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BRIEF CONTENTS

Preface.......................................................................................................................xv
Acknowledgments.................................................................................................xxi

Chapter 1 Health, Healthcare, and Healthcare Organizations.................................. 1

Chapter 2 Management......................................................................................... 29

Chapter 3 Planning................................................................................................ 51

Chapter 4 Organizing: Jobs, Positions, and Departments....................................... 79

Chapter 5 Organizing: Organizations.................................................................. 103

Chapter 6 Organizing: Groups and Teams........................................................... 131

Chapter 7 Staffing: Obtaining Employees............................................................ 157

Chapter 8 Staffing: Retaining Employees............................................................. 185

Chapter 9 Leading: Theories and Models............................................................. 215

Chapter 10 Leading: Motivating and Influencing................................................... 239

vii
viii Brief Contents

Chapter 11 Leading: Culture and Ethics................................................................ 265

Chapter 12 Controlling and Improving Performance............................................. 291

Chapter 13 Making Decisions and Solving Problems............................................. 319

Chapter 14 Managing Change............................................................................... 343

Chapter 15 Professionalism and Communication.................................................. 369

A Management Case Study: Partners HealthCare...................................... 397

Integrative Case Studies.................................................................................... 413
Real-World Applied Integrative Projects....................................................... 427
Your Management Toolbox................................................................................ 429
Glossary.................................................................................................................. 433
Index........................................................................................................................ 443
About the Author................................................................................................. 477
DETAILED CONTENTS

Preface.......................................................................................................................xv
Acknowledgments ................................................................................................xxi

Chapter 1 Health, Healthcare, and Healthcare Organizations.................................. 1

Health and What Determines It.............................................................. 2
Determinants of Health...................................................................... 3
Healthcare and Health Services............................................................... 6
Healthcare Organizations........................................................................ 9
The External Environment of Healthcare Organizations........................ 10
Healthcare Trends and Future Developments........................................ 12
Stakeholders and Expectations of Healthcare Organizations............. 16
Healthcare Management Jobs and Careers............................................. 18
Chapter 2 Management......................................................................................... 29
What Is Management?........................................................................... 31
The History and Evolution of Management Theory............................... 31
Taylor and Scientific Management.................................................... 31
Fayol and Administrative Theory...................................................... 32
Mayo and Human Relations............................................................. 36
Gulick, Urwick, and Management Functions................................... 37
Weber and Bureaucratic Theory........................................................ 38
Bertalanffy, Boulding, and Open Systems Theory............................. 39
ix
x Detailed Contents

Lewin and Organization Development Theory................................. 41

Woodward and Contingency Theory................................................ 42
Katz and Management Skills............................................................ 42
Meyer and Rowan, DiMaggio and Powell,
and Institutional Theory............................................................ 42
Mintzberg and Management Roles................................................... 43
Do All Managers Manage the Same Way?.............................................. 45

Chapter 3 Planning................................................................................................ 51
What Is Planning?................................................................................. 52
Strategic Planning................................................................................. 54
Strategic Planning Stage 1: Environmental Assessment..................... 55
Strategic Planning Stage 2: Organizational Direction........................ 60
Strategic Planning Stage 3: Strategy Formulation.............................. 63
Strategic Planning Stage 4: Transition to Implementation................. 64
Planning at Lower Levels....................................................................... 66
Project Planning and Project Management....................................... 68
Data and Information for Planning....................................................... 71
Final Thoughts About Planning............................................................. 73

Chapter 4 Organizing: Jobs, Positions, and Departments....................................... 79

Organizations........................................................................................ 81
Organizing Work in Healthcare Organizations...................................... 81
Organizing Tasks into Jobs and Positions............................................... 82
Organizing Jobs and Positions into Departments................................... 85
Factors That Influence Organizing Work............................................... 89
External Factors................................................................................ 89
Internal Factors................................................................................ 92
A Few Complications............................................................................ 92
Informal Organization...................................................................... 93
Contract Workers............................................................................. 94
Unionized Workers........................................................................... 95
Medical Jobs with Physicians............................................................ 95

Chapter 5 Organizing: Organizations.................................................................. 103

Organization Structures....................................................................... 105
Functional Structure....................................................................... 106
Divisional Structure........................................................................ 108
Matrix Structure............................................................................. 110
Horizontal Structure....................................................................... 113
Network Structure.......................................................................... 115
 Detailed Contents xi

Hybrid Structures........................................................................... 117

Governing Body.................................................................................. 118
Coordination Within and Beyond a Healthcare Organization............. 119
Coordination Structures and Processes........................................... 120
Complications..................................................................................... 123
Contract Departments.................................................................... 123
Physicians and the Organized Medical Staff in a Hospital............... 124

Chapter 6 Organizing: Groups and Teams........................................................... 131

Groups and Teams............................................................................... 133
Groups and Teams in Healthcare Organizations............................. 134
Structures of Groups and Teams.......................................................... 135
Purpose.......................................................................................... 135
Size ................................................................................................ 136
Membership................................................................................... 137
Relation to Organization Structure................................................. 138
Authority........................................................................................ 140
Leader............................................................................................ 140
Culture........................................................................................... 141
Processes of Groups and Teams............................................................ 142
Developing..................................................................................... 142
Leading.......................................................................................... 144
Communicating and Interacting.................................................... 145
Decision Making............................................................................ 147
Learning......................................................................................... 148
Effective Groups and Teams................................................................ 149
Effective Virtual Teams................................................................... 150
Guidelines for Effective Meetings................................................... 150

Chapter 7 Staffing: Obtaining Employees............................................................ 157

Staffing Processes................................................................................. 159
Workforce Diversity and Inclusion................................................. 160
Centralized, Decentralized, and Outsourced Staffing...................... 163
Laws and Regulations..................................................................... 165
Planning for Staff................................................................................ 165
Designing Jobs and Work.................................................................... 168
Job Analysis.................................................................................... 169
Work Rules and Schedules.............................................................. 170
Hiring Staff......................................................................................... 171
Recruiting...................................................................................... 171
Selecting......................................................................................... 174
xii Detailed Contents

Chapter 8 Staffing: Retaining Employees............................................................. 185

Developing Staff.................................................................................. 187
Orientation of New Staff................................................................ 187
Training Staff.................................................................................. 189
Developing Staff............................................................................. 190
Appraising Performance of Staff.......................................................... 192
Appraisal Process and Methods....................................................... 194
When Job Performance Is Deficient................................................ 196
Compensating Staff............................................................................. 199
How Is Pay Determined?................................................................ 200
How Are Benefits Determined?...................................................... 203
Protecting Staff.................................................................................... 203
Onboarding......................................................................................... 207

Chapter 9 Leading: Theories and Models............................................................. 215

Theories and Models for Leading......................................................... 217
Trait Theory and Skill Theory......................................................... 217
Behavior Theory............................................................................. 218
Situational Theory.......................................................................... 221
Theory X, Theory Y, and Theory Z................................................. 224
Transactional and Transformational Leadership.............................. 225
Servant Leadership......................................................................... 227
Collaborative Leadership................................................................ 227
Authentic Leadership and Ethical Leadership................................. 229
Leadership Competency Models..................................................... 229
Leading Physicians.............................................................................. 230

Chapter 10 Leading: Motivating and Influencing................................................... 239

Motivation Theory and Models........................................................... 241
Maslow’s Hierarchy of Needs Theory.............................................. 242
Alderfer’s ERG Theory.................................................................... 243
Herzberg’s Two-Factor Theory........................................................ 244
McClelland’s Acquired Needs Theory............................................. 247
Adams’s Equity Theory................................................................... 248
Vroom’s Expectancy Theory............................................................ 249
Locke’s Goal-Setting Theory........................................................... 251
Skinner’s Reinforcement Theory..................................................... 252
Power and Politics............................................................................... 255
Sources and Types of Power............................................................ 255
Organization Politics...................................................................... 257
 Detailed Contents xiii

