m u n i t y . A C o m m i t t e e must h a v e a f e e l f o r what i s g o i n g on a r o u n d t h e h o s p i t a l . I t must be i n c o m m u n i c a t i o n on an o n - g o i n g b a s i s w i t h t h e communi ty and t h e i n d i v i d u a l s who l i v e t h e r e . To do t h i s , one must d e v e l o p s e n s i t i v e l i s t e n i n g - p o s t s i n t h e c o m m u n i t y . T h e r e a r e s e v e r a l t e c h n i q u e s t h a t c a n be u s e d h e r e t o be i n t u n e w i t h t h e c o m m u n i t y : - consumer a t t i t u d e r e s e a r c h , u s i n g a v e r y b a s i c q u e s t i o n a i r e t h a t c a n be d e v e l o p e d by t h e c o m m i t t e e o r u s e e x i s t i n g o n e s f r o m o t h e r h o s p i t a l s . The o b j e c t i v e o f t h i s i s t o - measure y o u r p r o g r e s s - d e t e r m i n e how p a t i e n t s v i e w you - compare y o u r p r o f i l e w i t h t h a t o f h o s p i t a l s n e a r you - g a i n some i n d i c a t i o n o f how p a t i e n t s o f o t h e r h o s p i t a l s p e r c e i v e y o u . Such s u r v e y s s h o u l d be done on an a n n u a l b a s i s . T h a t w a y , e a c h s u c c e s s i v e y e a r i s a f o l l o w - u p and w i l l t e l l you i f you a r o mak ing p r o g r e s s . A n o t h e r t e c h n i q u e i s t o r e v e r s e t h e h i s t o r i c a p p r o a c h w i t h s e r v i c e c l u b s . I n s t e a d o f t r u s t e e s and a d m i n i s t r a t o r s g o i n g t o t h e s e r v i c e c l u b s and t e l l i n g them a b o u t t h e h o s p i t a l , i t w o u l d be b e t t e r i f a h o s p i t a l r e p r e s e n t a t i v e were t o l i s t e n i n s t e a d o f t a l k . One way t o a c h i e v e t h i s i s w i t h a b r i e f q u e s t i o n a i r e t o be handed o u t - 69 -t o s e r v i c e c l u b . j n e m b e r s and t o be r e t u r n e d p r i o r t o t h e m e e t i n g . An example o f s u c h a q u e s t i o n a r e may be " l i s t t h r e e t h i n g s you l i k e a b o u t t h e h o s p i t a l ; l i s t t h r e e t h i n g s you d i s l i k e . " T h e s e l e t t e r s s h o u l d be r e v i e w e d p r i o r t o t h e r e p r e s e n t a t i v e a t t e n d i n g t h e s e r v i c e c l u b . T h i s h a s n o t happened i n most c a s e s and t h e r e s u l t s a r e o b v i o u s . A s s t a t e d e a r l i e r , t h e p r i n c i p a l r e a s o n so many h o s p i t a l s a r e b e i n g h i g h l y s c r u t i n i z e d by t h e p o l i t i c a l p r o c e s s i s t h a t t h e p o l i t i c i a n s were more s e n s i t i v e t o what t h e communi ty was s a y i n g t h a n t h e h o s p i t a l was . O t h e r P r o v i d e r s ; W h i l e i t i s c o n s i d e r e d somewhat demeaning i n t h e h o s p i t a l w o r l d t o r e f e r t o o t h e r h e a l t h c a r e i n s t i t u t i o n s a s c o m p e t i t o r s , i t i s an e s s e n t i a l s t e p i n t h e s t r a t e g i c p l a n n i n g p r o c e s s . T h i s i s so b e c a u s e t h e c o n c e p t o f c o m p e t i t i o n i s v a l u a b l e , a l t h o u g h i t i s p o s s i b l e f o r c o m p e t i t i o n t o be c a r r i e d t o o f a r . I n t h e l i t e r a t u r e r e v i e w , I have f ound no s i n g l e r e f e r e n c e where c o m p -e t i t i o n , even i n t h e U . S . s e t t i n g , h a s been c o n s i d e r e d t o be c a r r i e d t o o f a r . I f t h e c o m m i t t e e d o e s n ' t r e v i e w and u n d e r s t a n d t h e c o m p e t i t i o n , we w i l l be making p o o r d e c i s i o n s a b o u t a d e q u a t e s e r v i c e , d u p l i c a t i o n o f s e r v i c e s , and c o s t s , and we w i l l n o t be a b l e t o d e t e r m i n e where t h e g a p s a r e i n t h e s e r v i c e s . I n r e v i e w i n g t h e c o m p e t i t o r s , we must a l s o r e v i e w t h e i r s t r a t e g i e s . We must d e t e r m i n e . w h a t l e v e l s o f c a r e a r e a v a i l a b l e i n t h e r e g i o n , what p l a n s a r e t h e r e t o change t h e s e l e v e l s , what t h e y a r e good a t , what t h e y e x p e c t t o b u i l d , and where t h e y a r e a l s o g o i n g . The governments a l s o w o u l d be i n t e r e s t e d i n a c o m p e t i t i v e a p p r o a c h as i t may e n s u r e t h a t t h e l i m i t e d r e s o u r c e s a r e b e i n g s p e n t w i s e l y and not w a s t e d on m a t c h i n g c o m p e t i t i o n . A t e c h n i q u e u s e d t o r e v i e w comp-e t i t i o n o r gaps i n s e r v i c e i s a s i m p l e M a t r i x ( A p p e n d i x 12 (a ) and ( b ) ) . A q u e s t i o n t h a t may a r i s e i s how do we o b t a i n t h i s i n f o r m a t i o n . One way i s t o m e r e l y ask f o r i t . Most h e a l t h p r o v i d e r s a r e q u i t e r e a d i l y w i l l i n g t o exchange s u c h i n f o r m a t i o n . I t i s a l s o p u b l i s h e d i n t h e i r a n n u a l r e p o r t s and by t h e p r o v i n c i a l g o v e r n m e n t s . The most s u c c e s s f u l way w o u l d be t h r o u g h r e g i o n a l p l a n n i n g g r o u p s s u c h . a s h o s i t a l d i s t r i c t s o r h o s p i t a l a d v i s o r y c o m m i t t e e s . A l o g i c a l e x p l a n a t i o n o f t h e r e v i e w o f c o m p e t i t i o n i s t o l o o k a t i n t e r - i n s t i t u t i o n a l r e l a t i o n s h i p s . Some b a s i c q u e s t i o n s t h a t t h e c o m m i t t e e s h o u l d a s k a r e - what h e a l t h s e r v i c e a g e n c i e s t o we work w i t h - what o t h e r f a c i l i t i e s do we exchange i n f o r m a t i o n w i t h - how do we work t o g e t h e r t o l o w e r c o s t s . A g a i n , t h e r e i s a b a s i c t e c h n i q u e t h a t can be u s e d t o d e t e r m i n e t h i s and t h e g e n e r a l o u t c o m e , t o e v e r y o n e ' s s u r p r i s e , i s t h e l e n g t h o f s h a r i n g a r r a n g e m e n t s . A s i m p l e M a t r i x can a l s o be u s e d ( A p p e n d i x 1 3 ) . The e x a m p l e s o f a r e a s we a r e l o o k i n g a t h e r e a r e e i t h e r j o i n t o w n e r s h i p o r p u r c h a s e s e r v i c e s o f l a u n d r y , l i n e n , l a b s e r v i c e s , compute r s e r v i c e s , e d u c a t i o n a l p r o g r a m s , g r o u p d r u g p u r c h a s e s , e t c . The o f f -s h o o t o f t h i s i s t h a t i t c l e a r l y i n d i c a t e s t o t h e l o c a l c o m m u n i t i e s and t o t h e M i n i s t r y o f H e a l t h i n d i v i d u a l s t h a t we a r e d e v e l o p i n g c o - o p e r a t i v e v e n t u r e s and j o i n t p l a n n i n g r a t h e r t h a n a d u p l i c a t i o n o f s e r v i c e . Some o t h e r e l e m e n t s o f t h e e x t e r n a l p r o f i l e s can be f o u n d i n A p p e n d i x #14. - 71 -. I n o r d e r t o d e v e l o p t h e s e s t r a t e g i e s , t h e b o a r d and management must have an u n d e r s t a n d i n g o f t h e p u b l i c p o l i c y i m p l i c a t i o n s o f what t h e h o s p i t a l d o e s . M o r e o v e r , t h e y must have a f u n d a m e n t a l i n t e r e s t i n d e a l i n g w i t h s u c h i m p l i c a t i o n s . I t w i l l be e s s e n t i a l t h a t t h e b o a r d and management have g o o d , a c c u r a t e and p r e f e r a b l y e a r l y i n f o r -m a t i o n about t h e f o r c e s e x t e r n a l t o i t w h i c h a r e a t p r e s e n t o r i n t h e f u t u r e g o i n g t o a f f e c t t h e manner i n w h i c h t h e h o s p i t a l o p e r a t e s . T h i s may i n v o l v e p o l i t i c a l a n a l y s i s so t h a t e m e r g i n g i s s u e s and t r e n d s c a n be i d e n t i f i e d . W h i l e some m a j o r changes t h a t may d r a m a t i c a l l y i n f l u e n c e t h e f u t u r e o f t h e h o s p i t a l c a n n o t be f o r e c a s t e d , most m a j o r g o v e r n m e n t a l p o l i c i e s a r e a c o n s i d e r a b l e t i m e i n d e v e l o p m e n t . I n d e e d , t h e p u b l i c p o l i c i e s o f tomorrow c a n o f t e n be seen i n t h e w o r k s o f t h e r e s e a r c h e r s , a c a d e m i c s , and t h e s c h o l a r s o f t o d a y . To be s u c c e s s f u l , a b o a r d and management have t o m o n i t o r t h e e n v i r o n m e n t d e f i n e d i n t h e b r o a d e s t s e n s e p o s s i b l e . I t g o e s w i t h o u t s a y i n g t h a t t h e b o a r d must know t h e way i n w h i c h government makes i t s d e c i s i o n s and who t h e s i g n i f i c a n t p o l i c y - m a k e r s a r e . T h i s i s n o t a l w a y s o b v i o u s , p a r t i c u l a r l y i n t h e l a s t decade s i n c e many new p l a y e r s and new s y s t e m s o f d e c i s i o n - m a k i n g have o f t e n been put i n p l a c e a t t h e p r o v i n c i a l l e v e l . Once t h e n e c e s s a r y o r i n d i c a t e d d a t a has been c o l l e c t e d , t h e a r d u o u s t a s k o f a n a l y s i s b e g i n s . T h i s a n a l y s i s w i l l a i d t h e h o s p i t a l i n a n s w e r i n g t h e q u e s t i o n s - what i s o u r p r e s e n t p u r p o s e ? - what s e r v i c e s do we r e a l l y p r o v i d e , t o whom? T h i s a n a l y s i s r e q u i r e s t h e c o m m i t t e e t o s w i t c h i t s o r i e n t a t i o n b a c k and f o r t h f rom i n t e r n a l e f f i c i e n c i e s t o e x t e r n a l f o r c e s . The - 72 -end r e s u l t o f t h e a n a l y s i s must be t o p r o v i d e t h e most a c c u r a t e p o s s i b l e p i c t u r e o f t he o p p o r t u n i t i e s and t h r e a t s t h e f u t u r e w i l l pose f o r t h e o r g a n i z a t i o n and t h e e n v i r o n m e n t i n w h i c h t h e o r g a n i z a t i o n must manage and compete . The i m p l i c a t i o n s o f t h i s s t e p i s t h a t i t f o r c e s t h e c o m m i t t e e t o r e c o n s i d e r and d e f i n e t h e i r h o s p i t a l as p a r t o f a " s y s t e m " . S i g h t s a r e now r a i s e d f rom t a c t i c a l p l a n n i n g t o t h a t o f s t r a t e g i c p l a n n i n g o f t h e s y s t e m . T h i s f a c t g a t h e r i n g y i e l d s t h e i n f o r m a t i o n needed t o d e v e l o p t h e s t r a t e g y . I n t h e a n a l y s i s o f t h e d a t a h o s p i t a l s , even s m a l l o n e s , may have a c c e s s t o d a t a p r o c e s s i n g s e r v i c e s . W h i l e t h i s may ease t h e w o r k l o a d and speed t h e p r o c e s s , e l e c t r o n i c t e c h n o l o g y c a n n e v e r r e p l a c e management e f f e c t i v e n e s s . V i t a l as i t i s f o r a c c e l e r a t i o n , i t i s u s e l e s s f o r d i r e c t i o n . A c r i t i c a l a s p e c t o f d e v e l o p i n g a d a t a base d e s i g n e d t o c l o s e t h e p l a n n i n g gap i s t h a t o f f o r e c a s t i n g t r e n d s ( c r y s t a l b a l l g a z i n g ) . I t i s t h i s p o i n t t h a t f r u s t r a t i o n u s u a l l y r e a c h e s t h e h i g h e s t l e v e l . We h e a r "How c a n we p r e d i c t what m e d i c a l b r e a k t h r o u g h s w i l l be i n t h e n e x t 10 y e a r s " ; and "How can we p r e d i c t what p o l i t i c i a n s and u n i o n s w i l l d o " ; and "We ' re d i f f e r e n t , we c a n ' t p l a n l i k e i n b u s i n e s s " . A l l t h e s e s t a t e m e n t s have a g r a i n o f t r u t h but u n c e r t a i n t y can be d e a l t w i t h by b u i l d i n g i n f l e x i b i l i t y . A method o f b u i l d i n g i n f l e x i b i l i t y i s t o l i s t e x p e c t e d c o n s e q u e n c e s o f t h e d e t e r m i n e d t r e n d s . T r e n d s a r e no t a l l m y s t e r i o u s and d o p i n g out t h e f u t u r e i s somewhat more p r e d i c t a b l e t h a n what many p e o p l e w o u l d l i k e i t t o b e . Whatever w i l l happen i n t h e f u t u r e i s a l r e a d y h a p p e n i n g . T r e n d s i n s o c i e t y s t a r t s m a l l and b u i l d g r a d u a l l y o v e r a l o n g span o f y e a r s , t h e y a r e not sudden a t a l l , t h e y - 7 3 -j u s t a p p e a r t h a t way b e c a u s e o f o u r u n p r e p a r e d n e s s . What we a r e d o i n g i n p r e d i c t i n g t r e n d s i n p l a n n i n g i s a t t e m p t i n g t o f i g u r e out what t h e f u t u r e h o l d s by b e i n g good s t u d e r t s o f t h e p a s t and p r e s e n t . F o r e x a m p l e , t h e c o m m i t t e e c a n r e v i e w what i s h a p p e n i n g t o o c c u p a n c y r a t e s o f o t h e r h o s p i t a l s i n t h e c o m m u n i t y , p r o v i n c e , o r even t h e n a t i o n . I n f o r m a t i o n on new t e c h n i q u e s u s e d i n m e d i c a l s c h o o l s i s r e a d i l y a v a i l -a b l e . P r o f e s s i o n a l p a p e r s and t r a d e m a g a z i n e s c l e a r l y i n d i c a t e t r e n d s . F o r e x a m p l e , t h e p l a n n i n g c o m m i t t e e s h o u l d t r y f o r e c a s t i n g t h e t r e n d o f i n c r e a s i n g government c o n r o l o f t he q u a n t i t y and c o s t o f h e a l t h c a r e , and t o e x t r a p o l a t e ( g u e s s ) what f u t u r e c o n s e q u e n c e s t h e t r e n d w i l l have on t h e h o s p i t a l i n t h e n e x t 5 - 10 y e a r s . I l l u s t r a t i o n : Consequence 1 . The b o a r d o f t r u s t e e s w i l l become l e s s o f a d e c i s i o n -m a k i n g g r o u p and move t o a recommender r o l e , b e c a u s e a government agency w i l l make t h e f i n a l d e c i s i o n . Consequence 1. The h o s p i t a l w i l l n o t g e t p r o j e c t s a p p r o v e d by t h e M i n i s t r y u n l e s s i t r e s p o n d s t o t h e i r " r e q u e s t s " . You s h o u l d f i g u r e ou t what t h o s e r e q u e s t s w i l l b e . Consequence 3 . Whether t h e government pays an i n c r e a s i n g o r d e c r e a s i n g s h a r e o f a l l b i l l s i n c u r r e d by p a t i e n t s , s u c h payments a r e g e n e r a l l y g o i n g t o be s l o w e r and w i l l r e q u i r e more h a n d l i n g . The h o s p i t a l w i l l t h e r e f o r e need more w o r k i n g c a p i t a l and i m p r o v e d c a s h f l o w . Consequence 4 . The h o s p i t a l w i l l need t o f u r t h e r e n l a r g e i t s s t a f f t o r e s p o n d t o government r e q u e s t s f o r d a t a and t o p r o c e s s f o r m s and p a p e r s . Consequence 5 . More a g e n c i e s o f government w i l l i n s p e c t t h e h o s p i t a l . Consequence 6 . A key management j o b w i l l have t o be e s t a b l i s h e d t o - 74 -c o - o r d i n a t e a l l r e s p o n s e s and a c t i v i t i e s t h a t r e s u l t f r om government i n q u i r i e s . Consequence 7 . Overhead o r s t a f f c o s t s w i l l p r o b a b l y go up f a s t e r t h a n d i r e c t p a t i e n t c a r e c o s t s b e c a u s e o f c o n s e q u e n c e s 3 - 6 . Consequence 8 . D o c t o r s w i l l c o n t i n u e t o y i e l d g round t o " p l a n n e d m e d i c i n e " and w i l l s t e a d i l y l o s e t h e i r c h e r i s h e d f r e e d o m . Consequence 9 . D o c t o r s ' b i l l s w i l l be m o n i t o r e d , and g r e a t e r f o r m s o f r e g u l a t i o n may o c c u r . H o s p i t a l r a t e s , a r e r e g u l a t e d now; t h e d o c t o r s ' p o r t i o n o f h e a l t h c a r e c o s t s w i l l no t be exempted f o r l o n g . Consequence 10 . D o c t o r s ' o f f i c e s w i l l be f u r t h e r a f f e c t e d by t h e r i s i n g t i d e o f f o rms and d a t a r e q u e s t s f rom t h e g o v e r n m e n t . T h i s w i l l r e s u l t i n d o c t o r s f o r m i n g i n t o c o l l e c t i v e s o r g r o u p s i n o r d e r t o a f f o r d t h e management and c l e r i c a l s y s t e m s needed t o c o p e . Consequence 1 1 . The government may a t t e m p t t o push some o f r e g u l a t o r y s c o r e k e e p i n g o f d o c t o r s ' i ncomes and p r a c t i c e s o n t o h o s p i t a l s . H o s p i t a l s and d o c t o r s w i l l need t o be c a r e f u l no t t o g e t c a u g h t on o p p o s i t e s i d e s o f t h e f e n c e . Consequence 12 . About 10 y e a r s a h e a d , ou r h e a l t h c a r e s y s t e m s may d e v e l o p i n t o a t w o - t i e r s y s t e m . One t i e r w i l l be h o s p i t a l s f o r p a t i e n t s who want t o e s c a p e t h e " s y s t e m " and f o r d o c t o r s who want t o a v o i d t h e r e d t a p e o f g o v e r n m e n t . The o t h e r w i l l be h o s p i t a l s f o r e v e r y o n e e l s e . Y o u r b o a r d w i l l need t o t h i n k about w h i c h way y o u r h o s p i t a l w o u l d l e a n , i f s u c h a s p l i t d e v e l o p e d . (11) 4 . P h i l o s o p h y o r S t a t e m e n t o f P u r p o s e T h i s s t a g e t r a n s l a t e s t h e p o t e n t i a l a r e a s o f o r g a n i z a t i o n a l r e s p o n s e s t o n e e d s , demands, w a n t s , o p p o r t u n i t i e s , i n t o a s p e c i f i c f r a m e w o r k . I t i s t h e c o r n e r s t o n e o f t h e o r g a n i z a t i o n . Sooner o r l a t e r , when an - 75 -i n s t i t u t i o n l o o k s a t i t s e l f and i t s f u t u r e , i t must ask s o m e . f u n d a m e n t a l q u e s t i o n s about i t s r e a s o n f o r e x i s t a n c e . Most m e d i c a l c a r e i n s t i t u t i o n s were o r g a n i z e d f o r a s p e c i f i c p u r p o s e , bu t w i t h t h e p a s s a g e o f t i m e i t i s o f t e n o n l y h a l f remembered o r even d i s t o r t e d i n t h e memory o f a few f o u n d e r s o r l o n g - t i m e e m p l o y e e s . I n many c a s e s , i n s t i t u t i o n s have added so many new p rograms t o meet new demands, and t o keep a b r e a s t o f m e d i c a l a d v a n c e s t h a t t h e i r o r i g i n a l p u r p o s e i s s u b o r d i n a t e . And y e t , u n l e s s an i n s t i t u t i o n has a c l e a r i d e a o f i n t e n t , i t c a n n o t hope t o p r o g r e s s v e r y f a r i n i t s p l a n n i n g . A c o n c i s e s t a t e m e n t i s needed a r t i c u l a t i n g t h e b a s i c p r i n c i p l e s o r p u r p o s e t h a t d i f f e r e n t i a t e s y o u r h o s p i t a l i n some way f r o m a l l i t s c o m p e t i t o r s and stems f r o m a p e r c e p t i o n o f p r e s e n t and f u t u r e communi ty n e e d s , ( m a r k e t ) o p p o r t u n i t i e s , d i s t i n c t i v e c o m p e t e n c e , c o m p e t i t i v e a d v a n t a g e , a v a i l a b l e r e s o u r c e s , and board /management p e r s o n a l a s p i r -a t i o n s and v a l u e s . I t i s t h e " b e s t f i t " between s e r v i c e s t h a t a r e c o n -i s t e n t w i t h t h e o r g a n i z a t i o n ' s a v a i l a b l e r e s o u r c e s and t h e c o m m u n i t y ' s n e e d s . I t r e c o n c i l e s what a h o s p i t a l m i g h t do i n t e r m s o f t h e s e o p p o r t u n i t i e s , what i t c a n do i n t e r m s o f i t s s t r e n g t h s , what i t s management w a n t s i t t o d o , and what i t t h i n k s i s e t h i c a l , l e g a l , and m o r a l . T h i s c o n c e p t o f p r i n c i p l e s i n v o l v e s e c o n o m i c , s o c i a l , and p e r s o n a l p u r p o s e s . A l t h o u g h i t e v o l v e s w i t h t h e d e v e l o p m e n t o f p r o f i l e s , s t r e n g t h s , and v a l u e s , a h o s p i t a l p r i n c i p l e marks ou t a d e l i b e r a t e l y c h o s e n d i r e c t i o n and g o v e r n s d i r e c t l y t h e s e r v i c e d e c i s i o n s , o r g a n i z a t i o n a l s t r u c t u r e , communi ty r e l a t i o n s , and i n d e e d t h e e s s e n t i a l c h a r a c t e r o f t h e h o s p i t a l . I t embodies a u n i t y o f p u r p o s e , a p u r p o s e w h i c h t o be p o w e r f u l - 76 -must be c l e a r and w o r t h y o f t h e commitment o f e n e r g e t i c and i n t e l l i g e n t p e o p l e . I t r e f l e c t s q u a l i t a t i v e l y what k i n d o f b u s i n e s s o r g a n i z a t i o n t h e h o s p i t a l i n t e n d s t o p u r s u e a n d / o r e x c e l i n f o r a l l i t s c o n s t i t u e n t s - t r u s t e e s , e m p l o y e e s , p h y s i c i a n s , and t h e c o m m u n i t y . A s p i r a t i o n s o f q u a l i t y , s t y l e , t o n e and s o c i a l r e s p o n s i b i l i t y b e l o n g i n t h i s d e t e r m i n a t i o n . T h i s k i n d o f summary s t a t e m e n t o f p u r p o s e s h o u l d be c l e a r enough n o t t o p r e v e n t t h e g e n e r a t i o n o f i n n o v a t i v e , d e t a i l e d a c t i o n p r o g r a m s and t h e p a r t i c i p a t i o n o f p e o p l e who a r e m o t i v a t e d by t h e i r p e r c e p t i o n o f p u r p o s e s t h a t have o p p o r t u n i t y and a t t r a c t i o n f o r t hem. I t s h o u l d n ' t be so vague a s t o p r o v i d e no d i r e c t i o n , n o r so r e s t r i c t i v e a s t o s t i f l e t h e s t r a t e g i c p l a n n i n g p r o c e s s , n o r s h o u l d i t be so a l l - e n c o m p a s s i n g a s t o s u b s t i t u t e f o r t h e f i n a l p l a n n i n g document . I n t i m e s o f r a p i d change and i n e m e r g e n c i e s , d e t a i l s c a n and w i l l be b y p a s s e d ; i t i s t h i s r e c o g -n i t i o n o f p u r p o s e f o r each a c t i o n w h i c h h o l d s t h e e n t i r e o r g a n -i z a t i o n t o g e t h e r . Such a s t a t e m e n t makes an i m p o r t a n t c o n t r i b u t i o n t o management. I t f o r c e s c o n t i n u o u s s e n s i t i v i t y t o c h a n g e s t a k i n g p l a c e i n t h e h o s p i t a l ' s e n v i r o n m e n t and r e s o u r c e s . I t r e q u i r e s t h e managers t o l a y c o n f l i c t i n g p e r s o n a l and o f t e n " i n v i s i b l e " a g e n d a s on t h e t a b l e and t o l o o k beyond i m m e d i a t e o p p o r t u n i t i e s t o w a r d l o n g - t e r m g r o w t h and d e v e l o p m e n t . The s t a t e m e n t summons up i m a g i n a t i o n , i n n o v a t i o n , and a z e s t f o r r i s k . The c o n c e p t o f a " S t a t e m e n t " h a s i t s s h o r t c o m i n g s , a s w e l l , f o r i t demands t o u g h , h i g h - r i s k commitment t o a c h o i c e o f d i r e c t i o n . I t c a n o f t e n be s u b j e c t o n l y t o j u d g e m e n t , n o t t o d e f i n i t i v e e v a l u a t i o n i n a d v a n c e o f i t s v a l i d i t y . T h i s i s t h e f i r s t and f o r e m o s t s t r a t e g i c d e c i s i o n an o r g a n i z a t i o n must make. T h i s r e p r e s e n t s t h e " b i g p i c t u r e " o f t h e f a c i l i t y ' s f u t u r e . F a i l i n g t o d e t e r m i n e t h i s and d e t e r m i n e i t w e l l l e a v e s t h e o r g a n i z a t i o n w i t h no f o c a l p o i n t o r c e n t r a l t h r u s t f o r l i n i n g up t h e o r g a n i z a t i o n ' s e n e r g i e s and r e s o u r c e s t o a c c o m p l i s h t h e most d e s i r a b l e e n d s . The n a t u r a l r e s u l t o f t h i s f a i l u r e i s t h e d i s s i p a t i n g o r s c a t t e r - g u n n i n g o f e f f o r t s i n many d i v e r s e d i r e c t i o n s t y p i c a l l y e v i d e n c e d by a m y r i a d o f d i f f e r e n t p r o g r a m s w h i c h do n o t meet t h e n e e d s o f communi ty and some p r o g r a m s w h i c h may a c t u a l l y c o n f l i c t w i t h o t h e r s . The S t a t e m e n t i s bu t a t o o l d e s i g n e d t o c o m m u n i c a t e b o t h i n t e r n a l l y and e x t e r n a l l y what t h e h o s p i t a l s t a n d s f o r . I t i s t h e b e g i n n i n g p o i n t - o f d i s c i p l i n e t h a t w i l l a l l o w you t o e v a l u a t e t h e a p p r o p r i a t e n e s s o f p r e s e n t a c t i v i t i e s , f u t u r e d i r e c t i o n s , and a s s i s t s i n a p p r a i s i n g r e q u e s t s f o r new s t a f f , e q u i p m e n t , and t o c o n s i d e r new f a c i l i t i e s . The S t a t e m e n t o f P u r p o s e i s t h e b e g i n n i n g o f t h e p l a n and s h o u l d s t a r t w i t h an a c c e p t e d s o c i a l v a l u e . L i t e r a t u r e i n d i c a t e s t h a t 9 o u t o f 10 h o s p i t a l t r u s t e e s , a d m i n i s t r a t o r s , and d o c t o r s a r e unaware w h e t h e r a S t a t e m e n t o f P u r p o s e e x i s t s , l e t a l o n e what i t s a y s . T r a d i t i o n a l l y , t h e p r o b l e m t h a t most h o s p i t a l s e n c o u n t e r i s t h a t t h e y do n o t answer any q u e s t i o n s t h a t may be r a i s e d . They - 78 -s t a t e " t h a t t h e m i s s i o n o f t h i s h o s p i t a l s h a l l be t o p r o v i d e t h e p r o v i s i o n o f h e a l t h c a r e a t t h e l o w e s t c o s t f o r a l l who e n t e r " . The s t a t e m e n t s h o u l d answer c e r t a i n q u e s t i o n s and c o n c e r n s r a i s e d by any o f t h e key p l a y e r s o f t h e c o m m u n i t y , s u c h a s "what d o e s t h e h o s p i t a l s t a n d f o r ; where i s i t g o i n g ; what c a n t h e h o s p i t a l a f f o r d t o d o ; what do p a t i e n t s e x p e c t o f t h e h o s p i t a l ; what m e d i c a l p r o c e d u r e s i s t h e h o s p i t a l q u a l i f i e d t o p e r f o r m ; who d o e s t h e h o s p i t a l s e r v e ; how s h o u l d i t s e r v e i t s c o m m u n i t y ? " The s t a t e m e n t t h a t i s g e n e r a l i s b a s i c a l l y u s e l e s s , a s i t p r o v i d e s no d i r e c t i o n and i s so vague t h a t i t m e r e l y c r e a t e s no r e a c t i o n s a l s o . How c l e a r i t i s i n w o r d s o r p r a c t i c e , how c o n s i s t e n t i t i s w i t h o r g a n i z a t i o n c o m p e t e n c e and r e s o u r c e s (both p r e s e n t and p r o j e c t e d ) and how i n t e r n a l l y c o n s i s t e n t i t i s c a n a l l be s u b m i t t e d t o q u a l i t a t i v e a n a l y s i s . How much i t r e f l e c t s t h e v a l u e s and a s p i r a t i o n s o f t h e key p e r s o n s i n t h e h o s p i t a l , how much i t c o n s t i t u t e s a c l e a r s t i m u l u s t o e f f o r t and c r e a t i v i t y , and w h e t h e r i n e t h i c a l and m o r a l t e r m s i t i n s p i r e s commitment and t h e r e q u i r e d q u a l i t y c a n a l s o be e s t i m a t e d i n t h e l i g h t o f r e l e v a n t , i f u n q u a n t i f i a b l e , e v i d e n c e . The f i t n e s s o f t h e match between r e s o u r c e s and o p p o r t u n i t y and i t s p o t e n t i a l c a n be q u a n t i f i e d . A sample s t a t e m e n t t h a t a d e q u a t e l y d e s c r i b e s y o u r h o s p i t a l i s f ound i n A p p e n d i x #15. I t s h o u l d be n o t e d a t t h e o n s e t t h a t an o r g a n i z a t i o n d o e s n o t d e t e r m i n e i t s p u r p o s e . The communi ty w h i c h i t s e r v e s - 79 -makes t h i s d e t e r m i n a t i o n f o r t h e o r g a n i z a t i o n . An e f f e c t i v e S t a t e m e n t o f P u r p o s e a l w a y s p r o c e e d s f r o m t h e o u t s i d e ( p a t i e n t and e n v i r o n m e n t needs) t o t h e i n s i d e (a h o s p i t a l ' s r e s p o n s e t o t h e s e n e e d s ) . I f one n e e d s t o t e s t t h i s p r e m i s e , you need l o o k no f u r t h e r t h a n t h e c o u n t l e s s number o f o r g a n i z a t i o n s w h i c h have f a i l e d i n t h e p a s t b e c a u s e t h e y (not t h e c l i e n t ) d e t e r m i n e d t h e i r p u r p o s e . A f t e r g e a r i n g up t o c a r r y o u t t h e i r p u r p o s e , t h e y found t h e y were t r y i n g t o p r o v i d e p r o g r a m s and s e r v i c e s w h i c h t h e comm-u n i t y d i d n o t need o r w a n t . The p u r p o s e and r o l e o f an i n s t i t u t i o n a r e m a t t e r s o f p o l i c y t o be d e t e r m i n e d by i t s g o v e r n i n g b o a r d . I t i s r a r e , h o w e v e r , t h a t t h e b o a r d , e i t h e r on i t s own i n i t i a t i v e o r t h r o u g h i t s p l a n n i n g c o m m i t t e e , a c t u a l l y s p e l l s o u t p u r p o s e and r o l e . R a t h e r , t h e y a r e u s u a l l y d e f i n e d , i n p a r t , by a s e r i e s o f a c t i o n s t a k e n and p o l i c i e s made o v e r a p e r i o d o f y e a r s . Much o f t h e p l a n n i n g c o n d u c t e d a t t h e b o a r d l e v e l p r o c e e d s on t a c i t a s s u m -p t i o n s o f what t h e i n s t i t u t i o n s h o u l d do and what t h e communi ty e x p e c t s i t t o d o . The a s s u m p t i o n s may n o t a l w a y s be c l e a r o r r a t i o n a l . P l a n n i n g h a s been d e s c r i b e d a s a means o f c l a r i f y i n g t h e s e a s s u m p t i o n s and s h a r p e n i n g t h e i r r a t i o n a l i t y . T h i s s t a g e s h o u l d a n s w e r t h e q u e s t i o n "where do we want t o g o ? " I t s p e c i f i e s t h e end t o w a r d s w h i c h t h e h o s p i t a l w o u l d l i k e t o move d u r i n g a s p e c i f i e d p e r i o d o f t i m e . One o f t h e most d i f f i c u l t a s p e c t s o f t h i s s t a g e i s t h a t i t r e q u i r e s t h e h i e r a r c h a l s t r u c t u r i n g o f g o a l s and o b j e c t i v e s w i t h i n a c o m p l e x , d y n a m i c and i n t e r d e p e n d e n t f ramework . C y e r t - 80 -and March (1963); and A n s o f f (1969); have w r i t t e n e x t e n s i v e l y on o r g a n i z a t i o n a l g o a l s and i t i s beyond t h e s c o p e and i n t e n t o f t h i s s t u d y t o d e a l w i t h t h i s m a t t e r o t h e r t h a n t o c a u t i o n c o m m i t t e e s t h a t c o n s i d e r a t a b l e a t t e n t i o n must be p a i d t o r e a c h i n g c o n s e n s u s on s p e c i f i c t a r g e t s ( g o a l s and o b j e c t i v e s ) . I t may come a s a shock t o t h e c o m m i t t e e t h a t , upon r e v i e w i n g e v e r y t h i n g and making y o u r s t a t e m e n t o f p u r p o s e , t h a t y o u r h o s p i t a l i s i n d e e d n o t t h e g r e a t e s t , n o r t h e l e a d e r i n some f i e l d s t h a t you have e x p e c t e d . W h i l e t h e s t a t e m e n t c a n be d r e s s e d up f o r e x t e r n a l u s e , i t i s i m p o r t a n t t h a t i t be e x p r e s s e d i n p l a i n t e r m s . I f t h e c o m m i t t e e f i n d s t h a t t h e r e a r e s h o r t c o m i n g s i n t h e h o s p i t a l w i t h some o f t h e p r o g r a m s and l o w u t i l i z a t i o n , one must n o t be a f r a i d t o v i e w c e r t a i n p r o g r a m s and s e r v i c e s w i t h an eye t o e u t h a n a s i a . I t i s a b i g r e s p o n s -i b i l i t y f o r t h e c o m m i t t e e t o t a k e t h e s u g g e s t i o n o r recommend-a t i o n t o t h e b o a r d t h a t t h ^ h a v e r e v i e w e d t h e f a c t s and some t h i n g s a r e n o t w o r k i n g . F a i l u r e o f a p r o g r a m o r s e r v i c e i s n o t t o be i n t e r p r e t e d n e g a t i v e l y . I t i s a n a t u r a l c o n s e q u e n c e o f o u t - d a t e d p r o g r a m s o r new i d e a s t h a t a r e n o t a d e q u a t e i n t h e p r e s e n t tough e n v i r o n m e n t t h a t we e x i s t . I t makes no s e n s e t o do e v e r y t h i n g r i g h t i f we a r e n o t d o i n g t h e r i g h t t h i n g s . I f t h e b o a r d i s r e l u c t a n t t o a c t upon t r e n d s t h a t may i n d i c a t e , however s l i g h t l y , t h a t c e r t a i n s e r v i c e s s h o u l d be e l i m i n a t e d , t h e n c e r t a i n l y a f u t u r e e v a l u a t i o n i s n e c e s s a r y . The s t a r t i n g p o i n t s h o u l d be some b e n c h m a r k s t h a t w i l l be e v a l u a t e d one o r two y e a r s down t h e r o a d , s u c h t h i n g s a s : 1. a d e f i n i t i o n o f s u c c e s s e . g . o c c u p a n c y r a t e s h o u l d be a t s u c h a l e v e l - 81 -2. a t i m e t a b l e o f e v e n t s e . g . t h e number o f p r o c e d u r e s we e x p e c t t o p e r f o r m 3. a p r o j e c t i o n o f s u r p l u s o r d e f i c i t 4 . a d e f i n i t e s t a t e m e n t o f a c t i o n c o u r s e s on new p r o g r a m s . The p r i n c i p l e t o t h i s e x e r c i s e i s v e r y s i m p l e : t h e s u r v i v a l o f y o u r h o s p i t a l d e p e n d s on you c o n c e n t r a t i n g y o u r r e s o u r c e s on t h e f a c i l i t i e s and p r o g r a m s t h a t a r e most demanded by t h e communi ty you have d e c i d e d t o s e r v e and t h i s means e l i m i n a t i n g f a i l i n g e f f o r t s . D e v e l o p i n g such a s t a t e m e n t i s an ambiguous and c o n t r o v e r -s i a l e x e r c i s e . T h e r e h a s t o be d i s s e n t and c o n t r o v e r s y b e f o r e a v i a b l e d e f i n i t i o n c a n be f o u n d , b e c a u s e you s e r v e s u c h a v a r i e t y o f c o n s t i t u e n t s . You have t o s a t i s f y t h e p a t i e n t , t h e d o c t o r s , t h e n u r s e s , t h e t e c h n i c a l s t a f f , and o t h e r e m p l o y e e s , t h e p a t i e n t s ' f a m i l i e s , t h e t a x p a y e r s , t h e d o n o r s , and o t h e r t h i r d p a r t y p a y e r s who p r o v i d e t h e b u l k o f t h e s u p p o r t o f most h o s p i t a l s . U n t i l you have s u c h a s t a t e m e n t a g r e e d t o by y o u r m a n a g e r s , f i n a n c i a l s u p p o r t -e r s , b o a r d members, e m p l o y e e s and a l l o t h e r c o n s t i t u e n t s , you a r e n o t r e a d y t o a p p r o a c h s u g g e s t i o n s f o r c h a n g e . 5 . The p l a n n i n g g a p . A f t e r t h e s t a t e m e n t o f p u r p o s e i s d r a f t e d , t h e n e x t s t e p i s t o d e t e r m i n e w h e t h e r i t c o i n c i d e s w i t h t h e r e a l i t y , a s d e t e r m i n e d by a r e v i e w o f y o u r d a t a b a s e ; t h e p l a n s o f o t h e r h o s p i t a l s i n t h e c o m m u n i t y ; communi ty p e r c e p t i o n s ; p l a n s o f h e a l t h p l a n n i n g a g e n c i e s ; d e m o g r a p h i c d a t a ; and a n t i c i p a t e d c h a n g e s i n t h e p r a c t i c e o f m e d i c i n e . How c l o s e l y i t c o i n c i d e s d e t e r m i n e s t h e e x t e n t o f y o u r " p l a n n i n g g a p " . To h e l p c l o s e t h e gap we must now a s s e s s o u r c u r r e n t o r g a n i z a t i o n a l c a p a b i l i t i e s ( p r e s e n t ) - 82 -p o s i t i o n ) i n l i g h t o f t h e s t a t e m e n t o f p u r p o s e ( d e s i r e d p o s i t i o n ) . The s t r e n g t h s a r e a s s e t s and a r e b u i l d i n g b l o c k s f o r t h e f u t u r e . Y o u r w e a k n e s s e s , o f c o u r s e , a r e on t h e n e g a t i v e s i d e . B o t h a r e t o be a p p r e c i a t e d . To d i s c o v e r them t h e r e a r e two s t e p s t o be t a k e n i n t h e s t r a t e g i c p l a n n i n g p r o c e s s : 1. E n s u r e t h e c o m m i t t e e members a l l have t h e S t a t e m e n t o f P u r p o s e i n f r o n t o f them, f o r w i t h o u t t h e S t a t e m e n t , t h e y c a n n o t t e l l t h e w e a k n e s s e s and s t r e n g t h s . F o r e x a m p l e , i f S t a t e m e n t d e c l a r e s t h a t t h e h o s p i t a l ' s r o l e i s t o s p e c i a l i z e i n day c a r e s u r g e r y , and y o u h a v e a l a r g e p r o g r a m f o r g e r i a t r i c day c a r e , t h e p r o g r a m f o r t h e e l d e r l y w i l l n o t be a s t r e n g t h , even i f i t i s m e d i c a l l y and f i n a n c i a l l y s u c c e s s f u l , b e c a u s e i t n e i t h e r f i t s t h e P u r p o s e , n o r enhances i t . What you o n c e t h o u g h t o f a s a s t r e n g t h i s i n r e a l i t y one more t h i n g t o be c o r r e c t e d o r t h e S t a t e m e n t o f P u r p o s e s h o u l d be c h a n g e d . ?.. The s t r e n g t h s and w e a k n e s s e s must be e x p l i c i t l y a r t i c u l a t e d and w r i t t e n down. A s s t a t e d i n t h e example o f t h e g e r i a t r i c day c a r e p r o g r a m , i f t h e S t a t e m e n t i s i n c o n f l i c t w i t h t h e m a j o r s t r e n g t h o f t h e h o s p i t a l , e i t h e r t h e s t r e n g t h must be abandoned by d e c l a r i n g i t no l o n g e r c o n s i s t e n t w i t h t h e h o s p i t a l ' s p u r p o s e , g o a l s and o b j e c t i v e s o r t h e P u r p o s e must be c h a n g e d . W i t h p l a n n i n g i n p l a c e , t h e b o a r d and management s h o u l d be a l e r t t o t h e need f o r c h a n g e l o n g b e f o r e o u t s i d e f o r c e s p r e s s f o r a c t i o n . Under no c i r c u m s t a n c e s s h o u l d t h e h o s p i t a l t r y t o l i v e w i t h t h e i n c o n s i s t e n c y . D r u c k e r (1977) s t r e s s e s two t r a i t s t h a t a r e n e c e s s a r y b o t h f o r an e f f e c t i v e e x e c u t i v e and f o r an e f f e c t i v e o r g a n i z a t i o n : - 83 -1. b u i l d i n g on y o u r s t r e n g t h s , and 2. c o n c e n t r a t i n g on t h e few m a j o r a r e a s i n w h i c h s u p e r i o r p e r f o r m a n c e w i l l y i e l d o u t s t a n d i n g r e s u l t s . The i m p o r t a n c e o f t h i s l e s s o n i n t h e h o s p i t a l f i e l d w i l l i n c r e a s e . I f y o u r h o s p i t a l i s g o i n g t o s t a n d o u t i n t h e c r o w d and p o s i t i o n i t s e l f t o p r o v i d e t h e s e r v i c e s t h a t a r e most a p p r o p r i a t e , you f i r s t need t o r e c o g n i z e y o u r h o s p i t a l ' s u n i q u e s t r e n g t h s and t o f o c u s y o u r p l a n n i n g e f f o r t s on b u i l d i n g on them. I n c o n d u c t i n g i t s a s s e s s m e n t o f t h e l e v e l and t h e s c o p e o f s e r v i c e s t o p r o v i d e , t h e h o s p i t a l n e e d s t o c o n s i d e r s e r v i c e s t h a t a r e r e q u i r e d t o s u s t a i n n e e d s r a t h e r t h a n s e r v i c e s r e q u i r e d t o d e a l w i t h a c u t e i l l n e s s . T h i s may w e l l be a new a p p r o a c h t o h e a l t h c a r e d e l i v e r y f o r many s m a l l o r r u r a l h o s p i t a l s . T h e s e two s t e p s make i t o b v i o u s t h a t r e a l i s t i c g o a l s and o b j e c t i v e s c a n n o t be e s t a b l i s h e d w i t h o u t knowing y o u r c u r r e n t c a p a b i l i t i e s . The r e v i e w o f s t r e n g t h s and w e a k n e s s e s s h o u l d be a n a l y z e d , a l o n g w i t h t h e d a t a b a s e , i n t e r m s o f c o n s t r a i n t s . The a w a r e n e s s o f c o n s t r a i n t s , b o t h a b s o l u t e and r e l a t i v e , i n becoming i n c r e a s -i n g l y i m p o r t a n t i n d e v e l o p i n g a m e a n i n g f u l p r o c e s s . C o n s t r a i n t s a r e p l a c e d i n t h e sequence o f p l a n n i n g b e c a u s e t h e y h e l p e s t a b l i s h p a r a m e t e r s t h a t must be o b s e r v e d o r o b s t a c l e s t h a t must be o v e r c o m e . Subsequent p l a n n i n g a c t i v i t i e s must a c k -n o w l e d g e t h e b a r r i e r s o r g r o u n d r u l e s t h a t t h e i n t e r n a l o r g a n -i z a t i o n o r t h e e n v i r o n m e n t i m p o s e s . C o n s t r a i n t s s h o u l d n o t d i c t a t e p l a n n i n g a c t i v i t i e s , b u t t h e y p r o v i d e a f ramework f o r i d e a g e r m i n a t i o n . I t i s n e c -e s s a r y t o r e c o g n i z e t h e r e a l i t i e s o f t h e c u r r e n t h e a l t h c a r e e n v i r o n m e n t . - BU -A t t h i s p o i n t a l s o t h e c o m m i t t e e s h o u l d r e v i e w t h e i r s t r e n g t h s and w e a k n e s s e s i n c o n j u n c t i o n w i t h any p r o b l e m s o r i s s u e s c h a t c a n be i d e n t i f i e d . The p l a n n i n g c o m m i t t e e s h o u l d d e v e l o p a l i s t o f p r o b l e m s and i s s u e s t h e h o s p i t a l f a c e s and i t must a d d r e s s . The f i r s t s t e p o f c o u r s e i s t o c o l l e c t and i d e n t i f y t h e i s s u e s . T h i s p r o c e d u r e s h o u l d n o t be c o m p l e x and s h o u l d n o t be o v e r w o r k e d b e c a u s e t h e r e i s o f t e n a r e d u n d a n c y i n r e l a t i o n t o t h e i d e n t i f i c a t i o n o f t h e h o s p i t a l s t r e n g t h s and w e a k n e s s e s . However , t h i s does d i s c u s s s i m i l a r a r e a s f rom a s l i g h t l y d i f f -e r e n t a n g l e and w i l l have t h e e f f e c t o f n a r r o w i n g t h e m a r g i n o f e r r o r and i n c r e a s e t h e p r o b a b i l i t y t h a t what a i l s t h e i n s t i -t u t i o n h a s been c o r r e c t l y i d e n t i f i e d . . O f t e n t h e b e s t p r o c e d u r e i s f e r each c o m m i t t e e member t o work i n d e p e n d e n t l y on a l i s t o f p r o b l e m s and p e r h a p s , u s i n g two l i s t s o f c u r r e n t p r o b l e m s t h e h o s p i t a l w i l l f a c e . I t w i l l become o b v i o u s t h a t many o f t h e p r o b l e m s l i s t e d c a n be g r o u p e d i n t o c l u s t e r s and b a s i c a l l y have one i s s u e u n d e r l y i n g many p r o b l e m s . In a t t e m p t i n g t o d e a l w i t h c r i s e s , and g a i n t h e o p p o r -t u n i t y t h e y p r o v i d e , one must l o o k b e h i n d t h e c r i s e s a t t h e i s u u e s and p r o b l e m s . The d i f f e r e n c e between an i s s u e and a p r o b l e m i s t h a t t h e i s s u e i s t h e u n d e r l y i n g c a u s e o f t h e p r o b l e m . I t i s t h e t h i n g t h a t w i l l keep c a u s i n g p r o b l e m s i f i t i s n o t c o r r e c t e d . An i s s u e i s a p r o b l e m g e n e r a t o r . R e s o l v e i t and you g e t r i d o f many p r o b l e m s . O f t e n b o a r d and a d m i n i s t r a t i o n b e g i n t h e i r p l a n n i n g e f f o r t s w i t h s o l u t i o n s and t h e n l o o k f o r p r o b l e m s t o s o l v e . T h i s i s p r o b a b l y a n a t u r a l t e n d e n c y f o r f i n d i n g and f a c i n g i s s u e s r e q u i r e s a l o t o f demanding and t i m e - c o n s u m i n g w o r k . I n a t t e m p t i n g t o g e t t o t h e b o t t o m o f i s s u e s i t h e l p s t o b e g i n w i t h some key q u e s t i o n s : 1. How d i d t h i n g s g e t so f a r w i t h o u t someone r e c o g n i z i n g t h e i s s u e and p r o b l e m ? 