Dynamics of Institutional Change: The Hospital in Transition

Readers particularly interested in problems of mental illness will find a wealth of material on issues that are still valid in the field.

Category: Healthcare

This title is part of the Healthcare Administration list.

Of Interest:

Comprehensive Emergency Mental Health Care

Harvest Moon: Portrait of a Nursing Home

Long-Term Care in Transition: The Regulation of Nursing Homes

This penetrating study, first published in 1971, expounds on the challenges of administering and attempting to modify a large mental hospital. In a fresh and welcome approach to the study of leadership and organizational change, the book captures the administrative experiences of the Superintendent of Boston State Hospital in dealing with a wide variety of issues common to many different kinds of public-service organizations such as schools, welfare agencies, prisons, and general hospitals. Interwoven are vivid narrative descriptions of the process of change with theoretical discussions. Some general issues include the turmoil of management succession, the pacing of change, staff resistance to change, and the strategy and tactics of decentralizing a large bureaucratic organization.

Like many other private-sector and public institutions in modern society, hospitals are regularly undergoing change. The three authors of this volume have been leaders in change at Boston State Hospital, a large public mental hospital, that serves as the test case for the experienced advice and hard-earned lessons found in this work.

With their academic and professional backgrounds, the three authors combined offer an incomparable fund of knowledge and experience for the reader. In keeping with their positions, they focus on the position and the role of the leaders of institutional change. They do not recommend any particular choices, direction, or outcome. They do not presume to know what is the best for all institutions, or to understand the culture, realities, goals, or values of all institutions. They do not even presume to know what is best or desirable for hospitals, the institution with which they are most familiar. Instead, the authors direct their attention to "the problems hampering change and the gains and losses of one or another strategy of change." In relation to this, they are "more concerned with the study of process than with outcome." By not recommending specific policies or arguing for specific values or goals, the authors make their book relevant to all institutions involved in change, but particularly public-health institutions.

All of the subjects are dealt with from the perspective of top executives and administrators. Among the subjects taken up are not only the staff and structure of the institution, specifically the medical institution, but also consultants, volunteers, local communities, and state and federal government agencies. The detail given to each subject goes beyond the administrator's relationship to it to discussion concerning the relationship of lower-level employees with the subject. This relationship of lower-level employees has everything to do with how change occurs within the institution, and often whether it occurs. The authors go into such detail because they understand that the performance and goals of top administrators are affected by everything that goes on within their institution, and often by much that goes on outside of it.

For example, the authors begin the subject of volunteers by defining three types of volunteers: volunteers from organizations, student or independent volunteers, and government-appointed or statutory volunteers. Volunteers of whatever type can cause anxiety, resistance, and even resentment among regular staff of an institution. Volunteers are not simply "free help," but require administration, training, and oversight - which can distract regular employees from work they consider more important and interesting, and use up departments' resources. The transitional nature of volunteers, their ignorance of institutional and occupational concerns of the regular staff, and their lack of professionalism can cause disruptions and personnel problems in parts of an institution. The authors advise the top administrators, "The intrusive evangelism of student volunteers can be threatening not only to professional supervisors, but to the entire hospital staff as well, from the attendant to the top administrator." While recognizing the problems which may be caused by volunteers, especially younger ones, the authors point out the worth of volunteers to the hospital despite the potential problems they bring. Overall, the different types of volunteers "improve the physical and social environment" of the workplace, "make direct and beneficial contacts with chronic patients," and often "establish true innovations." After discussing the pros and cons of volunteers and providing detailed guidance on how to manage volunteers so as to minimize potential problems, the authors advise the administrator and his or her staff how to regard volunteers. "Both staff and administrator must constantly keep in mind that volunteers are not personally helping them [word in italics in original], but are helping the patients or the community." Along with the technical management and administrative guidance, such counsel is clearly relevant and important in keeping perspective on the matter of volunteers.

The treatment of volunteers in a medical institution exemplifies the comprehensive, empathetic, and experienced treatment of all the subjects. Personnel - whether professional, clerical, service, or volunteer - is obviously a major concern of any institution and change in it. The structure of an institution is another crucial concern. This is addressed under the heading "decentralization through unitization." In the context of a large public medical facility, decentralization "involves breaking up the institution into semiautonomous units...; each of which is like a small community health center in that it is responsible for serving a specific part of the community." As with the subject of volunteers, the authors treat this subject of the structure of the institution by examining its various sides, discussing related personnel and administrative matters, relating instructive anecdotes from their own experience, and in the end, offering relevant and practical advice and actions whose sense is apparent to the reader by this point.

