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"Our first-line supervisors don't seem to feel that they are real managers and, thus, important to the organization. Why does this attitude exist, and how can it be changed?"


This question, asked by a head nurse during a management development class, is worthy of serious examination by managers at all levels and especially by first-line supervisors and middle managers.


Unfortunately, however, much of the kind of change that might be suggested in answer to the question is most effectively implemented in any organization from the top to down. If an organization's first-line supervisors do not feel like true managers, it is sometimes because they have not really been treated as managers. If supervisors' feelings and needs were recognized by the top management, the problem will be more than half-solved because the top management will then begin to treat supervisors accordingly.


The question suggests a primary concern with treatment by the organization. The inference is that supervisors have not been treated in a way that would allow them to feel like managers. However, there is another dimension of the problem to be considered-the matter of behavior.


Treatment and behavior are opposite sides of the same coin, and no one can say for a fact which should come first. Does one get treated as a manager by first behaving as a manager, thus earning such treatment? Or is one inspired to behave as a manager because one is first treated as such? While recognizing that each action is supportive of the other, one could argue forever as to which should legitimately come first.


It is unlikely that top-down change will readily be instituted without top management turnover or without some unusual occurrence that immediately brings home the importance of first-line supervisors as managers-an occurrence such as, perhaps, an active union organizing attempt. Nevertheless, top-down change, once the management acknowledges the need for such change, is much easier than bottom-up change. Change from the bottom is usually a lengthy uphill struggle.


One may encounter supervisors who imply by their conduct that they are waiting to be treated as managers before they willingly behave as managers. However, passive or reactive supervisors are likely to discover that they could wait forever. To begin to effect positive change, one party-either the individual or the top management-has to make the first move. If the top management is not inspired to start the process for all supervisors, then the individual supervisor must take the initiative to start alone.


To be dealt with successfully from the bottom up, the problem must be personalized by the individual supervisor. One cannot simply feel that "supervisors don't feel they are real managers." Rather, the individual must adopt a posture that says, in effect, "If I don't have the feeling that I'm really a manager, what can I do about it?" Oriented as such, the individual supervisor can proceed along several lines:


1. Behave as a manager ought to behave, accepting the fact that traveling a 1-way street in that appropriate treatment might not be forthcoming in response to that behavior.


2. Learn all that can possibly be learned about the scope of one's duties and the precise limits of one's authority. Beyond simply becoming conversant with all elements of one's job description, this may be done by taking specific questions on tasks, problems, and responsibilities to one's immediate superior.


3. Display initiative whenever possible. Attempt to head off problems by calling them to the attention of one's immediate superior. Rather than always waiting to be told what to do, suggest what specific action might be taken and ask for the management's blessing to proceed.


4. Treat the employees in the group as one would like to be treated by higher management, as responsible individuals capable of doing important work and interested in learning and growing. If successful, one may well stand out as a model for other supervisors. Several supervisors behaving in this fashion can turn the tide and eventually change the organization.



Overall, bottom-up organizational change requires of supervisors sustained, professional management behavior and conscientious self-development as managers.


Recognizing that reading and studying are part of a manager's self development, The Health Care Manager attempts to provide topical information and advice on a variety of current concerns in the rapidly changing health care environment. Presented in this issue are the following:


* "Impact of Medicare's Prospective Payment System on Hospitals, Skilled Nursing Facilities, and Home Health Agencies" explains how the Medicare prospective payment system, originally developed for the payment of inpatient hospital services, has become a dominant factor in all health care cost reimbursement. (This is the third in a series of 3 articles addressing the aspects of Medicare. The 2 earlier articles appeared in issues 24:4 and 25:1).


* "The Role of Clinical Information Systems in Healthcare Quality Improvement" addresses the increasing use of electronic medical records and supporting information systems and suggests how such modern approaches can help improve quality of care and enhance competitiveness in the health care marketplace.


* "Valuable Human Capital: The Aging Health Care Worker" suggests that striving to retain an increasing number of aging health care employees may become a near-term necessity given the aging of the work force and the diminishing supply of younger workers.


* "Reorganizing Care and Work: Process and Productivity Gains" describes the participatory approach by which a Montreal-area hospital developed and implemented organizational changes intended to improve the psychosocial environment for patients and health care workers and enhance organizational efficiency.


* "Managed Care and the Bottom Line of Your Practice" advances the necessity for medical practices to develop effective working relationships with managed care companies and suggests strategies for establishing fee schedules and negotiating reimbursement contracts.


* "Case in Health Care Management: 'The Silent Majority'" asks the reader to consider how to go about opening up a group of employees whose history might suggest that they were never encouraged to speak up or perhaps were even afraid to do so.


* "The Nursing Extern Program: Innovative Strategies for Students in Transition" describes a program that provides early exposure to clinical nursing practice to promote knowledge of the clinical unit, facilitate the acquisition and application of nursing knowledge, and engage motivated nursing students in the learning process.


* "The Magnet Designation Process: A Qualitative Approach Utilizing Donabedian's Conceptual Framework" addresses how a magnet culture is achieved when various structural factors, such as adequate staffing and pay, are present before the building process and how certain additional ingredients are integrated to achieve the desired magnet outcome.


* "National Health System Steps in Turkey: Concerns of Family Physician Residents in Turkey Regarding the Proposed National Family Physician System" reports on a study of the concerns of a number of family practice residents about a government proposal to institute a primary care approach based on the systems found in the United Kingdom and Germany.


* "The BSN Degree as Entry Level for Practice: Recapturing the Vision in Nursing" describes how much of the rest of the world has gravitated toward the Bachelor of Science in Nursing degree as the standard for entry into nursing while the United States has not done so and suggests that the Bachelor of Science in Nursing degree should be the entry requirement for all professional nursing.


* "Sustainability of Cross-functional Teams for Marketing Strategy Development and Implementation" addresses a case study concerning a cross-functional team used for marketing strategy development and execution at a health insurance company and presents dome "challenge motivators" intended to enhance such a team's productivity over time.


* "Wasteful Use of Financial Resources in Public Hospitals in Turkey," this issue's second submission from Turkey, reports on a study of Ministry of Health hospitals in Turkey, concluding that the subject hospitals are not well managed financially and that their financial resources are not used effectively.


* "The Monte Carlo Method Improves Physician Practice Valuation" demonstrates the use of the Monte Carlo simulation method in valuation of physician practices, suggesting that, essentially, all hospitals support information systems that can readily accommodate such simulation.