2. How i s i t p o s s i b l e f o r a s i t u a t i o n l i k e t h i s t o go on so l o n g ? 3. What o t h e r p r o b l e m s and i s s u e s a r e i n t h e o r g a n i z a t i o n t h a t we do n o t know a b o u t ? 4 . I s t h e r e a p r o b l e m w i t h c o m m u n i c a t i o n ? 5 . What p r o b l e m s and i s s u e s do we need t o c l e a r away? T h e r e a r e a few p e c u l i a r t h i n g s a b o u t i s s u e s . F i r s t , upon i n v e s t i g a t i o n t h e y a r e r a r e l y t h e same a s y o u t h i n k t h e y were a t f i r s t . P r o b l e m s and i s s u e s a r e a l m o s t n e v e r what you were o r i g i n a l l y t o l d . S e c o n d l y , i s s u e s a r e o f t e n f a i r l y d e l -i c a t e and u n s p e a k a b l e . T h i s i s u s u a l l y b e c a u s e p e o p l e do n o t want t o d i s p a r a g e a s s o c i a t e s and t h e y f e e l t h a t i t i s an a c t o f k i n d n e s s t o say n o t h i n g . T h i r d , most p e o p l e i n t h e h o s p i t a l do n o t s e e t h e w h o l e p i c t u r e a s t h e y work o n l y i n a segment and may o n l y see t h e s m a l l p r o b l e m s and n o t t h e e n t i r e i s s u e . However d i f f i c u l t i t i s t o d i g t h r o u g h t h e p r o b l e m s t o f i n d t h e m a i n i s s u e , i t i s t h e b o a r d and a d m i n i s t r a t i o n ' s o b l i g a t i o n t o show t h e i r w i l l i n g n e s s and a b i l i t y t o t a c k l e t h e s e i s s u e s . F o r m u l a t i o n o f G o a l s and O b j e c t i v e s ( I d e n t i f y i n g , s e l e c t i n g and d e s i g n i n g a l t e r n a t i v e c o u r s e s o f a c t i o n )  T h i s s t a g e d e a l s w i t h t h e s p e c i f i c a t i o n o f o r g a n i z a t i o n a l g o a l s and d e s i g n i n g t h e o b j e c t i v e s by w h i c h t h e y a r e t o be a c h i e v e d . - 86 -S u b s e q u e n t t o t h e i n s t i t u t i o n ' s i d e n t i f i c a t i o n o f p o t e n t i a l n e e d s , demand, o p p o r t u n i t i e s , e t c . , and t h e d e c i s i o n t o p u r s u e a d i r e c t i o n , i t i s c r i t i c a l t o examine t h e v a r i o u s o p t i o n s t h a t d i r e c t i o n p r o v i d e s . A f t e r t h e f a c t s a r e g a t h e r e d by c o n s u l t a n t s , a d m i n i -s t r a t i o n and t h e p l a n n i n g c o m m i t t e e , t h e n e x t s t e p i s t o d i s s e c t and d i g e s t them. C a r e f u l a n a l y s i s and s t u d y w i l l d i s c l o s e t r e n d s , w e a k n e s s e s , and i s s u e s t h a t s h o u l d be a d d r e s s e d by t h e c o m m i t t e e . O r g a n i z a t i o n s must c o n t i n u a l l y e v a l u a t e v a r i o u s c o u r s e s o f a c t i o n t h r o u g h o u t t h e p l a n n i n g p r o c e s s b u t i t i s h e r e t h a t a d i s t i n c t p o i n t i s r e a c h e d where ma jo r e v a l u a t i o n s s h o u l d o c c u r . Many f u t u r e p r o b l e m s c a n be e l i m i n a t e d by r i g o r o u s r e v i e w a t t h i s t i m e . T h i s i s t h e most c r i t i c a l p h a s e o f t h e e n t i r e p l a n n i n g p r o c e s s . A t t h i s p o i n t , t h e c o m m i t t e e members h a v e t h e k n o w l e d g e -b u t n o t n e c e s s a r i l y t h e c o u r a g e - t o p u t t o g e t h e r an e f f e c t i v e p l a n . The e c o n o m i c s o f r u n n i n g a h o s p i t a l may be f o r c i n g t h e c o m m i t t e e t o t h i n k i n t e r m s o f d o l l a r s and c e n t s a s w e l l a s q u a l i t y o f c a r e . P e t p r o j e c t s may have t o be a x e d . D o c t o r p r o b l e m s may be s u r f a c i n g a s c e r t a i n d i r e c t i o n s and d e c i s i o n s become a p p a r e n t . The c o m m i t t e e may be f a c i n g t h e u n s e t t l i n g d i s c o v e r y t h a t t h e f u t u r e c a n n o t be p r e d i c t e d , o n l y g u e s e d a t , and t h a t some p r o b l e m s may n o t have a p p a r e n t s o l u t i o n . The t i m e h a s come t o f a c e t h e m u s i c . I t i s a t t h i s s t a g e t h a t we a r e r e q u i r e d t o p r o j e c t t h e c o n s e q u e n c e s o f t h e v a r i o u s a l t e r n a t i v e s l a i d o u t i n S t a g e 5 . - 87 -These c o u r s e s o f a c t i o n ( a l t e r n a t i v e s ) w h i c h a r e n o t c o n s i s t e n t and do n o t r e l a t e t o o t h e r g o a l s o r t o t h e o v e r a l l m i s s i o n , a r e p o l i t i c a l l y n o t v i a b l e o r a r e u n r e a l i s t i c o r n o t a c h i e v a b l e , must be d i s c a r d e d . The r e m a i n i n g o n e s a r e e v a l u a t e d i n t e r m s o f p r i o r i t i e s . T h i s s t a g e n a r r o w s t h e a l t e r n a t i v e s and may i n i t s e l f f o r c e a s i n g l e c h o i c e . A t r u l y e f f e c t i v e s t r a t e g i c p l a n s h o u l d f a c i l i t a t e t h e d e c i s i o n - m a k i n g p r o c e s s t o s u c h a d e g r e e t h a t d e c i s i o n s a r e n o t a g o n i z e d o v e r b u t seem i n e v i t a b l e . T h i s s e l e c t i o n s t a g e e n t a i l s t h e i n s t i t u t i o n making a d e c i s i o n on a c o u r s e o f a c t i o n . I t r e p r e s e n t s t h e " g o - n o - g o " p o i n t i n t h e p l a n n i n g p r o c e s s c a r r y i n g t h e f u l l w e i g h t o f t h e g o v e r n i n g b o d y , a n d , p r e s u m a b l y , t h e e n d o r s e m e n t o f t h e i n s t i t u t i o n ' s manage -ment and m e d i c a l s t a f f . W h i l e t h e i m p o r t a n c e o f t h i s s t a g e a p p e a r s o b v i o u s and r a t i o n a l t o t h e o n l o o k e r , i t i s one o f t h e c r i t i c a l d e f i c i e n c i e s o f many h o s p i t a l s - t h e i n a b i l i t y t o make d e c i s i o n s . S e l e c t i o n s h o u l d mean t h a t t h e r e w i l l n o t be any t u r n i n g back o r r e h a s h i n g o f p r e v i o u s s t e p s u n l e s s w a r r a n t e d by new d e v e l o p m e n t s . A t t h i s p o i n t t h e r e w i l l be an a s s i g n i n g o f r e s p o n s i b i l i t i e s and a t i m e -t a b l e f o r c o m p l e t i o n . What i s needed a t t h i s p o i n t i s a c o m m i t t e e c h a i r m a n who i s d e t e r m i n e d , w i t h t h e b a c k i n g o f t h e b o a r d c h a i r m a n , t o s e e t h e p r o j e c t t h r o u g h t o t h e e n d . H a v i n g w r e s t l e d w i t h t h e t o u g h i s s u e s , t h e c o m m i t t e e now must f o c u s on p u l l i n g t h e i d e a s t o g e t h e r i n t o a s t r a t e g i c p l a n . U s u a l l y , v a r i o u s p i e c e s o f t h e p l a n a r e a l r e a d y ( w r i t t e n b u t must be b r o u g h t t o g e t h e r i n t o a c o h e s i v e document . - 88 -I n r e a c h i n g d e c i s i o n s , h o s p i t a l s d i f f e r f rom most o t h e r o r g a n i z a t i o n s b e c a u s e o f t h e p r e p o n d e r a n c e o f p r o -f e s s i o n a l s who a r e i n c l i n e d t o r e l a t e on a c o l l e a g u a l b a s i s > and b e c a u s e o f t h e d i s c r e t n e s s o f g o v e r n a n c e and management. P r o f e s s i o n a l s u s u a l l y come t o agreement by d e b a t i n g , v i e w -p o i n t s h a r i n g and c o n s e n s u s r a t h e r t h a n by v o t i n g o r by an a u t h o r i t a r i a n a p p r o a c h . C o n s e n s u s i s e s s e n t i a l t o t h e i m p l e m e n t a t i o n o f a s t r a t e g i c p l a n . I t c a n n o t be a c h i e v e d i f one o r two p e r s o n s d o m i n a t e t h e p l a n n i n g p r o c e s s . A l t h o u g h i t i s somet imes p o s s i b l e f o r one p e r s o n t o i n f l u e n c e t h e d e s t i n y o f t h e h o s p i t a l o r o r g a n i z a t i o n , p l a n -n i n g i n most m e d i c a l c a r e s e t t i n g s u s u a l l y i n v o l v e s many p e r s o n s r e p r e s e n t i n g d i v e r s e i n t e r e s t s , who t h i n k and work t o g e t h e r , come t o an ag reement on what s h o u l d be d o n e . The s u c c c e s s o f t h e p r o c e s s r e s t s on h i g h l y m o t i v a t e d p a r t i c i -p a n t s who c o m m u n i c a t e w e l l w i t h e a c h o t h e r and who a r e comm-i t t e d t o t h e g o a l s o f t h e h o s p i t a l . The p r o c e s s i s o f t e n a " g i v e and t a k e " s i t u a t i o n t h a t a t many t i m e s may d e f y l o g i c and r e a s o n . The need t o compromise d o e s n o t n e c e s s a r i l y mean f a i l u r e , n o r d o e s i t n e c e s s a r i l y d e f e a t t h e p u r p o s e o f t h e a c t i v i t y . I n t h i s r e s p e c t , p l a n n i n g a t t h e h o s p i t a l l e v e l i s e s s e n t i a l l y a c o n s e n s u s f o r m i n g a c t i v i t y . T h i s s e l e c t i n g o f s p e c i f i c g o a l s and o b j e c t i v e s i s a m i x t u r e o f what t h e c o m m i t t e e w o u l d l i k e t o see a c c o m p l i s h e d and what i t b e l i e v e s c a n be a c h i e v e d , p r o v i d e d i t s f o r e c a s t s and a s s u m p t i o n s m a t e r i a l i z e . G o a l s a r e an a m a l g a m a t i o n o f - 89 -what t h e c o m m i t t e e b e l i e v e s w i l l e n a b l e t h e h o s p i t a l t o c a r r y o u t i t s m i s s i o n ( a t t a i n p u r p o s e ) t o s a t i s f y s p e c i f i c commun i ty n e e d s ( d e s i r e d p o s i t i o n ) . G o a l s , under t h e d e f i n i t i o n u s e d t h r o u g h o u t t h i s s t u d y , a r e a s i t u a t i o n o r end t o w h i c h t h e o r g a n i z a t i o n a s p i r e s . W h i l e i t i s n o t an a c t u a l a c t i v i t y , i t s h o u l d be s u b m i t t e d t o t h e t e s t s o f : - s u i t a b i l i t y t o t h e p r i n c i p l e s (pu rpose ) - c o n s i s t e n c y o r r e l e v a n c y t o communi ty needs - f e a s i b i l i t y (can i t be c a r r i e d o u t ) - a c h i e v a b i l i t y (do we have t h e r e s o u r c e s ) - s p e c i f i c i t y ( i s i t d e t a i l e d enough t o p r o v i d e a b a s i s f o r a c t i o n ) - e f f e c t i v e n e s s ( w i l l i t a c h i e v e o u r d e s i r e d p o s i t i o n ) - a c c e p t a b i l i t y ( to a l l c o n s t i t u e n t s ) - c o s t i m p l i c a t i o n s . Once g o a l s a r e s e t , t h e y must be r a n k e d . The t a s k o f r a n k i n g one g o a l o v e r a n o t h e r i s p r i m a r i l y one o f e x e r c i s i n g j u d g e m e n t . A n d , a s s t a t e d , a t t h i s a d v a n c e d s t a g e o f p l a n n i n g , e d u c a t i o n , and i n f o r m a t i o n , s e t t i n g p r i o r i t i e s i s u s u a l l y n o t a s d i f f i c u l t a s i t may f i r s t a p p e a r . When d e s i g n i n g a l t e r n a t i v e g o a l s ( c o u r s e s o f a c t i o n ) , s e v e r a l s t r a t e g i c p l a n n i n g t e c h n i q u e s a r e a v a i l a b l e . One s u c h t e c h n i q u e i s " p o s i t i o n i n g " on a s t r a t e g y g r i d , a n o t h e r " s e g m e n t i n g " . P o s i t i o n i n g r e q u i r e s t h e o r g a n i z a t i o n t o t a k e e a c h one o f i t s p r o g r a m s o r a c t i v i t i e s and t h e " p o s i t i o n " i t on a s t r a t e g y g r i d a s d e s c r i b e d b e l o w . HIGH ^ Demand f o r S e r v i c e s (LOW) (B) (D) (A) (C) Segment ing r e c o g n i z e s t h a t t h e e s s e n c e o f s t r a t e g y i s " d i f f e r e n t i a t i o n " . How c a n an o r g a n i z a t i o n make i t s e l f d i f f e r e n t t o h e l p i t g a i n an a d v a n t a g e o v e r o t h e r o r g a n i z a t i o n s i n t h e same f i e l d ? V a r i o u s ways by w h i c h d i f f e r e n t i a t i o n c a n be r e a l i z e d i n c l u d e : - by u s e r s - by g e o g r a p h y - by age - by d e l i v e r y s y s t e m - by p r o g r a m s - by s e r v i c e s . - 91 -The s e c o n d a s p e c t o f t h i s p h a s e i s d e t e r m i n i n g s p e c i f i c o b j e c t i v e s t o a c h i e v e each o f o u r g o a l s w h i c h i n t u r n , i n a g g r e g a t e , r e p r e s e n t o u r s t a t e m e n t o f p r i n c i p l e s . S e t t i n g c l e a r o b j e c t i v e s i s t h e e s s e n c e o f s t r a t e g i c p l a n n i n g . O b j e c t i v e s r e f e r t o t h e g o a l s w i t h t h e i m p l i c a t i o n t h a t t h e y c a n be r e a c h e d . O b j e c t i v e s s p e c i f y and o p e r a t i o n a l i z e t h e o v e r a l l s t r a t e g y and s h o u l d have t h r e e i n h e r e n t c h a r a c t e r -i s t i c s : - m e a s u r a b l e - a s p e c i f i e d t i m e f o r c o m p l e t i o n - t h e r e s p o n s i b l e p e r s o n s h o u l d be i d e n t i f i e d . E x a m p l e s o f g o a l s and o b j e c t i v e s a r e p r o v i d e d i n A p p e n d i x (16) and a l s o i n t h e C a s e S t u d y . 7 . I m p l e m e n t a t i o n ( m a r k e t i n g t h e p l a n ) T h i s s t a g e i s where d e f i n i t e r e s o u r c e a l l o c a t i o n commitments a r e made. I m p l e m e n t a t i o n may be e a s i e r t h a n e x p e c t e d a s t h e r e h a s been an u n d e r s t a n d i n g and commitment t o t h e h o s p i t a l ' s o b j e c t i v e s i f a l l i n t e r e s t s have been r e p r e s e n t e d d u r i n g t h e p l a n n i n g p r o c e s s . T h i s i s t r u e b e c a u s e t h e p l a n -n i n g h a s been done by a w e l l - r e p r e s e n t a t i v e g r o u p f rom t h e b o a r d , m e d i c a l s t a f f and a d m i n i s t r a t i o n ; a s many s i d e s o f e v e r y i s s u e have been c o n s i d e r e d ; p r o b l e m s have been a i r e d ; c o n c l u s i o n s r e a c h e d and d e c i s i o n s made. I n a d d i t i o n , t h e r e h a s been much c o n t a c t w i t h p e o p l e i n t h e communi ty and t h e r e - 92 -s h o u l d be a f a i r a w a r e n e s s t h a t p l a n n i n g was g o i n g o n . A l s o , no d o u b t t h a t some t h i n g s h a v e l e a k e d o u t . However , t h e rumors on t h e g r a p e v i n e s h o u l d h a v e a h i g h d e g r e e o f a c c u r a c y so t h e r e s h o u l d n o t be any b i g s u r p r i s e s i n t h e f i n a l recomm-e n d a t i o n s . P e r i o d i c r e p o r t i n g o f p r o g r e s s t h r o u g h c o m m i t t e e m i n u t e s and g r o u p b r i e f i n g s e s s i o n s i s s u g g e s t e d so t h a t r u m o r s a r e r e d u c e d and t h a t t h e m e d i c a l s t a f f , e s p e c i a l l y , s e e s no s u r p r i s e s i n t h e f i n a l p l a n . The p l a n s h o u l d be c o n s i s t e n t l y p r e s e n t e d i n such a way a s t o e m p h a s i z e i t s g o a l o f s t r e n g t h -e n i n g t h e h o s p i t a l and t h e c o m m i t t e e ' s i n t e n t i o n n o t t o d e t r a c t f r o m t h e p r a c t i c e o f any p h y s i c i a n . I f we f a i l t o m a r k e t o r s e l l t h e p l a n i n t e r n a l l y t o d o c t o r s , t h e b o a r d , n u r s e s , e m p l o y e e s , a n d e x t e r n a l l y , t h e p r o c e s s h a s been i n t e r e s t i n g and s t i m u l a t i n g , b u t h a s no p a y o f f f o r a c t i o n . I t i s t h e r e s p o n s i b i l i t y o f t h e b o a r d t o m a r k e t o r commun ica te y o u r p l a n i n t e r n a l l y and t o g e t t h e commitment o f a l l t h o s e who must a c t t o make t h i n g s h a p p e n . The e f f o r t s t a k e n t o m a r k e t y o u r p l a n w i l l n o t be a l l t h a t d i f f i c u l t f o r t h e t e c h n i q u e s o f s t r a t e g i c p l a n n i n g , a s r e v i e w e d and o u t l i n e d i n t h i s s t u d y , a r e d e s i g n e d t o p r o d u c e a s o l i d p l a n and t o g e n e r a t e commitment . We have seen f r o m t h e p r o c e s s t h a t s t e p - b y - s t e p t h e p l a n h a s emerged and may w e l l m a r k e t i t s e l f when p r e s e n t e d . T h e r e f o r e , t h e c l i m a t e f o r a c t i o n and change s h o u l d be good and t h e f i n a l s e l l o r m a r k e t i n g s h o u l d n o t be d i f f i c u l t . T h i s i s o f c o u r s e t h e way t h i n g s s h o u l d b e , o n c e i n a w h i l e t h e y r e a l l y happen t h a t way . I n o r d e r t o i m p r o v e t h e s u c c e s s r a t e t h e c o m m i t t e e s h o u l d n o t o v e r l o o k t h e v a l u e o f a m a r k e t i n g a p p r o a c h . Many b e l i e v e t h a t m a r k e t i n g i s n o t a f u n c t i o n t h a t h o s p i t a l s s h o u l d p r a c t i c e . These who w o u l d b e l i e v e t h i s a r e b a r r i n g t h e i r o r g a n i z a t i o n s f rom a p r i m a r y v e h i c l e f o r i m p r o v e -ment . M a r k e t i n g p r o v i d e s any t y p e o f o r g a n i z a t i o n - p u b l i c o r p r i v a t e , p r o f i t o r n o n p r o f i t - w i t h t h e means f o r s e c u r i n g t h e a n s w e r s t o t h e two q u e s t i o n s w h i c h d e t e r m i n e e f f e c t i v e n e s s : 1. What i s t h e n e e d ? 2. How c a n t h e need be b e t t e r met? The m a r k e t i n g a p p r o a c h p u r s u e s t h e a n s w e r s by f o l l o w i n g a p l a n n i n g a p p r o a c h w h i c h i n c l u d e s a d e t e r m i n a t i o n o f : 1. Who i s t h e c l i e n t ? 2. Where i s t h e c l i e n t l o c a t e d ? 3. What d o e s t h e c l i e n t want and need? 4 . How c a n t h e o r g a n i z a t i o n d e l i v e r what t h e c l i e n t w a n t s and n e e d s ? P l a n n i n g and m a r k e t i n g a r e c l o s e l y r e l a t e d , b o t h c o n c e p t u a l l y and o p e r a t i o n a l l y . M a r k e t i n g i s t h e d e s i g n and management o f e x c h a n g e r e l a t i o n s w i t h a h o s p i t a l ' s i m p o r t a n t p u b l i c s : p a t i e n t s , p h y s i c i a n s , e m p l o y e e s , o t h e r h o s p i t a l s , t r u s t e e s , v o l u n t e e r s , t h e p u b l i c , r e g u l a t o r y o r f u n d i n g a g e n c i e s e t c . M a r k e t i n g s h o u l d r e s u l t i n r e l a t i o n s w i t h t h e s e p u b l i c s t h a t a r e u n d e r s t o o d , p r e d i c t e d and i n f l u e n c e d t h r o u g h i d e n t i f i e d - 94 -e x c h a n g e s o f v a l u e s . I t emp loys t h e same b a s i c c a p a b i l i t i e s and p r o c e s s e s a s p l a n n i n g . F o r t h e p u r p o s e o f t h i s s t u d y , i t i s n e c e s s a r y t o s t r e s s t h e i m p o r t a n c e o f m a r k e t i n g . No e f f o r t s h o u l d be s p a r e d b e f o r e , d u r i n g and a f t e r f o r m u l a t i o n o f t h e p l a n i n s e l l i n g p h y s i c i a n s on t h e p l a n ' s m e r i t s . The m e d i c a l s t a f f h a s t h e power t o d e s t r o y , by n e g a t i v e comments o r h a l f - h e a r t e d s u p p o r t , any c h a n c e s t h e p l a n may have f o r s u c c e s s . The b o a r d o f t r u s t e e s s h o u l d be t h e e a s i e s t g r o u p t o s e l l . A l t h o u g h t h i s g r o u p o r i g i n a l l y c o m m i s s i o n e d t h e p r o j e c t , t h e f u l l b o a r d may n o t have been a c t i v e i n t h e p l a n n i n g p r o c e s s and may n o t be f u l l y aware o f t h e c o m m i t t e e ' s e f f o r t s t o d a t e . I f t h e p l a n n i n g p r o c e s s h a s s t i r r e d up c o n t r o v e r s y , most b o a r d members w i l l have r e c e i v e d phone messages f r o m " c o n c e r n e d " c a l l e r s a n x i o u s a b o u t what t h e c o m m i t t e e i s p l a n n i n g f o r t h e h o s p i t a l . To f o r e s t a l l p o t e n t i a l p r o b l e m s , t h e b o a r d needs t o r e c e i v e c o n s t a n t and o n g o i n g f e e d b a c k so t h a t b o a r d members f e e l p a r t o f t h e r e s u l t a n t p l a n and a r e aware o f t h e p r o c e s s and t h e p r o b l e m s e n c o u n t e r e d a l o n g t h e way. I n t h i s w a y , t h e f u l l b o a r d w i l l be v i e w e d a s a p p r o v i n g o f t h e p r o c e s s and w i l l , i n f a c t , be c o m f o r t a b l e w i t h i t s o u t c o m e . The p l a n s h o u l d be p r e s e n t e d t o t h e f u l l b o a r d f o r a p p r o v a l o n l y a f t e r p r o p e r spadework h a s been d o n e . The p l a n s h o u l d be s o l d t o t h e m i n i s t r y o f h e a l t h w i t h t h e a w a r e n e s s t h a t t h e m i n i s t r y w i l l l o o k a t i t s e f f e c t on a l l - 95 -h o s p i t a l s w i t h i n t h e r e g i o n . The p l a n s h o u l d be f l e x i b l e enough t o l e t m i n i s t r y members c o n t r i b u t e t o i t w i t h o u t s u b -s t a n t i a l l y a f f e c t i n g i t s d i r e c t i o n o r i n t e n t . A p l a n t h a t d o v e t a i l s w i t h t h e m i n i s t r y ' s own p l a n s i s l i k e l y t o be r e a d i l y a c c e p t e d . I n a d o p t i n g s t r a t e g i e s , a h o s p i t a l ' s p o l i c y m a k e r s must r e c o g n i z e t h a t two ma jo r t a r g e t marke t g r o u p s , p o t e n t i a l p a t i e n t s and a d m i t t i n g p h y s i c i a n s , make t h e d e c i s i o n s on w h e r e t h e y w i l l seek t h e m e d i c a l s e r v i c e s t h a t h o s p i t a l s o f f e r . The h o s p i t a l ' s o f f e r i n g o f a m e d i c a l s e r v i c e d o e s n o t n e c e s s a r i l y mean t h a t t h e p u b l i c i s aware t h a t t h e h o s p i t a l o f f e r s t h e s e r v i c e n o r t h a t i t w i l l c h o o s e t h e s e r v i c e when need a r i s e s . I n c o n s i d e r i n g t h e s e r v i c e a r e a and t h e p o p u l a t i o n you w i l l be s e r v i n g ( m a r k e t i n g ) , t h e l o n g - s t a n d i n g q u e s t i o n t o c o n s i d e r i s t h e o r i e n t a t i o n t o w a r d s t h i s p o p u l a t i o n . The mere f a c t we r e f e r t o p a t i e n t and n o t c u s t o m e r o r consumer g i v e s u s an o r i e n t a t i o n t h a t may n o t h e l p o u r s u r v i v a l i n s t r a t e g i c p l a n n i n g . Once t h e p l a n i s i n p l a c e and we must m a r k e t t h e s t r a t e g i c p l a n , we a r e i m p l y i n g a c u s t o m e r , n o t a p a t i e n t . The t e r m " p a t i e n t " and " s i c k r o l e " t h a t i s i n -h e r e n t i n t h e w o r d " p a t i e n t " i s a s t u d y o f i t s own. I t i s s u f f i c i e n t i n t h e c o n t e x t t h a t we a r e u s i n g h e r e t o b r i n g t o t h e r e a d e r ' s a t t e n t i o n t h a t " p a t i e n t " i m p l i e s " s u b o r d i n a t e and d e p e n d e n t " . The word " p a t i e n t " h a s c o n n o t a t i o n s t h a t a r e p r o b a b l y a t t h e h e a r t o f much d i s t r e s s and f r i c t i o n t h a t e x i s t s between h e a l t h c a r e p r o f e s s i o n a l s and t h e p e o p l e who - 96 -go t o h o s p i t a l s f o r h e l p . I t i m p l i e s t h a t t h e p a t i e n t w a i t s p a t i e n t l y u n t i l we c a n s e e them. " P a t i e n t " i m p l i e s t h a t i f t h e y were a s smar t a s p r o f e s s i o n a l s t h e y w o u l d a l s o be a d o c t o r o r n u r s e o r t r u s t e e . The p a t i e n t i s someone who l o o k s t o u s f o r h e l p , t h e p a t i e n t i s u s u a l l y s e a t e d o r l y i n g down when t a l k e d t o . I t i s u s u a l l y c o n s i d e r e d t h a t a p a t i e n t i s h e l p e d , and when t h e y a r e h e l p e d , t h e y s h o u l d be g r a t e f u l , t h a n k t h e p r o f e s s i o n a l , and a c t l i k e a p a t i e n t . T h i s p e r c e i v e d r o l e o f t h e p a t i e n t , combined w i t h t h e f a c t t h a t most p e o p l e who a r e emp loyed by h o s p i t a l s have a s o c i a l s e r v i c e l e a n , and t h e y d e s i r e t o be o u t and above t h e d a y - t o - d a y g r i n d o f t h e b u s i n e s s w o r l d , t h e y m e r e l y want t o h e l p o t h e r s . T h i s i s o f t e n h a r d t o r e c o n c i l e w i t h t h e p a t i e n t when n e w s p a p e r s a r e p a c k e d w i t h s t o r i e s a b o u t n u r s e s g o i n g on s t r i k e , d o c t o r s becoming m i l i t a n t and c o n s i d e r i n g u n i o n s , and room r a t e s g o i n g up on a r e g u l a r b a s i s . The n o t i o n t h a t a l l who work i n t h e h o s p i t a l o n l y f o r t h e l o v e o f t h e i r f e l l o w man no l o n g e r h a s c r e d i b i l i t y i n o u r s o c i e t y and t h e image o f t h e h o s p i t a l a s a p l a c e o f c h a r i t y j u s t b a r e l y e x i s t s . I n c o n s i d e r i n g t h e s e few f a c t s , i t may become o b v i o u s t h a t t h e s e r v i c e p o p u l a t i o n s h o u l d be t r e a t e d more l i k e c u s t o m e r a l t h o u g h we have s a i d t h e y w i l l be t h e end u s e r and t h e m e d i c a l s t a f f t h e c u s t o m e r . T a k i n g a " c u s t o m e r " o r i e n t a t i o n w i l l a s s i s t i n s t r a t e g i c p l a n n i n g and no m a t t e r how h a r d a t i m e h o s p i t a l p e o p l e have s w a l l o w i n g t h i s f a c t , we a r e a b l e t o p r o v i d e - 97 -s e r v i c e t o o u r community t h r o u g h a c o m m e r c i a l - l i k e e n d e a v o u r and knowing what t h e needs o f t h e communi ty a r e . W i t h t h i s o r i e n t a t i o n , i t may be t h a t when a p a t i e n t l e a v e s , i t i s t h e s t a f f and a d m i n i s t r a t i o n who s a y " t h a n k y o u " . I f t h e h o s p i t a l d o e s n o t know what i t s c u s t o m e r s ( p a t i e n t s and m e d i c a l s t a f f ) want and h e l p them s a t i s f y t h e s e n e e d s , t h e h o s p i t a l c o u l d be i n t r o u b l e . H o s p i t a l s t h a t do n o t t a k e t i m e o u t t o l e a r n what t h e n e e d s a r e c a n p r o b a b l y b a s e t h e i r f a i l u r e s on n o t u n d e r s t a n d i n g c o n s u m e r s . M a r k e t i n g i n i t s b r o a d e s t s e n s e i s e s s e n t i a l f o r h o s p i t a l s . I t i s n e c e s s a r y f o r u s t o l o o k a t a f o rm o f m a r k e t a n a l y s i s and f i n d o u t e x a c t l y where and what ou r m a r k e t i s . H o s p i t a l s g e n e r a l l y i g n o r e a l l t h e t r i e d and t r u e m a r k e t i n g t e c h n i q u e s . W i t h t h e g r e a t s h i f t s t a k i n g p l a c e i n t h e p o p u l a t i o n p r o f i l e , we must c o n s i d e r t h e i m p a c t on t h e h o s p i t a l f u r t h e r down t h e r o a d . E f f e c t i v e m a r k e t i n g c a n b e n e f i t a h o s p i t a l i n s e v e r a l w a y s . I t p r o v i d e s b e t t e r consumer u n d e r s t a n d i n g o f how t o p r o p e r l y g a i n a c c e s s t o t h e s y s t e m , where p r o b l e m s l i e and what s e r v i c e s a r e a v a i l a b l e . Mos t p e o p l e know t h e h o s p i t a l i s a s e r v i c e b u t t h e y s e l d o m know what t h e s e r v i c e s p r o v i d e d a r e . 8 . E v a l u a t e The p l a n s h o u l d i n c l u d e a p r o c e s s f o r e v a l u a t i n g t h e g o a l s and o b j e c t i v e s so t h a t c r i t e r i a f o r s u c c e s s o r f a i l u r e a r e d e f i n e d b e f o r e any p r o g r a m s a r e i n i t i a t e d . The p l a n a l s o s h o u l d i n c l u d e a s t r o n g c o s t - c o n t a i n m e n t p r o g r a m . - 98 -The f i n a l s t a g e o f t h e p r o c e s s m e r e l y i l l u s t r a t e s t h e d y n a m i c n a t u r e o f t h e e n d e a v o u r . M o n i t o r i n g e n t a i l s t h e c o n t i n u a l r e v i e w o f s i g n i f i c a n t c h a n g e s i n t h e v a r i o u s p l a n n i n g p r o f i l e s a s w e l l a s a r e v i e w o f t h e p r o g r e s s o f v a r i o u s i m p l e -m e n t a t i o n a c t i v i t i e s . These become t h e " k e y i n d i c a t o r s " i n m e a s u r i n g o r g a n i z a t i o n a l p e r f o r m a n c e and e f f e c t i v e n e s s . We must know when t h i n g s o u t l i v e t h e i r u s e f u l n e s s , o r when t h e y n e v e r do l i v e up t o t h e i r p r o m i s e ; when t h a t happens we must abandom them. I t i s d i f f i c u l t enough t o g e t s o m e t h i n g new s t a r t e d ; i t i s many t i m e s more d i f f i c u l t t o t u r n i t o f f . Any p h a s e o f t h e p l a n n i n g p r o c e s s may need t o be r e p e a t e d i n o r d e r t o a d j u s t t o c h a n g i n g c i r c u m s t a n c e s . S t r a t e g i c p l a n s w i l l h a v e no i m p a c t on t h e o r g a n i z a t i o n i f t h e y a r e n o t k e p t u n d e r p r o p e r s u r v e i l l a n c e and c o n t r o l . I n Summary: The p l a n i s t h e key t o y o u r h o s p i t a l ' s f u t u r e . Once t h e s t r a t e g y o r p l a n h a s been d e v e l o p e d , i t c a n be l o s t u n l e s s we c a n p r e p a r e a m e t i c u l o u s p l a n o f c o m m u n i c a t i o n t o m a r k e t t h e p l a n . The p l a n s h o u l d i n d i c a t e t h a t a c t i o n and c h a n g e s w i l l show up i n an i m p r o v e d c a r e f o r more p a t i e n t s and more k i n d s o f p r o b l e m s a t l o w e r c o s t , and i t i s t h e o b l i g a t i o n o f t h e p l a n n i n g c o m m i t t e e t o s e t up measures t o e n s u r e t h a t p e r f o r m a n c e s t a n d -a r d s h a v e been i m p r o v e d . T h i s i s a c h i e v e d t h r o u g h t h e f o l l o w i n g p r o c e s s : 1. The need f o r p l a n n i n g , w h a t e v e r t h e b a s i s , must be r e c o g n i z e d and t h e d e c i s i o n made t o s t a r t - now. - 9 9 -The Commi t tee i s formed and t h e mandate i s p r o v i d e d . S t a r t y o u r p l a n n i n g by c o l l e c t i n g and r e v i e w i n g f a c t s a b o u t y o u r h o s p i t a l . S u r v i v a l s t a r t s w i t h t h e f a c t s o f t h e p r e s e n t s i t u a t i o n and h i s t o r i c a l i n f o r m a t i o n . S t r e n g t h s and w e a k n e s s e s a r e a n a l y z e d . P r o b l e m s and i s s u e s a r e i d e n t i f i e d . A t t h i s p o i n t , s o l u t i o n s h o u l d be t h e f a r t h e s t t h i n g f rom t h e comm-i t t e e ' s m i n d . The o b j e c t i v e o f t h e p l a n n i n g c o m m i t t e e i s t o a n t i c i p a t e t h e f u t u r e and t o p r o v i d e a c t i o n t h a t w i l l r e d u c e u n c e r t a i n t y . T h e r e f o r e , i n d i g g i n g o u t f a c t s we w i l l be l o o k i n g s e r i o u s l y f o r t r e n d s . T h i s c a n be a c c o m p l i s h e d by p r o j e c t i n g t h e h o s p i t a l ' s s t a t i s t i c a l d a t a and a good b a s i c q u e s t i o n t o k i c k t h i s o f f i s " i f we do n o t h i n g t o m o d i f y o u r b e h a v i o u r , i f t h e s o c i a l c l i m a t e r e m a i n s c o n s t a n t , i f o u r c o m p e t i t o r s s t a n d s t i l l , and i f no one comes up w i t h a m e d i c a l b r e a k t h r o u g h , t h i s i s w h a t w e c a n e x p e c t . " (12) T h i s b a s i c s t a t e m e n t assumes you a r e l i v i n g i n a c h a n g e -f r e e e n v i r o n m e n t and w h i l e i t i s w o r t h y o f a b a s i c s t a t e m e n t , you c a n now s t a r t c h a n g i n g some o f t h e key e l e m e n t s a r o u n d , s u c h a s t h e s o c i a l c l i m a t e , c o m p e t i t o r s , and t e c h n o l o g y , a l o n g w i t h t r e n d s i n s o c i e t y and g o v e r n m e n t . Make a c l e a r m i s s i o n s t a t e m e n t f o r t h e h o s p i t a l . The m i s s i o n s t a t e m e n t c a n be v i e w e d a s t h e j o b d e s c r i p t i o n f o r y o u r h o s p i t a l , o n l y s t a t e d i n commun i ty t e r m s , c o n s i d e r i n g communi ty n e e d s , t h e h o s p i t a l ' s c a p a b i l i t i e s , and t h e f i n a n c i a l a b i l i t y t o s e r v e . - 1 0 0 -5 . A l t e r n a t i v e a c t i o n c o u r s e s f o r s u r v i v a l a r e p r e s e n t e d a s g o a l s and o b j e c t i v e s . 6 . The c h o s e n c o u r s e s o f a c t i o n a r e i m p l e m e n t e d . 7 . The p l a n and t h e c o u r s e s o f a c t i o n a r e m o n i t o r e d and e v a l u a t e d . The s t r a t e g i c p l a n t h a t e v o l v e s f rom t h e p l a n n i n g p r o c e s s s h o u l d p r o v i d e a f ramework f o r o r d e r l y l o n g - r a n g e p l a n n i n g and d e c i s i o n - m a k i n g and s h o u l d make i t p o s s i b l e f o r p r o b l e m s , i s s u e s , and p r o j e c t s t o be e x a m i n e d w i t h a s e n s e o f p e r s p e c t i v e . The p l a n n i n g p r o c e s s i t s e l f s h o u l d be r e s p o n s i v e t o i n p u t f r o m o t h e r h o s p i t a l c o m m i t t e e s and i n t e r e s t e d p a r t i e s . Once you have d r a f t e d and i m p l e m e n t e d y o u r s t r a t e g i c p l a n , i s t h a t t h e end o f y o u r r e s p o n s i b i l i t i e s a s a b o a r d member, a d m i n i s t r a t o r , o r p h y s i c i a n , w i t h r e g a r d t o p l a n n i n g ? N o t i f we a c c e p t t h e d e f i n i t i o n o f t h e s t r a t e g i c p l a n g i v e n by t h e S t a n f o r d R e s e a r c h I n s t i t u t e : " The s t r a t e g i c p l a n i s t h e l o n g - t e r m means w h i c h t o p management u s e s t o g u i d e an o r g a n i z a t i o n t o w a r d a d e s i r e d f u t u r e p o s i t i o n . T h i s p l a n d e t e r m i n e s t h e n a t u r e and s c o p e o f a l l o t h e r p l a n s and r e a c h e s beyond them i n t i m e . " T h i s w o u l d s u g g e s t we need a s t a t e o f s t r a t e g i c t h i n k i n g , b e c a u s e t h e p l a n s h o u l d n e v e r be f r o z e n o r t h e p r o c e s s c o n s i d e r e d c o n c l u d e d . E f f e c t i v e s t r a t e g i c p l a n n i n g r e q u i r e s a l l o r g a n i z a t i o n s t o e s t a b l i s h a d y n a m i c p l a n n i n g a p p r o a c h t o c o p e w i t h t h e r a p i d s t a t e o f c h a n g e . - 101 -I n C o n c l u s i o n , i t i s c l e a r t h a t s t r a t e g i c p l a n n i n g i n s m a l l h o s p i t a l s , d e s p i t e i t s c r i t i c a l i m p o r t a n c e , f a c e s an u p h i l l s t r u g g l e . The i n i t i a l r o a d b l o c k i s t h e a c c e p t a n c e o f s t r a t e g i c p l a n n i n g a s a n e c e s s a r y g o v e r n a n c e and management t o o l . T h i s a c c e p t a n c e may be t h e c r i t i c a l f a c t o r i n i n i t i a t i n g and i m p l e m e n t i n g t h e s t r a t e g i c p l a n n i n g p r o c e s s . The h o s p i t a l w i t h k n o w l e d g e a b l e b o a r d members who a r e e n t h u s i a s t i c a b o u t s t r a t e g i c p l a n n i n g h a s t a k e n a g i a n t s t e p t o w a r d s t h e a c h i e v e m e n t o f t h i s most c r i t i c a l o f o r g a n i z a t i o n n e e d s . - 102 -ROLE OF THE CHIEF EXECUTIVE OFFICER As a f u n c t i o n o f management, p l a n n i n g i s i n t e r w o v e n w i t h t h e o t h e r management f u n c t i o n s , s u c h as o r g a n i z i n g , s t a f f i n g , d i r e c t i n g , and c o n t r o l l i n g . P l a n n i n g t h e n becomes t h e r e s p o n s -i b i l i t y o f a l l managers a t a l l l e v e l s o f an o r g a n i z a t i o n , a l t h o u g h t h i s r e s p o n s i b i l i t y w i l l v a r y s i g n i f i c a n t l y among t h e d i f f e r e n t l e v e l s . E f f e c t i v e p l a n n i n g by t h e o r g a n i z a t i o n ' s managers c a n n o t e x i s t w i t h o u t t h e s u p p o r t and i n v o l v e m e n t o f t h e c h i e f e x e c u t i v e o f f i c e r ( C . E . O . ) . T h i s b a s i c p r i n c i p l e s h o u l d be o b v i o u s b u t o f t e n i s n o t . Management e x p e r t s c i t e t h e r o l e o f p l a n n i n g i n t h e manage-ment p r o c e s s b u t f r e q u e n t l y do n o t a r t i c u l a t e the r o l e o f t h e CEO i n p l a n n i n g . A management e x p e r t who does r e c o g n i z e t h e r o l e o f t h e CEO i n p l a n n i n g i s P e t e r D r u c k e r , who n o t e s : "Management h a s no c h o i c e b u t t o a n t i c i p a t e t h e f u t u r e , t o a t t e m p t t o m o l d i t , and t o b a l a n c e s h o r t - r a n g e and l o n g - r a n g e g o a l s . . . . t h e t a s k o f t h i n k i n g t h r o u g h t h e m i s s i o n o f t h e b u s i n e s s , t h a t i s , o f a s k i n g , t h e q u e s t i o n 'What i s o u r b u s i n e s s and what s h o u l d i t b e ? ' T h i s l e a d s t o t h e s e t t i n g o f o b j e c t i v e s , t h e d e v e l o p m e n t o f s t r a t e g i e and p l a n s , and t h e m a k i n g o f t o d a y ' s d e c i s i o n s f o r t o m o r r o w ' s r e s u l t s T h i s c l e a r l y c a n be done o n l y b y an o r g a n o f t h e b u s i n e s s t h a t c a n see t h e e n t i r e b u s i n e s s ; t h a t c a n make d e c i s i o n s t h a t a f f e c t t h e e n t i r e b u s i n e s s ; t h a t c a n b a l a n c e o b j e c t i v e s and t h e needs o f t o d a y a g a i n s t t h e needs o f t o m o r r o w ; and t h a t c a n a l l o c a t e r e s o u r c e s o f men and money t o k e y r e s u l t s . " (13 ) I n s h o r t , t h e CEO manages management and i s u l t i m a t e l y r e s p o n s i b l e f o r t h e s t r a t e g i c p l a n n i n g and d e c i s i o n - m a k i n g p r o c e s s . O f t e n - 103 -t h e r e s p o n s i b i l i t y i s h a n d l e d i n f o r m a l l y . P e o p l e g e n e r a l l y b e l i e v e t h a t t h e y do p l a n and a r e p l a n n i n g , even w i t h o u t a f o r m a l p r o c e s s ; p e r h a p s t h e CEO b e l i e v e s t h e same. N o n e t h e -l e s s , t h e f o l l o w i n g m a t t e r s f a l l w i t h i n t h e p u r v i e w o f t h e C E O ' s d e c i s i o n - m a k i n g a u t h o r i t y , w h e t h e r o r n o t he a c k n o w l e d g e s them: (1) t h e manner i n w h i c h t h e o r g a n i z a t i o n ' s s t r a t e g y i s f o r m u l a t e d ( w i t h o r w i t h o u t a f o r m a l p l a n n i n g sys tem) and (2) t h e way i n w h i c h o p p o r t u n i s t i c i s s u e s and t h r e a t s a r e met . The CEO h a s t h e p r i m a r y r