Chapter 11 Leading: Culture and Ethics................................................................ 265

What Is Culture?................................................................................. 267
What Causes and Creates Culture?................................................. 268
Purpose and Benefits of Culture..................................................... 270
Interpreting Culture....................................................................... 271
Subcultures..................................................................................... 272
Shaping and Managing Culture........................................................... 273
What Is Ethics?.................................................................................... 275
Ethics Problems.............................................................................. 276
Sources of Ethics............................................................................ 278
Creating and Maintaining Ethics in a Healthcare Organization...... 283

Chapter 12 Controlling and Improving Performance............................................. 291

What Is Control?................................................................................. 293
Control in Healthcare Organizations.............................................. 293
A Three-Step Control Method............................................................. 295
Step 1: Set Performance Standards.................................................. 295
Step 2: Measure Actual Performance and Compare
It to Standards......................................................................... 297
Step 3: Improve Performance If It Does Not Meet Standards.......... 302
Quality Improvement Programs and Methodologies............................ 307
Six Sigma........................................................................................ 307
Lean Production............................................................................. 308
High Reliability.............................................................................. 309
Controlling People.............................................................................. 313

Chapter 13 Making Decisions and Solving Problems............................................. 319

Decision Making and Decisions.......................................................... 321
Who Makes Decisions?................................................................... 322
Methods for Making Nonprogrammed Decisions............................... 323
Rational Approach.......................................................................... 323
Satisficing Approach....................................................................... 326
Intuition Approach......................................................................... 327
Incremental Approach.................................................................... 327
Evidence-Based Approach............................................................... 328
Garbage Can Approach.................................................................. 329
Barriers to Effective Decision Making.................................................. 330
Data for Decision Making................................................................... 331
Trends in Decision Making................................................................. 333
Resolving Conflict............................................................................... 334
xiv Detailed Contents

Causes of Conflict.......................................................................... 334

Conflict Resolution Model............................................................. 335
Additional Suggestions for Managing Conflict............................... 336

Chapter 14 Managing Change............................................................................... 343

Change in Healthcare Organizations................................................... 345
Managing Organization Change.......................................................... 346
Small-Scale Change........................................................................ 346
Eight-Step Approach to Large-Scale Change................................... 349
Resistance to Change........................................................................... 352
Why People Resist Change............................................................. 352
Organization Characteristics That May Impede Change................. 354
Healthcare Characteristics That May Impede Change..................... 355
How People Resist Change............................................................. 355
Force Field Analysis........................................................................ 356
Overcoming Resistance to Change................................................. 358
Organization Learning and Organization Development...................... 361

Chapter 15 Professionalism and Communication.................................................. 369

Professionalism.................................................................................... 371
Emotional Intelligence.................................................................... 373
Cultural Competence..................................................................... 376
Communication.................................................................................. 378
Types of Communication............................................................... 378
Directions of Communication........................................................ 380
Communication Process................................................................. 382
Tips for Effective Communication................................................. 391

A Management Case Study: Partners HealthCare...................................... 397

Integrative Case Studies.................................................................................... 413
Real-World Applied Integrative Projects....................................................... 427
Your Management Toolbox................................................................................ 429
Glossary.................................................................................................................. 433
Index........................................................................................................................ 443
About the Author................................................................................................. 477
PREFACE

T
he healthcare field and the size of healthcare organizations (HCOs) continue to
grow. So does the need for excellent management of these HCOs. Fortunately, many
students and healthcare professionals aspire to management positions in HCOs.
Management education for HCOs will help them succeed.
Having been a healthcare management student, healthcare manager, and healthcare
management professor, I appreciate good books that help us learn management and how to
apply it to HCOs. I studied management at the undergraduate, graduate, and doctoral levels.
I worked in senior management at three hospitals during 14 years as a hospital executive.
And for 25 years, I taught undergraduate and graduate courses in healthcare management
and related subjects. All that has motivated and enabled me to write this book.
The purpose of this book is to help people learn the body of knowledge we call
management and then apply it to HCOs. The primary intended audience is undergradu-
ate students who are interested in managing HCOs but have no prior knowledge of the
subject. This book will also be useful to students who are majoring in allied health profes-
sions and want to understand management of HCOs, and to current supervisors seeking
to learn more about management. This book can help healthcare professionals prepare for
advancement to management positions.
The content includes timeless fundamental principles as well as new concepts and
current information. Both theory and practice are presented, along with terms, concepts,
theories, principles, methods, and tools—and how to use them. A recurring theme in the
book is that management is contingent and the “right” approach depends on changing
factors. Students will learn that management problems are not multiple-choice questions

xv
xvi Preface

with a single best answer. The book teaches the principles, theories, methods, and tools
so students can assess situations and develop solutions. Students can practice skills using
exercises and activities within and at the end of each chapter. Both the content and the
writing style strive to engage students, keep them actively interested, provide a few laughs,
and help them understand and remember what they read. I have used this approach to
successfully teach management of HCOs to undergraduate and graduate students. The
publication design further enhances learning by making the material visually appealing
and easy to read and understand.
The book has 15 chapters on 15 interrelated subjects needed for management of
HCOs. They are connected and organized into a cohesive body of knowledge. By the
end of this book, students will understand management and how to apply it to HCOs.
(Because this book is about management, it does not include some other disciplines found
in healthcare management curricula, such as finance, law, and marketing.)
Each chapter opens with a relevant quote or saying, which is followed by Learn-
ing Objectives. Next is Here’s What Happened—a real-world example that demonstrates
concepts discussed in the chapter. Each Here’s What Happened is drawn from the same
complex, real-world case study that we follow through the book. In each chapter, headings
and subheadings organize content and guide the reader. Key points are bolded in a different
font. Important terms are defined in the page margins and included in the end-of-book
glossary. Exhibits, bulleted lists, examples, activities, and exercises in each chapter keep
students engaged and learning. There are sidebars and boxes called Check It Out Online;
Try It, Apply It; and Using Chapter   in the Real World. At the end of each chapter are
One More Time (a chapter summary), For Your Toolbox, For Discussion, Case Study
Questions, Riverbend Orthopedics Mini Case Study with questions, and References. The
Riverbend mini case study and questions at the end of each chapter make up a practical
hands-on exercise that is new in this edition. In each chapter, this mini case begins with
a recurring paragraph (applicable to all chapters), which is followed by brief additional
content and questions that are unique and relevant to that one chapter.
At the back of the book are appendices with more resources. The first is the lengthy,
real-world management case study of Partners HealthCare (used to create the Here’s What
Happened in each chapter). The next appendix—Integrative Case Studies—has seven short
(one- to two-page) case studies for which there are questions at the end of each chapter. The
Real-World Applied Integrative Projects appendix suggests ten real-world applied projects
that students can work on during the course using and integrating management tools
from multiple chapters. All tools listed at the end of the chapters throughout the book are
combined in the Your Management Toolbox appendix. All defined terms from throughout
the book are repeated in the glossary, which is followed by an extensive detailed index.
Several features help students understand how chapters (and management methods)
are interrelated. The book is arranged in a logical sequence of chapters that continually
build on and connect with previous chapters. Chapter by chapter in the Here’s What
 Preface xvii

