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Essential Questions

· How does an organization's structure affect its decision-making processes?

· What is the role of the organizational vision?

· How does the alignment of nursing values and organizational values impact nurse commitment?

· How does the nurse leader advocate when the organizational values differ from nursing ethics?

· How does the nurse leader handle conflict to ensure positive outcomes for patients and staff?

· What approaches can nurse leaders and nurse managers use in times of conflict?

Introduction

Organizational culture  and  values  have a direct impact on staff engagement, quality of care, and patient outcomes. Various elements within an organization's immediate environment, as well as external contributors from larger systems (e.g., state or federal government, regulating agencies) can have a direct impact on culture. This chapter reviews different organizational structures, organizational characteristics, organizational systems, and the mission, vision, and values of an organization that have a direct impact on culture and engagement. Further, operational processes, continuous quality improvement, performance and data-driven decision making, technology, data analytics, patient advocacy, and social justice are reviewed in relation to creating safe working cultures that provide quality and safe care.

Organizational Structure

Structure is very important to the success of any organization, but it is not a "one size fits all" concept. Part of running a successful organization is identifying the structure that best meets the organization's needs and recognizing that the structure does not have to be set in stone. In fact, successful organizations are those that evaluate outcomes and determine the need for changes in  organizational structure  in order to maximize profitability and the experiences of  stakeholders .

Organizational structure is often related to the decision-making process, which can be characterized as being centralized or decentralized. When  decision making  is centralized, a very limited number of key individuals are identified as having decision-making powers.  Centralized decision making  can be found within both flat structures and tall hierarchies. Flat structures, also known as  horizontal organizational structures , have fewer levels of power separating the top from the bottom (see Figure 4.1). This differs from tall hierarchies, also known as  vertical organizational structures , in that several levels of power separate the top from the bottom (see Figure 4.2).  Decentralized decision making  spreads decision-making power throughout the organization. This type of decision making can be found in both flat structures and tall hierarchies.

Figure 4.1

Flat Organizational Structure

Figure 4.2

Vertical Organizational Structure

Henry Mintzberg, a top researcher in organizational structure and design, developed five distinct structures that characterize different organizations. While these structures are determined by three elements, the descriptions of each structure can be closely related to the products or services rendered as well as the overall goal or focus in mind (e.g., quantity versus efficiency) (Lunenburg, 2012; Mind Tools, n.d.). Mintzberg's five types of structures include the  entrepreneurial organization , the   machine organization , the   professional organization , the   divisional organization , and the   innovative organization  (Luneburg, 2012). Although, generally speaking, no one structure is more efficient than the other, organizations must determine the structure that is best suited to meet the organization's needs in order to remain successful and competitive in the global market.

The Entrepreneurial Organization

Entrepreneurial organizations focus on central leadership in which a limited number of managers over a flat structure have decision-making authority and maintain power over how the business is run. Kokemuller (2018) suggested that this structure is often seen in new companies that are managed by the founders. Although enthusiasm and a high drive for success are strengths of these ambitious individuals, a controlling environment with limited room for participative decision making presents potential disadvantages.

Although the entrepreneurial structure is most often found in new start-up businesses, more grounded businesses may choose to employ this structure to regain control during times when the business is struggling; however, the employment and effectiveness of this structure to regain control is highly dependent on the individuals taking control. Experienced managers with a record of reestablishing organizational success, who are not overwhelmed with making independent decisions regarding change within a business, should be considered for this scenario. The ongoing evaluation of productivity and growth can help determine when this structure should be employed.

The Machine Organization

The structure of a machine organization, also known as machine bureaucracy, also focuses on centralized power. The structure differs from the entrepreneurial organization in that a tall hierarchy characterizes the decision-making process. While several levels in the chain of command are identified, management is narrowly placed on this hierarchy. Military organizations are a prime example of this structure where the chain of command hierarchy is tall and narrow, and a large number of support staff is present (Lunenburg, 2012). While employing this structure helps to maintain internal efficiency, resistance to change and the focus on procedure over people can prove to be inefficient.