e s p o n s i b i l i t y f o r d e s i g n i n g and f o l l o w i n g a c o u r s e t h a t l e a d s t h e o r g a n i z a t i o n i n t h e f o r m -u l a t i o n o f s t r a t e g i e s and s t r a t e g i c p l a n n i n g . The d e s i g n must a l s o be c r e a t e d t o s u i t h i s management s t y l e and n e e d s . U n l e s s he i s c o m f o r t a b l e w i t h t h e manner i n w h i c h s t r a t e g i e s a r e f o r m -u l a t e d and s t r a t e g i c p l a n n i n g i s d o n e , he p r o b a b l y w i l l n o t u s e i t a s p a r t o f h i s d e c i s i o n - m a k i n g p r o c e s s . I f may be b e s t t h a t t h e f o r m u l a t i o n o f s t r a t e g i e s be a component o f a f o r m u l i z e d p l a n n i n g s y s t e m , b u t t h i s i s d i f f i c u l t t o a c h i e v e i f t h e CEO a c t s i n f o r m a l l y a s a manager . The CEO s e t s t h e management t o n e o f t h e o r g a n i z a t i o n ; i f he i s i n f o r m a l , so i s h i s a p p r o a c h t o p l a n n i n g , and so i s t h e way t h a t s u b o r d i n a t e managers p l a n . A s s t a t e d , t h e manner i n w h i c h s t r a t e g y i s f o r m u l a t e d i n an o r g a n i z a t i o n depends on t h e management s t y l e o f t h e CEO and h i s a s p i r a t i o n s f o r t h e o r g a n i z a t i o n . CEOs s h o u l d r e c o g n i z e t h e i r p e r s o n a l l i m i t a t i o n s and r e g u l a r l y t a p t h e m inds o f o t h e r s . I t i s o f t e n h e l p f u l t o team d i f f e r e n t managers and t h e i r s t y l e s t o g e t h e r , e . g . a d e t a i l e d o r i e n t e d , q u a n t i t a t i v e - o r i e n t e d - 104 -manager w i t h a q u a l i t a t i v e - o r i e n t e d manager . (14 ) CEOs w i l l t e n d t o h i r e management p e r s o n n e l whose v a l u e s y s t e m and p h i l o -s o p h i e s a r e s i m i l a r t o t h e i r own and t h o s e o f t h e i r o r g a n i z a t i o n . i P e o p l e w i t h t h e same v a l u e s y s t e m s t e n d t o r e a c t s i m i l a r l y t o s i t u a t i o n s . The C E O ' s p e r s o n a l i t y , t h e r e f o r e , w i l l be s t r o n g l y r e f l e c t e d i n t h e f o r m u l a t i o n o f s t r a t e g y . A f u t u r i s t i c , r i s k - t a k i n g , i n t u i -t i v e CEO w i l l s t r o n g l y i n f l u e n c e t h e s t r a t e g i c d i r e c t i o n t h a t t h e o r g a n i z a t i o n t a k e s . A l t h o u g h a CEO who t e n d s t o o p e r a t e i n t u i t i v e l y ( i n f o r m a l l y ) i s h a r d e r t o accommodate i n a f o r m a l p l a n n i n g s y s t e m , t h e i m p o r t a n c e o f a CEO who s u c c e s s f u l l y l e a d s by " g u t f e e l i n g s " c a n n o t be i g n o r e d . I n d e e d , i t c a n be s a i d , " S t r a t e g i e s o r o b j e c t i v e s a r r i v e d a t by judgement ( ' e d u c a t e d g u t f e e l ' ) a r e j u s t a s v a l i d (or more v a l i d t h a n ) t h o s e a r r i v e d a t by s u i t a b i l i t y , f e a s i b i l i t y , o r a c c e p t a b i l i t y s t u d i e s " (15) O t h e r CEOs f a v o r a team a p p r o a c h . T h i s a p p r o a c h o f t e n i s more f o r m a l , w i t h t h e CEO f r e q u e n t l y m e e t i n g w i t h key members o f t h e m e d i c a l s t a f f , b o a r d o f d i r e c t o r s , and a d m i n i s t r a t i v e s t a f f t o d i s c u s s s t r a t e g i c d i r e c t i o n , s e t t i n g o f l o n g - t e r m and s h o r t - t e r m g o a l s , and e v a l u a t i o n o f o p p o r t u n i t i e s and t h r e a t s . Such a " t e a m p l a y e r " CEO c a n a d a p t b e t t e r t o a f o r m a l i z e d p l a n n i n g p r o c e s s , w h i c h u s u a l l y i s v e r y s t r u c t u r e d and s y s t e m a t i c . O f t e n a w r i t t e n p l a n n i n g manual s h o u l d be u s e d t o g u i d e managers i n t h e i r t r a n s l a t i o n o f t h e o r g a n i z a t i o n ' s s t r a t e g i e s i n t o a p p r o -p r i a t e g o a l s . A l t h o u g h i n t u i t i v e and s y s t e m a t i c t h i n k e r s c e r t a i n l y d i f f e r , t h e i r a p p r o a c h e s c a n complement one a n o t h e r . I n d e e d , a f o r m a l - 105 -p l a n n i n g s y s t e m , by g i v i n g an o r g a n i z a t i o n a more d e f i n e d s t r a t e g i c d i r e c t i o n , c a n save t i m e s p e n t on p u t t i n g o u t f i r e s a n d , t h e r e b y , h e l p managers s h a r p e n t h e i r i n t u i t i v e s k i l l s . T h i s f a c t o f t e n i s o v e r l o o k e d by CEOs who w o n ' t c o n s i d e r f o r m a l i z i n g t h e p l a n n i n g p r o c e s s . An i n f o r m a l manager c a n work i n a f o r m a l mode. However , a CEO r a r e l y c a n c o n d u c t t h e p l a n n i n g p r o c e s s a l o n e . (16) A s S t e i n e r h a s n o t e d , "A C E O ' s d u t i e s a r e s p r e a d o v e r a w i d e r a n g e o f s u b s t a n c e a n d , even c e r e m o n y . The CEO must be a l e a d e r o f p e o p l e ; a s k i l l e d j u d g e o f human c h a r a c t e r , m o t i v a t i o n and c a p a b i l i t y ; a b u s i n e s s s t a t e s m a n i n d e a l i n g w i t h government and communi ty l e a d e r s ; a t h o u g h t f u l p e r s o n who c a n l o o k ahead and know how t o g e t t h e r e ; a p e r s o n o f a c t i o n who c a n make d e c i s i o n s ; an a r c h i t e c t o f t h e company management s y s t e m ; an i n n o v a t o r ; and a v i g i l a n t s e e k e r o f o p p o r t u n i t i e s who i s w i l l i n g t o come t o g r i p s w i t h and t a k e r i s k s . " (17) I n many o r g a n i z a t i o n s i n c l u d i n g t h e v e r y s m a l l , t h e CEO must s h a r e p l a n n i n g t a s k s w i t h s t a f f , c o n s u l t a n t s , and c o m m i t t e e s . N o n e t h e l e s s , i t i s i m p o r t a n t t h a t t h e CEO e n s u r e t h a t t h e p l a n n i n g s y s t e m i s d e s i g n e d and managed i n a way t h a t i s c o n s i s t e n t w i t h h i s management s t y l e and i n t e n t i o n s . He m a i n t a i n s t h e u l t i m a t e r e s p o n -s i b i l i t y f o r p l a n n i n g , so t h a t h i s f u n c t i o n s h o u l d o p e r a t e a s an e x t e n s i o n o f h i s o f f i c e . I n o t h e r w o r d s , he s h o u l d r e t a i n " o w n e r s h i p " o f t h e p r o c e s s . (18) " W i t h o u t t h e C h i e f E x e c u t i v e O f f i c e r ' s s u p p o r t and c o m m i t -ment t o t h e h o s p i t a l ' s p l a n n i n g and d e v e l o p m e n t p r o g r a m , t h e f u n c t i o n i s f u t i l e . " (19) The CEO need n o t be a c t i v e l y i n v o l v e d i n e a c h s t e p o f t h e p r o c e s s , b u t , p a r t i c u l a r l y i n t h e i n t r o d u c t o r y s t a g e s o f a new p l a n n i n g s y s t e m , h i s deep commitment t o t h e p r o c e s s - 106 -must be commun ica ted t o t h e managers o f t h e o r g a n i z a t i o n . W i t h o u t t h i s commi tment , t h e f o r m a l i z e d p l a n n i n g s y s t e m p r o b a b l y i s c o u r t i n g d i s a s t e r . I n d e e d , i f t h e CEO d o e s n o t a c t i v e l y s u p p o r t t h e p l a n n i n g s y s t e m , t h e o r g a n i z a t i o n ' s managers a r e l i k e l y t o meet i t w i t h h o s t i l i t y and c o m p l a i n t s . T h e r e f o r e , t h e CEO must r e c o g n i z e t h e p o t e n t i a l p r o b l e m o f a n t i - p l a n n i n g b i a s e s and a c t a s an e d u c a t o r i n t h e s t a r t - u p p e r i o d by e x p l a i n i n g t h e i m p o r t a n c e o f t h e s y s t e m . A CEO p l a n s , o r g a n i z e s , m o t i v a t e s , and c o n t r o l s h i s i n s t i -t u t i o n a s i t s p r i m a r y manager . Many CEOs f a i l t o r e c o g n i z e t h a t t h e y a r e i n v o l v e d i n t h e p l a n n i n g p r o c e s s even when t h e y i n t u i t i v e l y d e c i d e o r manage. C o n s e q u e n t l y , t h e y f r e q u e n t l y o v e r l o o k t h e i r r e s p o n s i b i l i t y t o i n t e g r a t e t h i s i n f o r m a l p l a n n i n g i n t o a s t r u c t u r e t o be u s e d b e n e f i c i a l l y by t h e e n t i r e o r g a n i z a t i o n . How t o f o r m a l i z e t h i s p r o c e s s c a n o n l y be d e t e r m i n e d a f t e r t h e CEO r e c o g n i z e s t h e need t o do s o . S m a l l o r g a n i z a t i o n s a r e o f t e n c h a r a c t e r i z e d by h a v i n g one p e r s o n who p r o v i d e s t h e power and d i r e c t i o n - t h e CEO. B e c a u s e o f t h e l a c k o f a v a i l a b l e manpower t o c o n d u c t l o n g - r a n g e p l a n n i n g , many a d m i n i s t r a t o r s o f s m a l l h o s p i t a l s a r e f i n d i n g t h a t segments o f t h e p l a n n i n g p r o c e s s c a n be a s s i g n e d s u c c e s s f u l l y t o t h e v a r i o u s d e p a r t m e n t h e a d s . T h i s a p p r o a c h n o t o n l y a i d s t h e a d m i n i s t r a t o r i n c o m p l e t i n g t h e p l a n , b u t a l s o c o m m i t s t h e d e p a r t m e n t h e a d s t o t h e outcome o f t h e p l a n n i n g . I t a l s o a l l o w s t h e CEO t o u t i l i z e a l l t h e t a l e n t s i n a h o s p i t a l . The CEO must e n s u r e t h a t t h e d i f f e r e n t o p i n i o n s a r e r e c o g n i z e d , u n d e r s t o o d and amended by p r o p e r l y i n t e r p r e t e d f a c t s b e f o r e p o s i t i o n s and j u d g e m e n t s a r e h a r d e n e d . F o r i n o r d e r t o d e v e l o p e f f e c t i v e s t r a t e g i e s , t h e CEO - 107 -must have a h i g h d e g r e e o f i n p u t and p a r t i c i p a t i o n f rom a l l l e v e l s o f management. H e l p must be g i v e n d e p a r t m e n t h e a d s t o d e v e l o p management s k i l l s and s u f f i c i e n t t e c h n i c a l c a p a b i l i t y t o a l l o w them t o manage t h e i r s p e c i f i c d a i l y i n t e r n a l o p e r a t i o n s o f t h e i n s t i t u t i o n . The CEO o f a s m a l l h o s p i t a l n e e d s t o be f r e e d f rom t h e s e r o u t i n e o p e r a t i o n a l r e s p o n s i b i l i t i e s so t h a t he c a n engage i n p o l i c y -mak ing t h a t w i l l have l o n g t e r m c o n s e q u e n c e f o r t h e i n s t i t u t i o n . O f t e n t h e a d m i n i s t r a t o r must d e c i d e how t o s t a f f t h e n u r s i n g d e p -a r t m e n t , how t o h a n d l e p h y s i c i a n demands , w h e t h e r t o u s e o u t s i d e c o n t r a c t o r s t o p r o v i d e c l e a n i n g s e r v i c e s and so o n , ad i n f i n i t u m . I n a d d i t i o n t o t h e s e p e r p e t u a l o p e r a t i o n a l p r o b l e m s , t h e a d m i n -i s t r a t o r e x p e r i e n c e s t h e f e e l i n g t h a t t h e w o r l d a r o u n d h i m i s s h i f t i n g d r a m a t i c a l l y and a s a r e s u l t , t h e s o l u t i o n s o f y e s t e r -day a r e no l o n g e r a d e q u a t e t o e n s u r e s u c c e s s i n t o d a y ' s f a s t -c h a n i n g e n v i r o n m e n t . E n v i r o n m e n t a l c h a n g e demands a change i n t h e C E O ' s p r i o r i t i e s and t i m e a l l o c a t i o n . More i n t e r n a l o p e r a t i n g d e c i s i o n s f o r t h e h o s p i t a l must be d e l e g a t e d t o o t h e r s t o a l l o w t h e a d m i n i s t r a t o r t i m e t o l o o k ahead and s t e e r s u c c e s s f u l l y t h r o u g h t h e s h i f t i n g w i n d s and t i d e s o f c h a n g i n g c i r c u m s t a n c e s . A m a s s i v e d e l e g a t i o n o f o p e r a t i n g r e s p o n s i b i l i t i e s by t h e CEO i s n e c e s s a r y t o a l l o w t i m e f o r s t r a t e g i c l e a d e r s h i p . A common ma jo r m i s t a k e i s t o g i v e an employee b o t h l i n e r e s p o n s i b i l i t y and a l s o a p l a n n i n g f u n c t i o n . A l i n e j o b w i l l a l w a y s consume more t i m e , l e a v i n g l i t t l e o r no t i m e f o r p l a n n i n g . When d i s c u s s i n g t h e i m p o r t a n c e o f d e l e g a t i o n t o f r e e t h e CEO and t o i n v o l v e d e p a r t m e n t h e a d s we must a l s o t o u c h b r i e f l y - 108 -on t h e i m p o r t a n c e o f - management d e c i s i o n - m a k i n g . We c a n b r i e f l y c l a s s i f y o r g a n i z a t i o n p r a c t i c e s on t h r e e l e v e l s : a u t h o r i t a t i v e , c o n s u l t a t i v e , and p a r t i c i p a t i v e . I t h a s been a r g u e d t h a t t h e most e f f e c t i v e a r e p a r t i c i p a t i v e . Many w r i t e r s have s u g g e s t e d t h a t t h e more an o r g a n i z a t i o n encompasses b r o a d p a r t i c i p a t i o n i n d e c i s i o n - m a k i n g , t h e h i g h e r t h e p r o d u c t i v i t y and o v e r a l l p e r f o r m -a n c e i t w i l l a c h i e v e . Such o r g a n i z a t i o n s have been shown t o d i s p l a y h i g h e r l e v e l s o f m o t i v a t i o n , b e t t e r c o m m u n i c a t i o n and g r e a t e r member c o - o p e r a t i o n . A l l o f t h e s e a r e e s s e n t i a l i n d e v e l o p i n g s t r a t e g i e s . I t s h o u l d be a p p a r e n t t h a t g r o u p d e c i s i o n - m a k i n g i n v o l v e s a g r e a t e r amount o f p a r t i c i p a t i o n , b u t t h a t such a method i s r e q u i r e d o n l y u n d e r c e r t a i n c i r c u m s t a n c e s . When we a r e d e a l i n g w i t h d e v e l o p m e n t o f s t r a t e g i e s , we f i n d most o f t h e c o n d i t i o n s where g r e a t e r p a r t i c i p a t i o n i s n e c e s s a r y . 1. The o b j e c t i v e q u a l i t y o f t h e d e c i s i o n c a n n o t be r e a d i l y measured a t t h e t i m e t h e d e c i s i o n i s made. In o t h e r w o r d s , t h e d e c i s i o n r e q u i r e s judgement r a t h e r t h a n a s s e m b l i n g f a c t s . 2. Group a c c e p t a n c e and u n d e r s t a n d i n g o f t h e p r o b l e m and i t s s o l u t i o n a r e r e q u i r e d . 3 . I m p l e m e n t a t i o n o f t h e d e c i s i o n r e q u i r e s a c c e p t a n c e by t h e g r o u p members. 4 . The q u a l i t y o f t h e d e c i s i o n i s enhanced by t h e g r o u p i n t e r a c t i o n . 5 . P r o f e s s i o n a l d e v e l o p m e n t o f t h e g r o u p members i s i m p o r t a n t . Group d e c i s i o n and p a r t i c i p a t i o n i s e x t r e m e l y u s e f u l i n p o l i c y -m a k i n g , g o a l - s e t t i n g and s t r a t e g y d e v e l o p m e n t s i n c e s u c h d e c i s i o n s c a n n o t be r e a d i l y v e r i f i e d when t h e y a r e made b u t do r e q u i r e a c c e p t a n c e and u n d e r s t a n d i n g i f t h e y a r e t o be i m p l e m e n t e d . - .109 -P a r t i c i p a t i o n i s u s e f u l i n s i t u a t i o n s o f s t r a t e g y where d i v e r s e i n t e r e s t s o r p e r s p e c t i v e s a r e r e p r e s e n t e d . F o r t h i s r e a s o n , d e c i s i o n s i n v o l v i n g v e s t e d i n t e r e s t o f p h y s i c i a n s , n u r s e s , a d m i n i -s t r a t o r s , b o a r d and communi ty must be made j o i n t l y . U s i n g p a r t i c i p a t i v e management o r g r o u p d e c i s i o n - m a k i n g , one must p a y a t t e n t i o n t o t h e d i f f e r e n t needs o f t h e g r o u p members and a l t e r n a t i v e s t o t h e p r o b l e m b e f o r e t h e g r o u p d e c i d e s on t h e b e s t s o l u t i o n . A s d e p a r t m e n t heads a r e g i v e n a u t h o r i t y and r e s p o n s i b i l i t y and a s t h e y d e v e l o p , t h e s e m b l a n c e o f a sound management team w i l l b e g i n t o t a k e s h a p e . I t may n o t be i d e a l , b u t i t s h o u l d be an improvement and a p r o m i s i n g s t a r t . The e m p h a s i s w i l l have t o be on teamwork and c o - o p e r a t i o n . A good CEO s h o u l d be p r e p a r e d t o g i v e more c o n t r o l t o t h e f u n c t i o n a l l i n e m a n a g e r s , a l l o w i n g them t o e x t e n d t h e m s e l v e s even a t t h e r i s k o f f a i l i n g t o p e r f o r m . H o s p i t a l s w i s h i n g t o i m p r o v e t h e i r p o s i t i o n s i n t h e h e a l t h c a r e i n d u s t r y need t o e s t a b l i s h l o n g - t e r m p r o g r a m s t o d e v e l o p t h e i r m i d d l e management and s e n i o r p e r s o n n e l . By r e g a r d i n g t h e d e v e l o p -ment o f s u p e r i o r human r e s o u r c e s a s an e s s e n t i a l a s p e c t o f s t r a t e g i c p l a n s , t h e CEO s h o u l d be a b l e t o a t t r a c t v e r y c a p a b l e p e o p l e . A g r o u p o f l o y a l p r o d u c t i v e e m p l o y e e s i s an o r g a n i z a t i o n ' s c h i e f a s s e t . S t r a t e g i c p l a n n i n g w i l l be i n e f f e c t i v e i n t h e l o n g r u n u n l e s s i t i s c o n s i d e r e d i n c l o s e c o - o r d i n a t i o n w i t h human r e s o u r c e s p l a n n i n g . Once t h e management team i s i n p l a c e t h e CEO i s f r e e d f r o m much o f t h e d a y - t o - d a y p r e s s u r e and c a n c o n c e n t r a t e on h i s m a j o r r o l e i n s t r a t e g i c p l a n n i n g , t h a t i s , t o keep t h e b o a r d i n f o r m e d - 110 -o f e n v i r o n m e n t a l c h a n g e s and recommend s t r a t e g i e s t h a t w i l l e n s u r e t h e l o n g - t e r m v i a b i l i t y o f t h e h o s p i t a l and i t s c o n t i n u e d s e r v i c e t o c i t i z e n s i n t h e a r e a . T h i s r e s p o n s i b i l i t y c a n n o t be d e l e g a t e d . The CEO must do i t , b u t he must a l s o have a d e q u a t e h e l p . The d e p a r t m e n t h e a d s and s t a f f p r o v i d e h i m w i t h t h e i n t e r n a l i n f o r m a t i o n and a s s i s t a n c e he c a n u s e i n making o p e r a t i n g d e c i s i o n s . S i m i l a r l y , t h e CEO needs someone t o b r i n g h i m i n t e l l i g e n c e on e x t e r n a l r e a l i t i e s and t o h e l p s t r u c t u r e t h e s t r a t e g i c d e c i s i o n -mak ing p r o c e s s . T h i s may be a s p e c i a l l y a s s i g n e d s t a f f , b o a r d members o r members o f t h e s t r a t e g i c p l a n n i n g c o m m i t t e e . The CEO o f a s m a l l o r g a n i z a t i o n i s p r o b a b l y t h e b e s t p e r s o n t o n u r t u r e t h e community r e l a t i o n s h i p s . However , o n c e t h e o r g a n -i z a t i o n g r o w s o r becomes more a c t i v e , a c o m m i t t e e o f t h e b o a r d may be s t r u c k t o assume r e s p o n s i b i l i t y f o r t h i s f u n c t i o n . A t t h e a d m i n i s t r a t i v e l e v e l , t h e r i s k s i n v o l v e d i n s t r a t e g i c p l a n n i n g a r e q u i t e h i g h . The r i s k i s compounded by t h e c o n f u s i o n t h a t i s c r e a t e d by t h e " t h r e e - l e g g e d s t o o l " model o f power i n h o s p i t a l s . The b a l a n c i n g o f power among t r u s t e e s , m e d i c a l s t a f f s , and t h e CEO o f t e n p r o m o t e s t h e a b s e n c e o f a u n i f i e d h o s p i t a l . The CEO, a s t h e c h i e f s t r a t e g i s t , s h o u l d a l s o be t h e c h i e f spokesman and t h e s i n g l e f o c a l p o i n t o f a u t h o r i t y f o r h o s p i t a l m a t t e r s . T h i s i s so b e c a u s e o f t h e i n c r e a s e d c o m p l e x i t y , u n i o n i z a t i o n , and r e g u l a t i o n s o f modern h e a l t h c a r e . I t h a s been e s t i m a t e d t h a t t h e a v e r a g e CEO spends between 60 - 70 p e r c e n t o f t h e i r t i m e i n s u c h a c t i v i t i e s a s p l a n n i n g and r e v i e w o f e x t e r n a l c h a n g e s . W h i l e p h y s i c i a n s f u n c t i o n b e s t on a o n e - t o - o n e b a s i s and o n l y p r o v i d e - I l l -s e c o n d a r y a l l e g i a n c e t o a h o s p i t a l , t h e y s t i l l have c o n s i d e r a b l e r e s e r v a t i o n s a b o u t " h a n d i n g e v e r y t h i n g o v e r t o t h e a d m i n i s t r a t o r . " A t t h e p r e s e n t , t h e t h r e e l e g g e d s t o o l i s n o t n e a r c o l l a p s e , b u t t h e p r e s s u r e s o f t o d a y a r e making i t e x t r e m e l y w o b b l y . To make t h e t r i u m v a r a t e f u n c t i o n b e t t e r p e r h a p s a t y p e o f l e a d e r s h i p c o m p a r a b l e t o t h a t o f i n d u s t r y s h o u l d be a t t e m p t e d . To a c c o m p l i s h t h i s i t may be n e c e s s a r y f o r CEO t o have membership on t h e h o s p i t a l b o a r d and p e r h a p s even o n t h e m e d i c a l s t a f f ' s e x e c u t i v e . They w o u l d a l s o be on t h e b o a r d ' s n o m i n a t i n g c o m m i t t e e . T h i s l e v e l o f r i s k , l i k e l y t o be a d j u s t a b l e , s h o u l d be d e t e r m i n e d j o i n t l y , and s h a r e d , by t h e b o a r d and management. O f t e n t h e g o v e r n i n g b o a r d s l e e p s t h r o u g h i n i t i a l w a r n i n g s o f h o s p i t a l d i s a s t e r o n l y t o p r o m p t l y wake up and f i r e t h e CEO. The CEO i s b e i n g f o r c e d t o be more o f a r i s k t a k e r j u s t t o c a r r y o u t h i s p r o f e s s i o n a l commitment t o keep t h e h o s p i t a l a f l o a t ( s o l v e n t ) and on c o u r s e ( p u r p o s e ) . B o a r d s h a v e an o b l i g a t i o n t o s u p p o r t t h e i r main r i s k t a k e r and must be made t o u n d e r s t a n d t h a t t h e CEO i s now c a u g h t i n t h e m i d d l e ; between t h e e x t e r n a l f o r c e s i n s i s t i n g on more c o s t c o n t a i n m e n t and t h e i n t e r n a l f o r c e s f rom t h e m e d i c a l and n u s r i n g s t a f f ; and a r e e x t r e m e l y v u l n e r a b l e . O r , i f a b o a r d i s g o i n g t o s i g n o f f a s t r a t e g y , i t i s s h a r i n g i t s r i s k s w i t h t h e CEO and must n o t t u r n on h i m a s a s c a p e g o a t a t a l a t e r t i m e o n l y f o r t h e r e a s o n t h a t t h e p l a n was w r o n g . T h e s e r i s k s a r e b r o u g h t a b o u t by t h e c o m p l e x i t y o f t h e s t r a t -e g i c p l a n n i n g p r o c e s s . The CEO must be p r e p a r e d f o r a v a r i e t y o f r e p e r c u s s i o n s o n c e he o r she s t a r t s t h e p l a n n i n g p r o c e s s . P l a n n i n g b e g i n s t o make a c c o u n t a b i l i t y much more e v i d e n t . Once one b e g i n s t h e p l a n n i n g p r o c e s s and t h i n g s d o n ' t go a s a n t i c i p a t e d , p e o p l e b e g i n t o ask why. Once members o f t h e b o a r d become i n v o l v e d i n p l a n n i n g , t h e y a r e l i k e l y t o want t o be more i n v o l v e d i n p o l i c y d e c i s i o n - m a k i n g and w i l l r e q u i r e more j u s t i f i c a t i o n f o r a c t i v i t i e s t h a t do n o t f o l l o w t h e a g r e e d upon g o a l s and o b j e c t i v e s . P r i o r i t i e s c a n change and t h e o n c e f a v o r e d d e p a r t m e n t s m i g h t need t o s h a r e s c a r c e r e s o u r c e s w i t h t h e i r p r e v i o u s l y l e s s f a v o r e d p e e r s . Once c o m m i t t e d t o p l a n n i n g , a CEO m i g h t f i n d t h a t he o r she must become much more c o m p e t i t i v e w i t h a p r e v i o u s l y a n t a g o n -i s t i c r i v a l . I n s h o r t , p l a n n i n g n o t o n l y s e t s a c o u r s e , b u t a l s o c a u s e s o r g a n i z a t i o n a l b e h a v i o u r change i n t h e i n s t u i t u t i o n . A l l of- t h i s c a n p r o b a b l y c a u s e d i s c o m f o r t , a t l e a s t i n i t i a l l y . The CEO must m a i n t a i n s u p p o r t f o r p l a n n i n g , m o n i t o r i n g , and c o r r e c t i n g t h e p r o c e s s t h r o u g h a l l o f t h e s e d i f f i c u l t c h a n g e s . E f f e c t i v e p l a n n i n g l e a d s t o a c t i o n and a c t i o n i n v o l v e s c h a n g e . At t h a t p o i n t , i t w i l l a g a i n f a l l upon t h e CEO t o c r e a t e a c l i m a t e t h a t i s r e c e p t i v e t o o r d e r l y b u t t i m e l y c h a n g e . The d a y s a r e gone f o r e v e r when a l o n g , l e i s u r e l y g e s t a t i o n p e r i o d was a c c e p t a b l e . I n c r e a s i n g government and c o m p e t i t i v e p r e s s u r e s w i l l o f t e n f o r c e a f a s t e r r e s p o n s e t i m e and a h i g h e r d e g r e e o f r i s k t a k i n g t h a n w o u l d have been n e c e s s a r y i n t h e p a s t i f t h e s t r a t e g y i s t o s u c c e e d . Those C E O ' s who have a c h i e v e d e x c e l l e n c e i n t h e i r i n s t i t u t i o n s , w h e t h e r i n s e r v i c e , q u a l i t y o r f i n a n c i a l r e s t r a i n t , have done so by c o n c e n t r a t i n g t i m e , a t t e n t i o n and r e s o u r c e s on i d e n t i f y i n g and s o l v i n g t h e i r p r o b l e m s . S u c c e s s f u l p l a n n i n g and e x e c u t i o n o f - 1 13 -s t r a t e g i e s t o meet t h e r a p i d l y c h a n g i n g e n v i r o n m e n t r e q u i r e s t h e same l e v e l o f commitment and f o c u s f r o m t h e CEO. W h i l e a l l c h i e f e x e c u t i v e o f f i c e r s f a c e r e a l i t i t e s b r o u g h t on by t h e d e c i s i o n t o p u t t o g e t h e r a p l a n n i n g f u n c t i o n , t h e y have a t e n d e n c y t o u n d e r -e s t i m a t e t h e amount o f t i m e and r e s o u r c e s t h a t a r e n e c e s s a r y f o r d e v e l o p i n g an a d e q u a t e p l a n . I t h a s been s a i d t h a t a s a b r o a d , g e n e r a l g u i d e l i n e , any h o s p i t a l t h a t h a s more t h a n 75 beds n e e d s t o h a v e s t a f f members who d e v o t e a t l e a s t p a r t o f t h e i r t i m e t o p l a n n i n g . Any i n s t i t u t i o n t h a t h a s more t h a n 200 beds s h o u l d have a f u l l - t i m e p l a n n e r . A s s t a t e d i n t h e o p e n i n g o f t h i s s e c t i o n , most CEOs a r e n o t r e a d y t o s e t up f o r m a l c o m m i t t e e s o f t h e b o a r d t o r e v i e w s t r a t e g y . T h i s may be a p p r o p r i a t e f o r p e r h a p s i n f o r m a l d i s c u s s i o n s o f t h e CEOs and d i r e c t o r s t o r e v i e w a l t e r n a t i v e s t r a t e g i e s s h o u l d come f i r s t . Such s e s s i o n s may s t i m u l a t e CEOs t o move f a s t e r t h a n t h e y m i g h t o t h e r w i s e t o c o n s i d e r b a s i c s t r a t e g y q u e s t i o n s ; and s h o u l d a s s u r e them o f t h e i r b o a r d ' s s u p p o r t and w i l l i n g n e s s t o t a k e p a r t i n p e r i o d i c d i s c u s s i o n s l e a d i n g e v e n t u a l l y t o c o n c l u s i o n s . The a s t u t e e x e c u t i v e , h o w e v e r , s e n s e s what i s r e a d y f o r d i s c u s s i o n and what i s n o t . He knows t h e v a l u e o f a s i n g l e i d e a n o t thought o f b e f o r e . He i s aware t h a t t h e more he knows a b o u t t h e way h i s managers and d i r e c t o r s t h i n k a b o u t s t r a t e g i c p r o b l e m s , t h e more l i e k l y he i s t o a r r i v e a t a s o l u t i o n t h a t i s p o l i t i c a l l y a c c e p t a b l e a s w e l l a s e c o n o m i c a l l y s o u n d . R a t h e r t h a n i n s c r u t a b l y k e e p i n g h i s p e a c e , he h a s t h e o p p o r t u n i t y t o open up t h e p r o c e s s , t o r a i s e q u e s t i o n s , t o e n c o u r a g e b u t n o t t o f o r c e t h e f a c i n g o f s t r a t e g i c r e a l i t y , and t o l e a d a p r o c e s s o f d e c i s i o n t h a t c a n e n l i s t t h e - 114 -t o t a l s t r e n g t h o f management and t h e s u p p o r t and detached , i n s i g h t o f t h e b o a r d . B e c a u s e o f t h e r o l e and i m p o r t a n c e t h e p o s i t i o n o f CEO h a s w i t h i n a s m a l l h o s p i t a l , t h e b o a r d s h o u l d c a r e f u l l y e v a l u a t e n o t o n l y t h e p e r f o r m a n c e b u t a l s o t h e p e r s o n a l i t y . Such an e v a l u a t i o n c a n be c a r r i e d o u t u s i n g t h e H . A . A . o f B . C . f o r m a t ( a p p e n d i x #17) -F r e q u e n t c h e c k s must a l s o be made t o e n s u r e t h a t management (CEO) i s " o u t on t h e f l o o r " and n o t s e e k i n g s h e l t e r somewhere o r i g n o r i n g r e a l i t i e s . The CEO s h o u l d make d a i l y p a t i e n t r o u n d s -t h i s s e r v e s t o c o u n t e r a c t t h e common image o f t h e a d m i n i s t r a t o r a s one who c l u t c h e s t h e f i n a n c i a l s t a t e m e n t l i k e a s e c u r i t y b l a n k e t o r t o o o f t e n d e f e r s m a t t e r s i n v o l v i n g p a t i e n t c a r e t o t h e m e d i c a l s t a f f o r t o t h e n u r s i n g s e r v i c e . What s h o u l d a b o a r d l o o k f o r i n a CEO? P l a n n i n g r e q u i r e s a b l e n d o f s c i e n t i f i c a n a l y s i s , human j u d g e m e n t , and e x p e r i e n c e . In t h e words o f B r a n c h (1966), many o f t h e r e q u i s i t e s o f t h e s u c c e s s f u l CEO and p l a n n e r - f l e x i b i l i t y , i n c l u s -i v e n e s s o f t h i n k i n g , d e d u c t i v e a b i l i t y , i n t u i t i v e p e r c e p t i o n , s e n s i t i v i t y t o human c o n s i d e r a t i o n s and c a p a c i t y t o l e a r n - depend a s much on t h e e m o t i o n a l m a t u r i t y a s s p e c i f i c b u s i n e s s e x p e r i e n c e o r p r o f e s s i o n a l t r a i n i n g . S t u e h l e r (1976) i d e n t i f i e s t h e t h r e e key r o l e s o f t h e h o s p i t a l p l a n n e r - f a c i l i t a t o r , c o - o r d i n a t o r , and c a t a l y s t . A n o t h e r r o l e i s a l s o i m p o r t a n t - t e a c h i n g . W r i t i n g , v e r b a l and o t h e r c o m m u n i c a t i o n s k i l l s , c o n c e p t u a l a b i l i t y , e v a l u a t i o n s k i l l s , a n a l y t i c a l s k i l l s , l e a d e r s h i p i n g r o u p p r o c e s s , a n d , i f p o s s i b l e , t r a i n i n g o r e x p e r i e n c e i n p l a n n i n g a l l w i l l h e l p w i t h t h e s e r o l e s . They s h o u l d be a g e n e r a l i s t , a b l e . t o d raw up p r i o r i t i e s , w e i g h t h e r i s k s , and make q u i c k d e c i s i o n s . They s h o u l d a l s o be p r e p a r e d - 115 -t o q u e s t i o n e v e r y t h i n g and t a k e n o t h i n g f o r g r a n t e d , p r e f e r r i n g t o go back t o b a s i c s a s much a s p o s s i b l e . P e o p l e ' s s k i l l s a r e e s s e n t i a l . They must a l s o s t r i v e t o be t o u g h , c o n s i s t e n t , and above a l l , f a i r i n mak ing d e c i s i o n s , making j u d g e m e n t s , and a r r i v i n g a t d e c i s i o n s . They s h o u l d be n e i t h e r o v e r - c o n f i d e n t a b o u t t h e i r c h a n c e s o f s u c c e s s n o r t o o o p t i m i s t i c . R a t h e r , i t i s o f t e n b e s t t o work f r o m t h e n e g a t i v e p o s i t i o n , b e i n g i n q u i s i t i v e and e n e r g e t i c and m a i n t a i n a s e n s e o f b a l a n c e a b o u t what i s t o be a c c o m p l i s h e d . I n d i v i d u a l d i r e c t o r s and t h e CEO c h a l l e n g e each o t h e r , and t h e i r r e l a t i o n s h i p s a r e s t r e n g t h e n e d by a s s o c i a t i o n s d e v e l o p e d i n s u c h s i t u a t i o n s a s o f f - s i t e d i s c u s s i o n s . They s h o u l d e x p l o r e t h i n g s i n f o r m a l l y a s w e l l a s more s e r i o u s l y . T h e r e must be c a r e f u l s e l e c t i o n o f t h e CEO f o r r u r a l a r e a s . They s h o u l d be a b l e t o h a n d l e t h e g r e a t e r v i s i b i l i t y o f t h e i r p e r s o n a l l i v e s and t h e i n e v i t a b l e j u d g e m e n t s t h a t w i l l be made a b o u t them by communi ty members. P e r h a p s o f g r e a t i m p o r t a n c e i s t h a t t h e CEO s h o u l d h a v e a r u r a l b a c k g r o u n d , f a m i l i a r w i t h s i m i l a r c u l t u r e s , and be a b l e to m a i n t a i n a l o w p e r s o n a l p r o f i l e . These f a c t o r s s h o u l d a s s i s t i n e n c o u n t e r i n g more a c c e p t a n c e and c o - o p e r a t i o n . - 116 -THE ROLE OF THE BOARD OF DIRECTORS A s an i n t r o d u c t o r y comment, I o f f e r a q u o t e f rom Dr . Gordon B u t e s , f o u n d e r o f t h e H e a l t h League o f C a n a d a : "No g o v e r n m e n t , however i n t e l l i g e n t o r e n e r g e t i c o r b e n e v o l e n t c a n c o v e r t h e w h o l e a r e a o f s o c i a l n e e d s . V o l u n t a r y e f f o r t and i n d i v i d u a l e f f o r t i s more i m p o r t a n t t h a n e v e r b e c a u s e t h e t a s k s o f t h e s t a t e a r e so v a s t t h a t w i t h o u t v o l u n t a r y a s s i s t a n c e , t h e y c a n n o t be a c c o m p l i s h e d and a f t e r a l l i s t h a t n o t t h e t r u e mean ing o f d e m o c r a c y ? Democrary means f a r more t h a n m e r e l y t h a t t h e c i t i z e n h a s t h e p o w e r , by h i s v o t e s , t o d e t e r m i n e t h e p e r s o n n e l o f h i s g o v e r n m e n t . I t a l s o means t h e c i t i z e n s h o u l d have a change o f h i m s e l f , a c t u a l l y a s s i s t i n g t h e work o f p u b l i c a d m i n i s t r a t i o n , f o r w i t h o u t t h a t you do n o t r e a l i z e t h e g r e a t i d e a o f s e l f g o v e r n m e n t . " I m p l i e d i n t h i s q u o t e a r e some b a s i c a s s u m p t i o n s : 1. T r u s t e e s a r e i m p o r t a n t t o t h e i r h o s p i t a l s . Many t r u s t e e s d o n ' t r e a l l y b e l i e v e i t , b u t t h e y a r e l e g a l l y i n p o w e r , l e g a l l y r e s p o n s -i b l e and a c c o u n t a b l e . T r u s t e e s have b i g - t i m e r e s p o n s i b i l i t i e s t h a t c a n n o t be d e l e g a t e d . 2. T r u s t e e s need more i n f o r m a t i o n a b o u t t h e h e a l t h c a r e p r o c e s s . T r u s t e e s a r e g e n e r a l l y k n o w l e d g e a b l e a b o u t t h e i r own b u s i n e s s a f f a i r s , b u t f o r t h e most p a r t t h e y do n o t know much a b o u t t h e c o m p l e x b u s i n e s s o f p r o v i d i n g h e a l t h c a r e . I t i s a h i g h l y r e g u l a t e d and t e c h n o l o g i c a l l y a d v a n c e d i n d u s t r y and t r u s t e e s need t o know a b o u t l a w and a b o u t m e d i c i n e and m e d i c a l g a d g e t r y . - 117 -3. The e c o n o m i c s a r e t o u g h . More and more o f t e n t h e g o v e r n m e n t t e l l s t h e h o s p i t a l what i t s c o s t s a r e , no m a t t e r how t h e b o o k s add u p . 4 . The economic c o n s e q u e n c e s o f d e c i s i o n s made i n h o s p i t a l s a r e n e v e r " c l e a n " ; some o f t h e b e s t d e c i s i o n s t h e h o s p i t a l makes l o s e money, b u t t h e y s a v e l i v e s . T h a t ' s t h e p r o b l e m ; e v e r y d e c i s i o n i s a t r a d e - o f f be tween t h a t w h i c h i s m e d i c a l l y d e s i r a b l e and t h a t w h i c h i s e c o n o m i c a l l y p o s s i b l e . The s i t u a t i o n i s n ' t s i m p l e t o b e g i n w i t h and i t c h a n g e s m o n t h l y , d a i l y , and w o r s e , o f t e n r e t r o a c t i v e l y . 5 . T r u s t e e s a r e o f t e n p a r t o f t h e p r o b l e m a s t h e y a r e n o t s u f f i c i e n t l y i n f o r m e d a b o u t t h e i s s u e s o r t h e m e c h a n i c s o f h e a l t h c a r e b u t w i t h t h e i r l a r g e v o t e , t h e y c o n t r i b u t e t o t h e p r o b l e m r a t h e r t h a n t h e s o l u t i o n . 