Implications for CEOs

If activities and episodes of work are such a good idea, why don't CEOs view their jobs in such terms, and why don't trustees evaluate CEOs in relation to patterns of episodes and results achieved relative to organizational objectives? Would there be any difference if these concepts were applied in large health care organizations? What are the costs of applying these concepts, and what is their validity and reliability in measuring CEO behavior? To what extent should CEO behavior be documented using that perspective? If the concepts are adopted, who should do the measuring? If CEO behavior is acceptable, why analyze it? Have the concepts of activities and episodes of work been successfully implemented anywhere? If so, with what results? These questions indicate limitations to the usefulness of these concepts. The limitations can be grouped into three categories: lack of standardized definitions, high costs of measurement; and limited rationale for such evaluation.

Lack of Standardized Definitions

Measurers are likely to disagree over what constitutes an activity or an episode. For example, how should different activities occurring in the same meeting be classified? Or the same activities occurring in different meetings? There is some question as to whether certain activities, constituting what Griffith refers to as noise or overhead, should be counted at all.



I agree that these limitations may be important for research in other than exploratory studies; however, I do not find them so significant as to outweigh the benefits of the concepts in analyzing CEO work. There are certain episodes of work that take up most of the CEO's time, or that should take up most of the time, relative to organizational objectives. CEOs should consider documenting what percentage of their time is being spent on what, what results they are accomplishing by episode, and how the pattern of results is and should be related to organizational objectives. I believe that documenting their work can significantly affect how CEOs decide to use their time and can thereby positively affect organizational performance.

High Costs of Measurement

A more serious limitation, I believe, is the perceived high cost of measuring activities and episodes. Activities will need to be coded by interactor, subject, disposition, and time spent, at least. To illustrate, the following are Tim George's first three activities on Monday:

1. Trustee requests the name of a doctor for a friend; CEO refers to COO (time spent: brief).
   
   
2. Other CEO calls indicating that his institution will not be part of a third organization's affiliation network for managed care (time spent: brief).
   
   
3. CEO participates with the dean in review of performance of a clinical chairman (time spent: intermediate).
   

These activities could be coded as follows:

1. Patient care request (PCR), from trustee X (T-X), brief time spent (B), referred to chief operating officer (REF-COO).
   
   
2. Managed care (MC), from chief executive officer Y (CEO-Y), brief time spent (B), information shared (INF).
   
   
3. Performance appraisal (PA), with dean re chief A (C-A), intermediate time spent (I), monitoring of fund raising (MON), dean must approve brochure (APP), must decide on space utilization re diabetes program and monitoring of outpatient surgery and resident program (DEC).
   

The log must be typed (and proofread for errors) and then the data grouped and analyzed. Activities can be grouped into episodes by an administrative assistant and reviewed by the CEO; however, the CEO may not wish to share how he or she spends time in such detail with anyone else. The time spent by the CEO on analysis will not be perceived as too long, I believe: it takes relatively little time for the CEO to read the data and decide whether he or she is spending enough time on organizational objectives or whether too much or too little time is being spent on certain episodes of work. What may take longer is analyzing how better to real-locate time or get better results for time spent, or whether to pursue changes in organizational objectives.

Limited Rationale

I am not suggesting that charting activities and episodes of work is necessary for effective management of large health care organizations, nor am I suggesting that effective managers of such organizations chart activities and episodes. I only suggest that the benefits of doing so may at times be significant. If there is no problem with organizational success or CEO performance, there may be no justification for such documentation. However, with today's increasing competition and turnover among CEOs, such charting and analysis will be beneficial to many of them as documentation of what they do; as an aid to formulation of more realistic organizational objectives; and as an aid to better allocation of their time at work.

Documenting what the CEO does. A record of what the CEO said to whom when may be useful in future conversations regarding claims and promises. The CEO will be able to share what he or she does with evaluators, peers, and subordinates. It is useful for CEOs to be able to explain what they do, compare their work with that of other CEOs in like positions and compare CEO work with that done by subordinates, in order to better organize work.

Given that many health care organizations are not-for-profit and that many of their trustees are not selected for proven ability to make policy decisions for such organizations, charting and analysis of CEO time by episode of work will be useful in orienting trustees to what the CEO does.

Formulating organizational objectives. Comparing what the CEO does with what the organization is supposed to be accomplishing can be useful whether the two are in alignment or not. If alignment is good, the CEO and those who evaluate the CEO have the documentation to validate it. If the alignment is off, analysis can reveal either that the CEO is not spending time as appropriately as he or she should or that the organization's objectives are not sufficiently specific, feasible, or desirable. Assuming the latter to be the case, trustees and managers may spend time specifying more useful organizational objectives.

Allocating the CEO's time. For the CEO, there are two effects of charting and analyzing time: (1) reallocation of time based upon analysis of past patterns and (2) reallocation of time to conform to the expectations of whoever holds the CEO formally accountable for how his or her time is spent. Perhaps one of the perquisites of CEOs has been not having to account for their time by episodes of work, but I question whether this is in the best interests of the organization and of those who pay for care and supply the organization with resources.

In practice, a CEO may implement such a charting and analysis system for his or her sole use during the first month or two, in order to overcome problems in implementation, refine the charting system, and evaluate benefits relative to costs. During a trial period the CEO and others can evaluate whether changes toward more complete documentation seem advisable.

Implications for Teaching Management

Criteria for graduate curricula in health services administration established by the Accrediting Commission on Education for Health Services Administration (1982) do not include any emphasis on the work managers do.

In three commonly used health services management textbooks namely, Health Care Management, edited by Shortell and Kaluzny (1983); Management of Health Services, edited by Kaluzny et al. (1982); and Managing Health Services Organizations, edited by Rakich, Longest, and Darr (1985)-there is no mention of episodes of work or time management in the index. In programs in health care management education this material may be covered in courses on organizational behavior or management-or it may be assumed that managers should learn this on the job rather than in school.

A few articles have been written about how managers of health care services spend their time. In a paper on hospital administrators and organizational effectiveness published in 1972, I cited studies of how administrators spend their time in a university teaching hospital (Connors and Hutt 1967) and in 55 Catholic and non-Catholic hospitals (Murray et al. 1968).