The Professional Organization

The professional organization, also known as professional bureaucracy, has a similarly tall structure to machine bureaucracy, but the decision-making power is decentralized. With this type of organization, experienced and skilled individuals with various academic backgrounds participate in decision-making processes at different levels. Staff within professional organizations are often highly skilled individuals who have undergone training or education. Although it seems that individuals are working in teams to complete the daily work, they actually work independently to complete daily tasks based on policies and procedures (Mintzberg, 2016). Further, Lunenberg (2012) suggested that the goal of professional organizations is to improve and transform services continually to increase customer satisfaction. This structure is often seen in health care because it encourages continuous quality improvement through participation in decision making among members of an interdisciplinary team.

The Divisional (Diversified) Organization

The divisional organization is characterized by its name. The organization is separated into divisions, and decision making is decentralized to each divisional unit. An example would be a large corporation with several sites that produce a variety of products. A main headquarters location houses top executives for the parent company, but different sites are responsible for a more specific product line. It is important to understand that, although the large picture of this organization is diversified, each division may employ a different structure based on the products or services rendered.

The Innovative Organization

Within innovative organizations, also known as adhocracies, a diverse range of talent is often consulted in order to produce innovative, cutting-edge results. Mintzberg (2016) suggested that filmmaking industries and advertisement agencies work within this structure. The decision-making process is highly decentralized, but teams of experts must work together to produce innovative solutions. This structure benefits from the diverse amount of talent they have access to, but because of the decentralization of power among several members with a team, control can be an issue.

Organizational Structures in Health Care

As the business of health care continues to evolve and prioritization on quality and patient satisfaction intensifies, the structure within health care must remain flexible to meet the changing needs of the industry. Hegwer (2016) suggested that different health care organizations are utilizing a variety of structures in order to meet the high standards that the industry demands. Adhocracy is often blended with entrepreneurial leadership in order to establish best routines in health care for a specific organization. Nurses can take advantage of these structural changes by serving as leaders and experts in their field. Further, nurses who are well versed on the changing health care arena and who stay abreast of the industry demands can often identify how to take advantage of different structures in order to meet challenges or maintain stability and growth within their field.

Organizational Culture

Before identifying what organizational culture is, culture must first be defined.  Culture  itself refers to the values, beliefs, or behaviors of a group of people sharing a common interest or characteristic displays. Groups of people can be as large as a whole country or as small as an office firm. Large or small, the commonality amongst the people is often dependent on the influences displayed by those they learn from or follow. Thus, organizational culture can be defined as the values, beliefs or behaviors that are displayed within a particular organization. Edgar Schein, a well-known scholar and author, suggested that a positive organizational culture is the mannerisms and attitudes displayed within an organization that have been effective in creating meaningful and productive relationships (Goodwyn & Gittell, 2011).

Characteristics of Organizational Cultures

The characteristics of an organization's culture are often defined through its  shared values  (Denison & Spreitzer, 1991). When the employees' values align with those of an organization's values, increased engagement and dedication to the organization is often noted.  “The application of new and fresh ideas allows companies to remain competitive in the market and supports continuous quality improvement of the products or services they provide.”Shared values among employees and their employers support a positive working culture that contributes to successful outcomes and outperforms competitors. While several descriptive words or phrases can be used to describe the characteristics of an exemplary organizational culture, some of the most important include innovative, detail oriented, outcomes oriented, people oriented, team player, aggressive, and stable (BizEducator, 2017).

The application of new and fresh ideas allows companies to remain competitive in the market and supports continuous quality improvement of the products or services they provide. Organizations must remain aggressive in supporting change based on the market-relevant evidence that shows what works and what does not work. Yet, what supports innovation more deeply and increases value within an organization's culture is the attention to detail and the focus on outcomes and people throughout the process. When an organization supports and appreciates the input and ideas from stakeholders (e.g., employees, customers), respect and value are often noted throughout the organization and in day-to-day operations.