Happened examples, students follow managers at Partners HealthCare who create and
manage telehealth services to improve population health. When students read the example
that begins each chapter, they may also look at the entire Partners HealthCare case in the
appendix to appreciate how each chapter’s opening case is interrelated with other chapters
and management topics. Chapters are further interconnected by end-of-chapter case study
questions, which all pertain to the same seven cases (three new to this edition) included in
the appendix. Students will realize that fully solving a case study (i.e., management problem)
requires them to use different kinds of management principles and tools (from different
chapters) just like managers do in the real world. Also, when students try to explain how
to address a project listed in the Real-World Applied Integrated Projects appendix, they
will realize they must combine various tools and methods (from multiple chapters) like
in the real world. This learning activity will develop their understanding of how chapters
must be used together to solve real-world problems. In addition, the book sometimes states
explicitly how specific chapters and concepts work together.
The purpose of each chapter, and the changes to each chapter in this new edition,
are described below. This third edition is longer and has more depth, topics, and tools than
prior editions. Prior content has been updated.
Chapter 1 provides the context and background for why HCOs exist and why HCO
managers are needed. It introduces readers to health, healthcare, healthcare services, HCOs,
and healthcare management jobs. This edition has more discussion of population health,
with a newer health model and explanation of forces that determine health (emphasizing
social determinants of health). The continuum of care is explained in more detail with
a new exhibit. The types of healthcare services, types of HCOs, and current trends and
developments are updated. The chapter now includes a section on stakeholders. The discus-
sion and lists of healthcare management job titles, careers, specialty areas, and employment
trends have been updated.
Chapter 2 teaches what management is and how it evolved as a body of knowledge,
theory, and practice beginning more than a century ago. The chapter briefly explains impor-
tant developments in the history of management theory. From this comes a framework for
organizing and connecting the subsequent chapters and content. New in this edition is an
explanation of organization development theory. The section on systems theory has been
moved here from chapter 4 and expanded. The chapter has additional explanation of some
concepts (e.g., authority) and updated examples.
In chapter 3, students learn how managers plan the purpose, goals, and work of their
HCOs. The chapter’s strategic planning section has been significantly revised and expanded,
with new real-world methods, examples, content, and exhibits from a consulting company.
Content for planning at lower levels (involving recent graduates in entry-level jobs) was
revised. Tools and techniques for short-term planning are described.
After managers plan as described in chapter 3, they must organize to achieve those
plans. We learn about organizing in chapters 4–6. In chapter 4, managers organize work
xviii Preface

into jobs and departments. This edition contains an expanded section on job design to
explain more about tasks, jobs, delegation, and authority. The chapter includes an expanded
description of mechanistic and organic structures and more detail about the informal orga-
nization. It explains how current trends (mentioned in chapter 1) are affecting how work
is organized. In chapter 5, the text and exhibits describe how managers organize depart-
ments into larger organization structures seen in organization charts. Concepts are applied
to organizing for clinical integration and the continuum of care. This edition includes a
new section on horizontal structure, which is explained and illustrated in an exhibit. This
chapter has an expanded section on coordination (previously split between chapters 4 and
5). Explanation of how a medical staff is organized has been updated to reflect current
trends. Chapter 6 focuses on how managers organize groups and teams. In this edition,
this chapter has revised definitions for group, team, and committee. Characteristics of groups
and group membership are explained in more depth. This new edition explains huddles
and self-managed work teams. The “Effective Groups and Teams” section now includes a
discussion of virtual teams.
After organizing, managers must staff the positions, departments, and organizations.
Chapter 7 explains how managers obtain staff. This new edition added two new sections
and expanded one existing section to emphasize three special concerns for staffing: (1) staff
diversity and inclusion; (2) centralized, decentralized, and outsourced staffing; and (3) laws
and regulations that affect staffing. The explanation of hiring, recruiting, and selecting
staff was expanded with more information and methods (e.g., realistic job previews) tied
to macro trends. Real examples of how HCOs have increased staff diversity were added,
and the chapter introduces a cultural competency assessment tool. Chapter 8 focuses on
how managers retain staff. This edition includes substantial revisions to prior content.
It emphasizes developing (rather than training) staff. The performance appraisal section
describes the shift from traditional annual appraisals to the newer approach of frequent
informal feedback. Compensation and incentives are connected to newer trends in health-
care, and the chapter further explains how pay is determined. There is additional discussion
of cultural diversity, including the multigenerational workforce. New information about
workplace violence and surveillance was added.
After managers staff the HCO, they must lead, direct, influence, and motivate the
staff. This is explained in a trilogy of leadership chapters. Chapter 9 presents leadership
theories and models. Compared to the prior edition, it reflects a slight shift from “leader-
ship” to “leading” (i.e., what managers do). This edition has added a section on situational
leadership theory and its practical application. The discussion of transformational and servant
leadership theories has been expanded, and the chapter touches on authentic leadership and
ethical leadership. It also has an important new section on leadership competency models for
the twenty-first century. Chapter 10 teaches leading by motivating, influencing, and using
power. It explains and applies motivation theories and methods. Exhibits for two theories
were updated, and Hackman and Oldham’s job characteristics model has been added for
 Preface xix

practical application of Herzberg’s motivation theory. The exhibit detailing types of power
was revised. This edition presents more discussion of political tactics and explanation of
how leaders use hard power and soft power. Chapter 11 explains leading with culture and
ethics. New in this edition are espoused (stated) and enacted (actual) organizational cultures.
Explanation of organizational socialization is also new, as is nonmaleficence as a fourth
ethical principle. Many short examples (to explain exhibits 11.1 and 11.2) were revised to
connect with current HCO trends described in chapter 1.
After planning, organizing, staffing, and leading, managers must control performance.
Chapter 12 teaches control and performance improvement. This edition provides more
information about Six Sigma. It greatly expands the explanation of Lean management with
value stream mapping (and an exhibit) along with root-cause analysis as a new tool. The
topics of high-reliability organization and key performance indicators are both explained.
New examples pertain to current priorities in healthcare, such as patient experience, value
rather than volume, and patient safety. There is an expanded explanation of where managers
obtain the data needed to measure and control performance.
After chapters 2 through 12 explain the five basic management functions (plan-
ning, organizing, staffing, leading, and controlling), the book presents three additional
chapters that will help students to manage HCOs. Chapter 13 teaches how to make deci-
sions needed to solve problems and resolve conflicts. This edition has updated definitions
and expanded sections on intuition and evidence-based decisions. The previous edition’s
section on data for rational decisions has been expanded to address data for all types of
decisions. That section was combined with more explanation of big data and analytics to
form a new “Data for Decision Making” section that is applicable to all decision-making
approaches. The “Who Makes Decisions” section was simplified. This edition describes
the conflict resolution process required by The Joint Commission and presents such a
process for HCOs.
Chapter 14 teaches how to manage change in organizations. The chapter has a new
section on assessing organizational and individual readiness for change. A new exhibit and
explanation of the force field analysis tool is also included. There is more detailed explana-
tion of why and how people resist change. The chapter has a new section on organization
learning and development, as well as a detailed example of primary care practices trying to
implement change in work processes.
Because all the management work taught in chapters 1–14 should be done with
professionalism, Chapter 15 explains professionalism for managers in HCOs. This includes
sections on professionalism, emotional intelligence (EI), cultural competence, and com-
munication. A new opening quote starts this chapter with relevant career advice. The new
edition provides more context, explanation, and examples for EI, along with advice on how
to improve EI for management. The chapter has added explanation of cultural competence
and steps to improve it (personally and organizationally). The communication model exhibit
was revised to better portray people communicating.
xx Preface

The content of this book contributes to numerous curriculum requirements for

Association of University Programs in Health Administration (AUPHA) undergraduate
certification. These include organization development, organization behavior, management
of HCOs, operations assessment and improvement, management of human resources and
professionals, governance, leadership, and strategy formulation and implementation.
Instructor resources for each chapter include PowerPoint slides, suggested answers
to discussion questions, and a test bank. For access to these instructor resources, please
e-mail [email protected].
When Enrico Fermi (who later won a Nobel Prize in physics) was a student, he once
told a professor, “Before I came here I was confused about this subject. Having listened to
your lecture I am still confused. But on a higher level.” I hope that after reading this book,
you will be less confused and on a higher level about the subject of management for HCOs.
Please share with me your feedback about this book. Thank you.

