CIVIMBUT ARY

A strategy for developing a graduate programto prepare managers in dieteticsMARY CAREY, PhD, RD; JUDITHB. MANOLA, MS, RD

ietetics educators are faced with challenges of meeting theever changing needs of the profession. The increasing costsof education and the scarcity of resources often make

expansion difficult. in this commentarywe describe the approachwe used in developing a management specialization within agraduate program in dietetics.

The development of management knowledge and skills hasbeen part of the preparation of entry-level dietitians since guide-lines for their educational preparation were developed. The needfor competence in management by dietitians is well documented(1-4). The 1985 report of the Study Commission on Dietetics (5)indicated that the education of dietitians needs to be strength-ened in the areas of management and business. Snyder et al (6)examined management competencies and identified that mana-gerial acumen is fundamental to the effective practice of dieteticsand that dietitians are in particularly strategic positions becausethey are often responsible for administering a large percentage ofthe work force and operating budget. They went on to identify theneed for competence beyond the entry level, especially in systemsanalysis; budget; establishment of goals, policies, and procedures;human relations; and labor negotiation (6). Daniels and Gregoire(7) examined capital budgeting techniques by hospital foodservicedirectors and concluded that educators should examine curricu-lums to ensure that graduates are prepared in capital expendituredecision making. Recent emphasis on process-oriented qualityimprovement as an approach to problem solving mandates strongconceptual, communication, and managerial skills (8,9). In asurvey of the perceptions of hospital administrators, food andnutrition department directors, and management dietetics edu-cators, Dowling et al (10) examined the skills required for depart-ment directors. Overall, the three skills most highly ranked weremanagement, communication, and finances. Administratorsranked the need for managers to have political savvy and nutritionskills higher than did department directors.

M. Carey is a professor and the director and J. B. Manola isan instructor in the Graduate Program in Dietetics, MGHInstitute of Health Professions, Boston, Mass.

Address correspondence to: M. Carey, PhD, RD, GraduateProgram in Dietetics, MGH Institute of Health Professions,101 Merrimac St, Boston, MA 02114.

Others have emphasized the qualitative management skills ofcommunication, critical thinking, and problem solving for dieti-tians in health care and inbusiness and industry (11,12). The needfor these qualitative skills was reinforced by the report of the PewHealth Professions Commission (13), which identified the needfor leadership, planning, and communication skills. After survey-ing clinical managers, Gates and Holdt (14) suggested that thesemanagers needed additional training in performance appraisals oftheir professional staff.

The need for management skills has been related to the com-plexity of health care and the belief that management innovationshave not kept pace with technologic advances (10,15). Indeed,the trends of increased technologies and the shift from profes-sional to managerial values have been identified as trends thatneed to be addressed in the education of health professionals(13). The popular press has identified a trend favoring managerswith technical expertise over those with only general manage-ment skills (16).

Dietitians have the potential to combine technical expertisewith management skills. The profession itself requires a criticalmass of effective managers to survive and flourish. In a commen-tary on this subject, Dowling et al (17) identified compellingissues for the 1990s. Dietitians will need both qualitative andquantitative analytic skills to evaluate practice, to apply market-ing techniques, to manage change, and to empower others. Theauthors state, "it is vital to our profession that dietitians remainviable in management practice and central to the decision-makingprocesses" (17, p1066). Inananalysis of the projected demand fordietitians in the year 2000, a committee of the National Instituteof Medicine identified the possibility that jobs now held bydietitians will be lost to other professionals if employers find itdifficult to hire registered dietitians (18). The committee pro-jected more modest growth for dietetics than for some other alliedhealth professions. Hospitals, which currently employ 39% ofdietitians, had already experienced a reduction in the number offull-time employees even before the introduction of prospectivepayment systems. Several factors were identified as importantdeterminants of demand for dietitians, including the availability ofnew fields of employment, trends in private practice, ability toresist"substitutability" by other professionals, and interest in andpayment for health promotion and disease prevention. Generat-

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ing employment opportunities in all of these areas requiresmanagement expertise.