6. T r u s t e e s c a n be b i g g e r c o n t r i b u t o r s t o s o l u t i o n s b e c a u s e : d o c t o r s , n u r s e s , a d m i n i s t r a t o r s , gove rnment p l a n n e r s , and e d u c a t o r s a r e a l l d e e p l y enmeshed i n t h e i r own c o r n e r s o f t h e h e a l t h c a r e f i e l d , w h i c h i s n o t o n l y c o m p l e x , b u t so b i g t h a t no one p e r s o n knows any more t h a n a f r a g m e n t . No one h a s a b e t t e r c h a n c e t o see i t a l l and t o s e e i t i n p e r s p e c t i v e t h a n i n f o r m e d t r u s t e e s . They come w i t h t h e i r o u t s i d e e x p e r i e n c e and a de tachment t h a t i s a l m o s t i m p o s s i b l e f o r i n s i d e r s t o a c h i e v e . To be p a r t o f t h e s o l u t i o n , t r u s t e e s need b a c k g r o u n d and t h e y need c o n s t a n t u p d a t i n g on t h e c h a n g i n g g r o u n d r u l e s . A t r u s t e e i s t h e one p e r s o n i n t h e h o s p i t a l who i s n e i t h e r so n a r r o w l y t r a i n e d n o r so t h o r o u g h l y embedded i n t h e p r e s e n t s y s t e m - 118 -t h a t t h e y c a n ' t see t h e w h o l e i n s t i t u t i o n i n t h e c o n t e x t o f t h e communi ty i t s e r v e s . They a r e t h e one g e n e r a l i s t a r o u n d , t h e one p e r s o n i n t h e w h o l e p l a c e who c a n a s k q u e s t i o n s w i t h o u t f e a r o f a p p e a r i n g dumb, t h e one p e r s o n who c a n demand t h a t c o m p l e x i s s u e s be e x p l a i n e d s i m p l y so t h e y c a n u n d e r s t a n d - and t h u s e v e r y o n e e l s e w i l l u n d e r s t a n d b e t t e r . H e a l t h c a r e t r u s t e e s a r e a l w a y s h a v i n g t h e i r r o l e and r e s p o n s i b i l i t i e s d e f i n e d , o u t l i n e d and d e s c r i b e d . One w o u l d t h i n k t h e y s h o u l d be c l e a r by now, b u t p o s s i b l y t h e s u b j e c t w i l l a l w a y s be o f i n t e r e s t , s i n c e t r u s t e e s by t h e i r v e r y n a t u r e change on a r e g u l a t e d and f a i r l y s h o r t t e r m b a s i s . T h i s i s p a r t i c u l a r l y t r u e a t t h i s t i m e i n B . C . ' s h i s t o r y a s t h e v e r y n a t u r e and s t r u c t u r e o f h o s p i t a l b o a r d s i s b e i n g c a r e f u l l y s c r u t i n i z e d by t h e M i n i s t r y o f H e a l t h , t h e p r o f e s s i o n a l s , and t h e p u b l i c . I t i s t h e r e f o r e i m p o r t a n t t o keep r e d e f i n i n g t h e r o l e o f t h e t r u s t e e . T h e r e a r e a t l e a s t t h r e e ma jo r a r e a s o f r e s p o n s i b i l i t y f o r a h e a l t h c a r e t r u s t e e . One o f t h e s e i s o p e r a t i n g t h e i n s t i t u t i o n a l p r o g r a m f o r w h i c h t h e a p p o i n t m e n t o f t r u s t e e made. A s e c o n d ma jo r a r e a i s a s s u r i n g t h a t t h e q u a l i t y o f c a r e i s a d e q u a t e w i t h i n a c c e p t -a b l e c u r r e n t s t a n d a r d s . A t h i r d ma jo r r e s p o n s i b i l i t y i s t h e a s s e s s m e n t o f h e a l t h c a r e r e q u i r e m e n t s . T h i s r e s p o n s i b i l i t y i n v o l v e s t h e t r u s t e e d i r e c t l y w i t h a r e s p o n s i b i l i t y f o r p l a n n i n g . A r e h o s p i t a l b o a r d s i n v o l v e d i n t h i s p l a n n i n g a s p e c t ? Ore r e s e a r c h s t u d y i n t o t h e b o a r d o f d i r e c t o r s o f b u s i n e s s c o r p o r -a t i o n s p o s e d t h i s q u e s t i o n : " I t was f ound t h a t b o a r d s o f d i r e c t o r s o f most l a r g e and m e d i u m - s i z e d c o m p a n i e s do n o t e s t a b l i s h o b j e c t i v e s , s t r a t e g i e s o r p o l i c i e s , however t h e y a r e d e f i n e d . The s t u d y i n d i c a t e d t h a t t h e s e r o l e s were p e r f o r m e d by company managements and t h a t p r e s i d e n t s and o u t s i d e d i r e c t o r s g e n e r a l l y a g r e e d t h a t o n l y management s h o u l d have t h e s e r e s p o n s i b i l i t i e s . T y p i c a l o u t s i d e d i r e c t o r s do n o t have t i m e t o d e t e r m i n e an o r g a n i z a t i o n ' s o b j e c t i v e s , s t r a t e g i e s and d i r e c t i o n s as" t h e s e r e q u i r e c o n s i d e r a b l e s t u d y . A t m o s t , t h e y c a n a p p r o v e p o s i t o n s t a k e n by management and t h e a p p r o v a l i s based on s c a n t y f a c t s and n o t t i m e - c o n s u m i n g a n a l y s i s (20) T h i s l a c k o f p o l i c y and s t r a g e g y f o r m u l a t i o n by a b o a r d o f d i r e c t o r s i s p r o b a b l y t r u e i n t h e h o s p i t a l s e c t o r , a l t h o u g h t h e r e a p p e a r s t o be a l a c k o f r e s e a r c h on t h e t o p i c . Many f a c t o r s may a c c o u n t f o r t h e s m a l l amount o f l i t e r a t u r e on g o v e r n i n g b o a r d s and t h e i r r o l e i n s t r a t e g i c p l a n n i n g . These g r o u p s a r e n o t e a s i l y a c c e s s i b l e f o r i n d e p t h a n a l y s i s and o f t e n t h e m i n u t e s o f m e e t i n g s r a r e l y r e f l e c t t h e d e l i b e r a t i o n p r o c e s s . Whether t h e p l a n n i n g r o l e i s c a r r i e d o u t o r n o t , i t r e m a i n s . T h i s r o l e r e q u i r e s t h a t t h e b o a r d r e l a t e t h e o r g a n i z a t i o n , i t s r e s o u r c e s , and p r o g r a m s t o r e l e v a n t e x t e r n a l components and i s t h e most i m p o r t a n t f u n c t i o n o f a l l g o v e r n i n g b o a r d s o f t r u s t e e s . A c l u e t o t h i s p l a n n i n g a s p e c t i s f o u n d i n t h e words t h e m s e l v e s . " G o v e r n i n g " c l e a r l y i m p l i e s t h a t t h e b o a r d i s t h e t o p o f t h e i n t e r n a l management h i e r a r c h y . I t i s t h e r e f o r e u l t i m a t e l y r e s p o n s i b l e f o r a l l p r o g r a m s and a c t i v i t i e s o f t h e h o s p i t a l . W h i l e t h e d a i l y o p e r a t i o n a l d e c i s i o n s a r e d e l e g a t e d t o s u b o r d -i n a t e s t h r o u g h a c h a i n o f command, t h e b o a r d i s where " t h e buck s t o p s " . B u t t h e r e i s a n o t h e r p a r t o f t h e t i t l e , "trustees, w h i c h h a s s e v e r a l l e g a l and m o r a l i m p l i c a t i o n s . The t h r u s t o f t h e s e i s - 120 -i s t h a t t h e b o a r d h a s a communi ty t o s e r v e and r e l a t e t o . T h i s i s where t h e h o s p i t a l - c o m m u n i t y , o r g a n i z a t i o n a l - e n v i r o n m e n t a l t h e o r y becomes a r e a l i t y . T h i s b o u n d a r y - s p a n n i n g r o l e between t h e o r g a n i z a t i o n and i t s e n v i r o n m e n t h a s p r o m p t e d some t h e o r i s t s t o examine t h i s p r o c e s s . S e v e r a l a u t h o r s have d e f i n e d boundary management as t h e c o n c e r n o f t r u s t e e s i n d e f i n i n g t h e d e s i r e d s t a t e o f e n v i r o n m e n t a l r e l a t i o n s . F o r any o r g a n i z a t i o n a l u n i t t o f u l f i l l t h i s r o l e , i n f o r m a t i o n f r o m and a b o u t t h e e n v i r o n m e n t i s n e e d e d . S i n c e g o v e r n i n g b o a r d s a r e s t r u c t u r e d most o f t e n i n t o c o m m i t t e e s f o r t a s k a c c o m p l i s h m e n t , t h e s e work g r o u p s become an i n t e g r a l p a r t o f t h e b o u n d a r y management p r o c e s s . W h i l e t h e u l t i m a t e p u r p o s e o f a b o a r d i s t o make p o l i c y and p r o g r a m d e c i s i o n s , a key p r i o r s t e p i s t h e p l a n n i n g p r o c e s s t h r o u g h w h i c h t h i s d e c i s i o n - m a k i n g body r e c o g n i z e s t h e need t o make t h o s e s e l e c t i o n s . T h i s a w a r e n e s s i s s u e i s a m a n d a t o r y s t e p . E a r l y p r o b l e m r e c o g n i t i o n i s b e t t e r t h a n l a t e p r o b l e m r e c o g n i t i o n . I f an o r g a n i z a t i o n c a n l e a r n o f a p r o b l e m b e f o r e i t becomes a c r i s i s , t h e n t h e r e i s l e a d t i m e f o r d e c i s i o n - m a k i n g and c o p i n g s t r a t e g i e s . F i r e - f i g h t i n g on a c o n t i n u a l b a s i s i s a l m o s t a n t i -t h e t i c a l t o p l a n n i n g . I f t h e g o v e r n i n g b o a r d i s seen a s t h e m a j o r o r g a n -i z a t i o n a l l i n k t o t h e e x t e r n a l e n v i r o n m e n t , t h e n i t s h o u l d be a n t i c i p a t i n g and s t a y i n g a b r e a s t o f t r e n d s a s t h e y d e v e l o p , n o t a f t e r t h e y have a l r e a d y had an i m p a c t on t h e h o s p i t a l . T h i s r e i n f o r c e s much o f t h e c u r r e n t c r i t i c i s m l e v e l e d a g a i n s t h e a l t h c a r e b o a r d s . T h i s s t u d y c o n f i r m s much o f t h i s r e l a t i v e l y r e a c t i v e p o s t u r e . The h i s t o r i c a l g r o w t h and change i n t h e h o s p i t a l and i t s g o v e r n i n g b o a r d p r o v i d e s one l o g i c a l e x p l a n a t i o n f o r t h i s p o s t u r e . The p a s t c a n be c h a r a c t e r i z e d by a g r a d u a l , y e t r a t h e r c o n s i s t e n t , e r o s i o n o f g o v e r n i n g b o a r d power i n t h e d a i l y a d m i n -i s t r a t i o n o f t h e h o s p i t a l . Once b a s e d on f i n a n c i a l c o n c e r n s , g o v e r n i n g b o a r d c o n t r i b u t i o n s h a v e been r e p l a c e d by i n s u r a n c e f u n d s , government m o n i e s , and o t h e r s o u r c e s o f r e v e n u e . T h i s p a s t h i s t o r y h a s a l s o w i t n e s s e d a s h i f t i n g o f power t o a more p r o f e s s i o n a l a d m i n i s t r a t i v e s t r u c t u r e , and a more i n v o l v e d and c o n c e r n e d m e d i c a l s t a f f . The f u t u r e w i l l , a c c o r d i n g t o many, be n o t e w o r t h y i n a more e q u a l d i v i s i o n o f power and i n f l u e n c e between t h e s e t h r e e p a r t i e s . One r o l e t h a t emerges f o r a b o a r d i s t o c o n s c i o u s l y n o t become o v e r l y i n v o l v e d i n t h e r o u t i n e o f h o s p i t a l f u n c t i o n i n g t o t h e p o i n t t h a t i t d e t r a c t s f rom p o l i c y - m a k i n g . The h o s p i t a l h a s e v o l v e d o v e r t h e y e a r s f rom a p l a c e where t h e h o m e l e s s came t o d i e t o an i n s t i t u t i o n o f q u a l i t y . The q u e s t i o n i s , how w i l l t h e h o s p i t a l be r e g a r d e d i n t h e f u t u r e ? The c e n t r a l p a r t o f t h e answer l i e s i n t h e a b i l i t y t o r e a c h p r e d e t e r m i n e d g o a l s and o b j e c t i v e s b e c a u s e , " I n f o r m a t i o n must p e r m e a t e t h e o r g a n i z a t i o n ' s b o u n d a r i e s b e f o r e a d e c i s i o n c a n be made . " (21) The a d a p t a b i l i t y o f h o s p i t a l s i s an i m p o r t a n t i s s u e f o r c o n t e m p o r a r y h e a l t h i n s t i t u t i o n s . I n an e r a o f r i s i n g c o s t s , p u b l i c c o n c e r n a b o u t t h e q u a l i t y o f c a r e and g o v e r n m e n t a l a n a l y s i s o f m e d i c a l c a r e , a s w e l l a s t h e a b i l i t y o f t h e h o s p i t a l t o r e g u l a t e and g u i d e i t s e l f , i s i m p o r t a n t . I f t h e h o s p i t a l i s n o t g u i d e d by - 1 2 2 -i t s t o p t r u s t e e s , t h e n t h e p o t e n t i a l e x i s t s f o r o t h e r t o s t e p i n and assume t h e s e r e s p o n s i b i l i t i e s . L i t e r a t u r e seems t o i n d i c a t e t h a t : t h e s e e k i n g and u s e o f e n v i r o n m e n t d a t a by governing b o a r d s i s p o s i t i v e l y r e l a t e d t o p r o b l e m r e c o g n i t i o n a t an e a r l y s t a g e , t h e r a t i o n o f e x t e r n a l l y t o i n t e r n a l l y f o c u s e d c o m m i t t e e s o f t h e b o a r d i s p o s i t i v e l y r e l a t e d (a) t o t h e u s e o f e x t e r n a l d a t a i n r e c o g n i z i n g p r o b l e m s , and (b) t o p r o b l e m r e c o g n i t i o n a t an e a r l y s t a g e . t h e o c c u r r e n c e o f m a j o r , n o n - r o u t i n e e v e n t s i n o r g a n i z a t i o n i s p o s i t i v e l y r e l a t e d t o e a r l y p r o b l e m r e c o g n i t i o n . To f u l f i l l t h e s e r e s p o n s i b i l i t i e s t h e r e must be a f u l l e r engagement o f t h e b o a r d o f d i r e c t o r s i n d e s i g n and e x e c u t i o n o f a h o s p i t a l ' s s t r a t e g i c p l a n . E f f e c t i v e b o a r d p a r t i c i p a t i o n i n s t r a t e g i c p r o c e s s e s c a n make an i m p o r t a n t l o n g t e r m d i f f e r e n c e i n a h o s p i t a l ' s p e r f o r m a n c e and c o n t r i b u t e t o t h e l o n g e v i t y and p r i d e i n a c h i e v e m e n t o f t h e a d m i n i s t r a t o r s . When t h e b o a r d c h a i r m a n opens t h e d o o r t o d i s c u s s i o n o f s t r a t e g y , t h e o t h e r d i r e c t o r s b e g i n t o p a r t i c i p a t e . T h e r e a r e s e v e r a l u n r e s o l v e d p r o b l e m s w h i c h d e l a y t h i s p a r t i c i p a t i o n and t h e b o a r d becoming p r o d u c t i v e i n s t r a t e g y f o r m u l a t i o n and i m p l e m e n t i n g . These a r e : 1. I t i s n o t t h e b o a r d ' s f u n c t i o n t o f o r m u l a t e b u t t o r e v i e w and t o m o n i t o r t h e p r o c e s s t h a t p r o d u c e s i t . 2. What i s meant by s t r a t e g y and how c l e a r l y i t i s s e t f o r t h a r e n o t g e n e r a l l y u n d e r s t o o d . 3. The h o s p i t a l a d m i n i s t r a t o r s a r e u s e d t o t h i n k i n g t h a t t h e b o a r d ' s p r i n c i p l e f u n c t i o n i s t o s e l e c t , s u p p o r t and r e p l a c e them and w i l l - 123 -a p p r o a c h e n l a r g e m e n t o f t h e b o a r d ' s s t r a t e g i c r o l e w i t h much h e s i t a t i o n and l i t t l e e x p e r i e n c e . 4 . D i r e c t o r s a r e v e r y b u s y and a r e n o t u s u a l l y w e l l - i n f o r m e d a b o u t t h e s t r a t e g i c r e c o m m e n d a t i o n s t h e y may be a s k e d t o e v a l u a t e and a p p r o v e . 5. C e n t r a l d e c i s i o n s t h a t w i l l d e t e r m i n e t h e h o s p i t a l ' s n a t u r e and p e r f o r m a n c e t e n and t w e n t y y e a r s i n t o t h e f u t u r e a r e l a d e n w i t h r i s k , u n c e r t a i n t y and c o n t e n t i o n . We do n o t have t o l o o k f a r t o f i n d o u t why. Many a C . E . O . , r e j e c t i n g t h e p r a c t i c a l i t y o f c o n s c i o u s s t r a t e g y , p r e s i d e o v e r u n s t a t e d , i n c r e m e n t a l , o r i n t u i t i v e s t r a t e g i e s t h a t have n e v e r been a r t i c u l a t e d o r a n a l y z e d and t h e r e f o r e c o u l d n o t be d e l i b e r a t e d by t h e b o a r d . O t h e r s do no t b e l i e v e t h e i r o u t s i d e d i r e c t o r s know enough o r have t i m e enough t o do more t h a n a s s e n t t o s t r a t e g i c r e c o m m e n d a t i o n s . S t i l l o t h e r may keep d i s c u s s i o n s o f s t r a t e g y w i t h i n management t o p r e v e n t b o a r d t r a n s g r e s s i o n o n t o management t u r f and c o n s e q u e n t r e d u c t i o n o f e x e c u t i v e s ' power t o s h a p e , by t h e m s e l v e s , t h e f u t u r e o f t h e i r h o s p i t a l s . The f o r e g o i n g l e a d s t o t h r e e o b s e r v a t i o n s . F i r s t , many t r u s t e e s do n o t p a r t i c i p a t e i n s t r a t e g i c d e c i s i o n s b e c a u s e t h e y f i n d i t d i f f i c u l t t o i n f u s e t h e i r v a l u e s i n t o t h e s t r a t e g i c p r o c e s s . S e c o n d , t h e n e u t r a l i z a t i o n o f t h e i r v a l u e s t e n d t o r e i n f o r c e t h e e x e c u t i v e d i r e c t o r ' s v a l u e s y s t e m . T h i r d , t h e t i m e f a c t o r m i l i t a t e s a g a i n s t i n v o l v e m e n t . T r u s t e e s a r e n o t a l w a y s w i l l i n g t o spend t h e n e c e s s a r y t i m e t o do t h e n e c e s s a r y homework. These t r u s t e e s , b e c a u s e o f t h e i r busy s c h e d u l e s , must r e l y on t h e e x e c u t i v e d i r e c t o r f o r a f l o w o f i n f o r m a t i o n , d e f i n i t i o n o f t h e i r r o l e a n d , f r e q u e n t l y - 121 -e v a l u a t i o n o f t h e o r g a n i z a t i o n ' s a c h i e v e m e n t o f i t s g o a l s . T h u s , t h e m a j o r r o l e o f any t r u s t e e ( t h i s i s p o l i c y f o r m u l a t i o n ) i s u s u a l l y l o s t o r f o r g o t t e n . The r e s u l t i s t h a t t h e f o r m u l a t i o n o f g o a l s and p o l i c i e s i s t h e n a u t o m a t i c a l l y r e l e g a t e d t o t h e e x e c u t i v e d i r e c t o r , and t h e r e f o r e he o r she p r a c t i c a l l y h a s t h e power o f t h e C . E . O . and t h e b o a r d a l l i n o n e . M o r e o v e r , c o n f l i c t between e x e c u t i v e d i r e c t o r s and t r u s t e e s i s a l l t o o common i n h o s p i t a l s , e s p e c i a l l y i n m i d d l e -s i z e d and s m a l l h o s p i t a l s (where d i f f e r e n c e s may become p e r s o n a l ) . Even i f s t r a t e g y were n o t such a s e n s i t i v e t o p i c , i n v o k i n g l a t e n t t e n s i o n between C . E . O . and i n d e p e n d e n t d i r e c t o r s , i t w o u l d r e q u i r e more t i m e and s o p h i s t i c a t i o n t h a n c h a i r m e n o r o u t s i d e d i r e c t o r s , however w i l l i n g , c o u l d e a s i l y summon t o t h e t a s k . A t b e s t , o r i g i n a l c o n t r i b u t i o n s by o u t s i d e d i r e c t o r s i s l i m i t e d and i n f r e q u e n t . N o n e t h e l e s s , t h e f o r c e s s h a p i n g h o s p i t a l g o v e r n a n c e , , i n c l u d i n g r e s t l e s s n e s s among i n d e p e n d e n t d i r e c t o r s , a r e p r e s s i n g b o a r d s t o w a r d g r e a t e r p a r t i c i p a t i o n i n d e t e r m i n i n g t h e f u t u r e d i r e c t i o n and c h a r a c t e r o f t h e i r o r g a n i z a t i o n s . A d m i n i s t r a t o r s , s t a f f and m e d i c a l s t a f f s h o u l d n o t t a k e t h e a p p r o a c h o f w o n d e r i n g w h e t h e r t h e y a r e e x p e c t i n g more o f t h e d i r e c t o r s t h a n most c a n p r o v i d e i n t e r m s o f t i m e and t a l e n t . T h e r e i s u s u a l l y ample o f b o t h . A l l i n a l l , t h e s t r a t e g i c management v o i d c r e a t e d by an u n w i e l d y and e v e r / c h a n g i n g b o a r d i s compounded by e x e c u t i v e d i r e c t o r s whose j o b s u r v i v a l r e q u i r e s s a t i s f y i n g t r u s t e e s w i t h i n a l i m i t e d t e r m . The a d m i n i s t r a t o r s must r e c o g n i z e t h a t t h e y depend more t h a n o n l y o b l i q u e l y on t h e i r b o a r d s o f d i r e c t o r s f o r g u i d a n c e on h o s p i t a l - 125 -s t r a t e g y . The b o a r d must a l s o d e t e r m i n e i f t h e i r a d m i n i s t r a t o r i s a s t r a t e g i c t h i n k e r . I f he i s , t h e y must be aware o f t h e f a c t t h a t he w i l l s e l d o m be i n h i b i t e d by a n y o n e ; b u t w i l l work c l o s e l y w i t h h i s o t h e r t o p m a n a g e r s , t h e b o a r d o f d i r e c t o r s , o u t s i d e p r o f e s s i o n a l p l a n n e r s , o r t h e g o v e r n m e n t . Combined w i t h t h e above s t a t e d p r o b l e m s , one o f t h e g r e a t e s t h i n d r a n c e s t o s t r a t e g i c p l a n n i n g a t t h e b o a r d l e v e l and t h e a d m i n i s t r a t i o n i s t h e p r o t e c t i o n o f t h e f u t u r e a g a i n s t t h e o v e r w h e l m i n g p r e s s u r e s o f t h e p r e s e n t . These p r e s s u r e s a r e o f t e n e a s y t o s p e c i f y a s e s s e n t i a l b u t b r i n g i n g a b o u t t h e t r a d e -o f f and s u r v i v i n g r e q u i r e s judgement on t h e p a r t o f t h e b o a r d and a d m i n i s t r a t i o n . O f t e n , no one c a n d e s c r i b e t h e judgement a p p l i e d t o f u t u r e / p r e s e n t t r a d e - o f f s b u t s t r a t e g i c t h i n k e r s know i t when t h e y see i t . S i m i l a r l y , t h e b o a r d o f t r u s t e e s a l s o n e e d s t o r e f l e c t a c o r p o r a t e b o a r d s t y l e . T h i s a p p r o a c h w i l l a s s i s t t r u s t e e s as r e o r g a n i z a t i o n w i l l p r o b a b l y i n v o l v e g r e a t e r e m p h a s i s on p o l i c y f o r m a t i o n , e v a l u a t i o n , and a c c o u n t a b i l i t y ; d e v e l o p m e n t o f l e s s c a s u a l a t t i t u d e s on t h e b o a r d and i t s c o m m i t t e e s ; more o p e n n e s s ; and a v a r i e t y o f s t e p s t o e n s u r e t h a t d e l i b e r a t i o n and d e c i s i o n s o f t h e b o a r d p r o v i d e an a p p r o p r i a t e b a l a n c e o f p r o v i d e r and consumer i n t e r e s t . " The b o a r d and i t s c o m m i t t e e s no l o n g e r c a n a f f o r d t o spend t i m e r e v i e w i n g d a i l y i n t e r n a l a c t i v i t i e s o f t h e h o s p i t a l . I n s t e a d , t h e b o a r d must t a k e a f a r more g l o b a l p e r s p e c t i v e , p l o t t i n g t h e h o s p i t a l ' s r o l e w i t h t h e i n t e n t t o e n s u r e t h e h o s p i t a l ' s f u t u r e v i a b i l i t y . THE ROLE OF PHYSICIANS A s s t a t e d , p l a n n i n g d e a l s w i t h t h e f u t u r e and i s somewhat u n p r e d i c t a b l e . One o f t h e e l e m e n t s o f t h e u n p r e d i c -a b i l i t y h o s p i t a l s have t o w r e s t l e w i t h i s how s t r a t e g i c p l a n n i n g a f f e c t s and w i l l be a f f e c t e d by t h e p r a c t i c e o f m e d i c i n e . I c a n s a y w i t h o u t c o n t r a d i c t i o n , t h a t a ma jo r i s s u e i n h o s p i t a l s t r a t -egy f o r m u l a t i o n i s t h e r o l e o f t h e m e d i c a l s t a f f , a g r o u p w h i c h s e l d o m p a r t i c i p a t e s f o r m a l l y i n t h e i n s t i t u t i o n ' s management d e c i s i o n s . The f o l l o w i n g a r e some e x p l a n a t i o n s f o r t h e a b s e n c e o f t h e m e d i c a l s t a f f p a r t i c i p a t i o n : p h y s i c i a n s a r e u s u a l l y v i e w e d a s r e s i s t a n t t o change p h y s i c i a n s have l i m i t e d t i m e t o g e t i n v o l v e d p h y s i c i a n s a r e f e a r f u l o f becoming i n v o l v e d i n d e c i s i o n -making b e c a u s e t h e y w i l l be h e l d more a c c o u n t a b l e f o r t h e r e s u l t s t h e m e d i c a l s t a f f , even i n a s m a l l h o s p i t a l , i s u s u a l l y a l a r g e and d i v e r s e g r o u p . I t i s d i f f i c u l t t o have w i d e p a r t i c i p a t i o n and r e p r e s e n t a t i v e s do neb n e c e s s a r i l y speak f o r o r r e p r e s e n t a b r o a d c r o s s - s e c t i o n o f t h e s t a f f , a d m i n i s t r a t o r s a r e f e a r f u l t h a t i f p h y s i c i a n s a r e f o r m a l l y i n v o l v e d i n d e c i s i o n s , t h e y w i l l r e l i n q u i s h some o f t h e i r power t h e r e i s an i n h e r e n t m i s t r u s t among a d m i n i s t r a t o r s , p h y s i c i a n s , and nurses w h i c h c r e a t e s b a r r i e r s t o j o i n t e f f o r t s . Whether o r n o t t h e s e r e a s o n s a r e v a l i d o r a c c u r a t e , t h e r e a r e s i g n i f i c a n t d i f f e r e n c e s between t h e m e d i c a l s t a f f and t h e a d m i n i s t r a t i v e / - 127 -b o a r d component o f t h e h o s p i t a l , d i f f e r e n c e s w h i c h p r e s e n t r e a l b a r r i e r s t o p a r t i c i p a t i o n . F o r e x a m p l e , t h e power and a u t h o r i t y o f t h e m e d i c a l s t a f f a r e b a s e d on e x p e r t i s e . F o r t h e a d m i n i s t r a t o r s , t h e power i s o f t e n d e s i g n e d by t h e o r g a n i z a t i o n . F u r t h e r , p h y s i c i a n s a r e o r i e n t a t e d t o t h e p r o f e s s i o n a l s p e c i a l t i e s and p a t i e n t s r a t h e r t h a n t o t h e h o s p i t a l f o r t h e i r s o u r c e s o f c a r e e r r e w a r d s . A d m i n i s t r a t o r s , on t h e o t h e r h a n d , a r e o r i e n t a t e d t o t h e h o s p i t a l f o r t h e i r c a r e e r r e w a r d and a d v a n c e m e n t . I n a d d i t i o n , r e l a t i o n s h i p s among p h y s i c i a n s a r e more l i k e l y t o be c o l l e a g u a l and i n f o r m a l . F o r a d m i n i s t r a t o r s , r e l a t i o n s h i p s a r e more f o r m a l and b a s e d upon t h e s t r u c t u r e o f t h e o r g a n i z a t i o n . P h y s i c i a n s ' g o a l s a r e t r e a t m e n t - c e n t r e d , a d m i n i s t r a t o r s ' g o a l s f o c u s on o r g a n i z a t i o n m a i n t e n a n c e and e f f i c i e n c y . F i n a l l y , t h e w o r k -f l o w o f p h y s i c i a n s i s i n t e n s i v e - i t i n c o r p o r a t e s a v a r i e t y o f s k i l l s n e c e s s a r y t o t r e a t an i n d i v i d u a l p a t i e n t . I n c o n t r a s t , t h e w o r k f l o w o f a d m i n i s t r a t i o n i s d i f f u s e w i t h d i s p a r a t e v a l u e s , g o a l s , r e s o u r c e s and s t r a t e g i e s . Even w i t h t h e most a f f a b l e o f m e d i c a l s t a f f s t h e p o t e n t i a l f o r c o n f l i c t w i t h t h e b o a r d and a d m i n i s t r a t i o n i s s t r o n g . A b e n e f i c i a l a s p e c t o f t h i s i s t h a t s u c h c o n f l i c t may be n e c e s s a r y , o r g a n i z a t i o n a l l y h e a l t h y , and s o c i a l l y u s e f u l . I t seems l i k e l y t h a t a l l t h e s e r e a c t i o n s , and p r o b a b l y o t h e r s a s y e t u n f o r e s e e n , w i l l c o n t i n u e t o be e n c o u n t e r e d a s t i m e g o e s o n , v a r y i n g f rom p l a c e t o p l a c e and i n some c a s e s , f r o m d o c t o r t o d o c t o r . In a t t e m p t i n g t o b r i d g e some o f t h e s e e x i s t i n g - 128 -d i f f e r e n c e s , a number o f h o s p i t a l s o f medium and l a r g e s i z e have e s t a b l i s h e d a p o s i t i o n of m e d i c a l d i r e c t o r . However , t h i s may n o t be s u f f i c i e n t t o overcome b a r r i e r s o f p a r t i c i p a t i o n , g e n e r a l l y b e c a u s e t h e m e d i c a l d i r e c t o r i s o f t e n seen e i t h e r on one s i d e o r t h e o t h e r . The above s t a t e d r e a c t i o n s and d i f f e r e n c e s s u c h a s t r a i n i n g and o u t l o o k , a r e b a s i c a l l y t h o s e o f t u r f , e c o n o m i c s , and v e s t e d i n t e r e s t s and a r e t h e r e f o r e n e g o t i a b l e . However f a r h o s p i t a l s a r e f o r c e d t o s t r a y f rom t h e i r a c c u s t o m e d p a s t due t o r e s t r a i n t and c o m p e t i t i o n , i t i s l i k e l y t h e h o s p i t a l w i l l r e m a i n e s s e n t i a l l y a p l a c e where d o c t o r s w o r k . I t must be remembered t h a t a l o t o f p h y s i c i a n s have a h a r d t i m e i n t h e p r a c t i c e o f m e d i c i n e , e x c l u d i n g t h e p r e s s u r e o f mak ing i t f i n a n c i a l l y . The r e a s o n h a s t o be t h a t above e v e r y t h i n g e l s e , p h y s i c i a n s v a l u e t h e p r o f e s s i o n a l f r e e d o m t o make t h e i r own d e c i s i o n s a b o u t t h e i r own p a t i e n t s and t h e i r own p r a c t i c e . Some o f t h i s f r e e d o m h a s a l r e a d y v a n i s h e d i n t o t h e h o s p i t a l where c o l l e c t i v e d e c i s i o n s a r e made a b o u t t e c h n o l o g y , u t i l i z a t i o n and money, and t h a t makes t h e f reedom t h a t r e m a i n s t h e more t o be c h e r i s h e d and t h e more r e l u c t a n t l y t o be s u r r e n d e r e d . The b o a r d and a d m i n i s t r a t i o n must r e a l i z e t h a t t h e p h y s i c i a n must be a b l e t o s a t i s f y t h e i r p r e - e m i n e n t l o y a l t y t o t h e i r p r o f e s s i o n by t a k i n g l e a d e r s h i p i n t h e i r a r e a o f m e d i c a l e x p e r t i s e and k n o w l e d g e . The b o a r d and a d m i n i s t r a t i o n must v i e w t h e i r r o l e a s t h e v e h i c l e t h r o u g h w h i c h p h y s i c i a n s r e l a t e t h i s k n o w l e d g e and e x p e r t i s e t o t h e p e r f o r m a n c e and r e s u l t s o f t h e o r g a n i z a t i o n . - 129 -I t must a l s o be remembered t h a t t h e p r a c t i c e o f m e d i c i n e i s a bond between two p e r s o n s , b o t h o f whom b r i n g and t a k e away f e e l i n g s a s w e l l a s i n f o r m a t i o n . I n e v i t a b l y , t h e p a t i e n t - p h y s i c i a n bond i s s t r e t c h e d and s t r a i n e d by t h e u n a v o i d a b l e t e c h n o l o g i c a l and economic c o m p l e x i t i e s o f government r e g u l a t i o n s and h o s p i t a l manage-ment , and i t w i l l be f u r t h e r s t r e t c h e d and s t r a i n e d i n an e r a o f r e s t r a i n t . I n a d d i t i o n t o p r o f e s s i o n a l f r e e d o m and p a t i e n t c a r e r e s p o n s i b i l i t i e s , p h y s i c i a n s have an i m p l i e d r i g h t t o i n f l u e n c e h o s p i t a l management i n i t s p e r f o r m a n c e o f t h a t c a r e . P h y s i c i a n s seek a r o l e i n management t o f u l f i l l t h e i r o b l i g a t i o n s t o t h e i r p a t i e n t s , t o meet t h e i r p e r s o n a l l e g a l l i a b i l i t y , t o have c o n t r o l o f t h e u s e o f t h e i r t i m e , and t o r e t a i n c o n t r o l o v e r t e c h n o l o g y . The p h y s i c i a n s e e k s a c c e s s t o management f o r a f e e l i n g o f i n f l u e n c e o v e r t h e i r d e s t i n y . B a s e d on t h e i r p r o f e s s i o n a l p o s i t i o n , p a t i e n t c a r e r e s p o n s i b i l i t i e s , and " i m p l i e d r i g h t s " , t h e p h y s i c i a n i s t h e p r i n c i p a l medium t h r o u g h w h i c h t h e r e s o u r c e s o f t h e h o s p i t a l a r e made a v a i l a b l e t o t h e p a t i e n t s and a s s u c h a r e an e f f e c t i v e s t r a t e g i c weapon. P h y s i c i a n s p l a y t h r e e i m p o r t a n t advocacy r o l e s : 1. on b e h a l f o f t h e i r p a t i e n t s 2 . on b e h a l f o f good m e d i c a l p r a c t i c e 3. on b e h a l f o f t h e communi ty i n d e f i n i n g and m e e t i n g t h e h e a l t h c a r e n e e d s . To e n s u r e p h y s i c i a n ' s c o - o p e r a t i o n and l o y a l t y , t h e h o s p i t a l needs t o e n s u r e t h e p r e s e n c e o f t h o s e t h i n g s t h a t move - 130 -t h e p h y s i c i a n s p e e d i l y and e f f e c t i v e l y t h r o u g h t h e h o s p i t a l . S i n c e h o s p i t a l s do n o t d i r e c t l y c h a r g e p h y s i c i a n s who u s e h o s p i t a l s e r v i c e s , i t i s e a s y f o r h o s p i t a l s t o o v e r l o o k and n e g l e c t p a y i n g a t t e n t i o n t o t h e " p r i c e " o f s e r v i c e s t h a t p h y s i c i a n s o f f e r t o h o s p i t a l s . P h y s i c i a n s ' b a s i c commodi ty i s t h e i r p r o f e s s i o n a l t i m e , so a h o s p i t a l ' s p a r t i c i a p t i o n r e q u i r e m e n t s , s u c h a s c o m m i t t e e w o r k , a s a f u n c t i o n o f m e d i c a l s t a f f membersh ip , a r e a d i r e c t c o s t o f b u s i n e s s f o r p h y s i c i a n s . A h o s p i t a l must d e t e r m i n e how i t c a n m i n i m i z e t h i s c o s t f o r p h y s i c i a n s . P e r h a p s i t c a n i n t e r m s o f t h e t i m e r e q u i r e d , o f c o n v e n i e n c e a f f o r d e d t o t h e p h y s i c i a n s , o r o f p u b l i c o r o t h e r r e c o g n i t i o n f o r e f f o r t s made i n p a r t i c i p a t i o n . Such t h i n g s a s p a r k i n g p r i v i l e g e s , c o n v e n i e n t d i c t a t i n g f a c i l i t i e s , and w e l l - s c h e d u l e d o p e r a t i n g room t i m e s a r e c r i t i c a l . A c c e s s i b i l i t y , e v i d e n c e o f f o l l o w - t h r o u g h and f e e d - b a c k , and a c l e a r i n d i c a t i o n o f r e c e p t i v e n e s s t o p h y s i c i a n i n p u t a r e m u s t s t o e n s u r e t h e r e c i p r o c a l o b l i g a t i o n s o f m a i n t e n a n c e o f c l i n i c a l c o m p e t e n c e , t h e a s s u r a n c e o f a p p r o p r i a t e c o m m u n i c a t i o n s , and t h e m e e t i n g o f h o s p i t a l " c i t i z e n s h i p " . P h y s i c i a n s name n u r s i n g a s t h e number one s e r v i c e t h a t t h e y e x p e c t h o s p i t a l s t o p r o v i d e . The d i f f i c u l t y o f s t r u c t u r i n g t h i s s e r v i c e t o meet p h y s i c i n s ' needs i s c o m p l i c a t e d by t h e d i f f e r e n c e s between p h y s i c i a n s ' and n u r s e s ' p e r c e p t i o n s o f n u r s i n g . A n o t h e r way i s t o g i v e c a r e f u l c o n s i d e r a t i o n t o i t s a c t i v i t i e s t h a t m i g h t be p e r c e i v e d by i t s m e d i c a l s t a f f a s e n g a g i n g i n d i r e c t c o m p e t i t i o n w i t h t h e i r p r i v a t e p r a c t i c e o f m e d i c i n e . T r a d i t i o n a l h o s p i t a l o u t p a t i e n t c l i n i c s g e n e r a l l y a r e n o t p e r c e i v e d a s b e i n g i n d i r e c t c o m p e t i t i o n w i t h m e d i c a l s t a f f members. However , i f a h o s p i t a l engages i n p r i m a r y c a r e , i t i s g o i n g t o be p e r c e i v e d a s b e i n g engaged i n d i r e c t c o m p e t i t i o n w i t h i t s own s t a f f members. D i a g n o s t i c and t r e a t m e n t s e r v i c e s c o n s t -i t u t e a p o t e n t i a l a r e a f o r c o n f l i c t between a h o s p i t a l and i t s m e d i c a l s t a f f members. R e l a t i v e l y few p h y s i c i a n s i n p r i v a t e p r a c t i c e a r e g o i n g t o i n v e s t i n h i g h t e c h n o l o g y and c a p i t a l -i n t e n s i v e s e r v i c e s , such a s C . T . S c a n n e r s , i n t h e i r p r i v a t e o f f i c e s e t t i n g s . However , some p h y s i c i a n s , p a r t i c u l a r l y t h o s e i n g r o u p p r a c t i c e s , a r e i n v e s t i n g i n an i n c r e a s i n g a r r a y o f d i a g n o s t i c and t r e a t m e n t s e r v i c e s o f medium c a p i t a l i n t e n s i t y a s a l l o w e d by r e g u l a t i o n s on p r i v a t e l a b o r a t o r i e s . I n what ways c a n t h e h o s p i t a l , w i t h i t s h e a v y i n v e s t m e n t i n t h e s e s e r v i c e s , make i t a t t r a c t i v e f o r t h e p h y s i c i a n s t o c o n t i n u e t o buy them f r o m t h e h o s p i t a l r a t h e r t h a n t o b u i l d them i n t o t h e i r p r a c t i c e s ? I n p a t i e n t c a r e may seem t o be an u n l i k e l y a r e a f o r c o m p e t i t i o n between t h e p r i v a t e p r a c t i t i o n e r s and t h e h o s p i t a l . However , p r i v a t e p r a c t -i t i o n e r s m i g h t see t h e g r o w t h i n numbers and v a r i e t y o f s p e c i a l i s t s who h a v e p r i v i l e g e s w i t h t h e h o s p i t a l a s d i r e c t c o m p e t i t i o n between o f f i c e - b a s e d m e d i c a l p r a c t i c e and h o s p i t a l c a r e . F i f t e e n y e a r s ago a h o s p i t a l may have had r e l a t i o n s h i p s w i t h a n a e s t h e s i o l o g i s t s , r a d i o l o g i s t s , and p a t h o l o g i s t s . Now, i t may have such a r r a n g e m e n t s w i t h n o t o n l y more o f t h e s e s p e c i a l i s t s , b u t a l s o w i t h emergency d e p a r t m e n t p h y s i c i a n s ; c a r d i o l o g i s t s ; p u l m o n a r y d i s e a s e s p e c i a l i s t s s p e c i a l i s t s i n n u c l e a r m e d i c i n e and r e h a b i l i t a t i o n . T h i s a r r a y o f s p e c i a l i s t s may a c c o u n t , i n p a r t , f o r t h e d e c r e a s i n g number o f h o u r s t h a t o f f i c e - b a s e d p h y s i c i a n s r e p o r t t h e y a r e p r a c t i c i n g i n h o s p i t a l s . ( 2 2 ) P h y s i c i a n s w i l l be more o r l e s s s a t i s f i e d w i t h t h e - 132 -h o s p i t a l d e p e n d i n g on t h e s a t i s f a c t i o n o f t h e i r p a t i e n t s , t h e i r own a s s e s s m e n t o f t h e h o s p i t a l e n v i r o n m e n t , how e a s y t h e y a r e a b l e t o a s s o c i a t e w i t h t h e h o s p i t a l , and t h e i r c o m f o r t w i t h a d m i n i s t r a t i o n ' s management s t y l e . B e c a u s e o f t h e i r t r e a t m e n t s k i l l s and k n o w l e d g e , p h y s i c i a n s w i l l r e t a i n a paramount p o s i t i o n i n t h e p r o v i s i o n o f h e a l t h s e r v i c e s f o r a t l e a s t t h e n e x t 10 y e a r s . P h y s i c i a n s d e t e r m i n e who w i l l r e c e i v e h e a l t h s e r v i c e s ; when , how and where t r e a t m e n t w i l l be p r o v i d e d ; and what k i n d o f t r e a t m e n t w i l l be p r o v i d e d . They a r e t h e p r i m a r y " c u s t o m e r s " o f h e a l t h s e r v i c e s , w h e r e a s p a t i e n t s a r e t h e " e n d " u s e r s . T h u s , p h y s i c i a n s ' j u d g e m e n t s w i l l d e t e r m i n e r e s o u r c e a l l o c a t i o n s i n v e r t i c a l l y i n t e g r a t e d h e a l t h c a r e s y s t e m s . In f a c t , no h e a l t h c a r e o r g a n i z a t i o n c a n p r o s p e r u n l e s s i t h a s r e c o g n i z e d t h a t , a l t h o u g h i t s managers make p r o n o u n c e m e n t s , i t s p h y s i c i a n s make t h e u l t i m a t e d e c i s i o n s a s p a r t o f t h e i r p r o f e s s i o n a l commitment . I t g o e s w i t h o u t s a y i n g t h a t t h e m e d i c a l s t a f f s h o u l d be c a r e f u l l y p r e p a r e d r e g a r d i n g t h e p l a n n i n g p r o c e s s . The C . E . O . s h o u l d u s e t h e i r m a n a g e r i a l s k i l l s t o see t h a t t h e a p p r o p r i a t e s t a f f member i s s e l e c t e d a s t h e m e d i c a l s t a f f r e p r e s e n t a t i v e on t h e p l a n n i n g team. T h i s p h y s i c i a n must have t h e r e s p e c t o f h e r o r h i s p e e r s and be w i l l i n g and o b j e c t i v e enough t o f u l l y p a r t i c -i p a t e i n t h e p l a n n i n g p r o c e s s . To h e l p make t h i s p a r t i c i p a t i o n p o s s i b l e , some c o n s i d e r a t i o n c o u l d be g i v e n t o p a y i n g ^ t h e p h y s i c i a n f o r s t a f f t i m e c o n t r i b u t e d t o t h e p l a n n i n g p r o c e s s . Make no m i s t a k e , t h e m e d i c a l s t a f f w i l l be a p o w e r f u l f o r c e e i t h e r i n h i n d e r i n g o r h e l p i n g t h e h o s p i t a l ' s p l a n n i n g p r o c e s s . / - 133 -T h e r e h a s n e v e r been a g r e a t e r need f o r c o - o p e r a t i o n between h o s p i t a l s and m e d i c a l s t a f f . D o c t o r s need h o s p i t a l s and h o s p i t a l s need d o c t o r s . T h i s h a s been t r u e f o r a c o n s i d e r a b l e t i m e , and w i l l be t r u e i n t o t h e f u t u r e . The r e l a t i o n s h i p between t h e h o s p i t a l and i t s m e d i c a l s t a f f i s a s y m b i o n i c o n e ; ' ; i f t h e h o s p i t a l i s t o s u r v i v e and p r o s p e r , so must i t s m e d i c a l s t a f f . H o s p i t a l s i n t o d a y ' s t r o u b l e d e n v i r o n m e n t c a n no l o n g e r t a k e t h e i r m e d i c a l s t a f f f o r g r a n t e d and must do e v e r y t h i n g p o s s i b l e t o i m p r o v e t h e i r somet imes t e n s e r e l a t i o n s h i p w i t h them. A d v e r s a r y r e l a t i o n s h i p s w i l l o n l y weaken t h e o r g a n i z a t i o n and l e a v e i t u n a b l e t o c o n f r o n t t h e p r o b l e m s and i s s u e s f a c i n g i t . A t t h i s p o i n t , t h e r e w i l l be no w i n n e r s be tween b o a r d , a d m i n i s t r a t i o n and m e d i c a l s t a f f d i s p u t e s . I f t h e d e l i v e r y o f h e a l t h a s we now know i t i s t o be p r e s e r v e d , p h y s i c i a n s , t r u s t e e s and a d m i n i s t r a t o r s must work t o g e t h e r more e f f e c t i v e l y and p u t a s i d e any d i f f e r e n c e s . The o r g a n i z e d m e d i c a l s t a f f i s t h e most v i t a l mechan ism i n t h e h o s p i t a l , e x i s t i n g a s a s o u r c e f o r s e l f - g o v e r n a n c e and a means o f c o m m u n i c a t i o n . I t i s o n l y t h r o u g h a s t r o n g , o r g a n i z e d , and i n t e r e s t e d s t a f f t h a t e f f e c t i v e c o m m u n i c a t i o n and a c t i o n c a n t a k e p l a c e . One p r e d i c t i o n seems s a f e : any c h a n g e w i l l be i n t r o -d u c e d more s u c c e s s f u l l y where t h e s t r a t e g i c p l a n had i n v e s t i g a t e d and j u d g e d t h e r e s p o n s e o f t h e p h y s i c i a n s and had most c a r e f u l l y p r e p a r e d f o r i t ' . ROLE OF THE CONSULTANT A t t i m e s i t may be n e c e s s a r y t o e n l i s t t h e a i d o f a c o n -s u l t i n g f i r m i n o r d e r t o a s s i s t w i t h s t r a t e g i c p l a n n i n g , e i t h e r a t t h e s t a r t i n g p o i n t o r a t some l a t e r d a t e . When t o b r i n g i n a c o n s u l t i n g f i r m depends on t h e a v a i l a b i l i t y o f s k i l l e d s t a f f , and t h e p e c u l i a r i t i e s o f t h e i n s t i t u t i o n ' s own p r o b l e m s and p l a n n i n g p r o c e s s . I n t h i s s e c t i o n , I w i l l assume t h a t t h e use o f a c o n s u l t -a n t i s i n d i c a t e d and t h a t a h o s p i t a l p l a n n e d and b u d g e t e d f o r t h i s a s s i s t a n c e w i t h i t s s t r a t e g i c p l a n n i n g . I n s e l e c t i n g a c o n s u l t i n g f i r m , s e v e r a l o b s e r v a t i o n s a r e r e l e v a n t : - w h a t i s t h e f i r m ' s r e p u t a t i o n ? whom h a s i t w o r k e d f o r and how w e l l h a s t h e c l i e n t done? a r e t h e y known and r e c o g n i z e d by y o u r p r o v i n c i a l h e a l t h a s s o c -i a t i o n and t h e M i n i s t r y o f H e a l t h ' s c o n s u l t a n t s a s s i g n e d t o y o u r h o s p i t a l ? - who a r e t h e i r s t a f f members t o be a s s i g n e d t o y o u r p r o j e c t ? how w e l l does t h e f i r m ' s p e r s o n a l i t y match w i t h y o u r i n s t -i t u t i o n ' s p e r s o n a l i t y ? a r e t h e c o n s u l t a n t s w i l l i n g t o t e a c h and d e v e l o p y o u r s t a f f and i n s t i t u t i o n t o f u r t h e r y o u r own s o p h i s t i c a t i o n and c a p -a b i l i t y i n p l a n n i n g ? H o s p i t a l s s h o u l d i n t e r v i e w more t h a n one c o n s u l t i n g f i r m . T h e r e i s a l o t o f c o n s u l t i n g t a l e n t a v a i l a b l e s o make s u r e y o u r d o l l a r s buy t h e b e s t f o r y o u r i n s t i t u t i o n . - 135 -An a s p e c t t o remember i n e n l i s t i n g t h e a i d o f a c o n s u l t a n t i s t h a t y o u may want t o c o n s i d e r i t an o n g o i n g a r r a n g e m e n t . When a c o n s u l t a n t i s g i v e n t h e o p p o r t u n i t y t o work w i t h a h o s p i t a l o v e r a p e r i o d o f , t i m e , t h e i r v a l u e i n c r e a s e s . To g i v e a c o n s u l t a n t o n l y a few weeks t o p r o d u c e . w r i t t e n p l a n s i s t o f o r c e them t o s p e n d t i m e on d o c u m e n t a t i o n r a t h e r t h a n a n a l y z i n g , i n f o r m i n g , a s s i s t i n g and c h a l l e n g i n g . A c o n s u l t a n t needs ample t i m e t o h e l p t h e h o s p i t a l f a c e r e a l i t y . The f i r s t t a s k o f t h e c o n s u l t a n t i s a l w a y s t o a s s e s s i n -p l a c e management. A q u i c k b u t t h o r o u g h a n a l y s i s o f k e y p e r s o n n e l i s e s s e n t i a l t o g a i n i n g an o p i n i o n o f t h e i r i n d i v i d u a l c a p a b i l i t i e s . A l l f u n c t i o n a l a r e a s s h o u l d b e r e v i e w e d f o r w e a k n e s s e s s and s t r e n g t h s . The p r o b l e m s as p e o p l e v i e w them s h o u l d be i d e n t i f i e d and r a t e d a c c o r d i n g t o t h e i r s e r i o u s n e s s . The p u r p o s e o f t h e c o n s u l t a n t ' s r o