Vision, Mission, and Values

Vision  and  mission  statements are essential elements of a business or organization, large or small. These statements define the goals and objectives of the organization and, more importantly, how the organization meets the needs of the community or population being served. It is important to note that mission and vision statements are very different, although many tend to use the terms interchangeably.

Vision statements describe the dream of an organization and what the organization hopes to accomplish. The Health Resources and Services Administration (HRSA) suggested that the vision statement is "the type of statement that answers the questions 'where are we going' and 'what can we achieve'" (HRSA, n.d., para. 2). It provides direct insight into how an organization will make a direct impact with the community or in the world. Brάtianu and Bάlάnescu (2008) further mentioned that vision statements are powerful, purposeful, self-determining, concrete, multifaceted, and emotional.

The vision statement is a very important part of the organization's development and success. Strong vision statements further entail what the organization  will achieve and a clear developmental path.

The mission statement differs from the vision statement in that it focuses on the purpose of the organization now. Emphasis is placed on whom the organization is serving and how it is serving them (HRSA, n.d.). It is also the guiding principle of how the organization operates. Brάtianu and Bάlάnescu (2008) suggested that a strong mission easily identifies how the vision of the organization can be "transformed into a tangible existence for the company" (p. 21).

While the mission and vision statements clearly identify where the organization is going, how it is getting there, and who it is serving, values within an organization are its driving force behind maintaining a positive culture. Values within an organization are the  ethical standards  the organization promotes and follows. Values define how the organization chooses to operate and the ethical standards to which the organization requires employees to adhere; however, simply stating an organization's values is not enough to engage a positive working culture. Values must be noted in everyday practices, and managers and leaders must consistently use shared-value principles in order to ensure a congruent culture is experienced throughout the organization (HRSA, n.d.). Further, the incompatibility of values among staff and the organization can lead to decreased staff engagement, poor culture, and, in turn, poor patient outcomes.

Check for Understanding

Grand Canyon University (2018), for example, states its mission as,

GCU is a missional, Christ-centered university with an innovative and adaptive spirit that addresses the world’s deep needs by cultivating compassionate Christian community, empowering free and virtuous action, and serving others in ways that promote human flourishing.

Through academic excellence, the university equips students with knowledge of the Christian worldview, instilling in them a sense of purpose and vocational calling that enables them to be innovative thinkers, effective communicators, global contributors, and transformative leaders who change their communities by placing the interests of others before their own.

1. Based on GCU’s mission statement, who is GCU serving and how is the organization serving them?

2. Is the mission clear and does it provide a powerful message regarding what the organization stands for?

Organizational Change Management

Change is an inevitable part of any organization. The introduction of newer technology along with revolutionized theories and changes in generational outlooks produces continuous improvement goals that organizations must unceasingly strive to meet in order to remain competitive in the market (Hayes, 2014). This process of change and the ability to help people adapt to change is known as  organizational change management . The purpose of organizational change management is to identify the goals of an organization clearly and develop strategies to meet those goals. Organizations must be flexible in order to implement change and shift processes that would contribute to their success. Further, they must develop strategies to help those affected by the changes, such as stakeholders, in order to promote buy-in and smooth transitions.

The implementation of change must be strategized and a clear process plan should be identified before any change occurs. This ensures that smooth transitions ensue and that companies are successful in meeting the new goals. It is like going on a road trip. A driver wants to get from Point A to Point B, 500 miles away. Simply getting on the road and driving may get the driver to the final destination, but the driver is bound to get off track and add time to the drive; however, if a driver looks at a map and chooses a route and plans stops along the way as well as unexpected contingencies, the driver is more likely to reach the destination by the proposed time with fewer hurdles and more efficiency.