As a career path for dietitians, management seems to providean alternative with greater compensation. An analysis of ADA'smember database reveals that in all pay categories over $30,000,managers are more highly represented than those in clinicalpractice. Additionally, although it has not always been easy tocorrelate the acquisition of an advanced degree in dietetics withincreased compensation, in all pay categories over $40,000 mem-bers with master's degrees are more highly represented thanthose with only a bachelor's degree (19).

The dilemma facing educators is how to corral additionalresources to establish or enhance management education fordietitians. Education programs are facing tough economic times.The modest growth projections for dietitians, compared withother health professionals, may lead administrators to targetdietetics programs for cutbacks. McKinney (20) cities 10 possiblereasons a program might become the target for cutbacks, includ-ing high program costs and lack of revenue production, lowenrollment, a low number of tenured faculty, and a lack of broadsupport or involvement in the larger academic community. Clearly,the survival of dietetics programs depends on cost-effectivestrategies and careful and realistic planning processes.

MARKETING STRATEGIESGiven these constraints, yet with evidence of need, the GraduateProgram in Dietetics at the MGH Institute of Health Professionssought to explore the development of a specialty in managementthat would also enhance clinical knowledge and expertise. TheEight-Step Marketing Model outlined in The Competitive Edge(21) became the conceptual framework for this effort. Parks et al(22), who applied a marketing concept to an existing educationprogram, concluded that the effort contributed to a more cost-effective use of resources. The following description discusseshow each step of the eight-step model might be applied to aproposed program.

Step 1: Identify Target Market and Product LineBased on the profile of students currently enrolled in otherspecialties in the Graduate Program in Dietetics, we targetedregistered dietitians with 3 to 5 years of professional experience.We focused on students in the New England area. We were ableto identify the number of potential students and make preliminarydeterminations of the number of students we might expect torecruit. Our principal product was identified as a master's degreein dietetics, with a specialization in management and complemen-tary coursework in a clinical dietetics area of interest. We identi-fied certificate/dual degree options and continuing education ascomplementary secondary products.

Step 2: Conduct Market ResearchA committee was established to flush out the additional informa-tion that would be needed to develop a proposal. Three activitieswere undertaken: convening a focus group, interviewing dieti-tians in management positions and hospital administrators, andsurveying directors of dietetics departments. The committeeinvited a hospital administrator, two directors of departments ofdietetics (one with a graduate educational program), and afoodservice management consultant-all of whom were viewedas leaders and experts-to participate in a focus group to identifyskills and attributes required in dietetics management. Theirresponses reinforced the literature cited, and they identified thefollowing skills: leadership, problem solving, finance, communica-tion, interpersonal, and nutrition-related. These experts believedmanagers need to be innovative, creative, accountable, serviceoriented, sensitive, and objective. The consensus of the group was

that (a) some of these skills and attributes could be taught and allcould be enhanced by a graduate program in the Institute'senvironment; and (b) such a program would be attractive todietitians and, ultimately, to employers who would hire thegraduates.

The interviews with dietitians focused on how they had achievedthe managerial skills they were using in their positions, what otherknowledge and skills would be beneficial, and whether a programaddressing both clinical and management knowledge and skillswould be viable. The meetings with hospital administrators fo-cused on the knowledge and skills they would look for in hiringmanagers and howthese might best be attained. These interviewsreinforced the focus group conclusions, but the managers stressedthe additional need for experiential learning and skills in researchand problem solving.

Finally, a survey of a random sample of directors of dieteticsdepartments in US hospitals with more than 250 beds was con-ducted to determine characteristics of middle management posi-tions. From a sample of 480, 172 responses (36%) were received,which represented 10% of the target population. The resultsindicated that dietetics departments had a mean of 3.7 manage-ment positions (median=3). Thirty-eight of the respondentsindicated that a master's degree was required for one or more ofthese positions and half of the respondents indicated a preferencefor master's prepared individuals. Attributes these directors werelooking for in managers reinforced the conclusions of the focusgroup and the comments of the interviewees.