l e i s t o p r o v i d e a s s i s t -ance i n r e a c h i n g t h e c o n s e n s u s t h a t i s n e c e s s a r y f o r t h e h o s p i t a l ' s s t r a t e g i c p l a n n i n g . wThere a r e some g e n e r a l r u l e s t h a t s h o u l d a p p l y when a c o n s u l t a n t i s i n v o l v e d . I t i s i m p o r t a n t t h a t w h a t e v e r i s done , t h e r e i s v i s i b i l i t y a n d a c o n s u l t a n t must e s t a b l i s h t h e m s e l v e s q u i c k l y . M o s t p l a n n i n g i s o n l y a c c o m p l i s h e d f r o m a b a s e o f s o u n d i n f o r m a t i o n w h i c h , i f n o t a v a i l a b l e , must be s o u g h t o u t . The c o n s u l t a n t s h o u l d be a s k i n g h u n d r e d s o f q u e s t i o n s o f t h e a d m i n i s t r -a t i o n , b o a r d and t h e c o m m u n i t y . I n summary, c o n s u l t a n t s c a n p l a y many l e g i t i m a t e r o l e s , b u t a h o s p i t a l s h o u l d be c a u t i o u s a b o u t u s i n g a c o n s u l t a n t t o d e s i g n and i n s t a l l a p l a n n i n g s y s t e m and t o p r e p a r e p l a n s . G e n e r a l l y , t h i s a p p r o a c h w i l l n e i t h e r a s s i s t t h e h o s p i t a l ' s management p r o c e s s n o r d e v e l o p a s e n s e o f commitment t o and o w n e r s h i p o f t h e p l a n s . - 136 -C o n s u l t a n t s s h o u l d be u s e d as s o u n d i n g b o a r d s b u t t h e y s h o u l d n o t do y o u r p l a n n i n g f o r y o u . Once t h e p l a n e m e r g e s , i t must be t h e c o i t i m i t t e e ' s o r t h e b o a r d ' s . I t must be v i e w e d as an o r i g i n a l , a u t h o r e d b y y o u r h o s p i t a l and b e l i e v e d i n by y o u r s t a f f and c o m m u n i t y . - 137 -THE ROLE OF P O L I T I C S "A Q u e s t i o n o f D e c e n t r a l i z e d VS C e n t r a l i z e d " An i m p o r t a n t g e n e r a l i t y t h a t p r o b a b l y h a s n o t y e t been f u l l y g r a s p e d i s t h a t h e a l t h c a r e i s no l o n g e r j u s t t h e a r t o f h e a l i n g t h e s i c k o r p r e v e n t i n g t h e w e l l f r o m g e t t i n g i l l . To p r o v i d e h e a l t h c a r e e f f e c t i v e l y now r e q u i r e s a h o s p i t a l t o a p p r e c i a t e t h a t i t i s d e e p l y enmeshed i n p o l i t i c s . I t i s no l o n g e r p o s s i b l e f o r a h o s p i t a l t o p r o v i d e good h e a l t h c a r e w i t h o u t h a v i n g good r e l a t i o n s h i p s w i t h v a r i o u s government d e p a r t m e n t s and p o l i t i c i a n s . F u n d i n g and r e g u l a t o r y agency s t a f f o f t e n a r e a s c o n f u s e d and c o n c e r n e d a s h o s p i t a l s a r e a b o u t how t o b e s t r e s o l v e p l a n n i n g d i l e m m a s . You w i l l be most s u c c e s s f u l i n h o s p i t a l p l a n n i n g i f you r e c o g n i z e t h a t t h i s s i t u a t i o n i s an o p p o r t u n i t y and i f you a t t e m p t t o c r e a t e an e n v i r o n m e n t f o r r e c e p t i v i t y t o y o u r i d e a s and t o o f f e r g o o d , a l t e r n a t i v e i d e a s . C r e a t i n g an e n v i r o n m e n t f o r r e c e p t i v i t y i n c l u d e s b e i n g p e r c e i v e d a s a r e s p e c t e d r e s o u r c e by t h e a g e n c i e s and b e i n g p o l i t i c a l l y a d e p t . B o a r d and management must h a v e t h e c a p a c i t y , r e s p o n s i b i l i t y , and a u t h o r i t y t o be a b l e t o a p p r o a c h t h e government on any p r o b l e m o r i s s u e . However , i t i s d e s i r e d by gove rnment h e a l t h o f f i c i a l s t o meet w i t h o r g a n i z a t i o n s r e p r e s -e n t i n g a number o f h o s p i t a l s r a t h e r t h a n w i t h i n d i v i d u a l h o s p i t a l s , t h e r e f o r e t h e b o a r d h a s a r e s p o n s i b i l i t y f o r d e v e l o p i n g good w o r k i n g r e l a t i o n s h i p s and i n f o r m a t i o n f l o w s w i t h i t s a s s o c i a t i o n . We must remember t h a t government o f f i c i a l s a r e i n need o f g o o d , s o l i d , f a c t u a l m a t e r i a l and i d e a s a b o u t how t o d e a l w i t h p r o b l e m s . They a r e t o t a l l y u n i n t e r e s t e d i n any t y p e o f s p e c i a l p l e a d i n g a p p r o a c h t h a t i s n o t a s s o c i a t e d w i t h a s o l u t i o n t o a p r o b l e m . - 138 -S t u d e n t s and p r a c t i t i o n e r s o f management who have c l o s e l y a n a l y z e d t h e r e l a t i o n s h i p o f h o s p i t a l s t o gove rnment a r g u e t h a t one o f t h e g r e a t e s t p r o b l e m s t h a t management e x h i b i t s i n i t s d e a l i n g s w i t h gove rnment i s that i t d o e s n o t have any s t r a t e g y a t a l l . Too o f t e n h o s p i t a l s c a n n o t d e c i d e w h e t h e r o r n o t t o r e s p o n d t o government i n i t i a t i v e and o f t e n by t h e t i m e t h e y d e c i d e t h e y s h o u l d do s o m e t h i n g , i t i s t o o l a t e t o be e f f e c t i v e . A word o f c a u t i o n i s t h a t t h e c e n t r a l gove rnment w i l l do e v e r y t h i n g we h e s i t a t e t o d o . B e c a u s e C a n a d i a n h o s p i t a l s o p e r a t e i n a gove rnment / t a x p a y e r funded e n v i r o n m e n t , t h e y c a n e i t h e r i n f l u e n c e government o r w a i t f o r government t o i n f l u e n c e them. I t i s e s s e n t i a l t h a t h o s p i t a l p e o p l e l e a r n t o p l a n w e l l b e f o r e t h e government p l a n n e r s g e t t h e message b e c a u s e someone h a s t o f i l l any vacuum i n p l a n n i n g . W h i l e i t i s e s s e n t i a l t h a t s t r o n g p o l i t i c a l t i e s be d e v e l o p -ed and m a i n t a i n e d , i t i s c r i t i c a l t h a t s t r a t e g i c p l a n n i n g be beyond t h e p o l i t i c a l t i d e s . S t r a t e g i c p l a n n i n g must r e m a i n w i t h t h e i n d i v i d u a l h o s p i t a l o r r e g i o n a l h o s p i t a l d i s t r i c t r a t h e r t h a n becoming a c e n t r a l i z e d f u n c t i o n a t t h e p r o v i n c i a l h e a l t h l e v e l . I f s t r a t e g i c p l a n n i n g and p l a n n i n g i n g e n e r a l a r e i m p l e m e n t e d a t a p r o v i n c i a l l e v e l , t h e y may n o t be a b l e t o c o m p e n s a t e f o r t h e d i v e r s e l o c a l and communi ty n e e d s . A u n i f o r m l y s t r u c t u r e d p r o g r a m may n o t be s e n s i t i v e t o t h e needs and f o c u s o f i n d i v i d u a l c o m m u n i t i e s . S i m p l y p u t , s h o u l d t h e h o s p i t a l b o a r d and r e g i o n a l h o s p i t a l d i s t r i c t s w i t h t h e i r u n d e r s t a n d i n g o f l o c a l c o n d i t i o n s have t h e power t o make d e c i s i o n s f o r t h e i r h o s p i t a l and c o m m u n i t y , o r s h o u l d - 139 -t h e government w i t h i t s p r o v i n c i a l p e r s p e c t i v e , be a l l o w e d t o impose d e c i s i o n s on t h e h o s p i t a l and d i s t r i c t ? A t t h i s t i m e o f r e s t r a i n t and c h a n g i n g h e a l t h n e e d s , some l o c a l c o m m u n i t i e s have become s e n s i t i v e t o t h e i m p o r t a n c e o f h e a l t h p l a n n i n g . The i m p o r t a n c e o f a s t r o n g v o l u n t a r y p l a n n i n g p r o c e s s l i n k e d w i t h l o c a l d e c i s i o n - m a k i n g s t r u c t u r e s h a s i n c r e a s e d b e c a u s e o f t h e p o t e n t i a l f o r an a l t e r n a t i v e t h a t i s a h i g h l y r e g u l a t e d p l a n n i n g s y s t e m . The s e n s i t i v i t y i s t h a t no p l a n n i n g s t r u c t u r e , no m a t t e r how a d e q u a t e l y f u n d e d o r empowered t h r o u g h s t a t u t o r y o r o t h e r means, c a n s t i m u l a t e a c o s t - e f f e c t i v e a l l o c a t i o n o f h e a l t h r e s o u r c e s u n l e s s i t i s a c c e p t e d by t h e l o c a l communi ty and u n l e s s i t c a n s u p p o r t t h e p l a n n i n g p r o c e s s o f i n d i v i d u a l h o s p i t a l s . S t r a t e g i c p l a n n i n g f o r a s m a l l communi ty h o s p i t a l c a n be d e s i g n e d t o h e l p c o r r e c t t h e d e f i c i e n c i e s i n c u r r e n t h e a l t h p l a n n i n g and to. r e d u c e t h e need f o r c e n t r a l i z e d p l a n n i n g . The l o c a l n a t u r e o f p l a n n i n g s h o u l d be s t r e s s e d t h r o u g h t h e r e c o g n i t i o n t h a t any l o c a l h e a l t h p l a n n i n g mechan ism must be d e s i g n e d by and a t l e a s t p a r t i a l l y funded by t h e communi ty i t s e r v e s . The l e a d e r s and d e c i s i o n - m a k e r s o f t h e p a r t i c u l a r community s h o u l d be i n v o l v e d i n d e c i d i n g what t y p e o f h e a l t h p l a n n i n g mechan ism, i f a n y , w i l l e x i s t i n t h e i r commun i t y . A c o m m u n i t y ' s p l a n n i n g mechanism and a u t h o r i t y s h o u l d be b a s e d on i t s e f f e c t i v e n e s s i n r e s p o n d i n g t o t h e communi ty and on t h e c r e d i b i l i t y o f i t s l e a d e r s h i p . To be e f f e c t i v e , , t h e c o m m u n i t y - b a s e d p l a n n i n g mechan ism must be i n t e g r a t e d w i t h t h e e x i s t i n g s o c i o e c o n o m i c and p o l i t i c a l s t r u c t u r e s o f t h e communi ty and p e r c e i v e d a s a c c e p t a b l e by t h e c o m m u n i t y ' s l e a d e r s and d e c i s i o n -m a k e r s . The r e g i o n a l h o s p i t a l d i s t r i c t s a r e an e x i s t i n g and n e a r l y - 110 -i d e a l mechan ism t o u s e . What i s needed t o c o m p l e t e t h e p r o c e s s i t t h e e n l i s t m e n t o f t h e " n o n - i n s t i t u t i o n a l " g r o u p s o r t h e c o m m u n i t y - b a s e d s e r v i c e s s u c h a s p u b l i c h e a l t h , m e n t a l h e a l t h , l o n g t e r m c a r e , homemaker, e t c . H o s p i t a l s must be a b l e t o w o r k w i t h t h e c o m m u n i t y - b a s e d p l a n n i n g mechan ism t o a c h i e v e c o s t - e f f e c t i v e a l l o c a t i o n o f r e s o u r c e s . The commitment by t h e p r o v i n c i a l government s h o u l d be t o t h e o v e r -r i d i n g p r i n c i p l e t h a t c o m m u n i t y - b a s e d p l a n n i n g and o t h e r mechanisms s h o u l d s t i m u l a t e and s u p p o r t t h e i n d i v i d u a l h o s p i t a l ' s s t r a t e g i c p l a n n i n g e f f o r t s t o meet q u a l i t y , a c c e s s , and p r o d u c t i v i t y o b j e c t -i v e s on a communi ty o r r e g i o n a l b a s i s . A c c e p t i n g t h i s p l a c e s a g r e a t d e a l o f r e s p o n s i b i l i t y on t h e i n d i v i d u a l f a c i l i t y t o e f f e c t -i v e l y p l a n and c o - o r d i n a t e p l a n s w i t h o t h e r h e a l t h c a r e p r o v i d e r s i n t h e c o m m u n i t y . • T h i s need t o c o - o r d i n a t e and c o - o p e r a t e i s a common s e n s e p o i n t , b u t one t o w h i c h a d h e r e n c e i s t h e e x c e p t i o n r a t h e r t h a n t h e r u l e . O b v i o u s l y , u n i t y among h o s p i t a l s on a l l i s s u e s i s i m p r a c t i c a l and i s p r o b a b l y n o t b e n e f i c i a l . However , t o t h e e x t e n t t h a t h o s p i t a l s r e c o g n i z e how t h e y o f t e n weaken t h e i r p o s i t i o n when t h e y p u b l i c l y d i s a g r e e w i t h one a n o t h e r , more agreement i n more c i r c u m s t a n c e s i s l i k e l y t o o c c u r . T h e r e a r e many i m p o r t a n t r e a s o n s f o r h o s p i t a l s t o s t r i v e f o r maximum u n i t y , p a r t i c u l a r l y i n p u b l i c a r e a s and on r e g u l a t o r y i s s u e s . I n some c a s e s , p u b l i c d i s a g r e e m e n t s a l l o w r e g -u l a t o r s t o p l a y one h o s p i t a l o f f a g a i n s t a n o t h e r i n o r d e r t o a c h i e v e t h e i r o b j e c t i v e s w i t h o u t h a v i n g t o be a c c o u n t a b l e o r h a v i n g t o b u i l d a s u f f i c i e n t c a s e t o j u s t i f y t h e i r o b j e c t i v e s . The o v e r a l l p o s i t i o n s o f t h e h o s p i t a l i n d u s t r y i s weakened b e c a u s e t h e ; r e g u l a t o r s - 141 -d i s c o u n t f u t u r e p o s i t i o n s t a t e m e n t s on b e h a l f o f t h e i n d u s t r y . I t i s i m p o r t a n t f o r h o s p i t a l s t o be u n i t e d a s much a s p o s s i b l e b e c a u s e , p a r t i c u l a r l y i n j o i n t p l a n n i n g , u n i t y c a n m i n i m i z e e x t e r n a l r e g -u l a t i o n . The q u e s t i o n o f when u n i t y among h o s p i t a l s i s p o s s i b l e i s much more d i f f i c u l t t o answer t h a n t h e q u e s t i o n o f why u n i t y i s i m p o r t a n t . Some i s s u e s a r e so i n c o n s e q u e n t i a l t h a t h o s p i t a l s a r e n o t g o i n g t o r e a c h agreement w i t h t h e i r m a j o r c o m p e t i t o r s under any c i r c u m s t a n c e s . The s t a r t i n g p o i n t f o r i n c r e a s i n g u n i t y i s t o i d e n t i f y a r e a s i n w h i c h i t i s more p o s s i b l e and t h e n t o p romote t h o s e a r e a s . The f o l l o w i n g c r i t e r i a a r e a s t a r t i n g p o i n t f o r d e t e r m i n i n g i s s u e s t h a t l e n d t h e m s e l v e s t o a u n i f i e d p u b l i c p o s t u r e by h o s p i t a l s . I n o t h e r w o r d s , t h e p o t e n t i a l f o r u n i t y i n c r e a s e s a s ; : t h e i m p a c t o f t h e i s s u e i s more l o n g t e r m i t i s n o t c l e a r s p e c i f i c a l l y w h i c h i n s t i t u t i o n s w i l l be a f f e c t e d and i n what e x a c t way i t a p p e a r s t h a t t h e i m p a c t w i l l be a r b i t r a r y so t h a t a l l h o s p i t a l s h a v e r e l a t i v e l y e q u a l c h a n c e s o f b e i n g a f f e c t e d t h e i s s u e i s " l e s s t a n g i b l e " . F o r e x a m p l e , h o s p i t a l s more l i k e l y w i l l s u p p o r t b o t t o m - u p p l a n n i n g t h a n a p a r t i c u l a r bed number d e v e l o p e d by t h e i r m i n i s t r y o f h e a l t h e f f o r t s a r e p r o a c t i v e a t t e m p t s t o b u i l d new i d e a s i n t o t h e s y s t e m r a t h e r t h a n s t r i c t l y r e a c t i v e r e s p o n s e s t o c u r r e n t t h r e a t s t h e i s s u e t h r e a t e n s t h e f i n a n c i a l v i a b i l i t y o f h e a l t h c a r e i n s t i t u t i o n s i n g e n e r a l . I t i s a l s o f e l t t h a t p l a n n i n g and r e g u l a t o r y p r o c e s s e s s h o u l d be f o r m a l l y s e p a r a t e . T h u s , i f t h e p r o v i n c i a l g o v e r n m e n t i s p r o v i d i n g t h e r e g u l a t i o n and f u n d i n g , t h e y s h o u l d n o t be i n v o l v e d i n t h e p l a n n i n g . The d e s i r e t o c r e a t e e f f e c t i v e r e l a t i o n s h i p s w i t h g o v e r n m e n t s must n o t p r e c l u d e t h e f a c t t h a t t h e r e a r e t i m e s when h o s p i t a l s must abandon t h e more g e n t l e m a n l y , r e a s o n a b l e t a c t i c s and t u r n p o l i t i c -a l l y a g g r e s s i v e ; a g g r e s s i v e enough t o g a i n p u b l i c s u p p o r t and f o r c e t h e g o v e r n m e n t t o back down on c l o s u r e s o r b u d g e t r e s t r i c t i o n s . I t may be t h e t i m e t h a t h o s p i t a l s l e a r n t h e l e s s o n t h a t i f t h e y e x p e c t t o w i n any c o n c e s s i o n s f r o m t h e p o l i t i c a l a r e n a , t h e y a r e g o i n g t o h a v e t o p l a y t h e game by t h e p o l i t i c a l r u l e s . H o s p i t a l s may have t o p r e s e n t t h e i r s i d e o f t h e p r o b l e m t o t h e p u b l i c b e c a u s e t h e p u b l i c , o r more a c c u r a t e l y , t h e v o t e r , i s t h e f i n a l j u d g e . I f t h e . p o l i t -i c i a n b e l i e v e s t h e p u b l i c d o e s n o t a p p r o v e h i s a c t i o n s , he s h o u l d r e v i e w h i s t o r y . When n a t i o n a l h e a l t h c a r e came i n , i t was an e l e c t i o n v o t e g e t t e r , b u t t h e r e i s a n o t h e r s i d e t o t h i s p o l i t i c a l c o i n t h a t c a n l o s e v o t e s . I f h o s p i t a l s c l o s e b e d s , and t h e p u b l i c i s . u n d u l y d i s t u r b e d , i t means a l o s s o f v o t e s . Why t h i s i s n ' t o b v i o u s t o h o s p i t a l s and why t h e y d o n ' t t a k e a d v a n t a g e o f t h i s s i t u a t i o n i s q u i t e s i m p l e . Most h o s p i t a l s a r e under i n c r e a s i n g budge t p r e s s u r e and a r e i n t e r e s t e d i n o n l y one t h i n g : s u r v i v a l . They have t h e i r own i n t e r n a l p o l i t i c a l p r o b l e m s w i t h o u t t a k i n g on t h e g o v e r n m e n t , and t h e y u s u a l l y r e a c t a s i n d i v i d u a l s r a t h e r t h a n a s a g r o u p t h r o u g h t h e i r a s s o c i a t i o n . - 143 -Whatever p o l i t i c a l s t a n c e i s t a k e n , i t must be remembered t h a t when d e v e l o p i n g s t r a t e g i e s t o meet s o c i a l , p o l i t i c a l and e c o n o m i c p o l i c i e s s e t by t h e s e n i o r g o v e r n m e n t , t h e g u i d i n g p r i n c i p l e must a l w a y s b e , i f a t a l l p o s s i b l e , t o keep t h e g o a l s o f t h e h o s p i t a l i n r e a s o n a b l e c o n g r u e n c e w i t h t h e g o a l s o f s o c i e t y . I n summary, t h e p r i m a r y l o y a l t y o f any c o m m u n i t y - b a s e d p l a n n i n g mechanism must be t o t h e community a t l a r g e and n o t t o any one f a c i l i t y o r s p e c i a l i n t e r e s t g r o u p . Even i n an e r a o f r e s t r a i n t , l i m i t e d r e s o u r c e s , and somet imes i n c r e a s e d c o m p e t i t i o n , t h e comm-u n i t y h a s an i n t e r e s t i n t h e outcome o f h e a l t h s e r v i c e s and t h a t i n t e r e s t r e v o l v e s a r o u n d what happens t o a l l o f t h e p e o p l e i n t h e c o m m u n i t y , and t h e h e a l t h c a r e s y s t e m ' s r o l e i n t h e c o m m u n i t y ' s economic and p o l i t i c a l s t r u c t u r e . I t must r e m a i n c l e a r i n t h e t r u s t e e s ' e y e s t h a t t h e i r r e s p o n s -i b i l i t y i s t o see t h a t t h e p u r p o s e and t h e m o t i v a t i n g f o r c e o f t h e h o s p i t a l a r e and r e m a i n t h e i m p r o v e d h e a l t h and w e l l - b e i n g o f t h e p u b l i c and t h a t a l l o f t h e i r g o a l s and o b j e c t i v e s a s s o c i a t e d w i t h t h e h o s p i t a l a r e s u b o r d i n a t e t o t h a t p u r p o s e . When t h i s o c c u r s , t h e r e s t o f t h e h o s p i t a l w i l l u n d e r s t a n d t h a t t h e t r u s t e e s must be a b l e t o f u n c t i o n a s p u b l i c r e p r e s e n t a t i v e s and must p u t t h e h s o p i t a l ' s m i s s i o n , t h a t b e i n g b e t t e r p u b l i c h e a l t h , ahead o f i t s own s u r v i v a l . - 144 -I N V I S I B L E FACTORS I n h e r e n t i n e v e r y p l a n n i n g d e c i s i o n i s an e l e m e n t o f c h o i c e . M a n a g e r s r e a l i z e t h a t t h e r e u s u a l l y a r e many o p t i o n s open t o an o r g a n i z a t i o n f o r d e a l i n g w i t h change and t h a t e a c h o p t i o n h a s c e r t a i n a d v a n t a g e s and d i s a d v a n t a g e s . L i k e so much o f l i f e , good management and sound p l a n n i n g depend on knowing how t o c h o o s e w e l l ; b u t , a s everyone knows , mak ing a good c h o i c e s e l d o m i s e a s y . I t i s p a r t i c u l a r l y d i f f i c u l t when i t i n v o l v e s s e l e c t i n g t h e b e s t o p t i o n t o g u i d e an o r g a n i z a t i o n t h a t i s a s c o m p l e x and a s s o c i a l l y r e l e v a n t a s a h o s p i t a l i s . C h o o s i n g w i s e l y i m p l i e s s o m t h i n g more t h a n r a t i o n a l i t y o r s e l e c t i n g an a c t i o n t h a t i s b e s t s u i t e d t o a c h i e v i n g a d e s i r e d r e s u l t , o r a p p r a i s i n g t h e r i s k t h a t a p r o p o s e d a c t i o n i n t e r m s o f what c a n be done t o r e s p o n d to o p p o r t u n i t i e s and t h r e a t s . C h o o s i n g w i s e l y h a s an e t h i c a l a s p e c t t h a t r e f l e c t s n o t o n l y t h e p e r s o n a l p r e f e r e n c e s and v a l u e s o f t h e i n d i v i d u a l s who make t h e c h o i c e b u t a l s o t h e s h a r e d b e l i e f s , m o r a l s t a n d a r d s , s o c i e t a l r e s p o n s i b i l i t i e s , and a c k n o w l e d g e d o b l i g a t i o n s o f t h e o r g a n -i z a t i o n i n w h i c h t h e y o p e r a t e . The b a s i c q u e s t i o n s i m p l y i s "What s h o u l d t h e o r g a n i z a t i o n d o ? " o r b e t t e r s t i l l , "What i s t h e • r i g h t " t h i n g f o r i t t o d o ? " E t h i c a l c o n s i d e r a t i o n s , e i t h e r i n d i v i d u a l o r o r g a n i z a t i o n a l , r a r e l y a r e d i s c u s s e d i n t h e l i t e r a t u r e on h o s p i t a l s t r a t e g i c p l a n n i n g . I n s t e a d , much o f t h e l i t e r a t u r e t h a t s u p p o r t s t h i s s t u d y h a s f o c u s e d on t h e r a t i o n a l e l e m e n t s o f t h e p r o c e s s - use and l i m i t a t i o n s o f d a t a , d e t e r m i n a t i o n o f communi ty need f o r h o s p i t a l beds and s e r v i c e s , - 145 -i d e n t i f i c a t i o n and r o l e s o f v a r i o u s p a r t i c i p a n t s , and o t h e r i m p o r t a n t m a t t e r s t h a t d e t e r m i n e how t h e p r o c e s s i s c a r r i e d o u t i n a h o s p i t a l s e t t i n g . T h i s f o c u s i s n o t enough - t h e r e a r e o v e r r i d i n g e t h i c a l and s o c i e t a l c o n s i d e r a t i o n s t h a t must be h e l d by t r u s t e e s , a d m i n -i s t r a t o r s , and o t h e r p a r t i c i p a n t s i n managing a h o s p i t a l ' s s t r a t e g i c p l a n n i n g e f f o r t s . In h o s p i t a l p l a n n i n g and management, c o n s i d e r a t i o n o f i n d i v i d u a l , o r g a n i z a t i o n a l , and s o c i e t a l v a l u e s i s c r u c i a l t o e n s u r i n g t h a t i n s t i t u t i o n s i n d i v i d u a l l y and c o l l e c t i v e l y f u l f i l l t h e e x p e c t a t i o n s and meet t h e h e a l t h c a r e needs o f t h e c o m m u n i t i e s t h a t t h e y s e r v e . O r g a n i z a t i o n s t h e m s e l v e s have v a l u e s y s t e m s and g o a l s . These s y s t e m s and g o a l s b o t h f o s t e r and l i m i t an o r g a n i z a t i o n ' s a c t i o n s . They d e t e r m i n e how t h e o r g a n i z a t i o n o p e r a t e s ( i t s s t y l e ) and how i t i n t e n d s t o d e a l w i t h t h e f u t u r e ( i t s s t r a t e g y ) . A l l o r g a n i z a t i o n s a r e r e s p o n s i b l e f o r t h e s o c i a l c o n s e q u e n c e s o f t h e i r a c t i o n s and a r e h e l d a c c o u n t a b l e f o r a c t i o n s t h a t v i o l a t e s o c i e t y ' s p r e v a i l i n g e t h i c a l c o d e s . B e c a u s e o f t h e n a t u r e o f t h e i r s e r v i c e s and t h e i r u n i q u e r o l e i n s o c i e t y , h o s p i t a l s a r e e x p e c t e d t o a d h e r e t o h i g h e r s t a n d a r d s o f e t h i c s , r e s p o n s i b i l i t y , and a c c o u n t a b i l i t y t h a n a r e b u s i n e s s o r o t h e r l e s s a l t r u i s t i c o r g a n i z a t i o n s . The p r o v i s i o n o f h o s p i t a l s e r v i c e s t r a d i t i o n a l l y h a s been b a s e d on and m o t i v a t e d by t h e c o n c e p t s o f " c h a r i t y " and " g i f t g i v i n g " . These c o n c e p t s c o n s t i t u t e a t r a d i t i o n a l v a l u e s t r u c t u r e ( o f t e n te rmed t h e J u d e o - C h r i s t i a n e t h i c ) t h a t d r i v e s t h e p r o v i s i o n o f b a s i c g o o d s and s e r v i c e s t h a t i n d i v i d u a l s r e q u i r e ... - 146 -t o s u r v i v e . - T h r o u g h o u t h i s t o r y , s o c i e t y has o r g a n i z e d what s o c i o l o g i s t s t e r m " s u s t e n a n c e o r g a n i z a t i o n s " i n o r d e r t o p r o v i d e t h e s e needed g o o d s and s e r v i c e s . A s s u s t e n a n c e o r g a n i z a t i o n s , h o s p i t a l s have an e s s e n t i a l s o c i a l m i s s i o n and p u r p o s e - t o e n s u r e t h e p u b l i c ' s g e n e r a l h e a l t h and w e l l - b e i n g t h r o u g h t h e p r o v i s i o n o f h e a l t h c a r e and r e l a t e d communi ty h e a l t h improvement s e r v i c e s . A t t h i s t i m e i n C a n a d i a n h i s t o r y , t h e p r o v i s i o n o f h o s p i t a l s e r v i c e s h a s an o b v i o u s economic d i m e n s i o n . The a v a i l a b i l i t y and u s e o f h o s p i t a l s e r v i c e s a r e b e i n g a f f e c t e d by economic c o n s i d e r a t i o n s . U n p r e c e d e n t e d a d v a n c e s i n m e d i c a l t e c h n o l o g y c a n s a v e l i v e s , b u t t h i s t o o p r o d u c e s c o m p l e x e t h i c a l q u e s t i o n s f o r h o s p i t a l s , p a t i e n t s , t h e c o m m u n i t y , and g o v e r n m e n t . What i s t h e v a l u e o f human l i f e ? When, i f e v e r , i s a l i f e n o t w o r t h s a v i n g ? Many renowned w r i t e r s h a v e e x t e n s i v e l y a d d r e s s e d t h e s e i s s u e s and t h e d i s c u s s i o n s t i l l p r e v a i l s . T h i s s t u d y o n l y b r i e f l y c o n s i d e r s t h e q u e s t i o n and p r e s e n t s t h e p o s i t o n t h a t a h o s p i t a l a s a " m o r a l a g e n t " c a n n o t c o n s i d e r t h e t o p i c o f c o s t b e n e f i t a n a l y s i s i n e t h i c a l q u e s t i o n s . Any p o l i c y s t a t e m e n t o r s t r a t e g i c p l a n i n v o l v i n g same w o u l d be " m o r a l l y i n d e f e n s i b l e " . A h o s p i t a l ' s e t h i c a l p o l i c y s h o u l d be embodied i n t h e s e r v i c e s i t c h o o s e s t o o f f e r o r d e n y . F o r e x a m p l e , you w i l l o f f e r h e m o d i a l y s i s t o a l l p a t i e n t s , o r n o t t o a n y . However , t h i s f a c t d o e s n o t mean t h a t s o c i e t y ' s v i e w o f t h e r o l e o f t h e h o s p i t a l has s h i f t e d f rom t h e c h a r i t a b l e e t h i c t o t h e e x c h a n g e e t h i c t h a t g o v e r n s most goods and s e r v i c e s i n a c o m p e t i t i v e , f r e e m a r k e t . - 147 -I n v i e w o f r e c e n t e c o n o m i c d e v e l o p m e n t s , w i l l h o s p i t a l s c h a n g e so much t h a t t h e y must a d o p t o t h e r v a l u e s , such a s t h e e x c h a n g e e t h i c , i n o r d e r t o s u r v i v e ? Would such a s h i f t i n v a l u e s be a c c e p t a b l e t o t h e p u b l i c s t h a t t h e y s e r v e ? B e c a u s e t h e s e q u e s t i o n s a r e so i m p o r t a n t i n t h e p l a n n i n g and f u t u r e management o f h o s p i t a l s e r v i c e s , t h e y m e r i t d i s c u s s i o n . Most p u b l i c o p i n i o n s t u d i e s show t h a t , d e s p i t e p e r s i s t a n t c o m p l a i n t s a b o u t h o s p i t a l c o s t s , f o o d , s c h e d u l e s , and o t h e r o p e r a t i n g m a t t e r s , t h e p u b l i c c o n t i n u e s t o have a h i g h r e g a r d f o r h o s p i t a l s and what t h e y s t a n d f o r . I t a l s o c o n t i n u e s t o v i e w h o s p i t a l s a s s u s t e n a n c e o r g a n i z a t i o n s and t h e r e a r e no s i g n s t h a t t h i s v i e w i s c h a n g i n g s i g n i f i c a n t l y . (Both t h e C H . A . and A . H . A . g u i d e -i n e s were d e v e l o p e d by and f o r t h e h o s p i t a l i n d u s t r y , b u t t h e y do seem t o r e f l e c t w i d e l y a c c e p t e d s o c i e t a l and communi ty v a l u e s . ) However , t h i s i n f o r m a t i o n d o e s n o t r e s o l v e t h e i s s u e o f w h e t h e r h o s p i t a l s must now a d o p t some o t h e r e t h i c i n o r d e r t o s u r v i v e i n what p r o m i s e s t o be a more f i n a n c i a l l y r e s t r i c t e d and d i f f i c u l t e n v i r o n m e n t . T h i s quest ion i s more d i f f i c u l t t o a n s w e r , a n d , i n d o i n g s o , i t may be h e l p f u l t o c o n s i d e r some r e c e n t w r i t i n g s on t h i s s u b j e c t . T i t m u s s h a s e x p l o r e d t h e i s s u e o f m e d i c a l c a r e b e i n g c o n s t r u e d a s a c o m m e r c i a l s e r v i c e r a t h e r t h a n a s a s u s t e n a n c e s e r v i c e . He n o t e d t h a t t r e a t i n g b l o o d t i s s u e a s a c o m m e r c i a l commodi ty r a i s e s some i m p o r t a n t e t h i c a l c o n s i d e r a t i o n s : "The m o r a l i s s u e s t h a t a r e r a i s e d e x t e n d f a r beyond t h e o r i e s o f p r i c i n g and t h e o p e r a t i o n s o f t h e m a r k e t p l a c e . M o r e -- 148 -o v e r , t h e y i n v o l v e t h e f o u n d a t i o n s o f p r o f e s s i o n a l f r e e d o m i n m e d i c a l c a r e and o t h e r s e r v i c e r e l a t i o n s h i p s w i t h p e o p l e , t h e c o n c e p t o f t h e h o s p i t a l and t h e u n i v e r s i t y a s n o n - p r o f i t - m a k i n g o r g a n i z a t i o n s , and t h e l e g a l d o c t r i n e i n t h e U n i t e d S t a t e s o f c h a r i t a b l e i m m u n i t y . C h a r i t y i n t h a t c o u n t r y w o u l d be s u b j e c t t o t h e same l a w s o f r e s t r a i n t and w a r r a n t y and h a v e t h e same f reedoms a s b u s i n e s s m e n i n t h e p r i v a t e m a r k e t . " (23) K i n z e r echoed t h i s v i e w i n h i s r e c e n t commentary o n c m p e t i t i o n a s a s t r a t e g y t o c o n t a i n h o s p i t a l c o s t s . (24) Even more r e c e n t l y , i n h i s r e v i e w and e x a m i n a t i o n o f t h e o n g o i n g d e b a t e on c o m p e t i t i o n i n h e a l t h c a r e , G i n z b e r g s a i d t h a t w h a t e v e r g a i n s may r e s u l t f r o m t h e p r o - c o m p e t i t i o n p r o p o s a l s a r e " p r o b l e m a t i c " and t h a t " r a t h e r t h a n s e e k i n g t o t r a n s f o r m t h e m u l t i - s e g m e n t e d h e a l t h c a r e m a r k e t i n t o one t h a t r e s e m b l e s t h e i d e a l i z e d mode l o f p e r f e c t c o m p e t i t i o n , h e a l t h c a r e r e f o r m e r s s h o u l d f o c u s on t h e i m p o r t a n t c h a l l e n g e s f a c i n g t h e h e a l t h c a r e f i e l d - s p e e d i n g t h e s h i f t o f r e s o u r c e s f rom i n p a t i e n t t o a m b u l a t o r y c a r e s e t t i n g s , e n s u r i n g t h a t t h e p o o r do n o t become v i c t i m s o f g o v e r n m e n t a l c u t b a c k s , d e v e l o p i n g a l t e r n a t i v e s t o dumping t h e aged i n t o n u r s i n g homes, and f i n d i n g a l t e r n a t i v e s o u r c e s o f f i n a n c i n g so t h a t h e a l t h s c i e n c e c e n t r e s and R & D r e c e i v e e s s e n t i a l r e s o u r c e s t o a d v a n c e t h e f r o n t i e r s o f k n o w l e d g e and t h e r a p e u t i c s . " (25 ) G i n z b e r g c o n c l u d e d t h a t h o s p i t a l s and t h e p u b l i c c o n t i n u e t h e i r p a s t commitment and match i t w i t h r e s o u r c e s t h a t s o c i e t y c a n a f f o r d t o i n v e s t i n needed h e a l t h c a r e s e r v i c e s . None o f t h i s d i s c u s s i o n i m p l i e s t h a t sound f i n a n c i a l s u p p o r t and p e r f o r m a n c e a r e n o t e s s e n t i a l t o e n s u r i n g t h a t h o s p i t a l s e f f e c t i v e l y s e r v e t h e i r c o m m u n i t i e s . H o s p i t a l s c a n go b r o k e i f t h e y a r e n o t managed i n a f i s c a l l y sound manner , and g o i n g b r o k e may n o t be i n t h e i r c o m m u n i t i e s ' b e s t i n t e r e s t , b u t t h i s i m p l i c a t i o n d o e s n o t mean t h a t h o s p i t a l s must be d r i v e n s o l e l y by f i n a n c i a l c o n s i d -e r a t i o n s o r by b o t t o m - l i n e p e r f o r m a n c e . B e f o r e d e v e l o p i n g s t r a t e g i e s and d e c i s i o n s , a h o s p i t a l must f i r s t d e t e r m i n e w h e t h e r i t s g o a l i s t o m a x i m i z e i t s f i n a n -c i a l w e l l - b e i n g s o l e l y o r t o p romote i t s c o m m u n i t y ' s more g e n e r a l b e n e f i t i n t h e u s e o f t h e h o s p i t a l . E x p l i c i t c o n s i d e r a t i o n o f t h e c o m m u n i t y ' s b e n e f i t h e l p s t o e n s u r e t h a t s o c i e t a l v a l u e s and e x p e c t a t i o n s a r e c o n s i d e r e d i n t h e d e c i s i o n - m a k i n g p r o c e s s . V a l u e s pe rmeate a h o s p i t a l ' s d e c i s i o n s n o t o n l y c o n c e r n -i n g w h i c h s e r v i c e s i t w i l l p r o v i d e b u t a l s o c o n c e r n i n g w h i c h p a t i e n t s i t w i l l s e r v e . V a l u e s a f f e c t t h e c o m p e t i t i v e / c o - o p e r a t i v e d e c i s i o n s t h a t h o s p i t a l s make i n r e l a t i o n t o o t h e r h o s p i t a l s and h e a l t h c a r e p r o v i d e r s . The c h a r i t a b l e e t h i c t h a t g o v e r n s t h e p r o v i s i o n o f h e a l t h c a r e s e r v i c e s t r a d i t i o n a l l y h a s e m p h a s i z e d t h e i m p o r t a n c e o f c o - o r d i n a t i o n among p r o v i d e r s t o m a x i m i z e t h e i r c o m m u n i t i e s ' b e n e f i t f rom t h e s e r v i c e s t h a t t h e y r e n d e r . Few h o s p i t a l s a r e w i l l i n g t o t a k e a c t i o n s t h a t w o u l d d e s t r o y o r s e r i o u s l y c r i p p l e n e i g h b o u r i n g i n s t i t u t i o n s . What i s t h e r e l e v a n c e o f t h i s d i s c u s s i o n f o r h o s p i t a l management and s t r a t e g i c p l a n n i n g ? E s s e n t i a l l y , i t i s e a s y f o r an i n s t i t u t i o n t o f o r g e t a b o u t v a l u e s and t h e i r i m p o r t a n c e when - 150 -i t f a c e s mount ing economic p r e s s u r e s , c o u n t e r v a i l i n g t e c h n o l o g i c a l p r e s s u r e s , and communi ty demands f o r i n c r e a s e d s e r v i c e s . N o n e t h e -l e s s , v a l u e s a r e i n t e g r a l t o e n s u r i n g t h e o n g o i n g " l e g i t i m a c y " o f e a c h h e a l t h c a r e i n s t i t u t i o n . The c o n c e p t o f " l e g i t i m a c y " i s a imed a t d e f i n i n g t h e b e h a v i o u r a l bounds w i t h i n w h i c h a h o s p i t a l , a s p a r t o f a l a r g e r s o c i o e c o n o m i c s y s t e m , c o n t i n u e s t o have r e l e v a n c e and meaning w i t h i n t h a t s y s t e m . A h o s p i t a l g e n e r a l l y h a s l i t t l e o r no i n f l u e n c e o v e r s o c i e t a l v a l u e s and e x p e c t a t i o n s ; h o w e v e r , i t h a s c o m p l e t e c o n t r o l o v e r how w e l l i t p e r f o r m s i n s a t i s f y i n g t h e s e v a l u e s and e x p e c t a t i o n s . A h o s p i t a l c a n become " i l l e g i t i m a t e " -t h a t i s , i t c a n f a i l t o be r e l e v a n t t o t h e l a r g e r s o c i o e c o n o m i c s y s t e m i f i t s p e r f o r m a n c e o f i t s p u r p o s e i s u n s a t i s f a c t o r y o r i t s p u r p o s e i s c o n t r a r y t o s o c i e t y ' s v a l u e s and e x p e c t a t i o n s . L o s s o f l e g i t i m a c y u s u a l l y r e s u l t s i n d e c l i n i n g p u b l i c s u p p o r t and e v e n t u a l l y r e s u l t s i n l o s s o f p h y s i c i a n s , , e m p l o y e e s and p a t i e n t L " . h o s p i t a l managers o f t e n must make d e c i s i o n s i n w h i c h s o c i e t y ' s e x p e c t a t i o n s must be t a k e n i n t o a c c o u n t . Now, e c o n o m i c p r e s s u r e s a r e c a u s i n g an i n c r e a s i n g number o f h o s p i t a l s t o f a c e " i n s t i t u t i o n a l s u r v i v a l " i s s u e s a s w e l l . However , a h o s p i t a l ' s l e g i t i m a c y may be a f f e c t e d when i n s t i t u t i o n a l s u r v i v a l i t s e l f becomes t h e e n d , r a t h e r t h a n t h e means t o t h e end (community s e r v i c e ) . I n 1930 , R u f u s Rorem n o t e d , " N i n e t y - o n e p e r c e n t o f t h e h o s p i t a l c a p i t a l h a s been p r o v i d e d by t h e p u b l i c , w i t h o u t e x p e c t a t i o n o f repayment o r b u s i n e s s r e t u r n on t h e i n v e s t m e n t . " (26) From t h i s c h a r i t a b l e b e g i n n i n g , t h e manner o f m e e t i n g t h e - 151 -f i n a n c i a l r e q u i r e m e n t s o f h o s p i t a l s h a s s h i f t e d f rom i n f o r m a l , l o c a l communi ty s o u r c e s t o more f o r m a l and i m p e r s o n a l . T h i s s h i f t and t h e r a p i d i n c r e a s e i n t h e c o m p l e x i t y o f h o s p i t a l o r g a n i z a t i o n p e r h a p s have c o n t r i b u t e d t o d e s e n s i t i z i n g h o s p i t a l s t o t h e i r communi ty r o o t s . Where t h e s e r o o t s a r e s t i l l s t r o n g , t h e y a r e s t r a i n e d by t h e m o u n t i n g e c o n o m i c p r e s s u r e s c o n f r o n t i n g h o s p i t a l s . I n t h e l o n g r u n , h o w e v e r , r e g a r d l e s s o f economic p r e s s u r e s , h o s p i t a l s ' s u r v i v a l a s v i a b l e s o c i a l i n s t i t u t i o n s w i l l be e n s u r e d o n l y t h r o u g h m a i n t a i n i n g l e g i t i m a c y - t h a t i s , by k e e p i n g s i g h t o f s o c i e t a l v a l u e s and e x p e c t a t i o n s . W h i l e t h e s e v a l u e s i n c r e a s i n g l y e m p h a s i z e t h e i m p o r t a n c e o f e f f i c i e n t management, t h e y a l s o c o n t i n u e t o be f i r m l v r o o t e d i n t r a d i t i o n s o f c h a r i t y i n t h e p r o v i s i o n o f h o s p i t a l s e r v i c e s . When h o s p i t a l s a r e a b l e t o match s o c i e t a l v a l u e s w i t h t h e o r g a n i z a t i o n a l g o a l s , and when t h e s e v a l u e s a r e s u p p o r t e d by t h e p e r s o n a l p r e f e r e n c e s and v a l u e s o f t h e h o s p i t a l ' s b o a r d and management, h o s p i t a l s a r e w e l l - p r e p a r e d t o d e a l w i t h t h e many o p p o r t u n i t i e s and t h r e a t s t h a t t h e y c e r t a i n l y w i l l f a c e i n t o d a y ' s t u r b u l e n t e n v i r o n m e n t . E v e r y o n e w i l l a g r e e t h a t p r e d i c t i n g w h e t h e r a h o s p i t a l w i l l g row and p r o s p e r i s a h i g h - r i s k game. S u c c e s s f u l h o s p i t a l s w i l l g i v e o f f c e r t a i n c l u e s a s t o t h e e x t e n t o f such t h i n g s a s a w r i t t e n s t r a t e g y , a s t a n d i n g c o m m i t t e e f o r s t r a t e g i c p l a n n i n g , d e t a i l p l a n n i n g m e c h a n i s m , a demanding b o a r d o f d i r e c t o r s , and s t r a t e g i c t h i n k e r s w i t h i n t h e o r g a n i z a t i o n . - 152 -The s u c c e s s f u l h o s p i t a l w i l l d e v e l o p s t r a t e g i e s t h a t w i l l p r e v e n t i t f r om b e i n g a t t h e mercy o f i t s e n v i r o n m e n t , t h a t t e n d t o s t a b i l i z e t h e e n v i r o n m e n t and p r o v i d e t h e h o s p i t a l w i t h some measure o f c o n t r o l o v e r key e n v i r o n m e n t a l f a c t o r s a l l t h e w h i l e m e e t i n g s o c i e t a l v a l u e s and e x p e c t a t i o n s . - 153 -CASE STUDY The communi ty and h o s p i t a l u s e d i n t h i s s t u d y a r e f a c t u a l . The C i t y o f R o s s l a n d , p o p u l a t i o n 4 0 0 0 , i s l o c a t e d a p p r o x i m a t e l y 8 km. w e s t o f T r a i l , p o p u l a t i o n 1 1 , 0 0 0 . I t i s a bedroom communi ty f o r T r a i l w i t h a b o u t 40% o f t h e l a b o u r f o r c e w o r k i n g f o r C o m i n c o , t h e w o r l d ' s l a r g e s t l e a d and z i n c s m e l t e r . The communi ty o f T r a i l s u p p o r t s