Recognizing that the authors have faced many of the same situations, decisions, pressures, challenges, and aims as they have, top hospital and public-health administrators will no doubt adopt many of the authors' recommendations for managing the process of change. The content of the book as well as its style (which is obviously meant to be helpful, sympathetic, and realistic) offers the reader not only resolutions, but also encouragement. The top hospital administrators and their staffs, who are the main audience for "Dynamics of Institutional Change," will not find a better study and handbook to help them through the changes their institutions are being called upon to undergo to deal with the health concerns and problems of today's society.

"Few social issues are more important today than the question of changing our public institutions so that they are more responsive to human want." This observation, made by the authors in 1971 when Dynamics of Institutional Change: The Hospital in Transition was first published, is even more relevant today. As the co-authors foresaw, the problem of sclerotic institutions threatening the social and moral commitments of government and other organizations was likely to become even more severe with the expanding population and with a more informed public having higher expectations and seeking accountability for shortcomings and failures. Hence, "[t]his book is concerned with the transitional period in the reorganization of a large public institution." As Superintendent of Boston State Hospital from 1963 to 1967, Milton Greenblatt, the book's principal author, ushered this large public institution through a transitional period. The hospital improved its services and better served not only its patients, but also its employees and the public, which funded the hospital through its taxes.

While transition within complex, established organizations is the general topic, the focus is especially on "problems hampering change and the gains and losses of one or another strategy of change." These seemingly contradictory ends that must be considered in most transitions are: centralization versus decentralization; unified philosophy versus multiple ideologies; equal distribution versus special concentration of wealth; and professional domain versus use of volunteers. Evaluating and balancing these ends are discussed in the early chapters. The later chapters explore in greater depth the issues Greenblatt confronted when he led the transition at Boston State Hospital.

While the work is based mainly on Greenblatt's assignment and experiences with the hospital, the majority of the content takes a broad enough look at the transition to make it an instructive and invaluable guide for any healthcare professional responsible for planning and effecting a transition in healthcare delivery. As the authors state at the start of this book, the Boston State Hospital case affords "parallels and similarities" with other large institutions. The book offers a blueprint for structuring, planning, implementing, leading, and monitoring a major, organization-wide transition. At the same time, readers will find encouragement and, at times, will sympathize with Greenblatt's experiences from his difficult, and ultimately satisfying, task in leading a large public healthcare institution through a wrenching transition. Like any determined leader, Greenblatt was the focal point for concerns, disagreements, resistance, and resentment among some members of the staff. How he overcame these personnel issues while keeping the transition moving along provides a "real world" perspective to the subject matter.

The core of Dynamics of Institutional Change is how decentralization through unitization was implemented at Boston State Hospital. Sometimes known more simply as "unitization," the authors prefer the longer term "decentralization through unitization" because it connotes the purpose of unitization, which is decentralization. Decentralization is an especially desirable result for large public institutions that have become unresponsive to public needs because of entrenched bureaucratic practices and the vested interests of various factions. Furthermore, decentralization helps organizations better utilize today's more educated and productive workforce. "[I]n the context of the state mental hospital, decentralization, or unitization as it is commonly called, involves breaking up the hospital into semiautonomous units." With the hospital, this means that each semiautonomous unit has its own admission service, respective treatment programs, and transitional and aftercare programs-in effect, serving a specific part of the community by virtually becoming a "small mental health center."

As explained by the authors, decentralization through unitization advances the "delegation of responsibility and maximum participation in decision-making" among employees in key positions. Thus, this approach helps diminish the inevitable skepticism and resistance to a transition, clarifies its purposes and ends among employees, and insures that it takes root in the different sectors of the organization.
Dynamics of Institutional Change advocates change in massive, tangled healthcare organizations. However, the authors offer more than just a tired discourse on the nature of transition. This book tells how the needed transformation can be achieved by making difficult decisions, addressing nettlesome problems, and attending to daily management details. Readers can judge for themselves whether decentralization through unitization is relevant for resolving chronic institutional problems. However, planners and leaders in charge of transitions in other institutions will find this book especially worthwhile reading. �

Milton Greenblatt is a former Commissioner of the Massachusetts Department of Health who is on the teaching staffs of the medical schools at Tufts, Harvard, and Boston University. Co-authors Myron Sharaf and Evelyn M. Stone have experience in the areas of medicine and public health in the Boston area.

Milton Greenblatt, M.D. was Commissioner of the Massachusetts Department of Mental Health, Professor of Psychiatry at Tufts University School of Medicine, and Lecturer in Psychiatry at Harvard Medical School and Boston University School of Medicine.

Myron R. Sharaf, Ph. D. was Associate Area Director of Boston State Hospital and Assistant Professor of Psychology at Tufts University School of Medicine.

Evelyn M. Stone served as Executive Editor for the Massachusetts Department of Mental Health.