...also show that many of the issues faced by hospital administrators hundred years ago remain relevant today. They include the tension between adoption of new technology and the cost of hospital care, advocacy for business practices from the private sector, and the administrator's responsibility in the area of quality of care.

The number of hospitals in the United States grew from 149 in 1873 to 6,665 in 1913 (Ochsner 1913; Modern Hospital 1913a). The vast majority were small. Almost 70 percent had no more than 50 beds, and fewer than 200 had more than 200 beds (McClure 1918; Modern Hospital 1914a). To attract patients accustomed to medical care in the home, hospitals had to overcome the traditional image of the hospital as an unclean house of death or a refuge for the poor and had to transform into "a work place for the production of health" based on scientific principles (Start 1982, 146; Hornsby 1913; Hurd 1913).

The extant literature has described eloquently the social and symbolic role of hospitals in their communities and the influence of science and the professionalization of medicine and nursing on the hospital's role and development (Starr 1982; Stevens 1986; Reverby 1987; Melosh 1982; Freidson 1970). Much less is known about the actual work of hospital superintendents (as administrators were then called) in the early 1900s or about the emergence of hospital management as a distinct occupation (Neuhauser 1995). This article addresses these gaps. First, we show that a vision of the modern hospital administrator as a business leader emerged along with a vision of the modern hospital as a scientific institution. The conceptualization of these new roles developed under the aegis of the American Hospital Association (AHA), the professional association for hospital administrators at the time. Second, we describe the actual work of hospital officials during those early years and compare it to the emerging view. The article closes with a discussion of the links between our findings and hospital management today.

DATA SOURCES

The primary data source for this article is the journal Modern Hospital. Founded in 1913, Modern Hospital was the only journal in the early 1900s to focus entirely on hospital management, advising superintendents on "the most intimate details of hospital administration" (Modern Hospital 1913b, 185). The journal's editorial board was composed mostly of AHA officers, and its editorial content reflected the opinions of the AHA (Arndt and Bigelow 2005).

Our study covers the years 1913 through 1920, when the hospital administration occupation first received attention. For the analysis of practitioners' actual work, we drew on the column "Queries and Answers," a regular feature in Modern Hospital addressing questions from readers. Through the use of an inductive coding scheme, inquiries were assigned to categories that represented specific management areas (Miles and Huberman 1994). If an inquiry addressed multiple topics, each was assigned to its respective category. We did not approach the reading with an a priori list of topics because that would have reflected today's notions about the nature of hospital administration. Instead, we let the topics emerge inductively through the reading. Similar to the constant comparative method, categories were created, split, abolished, or subsumed as the reading progressed (Glaser and Strauss 1967). Appendix 1 shows an abbreviated set of categories and samples of inquiries in each. To access the complete appendix, go to www.ache.org/pubs/jhmsub.cfm.

THE EARLY 1900s VISION OF MODERN HOSPITAL ADMINISTRATION

The early years of the twentieth century were characterized by "the expanding work of the modern hospital and the responsibilities of its administrators" (Washburn 1913, 127). Although a "theory of hospital administration... still lack[ed] definition," management in the private sector provided a model (Goldwater 1920, 275-76). Keppel (1916, 304-305) wrote about "the modern hospital as a health factory," arguing that "the hospital is to all intents and purposes a manufacturing plant, and any scheme looking towards its successful management must be similar to the schemes used in other manufacturing establishments of equal size and grade." Consistent with this view of the hospital as akin to manufacturing plants, the AHA, as reflected in its editorial control of Modern Hospital, advocated a model of modern hospital administration that focused on business practices and on the hospital as a scientific institution.

First, administrative work was to resemble management in the private sector. It would span all hospital departments (Edsall 1915; Valentine 1916; Lyons 1919; Goldwater 1920), and like the businessman in the private sector, the administrator would sit at the top of a hierarchy and provide direction (Waldheim 1920; Edsall 1915; Wilson 1915; Tipping 1914). The board's role would have to change accordingly (Tipping 1914; Walsh 1915). Trustees provided important expertise in law, accounting, and other business matters, but they often used their position to engage in the hospital's daily affairs. Such "dominating and domineering" conduct was now deemed inappropriate (Modern Hospital 1916a, 426), and articles called on trustees to let the superintendent have "direct executive authority over all the departments of the hospital" (Babcock 1920, 178).

In addition to a hierarchical structure, other business practices to be adopted from the private sector included cost accounting and bookkeeping (Carter and Porter 1918; Mann 1914; Warner 1916; Wechsler 1914), budgeting and cash control (Hurd 1916; Loder 1915), purchasing and inventory practices (Greener 1914a), and formal admission procedures and billing policies (Greener 1914b; Poll 1916; Van Norman 1914). Internal control systems would rationalize and improve operations and facilitate comparisons across hospitals (Modern Hospital 1916b; Warner 1916; Wilson 1915). This, in turn, would help hospitals contain their costs, a challenge that was deemed "one of the most insistent and difficult problems before the hospital people" (Modern Hospital 1916c, 355). Costs were of particular importance because hospitals' major source of revenue was private patients, and high charges made it difficult to attract self-paying patients, especially from members of the middle class, who were more likely to receive care in the home.

Second, if the hospital were to attract private patients, it had to be seen as a preferred place of care, so the hospital's emergence as a scientific facility was important. New facilities and technology would create this modern scientific institution. Modern Hospital presented information on how to plan and construct facilities (Hornsby 1916a; Hubbard 1917; Modern Hospital 1914b, 1915b, 1916d); how wards, kitchens, and administrative offices should be laid out and furnished; and what equipment to buy and how to use it (Hannaford 1914; Hornsby 1916b; Hornsby et...

NOTE: All illustrations and photos have been removed from this article.



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