two ma jo r m e d i c a l g r o u p s (95% o f t h e l o c a l p h y s i c i a n s a r e i n c l u d e d ) t h a t have a h i s t o r y o f c o m p e t i t i o n . R o s s l a n d s u p p o r t s two s m a l l g r o u p s (a one p h y s i c i a n p r a c t i c e and a g r o u p o f t h r e e ) , b o t h o f w h i c h have d i r e c t t i e s t o t h e T r a i l C l i n i c s . R o s s l a n d was o r i g i n a l l y i n c o r p o r a t e d i n 1897 and had a p o p u l a t i o n o f o v e r 10 ,000 d u r i n g t h e h e y d a y o f t h e m i n i n g i n d u s t r y . S i n c e t h a t t i m e , t h e R o s s l a n d p o p u l a t i o n h a s been s t e a d i l y d e c l i n i n g w i t h i n t e r m i t t e n t p e r i o d s o f g r o w t h . The d e c l i n e i n r e c e n t y e a r s h a s n o t a b a t e d a s between t h e two c e n s u s y e a r s 1966 t o 1976 t h e p o p u l a t i o n d e c l i n e d f rom 4 , 2 6 4 t o 3 , 7 1 6 . However , t h i s t r e n d may be r e v e r s i n g i t s e l f a s t h e most r e c e n t e s t i m a t i o n o f p o p u l a t i o n a s o f 1978 was a p p r o x i m a t e l y 3 , 9 0 0 . T h i s may be due t o t h e c o s t o f h o u s i n g and t h e u s a b l e l a n d w i t h i n t h e T r a i l a r e a , mak ing R o s s l a n d an a t t r a c t i v e a l t e r n a t i v e t o younger f a m i l i e s and r e t i r e e s who f o r m e r l y went t o t h e C o a s t , , b u t who c a n no l o n g e r a f f o r d t o . T h e r e a r e s m a l l c o m m u n i t i e s i n t h e - 154 -K o o t e n a y - B o u n d a r y H o s p i t a l D i s t r i c t and w h i l e t h e r e have been some p o p u l a t i o n s h i f t s among t h e c o m m u n i t i e s , t h e r e g i o n h a s e x p e r i e n c e d a s t a t i c g r o w t h p a t t e r n . S i n c e 1961 , t h e r e h a s been a s t e a d y d e c l i n e i n t h e p r e -s c h o o l (0 -4 ) and e l e m e n t a r y s c h o o l (5 -9 ) age g r o u p s , a g r a d u a l d e c l i n e i n t h e s e c o n d a r y s c h o o l ( 10 -19 ) age g r o u p s i n c e 1966 , and a g r a d u a l d e c l i n e i n t h e l a b o u r f o r c e (20 -64 ) age g r o u p . I n c o n t r a s t , t h e r e h a s been a s t e a d y i n c r e a s e i n t h e s e n i o r c i t i z e n (65+) age g r o u p s i n c e 1961 . B i r t h r a t e s have r e m a i n e d a l m o s t s t a t i c , b u t t h e d e a t h r a t e h a s i n c r e a s e d s l i g h t l y , a s w o u l d be e x p e c t e d w i t h an a g i n g p o p u l a t i o n . Compared w i t h t h e r e m a i n d e r o f t h e r e g i o n and t h e P r o v i n c e , t h e r a t e s a r e n o t s i g n i f i c a n t l y d i f f e r e n t . I n o v e r a l l t e r m s , n e i t h e r c h a n g e s i n d e a t h o r b i r t h r a t e s a r e s u f f i c i e n t t o a f f e c t n e t m i g r a t i o n , b u t t h e a g i n g o f t h e p o p u l a t i o n i s o f i n t e r e s t i n t e r m s o f t h e t y p e o f s e r v i c e s t h a t w i l l be r e q u i r e d . The h i s t o r y o f t h e M a t e r M i s e r i c o r d i a e H o s p i t a l h a s been p a r t o f R o s s l a n d ' s l i f e e v e r s i n c e i t s i n c e p t i o n i n 1896. I t was i n t h a t y e a r when t h e l o c a l p a r i s h p r i e s t w r o t e t o t h e S t . J o s e p h ' s C o n v e n t i n New J e r s e y r e q u e s t i n g t h a t S i s t e r s be s e n t t o e s t a b l i s h a much needed h o s p i t a l i n t h i s new m i n i n g camp. Two S i s t e r s d i d a r r i v e and f o r a t i m e were t h e o n l y f e m a l e s i n t h e camp. A s m a l l h o s p i t a l was e s t a b l i s h e d and m a i n t a i n e d by f e e s f r o m p a t i e n t s , a one d o l l a r a month p a y r o l l d e d u c t i o n f r o m each m i n e r , and o c c a s i o n a l c o l l e c t i o n s . The c a r i n g and s h a r i n g r e l a t i o n s h i p between town r e s i d e n t s and t h e h o s p i t a l was e s t a b l i s h e d f rom t h e b e g i n n i n g . I n t h e S p r i n g o f 1897 c o n s t r u c t i o n began on t h e p r e s e n t s i t e ; and t h e - 155 -new h o s p i t a l was opened i n J u n e , 1897. Land a c q u i s i t i o n s and fund r a i s i n g a l l o w e d f o r a d d i t i o n s t o be b u i l t i n 1899 and 1921. The p r e s e n t 41 bed f a c i l i t y and t h e N u r s e s R e s i d e n c e were i n i t i a t e d i n 1938 w i t h t h e new k i t c h e n and l a u n d r y w i n g b e i n g b u i l t i n 1953. New a d m i n i s t r a t i v e s p a c e was added i n 1965. I n 1969 t h e R o s s l a n d H o s p i t a l S o c i e t y was formed t o t a k e o v e r t h e r u n n i n g o f t h e h o s p i t a l f o l l o w i n g t h e d e p a r t u r e o f t h e S i s t e r s . A t t h e 1982 F o u r t e e n t h A n n u a l M e e t i n g , t h e membership s t o o d a t 296. S i n c e i t s modest b e g i n n i n g s 86 y e a r s a g o , t h e h o s p i t a l h a s p r o v i d e d i n v a l u a b l e s e r v i c e t o t h e c o m m u n i t y . I t h a s a l s o r e m a i n e d a s a s i g n i f i c a n t s o u r c e o f e c o n o m i c s t a b i l i t y , b e i n g t h e f o u r t h l a r g e s t e m p l o y e r w i t h an a n n u a l p a y r o l l i n e x c e s s o f $1.5 m i l l i o n . The f i r s t H o s p i t a l A u x i l i a r y was formed i n 1938, j o i n e d t h e B . C . H o s p i t a l A u x i l i a r i e s i n 1947, and h a s now grown t o 67 members i n 1982. They have been r e s p o n s i b l e f o r r a i s i n g a c o n s i d e r a b l e sum o f money o v e r t h e p a s t y e a r s o f s e r v i c e and have d o n a t e d a l o n g l i s t o f equ ipment and s u p p l i e s . The A u x i l i a r y i s an e x t r e m e l y a c t i v e and s u p p o r t i v e g r o u p w h i c h h a s t h e a b i l i t y o f g e n e r a t i n g communi ty s u p p o r t , and r a i s e s s i z e a b l e sums o f money t h r o u g h v a r i o u s a c t i v i t i e s and t h e o p e r a t i o n o f t h e i r T h r i f t Shop . The A u x i l i a r y P r e s i d e n t becomes a v o t i n g member o f t h e B o a r d o f T r u s t e e s . The B o a r d o f T r u s t e e s o f t h e M a t e r M i s e r i c o r d i a e H o s p i t a l were p r o u d o f t h e i r r e c o r d o f r e c o g n i z i n g community needs and a c t i v e l y i n i t i a t i n g c h a n g e s a c c o r d i n g l y . W h i l e t h e y b e l i e v e d t h a t p l a n n i n g i s p r i m a r i l y a b o a r d ' s r e s p o n s i b i l i t y , t h e y a r e a l s o p r o u d o f t h e i r r e c o r d o f s u p p o r t and a s s i s t a n c e i n t h e i m p l e m e n t a t i o n o f - 156 -p a s t M i n i s t r y ' s r e c o m m e n d a t i o n s : I n 1968 t h e o b s t e t r i c s , and n e o - n a t a l c a r e were moved t o t h e T r a i l R e g i o n a l H o s p i t a l b e c a u s e o f t h e r e c o g n i z e d p o t e n t i a l f o r s e r i o u s c o m p l i c a t i o n s and r e d u c e d u t i l i z a t i o n r a t e s . I n 1977 n i n e t e e n o f t h e M a t e r M i s e r i c o r d i a e H o s p i t a l a c u t e b e d s were c o n v e r t e d t o 15 e x t e n d e d c a r e b e d s , a g a i n t o meet communi ty and r e g i o n a l n e e d s . A t t h i s t i m e o u r r a t e d bed c a p a c i t y was r e d u c e d f r o m 4 5 t o 41. - A l s o i n 1977, t h e o u t d a t e d l a u n d r y f a c i l i t y was d i s m a n t l e d . The a v a i l a b l e s p a c e p r o v i d e d t h e o p p o r t u n i t y t o p l a n , d e v e l o p and i m p l e m e n t a much needed p h y s i o t h e r a p y d e p a r t m e n t w h i c h now s e r v i c e s t h e i n c r e a s i n g i n p a t i e n t and o u t p a t i e n t n e e d s . The l a u n d r y r e q u i r e m e n t s a r e now p r o v i d e d on a p u r c h a s e s e r v i c e s b a s i s f r o m t h e T r a i l R e g i o n a l H o s p i t a l . A l l t h e s e r e s p o n s e s and c h a n g e s were made by t h e B o a r d o f T r u s t e e s and s t a f f t o meet t h e n e e d s o f t h e communi ty and t h e R e g i o n , and t o a d a p t t o a d v a n c i n g m e d i c a l t e c h n o l o g y , m e a n w h i l e c o n t i n u i n g t o m a i n t a i n an a c t i v e a c u t e c a r e s e r v i c e f o r t h e R o s s l a n d c o m m u n i t y . I n M a r c h , 1980, t h e p e n d i n g r e t i r e m e n t o f t h e a d m i n i s t r a t o r and t h e c o n t i n u i n g e f f e c t s o f t h e 1979-1980 f i v e p e r c e n t f i s c a l c u t b a c k s - w h i c h were f u l l y c o m p l i e d w i t h - p r o v i d e d t h e B o a r d w i t h a u n i q u e o p p o r t u n i t y t o e v a l u a t e : 1. The o r g a n i z a t i o n s t r u c t u r e and e f f e c t i v e n e s s . 2. The communi ty n e e d s . 3. M a t e r M i s e r i c o r d i a e H o s p i t a l ' s r o l e . - 157 -F o l l o w i n g t h e r e t i r e m e n t o f t h e a d m i n i s t r a t o r , t h e M i n i s t r y o f H e a l t h " s u g g e s t e d " t o t h e B o a r d o f T r u s t e e s t h a t t h e y r e t a i n a c o n s u l t i n g f i r m t o p r o v i d e i n t e r i m a d m i n i s t r a t i o n and t o c o n d u c t an A d m i n i s t r a t i v e O v e r v i e w and R o l e S t u d y , w i t h f u n d i n g p r o v i d e d by t h e M i n i s t r y . The A d m i n i s t r a t i v e O v e r v i e w w o u l d a s s e s s t h e i n t e r n a l o r g a n -i z a t i o n . - The R o l e S t u d y w o u l d a s s e s s commun i ty n e e d s , c l e a r l y i n d i c a t e p o t e n t i a l f u t u r e r o l e s f o r t h e R o s s l a n d H o s p i t a l and comb ined w i t h t h e A d m i n i s t r a t i v e O v e r v i e w , w o u l d deve lop ' t h e methods t o i m p l e m e n t t h e d e t e r m i n e d r o l e . D u r i n g t h e e a r l y s t a g e s o f t h e R o l e S t u d y , t h e c o n s u l t i n g f i r m recommended t h a t t h e i n t e r i m a d m i n i s t r a t i o n be r e p l a c e d by a s h a r e d a d m i n i s t r a t i v e a r r a n g e m e n t w i t h C o l u m b i a V i e w L o d g e , an 84 bed I n t e r m e d i a t e C a r e Home s i t u a t e d i n T r a i l and owned by t h e T r a i l I n t e r m e d i a t e C a r e Home S o c i e t y . On J u n e 1 3 , 1980 , t h e R o l e S t u d y was c o m p l e t e d and s u b -m i t t e d t o t h e B o a r d o f T r u s t e e s . S e v e r a l s p e c i f i c m e e t i n g s w h i c h i n c l u d e d B o a r d Members , A d m i n i s t r a t i o n and M e d i c a l S t a f f were h e l d and t h e r e c o m m e n d a t i o n s o f t h e R o l e S t u d y were e v a l u a t e d i n c o n s i d -e r a b l e d e p t h . I t was t h e B o a r d o f T r u s t e e s ' f e e l i n g t h a t a l t h o u g h i t was n o t i n t o t a l ag reement w i t h a l l t h e r e c o m m e n d a t i o n s , t h e t i m e f o r d i s c u s s i o n had p a s s e d and t h e t i m e f o r a c t i o n had a r r i v e d . T h i s need f o r a c t i o n r e s u l t e d i n t h e B o a r d , M e d i c a l S t a f f and Management t a k i n g on a s t r a t e g i c p l a n n i n g f u n c t i o n . - 158 -P h a s e One o f t h e p r o c e s s had o c c u r r e d by way o f t h e " s u g g e s t i o n s " f r o m t h e M i n i s t r y and t h e recommendat ions o f t h e R o l e S t u d y . The B o a r d was f o r c e d t o r e c o g n i z e t h e need t o p l a n ; t h e r e was no o t h e r v i a b l e a l t e r n a t i v e . The B o a r d , w i t h o u t r e a l i z i n g , embarked upon Phase Two by o r g a n i z i n g i t s e l f i n t o a p l a n n i n g c o m m i t t e e . T h i s was a c h i e v e d more by a change i n f o c u s r a t h e r t h a n s t r u c t u r e . B e c a u s e o f t h e s i z e o f t h e e x i s t i n g B o a r d (9 members) and t h e d e s i r e t o keep e v e r y o n e i n v o l v e d and i n f o r m e d , t h e e n t i r e B o a r d assumed t h e r o l e o f t h e p l a n n i n g c o m m i t t e e . The e x i s t i n g B o a r d C h a i r m a n assumed t h e r o l e o f Commi t tee C h a i r m a n and a d d i t i o n a l members, w h i c h i n c l u d e d t h e M e d i c a l A d v i s o r y C o m m i t t e e and S e n i o r Management w e r e b r o u g h t o n t o t h e C o m m i t t e e . I t was f e l t t h a t g i v e n t h e s i z e o f t h e communi ty t h a t t h e B o a r d was r e f l e c t i v e and r e p r e s e n t a t i v e o f t h e communi ty and no consumer member was r e q u i r e d . The C o m m i t t e e , w h i c h a s i n f a c t t h e f u l l B o a r d w i t h added r e p r e s e n t a t i v e s , was a l r e a d y mandated a s a d e c i s i o n - m a k i n g C o m m i t t e e , n o t an a d v i s o r y o n e . S e v e r a l o f t h e above a s p e c t s were d e p a r t u r e s f r o m t h e t h e o r e t i c a l p r o c e s s . The r e a s o n s f o r t h i s a r e t h r e e f o l d : 1. I t e l i m i n a t e d one s t e p i n t h e d e c i s i o n - m a k i n g p r o c e s s . 2. I t r e d u c e d t h e amount o f m e d i c a l s t a f f r e q u i r e d . 3. A t t h i s p o i n t t h e Commi t tee d i d n o t know i t was i n v o l v e d i n any s p e c i f i c t h e o r e t i c a l p l a n n i n g p r o c e s s . Phase T h r e e was w e l l e s t a b l i s h e d f o r t h e Commi t tee a s t h e d e v e l o p m e n t o f a d a t a b a s e had fo rmed t h e b a s i s o f t h e A d m i n -i s t r a t i v e O v e r v i e w and t h e R o l e S t u d y . Ample i n f o r m a t i o n had been - 159 -c o m p i l e d and t h e r e s u l t s a n a l y z e d . I t was a t t h i s p o i n t where t h e C o m m i t t e e r e a l i z e d i t must d e v e l o p some f o r m a l method o f h a n d l i n g t h e d a t a base and f o r " r e - a n a l y z i n g " i t and t h e c o n s u l t -a n t ' s r e p o r t . S t r a t e g i c p l a n n i n g a w a r e n e s s had been c r e a t e d . S e v e r a l m e e t i n g s ensued t o d i s c u s s what s t r a t e g i c p l a n n i n g i s and how i t i s c a r r i e d o u t . The q u e s t i o n o f "how we g o t t o Phase T h r e e w i t h o u t knowing i t " became o b v i o u s a s t h e p r o c e s s and t h e p h a s e s were s t u d i e d . The B o a r d i n v o l v e d i t s e l f i n an e d u c a t i o n a l p r o g r a m t o s t u d y t h e s t r a t e g i c p l a n n i n g p r o c e s s and i t s a p p l i c a b i l i t y t o i t s own p e c u l i a r s i t u a t i o n - a s m a l l communi ty h o s p i t a l . T h i s e d u c a t i o n a l p r o c e s s came u n d e r t h e r e s p o n s i b i l i t y o f t h e s h a r e d a d m i n i s t r a t i v e C . E . O . and due t o t h e u r g e n c y o f t h e s i t u a t i o n , a v e r y l i m i t e d b i b l i o g r a p h y was u s e d . These b o o k s were s u p p l e m e n t e d by B o a r d Members a n d Management a t t e n d a n c e a t one C o n f e r e n c e s p o n s o r e d by t h e A . H . A . ' s C e n t r e f o r S m a l l and R u r a l H o s p i t a l . - Norman H. M c M i l l a n - J o s e p h P . P e t e r s From t h i s c u r s o r y r e v i e w two a s p e c t s became o b v i o u s . One, s t r a t e g i c p l a n n i n g , i n a s i m p l i f i e d f o r m was a p r o c e s s t h a t c o u l d h e l p t h e B o a r d r a t i o n a l i z e and f o r m a l i z e t h e i r t h o u g h t . Two, t h e y a g r e e d w i t h t h e t h r e e b a s i c a s s u m p t i o n s p r e s e n t e d i n t h e M c M i l l a n (1978) book w h i c h r e s u l t e d i n t h e B o a r d ' s p l a n n i n g b e i n g a d v o c a c y and p r e s c r i p t i v e i n n a t u r e . These a s s u m p t i o n s a r e : 1. "The d i v e r s i t y o f h o s p i t a l s ( s m a l l and l a r g e ; r u r a l and u r b a n ) s h o u l d be p r e s e r v e d a s a s o u r c e o f i d e a s and i n n o v a t i o n . The g r e a t e s t good w i l l be s e r v e d and c o s t s t h e l o w e s t when d i v e r s e methods a r e a l l o w e d t o s e r v e t h e d i v e r s e n e e d s o f o u r s o c i e t y , - 160 -and we s h o u l d n o t d e c r e a s e o u r d i v e r s i t y w i t h o u t c l e a r l y p r o v e n a l t e r n a t i v e s i n s i g h t . " 2. " W h i l e government a g e n c i e s u s u a l l y become i n v o l v e d i n p l a n n i n g t h r o u g h a h o s p i t a l ' s d e f a u l t , t h e y do n o t have an i m p r e s s i v e p l a n n i n g r e c o r d and t h e i r e f f o r t s s h o u l d be v i e w e d w i t h c a u t i o n . " 3. " H o s p i t a l s ' p l a n n i n g r e c o r d s a r e a l s o l e s s t h a n i m p r e s s i v e and t h e y must b e g i n t o f i l l t h e vacuum t h e y have c r e a t e d o v e r t h e y e a r s by n o t a n t i c i p a t i n g t h e f u t u r e . " T h e s e t h r e e a s s u m p t i o n s i n d i c a t e t h a t t h i s s t u d y i s a d v o c a c y i n n a t u r e . The a u t h o r a g r e e s w i t h G i l b e r t and S p e c h t ' s ( 1 9 7 4 ) s u g g e s t i o n t h a t t h e r e a r e t h r e e d i f f e r e n t r o l e s o f p r o f e s s i o n a l p l a n n e r s , one b e i n g - a s an a d v o c a t e a c c o u n t a b l e p r i m a r i l y t o t h e consumer g r o u p t h a t p u r c h a s e s h i s s e r v i c e s and o p e r a t i n g w i t h a v i e w o f t h e p u b l i c i n t e r e s t d e r i v e d f r o m consumer p r e f e r e n c e . Armed w i t h an a w a r e n e s s o f t h e s t r a t e g i c p l a n n i n g p r o c e s s , t h e C o m m i t t e e now began a r e v i e w o f t h e d a t a b a s e c o m p i l e d by t h e c o n s u l t i n g f i r m and d e t e r m i n e d what t r e n d s were o b v i o u s . The d a t a b a s e t h a t was d e v e l o p e d was v e r y s i m p l i s t i c b u t i t g e n e r a t e d ample i n f o r m a t i o n f o r d i s c u s s i o n and p l a n n i n g . From r e v i e w s o f t h e n o r m a l r e p o r t i n g mechan isms t h e f o l l o w i n g i n t e r n a l and e x t e r n a l a s s e s s m e n t s w e r e made, s e v e r a l p r o b l e m s / i s s u e s i d e n t i f i e d , and t r e n d s d e v e l o p e d . A t t h i s p o i n t t h e C o m m i t t e e now had t o assume t h e t a s k o f d e v e l o p i n g a S t a t e m e n t o f P u r p o s e ( P h i l o s o p h y , M i s s i o n ) f o r t h e H o s p i t a l (Phase 4 ) . The a p p r o a c h t a k e n was t h a t w h i l e such a d e v e l o p -ment was d e p e n d e n t i n p a r t on t h e d a t a b a s e and t r e n d s , i t was a l s o - 161 -i n d e p e n d e n t and c o u l d be m o d i f i e d i n s u b s e q u e n t p h a s e s . The D e s c r i p t i o n and P h i l o s o p h y d e v e l o p e d a r e f ound i n A p p e n d i x XV. W i t h t h e d a t a b a s e d e v e l o p e d and r e v i e w e d and some t r e n d s d e t e r -mined i t was now p o s s i b l e f o r t h e C o m m i t t e e t o p l o t t h e i r p r e s e n t p o s i t i o n (where we a r e and where we a r e h e a d e d ) . The c r e a t i o n o f t h e p h i l o s o p h y now p r o v i d e d t h e C o m m i t t e e w i t h a d e s i r e d p o s i t i o n (where we want t o b e ) . The d i s t a n c e between t h e two p o s i t i o n s , " t h e p l a n n i n g g a p " , g a v e an i n d i c a t i o n o f t h e r e v i e w s and work t h a t r e m a i n e d t o be p e r f o r m e d . I n c l o s i n g t h e gap (Phase 5) i t was now n e c e s s a r y t o r e v i e w t h e d a t a b a s e i n f o r m a t i o n and t h e p h i l o s o p h y i n t e r m s o f WOTS (Weaknesses , O p p o r t u n i t i e s , T h r e a t s and S t r e n g t h s ) a s s o m e t h i n g i s o n l y a s t r e n g t h o r weakness i n r e l a t i o n t o a g i v e n . The r e f e r e n c e p o i n t i s t h e p h i l o s o p h y and u n l e s s t h e WOTS a r e c o n s i s t e n t w i t h t h i s m i s s i o n t h e m i s s i o n must be c h a n g e d . T h i s i s o f c o u r s e r e q u i r e d on a r e g u l a r b a s i s a s a S t r e n g t h t o d a y may be a Weakness tomorrow g i v e n t h e c h a n g i n g e n v i r o n m e n t . The f o l l o w i n g i s a d e s c r i p t i o n o f t h e C o m m i t t e e ' s f i n d i n g s : T h r e a t - t h e D i s t r i c t c o n f o r m e d t o t h e p a t t e r n o f b o t h t h e P r o v i n c e a s a w h o l e and a l s o o t h e r somewhat s i m i l a r h o s p i t a l d i s t r i c t s . A l l have seen a g r a d u a l d e c r e a s e i n t h e number o f d a y s t h a t t h e a c u t e c a r e p o p u l a t i o n s t a y s i n h o s p i t a l , t h i s i n s p i t e o f t h e f a c t t h a t now t h e c a s e - m i x i s l i k e l y t o r e p r e s e n t more c o m p l e x m e d i c a l and s u r g i c a l p r o b l e m s t h a n i t d i d i n t h e m i d - s i x t i e s ( t h i s i s b e c a u s e o f t h e d e v e l o p m e n t o f home c a r e s e r v i c e s w h i c h d e a l w i t h more m i n o r p r o b l e m s t h e r e b y - 162 -r e d u c i n g t h e need f o r h o s p i t a l i z a t i o n ) . (The number o f a c u t e p a t i e n t d a y s h a s d e c r e a s e d s i g n i f i c a n t l y be tween 1977 - 1978 b u t t h e m a l e / f e m a l e m ix h a s been c o n s t a n t . ) A l s o i n l i n e w i t h t h e r e m a i n d e r o f B r i t i s h C o l u m b i a t h e a v e r a g e l e n g t h o f s t a y f o r a c u t e p a t i e n t s h a s d r o p p e d o v e r t h e p e r i o d and i n 1978 was 6.4 d a y s . Weakness - The H o s p i t a l h a s been i n t h e communi ty s i n c e 1896 and h a s n o t changed o r r e v i e w e d i t s r o l e i n t o t a l i t y . R a t h e r , i t h a s been w a t c h i n g and r e a c t i n g t o i n t e r n a l and e x t e r n a l c h a n g e s . Weakness - The R e g i o n a l D i s t r i c t o f K o o t e n a y B o u n d a r y h a s p l a y e d no r o l e i n t h e p l a n n i n g o f h e a l t h c a r e f o r t h e d i s t r i c t b u t r a t h e r h a s a c t e d a s p u r e l y a f i s c a l a g e n c y . The R e g i o n a l D i s t r i c t a p p e a r s t o be t r y i n g t o d i v o r c e i t s e l f e v e n more f rom i t s r o l e a s a h o s p i t a l d i s t r i c t and w i s h e s t o t r a n s f e r a l l f u n d i n g r e s p o n s i b i l i t y t o t h e P r o v i n c i a l Government M i n i s t r y o f H e a l t h i n s t e a d o f r a i s i n g h M i l l f u n d s . T h r e a t - The H o s p i t a l ' s o c c u p a n c y r a t e had shown a s t e a d y d e c l i n e f o r t h e p a s t t h r e e y e a r s . The a c u t e c a r e o c c u p a n c y (55%) must be c o n s i d e r e d l o w even f o r a s m a l l h o s p i t a l s u c h a s M a t e r M i s e r i c o r d i a e . 70 - 75% o c c u p a n c y w o u l d be r e g a r d e d a s " f u l l " g i v e n t h e c o m p l i c a t i o n s o f d e a l i n g w i t h i n f e c t i o n s , m a l e / f e m a l e a c c o m m o d a t i o n , and p o s t - s u r g i c a l c a s e s w h i c h may need i n d i v i d u a l rooms when o n l y f o u r bed rooms a r e a v a i l a b l e . T h r e a t / - The l a c k o f a v a i l a b i l i t y o f an a n a e s t h e t i s t w o u l d l i k e l y Weakness mean a d e c l i n e i n s u r g e r y . The u s e o f t h e s u r g i c a l f a c i l i t i e s - 1 6 3 -f o r one day p e r week m i g h t t h r o w i n t o q u e s t i o n c o n t i n u e d e x i s t e n c e g i v e n t h e c u r r e n t c o s t s o f s t a f f i n g . O p p o r t u n i t i e s - T h e r e had been a g r a d u a l d e c l i n e i n r e q u i r e m e n t s f o r s u p p o r t s e r v i c e s ( l a b o r a t o r y , e l e c t r o - c a r d i o g r a m s and r a d i o -l o g y ) on an i n p a t i e n t b a s i s , w i t h t h e e x c e p t i o n o f p h y s i o -t h e r a p y ( r e f l e c t i n g a need i n t h e e x t e n d e d c a r e a r e a . ) However , t h e r e was a r i s e i n o u t - p a t i e n t a c t i v i t y , w h i c h r e f l e c t s b o t h t h e c h a n g i n g s t y l e o f m e d i c a l p r a c t i c e and a l s o a v a l u a b l e f u n c t i o n s e r v e d by t h e h o s p i t a l f a c i l i t i e s i n t h e commun i ty . R a d i o l o g y h e r e r e m a i n s t h e e x c e p t i o n h a v i n g s t a y e d r e l a t i v e l y s t a b l e . Weakness - I t became c l e a r t h a t from t h e a c u t e c a r e s e p a r a t i o n s t h e m a j o r i t y o f p a t i e n t s o r i g i n a t e f r o m R o s s l a n d ; b u t i t was n o t e d t h a t i f t h e H o s p i t a l were n o t used by o t h e r t h a n R o s s l a n d r e s i d e n t s i t s a c u t e bed o c c u p a n c y w o u l d be v e r y l o w i n d e e d . F o r e x t e n d e d c a r e , t h e H o s p i t a l c l e a r l y s e r v e s a s p a r t o f a w i d e r s y s t e m o f h e a l t h c a r e and m a i n l y c a t e r s t o n o n - R o s s l a n d r e s i d e n t . T h r e a t - The H o s p i t a l had an a g i n g p h y s i c a l p l a n t and o u t d a t e d t e c h n o l o g y . O p p o r t u n i t y - On t h e a c t i v e s t a f f was a young o r t h o p e d i c s u r g e o n w i t h a keen i n t e r e s t i n a r t h r o s c o p i c m e n i s e c t o m i e s (knee s u r g e r y ) . T h r e a t - T h e r e r e m a i n s t r o n g " s u g g e s t i o n s " t h a t t h e H o s p i t a l move t o w a r d s a D i a g n o s t i c and T r e a t m e n t C e n t r e t y p e s e r v i c e , w i t h more e x t e n d e d c a r e a n d / o r p s y c h o g e r i a t r i c b e d s . The o c c u p a n c y r a t e l e n d e d t o r e d u c i n g a c u t e beds i n a c c o r d a n c e w i t h t h e R . H . D . p r o j e c t i o n s : - 164 -ACUTE CARE BEDS PER 1000 POPULATION RHD 2A 1976 - 1986 ACTUAL AND PROJECTED REQUIREMENTS Year Beds/1000 Population 1976 (actual) 1977 (actual) 1980 (with 5 bed decrease) 1981 (projected) 1986 (projected) 8.04 7.44 7.20 6.66 6.56 The most common ailments a f f e c t i n g patients receiving treatment represents both diagnoses and procedures: Weakness - signs and symptoms (general investigation) rank very highly over a l l years i n d i c a t i n g that the physicians use the Hospital for surveillance of patients for whom observation i s necessary. Trend - the proportion of patients using the Hospital for res p i r a t o r y disorders has declined s t e a d i l y . Trend - dental surgery, once highly ranked, no longer i s performed at the Hospital. Strength - s u r g i c a l procedures, i n general, rank highly, e s p e c i a l l y i n the musculo-skeletal area. Opportunity - o v e r t h e years 1972 to 1978 a s t e a d i l y increasing pro-p o r t i o n of the t o t a l separations i s represented by the six top ranked discharge diagnoses (1972 = 36.7%, - 165 -1978 = 50.6%) i n d i c a t i n g a c o n c e n t r a t i o n o f a c t i v i t y i n t h e H o s p i t a l , p a r t i c u l a r l y i n t h e s u r g i c a l a r e a . A g a i n , t h e a b s e n c e o f a r e s i d e n t a n a e s t h e t i s t may r e s u l t i n a c h a n g i n g p a t t e r n i n 1979/80 . Weakness - t h e p a t t e r n o f emergency c a r e was i n c o n c l u s i v e a s b o t h o u t p a t i e n t ( non -emergen t ) and emergency s e r v i c e s were e n t e r e d i n t h e same book . T r e n d - t h e l e v e l o f f u l l - t i m e n u r s i n g s t a f f had been g r a d u a l l y d e c r e a s i n g ( p r o b a b l y due t o a v a i l a b i l i t y ) and a s u b -s t i t u t i o n t h r o u g h t h e u s e o f p a r t - t i m e w o r k e r s was made. T h r e a t - t h e a n a l y s i s showed a d i r e c t i n v o l v e m e n t o f t h e B o a r d i n t o t h e d a y - t o - d a y o p e r a t i o n o f t h e H o s p i t a l . T h r e a t - t h e r a t i o o f p h y s i c i a n t o p o p u l a t i o n i s i n l i n e w i t h t h e p r o v i n c i a l s t a n d a r d o f one p h y s i c i a n p e r a p p r o x i m a t e l y 566 r e s i d e n t s . I t a p p e a r e d t h e m e d i c a l s t a f f r e a l i z e d t h e l i m i t a t i o n o f t h e H o s p i t a l and do n o t u s e t h e H o s p i t a l beyond t h e m e d i c a l c a p a b i l i t i e s o f t h e e x i s t i n g s t a f f . However , due t o t h e d e c l i n e i n v a r i o u s t y p e s o f c a s e s coming t o t h e M a t e r M i s e r i c o r d i a e H o s p i t a l , f u r t h e r r e f e r r a l p a t t e r n s t o t h e T r a i l R e g i o n a l H o s p i t a l had been e s t a b l i s h e d . T h i s h a s been h a s t e n e d by t h e l a c k o f an a n a e s t h e t i s t a v a i l a b l e t o t h e M a t e r M i s e r i c o r d i a e H o s p i t a l . O p p o r t u n i t y - t h e a n a l y s i s a t t h i s p o i n t moved t o w a r d s an a r e a o f s o f t e r d a t a w h e r e , r a r e l y i f e v e r , f i g u r e s a r e a v a i l a b l e t o make a c a s e . The d a t a i s , h o w e v e r , o f c o n s i d e r a b l e i m p o r t a n c e b e c a u s e , i n a s m a l l way , i t r e p r e s e n t s a s a m p l i n g o f o p i n i o n a b o u t M a t e r M i s e r i c o r d i a e H o s p i t a l ' s - 166 -c u r r e n t f u n c t i o n i n g and i t s p o t e n t i a l f o r s e r v i n g t h e communi ty i n t h e f u t u r e . I n h e a l t h p l a n n i n g t h e r e i s a n e c e s s i t y t o r e c o g n i z e t h a t a number o f r a t i o n a l i t i e s come i n t o p l a y when any d e c i s i o n - m a k i n g i s u n d e r w a y . I n t h e c a s e o f t h e l a y p e r s o n s t h a t were i n t e r v i e w e d t h e r e w a s , q u i t e p r e d i c t a b l y , c o n s i d e r a b l e e m o t i o n d i s p l a y e d a b o u t t h e H o s p i t a l . I t was c i t e d a s r e p r e s e n t i n g i t s e l f a s e n s e o f c o m m u n i t y , a s p r o v i d i n g warm, p e r s o n a l c a r e , t o t h e p o i n t t h a t t h e t o w n s p e o p l e may even be s p o i l t . I n t h e c a s e o f g e n e r a l s i c k n e s s , t h e H o s p i t a l was seen a s p r o v i d i n g a s e n s e o f s e c u r i t y : t h i s e s p e c i a l l y was v i e w e d a s i m p o r t a n t i n t h e c a r e o f o l d e r p e o p l e who needed t o m a i n t a i n c o n t a c t w i t h t h e i r r e l a t i v e s and f r i e n d s . H e r e t h e u n l i m i t e d a c c e s s w h i c h t h e H o s p i t a l p r o v i d e s i s much a p p r e c i a t e d . T h r e a t - one n e g a t i v e n o t e came t h r o u g h on a number o f o c c a s i o n s c o n c e r n i n g t h e r e c e p t i v e n e s s and o p e n n e s s o f t h e B o a r d o f T r u s t e e s . I t was f e l t t h a t much c o u l d be done t o i m p r o v e t h e f o r m a l r e l a t i o n s h i p between t h e B o a r d and o t h e r o r g a n i z a t i o n s and r e p r e s e n t a t i v e b o d i e s i n R o s s l a n d . T h r e a t - p r o f e s s i o n a l f e e l i n g s t e n d e d t o c o n c e n t r a t e a r o u n d a c o n c e r n t h a t t h e H o s p i t a l , o v e r t h e y e a r s , was g r a d u a l l y b e i n g downgraded . P r o f e s s i o n a l s who a r e d e p e n d e n t upon t h e H o s p i t a l f o r employment w o u l d l i k e t o s e e a r e t u r n o f s u r g i c a l a c t i v i t i e s b u t n o t e t h e d i f f i c u l t y w i t h o u t more a n a e s t h e t i c c a p a b i l i t y . O t h e r p r o f e s s i o n a l s q u e s t i o n t h e - 1 6 7 -a p p r o p r i a t e n e s s o f c a r e f o r p a t i e n t s r e p r e s e n t e d i n t h e a l r e a d y l o w o c c u p a n c y l e v e l s , s u g g e s t i n g a c o n s i d e r a b l e p r o p o r t i o n o f m e d i c a l c a s e s c o u l d be d i s c h a r g e d a t any one t i m e , and t h a t home c a r e s e r v i c e s c o u l d be u s e d q u i t e e a s i l y and e f f e c t i v e l y . I t was f e l t t o be a u s e f u l f a c i l i t y , w h i c h e n g e n d e r e d c o n s i d e r a b l e p u b l i c i n t e r e s t and s u p p o r t . However , on t h e p r a c t i c a l s i d e , t h e r e w e r e q u e s t i o n s a s t o w h e t h e r o r n o t t h e H o s p i t a l c o u l d o r s h o u l d be c o n t i n u i n g a s an a c t i v e s u r g i c a l f a c i l i t y . O p i n i o n by p r o f e s s i o n a l s o u t s i d e o f R o s s l a n d c e n t r e s on l a u d i n g t h e e x t e n d e d c a r e u n i t w h i l s t q u e s t i o n i n g t h e need f o r a c u t e c a r e f a c i l i t i e s . Some even q u e s t i o n e d t h e H o s p i t a l ' s v i a b i l i t y a s an a c u t e c a r e f a c i l i t y , s u g g e s t i n g t h a t T r a i l R e g i o n a l H o s p i t a l s h o u l d t a k e o v e r a l l s e r v i c e s . Even i n t e r m s o f o u t - p a t i e n t a c t i v i t i e s , p a r t i c u l a r l y p h y s i o t h e r a p y , i t i s f e l t t h a t T r a i l i s more a p p r o p r i a t e , e s p e c i a l l y f o r Cominco w o r k e r s f r o m t h e R o s s l a n d a r e a . I n g e n e r a l t e r m s , M a t e r M i s e r i c o r d i a e H o s p i t a l i s r e g a r d e d a s d u p l i c a t i n g s e r v i c e s u n n e c e s s a r i l y . O p p o r t u n i t i e s - a t a v e r y p r a c t i c a l l e v e l , a number o f t h e l a y p e r s o n s r e c o g n i z e d an i m p o r t a n t c u r r e n t f u n c t i o n o f t h e H o s p i t a l a s a c e n t r e o f employment i n R o s s l a n d . I n t r e a t m e n t t e r m s i t was r e c o g n i z e d a s a u s e f u l f a c i l i t y i n t h e i n s t a n c e o f p e o p l e n e e d i n g a few d a y s o f o b s e r v a t i o n u n d e r m e d i c a l s u p e r v i s i o n . C o n s i d e r a b l e comment was made on t h e u t i l i t y o f t h e emergency s e r v i c e s p r o v i d e d by M a t e r M i s e r i c o r d i a e - 168 -and t h i s , t o g e t h e r w i t h d i f f i c u l t y o f a c c e s s t o p a t i e n t s i n t h e T r a i l H o s p i t a l , b r o u g h t f o r t h a number o f comments a b o u t t r a n s p o r t a t i o n . I n t h e c a s e o f M a t e r M i s e r i c o r d i a e H o s p i t a l , t h i s was n o t f e l t t o be p r o b l e m a t i c ( a l t h o u g h b e t t e r s i d e w a l k c l e a r i n g i n w i n t e r w o u l d be a p p r e c i a t e d ! ) , b u t p u b l i c t r a n s p o r t a t i o n t o T r a i l ( o f t e n r e l i e d upon by o l d e r p e o p l e ) was j u d g e d i n a d e q u a t e . I t i s u n d e r s t o o d h o w e v e r , t h a t an i n c r e a s e i n s e r v i c e i s i m m i n e n t . C o n c e r n was e x p r e s s e d a l s o a b o u t t h e need t o c l o s e R o s s l a n d ' s a c u t e c a r e b e d s and w i n t e r a c c e s s t o T r a i l was c i t e d a s a p r o b l e m ( the R . C . M . P . were n o t , h o w e v e r , a b l e t o c o n f i r m t h e d i f f i c u l t y n o t i n g t h a t a c c e s s was v e r y r a r e l y i m p a i r e d ) . S t r e n g t h - a number o f p r o g r a m s were h i g h l y though o f , p a r t i c u l a r l y r e h a b i l i t a t i o n s e r v i c e s , t h e e x t e n d e d c a r e u n i t , and m e a l s on w h e e l s . c o n c e r n was e x p r e s s e d i n r e g a r d t o t h e l a c k o f a n a e s t h e t i c s e r v i c e s i n t h a t i t was f e l t p h y s i c i a n o r i e n t a t i o n w o u l d t u r n more and more t o T r a i l . F u r t h e r , t h e r e l a t i o n s h i p o f T r a i l R e g i o n a l H o s p i t a l t o M a t e r M i s e r i c o r d i a e H o s p i t a l was f e l t t o be one based on i n e q u a l i t y , one where s e r v i c e s had g r a d u a l l y gone f rom t h e R o s s l a n d H o s p i t a l . Much n e g a t i v e f e e l i n g e x i s t e d a b o u t t h e p r o s p e c t o f u s i n g T r a i l R e g i o n a l H o s p i t a l a s an a l t e r n a t i v e a c u t e c a r e f a c i l i t y : i t was f e l t t o be i n f l e x i b l e i n p r o v i d i n g s e r v i c e ; t h e r e was p e r c e i v e d t o be a d e l a y i n o b t a i n i n g t r e a t m e n t ; and t h e (Oppor -t u n i t y ) T h r e a t -(Oppor -t u n i t y ) - 169 -w a i t i n g l i s t s were d e s c r i b e d a s l o n g . O p p o r t u n i t y - s u g g e s t i o n s , o r s t a t e m e n t s o f w a n t s i n t h i s a r e a , were r a t h e r l i m i t e d , t e n d i n g t o w a r d s a r e q u i r e m e n t t h a t s e r v i c e s t h a t c u r r e n t l y e x i s t be n o t f u r t h e r r e d u c e d . The l a y r e s p o n d e n t s f e l t e s p e c i a l l y t h a t emergency s e r v i c e s s h o u l d be m a i n t a i n e d a t t h e c u r r e n t l e v e l and t h a t a c u t e c a r e beds w o u l d c o n t i n u e t o be needed e s p e c i a l l y f o r s i c k t o u r i s t s and o l d e r p e r s o n s and r e t i r e e s . Some p e r s o n s m e n t i o n e d t h e y w o u l d l i k e t o see a r e t u r n o f m a t e r n i t y f a c i l i t i e s , a s w e l l a s an i n c r e a s e i n s u r g e r y . O p p o r t u n i t y - p r o f e s s i o n a l r e s p o n s e s were c o n s i s t e n t and came m a i n l y f rom t h e p h y s i c i a n s . T h e r e was f e l t t o be a need f o r t h e f u t u r e t o m a i n t a i n t h e emergency c a p a c i t y o f t h e H o s p i t a l , b u t m a i n l y f o r m i n o r e m e r g e n c i e s ; h o w e v e r , i t i s r e c o g -n i z e d t h a t a c u t e beds w o u l d be r e q u i r e d i f t h e H o s p i t a l were t o o f f e r t h e s e s e r v i c e s . F u r t h e r , i t c a n be o b s e r -v e d t h a t i f t h e r e were no a c u t e beds t h e X - R a y and l a b -o r a t o r y f a c i l i t i e s c o u l d n o t be j u s t i f i e d . I t was n o t f e l t t h a t i t w o u l d be r e a s o n a b l e t o r e i n t r o d u c e m a t e r n i t y c a r e , b u t r e s t o r a t i o n o f o r t h o p e d i c work w o u l d be p o s s i b l e i n t h e e v e n t o f a n a e s t h e t i c c a p a b i l i t y b e i n g a v a i l a b l e . T h r e a t - The T r a i l - b a s e d p r o f e s s i o n a l v i e w o f t h e f u t u r e f o r t h e H o s p i t a l c e n t r e d upon i t s u s e a s a l o n g t e r m c a r e f a c i l i t y e x c l u s i v e l y s e r v i n g t h e T r a i l o v e r f l o w . Weakness - i n t h e r e v i e w o f t h e a d m i n i s t r a t i v e s t r u c t u r e o f t h e M a t e r M i s e r i c o r d i a e H o s p i t a l , i t was found t h a t t h e r e was l i t t l e - 170 -d e l e g a t i o n o f a u t h o r i t y o r r e s p o n s i b i l i t y f r o m t h e a d m i n i s t r a t o r t o t h e d e p a r t m e n t h e a d s . I n d i v i d u a l d e p a r t m e n t h e a d s were n o t aware o f t h e i r b u d g e t s n o r w e r e t h e y g i v e n f u l l a u t h o r i t y and r e s p o n s i b i l i t y t o p u r c h a s e , c o n t r o l s t a f f h o u r s , o r t o c o - o r d i n a t e and d i r e c t t h e i r d e p a r t m e n t s . R a t h e r , t h e r e was a c o n t i n u a l d i r e c t i n t e r f e r e n c e w i t h , t h e d a y - t o - d a y o p e r a t i o n by t h e a d m i n i s t r a t o r w i t h t h e d e p a r t m e n t heads w h i c h d i d n o t a i d i n t h e c o - o r d i n a t i o n o f t h e H o s p i t a l i n t o t a l . I n r e v i e w i n g t h e a d m i n i s t r a t i v e f i l e s and o p e r a t i o n , i t was f o u n d t h a t t h e r e was a l a c k o f w r i t t e n p o l i c y / p r o c e d u r e s - w i t h i n t h e H o s p i t a l and many o f t h e a d m i n i s t r a t i v e s u p p o r t s t a f f , e s p e c i a l l y t h e s e c r e t a r i a l and b u s i n e s s o f f i c e s t a f f , h a v e been u n d e r - u t i l i z e d and m i s u t i l i z e d . Weakness - t h e r e had been no e v a l u a t i o n o f t h e a d m i n i s t r a t o r n o r s p e c i f i c g o a l s o r o b j e c t i v e s he was t o a c h i e v e . T h i s l a c k o f o b j e c t i v e s and e v a l u a t i o n e v e n t u a l l y ended w i t h t h e B o a r d and t h e H o s p i t a l s t a f f w o r k i n g a r o u n d t h e f o r m e r CEO. T h i s c r e a t e d b o t h a d i f f i c u l t s i t u a t i o n w i t h t h e f o r m e r a d m i n i s t r a t o r , and t h e d e p a r t m e n t h e a d s , a s no i n d i v i d u a l c o u l d work f o r two m a s t e r s . I n summary, t h e M a t e r M i s e r i c o r d i a e H o s p i t a l was a t a c r o s s r o a d s . T h i s c r o s s r o a d p r e s e n t e d t h e H o s p i t a l w i t h p r o b a b l y t h e g r e a t e s t c h a l l e n g e t h a t i t had e v e r f a c e d i n i t s 83 y e a r h i s t o r y . T h e r e was an a t m o s p h e r e w i t h i n t h e i n s t i t u t i o n t h a t change must o c c u r - 171 -f o r s u r v i v a l o f t h e i n s t i t u t i o n . The i n s t i t u t i o n had p l a y e d a s i g n i f i c a n t r o l e w i t h i n t h e communi ty o f R o s s l a n d and i t may c o n t i n u e t o p l a y a s i g n i f i c a n t r o l e i n i t s f u t u r e i f p l a n n i n g and c h a n g e o c c u r r e d . I t was v i e w e d a s i m p o r t a n t t h a t t h e B o a r d o f T r u s t e e s m a i n t a i n an open mind and a c t q u i c k l y and d e c i s i v e l y t o g u i d e t h e M a t e r M i s e r i c o r d i a e H o s p i t a l t h r o u g h i t s needed t r a n s i t i o n . I t was a g r e e d t h a t t h e B o a r d w i l l have t o p l a y a h i g h l y v i s i b l e and p u b l i c r o l e i n a c c o m p l i s h i n g t h i s change w i t h i n t h e communi ty t h a t h a s o n l y known t h e M a t e r M i s e r i c o r d i a e H o s p i t a l a s a h o s p i t a l i n a t r a d i t i o n a l s e n s e . The Commit tee was now a t a s t a g e t o d e v e l o p t h e i r G o a l s and O b j e c t i v e s , t h e t i m e t a b l e f o r a c t i o n and t h e a s s i g n -ment o f r e s p o n s i b i l i t i e s (Phase 6). P r e a m b l e : The B o a r d o f T r u s t e e s d e s i r e d t o s e t a c o u r s e f o r t h e H o s p i t a l , and w i s h e d t o d e c l a r e i t t o t h e Commun i ty , t h e R e g i o n and t h e M i n i s t r y , s t a t i n g where t h e M a t e r M i s e r i c o r d i a e H o s p i t a l i s g o i n g i n t e r m s o f p r o g r a m s , f a c i l i t i e s and e q u i p m e n t . The i n t e n t i s t o p l a n and i n f l u e n c e o u r f u t u r e , t o m o n i t o r o u r s u c c e s s and e l i m i n a t e o u r f a i l u r e s . Our g o a l s and o b j e c t i v e s a r e t o d e v e l o p t h e f o l l o w i n g s p e c i f i c r o l e d e s c r i b e d i n o u r p h i l o s o p h y i n f u l l c o n s i d e r a t i o n o f o u r e x i s t i n g s t r e n g t h s , o u r r e l a t i o n s h i p t o o t h e r h e a l t h c a r e f a c i l i t i e s , and t h e M i n i s t r y ' s e c o n o m i c p a r a m e t e r s . G o a l s : 1. To m a i n t a i n h i s t o r i c a l commi tments t o p r o v i d e a c o m p r e h e n s i v e r a n g e o f a c u t e i n p a t i e n t and o u t p a t i e n t h e a l t h c a r e s e r v i c e s - 172 -f o r t h e l o c a l commun i t y . O b j e c t i v e s : 1. To m a i n t a i n a t l e a s t t h e e x i s t i n g l e v e l s o f m e d i c a l and s u r g i c a l i n p a t i e n t s e r v i c e s b a s e d on o c c u p a n c y , n o t beds s e t u p . 