PACEMAKER: Centennial 1998

UIHC's mission of service requires delicate organizational balance

At that time the hospital was understood to be an adjunct of the College of Medicine whose purpose was to furnish patients for the clinical instruction of medical students. That poor and indigent people from the counties surrounding Iowa City also received needed medical attention was considered an important but secondary benefit to society.

The organizational framework governing University Hospital reflected the preeminence of teaching. The hospital superintendent charged with responsibility for the nursing and dietary care of patients, as well as the many operational details of running the hospital on a day-to-day basis, reported to the dean of medicine.

Significantly, the superintendent also headed the small hospital-based nursing school and was invariably a woman. Historians have noted that this was a period of transition for American hospitals from their beginnings as charitable, nursing-oriented institutions run by women to medical facilities serving a broader range of clients and dominated by mostly male physicians.

By 1914 hospital administration was increasingly recognized as a distinct profession, and the College of Medicine hired a Des Moines physician-a man-to become superintendent of University Hospital. But for more than a decade this confused rather than clarified the hospital's mission. While a consultant recommended the superintendent have broad authority over the hospital and report directly to the UI president, he instead reported to the dean and had control of clerical and housekeeping staff only.

Not until 1928, after 14 years of high turnover in the superintendent's position, did University Hospitals' own identity as a service institution truly begin to emerge. That's when a new medical dean, Henry S. Houghton, and a new hospital administrator, Robert E. Neff, forged a working partnership that de-emphasized the administrative lines of authority between them. Neff, who was not a physician, still reported to the dean, but he enjoyed broad authority over all hospital operations except medical care.

This new attitude stemmed in large measure from the patient service obligations imposed by Iowa's indigent care program, which began in 1915. What university officials had at first regarded as a mechanism to ensure adequate numbers of patients for teaching gradually assumed statewide importance for its service aspect as well.

Other trends continued to give University Hospitals a stronger independent identity. Gerhard Hartman, who succeeded Robert Neff in 1946, articulated the primacy of patient service in the hospital's mission and insisted he stood equal, not subordinate, to the dean in the administrative hierarchy. Also, scientific advances made medicine more effective, spurring consumer demand that increased as hospitalization insurance became more common.

Finally, hospital licensing and accreditation, beginning in the 1950s, made University Hospitals accountable to authorities outside the university and even the state. Indeed, it was the Joint Commission on Accreditation of Hospitals, the national accrediting body, that prompted a significant organizational change for UIHC in 1976. To address a requirement that hospitals have written bylaws and clear oversight by governing boards, the state Board of Regents became UIHC's governing body.

This gave UIHC full independence to pursue its statewide patient care mission. Under the leadership of Director John W. Colloton the hospitals carried out an ambitious program of capital development and instituted organizational strategies to meet the profound challenges of a fast-changing health care market. What remained was to forge a new partnership with the College of Medicine that integrated UIHC's teaching and service missions.

So again in 1994 a new hospitals director/CEO-R. Edward Howell-and new College of Medicine dean-Robert P. Kelch, MD-worked collaboratively to achieve such a balance. Howell and Kelch consulted extensively and developed the Clinical Enterprise, an innovative structure for joint oversight of all clinical initiatives of the UIHC and the College of Medicine. Sharing the financial stakes and institutional responsibilities of this initiative, the partners are committed to providing aspiring physicians with top-flight educational opportunities at the College of Medicine, and providing the people of Iowa with quality health care services delivered in an efficient, cost-effective manner.