Peter C. Olden, PhD, MHA, LFACHE

University of Scranton
[email protected]

I nstructor R esourc es
This book’s Instructor Resources include PowerPoint slides for each chapter,
suggested answers to discussion questions, and a test bank.

For the most up-to-date information about this book and its Instructor Resources,
go to ache.org/HAP and search for the book’s order code (2378).

This book’s Instructor Resources are available to instructors who adopt this book
for use in their course. For access information, please e-mail [email protected].
ACKNOWLEDGMENTS

T
his book and my work on it have benefited from many people. I gratefully acknowl-
edge and deeply appreciate the support of the following, among others.
Many wonderful students at the University of Scranton inspired me to teach,
write, and educate future students. Graduate teaching assistant Michaela Dolde helped with
research, exhibit preparation, and other tasks. Colleagues at my university and elsewhere
shared resources, advice, and feedback on my writing. Faculty and students who used the
prior edition of this book gave positive feedback and suggestions.
Staff at Health Administration Press, especially Jennette McClain, Janet Davis,
Andrew Baumann, Sharon Sofinski, and Michael Cunningham have helped in more ways
than I can list. Health Administration Press kindly gave permission to use material from
some of its books, including exhibits prepared by Rose T. Dunn, Daniel B. McLaughlin,
John R. Olson, and Patrice Spath, as well as cases prepared by Deborah Bender, Jennifer
Lynn Hefner, Ann Scheck McAlearney, and Susan Moffatt-Bruce. Veralon Partners Inc.
graciously allowed use of several of its strategic-planning exhibits in this book. Brian Rinker
of Highmark Blue Cross Blue Shield gave permission to modify and use a diagram. The
Commonwealth Fund gave permission to use a case prepared by Andrew Broderick.
When I was a student, many professors helped me study and learn about manag-
ing healthcare organizations. During my management career, I worked with three hospital
CEOs—Dana Bamford, Charlie Boone, and Kirby Smith—each of whom helped me
develop practical management experience. What I learned from all of them has helped me
write this book.

xxi
xxii Acknowledgments

My wife, Debbie, and sons, Ryan and Alex, have been supportive and understand-
ing of my professional work and the time and effort needed to write this book. They have
also enriched my life in many ways for which I am especially grateful.
Finally, and yet before everyone noted above, my parents, Walter and Helen, instilled
in me a passion for reading and learning.
Thank you, everyone. I appreciate your support and could not have written this
book without you.

Peter C. Olden, PhD, MHA, LFACHE

University of Scranton
CHAPTER 1

HEALTH, HEALTHCARE,
AND HEALTHCARE
ORGANIZATIONS

Strike a balance between population health and individual health.

Howard R. Grant, CEO of Lahey Health

Learning Objectives

Studying this chapter will help you to

➤➤ explain what health and population health are,

➤➤ describe the major forces that determine the health of a population,

➤➤ identify types of health services in the continuum of care,

➤➤ identify types of healthcare organizations,

➤➤ explain the external environment and how it affects healthcare organizations,

➤➤ describe trends that will affect management of healthcare organizations in the

future, and

➤➤ appreciate the variety of healthcare management jobs and careers.

1
 2 Management of Healthcare Organizations

HERE’S WHAT HAPPENED

Partners HealthCare is an integrated healthcare delivery system that owns and oper-
ates numerous healthcare organizations (HCOs), including community health centers,
physician practices, hospitals, urgent care clinics, and home care businesses. Together,
these HCOs provide the continuum of care from prenatal to end-of-life. Based in
Boston, Partners is committed to its community, and it values innovation, technology,
openness, and preparation. Its managers have watched developments in the external
environment, such as demographic trends, the growth of social media, the empha-
sis on population health, and value-based payment for healthcare. They have been
transforming Partners HealthCare to better fit the changing external environment in
which it operates. For example, the managers have been forming patient-centered
medical homes and are striving to keep the local population healthy through proac-
tive preventive care (rather than reactive cure). Managers implemented a Connected
Cardiac Care program that uses telehealth to connect with remote patients and help
them care for their heart disease. People are living healthier lives because of what
Partners HealthCare’s executives, managers, supervisors, and staff have done.

A
s the opening example shows, healthcare organizations need managers. We will
follow managers at Partners HealthCare throughout this book as a management
case study. A brief example from Partners HealthCare opens each chapter to
demonstrate that chapter’s subject. (These examples are based on a lengthy case study
that is presented in “A Management Case Study: Partners HealthCare” later in this
book.) This book will help you learn how to manage HCOs to help people live healthier
lives, as managers at Partners do. You will be able to do important work (while earning
a good paycheck).
This chapter explains health and population health and examines the main forces
that determine them. It identifies health services in the continuum of care and the types
of HCOs in the healthcare sector. The chapter then describes the external environment
and important trends that are affecting HCOs, the healthcare industry, and the healthcare
sector. The chapter ends with information about healthcare management jobs and careers,
for which this book will prepare you. After reading this chapter, you will better understand
why communities need HCOs—and why HCOs need people like you to manage them.

health
A state of complete H e a lth a nd W h at D eterm i nes I t
physical, mental, and What is health? In a classic definition still widely used today, the World Health Organization
social well-being; not (WHO 1946, 100) states that health is “a state of complete physical, mental, and social
merely the absence of
well-being and not merely the absence of disease or infirmity.” Note that the definition of
disease or infirmity.
health is based on being well rather than just not having a health problem.
Discovering Diverse Content Through
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What is thy plea?
Pal. Though God himself should curse me,
My purpose hath been good.
Man. Ay, that I’ll grant:
Thou’rt for the right, but being too hot upon it
Mistakest right. Thou art numbered with the madmen
Who, thinking the whole world’s unhappiness
Hangs on one string, tread all else underfoot
So they may reach to cut it.—And where’s the good?
Thyself, too, in what plight, that after all
This sacrifice of others’ rights, thou rushest 2360
To die to save thine honour from a stain,
That needs no washing!
Pal. Enough: there let it end:
I die to-morrow.
Man. Nay, thou must escape:
Retrieve all that thou canst. I now shall go
To Margaret, whom before I feared to meet.
She will be working for thee. If she fail,
The archbishop yet hath power to stay thy death
Till I can serve thee. If thy love for her,
And hers for thee abide, you must be married.
Nay, all she urged was good.
Pal. O, ’tis impossible. 2370
Work not for my escape: ’tis best I die.
Man. Nay, nay. Thou that canst fight, fight with thyself.
The brave despair that fear not: that’s the shock
The strongest suffer. Thou wast ill of late;
Wert thou now strong, shame would not crush thy spirit.[Going.
Pal. Manuel, go not!
Man. Yes, I must go. Remember
My name is Father Thomas. None must guess
Who hath been with thee.—Farewell. Fight with thyself;
P li i ith th lf Th h lt b d [E it
Palicio, with thyself. Thou shalt be saved. [Exit.