2. To expand e f f o r t s t o i n c r e a s e t h e h o s p i t a l ' s r e c o g n i t i o n . i . I n c r e a s e p u b l i c r e l a t i o n s by l i a i s i n g c l o s e l y w i t h C i t y C o u n c i l , Chamber o f Commerce, c h u r c h g r o u p s , e t c . . T h i s w i l l be done t h r o u g h a s t a n d i n g c o m m i t t e e o f t h e B o a r d , t o be e s t a b l i s h e d i m m e d i a t e l y , i i . P r o v i d e communi ty e d u c a t i o n p r o g r a m s w i t h e m p h a s i s on e a r l y d e t e c t i o n and p r e v e n t i o n , p e r s o n a l h e a l t h c a r e e d u c a t i o n and t h e e f f e c t i v e u s e o f h e a l t h c a r e s e r v i c e s and f a c i l i t i e s t h r o u g h t h e p r o v i s i o n o f i n f o r m a t i o n and i n s t r u c t i o n . These a c t i v i t i e s t e n d t o keep p e o p l e w e l l and o u t o f h o s p i t a l s and p r o v i d e o p p o r t u n i t y f o r h o s p i t a l e m p l o y e e s t o t e a c h communi ty members i m p o r t a n t a s p e c t s o f h e a l t h m a i n t e n a n c e . T h i s w i l l be o v e r s e e n by t h e Community R e l a t i o n s C o m m i t t e e , i i i . To d e v e l o p w o r k i n g r e l a t i o n s h i p s t h a t w i l l make e x p l i c i t t h e b e l i e f t h a t t h e H o s p i t a l i s an i m p o r t a n t component o f a w i d e r s y s t e m o f h e a l t h c a r e w h i c h i n c l u d e s b o t h f a c i l i t i e s and c o m m u n i t y - b a s e d s e r v i c e s . To e n c o u r a g e h o s p i t a l s and o t h e r h e a l t h c a r e i n s t i t u t i o n s t o c o -o r d i n a t e and c o n s o l i d a t e s e r v i c e s and t o s h a r e s u p p o r t s e r v i c e s . T h i s w i l l be i n i t i a t e d t h r o u g h m e e t i n g s w i t h - 173 -t h e f a c i l i t y a d m i n i s t r a t o r s . To i n c r e a s e o u t p a t i e n t a c t i v i t y . T h i s i s c o n s i s t e n t w i t h e x i s t i n g t r e n d s . i . I n c r e a s e d a y - c a r e s u r g e r y p r o c e d u r e s ( a r t h r o s c o p i c m e n i s e c t o m i e s ) by 100% i n t h e n e x t 12 m o n t h s , u t i l i z i n g t h e i n t e r e s t and e x p e r t i s e o f t h e o r t h o p e d i c s u r g e o n . T h i s w i l l r e q u i r e an e x p e n d i t u r e o f $20,000 and t h e H o s p i t a l A u x i l i a r y w i l l be a s k e d t o s p o n s o r t h e p r o j e c t , i i . D e v e l o p a d e n t a l s u r g i c a l s u i t e t h a t c o u l d a t t r a c t a s p e c i a l i s t f r o m t h e Okanagan . I n c r e a s e s i n #i & i i may a t t r a c t t h e much -needed a n a e s t h e t i c s e r v i c e . i i i . To c a n c e l o u r c o n t r a c t p h y s i o t h e r a p y s e r v i c e w i t h t h e R e g i o n a l H o s p i t a l i n f a v o u r o f o u r own f u l l - t i m e t h e r a p i s t w i t h i n 6 months . T h i s t h e r a p i s t w i l l be C . A . R . S . t r a i n e d t o d e v e l o p s e r v i c e s t o t h e l a r g e p o p u l a t i o n o f a r t h r i t i s s u f f e r e r s . To m a i n t a i n o u r emergency d e p a r t m e n t s e r v i c e s . i . To u p g r a d e o u r f a c i l i t y w i t h i n t h e n e x t 12 months . T h i s w i l l be o v e r s e e n by t h e j o i n t a c t i o n o f t h e P l a n n i n g & D e v e l o p m e n t and t h e P h y s i c a l F a c i l i t i e s and P r o p e r t i e s C o m m i t t e e s . i i . To r e d u c e t h e number o f n o n - e m e r g e n c y c o n d i t i o n s t h r o u g h p a t i e n t e d u c a t i o n , i i i . The Community R e l a t i o n s Commi t tee w i l l d i s t r i b u t e P a t i e n t Q u e s t i o n a i r e s t o a l l Emergency Room p a t i e n t s t o a s s i s t i n a n a l y s i s o f p e r c e i v e d q u a l i t y o f c a r e w i t h i n 6 m o n t h s , i v . C o n t i n u e t o e v a l u a t e t h e q u a l i t y o f Emergency Room c a r e t h r o u g h m o n t h l y M e d i c a l S t a f f Emergency Room C o m m i t t e e c a s e e v a l u a t i o n s and m e d i c a l c a r e a u d i t s . To p r o m o t e c o s t - c o n t a i n m e n t . i . To d e v e l o p p r e - a d m i s s i o n t e s t i n g , i i . To d e v e l o p d i s c h a r g e p l a n n i n g , i i i . To d e v e l o p a w o r k i n g l i a i s o n w i t h t h e Home C a r e S e r v i c e . To d e v e l o p v a r i o u s l e v e l s o f c a r e b a s e d on communi ty n e e d , i . R e d e s i g n a t i o n o f 3 a c u t e c a r e beds t o e x t e n d e d c a r e . D i s c u s s i o n s w i t h t h e M i n i s t r y w i l l commence i m m e d i a t e l y , i i . R e v i e w t h e need f o r M e a l s on W h e e l s w i t h t h e d e s i r e t o i n c r e a s e numbers . To e x p l o r e some f o r m o f u t i l i z a t i o n f o r t h e v a c a n t N u r s i n g A n n e x . Such u s e s may b e : a d m i n i s t r a t i o n o f f i c e s - p r i v a t e p r a c t i c e o f f i c e s - a l c o h o l t r e a t m e n t c e n t r e h o s p i c e c a r e - p s y c h o g e r i a t r i c u n i t . To i m p r o v e t h e image o f t h e B o a r d . i . I t w i l l be i m p o r t a n t n o t o n l y t h a t t h e B o a r d n o t be i n v o l v e d i n t h e d a y - t o - d a y o p e r a t i o n b u t t h a t t h e r e be a p e r c e p t i o n w i t h i n t h e H o s p i t a l t h a t t h e y a r e n o t i n v o l v e d w i t h t h e d a y - t o - d a y o p e r a t i o n . T h i s i s e s p e c i a l l y i m p o r t a n t a s many o f t h e Depar tment Heads f e l t t h e y were w o r k i n g - 175 -d i r e c t l y f o r the Board of Trustees and not w i t h i n the a d m i n i s t r a t i v e s t r u c t u r e of the H o s p i t a l . This w i l l be a l a r g e task t o t u r n around i n the minds of the i n d i v -i d u a l Department Heads and i t w i l l be important t h a t t h a t Board be beyond reproach i n r e - e s t a b l i s h i n g t h i s a d m i n i s t r a t i v e h i e r a r c h y , i i . I t i s important t h a t the Board review i t s p o l i c y concerning having Trustees who a l s o have r e l a t i v e s working w i t h i n the i n s t i t u t i o n . I t i s hard i n a s m a l l community t o r e c r u i t Board members f o r the S o c i e t y without some type of f a m i l y r e l a t i o n s h i p working w i t h i n the H o s p i t a l . However, the Board should be cautious i n having any d i r e c t f a m i l y working w i t h i n the i n s t i t u t i o n , i i i . J u s t as the Board of Trustees must be seen not t o i n t e r -f e r e w i t h the i n s t i t u t i o n i n t e r n a l l y , i t i s a l s o important t h a t the community p e r c e i v e the Trustees' r o l e b e t t e r . The Board of Trustees a c t as Trustees o f the S o c i e t y which i s made up of r e s i d e n t s of the community. I t i s d i f f i c u l t i n a community the s i z e of Rossland not t o have d i r e c t d i s c u s s i o n s and communications concerning the H o s p i t a l and q u a l i t y o f care. I t i s t h e r e f o r e important t h a t the Board emphasize w i t h the community the r o l e o f the a d m i n i s t r a t i o n and the r e - d i r e c t i n g of complaints and p r a i s e t o the a d m i n i s t r a t i v e component of the H o s p i t a l . I t w i l l be important t h a t i n d i v i d u a l problems which are r a i s e d w i t h the Board of Trustees be r e - d i r e c t e d by the Board members t o the a d m i n i s t r a t o r . - 176 -T h i s w i l l b e o v e r s e e n b y t h e E x e c u t i v e C o m m i t t e e . 9. To d e v e l o p i m p r o v e d w o r k i n g r e l a t i o n s h i p s w i t h t h e R e g i o n a l D i s t r i c t a n d o t h e r h e a l t h p r o v i d e r s . i . i m p l e m e n t p r e - o p a s s e s s m e n t a n d p o s t - o p c a r e t o s e r v i c e t h e R o s s l a n d p u b l i c a n d t o a s s i s t t h e R e g i o n a l H o s p i t a l , i i . moves by t h e R e g i o n a l H o s p i t a l D i s t r i c t t o be exempt f r o m t h e i r p l a n n i n g r o l e s h o u l d be o p p o s e d by t h e H o s p i t a l a s i t w i l l , i f a c c o m p l i s h e d , c o m p l e t e l y c e n t r a l i z e a l l f u n d i n g i n t h e M i n i s t r y o f H e a l t h , t h u s r e m o v i n g l o c a l autonomy. 10. To d e v e l o p a m a i n t e n a n c e u p g r a d i n g p r o g r a m and s c h e d u l e . i . R e p l a c e m e n t o f e x i s t i n g HVAC s y s t e m w i t h i n 12 m o n t h s . N e g o t i a t i o n s w i l l commence i m m e d i a t e l y w i t h t h e M i n i s t y a s p r e l i m i n a r y c a l c u l a t i o n s i n d i c a t e a 3 y e a r p a y b a c k on new b o i l e r s , i i . P a i n t i n g o f H o s p i t a l w i t h i n s i x m o n t h s , i i i . P e r f o r m an equ ipment and t e c h n o l o g y r e v i e w w i t h i n 3 m o n t h s . T h e s e p r o j e c t s may d e l e t e t h e e x i s t i n g P l a n t Fund b u t a r e c o n s i d e r e d o f s u c h n e c e s s i t y t h e y must be commenced. 11. To make t h e M i n i s t r y more aware o f t h e f u t u r e r o l e o f t h e H o s p i t a l . i . P r e p a r e a B r i e f f o r s u b m i s s i o n t o t h e M i n i s t r y w i t h i n s i x m o n t h s . 12. To r e v i e w and i m p r o v e t h e o r g a n i z a t i o n a l s t r u c t u r e . i . U p d a t e o r g a n i z a t i o n a l c h a r t , p o l i c i e s and p r o c e d u r e s , i i . P e r f o r m a human r e s o u r c e a s s e s s m e n t and u p d a t e on a l l e v a l u a t i o n s . i i i . D e c e n t r a l i z a t i o n and d e l e g a t i o n t o be i m p l e m e n t e d , i v . D e v e l o p an e d u c a t i o n a l p r o g r a m f o r s t a f f t o i n d i c a t e t h e i r r e l a t i o n t o t h e B o a r d . - 177 -Summation o f G o a l s and O b j e c t i v e s : The c h a n g i n g r o l e o f h o s p i t a l s w i t h i n t h e h e a l t h c a r e d e l i v e r y s y s t e m r e q u i r e s i n s t i t u t i o n s t o r e c o g n i z e and m o d i f y t h e i r s e r v i c e s t o meet i n c r e a s i n g demands f o r n o n - i n p a t i e n t s e r v i c e s . The B o a r d o f T r u s t e e s must be aware o f t h e M i n i s t r y ' s d e s i r e s " t o p r o v i d e l e a d e r -s h i p t o t h e H o s p i t a l i n d u s t r y i n d e v e l o p i n g a f u l l r ange o f h o s p i t a l s p o n s o r e d o r h o s p i t a l a s s o c i a t e d n o n - i n p a t i e n t s e r v i c e s w h i c h w o u l d be r e s p o n s i v e t o c o m m u n i t y , e c o n o m i c and s e r v i c e n e e d s . " The B o a r d must a l s o a g r e e w i t h t h e M i n i s t r y o f H e a l t h ' s commitment " t o s h i f t t h e e m p h a s i s f rom a c u t e i n p a t i e n t c a r e i n h o s p i t a l beds t o a f u l l r a n g e o f i n t e g r a t e d c a r e and t o d a y - c a r e and h o m e - c a r e i n t h e b e l i e f t h a t t h e l a t t e r a r e b o t h b e t t e r f o r t h e p a t i e n t and l e s s c o s t l y . " The R o s s l a n d H o s p i t a l had done t h i s i n t h e p a s t and was a t t e m p t i n g t o p u r s u e t h i s p r o c e s s i n t h e f u t u r e . The Commi t tee was now f a c e d w i t h t h e t a s k o f s e l e c t i n g c o u r s e s o f a c t i o n ( p r i o r i t y ) f r om t h e many G o a l s and c o r r e s p o n d i n g O b j e c t i v e s . A s s t a t e d i n t h e s e c t i o n on " p r o c e s s e s " , t h e t a s k was e a s i e r t h a n a n t i c i p a t e d . The m a i n t e n a n c e o f t h e a c u t e r o l e was p a r a m o u n t . The C o m m i t t e e " k e y e d " on t h o s e g o a l s r e l a t i n g t o a c u t e h o s p i t a l f u n c t i o n s . A l l o f t h e g o a l s and c o r r e s p o n d i n g o b j e c t i v e s r e s u l t e d i n t h e d e v e l o p i n g o f more e x t e n s i v e i n d i v i d u a l s t r a t e g i e s s u c h a s t h e p r e p a r i n g o f b r i e f s , t i m i n g , c o m m u n i c a t i o n s , b u d g e t s , e t c . However , most o f t h e i n f o r m a t i o n was r e a d i l y a v a i l a b l e . The Commi t tee found t h a t most o f t h e g o a l s were i n t e r r e l a t e d and c o u l d / s h o u l d be w o r k e d upon s i m u l t a n e o u s l y . The a s s i g n m e n t o f r e s p o n s i b i l i t i e s was r e l a t i v e l y e a s y a s most g o a l s f e l l c o m f o r t a b l y - 178 -i n t o t h e mandate o f t h e e x i s t i n g S t a n d i n g C o m m i t t e e s , o r tin t h e r e s p o n s i b i l i t y o f S e n i o r Management. I n d e v e l o p i n g t h e t i m e t a b l e f o r i m p l e m e n t a t i o n (Phase 7) ample " l e a d - t i m e " was a l l o w e d . The C o m m i t t e e now e n t e r e d P h a s e 8 - t h e need t o d e v e l o p an e v a l u a t i o n mechan ism o r s y s t e m . S i n c e t h i s document and C a s e S t u d y a r e c u r r e n t , no a c t u a l e v a l u a t i o n h a s o c c u r r e d . I n c o n s i d e r a t i o n o f t h i s a s p e c t I w i l l i n c l u d e some a d d i t i o n a l g e n e r a l comments on Phase 8 and r e f e r t h e r e a d e r t o A p p e n d i x 18 where t h e E v a l u a t i o n Q u e s t i o n s a r e s e t o u t . I n e v a l u a t i o n t h e B o a r d must remeber t h a t a c t u a l p r o g r e s s i s an i n s u f f i c i e n t g u i d e t o a c c o m p l i s h m e n t . Of c o u r s e , i t i s e s s e n t i a l t h a t i f a p l a n move f r o m c o n c e p t t o r e a l i t y , f r om a p i e c e o f p a p e r t o d e s i r e d g o a l s , a c t i o n s must o c c u r . However , t h e a c t i o n s must be e v a l u a t e d t o d e t e r m i n e i f t h e y a r e a c c o m p l i s h i n g what was i n t e n d e d . Even though e v a l u a t i o n i s m e r e l y a way o f c o m p a r i n g a c t u a l p e r -f o r m a n c e w i t h i n t e n d e d e f f o r t , i t i s u n d o u b t e d l y t h e most d i f f i c u l t a n d , a t t i m e s , t h e most d i s t a s t e f u l o f t h e p l a n n i n g p r o c e s s . Few c o m m i t t e e members o r CEOs r e l i s h t h e d i s c o v e r y t h a t t h e i r l o n g d e l i b e r a t i o n s and l a b o u r s d i d n o t p r o d u c e t h e d e s i r e d r e s u l t s . Not o n l y d o e s e v a l u a t i o n i n v o l v e s e l f - c r i t i c i s m , b u t i t a l s o demands a d i s c i p l i n e t h a t makes i n d i v i d u a l s a n s w e r a b l e - f o r c a r r y i n g o u t a s s i g n e d t a s k s a s p l a n n e d . I t i s t h e r e f o r e n o t s u r p r i s i n g t h a t e v a l u a t i o n i s o f t e n o v e r l o o k e d and t h a t e v e r y o n e assumes t h a t t h e p l a n h a s a l i f e o f i t ' s own and i s a c h i e v i n g what i s e x p e c t e d . - 179 -CONCLUSIONS T h i s document i s l i m i t e d t o s t r a t e g i c p l a n n i n g , w h i c h i s d e s c r i b e d a s a p r o c e s s t h a t d i r e c t s an o r g a n i z a t i o n ' s a t t e n t i o n t o t h e f u t u r e , t h e r e b y e n a b l i n g i t t o a d a p t more r e a d i l y t o c h a n g e and t o d e t e r m i n e t h e d i r e c t i o n i n w h i c h i t c h o o s e s t o move. By i t s v e r y n a t u r e , s t r a t e g i c p l a n n i n g i s an u m b r e l l a - l i k e a c t i v i t y t h a t s e t s t h e t o n e and d i r e c t i o n f o r t h e v a r i o u s o t h e r p l a n n i n g e f f o r t s t h a t t a k e p l a c e w i t h i n an o r g a n i z a t i o n . T h i s document d o e s n o t a s p i r e t o be c o m p r e h e n s i v e and d e a l w i t h t h e e n t i r e range o f p l a n n i n g t h a t o c c u r s (or s h o u l d o c c u r ) w i t h a h e a l t h c a r e f a c i l i t y . The document and t h e C a s e S t u d y a r e p r e s e n t e d a s b e i n g u n a b a s h e d l y p r e s c r i p t i v e and a d v o c a t i v e . I t a l s o o f f e r s some s e c r e t s : 1. Keep i t s i m p l e . T h i s i s t h e b e s t a d v i c e g i v e n i n t h i s s t u d y a l t h o u g h t h e w r i t e r f u l l y r e a l i z e s t h a t t h e s i m p l i c i t y may be l o s t a s c o n s i d e r a t i o n h a s been g i v e n t o so many f a c t o r s . However , s t r a t e g i c p l a n n i n g i s n o t c o m p l i c a t e d . 2 . I t c a n be c a r r i e d o u t i n c r e m e n t a l l y ( e v o l u t i o n ) by t a k i n g one s m a l l s t e p a t a t i m e . 3 . I t i s h i g h l y u n l i k e l y t h a t any g r e a t m i s t a k e s w i l l be made i f t h e C o m m i t t e e i s w i l l i n g t o i n v o l v e enough p e o p l e . 4 . I t i s b e t t e r t o t a k e t h e r i s k s i n v o l v e d i n p l a n n i n g t h a n t o do n o t h i n g . A n o t h e r a s p e c t , o r s e c r e t , i s t h a t t h e r e i s no c o n c e n s u s on how s t r a t e g i c p l a n n i n g s h o u l d be p r a c t i c e d i n any s p e c i f i c s i t u a t i o n b e c a u s e p l a n n i n g means d i f f e r e n t t h i n g s t o d i f f e r e n t p e o p l e . However , i t s h o u l d no t be s u p p o s e d t h a t a d v i c e c a n n o t be - 1 8 0 -o f f e r e d on how t o p l a n . Above a l l , h o s p i t a l s must d e v e l o p t h e a b i l i t y t o q u e s t i o n a n d , i f n e c e s s a r y , c h a n g e t r a d i t i o n a l (and o f t e n p a r o c h i a l ) a s s u m p t i o n s and p o l i c i e s when t h e s e seem no l o n g e r a d e q u a t e f o r p r e s e n t o r f u t u r e c o n d i t i o n s . I f q u e s t i o n s a r e a s k e d and p l a n n i n g a t t e m p t e d , any h o s p i t a l w i l l l e a r n t h a t good p l a n n i n g comes a b o u t o n l y w i t h e x p e r i e n c e . The f i r s t s t e p i n t h i s e x p e r i e n c e i s c r e a t i n g a f a v o u r a b l e c l i m a t e . A S t u d y i n d i c a t e s t h a t a change i n t o p manage -ment i s t h e e v e n t most l i k e l y t o i n i t i a t e t h e p r o c e s s and t o s p u r a c t i o n o r a t l e a s t p r o v i d e s t h e o p p o r t u n i t y (27). T h i s i s a l s o b o r n e o u t i n t h e C a s e S t u d y . The ou tcome o f d e v e l o p i n g t h i s a b i l i t y t o q u e s t i o n and c r e a t i n g t h e c l i m a t e t o p l a n i s t h e r e q u i r e m e n t t o p r o d u c e a u n i q u e and d u r a b l e s t r a t e g y , t o r e v i e w i t p e r i o d i c a l l y f o r i t s v a l i d i t y , t o u s e i t a s t h e r e f e r e n c e p o i n t f o r a l l o t h e r b o a r d d e c i s i o n s , and t o s h a r e w i t h management t h e r i s k s a s s o c i a t e d w i t h i t s a d o p t i o n . I n d o i n g t h i s t h e l i n e s be tween management and b o a r d a u t h o r i t y must r e m a i n c l e a r , b u t t h e more c o m m u n i c a t i o n a c r o s s them t h e b e t t e r . T h i s t y p e o f c o m m u n i c a t i o n c a l l s f o r a f o rm o f p a r t i c i p a t i v e management w h i c h i s c o n s i s t e n t w i t h a s m a l l h o s p i t a l ' s budget and r e s o u r c e s . T h i s method c a l l s upon b o a r d members, management s t a f f and p h y s i c i a n s t o a c k n o w l e d g e t h e i r d i v e r s e i n t e r e s t s and p e r s p e c t -i v e s and t o a c c e p t t h e i r r e s p o n s i b i l i t y f o r c h a r t i n g t h e f u t u r e c o u r s e o f t h e o r g a n i z a t i o n . W i t h t h e c l i m a t e c r e a t e d i t i s e a s y t o r e v i e w , t h r o u g h o u r d a t a b a s e , what we have been d o i n g , where we a r e , and where we a r e h e a d e d . We must now l o o k o u t s i d e t o d e t e r m i n e i f o u r " h e a d i n g " i s - 181 -i s c o n s i s t e n t w i t h t h e s o c i e t y / c o m m u n i t y we s e r v e . The h o s p i t a l f i e l d i s now f a c i n g a c h a l l e n g e and an o p p o r t u n i t y . H o s p i t a l s , and even g r o u p s o f h o s p i t a l s , t h a t want t o s t a r t o v e r and t r y t o do a b e t t e r j o b o f i t now have t h a t c h a n c e . T h e i r b e s t hope w i l l be i n d e f i n i n g more c l e a r l y t h e r o l e o f h e a l t h p l a n n i n g i n t h e i r i n s t i t u t i o n s and i n t h e i r c o m m u n i t i e s , and i n u n d e r s t a n d i n g t h a t t h e s e two e n t i t i e s a r e u t t e r l y i n t e r t w i n e d . I f s m a l l h o s p i t a l s ; i n d e e d , a l l h o s p i t a l s o f any s i z e , a r e t o s u r v i v e , t h e n t h e i r p l a n s must be r e s p o n s i v e t o t h e community and must be b a s e d on good i n f o r m a t i o n a b o u t t h a t c o m m u n i t y . Most o f a l l , h o s p i t a l s h a v e a c h o i c e i n i n v o l v i n g t h e m s e l v e s i n communi ty p l a n n i n g o r h a v i n g a r e a l mess on t h e i r h a n d s . . E i t h e r we r e s p o n d t o communi ty e x p e c t -a t i o n s o r t h e communi ty w i l l c e a s e t o a c c e p t u s . I f t h e h o s p i t a l i s abandoned by t h e i r c o m m u n i t y , i t c a n s u d d e n l y f i n d t h a t i t s f a v o r a b l e p o l i t i c a l e n v i r o n m e n t and f i n a n c i a l s u p p o r t c a n d i s a p p e a r o v e r n i g h t . The l o c a l e n v i r o n m e n t c a n be more h o s t i l e t h a n any h o s p i t a l c o u l d r e a l i z e . To e l i m i n a t e t h i s p o s s i b i l i t y , and c r e a t e c o n g r u e n c e between t h e communi ty and t h e h e a l t h p r o v i d e r , s t r a t e g i c p l a n n i n g i s e s s e n t i a l . B e c a u s e t h e r e i s n o t h i n g so c o n s t a n t a s c h a n g e , a s e r v i c e o r g a n i z a t i o n must a c c e p t a p o s i t i o n o f c o n t i n u a l l y p l a n n i n g and e v o l v i n g . The need f o r c a r e f u l and c o m p r e h e n s i v e s t r a t e g i c p l a n n i n g i s i n d i c a t e d by each o f t h e many c h a l l e n g e s t h a t w i l l f a c e s m a l l o r r u r a l h o s p i t a l s i n t h e 1 9 8 0 s : c h a n g i n g p o p u l a t i o n s and c h a n g i n g s e r v i c e s d e s i g n e d t o accommodate t h e n e e d s o f c h r o n i c d i s e a s e and t h e s p e c i a l n e e d s o f t h e a g e d , a l t e r e d p a t t e r n s o f - 182 -health care delivery, innovative use of human resources, and adjust-ments in hospital organization and management. This i s the worst possible time to put a freeze on new programs. If ever in the hist-ory of our health care system we needed innovative policy and administration, i t i s now. What i s most exciting i s that small or rural hospitals, because of their size, are best equipped to shift gears and to be innovative in responding to the challenges that the future can and w i l l bring. As this entire study i s based upon being one of advocacy and prescriptive, I w i l l not hesitate to offer predictions on the future state of strategic planning based on current comments. In most hospitals, less mangement effort w i l l be expended on the creation of expli c i t , formal strategy development processes. Rather, i t w i l l be more widely accepted that strategies evolve gradually and informally as hospitals identify their values and attempt to reflect these values in their services and programs. The key challenge for hospital managers wi l l be to maintain or create a climate supported by value structures emphasizing excellence in programs and services. In a 1982 hospital planning review, James B. Webber (28) predicted a "growing disillusionment with the concept of strategy that i s predicated on the a b i l i t y to predict trends and to prepare for them." Based on research, in the corporate sector, Walter Keichel (29) observes that the concept of corporate strategy i s experiencing d i f f i c u l t y as a viable business management approach. Thomas J. Paters and Robert H. Waterman Jr. (30) note that many of the - 183 -c o m p a n i e s s t u d i e d t o n o t have p l a n n i n g s t a f f s . Where p l a n n i n g s t a f f s e x i s t , f o r m a l p l a n n i n g p r o c e s s e s a r e u s e d t o r e c o g n i z e c h a n g e a s i t t a k e s p l a c e and n o t a s a ma jo r i n p u t t o t h e d e c i s i o n -making p r o c e s s . They o b s e r v e t h a t " t h o s e who i m p l e m e n t t h e p l a n s must make t h e p l a n s . " (31) I n a n o t h e r s t u d y , James B r i a n Qu inn found t h a t , i n m a j o r b u s i n e s s e s , f o r m a l p l a n n i n g p r o c e s s e s o f t e n a r e s e p a r a t e d f r o m d e c i s i o n - m a k i n g p r o c e s s e s , w i t h t h e r e s u l t t h a t s t r a t e g i c d e c i s i o n s a r e made, more o f t e n t h a n n o t , o u t s i d e t h e f o r m a l p l a n n i n g p r o c e s s . " R e a l s t r a t e g y , " he n o t e s , " t e n d s t o e v o l v e a s i n t e r n a l d e c i s i o n s and e x t e r n a l e v e n t s f l o w t o g e t h e r t o c r e a t e a new, w i d e l y s h a r e d c o n s e n s u s f o r a c t i o n . " (32) Q u i n n ' s (1980) s t u d y , c o u p l e d w i t h s u p p o r t i n g a n e c d o n t a l e v i d e n c e f r o m h o s p i t a l s , h a s s t i m u l a t e d a r e c e n t s t u d y o f h o s p i t a l s t h a t , i n p a r t , l o o k s a t t h e r o l e o f f o r m a l p l a n n i n g i n t h e d e c i s i o n -making p r o c e s s e s o f t h o s e h o s p i t a l s . J o s e p h P. P e t e r s and S imone Tseng and t h e i r a s s o c i a t e s c o n d u c t e d i n - d e p t h i n t e r v i e w s a t 10 h o s p i t a l s t h a t were d i s t i n g u i s h e d a s h a v i n g s u c c e s s f u l l y managed some f o r m o f ma jo r c h a n g e . T h e i r p r e l i m i n a r y f i n d i n g s g e n e r a l l y a r e c o n s i s t e n t w i t h t h o s e o f Q u i n n . (33) The u n c e r t a i n t y o f a r i s k y e n v i r o n m e n t a r g u e f o r s t r a t e g i c p l a n n i n g b u t a l s o f o r mak ing s t r a t e g i c commitments i n t h e manner t h a t one p a y s t a x e s : a s l i t t l e and a s l a t e a s p o s s i b l e . We w i l l f i n d t h a t management w i l l r e q u i r e more i n t u i t i v e s k i l l s - 184 -t h a n t h e d e v e l o p m e n t o f t e c h n i c a l l y c o r r e c t a p p r o a c h e s . T h i s p l a c e s g r e a t e r e m p h a s i s on t h e r o l e o f t h e B o a r d , Management and M e d i c a l S t a f f a s s t r a t e g i c p l a n n e r s . T h i s change may be more i d e a l l y s u i t e d t o t h e s m a l l h e a l t h c a r e f a c i l i t y t h a n t h e l a r g e f a c i l i t i e s w i t h t h e i r p l a n n i n g d e p a r t m e n t . These i n t u i t i v e s k i l l s a r e i m p o r t a n t now and w i l l t a k e more i m p o r t a n c e i n two a r e a s o f p l a n n i n g . One, c h o o s i n g w i s e l y f r o m a l t e r n a t i v e s i n v o l v e s u n d e r -s t a n d i n g community e x p e c t a t i o n s o f t h e h o s p i t a l , a h o s p i t a l ' s h i s t o r i c a l r o l e and m i s s i o n i n p r o v i d i n g s p e c i f i c s e r v i c e s and s e r v i n g s p e c i f i c p o p u l a t i o n s e g m e n t s , and r e l a t e d v a l u e s , b e l i e f s , and e x p e c t a t i o n s h e l d by b o a r d s o f t r u s t e e s and key m e d i c a l and management s t a f f members. (34 ) Two, i m p l e m e n t a t i o n a s p e c t s o f a l t e r n a t e s draw h e a v i l y on an u n d e r s t a n d i n g o f v a l u e s , e s p e c i a l l y t h o s e h e l d by a h o s p i t a l ' s work f o r c e . I f a work f o r c e i s d e v o t e d t o e x c e l l e n c e o f p a t i e n t c a r e , management a d v o c a c y o f a h a r d - h i t t i n g , c o s t - c o n t a i n m e n t c a m p a i g n may f a i l i n p r a c t i c e i f i t l a c k s s u p p o r t f o r e m p l o y e e s ' c o m m i t -ment t o e x c e l l e n c e . T h i s l e a d s t o t h e i m p o r t a n c e o f u n d e r s t a n d i n g , a s w e l l a s m a n a g i n g , a h o s p i t a l ' s c u l t u r e . T e r r e n c e E . D e a l and A l l a n A . Kennedy (35) d e f i n e a c o r p o r a t e c u l t u r e a s " a c o h e s i o n o f v a l u e s , m y t h s , h e r o e s and s y m b o l s t h a t h a s come t o mean a g r e a t d e a l t o t h e p e o p l e who work" w i t h i n an o r g a n i z a t i o n . A s Webber (36) s t a t e s " t h e n e x t c o n c e p t u a l wave l a p p i n g a t t h e s h o r e s o f t h e h e a l t h c a r e f i e l d may be s t r a t e g i c management. " - 185 -Whether s t r a t e g i c p l a n n i n g e v e n t u a l l y becomes embodied i n s o m e t h i n g r e f e r r e d t o a s s t r a t e g i c management i s f o r f u t u r e c o n s i d -e r a t i o n s . F o r now, i t i s s u f f i c i e n t t o say t h a t s t r a t e g i c p l a n n i n g i s c r i t i c a l t o t h e h e a l t h f i e l d . I n t h e l i g h t o f i n f o r m a t i o n c o l l e c t e d , r e v i e w e d and a n a l y z e d d u r i n g t h e c o u r s e o f d e v e l o p i n g t h i s document ( P a r t s One t h r o u g h F i v e ) and t h e i n s i g h t s g a t h e r e d f r o m t h e C a s e S t u d y ( P a r t S i x ) , I o f f e r t h e f o l l o w i n g c o n c l u s i o n s : T h e o r e t i c a l s t r a t e g i c p l a n n i n g i s i n d e e d a p p l i c a b l e and  i m p l e m e n t a b l e i n a s m a l l , communi ty h e a l t h c a r e s e t t i n g . T h i s s t a t e m e n t t a k e s on even more c r e d e n c e when one v i e w s t h a t t h e f i r s t s e v e r a l p h a s e s o f " p l a n n i n g " i n t h e C a s e S t u d y a c t u a l l y o c c u r r e d w i t h o u t t h e B o a r d ' s k n o w l e d g e . T h i s i n d i c a t e s t h a t n o t o n l y i s s t r a t e g i c p l a n n i n g a p p l i c a b l e , i t may w e l l be an e v o l u t i o n a r y p r o c e s s t h a t one c a n n o t e s c a p e d u r i n g an o r d e r l y r e s p o n s e t o a c r i s i s . I t may a l s o i n d i c a t e t h a t t h e answer ( s t r a t e g i c p l a n n i n g ) i n d e a l i n g w i t h an u n c e r t a i n f u t u r e i s r i g h t i n f r o n t o f u s and t h a t we a r e o n l y bound and c o n s t r i c t e d by o u r i n a b i l i t y o r u n w i l l i n g n e s s t o p a r t i c i p a t e i n t h e a p p a r e n t demands o f i n n o v a t i v e t h i n k i n g t h a t a r e , i n f a c t , made s i m p l e r by u s i n g t h e s t r u c t u r e d and o r d e r l y f o r m a t o f s t r a t e g i c p l a n n i n g . - 186 - Appendix I (a) F u n c t i o n s o f t h e h o s p i t a l t r u s t e e — p a r t 1 Do you ever wonder just what it is that a trustee is supposed to do. what the chief executive officer (CEO) and the medical staff do, and how the three fit together? The first topic in the Trustee Development Program will focus on these questions. This first unit will identify nine functions of a trustee. Although these functions may differ somewhat from hospital to hospital, they do in general define the role and legal responsibilities of a hospital trustee. To facilitate your learning — or reviewing — these functions, we will present them in two parts. Here are the first four functions. It Is the function of the board of trustees to: A. Establish and maintain procedures for conducting the business of the board. * B. Establish and update goals and policies for the hospital. C. Develop and continuously update a long-range plan for the hospital and ensure that decisions are made in accordance with that plan. D. Monitor and evaluate plans and programs to ensure that they meet hospital goals and policies and the objectives of the long-range plan. Function: A. Establish board procedures for con-ducting business. B. Establish goals and policies. Description: The board develops and follows proce-dures for conducting board meetings; these should be spelled out in the hospital bylaws. The board generates or reacts to proposed goals (the purpose of the hospital, as stated in the constitution, bylaws, and long-range plan) and policies (general statements governing hospital actions). Examples: Follow parliamentary procedures. Hold regular meetings. Keep minutes of meetings. Establish committee structure. Provide high-quality medical care for the entire community (goal). Refuse to perform abortions (policy). Examine the establishment of a new medical specialty in the hospital (policy). Develop and update the long-range plan. The board ensures the existence and yearly updating of a three-year or longer plan indicating the goals, policies, and pro-grams of the hospital, to meet community needs. The long-range plan examines trends in medical care and diseases as well as community characteristics. Make current decisions in line with the long-range plan. Evaluate trends in medical care and delivery. Identify services to be offered and those not to be offered. D. Monitor plans and programs that imple-ment goals, policies, and the long-range plan. The board defines and/or approves specific actions or services that implement goals, policies, and the long-range plan. Approve affiliation with another hospital. Approve acquisition of major medical equipment. Review proposal for addition of burn unit. 1 - 187 - A p p e n d i x I (b) Functions of the hospital trustee — part 2 Here are the last five functions of-a hospital trustee. It Is the function of the board of trustees to: E. Ensure the hospital's financial stability, and a harmonious relationship with government and allied agencies. F. Select the C E O , define his duties and responsibilities, and evaluate his performance. G . Approve selection of medical staff and ensure that it is properly organized. H . Provide a process for evaluation of all phases of hospital performance, including the quality of medical care. ]. Ensure that the community the hospital serves is well informed about the goals and per-form a nee of the hospital; ensure that the hospital is meeting the community's needs. Function: Provide for financial stability. Description: The board is responsible for the approval of budgets and the financial management of the hospital; it reviews the effects of government budget allocations, inflation and new policies and programs on financ-es, income sources, and investments. Examples: Ensure funds are wisely spent. Review hospital occupancy. Make decisions concerning lease or purchase of equipment. P lan development program and engage in fund raising. Select and evaluate C E O . The board selects the C E O , defines his responsibilities, and evaluates his perfor-mance. Identify selection criteria. Conduct formal performance review. G. Approve selection of medical staff and its organization. H . Evaluate all phases of h o s p i t a l p e r f o r -mance. The board is responsible for the actions of the medical staff; the board approves medical staff appointments, privileges, and bylaws; it also approves standards set by the medical staff, requests support information for recommendations, and . approves disciplinary actions. The board is responsible for knowing areas in which standards are important (including both operation of the hospital and quality of medical care), and it en-sures that established standards are met. Approve addition of surgeon to medical staff. Award privileges to physicians. Approve recommended reappointments. Approve utilitation review reports. Approve ranges for efficient depart-mental operation. Question high rate of normal tissues removed. Ensure compliance with various codes and standards. Ensure hospital is meeting community health needs and that community is in-formed. The board must assess community needs and must seek solutions to community health problems through the offering of appropriate services. It must keep the community informed of available services, long-range plans, and hospital rate structures. Survey community health care needs. Provide for special health needs of the hospital's community. Represent varied community groups. 4 The Long-Range Planning Committee's Charge One hospital has labeled the long-range planning committee the chal-lenge committee. Whatever its name. Ihe committee should not begin work until its function has been agreed upon. Here is a suggestion for the charge: The long-range planning committee shall make recommen-dations for long-range goats and objectives for the hospital. It shall attempt to be aware of all developments in the health care field and trends in society and to interpret the effect of these developments and trends on the hospital. A principal function of the committee shall be the development of a written statement describing the hospital's specific role in . the community in relation to alt other health care facilities. The chief executive officer of the hospital shall be on the committee, and the hospital administrative staff, under the CEO's direction, shall assist the committee in its work. There shall be at least two members of the medical staff on the committee. This charge will serve as a model and give you a start on writing your own. Use it also as a resolution to modify the bylaws of your hospital in order to give the committee official status. Now let's examine the charge. It makes clear that the long-range planning committee derives its authority from the board of trustees. That means that, like any other board committee, it is responsible to the full board and reports back toil. The committee's time frame is explicitly long range. It should stay out of current operations and I he administrator's hair and out of the way of the other board committees, which are working on current business most of the time. The committee's job is to consider major issues of all sorts, major projects, and priorities, and to make recommendations to the board. Major expenditures should usually be considered first by this committee and next by the finance committee. 