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The chief executive officer (called superintendent, director, administrator or by some other title depending upon local preference) who is charged with the responsibility of effectively managing the administrative components of the institution in turn delegates authority to each department head in the administrative component.

Atypical pyramidal organisation, with a unified chain of command results within the administrative component.

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But a second conglomerate of organisational pyramids results from the organisation of the medical staff into clinical services, with each having a chief of service.

Had this been also a pyramidal structure with one single chief or director of medical staff, it would result in only a second pyramid in the organisation structure.

However, seldom is it possible to have a medical staff organisation where there is only one chief with other clinical service heads directly under him in the line of command.

At the same time, none in the administration hierarchy gives command to the medical staff. Often, doctors give command to those in administrative hierarchy, but this also is not direct. Therefore, full responsibility gets divided or blurred.

In matters of direct patient care, the physicians exercise professional authority, in matters of administrations the chief executive exercises authority.

Thus, many employees (such as nurses) are subject to more than one line of authority. Line officers in the administrative units may find that their authority is limited in some areas because of the specific jurisdiction of the medical staff.

The multiple pyramidal structures therefore call for a lot of coordination. This is achieved through the extensive use of committees to bridge the gap.

In an effort to consolidate authority and clarify responsibility, the top administrative level of the hospital may be expanded to include some central officers, to whom both the administrator and the chairman of medical staff report.

The Difficulties:

The absence of single line of authority in the hospital creates various administrative and operational problems. Firstly, it makes organisational coordination difficult.

Secondly, it allows for instances where apportionment of authority, responsibility and accountability is unclear. Thirdly, it creates difficulties in communication.

i. The administrator, feeling that doctors through their power and influence interfere in the discharge of his responsibilities, may actively attempt to circumvent the medical staff on various matters.

ii. The doctors in turn are likely to circumvent the administrator.

iii. The administrator may then resort to more and more bureaucratization, and

iv. Increased bureaucratization of organisational operations can further lead to resentment by doctors.

The controlling influence over a hospital is related to the goals, structure, and technology and resources provision. Goals, structure and technology are internal factors. Resource is the only external factor.

Those who influence the allocation of resources have a big say in controlling goals and technology and they dominate the structure. The four types of dominations in a hospital organisation are as follows.

Trustee Domination:

Trustees represent the community. They raise funds and sometimes themselves contribute in a big way.

They promote policies which contribute to community welfare. But in doing so, they may in reality be promoting their own names and their private interests. Their perceptions may not contribute for the development of the hospital.

Medical Domination:

Trustees had to depend more and more on doctors as medical knowledge, technology and equipment developed. Doctors are able to dominate the organisation through their professional knowledge and standing.

In doctor-dominated hospital, one may find high quality care, research and training. But they tend to form operative goals which are predominantly in favour of their personal goals.

Administrator Domination:

With a large number of persons with various orientations, with interdependent nature of work and need for colla­boration with other agencies and community, administration of hospitals has became more and more complex.

All this calls for a professionally trained hospital administrator. In an administrator-dominated hospital, such an administrator may tend to block the communication between the trustees and the medical staff.

Multiple Domination:

Here, the power is shared by trustees, doctors and adminis­trators. No single group can control the action of others. This multiple domination gives little scope to assess performance. A clear division of work and power sharing should be maintained, with as much avoidance of conflicting goals as possible.

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