ACT · V

SCENE · 1
 The same. PALICIO as before.
PALICIO.
2380
Three hours have fully passed since first I marked
Yon grated hole grow rosy, and exchange
Moonlight for dawn. Now soon will Margaret come:
And I must go forth to the world disgraced,
To fly my country or hide: ay, at the cue
Of the chief justiciary, led by a woman.
Hast thou the heart, Giovann Palicio,
To call this freedom. Nay, since thy right hand
Was raised ’gainst wrong in vain, and thou thyself
Art charged with wrong, and must admit the wrong,
Were’t not now best to end, and shroud thy fortune
In veils of death? Thou that hast led the people, 2391
Hast thou a knee for favours? Will thy tongue
Confess I wronged thee, Manuel, I come forth
To be thy prisoner: and I wronged thee, Margaret:
I will come forth to be thy pensioner?
Shame: rather would I die.
Enter Margaret.
MARGARET.
’Tis I, Giovanni: all is well: thou’rt safe,
Manuel has told me all. Thou dost repent.
All is prepared. Ask not my pardon: give me
One kiss—I have forgiven thee. Be not sad. 2400
’Twas like thee as I love thee, nobly done:
And being so cruel to thyself ’twas easy
Thou shouldst forget what I too now forget,
Recovering thee. I saw thee ride away,
And guessed before the letter. O, Giovanni,
Thank God, thou’rt safe. Look, I have brought the money
To serve thee on thy journey till the day
We meet again; and more. Thy ship will sail
We meet again; and more. Thy ship will sail
But to Messina: there thou wilt disbark.
Nay, take the money; thou wilt need it, love, 2410
’Tis Manuel’s gift, not mine.
Pal. (taking). I have no heart,
Margaret, for what is done on my behalf.
I thank him, but ...
Mar. Alas, alas! Giovanni:
I looked to find thee glad of heart and happy.
Our troubles all are over. Manuel lives,
Whom we thought drowned: Constance, who lay in death,
Hath risen from her bed: and even our marriage
Is furthered by my brother. How can it be
Thou art so dismal, and thy kiss as cold
As is this prison?
Pal. I would not leave this prison. 2420

Mar. Thou wouldst not leave it?

Pal. No: dankness and darkness
Are now my friends. I have failed. How can I wish
To step in the light of heaven?
Mar. O, then I see
This death-delivering dungeon hath o’ercome thee.
——There’s news. This morn the ships arrived from Spain.
They must bring tidings of the king’s accession.
We shall learn all to-day. When he’s proclaimed,
There’s nought that thou couldst do if thou wert free.
What thou hast done may have determined much.
Pal. When shall I hear of it?
Mar. Love, thou must sail 2430
Quickly and secretly: and canst not hear
Until thou come to land. But then if I
Should meet thee there with Manuel, oh, what joy,
Could I be first to tell thee.
 Pal. Dost thou think
That Manuel hath forgiven me for the wrong
I did him, stealing from his house by night?
Mar. That was my theft, Giovanni; and he forgives:
Cry not thou forfeit.—See, I bring thy dagger.
Pal. But, Margaret, I wronged thee too. I fled
From thee; canst thou forgive me?
Mar. Ask not me 2440
If I have forgiven. Hearken, I will tell thee,—
This dagger is the dagger which the woman,
Whose name thou didst not know, brought thee in prison:
By help of this thou madest thy first escape.
’Tis I that bring it now. These two days past,
These days of misery, I have held and worn it
But for one purpose; that if thou shouldst die,
I might have something which had once been thine
To end my life with.
Pal. Thou!
Mar. Ay. I had promised
This caseless blade my empty heart for sheath. 2450

Pal. Margaret!
Mar. Now take it. I have better hope.
[Palicio takes dagger, and puts it in his breast.
Thou shouldst be armed.
Pal. And thou hast thought of death?
Mar. Only if thou hadst died.
Pal. O, Margaret,
Margaret, I am not worthy of thy love.
Thou seest I am not. Look how poor a heart
I bring to take thee: ’tis too base. I thought
I loved thee overmuch. Now, fool, I see
I love too little.
Mar. ’Tis this hateful prison
Hath chilled thy spirits. When again thou’rt free
Thou’lt be Giovanni.
Pal. Canst thou love me so? 2460

Mar. O, what hath come to thee? Did I not love

The hour I bound thy wound: the day I brought
Rosso to heal thee, and led thee by the hand,
Threading the blindest midnight silently,
To set thee free? Dost thou forget?
Pal. But then,
Then I was brave, a leader of the people
Against their tyrant: thou didst hold of me
As of a hero: now I have failed, I am shamed.
Mar. O no, Giovanni; thou mistakest sadly
My love for thee.
Pal. I am no more myself. 2470

Mar. Then dare I prove to thee how much I love thee,

How little thy renown. Remember, thou didst scheme
To burn the palace.
Pal. Ay.
Mar. Didst thou not promise
Me, trembling for thy life, that if that failed,
Thou wouldst to Rome with me?
Pal. My scheme miscarried:
I broke my promise.
Mar. The cause of that miscarriage
Was the betrayal?
Pal. How should I forget?
Mar. Now wilt thou say I love but thy success?
’Twas I betrayed thy men
Twas I betrayed thy men.
Pal. Ha! thou was’t! was’t thou?
(Leaping up from Margaret, who staggers against the wall.)
From me, sorceress, thou viper, go from me! 2480
Traitress, was’t thou? Thou wast my secret curse!
Sent by the devil, wast thou, to destroy me,
To kill my soul? And bringest now thy money
[Strews it about.
To buy thy happiness: and of thy love
Pratest, and sayst, Come forth with me! With thee?
Rather all deaths, a thousand deaths of shame,—
The axe, the gallows. O, my faithful men,
My brave men! and for them!—Ah! I will love
My executioner more than thee. Love thee!
There is not any tyrant or crowned fiend 2490
Whom I will hate like thee.
Mar. Then kill me, Giovanni.
[Swoons falling.
Pal. (taking out dagger). This dagger in my heart, and I am
avenged.
Nay, nay, O God, I am adding wrong to wrong.
[Putting dagger back.
And Manuel. Alas! what have I done?
[Runs to Margaret.
I spake too roughly, Margaret; I was angry:
I knew not what I said. Margaret, I am sorry.
Forgive me, Margaret. Nay, I meant it not.
I am not angry with thee now. I think
I can forgive thee. Hear me! She doth not hear me.
She doth not breathe. Her eyes are fixed and sightless. 2500
Her hands are cold.
d h f h k ll d h
My God, oh, if I have killed her! Margaret, Margaret!
Dost thou not hear?—I have killed her.—Margaret!
I do forgive thee. I forgive thee all.
O God, she is dead, she is dead.—Now if I kiss her,
If she can feel (kissing). She stirs. O, Margaret,
Hear me. I do forgive thee all.
Mar. Giovanni:
I did it for thy love.
Pal. Thank God, thank God.
Now thou dost breathe and speak. O, I was cruel;
I was too angry.—Margaret, forgive me. 2510
Kiss me, forgive. [Noise at door.
Mar. Hark, at the door they come;
’Tis now thy time to fly.
Pal. How can I leave thee?
I cannot thus.
Enter Blasco with sword drawn, Livio and two soldiers.
Mar. Go for thy life, Giovanni:
Fly, fly: think not of me!
BLASCO.
Stay, not so fast,
You pretty pair of loving turtle-doves,
Cooing your sweet farewells in such a cote;
We shall not separate you yet so far.
Mar. Ah me!
Pal. What means this insult?
Bl. Forward, fellows.
Take ye the lady to the cell I shewed,
And bind her arms.
Pal. Who dares?
Bl Fool stand aside! 2520
 Bl. Fool, stand aside! 2520
Seest thou my sword?
Pal. Ho! villain, die! Palicio springs on Blasco
Bl. God! I am slain. [Falls. suddenly, and stabs him with
Pal. And thou, Thinking to dagger in his left. Seizing
find me here unarmed, Blasco’s sword in his right,
go thou! which he has disengaged from
the sling, he kills another with
Soldier. Ah! that; and when the rest fly is
[Dies ... the rest fly. left standing with a bloody
Pal. Two are escaped. weapon in each hand.
Mar. And one was Livio.
Pal. What means this damnable design?
Mar. Giovanni,
I see, I know. Fly now—take thou the sword.
Give me the dagger. Follow. I know the way.
There will be none to stay thee. If there be, 2528
Serve them as Blasco. Come, come; follow quickly. [Exit.
Pal. (following). Margaret, Margaret. [Exit.
SCENE · 2
 Room in the Palace. MANUEL, disguised as priest, meeting
ROSSO.
ROSSO.
In good time, Manuel: welcome. All is well.
MANUEL.
Thank God. And doth she know?
Ros. Ay, thou shalt hear.
’Twas Margaret’s doing: all night long she sat
By Constance’ bed, and there with gentlest presence
And soft accustomed voice most gradually
She soothed and won the wandering spirit back.
But, oh, the sweetest skill!—she, as she saw
Constance take note of her, made no discovery,
But spoke of thee and all things else, as if
There never had been change: and that so well, 2540
That Constance, who lay gazing on the wall,
And questioning of her error, whence it grew,
Soon laid it on herself, and by and by
Told Margaret of her dream, and asked how long
She had lain so sick in bed; nor ever learned
How real had her woe been, till she knew
That all was over.
Man. I thank God,—and thee,
Rosso, thee too. Margaret has had some cause
To blame herself,—to have helped in the repair
Will ease her heart of much. May I see Constance?
Ros. At once. But come prepared to find her weak. 2551