27 The charge implies that the committee has the further duties and obligations to: ' * Develop a framework for orderly decision making, through a defined community role called the mission statement, a'sel of long-term goals and objectives, a strategy for achievement, and a timetable for recommended progress. * Ensure that all recommendations coming from this and other com-mittees fit within the hospital's defined rote, facilitate achievement of its goats and objectives, and follow the long-range plan. It is a con-tinuing obligation of the committee to keep the hospital on course with its plan (or strategy) or to change the plan as new facts and con-ditionsdictate. * Develop a sense of priorities in its examination of issues and projects so that the hospital's limited resources of time and money are spent on those projects that take it the furthest in achieving its defined role in the community. * Act as a vehicle for good communication among the board, the medical staff, and the administration. That is the charge the long-range planning committee needs from the board to get started. SESS10II PEOPLE INVOLVED ACTIVITIES EXPECTED OUTCOME I III IV. Administrator Outside Consultant Administrator Planning Coniiil ttee Administrator Planning Coiimlttee-Ailmlnlstrator Planning Coiiinittca -I'.iMifital urii'iil.iLlnii Lit planning -Itnli.' of Planning Cnmiilttee -1*1 nunii• ij l.i'.t-.S -General HI sons Inn iif lln'.pltnl-relaled iiiln., slats, trends -tnlroiluclInn of ''immunity Survey -What ill) wu ilu next? - Informa t tun/Edui:al lunal 11.inn * -Hrlef Keview nf Hole ami Casks of Planning t'oimil LIi:c -Strengllis/We.irue'.sos Assessment -I)isenssinil of Mission Statement -llevlcw of a ilrnfl "Cuiumuilly Survey" •llliat ilu VII; dn next? -1 itronna 11 un/Kiliica 11 una I I tan -Itevlew Strengths/Weaknesses Listing -I'rluri 1.1/0 tup fi SLI-CIMJl.lis tn huilil on -Prioritize tup 'i Weaknesses to address -llelate ti> a future Mission Statement -fliiall/u Cniiiitiinlty Survey -What do we iln next? -1nformat ioii/r.ilut:at lonal I tem -0if.cnss preliminary results of Survey •Dlscusslim iif "Issi'u* (see format) -Discussion X development of Institiiliniial Coals -What do we iln next? Promote discussion of planning Answer questions about hospital, plannlnij, externa! agencies Initiate thinking about strengths and weaknesses Listing of Strengths Listing of Weaknesses Develop appreciation and under;tandIng of Mission Statement Gain Consensus on Survey Prioritization of areas to address Consensus on Survey Draft of a future Misslcui Statement Identify what Is to be addressed at next meeting Iteach consensus on a rccoiiincndatlon pertaining to 'Issue f l * Identify further Informational needs CO V, VI, VII Could- take same format as 11V or until all major Issues have been addressed VIII IX X Administrator Planning Committee Administrator Planning Committee Administrator Planning Committee Hospital Hoard -Finalize Mission Statement -Review draft or the Written Plan -Uiscuss additional areas of concern or Interest that may not he of tinned late concern to Committee, I.e. wliat should we he consIderlng after tills? What shuuld future goals he? -What do we do noxt7 -Finalize above from Session VIII -Present to Hospital Doard for approval. o Finalize the plan and prepare to present to Hospital Doard Identify future role of the Planning Count I ttee > TJ •a 3 - 190 - A p p e n d i x IV PLANNING CHECKLIST The S t a t u s o f Y o u r Need f o r P l a n n i n g : 1. Where i s y o u r l o n g - r a n g e p l a n n i n g document? 2. What i s t h e c o m p o s i t i o n and f u n c t i o n o f y o u r Long -Range P l a n n i n g C o m m i t t e e ? Do you have o n e ? 3. I s t h e n a t u r e o f t h e a r e a a r o u n d t h e h o s p i t a l c h a n g i n g i n any s i g n i f i c a n t manner ( c o m p o s i t i o n o f p o p u l a t i o n , a v a i l a b i l i t y o f h e a l t h f a c i l i t i e s ) ? 4 . What s t a f f r e s o u r c e s a r e d e v o t e d t o t h e h o s p i t a l p l a n n i n g p r o c e s s ? 5. What a r e t h e p o p u l a t i o n t r e n d s i n y o u r s e r v i c e a r e a s and what a r e y o u r p l a n s t o accommodate t h e p o p u l a t i o n and meet t h e need f o r s e r v i c e s r e q u i r e d by t h a t p o p u l a t i o n ? 6. Does t h e h o s p i t a l know t h e r e g u l a t o r y r e q u i r e m e n t s a f f e c t i n g i t s f u t u r e p l a n s ? 7. What new p r o g r a m s o r s e r v i c e s a r e you p l a n n i n g t o p r o v i d e i n t h e n e x t y e a r ? N e x t t h r e e y e a r s ? N e x t f i v e y e a r s ? - How were t h e s e i d e a s i d e n t i f i e d ? - Does y o u r m e d i c a l s t a f f a g r e e w i t h them? - What i m p a c t w i l l t h e y have on e x i s t i n g s e r v i c e s and p r o g r a m s ? 8. What e x t e r n a l f a c t o r s do you c o n s i d e r when d e v e l o p i n g y o u r p l a n and y o u r b u d g e t ? What i n t e r n a l ( e . g . c o s t c o n t a i n m e n t ) f a c t o r s ? 9. What a r e y o u r s p e c i f i c g o a l s and o b j e c t i v e s f o r t h e n e x t y e a r and o v e r t h e coming f i v e y e a r s ? 1 0 . A r e t h e r e p r e s e n t l y any f u n c t i o n a l d e f i c i e n c i e s i n t h e e x i s t i n g s i t e and b u i l d i n g s ? Do a l l f u n c t i o n a l f e a t u r e s c o n f o r m t o c u r r e n t minimum s t a n d a r d s ? - 191 -P l a n n i n g C h e c k l i s t - C o n t i n u e d 11. A r e t h e e x i s t i n g l o c a t i o n and a l l o c a t i o n s o f s p a c e f o r e a c h d e p a r t m e n t a d e q u a t e i n r e l a t i o n t o t h e p r e s e n t and f u t u r e o b j e c t i v e s o f t h e o r g a n i z a t i o n ? 12. A r e t h e r e any o t h e r p h y s i c a l p l a n t p r o b l e m s o r d e f i c i e n c i e s w h i c h d e t r a c t f rom e f f i c i e n t b u i l d i n g o p e r a t i o n ( e . g . m e c h a n i c a l , e l e c t r i c a l and v e n t i l a t i o n s y s t e m s , e t c ) ? 192 - Appendix Province of Ministry of British Columbia Health H O S P I T A L P R O G R A M S F I N A N C I A L R E P O R T F O R T H E M O N T H S E N D E D . H O S P I T A L N U M B E R . A . I N C O M E 1. HOSPITAL mOGUMS-HTFAnCMT 2. H O S P I T A L "(KNAMS-CO-mtimANCK 3. H O S P I T A L P R O G R A M S - O U T P A T I E N T 4. HOSPITAL PROGRAMS-SUS TTJIAL 5. IONO TERM CARE-INPATIENT f. OTMI «J. IMPATtE NT 7. OTMtR-OUTFAWNT I. ROOM tMFfI«CNTIAL{IO(MI t. C A F E T E R I A 10. O T H E R (MCOMf It. tm TOTAL ft TO 101 12. R O O M D I F F E R E N T I A L |40«| 11. HCTMCOMIMI U S t 12| 14. tXCLUOASLC (MCOW( II. OPERATING tNCOME (19 U f l 14) B . E X P E N D I T U R E S 1. SALARIES S WAGES 2. PROFESSIONAL FEES 2. EMPLOYEE SENEFfTS 4 . ME0*CAL / SURGICAL SUPPLIES 5. DRUGS S. DIETARY FOOD * SUPPLIES T. P L A N T MAINTENANCE •. U N I N 4 LAUNDRY t. RATH NT CARE. MAGNOSrrC * THERAPEUTIC 10. ADMINISTRATIVE 1 GENERAL SUPPORT 11. RIANT ORE RATION S HOUSE MERINO 12. OTHER 12. BADOESTS 14 . SUV TOTAL (1 TO 13) 15. IXCLUOASLE EXPENDITURES It. OPERATING EXPENDITURE ( 1 4 LESS 11 ) 17. SURPLUS / DEFICIT PROJECTED YEAR I NO SURPLUS / DEFICIT NOTES N A M E ( P L E A S E PRINT) H U M 1I3SS (MIA 3St| R E V tl/O* TfTU SIGNATURE DATE - 193 -Province of British Columbia Ministry of •Health HOSPITAL PROGRAMS S U P P L E M E N T A R Y F I N A N C I A L R E P O R T F O R T H E M O N T H S E N D E D H O S P I T A L N U M B E R . A . A U T H O R I Z E D C H A R G E S ( C O - I N S U R A N C E ) I N P A T I E N T ( H O S P I T A L P R O G R A M S D A Y S ) ACUTf /REHAB EXTENDED CARE CHARGED TO HOSPITAL PROGRAMS LONG TERM CARE CHARGED TO PATIENTS. CTC. TOTAL B . H O S P I T A L P R O G R A M S A D V A N C E S BALANCE ENO Of CURRENT MONTH C . S T A T E M E N T O F W O R K I N G C A P I T A L • C U R R E N T A S S E T S t. CASH >. RfVESTMENTS J . ACCOUNTS RECEIVABLE SCHR 4. ACCOUNTS RECEIVABLE OTHER 5. INVENTORIES B. PREPAIO EXPENSE 7. OTHER S. TOTAL C U R R E N T LIABILITIES t, BANK LOANS / OVERDRAFT 10. SALARIES k WAGES PAYABLE 11. EMPLOYEE DEDUCTIONS PAYABLE 11. ACCRUCO HOLIDAY t SICK RELIEF 13. OTHER ACCOUNTS PAYABLE 14. OTHER 15. TOTAL IB. WORKING CAPITAL OPERATING A/C CAPITAL A C D . C A S H F L O W P R O J E C T I O N - O P E R A T I N G F U N D MONTH MONTH MONTH 1. CASH ON HAND. BEGINNING OF PC*100 RECEIPTS 3. HOSPITAL PROGRAMS 3. M.S.P. 4. OTHER S. TOTAL CASH AVAILABLE PAYMENTS B. PAYROLL 7. EMPLOYEE DEDUCTIONS PAYABLE B. ACCOUNTS PAYABLE B. OTHER 10. TOTAL CASH DISBURSEMENTS 11. CASH ON HAND. END OF PERIOO |1 •S-IOI P R E P A R E D BY: D A T E : T ITLE: KITH IS JSC (MIA ISC) REV BJ/04 - 194 -Province of Ministry of British Columbia Health HOSPITAL mOGMAMS STATISTICAL REPORT FOR THE HOSPITAL N A M E . M O N T H S E N D E D 19 LOCATION : _ A . B E D S . A D M I S S I O N S . PAT I ENT D A Y S . E T C . ACVTI/MMAi 1 E X T E N D E D C A M a iONC T E R M PATIENTS i N E W B O R N 4 U)MC T E R M C A R E P R O G R A M • 01. MTONT D A Y S -HOSFTTAL P R O G R A M S 01. M T I I N T DAW-OTHER 03. A D M I S S I O N S 04. S E P A R A T I O N S 01. TOTAL DATS S T A Y - S E P A R A T I O N S Of. M N A O f U M T M Of S T A Y 07. RATIO U M ( A P P R O V E D , oi . M M S E T U P Ot. P E R C E N T A G E O C C U P A N C Y B. T Y P E S O F C A R E 10. MEDICAL 11. SURGICAL 11. MEDICAL/SURGICAL UNDIFFERENTIATED 13. PAf DtATWC 14. OBSTETRICAL 15. CU/COJ II. OTHER CRITICAL CARE (SPECTEr) 17. PSYCHIATRY U. REHABILITATION tt. OTHER (SPECIFY) JO. TOTAL PATIENT D A Y S C . L A B O R A T O R Y U N I T S (ENTER STANOARO LABORATORY UNITS FOR TECHNICAL ANO NONPROFESSIONAL WORKLOAD - DO NOT INCLUDE UNITS FOR PROFESSIONAL COMPONENT OF WORK SUCH AS MEDICAL INTERPRETATION. ETC., REFERRED IN 0MCL. PUBLIC HEALTH) ROUTINE HEALTH EXAMS. QUALITY CONTROL ETC. NUMMR OF TESTS REQUESTED FOR TOTAL TESTS MOUES1E0 ON SPECIMENS MFERRED OUT 3 NUMBER OF TESTS REQUESTED FROM INPATIENTS 1 OUTPATWN1S a PROV. OWNEO LABORATORIES 4 OTHER HOSPITALS. RED CROSS S OTHER LABORATORIES 6 N O T E S H U H 1l3t* ( M A I S A ] R E V tl/04 - 195 -Province ol British Columbia Ministry ol Health HOSPITAL PROGRAMS PAGE 1 Of 4 STATISTICAL REPORT FOR THE MONTHS ENDED . HOSPITAL NAME . LOCATION 0. SERVICES WHICH MAY BE PROVIDED BY LABORATORY. RADIOLOGY, OR A SEPARATE ORGANIZATIONAL UNIT OF THE HOSPITAL (00 NOT INCLUDE UNITS REPORTEO IN SECTIONS C or E) . MUMS Eft Of ST AN OA* D UNITS NAME O* ORGANIZATION CAR RV ING OUT THE SERVICE oa. sec 03. ULTRASOUNO 04. NUCLEAR MEDICINE 05. OTHER (SPECIFY) E. RADIOLOGY THERAPEUTIC RAOIOIOOY OS. NUMBER O* TREATMENTS BY HOSPITAL OUTPATIENT SCANNINO (CAT.) 07. NUMBER OF EXAMINATIONS OS. NUMBER Of STANDARD UNITS DtAONOSTIC (INCLU01N0 FLUOROSCOPY) M. NUMBER OF EXAMINATIONS 10. NUMBER OF STANDARD UNITS OUTPATIENTS |tt*CL ROUTINE EXAMINATIONS-STAFF) F. PHYSICAL MEDICINE AND REHABILITATION PHYSIOTHERAPY BY OTHER HOSPITAL STAFF OR OUTSIOE AGENCY FOR PATIENTS OF THE HOSPITAL  OUTPATIENTS 11. NUMBER OF PATIENT ATTENDANCES ia. NUMBER OF WEIGHT 10 UNITS OCCUPATIONAL THERAPY IS. NUMBER OF PATIENT ATTENDANCES 14. NUMBER OF WEIGHTED UNITS OTHER THERAPY 15. NUMBER OF PATIENT ATTENDANCES O. RESPIRATORY TECHNOLOGY IS. NUMBER OF TREATMENTS AND DIAGNOSTIC PROCEDURES MLTM 1B»A{HIA 3SA) REV 12/04 - 196 -Province of British Columbia Ministry of Health HOSPITAL H»OG«AMS STATISTICAL REPORT FOR THE • MONTHS ENDED . HOSPITAL NAME . LOCATION H. SURGICAL SERVICES 01 NUMttft OT VISITS 0UHING WHICH OPfPATTONS. TH CATMINTS OH CXAMINATIONS Wt*t CAPHtO OUT IN THE SU"G*CAL SUIU. 03. ItUMIEP. OT HOUHS—OnnATIHG HOOMS 0). riuMSin OT IIOUP.S-P.AP.. INPATIENTS 1 OUTPATIENTS TOTAL CARE 1 ALL OTHER OUTMTIEN1S 3 'llllllllllllll mi ium 'llllllllllllll I. EMERGENCY UNIT 0« NUMBER O* VISITS TO EMERGENCY UNIT {INCLUDE ALL URGENT 4 SHORT STAY VISITS. DO NOT MCLUOE SLWGtCAL DAT CARE OR ORGANUEO OUTPATIENT CLMKSJ J . AMBULATORY CARE OS. FSYCHWTRIC OAY / NIGHT CARE 04. OtABETtC OAT CARE 07. RENAL DAT CARE OB. nvoMTRrc OUTMHENT OB. DIETETIC COUNSELLING 10. GENERAL • SPECIAL CLINIC* It. OTHER OUTPATIENT NUMBER OF VISITS NUMBER OF PATIENTS K. DIETETICS (MEAL DAYS) IJ. PREPARED BY HOSPITAL 13. PURCHASED FROM OTHERS INPATIENTS 1 OUTPATIENTS 2 STAFF AND VISITORS 3 SUPPLIED TO OTHER INSTITUTIONS r TOTAL MEAL-DAYS S L LAUNDRY (SOILED WEIGHT • KILOGRAMS) t4. DONE FOR OWN HOSPITAL IS. DONE FOR OTHER HOSPITALS / INSTTTvTlONS I t . TOTAL NOTES — DONE IN HOSPITAL 1 SENT OUT a TOTAL 3 | HUM IS3IA (HIA 31 A) REV B3/D4 - 197 -Province of British Columbia Ministry of Health HOSPITAL PNOGAAMS P A G E 4 0 * 4 S T A T I S T I C A L R E P O R T F O R T H E M O N T H S E N O E O . H O S P I T A L N A M E . L O C A T I O N M . N U R S I N G P E R S O N N E L 1. MEDICAL J . SURGICAL 3. MEDtCAL/SUHCCAL UNDIFFERENTIATED 4. PAEDIATRICS s. R I H A H U T A no* s. tcu / ecu 10. OBSTETRICS 11. PSYCHIATRY 12. EXTENDED CARE 11. SUBTOTAL—INPATIENT (1-13t 14. LABOUR m DELIVERY IB. NURSERY IB. SURGICAL SCRVtCES 12. P A R . IB. EMERGENCY IB. AMBULATORY CARE 20. OTHER NURSINQ 31. SUB TOTAL |13-201 31. OTHER NURSES 23. NURSINO ADMINISTRATION 34. TOTAL (21-1«| N . O T H E R P E R S O N N E L / / 2S. LABORATORY \ 2S. EX.G*. 27. E C O . 2B. NUCLEAR MEDICINE I t . PHARMACY 30. RAOKXOGY 31. PHYSIOTHERAPY 31. OCCUPATIONAL THERAPY 33. OTHER THERAPY 34. RESPIRATORY TECHNOLOGY 36. DIETETICS SB. SOCIAL SERVICES 37. MEDICAL RECORDS 35. SUB TOTAL (26-37) PAPA-PROFESSIONAL 3*. ADMINISTRATION 40. MATERIALS MANAGEMENT 41. LAUNDRY m UNEN 42. HOUSEKEEPING 43. PLANT OPERATION t SECURITY 44. PLANT MAINTENANCE 41. OTHER (SPECIFY) 4B. OTHER (SPECIFY) 47. SUB TOTAL (3B-4B) 4B. SALARIED MEDICAL STAFF 41. STUOENTS-MEDICAL BO. STUOENTS-NURSING SI . STUDENTS-PARA-PROFESSIONAL SI. STUOENTS-OTHER S3. SUB TOTAL (4B-S2I O . T O T A L P E R S O N N E L S4. NURSING (LINE 24. COLUMN 3) IS. OTHER PCRSONNCL (UNt 47) SB. MEDICAL STAFF (LINE 4B| 17. SUB TOTAL (LMES M* t l *SS ) SB. STUOENTS (UNt SS) IB. TOTAL (LINES B7«SI| HLTH 1 I 3 S A (MIA 3 S A I R E V S 2 / 0 4 - 198 - A p p e n d i x V I STATISTICS CANAOA WORKSHEET ONLY 1 9 8 2 - 8 3 A N N U A L R E T U R N O F H E A L T H C A R E F A C I L I T I E S - H O S P I T A L S P A R T O N E HEALTH AND WELFARE CANADA (01) Norn* of ke»piiol . St.eel and M I M M I Cily, ele. - ,..LLU LLU TYPE CLASSIFICATION OF HOSPITAL - Check o. .p.cily oil epp.op.;.i. »••>• '•• " pe.ied) OWNERSHIP AND OPERATION (check »«ly •» t»«* t.l««i») Pwblic (inel. V.lwnl.ry, Pre.. 6> Munic.) 02. 03. Prepriafery Federal . . M IQ SERVICE General - »i>""«' »""• °" D . .iih I.n. •.•» Speciolty: P.di • Oik- (.pecily) Rehobilitetien (inel. Con.e1ef.eenl) 0•, O E.fended Cor. liiMl. Ch.enic) • O.he. (ippcily) "" Owntl (.hip 11 ii 14. IS. 16. 17. IB. Ley eofpoioli.n . , , _ R.ll,!... ....nil.!!.. Red Crete Municipal (wni.n *r ho.pitol di.u.el) . Pf.vi.ciet .— .- — Federal Proprietory „_ -—— . >•»• ' " • . . -III • '»• • . ••>• ..!»•• . !•>• ' •»• SIZE Rfl.ee Baa Capaci.y lAewlii end Child.on) . M i l l CERTIFICATION I h.<*»r ctify thot to th* k..f <"r l-na-.*dg* th* doto cantain*.! in .hit -*tu.-n f«pf»»«nt a tto* tta.*f"*n» eone*f«in| lh* **»*•!•»•• »• »•'*•€•» «n« a*p*nditvr* al th.* ho-pitgl. Signal*** *f Ho»piiol Avthafity Thi. r.twrn «a« k**n ea«p.*t*d in accordant* -ith th. Sfoii.tie. Act and .ilk th* f*Stfif*m*nti of th* Hatpitol In.vranc* and Oios«*»«ie S*»v.t*» Act, th* R*gulal..»n« thatawnd**, ant. th* Agr**n.«nl, and i» *ppr*>*d. SUPPLEMENTARY INFORMATION SpttCKil ••ptanotwr not.t an »igntficont chang** durinej ,h* d*»C»*«i Infha |n»tf«etion. ond 0*1 inition*- ( if no* • w d i c M n t spec* pl*o»* ca-"pUt* • uppl.m.nlory peg*: Euplonaiaiw Nat**): FOR OFFICE USE ONLY Do.. Rac'd (Cord**. Entarad • Pag*t Blank . — P,al\ Edit Dan* Qw*ri*d - — R*plp Adj Arith. Ch*ek • Final ln*p 1 B-2300-13.1 PART ONE - P. I *f IB, - 199 - A p p e n d i x V I I STATISTICS C A N A D A WORKSHEET ONLY M E A L I H A N D W E U F A R E £ A N A D A 1982 • 83 ANNUAL RETURN OF HEALTH CARE FACILITIES - HOSPITALS PART TWO Nom. af hoapilol . Str..l ond n u m b . , Cit,. to-n. .Ic. - P . . * ; B « . ^ : PMWI "do I I I I l l HOSPITAL CERTIFICATE I h.r.by «"i'7 tk« »• lh. »••» ef my hno-ladg* tho dot* contoift.d in lKi» t.twrn ,*pr.*.nt a lrw. H O M M r t of th. f.none id op.rotion* ol (hi* ho.pitol. Signature e' Mo»pilol Authority AUDITOR'S/AUDITORS' REPORT I/.. ha.. . . o m i n . d t h * Bolanc. Sh..t. «f t h . abo..-no-.d h o s p i t a l a. Ol 19 . o n d t h . Summo.y «f Op.roting E.p.n... Slot.r-ant of lr.com., ond Support ing »tot.m.nt«, >ch«dul«* and O n o l y . . . fo* tho y.ar t h . n o n d . d . M,/0gf . . o m . n g i . o n i n c l v d . d . fl.ft.tol r.»i.w of .K. a c coun t i ng proce-d u r a l o n d *ueh f «* t* of a c coun t i ng r e c o r d * and Othor tup port ing o v i d o n c * OS !/•• c©n»id.r.d n*<.**ary in th. <ir«um*tonc.». Q u a l i f i c a t i o n * : In my/our opinion, »ubj«et to lh. qualification* ».» out in th. pr.c.ding paragraph, th. attached financial *tet.m.nlt pt.S.nl fairly th. finonciel poii-. of th. Hoipitol a* ot 19 , th. r.»uln of it* operation* for th. y.or then .nd.d, in occordonc. with g.n.rolly oet.pt.d hoip.lol accounting principi** Cppliod on o bo»i» con*i*t.nt with that of lh. ptoc.ding y.ar. Auditor/Auditor* (Signature of Auditor /Auditor*) FOR OFFICE USE ONLY Dai. R.c'd — (Card*. Ent.rod Pag.* Blank ... . Prof. Edit Dona Queried • Reply Adi _ Atith. Chock Final ln»p __ B-2300-14.1 PART TWO - P. I *' 10 - 200 - A p p e n d i x V I I I Statistics Canada Stat'tstique Canada Quarterly Hospital Information System Statistics Canada Canadian Hospital Association HOSPITAL WORK1NC COPY Please return copy with address label to Institutional Statistics Sect ion, Statistics Canada in return envelope. Si voui prctcrci rtcevoir c« quettionniire en francais. veuillcz cocher Q (01) CLASSIFICATION OF HOSPITAL - Check Ol specify all appropriate ilemi (al at end of period) TYPE Public (ind. Voluntary, Prov. & Munic.) Oil Proprietary 021 Federal 031 SERVICE Ceneral - no long term units 041 - with long term units OSl Specialty: Pediatric 061 Other (specify) 0' 1 Rehabilitation (incl. Convalescent) 081 • Extended Care (incl. Chronic) 091 • Other (ipecify) 101 D. OWNERSHIP AND OPERATION (check one only in each column) Voluntary Ownership 12. Lay corporation 132 • 13. . Religious organization 132 G 14. Red Cross 142 • 15. Municipal (union or hospital district) .... 1S3 • 16. Provincial HI • 17. Federal 172 • 18. Proprietary 112 Q Operation 3 123 • 133 • 143 • 1.3 • 163 • 173 • 183 • 11. SIZE - Rated Bed Capacity I 1 I I I Trie rated bed capacity is the number of beds and cribs that the hospital (or a unit or the hospital) has been approved to accommodate, on the basis of established standards of floor area per bed. This capacity would have been approved at the time of: a) original construction, or b) after completion of additions or other structural changes. NOTE - Beds in the following areas should be excluded from the rated bed capacity: labor and delivery rooms; beds in diagnostic and treatment areas designed for patient rest immediately before or after receiving services; beds in outpatient and emergency units; beds in employee quarters including those used for sick staff; post-anesthesia recovery beds; beds in Day and/or Night Care Units. GENERAL INSTRUCTIONS (.Constant reference should be maJe to the Instructions and Definitions contained on these pages. For more detailed definitions check the Instructions & Definitions (Part I A Part II) for the Annual Return of Health Care Facilities - Hospitals. 2. For items not specified on the form USE lines designated as "OTHER" and provide supplementary information ON THE BACK OF PACE 7. 3. DO NOT use shaded areas. 4. All data, except beds, must be cumulative year to dale, therefore the data for the reporting quarter must be greater than data in pre-vious quarter. If the data reported this quarter aie less than in previous quarter, please give an explanatory note ON THE BACK OF PACE 7. 5. Do not report credits. The computer program will not accept credits in cxp«nsc accounts. 6. Should you have any problems in completing this return please contact Carry MacDonald. Production Manager, Doris Galling*' or Carolyn Lumsden - (613) 995-0991. ' Completed by: Telephone Number ( ) (Nim<> (Date) Area code 8-2300-IS.I: 22-2-82 BI0I619 - 201 - A p p e n d i x t-IOUP: IT MOSPlULt S02 - NlTtl MIU*IC0R0I>C MOSPITU t fl Fl I 1 I t 0 M a «. » i i a i B r » a t T D I w a I M I g . _*.».. •.Mir HI D * ..CUTE /"»[ Mi* ClTCNCCO ClBE LONG TO* ••TKNTS Nl •VBDH1. LONG lt«- CMC P*0ERIH • t-EJGHHD TCHL.OITS C. »*tRitVC STlT - ftCUIC/BCHIS •ITl Nl CftVUtS 1 BE 1T KEN 1 CLINKS tNCPGCNCT UNIT _PI*61CSTIC.CLINJCS_ SUBGIOL SUITE M Q S P l T t l P I 0 V I * C E fULL TIME COUIVALCM ST»ff NURSING 01M[» TBCATNENTS ( DllCNOSTlCS >u»ro«l_. S l U O r N T S SILMICD NCDICaL Stiff I O T I L s t*rr . I N C O N C JtOSMTll M0«»lRS_ N 3 S P I T I L MOG1.IHS OlMCR IkPlTltNT O T H E R OUTPATIENT 01HE* INCOME L E S S CXCLUOlllE HC0"C OPCBlTIHt INC0«tt EIPENOITUBtS S I L M I C S ( witts PKOrtSS10-.lL FEES CiPLCTCC BENEFITS _PCD1C*1/SU*G1CII SUMLItS -o««ucs D1E1*"T F O O D t SUPPLIES P L « N T P . I I N T C N I N C C LIMN ( L * U N D C Y PIl.tNI C M C , O i l *jnj-iii?r » T i v c t ttut«*L S U P P O R T ~PL»».T CPE«MIS« I MOUSE* t l M -»S C t H C B B I O DEBTS SUM3 ML LESS ElCLUOIBlC EIPE1011U«C1 _pPr»»,TlHC I*PCDITLUE SURPLUS/0EF1CIT PkOJCCTED TE*• E NO SUBPLUS/QEFIClT ?}c ). *. *  T S.P.0 0 -c. ? y. L. .0 » T J . N'JNfct R O F MOSPITILS R C P D B 1 1 - . B IS *.2*4 5**01 INPtllCNT I,SOI OtfTPMICM 2.35* 1*SBS i.m_ 1*0 nc si«rr 2B.4 _ua_ 0.0 t/BT-..III.. INQUNl l.JLP2*04l_ 23,323 12*,)43 3*.4*4 1MOUNT S/VT-OA r i 1,707,007 1SS.S1 4B C 0.00 0 155,7,4 11.12 B • 0, 100 4.BS 2 27, BIB 1 IS.102 7.1* 3 IT,COS 1.04 0 52.040 B-.2* 2 • l.H* 11.02 * • 0,7-10 t.74 4 44.3B4 S'.JS 2 0 0.00 0 10,110 1.31 0 1*171,t44 224.1* 19C f> 0 0.00 0 9 I.BTl.ff44 224.1* 100 0 113. Ml J'""-. 27.3SB /J»V7.1 7,10* Jjif-l B.7J7 1,01* <<* S.3 3,114,270 1,*S0.*2* 227,2*3 271.5*7 20**4C4 __5.**2.l»2 . )NP4TIC«T OUTP* TlfNT INPlI.t«T 17.I2B »**'. 45.211 J-***-* I.SSI,II* 2,l*t 42.JSS I""** 5V.74B _2B , ! 3 0_£ Qi Lg_ 41, J 4< 7 } 11 S , 3 7 7 _ ,47* />!•>"* 2.S32 111.SI) rit sTirr • 4».l 2SS.3 217.1_ 0.2 0.0 flT.% •Nou«r _*J»0B7,*77_ 41*,370 7.351,0*5 3*****714 *73.**3 151,777 _J3..«3».52i_ •/*T-D*T _l>7-01 3.to /II.Tl 13.*4 •POJuT 23,871,470 501,713 2.BT*.717 Ttt.1,4 T7S.7D4* *3t,3ll $00**1* 3*0,II* 1*441,442 1_,T00.2$* l,"3"3S,Wl" 41.344 •1*7*0 3*.Ml ,»7» 1)3**00 -l5.tU7j.UJL. 1*140,7*5 S/HT-PAf 1*1.** REPORT -NO. 30" TYPE 8L ' MINISTRY OF HEAL TH * HOSPITAL PROC RAMS 1982/83 HOSPITAL INDICATOR REPORT 07/11/83 PAGE MATER MISERICORDIAE . ROSSLAND . (802) PEER GROUPI 50 ._ ._ —.. TEAM 1 CARIBOO, CK.ANAGAM, -KOCTENAYS LAST REPORTED MONTH: MAR TAKEN FROM REPORT NO. 11 12 22 20 INDICATOR X OCCUPANCY BASED ON RATED BEDS - MONTH .X_OCCUPANCY BASED ON RATED BEDS - YTO X OCCUPANCY BASED ON BEOS SET UP - MONTH X OCCUPANCY BASED ON BEDS SET UP - YTO ACUTE/REHAB AVERAGE LENGTH OF STAY EXPENDITURES PER WEIGHTED PATIENT DAY WEIGHTED PATIENT DAYS PER FTE COST PER FTE -X NURSING FTE .TO TOTAL FTE X GRADUATE TfJ TOTAL NURSING FTE WEIGHTED PATIENT DAYS PER NURSING FTE OPERATING ROOM HOURS PER INPATIENT .. OPERATING kCLM HOURS PER S.D.C.VISIT VISIT STANbARO ' L'AB'UNlTS'PE^LA^ X SURG"DAYCARE VISITS TC ST AND ARO. LAB-UN ITS PERWTD.-PATIENT. OAY.._ KILCS OF LAUNDRY PER LAUNORY FTE KILCS OF LAUNDRY PER WTO. PATIENT DAY MEAL DAYS PEN DIETETIC FTE X INPATIENT MEAL DAYS TO TOTAL MEAL DAYS FOOC AND DIETARY EXPENSES PER MEAL DAY HOSPITALS STATISTIC 49.1 . . _ . 5 0.0 .. 49.1 26,866 — . • 5 3 . 3 i.3:l \\n 104,s4a 20.a 1:1 1,600.1 61,2 PEER GROUP STATISTIC 58. <> 58.7 .. 57 . 6 5 7 . 210.50 168,0 26,990 _.«6.0 . 66.6 365.a 1.12 0.83 109,7 i i ...... 43.3 .... 24,94|.| 1(85213 66.8 4.21 VARIANCE 9.8-.4.7-8.5-}'"' 0.1-3.81 5.3-124-7.3 7.5-60.0-0.09-0.03 s J s i : 22.9-2 4 . 9 4 3 : ! -252.2-14,4 0.83 VARIANCE AS A X OF PEER GROUP 16.6-8.0- .. 14.8-5.9-l « S " 1.8 3.2-0.5-15.9 .. 11.3-16.4-8.0-?:J-4 . 7 -52.9-!. 100.0-5.5 13.6-21.6 19.7 ro O r o > •a CD o. "•REP0R'T~N07~01 ~ TYPE L MATER MISERICORDIAE ROSSLAND (NU. 802) hlNISTKY" OF HEALTH "~HTfS"'P-lTAL: P R ' U G R A M S ' DETAILED 1982/63 FINANCIAL REPORT PEtR GkOuP 50 LAST REPORTED MONTH I MAR 07/05/83 MAGE RESPONSIBILITY: (JAVIL) fi ILKS CATEGORY HOSPITAL PROGRAMS - INPATIENT HOSPITAL PROGRAMS - COINSURANCE HOSPITAL PKO&RAMS - U U I P A T I E N T ~ H 0 S P i T A L PROGRAMS - 5UbTOTAL LONG TtRM CARE - INPATIENT OTHER - INPATIENT OTHER - OUTPATIENT ROOM DIFFERENTIAL (100X) CAFE1EKIA OTHER INCOME SUB TOTAL (LINES 1 TO 10) ROOM DIFFERENTIAL (40X) NET INCOME EXCLUDABLE INCOME OPERATING INCOME SALARIES"'* WAGES PROFESSIONAL FEES EMPLOYEE B E N t F l T S MEOICAL/SURGICAL SUPPLIES DRUGS OIcTARY FOO^ » SUPPLIES 82/83 YTO ACTUAL ( i ) 1,448,9118 3,113 23,323 I'lil'Yal 0 160,566 1C4,3o3 8,050 MARCH 31 82/63 PROJ CTUALS IJ) 1.498,940 3.113 18,740 1,520.801" 160,568 124,363 6,050 U:3ti PLANT MAINTENANCE -LINEN &_LAUNDRY. . PATIENT CAKE, OIAfj . , „. . THER. ADMINISTRATIVE i GtNERAL SUPPORT PLANT UPEHATIONS ArtO HOUSEKEEP*-OTHER BAD DEBTS SUBTOTAL ..EXCLUDABLE. EXPENDITURES ._ OPERATING EXPENDITURE SURPLUS/DEFICIT ING 1 , 8 5 2 , 9 8 1 ..... , 4 i 0 I ,849, 7ol 0 "178497761 1,267,002 ~ 0 155,716 40,100 27,876 tf'.tti 5 2 , 0 b 0 -91,194 60,740 14,066 0 10,860 — _0. -1.8/l79b6 22,205-1,848,398 3,220 1.64b7l76 0 "I78457I78 T72877do"2~ 0 155,716 40,100 27,878 bb, 30i> 17,006 -52, 060-44,086 0 10,880 1.671,96b 0 i.871,96b 26,788-MARCH 31 82/83 APPR BUUGtT ( i ) FAVOURABLE/ UNFAVOURABLE BUOG VAR PRUJ X INC UVtR 82/63 BUuGtT (A) 1,498,948 0 18,740 1,517,666 0 162,925 113,031 9,512 15,9b0 0 3,113 0 2,357-11.332 1.462-4,42b-0.00 O.Oo 0.00 0.2| 0.00 1 .45-10.03 15.37-~"l7s227565 3,805 "257833 585- x\:\u 1,618,760 0 26,416 0 1 .45 0.00 1,818.760 26,416 1.45 "T, 310,500 ' 131,050 36,212 25,650 58 ,4e6 24,696 -37,721. 82 ,966 67,898 39 6«7 3,772 0 23.498 "" 0 24,666-3 .686-2.226-6.634-7.666 14 ,339-.6.206-l e . 6 4 2 -4,479-3. 772 10.680-1.79 0.00 18.82-10.7*-8.69-»I . e9-31.66 38.01-18. J i -l l . 3 i -100.00 O.Ou 1,818,760 . 0. .. 53.206-• 0 2 .93-O.Ou 1,818,760 53,20b- 2 . 9 j -0 26,788- 1.47-o c .x-4 — 4 -4 O CA O - 4 — 4 J»  mc c c 1 c O C I C O C V . O - 4 -# -H X f . - 4 - 4 - 4 X C J> J» TJ > —icr*-* 7> CTJ TJ 3 > > : -H 1 - r* •—•COP" •—cn > o c z •—« !ni »• r ri > m ; o — 4 * -•X- • O —* X . S I 0 HOX O m J»C*»TJ ** CA X r-, m X c> •-» < n i r r a PT f-t-J» r rr 3> > . • rn XZ f- m — 4 « - » — # — 4 z m 0 - 4 *»o z O CD X ^ C") c — 4 *» —»< X CO ;-*-* —« O r~ J> m Cn n. rt-i 0 - 4 0 r-m c 3C O X m CO < A X X < . m z 1-4 cm -< f- > z x»-« O O M z - 4 •zx M O - 4 0 J > 0 2 .-n r* OO rt c/> 0 > C A > >• cr O c — 4 0 c c -< -< i l — 0 4 - 4 -< X X z r -< I- 2rO 0 < -< — 4 -< t-t 0 1 *»• rn COC » CA '< O 4 - 4 ' - 4 CA m 0 CA rr. 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ZU CA z I> 1 i m-4 r- X; 1 °: u i c ' -4X» CA CA, - n o c — TJ ISO 0 - 4 0 l—l' o^ c — C — 4 *- . *-4»» rn c*)Cr- Z CA U 4 >• - 4 1 -< 1— TJ CA O X; C ; ! j 1 * : j j ; 1 x-1 TJ—« <«0 CA f -OOCfc i •O X - 4 " - 1 ru rv i/ir O-v * « ( « ' <:r*a> i l»4 Ita i Oc c-Oc CV 1 rv 4 > 0 rr rv O" Cf in : ui OO 0 0 * act CD 0 * rv C c orv CCft 1 i ! ru ' ! 1 < * r- 1 1 i j» • CA 1 — 4 | | j : rv<r X X • m m ; X CA TJ 1 TJ O IT, > C X , z - 4 1 IP f C OC •c (S. p-- 4 ^ > — in 0 M ' 0 1 *— 0 irrv-J Oi— a • O 0 0 - i o«-u« cr • 1 f • 1 1 t-« X • r 0 <w* z • • — 4 1 -< X 0 < •* -v T a:. tzr X 0 >• 1* in <: X . "s, « x z 09 trro c Ul t—mm TJ n. Ui IV \ : 3 Of e 4 > *> O 00IV OOO 0D -4> »-* J> • • • • • • • • • • • • • • • • rv cr r cr. 0 - 4 1*4 in - « 4 O 0 0 cr ootv ^ m • • • • 1 1 1 cr - 1702 -- 205 - A p p e n d i x XI Canadian Council on Hospital Accreditation Conseil Canadien D'Agrfjment Des H&pitaux A.L. SWANSON. M.O.. F.AX.H_A„ E M C U I I V * Dvtctor 1815 ALTAVISTA DRIVE, OTTAWA. ONTARIO K1G 3V6 .TELEPHONE: (613) 523-9154 CAN AO) AN HOSPITAL ASSOCIATION f Ht CAN AO IAN MCOICAl ASSOCIATION TMC ROTU COLLtCt Of PHYSICIANS AND SUDCf ONS Of CANAOA (.'ASSOCIATION OfS MtOtClNS Of LANCUC r«AMCAISC DU CANADA CANAOUN NURSCS ASSOCIATION HOSPITAL SURVEY QUESTIONNAIRE Mater Misericordiae Hospital fsbma ol Hotpittl Loalion Dr. H. J . Warrick  NapMls) of Surveyorb) Ootober 20, 29' Datt and Y t a r of Survty - 206 - A p p e n d i x X I I (a). Number and Percentage of Beds f o r Area Your H o s p i t a l Hospital Hospital H o s p i t a l H o s p i t a l Type of Bed H o s p i t a l A B C D E Mecial S u r g i c a l Ob-Gyn P s y c h i a t r i c A l c o h o l i c Extended Care *The area may encompass more than one R.H.D. - 207 - A p p e n d i x X I I ( b ) Utilization of Beds Percentage of Beds Your Hospital Hospital Hospital Hospital Hospital Type of Bed Hospital A B C D E Medical Surgical Ob-Gyn Psychiatric - 208 - A p p e n d i x X I I I Working Relationships with Other Hospitals ( A l l i a n c e Strategies) Hospital H o s p i t a l Hospital Hospital . H o s p i t a l A c t i v i t y A B . C D E 1 X X X X X 2 x x 3 x k x 5 x 6 x x x 7 8 x x x x 9 x 10 x - 209 - A p p e n d i x X IV R e p o r t on Day c a r e S u r g e r y 1980/81 - R e s e a r c h D i v i s i o n , H o s p i t a l P r o g r a m s , M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h C o l u m b i a 1980 C a n a d i a n H o s p i t a l D i r e c t o r y - B u y e r s G u i d e , A u g u s t 1980 C a n a d i a n H o s p i t a l A s s o c i a t i o n S t a t i s t i c s o f H o s p i t a l C a s e s D i s c h a r g e d D u r i n g 1980 /81 - R e s e a r c h D i v i s o n , H o s p i t a l P r o g r a m s , M i n i s t r y o f H e a l t h , P r o v i n c e o f B . C . H o s p i t a l R o l e S t u d y Phase 1, A u g u s t 1979 - A D i s c u s s i o n P a p e r on H o s p i t a l S e r v i c e s i n B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h H o s p i t a l R o l e S t u d y Phase I - Addendum - 1981 - A D i s c u s s i o n P a p e r o n H o s p i t a l S e r v i c e s i n B . C . , M i n i s t r y o f H e a l t h Community H e a l t h S e r v i c e s - A n n u a l R e p o r t 1981 - West K o o t e n a y H e a l t h U n i t , M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h C o l u m b i a Changing S t a t i s t i c s f o r B . C . H e a l t h Management - From P r o g r a m Deve lopment t o C o s t C o n t r o l , May 1981 , Depa r tment o f H e a l t h C a r e and E p i d e m i o l o g y , U n i v e r s i t y o f B r i t i s h C o l u m b i a N a t i o n a l H e a l t h E x p e n d i t u r e s i n Canada 1960 - 1973 - H e a l t h and W e l f a r e C a n a d a , H e a l t h E c o n o m i c s and S t a t i s t i c s D i v i s i o n , H e a l t h P r o g r a m s B r a n c h , M i n i s t r y o f N a t i o n a l H e a l t h and W e l f a r e , O t t a w a V i t a l S t a t i s t i c s o f t h e P r o v i n c e o f B . C . , 1980 - M i n i s t r y o f H e a l t h , B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h A n n u a l R e p o r t 1979 - P r o v i n c e o f B r i t i s h C o l u m b i a - 210 - Appendix XV (a) DESCRIPTION OF HOSPITAL LOCATION: The Mater M i s e r i c o r d i a e H o s p i t a l i s l o c a t e d two b l o c k s from the c i t y c e n t r e on the c o r n e r o f Columbia Avenue and G e o r g i a S t r e e t . I t s e r v e s as a s m a l l community h o s p i t a l p r i m a r i l y f o r the r e s i d e n t s o f R o s s l a n d and the o u t l y i n g r u r a l a r e a . LEVEL OF CARE: The H o s p i t a l has 26 a c u t e c a r e and 15 e x t e n d e d c a r e b e d s . I t i s s t a f f e d and e q u i p p e d t o p r o v i d e e m e r g e n c y , p r i m a r y , and s e l e c t c a r e s e r v i c e s t o i t s community and t h o s e r e f e r r e d f o r m i n o r s p e c i a l i z e d s u r g e r y . These s e r v i c e s i n c l u d e i n p a t i e n t and o u t p a t i e n t m e d i c a l , s u r g i c a l , d i a g n o s t i c , p h y s i o t h e r a p y and t r e a t m e n t s e r v i c e s , emergency c a r e and e x t e n d e d c a r e . SPECIAL STRENGTHS: The H o s p i t a l c o n s i s t e n t l y seeks to m a i n t a i n i t s r o l e as a p r o v i d e r o f p r i m a r y and l i m i t e d secondary care and t o c o n t r i b u t e t o the a r e a -wide h e a l t h care system i n a c o - o p e r a t i v e and p r o g r e s s i v e manner. To t h i s end, the H o s p i t a l has i n i t i a t e d a s t a n d i n g committee f o r p l a n n i n g and c o - o p e r a t e s w i t h o t h e r p r o v i d e r s i n the a r e a to p l a n and ensure c o n t i n u i t y and an a c c e p t a b l e l e v e l o f q u a l i t y c a r e . The H o s p i t a l has s p e c i a l i z e d s t r e n g t h i n a r t h r o s c o p i c knee s u r g e r y . LIMITATIONS: P a t i e n t s r e q u i r i n g secondary and t e r t i a r y c a r e s e r v i c e s are r e f e r r e d t o h i g h e r l e v e l s o f care a t our r e f e r r a l c e n t r e - the T r a i l R e g i o n a l H o s p i t a l . The Mater M i s e r i c o r d i a e H o s p i t a l does not i n t e n d t o p r o v i d e e x t e n s i v e s p e c i a l t y s e r v i c e s , such as o b s t e t r i c a l and i n t e n s i v e care o r p s y c h i a t r i c and d e p e n d e n c y - r e l a t e d problems, nor t o compete w i t h our r e g i o n a l r e f e r r a l c e n t r e . Working r e l a t i o n s h i p s w i t h o t h e r p r o v i d e r s have been e s t a b l i s h e d t o ensure our l i m i t a t i o n s do n o t a f f e c t a r e a -wide s e r v i c e . HEALTH PROVIDER RELATIONSHIPS: The H o s p i t a l has a d i r e c t w orking r e l a t i o n s h i p w i t h Columbia View Lodge, an 84 bed I n t e r m e d i a t e Care Home i n T r a i l , through the j o i n t a d m i n i s t r a t i o n o f the Shared S e r v i c e s . I t a l s o s h a r e s an e x c e l l e n t w o r k i n g r e l a t i o n s h i p w i t h the R e g i o n a l H o s p i t a l i n a r e a s o f l a u n d r y , group p u r c h a s i n g , maintenance s e r v i c e s and pharmacy. Labour r e l a t -i o n s h i p s and f i n a n c e i n f o r m a t i o n i s f r e e l y s h a r e d . T h i s r e l a t i o n s h i p - 211 -e x t e n d s t o P u b l i c H e a l t h , t h e Long Term Care P rog ram and h e a l t h -r e l a t e d g r o u p s by way o f d i r e c t c o - o p e r a t i o n and c o m m u n i c a t i o n . EDUCATION: The H o s p i t a l s e e k s t o e n s u r e t h a t a p p r o p r i a t e o r i e n t a t i o n , i n s e r v i c e and c o n t i n u i n g e d u c a t i o n a re a v a i l a b l e t o h e a l t h p r o f e s s i o n a l s a s s o c i a t e d w i t h t h e H o s p i t a l . T h e r e a r e no f o r m a l a f f i l i a t i o n s w i t h m e d i c a l o r n u r s i n g s c h o o l s o r c e n t r e s f o r t r a i n i n g a l l i e d h e a l t h p r o f e s s i o n a l s . R e l a t i o n s h i p s e x i s t w i t h t h e R e g i o n a l H o s p i t a l so o u r s t a f f may p a r t i c i p a t e i n t h e i r p r o g r a m s . TECHNOLOGY: The H o s p i t a l s t r i v e s t o make a v a i l a b l e and m a i n t a i n t o s u p e r i o r f u n c t i o n i n g s u c h equ ipment as i s a p p r o p r i a t e f o r a p r o v i d e r o f p r i m a r y and s e c o n d a r y c a r e , s u c h as m o n i t o r i n g and d i a g n o s t i c e q u i p m e n t . I t i s t h e H o s p i t a l ' s i n t e n t i o n t o be an e a r l y a d a p t e r o f new e q u i p m e n t and t e c h n o l o g y t h a t w i l l e n s u r e o u r p r i m a r y r o l e and e x p a n d o u r s p e c i a l i z e d m i n o r day s u r g i c a l r o l e . New t e c h n o l o g y i s i n t r o d u c e d o n l y a t s u c h t i m e s as t h e need has b e e n d e m o n s t r a t e d and i t s c o s t e f f e c t i v e n e s s h a s b e e n d e t e r m i n e d , e i t h e r by t h e H o s p i t a l o r by o t h e r h o s p i t a l s o f e q u a l s i z e and r o l e . RELIGION: The H o s p i t a l i s a n o n d e n o m i n a t i o n a l f a c i l i t y whose b a c k g r o u n d i s C h r i s t i a n . I t was founded i n 1896 by t h e S i s t e r s o f S t . J o s e p h o f N e w a r k . The r e l i g i o u s o r d e r p a s s e d c o n t r o l o f t h e H o s p i t a l t o t h e R o s s l a n d H o s p i t a l S o c i e t y i n 1 9 6 9 . E f f o r t s a r e made t o m a i n t a i n t h e l o n g t r a d i t i o n o f c a r i n g and s h a r i n g . C h a p l a i n s o f a l l d e n o m i n a t i o n s p a r t i c i p a t e i n the m i n i s t r y t o t h e H o s p i t a l p a t i e n t s and l o n g - t e r m c a r e r e s i d e n t s . COSTS: The H o s p i t a l i s a p r o p o n e n t o f c o s t - c o n t a i n m e n t and i m p l e m e n t s s u c h c o s t - c o n t r o l programmes as a r e p o s s i b l e w i t h o u t s a c r i f i c i n g q u a l i t y p a t i e n t c a r e . The p r i o r i t y f o r d o i n g t h i s i s t o a t t e m p t t o p r o v i d e e x c e l l e n t c a r e f o r i l l n e s s e s whose t r e a t m e n t i s w i t h i n the scope o f o u r s k i l l s , t e c h n o l o g i c a l e q u i p m e n t and r e s o u r c e s . I n a d d i t i o n , t h e H o s p i t a l a t t e m p t s t o p r o v i d e s o p h i s t i c a t e d s k i l l s and e q u i p m e n t i n the na r row l i s t o f s p e c i a l t i e s a l r e a d y d e f i n e d . The H o s p i t a l s t r i v e s t o p r o v i d e h e a l t h c a r e s e r v i c e s i n a c o s t e f f e c t i v e manner w h i c h p e r m i t s a sound and s t a b l e f i n a n c i a l p o s i t i o n f o r t h e h o s p i t a l and r e a s o n a b l e h e a l t h c a r e c o s t s f o r t h e c o n s u m e r . The H o s p i t a l r e c o g n i z e s t h a t t h e d e s i r e f o r i n c r e a s e d s e r v i c e s and t e c h n o l o g y i s n o t a l w a y s c o m p a t i b l e w i t h the d e s i r e f o r r e d u c e d h e a l t h c a r e c o s t s . T h e r e f o r e , t h e H o s p i t a l e n d e a v o u r s t o m a i n t a i n a r e a l i s t i c b a l a n c e b e t w e e n c o s t - c o n t a i n m e n t - 212 -e f f o r t s and a d e q u a t e l y m e e t i n g the h e a l t h needs o f t h e p o p u l a t i o n . The B o a r d and A d m i n i s t r a t i o n f i r m l y b e l i e v e t h a t t h e key t o c o s t -c o n t a i n m e n t l i e s w i t h t h e c o s t - c o n s c i o u s n e s s o f t h e i n d i v i d u a l s t a and Depar tment H e a d s . - 2 1 3 - A p p e n d i x XV (b) P H I L O S O P H Y The P h i l o s o p h y o f t h e M a t e r M i s e r i c o r d i a e H o s p i t a l i s s i m p l y s t a t e d a s " c a r i n g and s h a r i n g " among o u r s e l v e s , w i t h p a t i e n t s , and among t h e communi ty . The M a t e r M i s e r i c o r d i a e H o s p i t a l was founded on a t r a d i t i o n o f c a r i n g and s h a r i n g by t h e S i s t e r s o f S t . J o s e p h o f Newark . I t i s o u r p r i v i l e g e and o b l i g a t i o n t o p r o v i d e f o r t h e p a t i e n t an a t m o s p h e r e w h i c h w i l l h a s t e n t h e p a t i e n t t o w a r d s o p t i m a l p h y s i c a l and e m o t i o n a l h e a l t h ; w i l l c o n s i d e r h i s p r i v a c y , s a f e t y and c o m f o r t ; and w i l l r e c o g n i z e and r e s p e c t h i s i n h e r e n t d i g n i t y , r i g h t s , w o r t h and u n i q u e n e s s . To do t h i s , we must a l w a y s be i d e a l i s t i c i n v i s i o n and r e a l i s t i c i n a c t i o n . Through o u r r e f l e c t i o n o f t h i s p h i l o s o p h y , we c a n g i v e p u r p o s e and meaning t o t h e l i v e s o f o t h e r s and a t t h e same t i m e g r e a t l y enhance o