BURNS, LAWTON ROBERT; PHD

                         THE UNIVERSITY OF CHICAGO, 1981

                         HEALTH SCIENCES, HEALTH CARE MANAGEMENT (0769)

                         This study seeks to explain the adoption of an innovation in hospital management and to describe the
                         process of its diffusion across large general hospitals. The particular innovation is called patient unit
                         management. It involves the decentralization of administrative functions to the patient unit level and the
                         installation of local level managers to coordinate activities on the unit. The population of large general
                         hospitals is selected for study because of their high proportionate adoption of unit management and
                         because of the theoretical relevance of decentralization for the management of large, complex
                         organizations. As its first agenda, the study describes the types of general hospitals most likely to adopt
                         unit management and the extent of their adoption over time. The study also describes the path of the
                         diffusion of unit management and seeks to explain how the innovation spreads across hospitals.
                         Research findings indicate that hospitals with a strong historical involvement in teaching exhibit the
                         highest levels of adoption. Indeed, the degree of teaching involvement is linearly related to the extent of
                         adoption. Over time, unit management programs diffuse from hospitals with strong teaching involvement
                         to hospitals with medium teaching involvement and, finally, to hospitals with little teaching activity. The
                         most important factor influencing the diffusion process is the presence of other hospitals in the same city
                         with the innovation. Further evidence suggests that early innovators in a city act as demonstration
                         models, thereby reducing the risks and costs involved in implementing unit management. As its second
                         agenda, the study compares the ability of various theoretical models to explain the adoption of unit
                         management. These models are formulated from research on hospital size and diversity, corporate
                         growth and decentralization, administrator characteristics and innovation, and innovation diffusion. The
                         predictive power of these models is decomposed into their common and unique effects. Research
                         findings indicate that hospital size and diversity explain most of the variation in adoption, either directly or
                         indirectly through their associations with variables in the other models. There is strong evidence for the
                         existence of threshold effects of size and diversity; however, there is only weak evidence for the
                         presence of developmental (growth) effects of size and diversity. Thus, the evidence reveals that
                         hospitals adopting unit management during different time periods attain the same level of scale and
                         complexity during those periods. These findings suggest that such hospitals have exceeded the
                         structural limits within which the traditional administration of patient units may operate. The coordination
                         of patient care activities required under conditions of large scale and high complexity exceeds the ability
                         of head nurses and physicians to provide it. This lack of fit between structure and administration, and the
                         coordinative problems left unattended, leads to the adoption of unit management. The findings also
                         reveal that administrator characteristics and the volume of program demonstration models in the local
                         environment explain some of the variation in adoption. Administrators with longer middle-management
                         experience in their hospital and higher professional education are more likely to promote the adoption of
                         unit management. Similarly, hospitals are more likely to adopt when there is a large number of ongoing
                         unit management programs in neighboring hospitals. Both sets of findings suggest that the adoption
                         process is characterized by 'system delay': more prestigious hospitals and their administrators delay
                         adoption until they have observed the results of programs implemented by their less prestigious
                         counterparts. As its final agenda, the study compares the reasons for adoption in older versus newer
                         hospitals. The results indicate that structural effects are less important in newer organizations, and that
                         administrative and external influences are more important.


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