Enter Philip.
PHILIP.
Father, a word.
 Man. I pray you excuse me now.
Ph. ’Tis that I know thy errand that I ask.
I would speak through thee to the lady Constance.
Man. What would you say?
Ph. Let me be private with thee.
Man. (to Ros.) Doctor, I’ll follow. (Aside.) Now to act my best.
[Exit Rosso.
Ph. Thou seest in me the man who wrought this ill.
I’d have thee use thine office with the lady,
To win her grace, that I may make confession
Of that which burdens me.
Man. How! what is this? 2560
What should I say?
Ph. I’ll tell thee: and thou must know
First, that I once was Manuel’s friend and pupil,—
My pride, alas! self-wrested to my shame—
And in those early days loved her, whom he
Should at this time have married. Five years spent
In graceless life meanwhile had far removed
My heart from my first love, nor had my thought
Once ventured back to think or wish her mine:
But, as it happened,—and being at the time
Stung by the sharp remorse of idle hours,— 2570
Chance sent me hither, and her presence soon
Awaked those memories that I had thought were dead.
Then vainly felt I worthier than I was,
Seeing my better part desired to win
What I too surely had deserved to lose.
Constance denied me:—but now hear my crime.
I won her father’s ear; and then, being lodged
In Manuel’s house, I lit on a discovery
Of some suspicion, and contrived thereby—
Betraying him who was my friend and host— 2580
 et ay g o as y e d a d ost
His absence and disgrace: whence by ill fate
His death and all this lady’s trouble sprung.
Man. ’Tis a sad tale you tell.
Ph. I was misled
To think he loved the lady less than I.
Yet urge I no excuse, nor look for pardon:
But if ’twould not add sorrow to her sorrow,
I would discharge this burden from my soul.
Man. Do so: for you shall find pity and pardon.
Ph. Nay, nay: that could not be.
Man. Though hard it seem,
Ay, and may force awhile some generous tears;
She cannot yet fail in the foremost duty 2591
Of all that sin. I shall prepare her well.
Ph. I thank thee, father. [Exit Manuel.
There is in these men
A quiet strength, which shames our self-esteem.
Enter Ferdinand and Hugo with despatches.
HUGO.
Philip, we have the news. Frederick is crowned.
See, here’s for thee. (Gives a despatch.) It bears the new king’s
seal.
Ph. Well, ’twill help nought. (Opens.)
Hu. I pray there may be nothing
That meddles with my place.
Ph. Read here, your excellence. [Reads.
By reason of advices late received,
The kings commands are that the sealed despatch 2600
Writ for emergency be now held valid,
And put in force by you.
 Hu. There’s the despatch?
FERDINAND.
’Tis in my keeping.
Hu. (to Philip). Know’st thou its contents?
Ph. Nay, sir; not I.
Hu. Pray let us see it, straight.
Ph. Adjourn we to my secretary’s chamber:
A moment will discover it. [Exeunt.
SCENE · 3
 Reception-room at the Palace. As first scene of first act.
CONSTANCE, ROSSO, and MANUEL disguised.
CONSTANCE.
Nay, I can walk. I am very well. See, Manuel,
There’s no one here: thou mayst be Manuel
Yet awhile. Is not this, love, a recovery
To make the memories of sickness glad? 2610
The days seem years since I stood here. But now
Must I see Philip?
MANUEL.
Be kind to him, Constance.
The self-condemned need more than full forgiveness
Ere they forgive themselves.
Con. I am too happy
To be unkind. And where is Margaret?
I long to rally her about her lover.
Sweet Margaret caught: Margaret who mocked us all.
Hath she not chosen a madcap brother for us?
Man. Well, I had wished for Rosso, love; but women
Favour strange fellows.
ROSSO.
She was difficult 2620
To win, and now at least she has met her match.
Man. I pray all may go well. Indeed I have hope
That Hugo is by this possessed of orders
Which will resolve all trouble.
Con. Hush, father Thomas;
See, here they come.
Enter Hugo, Philip, Livio, and Ferdinand.
HUGO.
 HUGO.
My dearest daughter, ’tis a happy day.
Thy health and safety—Ay, I am glad to see
Thy face of happiness, and I can add
Now to thy joy. King Frederick is crowned,
And I shall rule in Sicily.
Man. (aside). How is this? 2630

Con. Then for this happy news grant me, dear father,
One favour. Philip here will join in asking.
PHILIP.
Ere it be asked, I wish before all here
To say some words. Good father, hast thou won
The lady’s ear for me?
Man. I have, your grace.
Ph. May I speak, Constance?
Con. Philip, you may speak.
Ph. Once I asked this, and thou didst bid me then
Speak and end all. Hear while I speak my last.
I have wronged thee, Constance.
Con. That is now forgiven.
Hu. O, well done, Constance.
Ph. And I wronged Manuel. 2640
I violated friendship, and the bond
Of hospitality.
Con. All that I know,
And all forgive.
Hu. Forgive him, and forget it.
So should it be.
Ph. Yet if thou sayest that,
Thou dost not know that ’twas my treachery
Procured his exile whence ensued his death
Procured his exile, whence ensued his death.
Con. All this I know, and I forgive it all.
Hu. (aside). This is too soft. Doth her mind wander still?
Ph. Thou understandest? Knowest thou that did he live
To-day he were the ruler of his country? 2650