Step 3: Set Measurable and Realistic Goalsand ObjectivesAs is frequently the case in higher education, recruitment targetsfor the Graduate Program in Dietetics were established by theInstitute's administration. We determined what proportion oftotal admissions we expected the management specialty to fur-nish. Given Institute policies regarding faculty workload andgraduation requirements, we assembled a tentative curriculumand estimated the faculty requirements necessary to providecoursework to the expected number of students. We then as-sembled a pro forma budget that broadly identified income andexpenses.

Step 4: Determine Major StrategiesWith this information, the committee began to explore how themanagement specialty courses and experiences would be taught.It was evident that, at least initially, the Institute did not have theresources and expertise to launch such an effort. The committeeexplored the management options in the Boston area. The objec-tive was to identify programs that might be possibilities for acooperative venture. We were specificallyinterested in evaluating

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Expectations of graduates.

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compatibility so that students enrolled in a cooperative programcould move from one campus to the other with a degree ofcomfort. Programs were compared on the attributes of philoso-phy, total number of students, ratio of men to women, averageclass size, percent of students enrolled full time, presence orabsence of a thesis requirement, entrance requirements, andcourse offerings related to health care as stated in the catalog.After extensive review, the committee concluded that the HellerSchool at Brandeis University, Waltham, Mass, which offers theMaster's in Management of Human Services degree, would be thebest fit. The directors of the two programs met to develop amission, objectives, and a curriculum for review by the appropri-ate faculty at both institutions. In the first review, Institute facultyimmediately saw the need for the specialty to be open to alldisciplines at the Institute, with each discipline defining its ownclinical content.

The mission of the specialty is to prepare health care profes-sionals with the qualitative and quantitative analytic skills to plan,control, and organize resources effectively and to manage change.Expectations of graduates are found in the Figure. The course ofstudy provides students with the opportunity to enhance clinicalknowledge and expertise while honing valuable managementskills. The management courses were chosen because they ad-dress the deficits identified in the literature review and marketresearch, including financial, strategic, operational, and humanresource management. Clinical courses are defined by eachprogram to address the professional interests and goals of thestudents.

A practicum in the management of health care services pro-vides an opportunity for hands-on practice of managerial skills inan in-depth, real-world setting. The practicum is individualized toaddress the student's own objectives and the preceptors functionat the highest levels of organizations. Students have excellentopportunities to observe successful role models and to learn bydoing.

Step 5: Develop Action Plans and Assign ResponsibilityTo recruit students to the program, several action steps wereimplemented. Responsibility for these activities was divided amongprogram faculty. Recruitment activities included advertising,exhibiting at The American Dietetic Association and state annualmeetings, and developing a brochure. Sponsorship of a lecture ofinterest to area dietitians was also identified as a way to increaseprogram visibility.

Step 6: Develop a Financial Reporting SystemAlthough the framework for this system may exist at the institu-tional level, it is important that sufficient information about therevenues and expenses of the program be generated to assure theadministration that the program is viable. The more concrete thedata that can be provided, the more likely administrators are toadopt what they might perceive to be a risky new curriculum.

Step 7: Measure and Evaluate ResultsIt is essential to develop systems to provide feedback aboutprogram quality, student satisfaction, and program outcome.Although the concepts of Total Quality Management are widelyapplied in operations and health care, they have not been docu-mented in the education of health professionals. This approachwould merit future study.

Step 8: Enlist Organizational CommitmentThe approval of the administration is necessary at some level, butenthusiastic support must be generated for the program to trulysucceed. Members of the administration can be some of thestrongest supporters of the program. The joint venture described

in this model also requires good communication among thesponsoring institutions.