Con. Nay; now, sir, this is new. How came you by it?
Ph. In a despatch I hold, his full appointment
Is writ and sealed.
Con. He will be very glad
To hear of this.
Ph. What sayst thou, then?
Hu. (aside). O misery!
Con. I know you call him dead; but still to me
He makes his visitations. I have seen him
This morning in my chamber. Nay, I say,
I see him now.
Hu. What saith she? (To Livio.) Alas, alas!
Thy sister’s mind is gone. This was the reason
Of her strange cheerfulness.
Ph. May God forgive us 2660
Our fatal mischief.
Con. Give me the despatch:
I’ll shew it him, sirs, else he might not believe me:
But if I take it ...
Ph. (to Hu.). What, sir, shall I do?
Ros. Humour her fancy, I will lead her out.
Hu. Ferdinand, give it to her. Alas, alas!
Con. (taking). I thank thee, sir. (To Man.) Now, father, here’s a
matter
To make us laugh within.
 o a e us aug t
[Exeunt Rosso, Constance, and Manuel.
Hu. Philip, she is mad.
Ph. I see it, and I the cause.
Hu. A laughing idiot. O, cruel heavens,
Ye had no stroke more fearful. Would to God 2670
That Manuel yet were living, tho’ I hate him,
Rather than this.
[Shouting without of “Palicio,” etc.]
What noise is that?
LIVIO.
The rebels, sir, again.
Enter an Officer.
OFFICER.
The city, sire, is risen; and the people,
With John Palicio at their head, demand
The king’s despatches.
Hu. John Palicio!
Is he escaped again? Send Blasco hither.
Livio, where is he?
Liv. Sir, I do not know.
Hu. ’Tis this accursed rebellion hath done all:
I have been too merciful. I tell thee, Philip, 2679
That was the cause of all, of Constance’s madness,
Of Manuel’s death. By heaven, the sword shall fall.
I will have blood for blood, and wail for wail.
None of these villains whom I hold in prison
Shall see the sunset. Send me Blasco hither.
Call out the troops.
Ph. Pray you remember, sire,
Pardon to all is urged in the despatch.
Hu. Send pardon to the devil. Oppose me not!
I’ll teach these rebels I am master now.
[Cries heard without.
Enter Manuel (as himself, with paper in hand) and Constance.
Margaret, Lucia, and Rosso following.
Manuel! why, Manuel!
Ph. O, Manuel,
My friend, I am saved.
Con. My father, 2690
Let me present to you my ghostly father;
And at your will my loving living husband.
Hu. Why, what! How’s this? Is’t thou? Is this a trick?
Man. Ay: but a trick of fortune. Let my escape,
Which makes you wonder, be explained hereafter.
But now, since here I hold my title, sire,
I’ll fill my place at once. Philip, I pray thee
Go to the window, and make known to all
These latest tidings. Send the people home.
[Philip goes to window.
Meanwhile, sir; if before thou hadst some warrant
For anger shewn against me, now I ask 2701
Thy pardon; and for wrongs against me done
Assure thee, that if freely thou make over
Thy daughter for my wife, there is in my love
Means for full reconcilement. May I say
Constance is mine?
Hu. I see that she is thine.
Man. I pray thou never shalt regret this day.
Ph. (returning from window). There is John Palicio, with half the
t
 town
At their old cries. I can make nothing of him.
Man. Bid him surrender as my prisoner. 2710
I will receive him here.
Hu. Thou must not think
He comes at asking thus.
Man. He will obey.
But I will shew myself. [Goes to window.
Hu. How comes he out of prison?
MARGARET.
That I can tell.
Your secretary Blasco promised me,
Who desired nothing more than the release
Of John Palicio, that he would contrive
To free him, if on my part I returned
A certain letter to his hands, wherein, [Shewing.
As you may read, he had betrayed your person 2720
To John Palicio for a price. Then I,
As holder of this written ransom, came
To see my kinsman freed; when in the dungeon
False Blasco, with two villains and another,
Who was your son, appeared before us armed:
And thinking there to find Palicio
Defenceless, would have slain him, and forced me
To give them back this writing: but Palicio
Sprang up, slew Blasco, and escaped.
Ph. His death
Was due from me.
Hu. Give me the letter, pray. 2730
Say, Livio, is this true?
Liv. I never knew
Of this betrayal, sir; I trusted Blasco.
 Mar. He counts for nothing, since he ran away.
Enter Palicio.
Hu. Is this the man?
Man. Thou art my prisoner.
PALICIO.
I make submission to your excellence.
[Offering (Blasco’s) sword.
Man. Dost thou surrender of thy own free-will
To me, as legal viceroy of this island,
Under King Frederick, and now abjuring
Thy late rebellion, wilt thou trust henceforth
The people’s welfare to my lawful hands? 2740

Pal. I do, and all will trust thee as do I.

Man. That is thy pardon. (Takes sword.) For the king’s good will
Is grace to all. Yet there will be for thee
Question in Blasco’s death. But now I need
Elsewhere thy presence. (Returning sword.) Go forth to the people,
And make it known that I am their governour:
And that for all disorder ere this day
There will be pardon, but from this day none.
Bid them disperse.
Pal. Those hundred men of mine,
Who lie in prison: is their pardon granted? 2750

Mar. ’Tis I should plead for them. ’Twas I betrayed them.

Hu. Thou didst betray them?
Mar. Ay, sir.
Hu. ’Tis nought but wonder.
Man. (to Pal.). This is a day of grace. None will resent
Our stretching mercy. I shall grant their pardon,
But not without some cautions; for among them
But not without some cautions; for among them—
Hear me, Palicio, thou who so dost cry
Against the taxes—many among thy men
Are a most burdensome and fruitless tax.
They go free but to work, and with such measures
As will ensure it. [Palicio is going.
Now, sir, ere thou goest, 2760
Is there none here to whom a word is due?
Pal. O, Manuel, I dare not, nay,—I pray thee,
Be not too generous towards me: since my heart
Has fallen so far, let me have trial yet
That I may win what I but falsely stole,
And now would leave in thy security,
Till I may bring some right to claim it. Yet
I lack the worth to ask. But there’s one thing
Which I will ask (goes to Margaret), forgiveness; and for that
I kneel.
Mar. I will not hide it from thee, sir, 2770
That in the mutual interchange of pardons,
Which is our friendly game, I have had some pain
Standing out in the cold, merely for lack
Of such a suit as thine. I have looked and longed
To find a debtor; and I will take thee.
Rise, sir. I must present thee to a kinsman.
[Leads Palicio to Hugo.
(To Hugo.) Do you remember, sir, a cruel saying
Spoken to me against this gentleman?
Since that I have been his friend, ay, and yours too,
For I betrayed his people to your hands, 2780
When they were setting forth to burn the palace;
And so prevented Blasco’s treachery;
From which him too I saved, and for that deed
He takes me now in marriage.
Hu. All thou sayst
Margaret with much of what hath happed to day
Margaret, with much of what hath happed to-day
Needs explanation. I must see so far
That Livio by his conduct is cut off:
But if you tell me now that you will marry
This man ...
Man. Palicio is of noble blood,
My lord. Yourself have given him oft such praise
As by an enemy must be well deserved 2791
Ere it be spoken. The king’s pardon proves
Justification: he is quit of treason.
We shall restore his rank, the loss of which,
Due to his grandsire in the civil wars,
Brings him no stain: nay, we shall further make him
Chief secretary, where his ancient zeal
For all the commons’ rights may still be shewn.
Con. Margaret, we may be married the same day.
Hu.I see indeed this is a day of grace, 2800
Of wondrous grace: and where I take so much
I should be churlish did I not rejoice
That I may rank behind no one of you
In the free dispensation of my favour.
And there’s one act would set the balance even,
Lay it even lower against me: it is this,
For I will do it: John Palicio,
I do forgive thee ...
Mar. Now I thank thee, sire.
Pal. And I, my lord, who never thought to do it,
Will forgive thee. do you forgive us all.. 2810
 THE RETURN
OF
ULYSSES

A DRAMA IN FIVE ACTS

IN A MIXED MANNER

DRAMATIS PERSONÆ

ATHENA.
ULYSSES.
PENELOPE.
TELEMACHUS.
EUMÆUS swineherd to Ulysses.
EURTMACHUS
AMPHINOMUS
wooers of Penelope.
ANTINOUS
CTESIPPUS
 PHEMIUS a bard.
LEIODES a soothsayer.
CHORUS of WOOERS.

Neatherd and other servants to Telemachus and

Eumæus.
Retainers of Wooers; and Maids of Penelope.
The scene is laid in Ithaca. The first Act on the
sea-shore. The second at Eumæus’ hut.
The last three in the hall of Ulysses’ house.

ULYSSES

ACT · I
Ithaca: the seashore. Thick mist thro’ which Ulysses can scarcely
be discerned asleep under a tree. In the foreground, Athena.
ATHENA.
This day, the last of twenty fateful years,
Fulfils the toil and wanderings of the Greeks,
Who sailed with Agamemnon against Troy
To win back Argive Helen; for to-day
Ulysses, last and most despaired of all,
Is safe again in Ithaca: and in truth
Have I, Athena, though the wisest power
And mightiest in Olympus, striven long
In heaven and earth to save him from the wrath
Of great Poseidon; but at length my will 10
Nears its accomplishment, for on this isle
Of Ithaca was he at break of morn
Landed by good Phæacian mariners,
Who ply the convoys of the dangerous sea;
Even as they promised him, their king and queen,
Alcinous and Aretè, honouring him
With loving gifts, tripods of bronze and iron,
Raiment and bowls of gold: thro’ blackest night,
And the confusion of the baffling waters,
With sail and oar urging their keel they bore him, 20
Who all the while wrapt in sound slumber lay
Deep likest death; and in that trance they laid him
Beneath yon olive tree, and, by his feet,
The gifts they brought: there may ye see him lying,
And there the gifts: and yet ye scarce may see,
With so thick darkness have I drenched the air,
Lest when he wake, the sight and sweet desire
Of home supplant his cunning, and he rise
Forthwith, and entering suddenly his house
Fall by the treachery of the infatuate lords, 30
Who prey there on his substance unrestrained,
Sitting in idle suit to woo his wife,
Who weeps his fate unknown; and thus my will
At last were crossed. So hither am I come
Myself to break the sleep I sent, and warn him
Against his foes. And now must I awake him;
But first will doff my helmet, and appear
In mortal semblance, as a delicate youth,
Some prince of the isle: so shall my javelin,
Long robe and shining sandals not betray 40
My godhead. He to me, disguised and strange,
Will answer nothing truly, nor believe
What truth I tell: ’tis thus I love to prove him,
And catch his ready mind at unawares.
Wake, merchant, wake, awake; whoe’er thou beest,
That sleepest thus so nigh the public road:
Arouse thee, man, and guard thy store: Look to it!
Ay, if some passer-by have not already
Filched from thee a sad loan of bronze or iron.
For though we reverence Zeus, thou giv’st occasion
To make a thief even of an honest man. 51

ULYSSES (awaking).
Hail, friend, whom first my waking eyes behold
Here in this land: and since thou speakest friendly,
Prove now my friend, and show how best to save
These few things, ay, and save myself, being here
Without thee friendless. And, I prithee, tell me
What land is this? What people dwell herein?
Is it an island, or some mainland shore
That from its fertile plains shelves to the deep?
Ath. What hast thou asked, man? Couldst thou hither come, 60
Not shipwrecked, as is plain, and yet not know
Our famous isle? Not so am I deceived.
Thyself tell rather who thou art and whence,
Else learn’st thou nought of me: And speak but truth.
Ill speeds ent eat on a l ing tong e
Ill speeds entreaty on a lying tongue.
Ul. Indeed I speak but truth, friend, when I say
I know not where I stand; as thou must grant
At hearing how I came: for from wide Crete
Have I fared over sea with these my goods—
Where to my sons I left as much again, 70
When thence I fled in fear, because I slew
The noble and swift-footed prince of Crete,
Orsilochus, son of Idomeneus;
Who threatened to despoil me of the wealth
I won at Troy, suffering for many years
The woes of that long war; and all his grudge
Was that I had not served the king his father,
But kept my own retainers—for which thing
He would have robbed me: but I smote him dead.—
Ath. Ah, king of ready wile, what tale is this 80
Of Crete and of thy sons, which when I bid thee
Speak truth, trips on thy tongue? Dost thou not know
Thy goddess, great Athena? Was’t not I
Who stirred the hearts of those Phæacian men
To bring thee hither? Wherefore in my ears
Pourest thou fables?
Ul. ’Tis thy voice indeed,
Which tho’ my eyes were blinded, well I knew.
Voice of Athena, dearest of the gods!
Now with my soul I grasp thee, now I see,
And worship thee, divine one, and thy knees 90
Embrace: but in this darkness and disguise
Not even a god had known thee; blame me not.
Ath. Nor for thy false tale to a stranger spoken?
Ul. Since thou who lackest cause hast more deceived.
And I—where were I now without my guile,
Without thy help?
Ath. If I should help thee still,
 p ,
What wouldst thou ask?
Ul. Answer me.—Say, what shore
Is this I stand on, which is hidden from me
By so thick mist: whether they promised true
Who brought me hither, and it be indeed 100
Ithaca, or whether, as I rather fear,
Some other land, to which my fated curse
Hales me, or ever I may see my own?
Ath. ’Tis Ithaca.
Ul. I pray thee by my longing
For that dear boon, goddess, deceive me not.
Ath. Thou dost not yet believe; but if I show thee
Thy very Ithaca, wilt thou believe?
Turn now and set thy back against the noise
Of the stilly-moaning surge and look inland.
Ul. Nought. 110

Ath. Look!
Ul. I see nought. ’Tis a thicker mist
Than ever in my own cloud-gathering isle
Clung to the frowning cliffs, when the warm south
Beat up the vapours from the seas at morn.
Ath. Look.
Ul. Now it brightens somewhat, or mine eye
Wearies with vainly poring on the dark.
Ath. Look.
Ul. Ay, the vapours lift, the highlands loom,
The air obeys thee: thro’ its thinning veils
The figure of some mountain jags the sky;
And those should be my hills: ’tis Neritos,
’Tis Ithaca indeed.
Ath. ’Tis Ithaca. 120
 Ul. O Blessed Light, that unto all men’s eyes
Shewest the lands and waters: that uprisest
Day after day upon the windy seas
And fertile plains, valleys and lovely hills,
Rivers and shores, and heights and peopled towns;
Now in all Greece is no tongue praiseth thee
As mine, nor heart thanketh; nor any eye
Rejoicest thou as mine.
Ath. Turn now to left.
There is the haven of Phorcys, here the tree,
Thy well-remembered olive; and to right 130
The rock-roofed cave, where thou so oft hast done
Sweet sacrifice unto the native Nymphs.
Ul. Soil of my dear-desirèd fatherland,
For warrant that I dream not, take this kiss;
My home! And ye, dear sisters of the spring,
I raise my hands to you, whom nevermore
I looked to greet; but now, children of heaven,
As once of old I praise you, and henceforth
Will pay with loving vows, if your fair queen
But grant me life, and comfort in my son. 140

Ath. Now thou believest.

Ul. See, there be the firs,
Which eastward of my house bar the red dawn
With black, and in their feathery tops at night
Sigh to the moon. Ay, and my house I see
Unchanged. ’Tis Ithaca.
Ath. Wilt thou not go
Now to thy home, and with the sweet surprise
Of thy desired return gladden thy wife,
And greet thy son, a man, whom thou didst leave
In cradle? See, I here will guard thy goods.
Thou wouldst be gone.