APPLICATIONSWith the increasing complexity of the health care system and theneed for health care professionals to possess diverse skills, theopportunity to gain advanced knowledge, skills, and researchexperience that relates to both the practice of clinical dieteticsand management is a marvelous opportunity for dietitians. Froman educator's perspective, the joint venture with a recognizedinstitution in the areas of human services and public policy is amost cost-effective use of resources. From a student's perspec-tive, the opportunity to obtain a certificate of recognition ofachievement enhances the degree. In addition, the potential toobtain a second master's degree with very little additional work isattractive. We believe that the approach we used in developmentcan serve as a model to other programs in exploring innovativeways of educating dietitians.

References1. Brown DM, Hoover LW. Quantitative management techniques indietetics: improving practice through technology transfer. JAm DietAssoc. 1988; 88:1567-1575.2. Brown DM, Fruin MF. Management activities in community dietet-ics. JAm Diet Assoc. 1989; 89:373-377.3. Hoover LW. Enhancing managerial effectiveness in dietetics. JAmDiet Assoc. 1983; 82:58-61.4. Position of The American Dietetic Association: management ofhealth care food and nutrition services. JAm Diet Assoc. 1993; 93:914-915.5. Study Commission on Dietetics: A New Look at the Profession ofDietetics. Chicago, Ill: American Dietetic Association; 1984.6. Snyder JR, Schiller MR, Smith JL. A comparison of career-entryadministrative competencies with skills required in practice: implica-tions of continuing education. JAm Diet Assoc. 1985; 85:934-938.7. Daniels RD, Gregoire MB. Use of capital budgeting techniques byfoodservice directors in for-profit and not-for-profit hospitals. J AmDiet Assoc. 1993; 93:67-69.8. Hess MA. President's page: minding your TQMs. JAm Diet Assoc.1991; 91:1126-1128.9. Puckett RP. JCAHO's agenda for change. JAm Diet Assoc. 1991;91:1225-1227.10. Dowling R, Lafferty LJ, McCurley M. Credentials and skills requiredfor hospital food and nutrition department directors. JAm Diet Assoc.1990; 90:1535-1540.11. Cluskey M, Messersmith AM. Instructional model for buildingqualitative management skills. JAm Diet Assoc. 1990; 90:1271-1273.12. Kirk D, Shanklin CW, Gorman MA. Attributes and qualificationsthat employers seek when hiring dietitians in business and industry. JAm Diet Assoc. 1989; 89:494-498.13. Shugars DA, O'Neil EH, Bader JD, eds. Healthy America: Practi-tionersfor 2005, an Agendafor Actionfor U.S. Health ProfessionsSchools. Durham, NC: Pew Health Professions Commission; 1991.14. Gates GE, Holdt CS. Evaluating the performance of clinical dieti-tians. JAm Diet Assoc. 1993; 93:564-567.15. Charns MP, SchaeferMJ.Health Care Organizations:A ModelforManagement. Englewood Cliffs, NJ: Prentice-Hall; 1985.16. Linden DW. Another boom ends. Forbes. January 20, 1992:76-80.17. Dowling R, Lafferty LJ, Norton C. The management component ofour profession. JAm Diet Assoc. 1990; 90:1065-1066.18. Institute of Medicine. Allied Health Services: Avoiding Crisis.Washington, DC: National Academy Press; 1989.19. American Dietetic Association Member Database. Chicago, Ill:American Dietetic Association; 1990.20. McKinney S. Surviving the '90s in dietetics education. Part I. Is yourdepartment a target for opportunity? DEP-Line. 1994; 12:8-10.21. The Competitive Edge: Marketing Strategiesfor the RegisteredDietitian. Chicago, Ill: American Dietetic Association; 1986.22. Parks SC, Moody DL, Barbrow EP. The marketing concept appliedto an education program. JAm Diet Assoc. 1984; 84:1031-1034.

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