Change Management Models

There are several change management models that organizations can adopt to help them achieve their goals. Some of the most widely used models include  Lewin's change management model ,   Kotter's theory ,   nudge theory ,  and the   ADKAR model . These models will be further examined through this chapter.

Lewin's Change Management Theory

Lewin's change management theory is conceptually easy to understand. Three stages to the change process, including unfreezing, making changes, and refreezing, occur to identify processes needing revision, implement changes to support the revision with the least amount of resistance, and establish a new  status quo . Each stage is instrumental in the change process and allows organizations to follow a very strategic plan. Utilizing this plan is beneficial because it supports the organization to flourish as process improvement occurs.

Figure 4.3

Lewin's Change Management Theory

The unfreezing process is the most tedious of the three stages, but is undeniably the foundation of identifying what needs to change. It involves taking an in-depth look into every single step within a process to determine where inefficiencies occur. Gaining employees' perspectives, determining flaws or outdated practices, gaining support from management, and addressing stakeholder concerns are all part of the unfreezing process (Mulholland, 2017). By unfreezing current practices, organizations open a gateway toward achieving positive outcomes as they move on to making changes.

The transition from old to new can be daunting to those affected by the change; however, Lewin's theory suggests that an organization can limit the strain during the transition through effective communication, education, and genuine support (Mulholland, 2017). While communication should begin in the unfreezing stage, concise and consistent communication and support is needed heavily throughout the change stage because this is when increased tension is bound to occur. Genuine support involves employees in the change process by allowing them to relay feedback and ask questions that would help to relieve their tension. This, in turn, creates an environment where employees feel valued, making them more willing to comply with changes.

Another method of decreasing tension and increasing acceptance of change processes is through education. Whether introducing a new product or a new process, education must be provided to help employees understand the changes occurring. Further, evaluation of knowledge is necessary to ensure full understanding of the new product or process.

After unfreezing and making change, refreezing must occur. This is a step that many organizations forget or fail to follow through with, which is why processes often revert to old, inefficient practices or behavior. The refreezing stage sets the tone for the new status quo. It involves continuous evaluation of the processes and allows organizations to recognize employees for the hard work and dedication they have toward creating better outcomes. The positive reinforcement and continuous evaluation sets a new status quo regarding the processes changed and minimizes the occurrences of employees reverting back to inefficient behavior.

Kotter's Theory

Kotter's theory of organizational change also focuses on implementing new processes and developing a new status quo, but the methods focus more on people than the change itself (Mullholland, 2017). In other words, it inspires the development of process improvement by focusing on the individuals who will make the change occur (see Table 4.1). There are eight distinct steps to Kotter's theory:

· Creating a sense of urgency

· Building a core coalition

· Forming a strategic vision

· Getting everyone on board

· Removing barriers and reducing friction

· Generating short-term wins

· Sustaining acceleration

· Setting the changes in stone

Table 4.1

Kotter's Theory

Create a sense of urgency	Before announcing the implementation of a new process or product, informally get your staff involved in identifying the need for change. This happens by creating a sense of urgency that was not formally presented. For example, during a management staff meeting, the chief nursing officer (CNO) announces that there has been a 7% rise in medication errors in the last 6 months and that these numbers have alerted regulating agencies to make a visit to the facility. She announces that changes will have to occur and research is being done to determine the best ways to combat this disparity. Through “word of mouth,” the managers relay the data to staff during a staff meeting and this provides a heads-up that change to the medication administration process is coming.
Build a core coalition	This is a very important part in the change process. In order to ensure change occurs and is accepted, a team of individuals from various experience levels must be identified as the driving change agents (Mulholland, 2017). Within the health care system, these are often seen as committees. In the case of the medication administration change process, a committee can be formed to include nurses from various departments, nurse managers or directors, a physician representative, the administrator overseeing the project (potentially the CNO), a pharmacy representative, and a member from any other department that might be directly affected by the change.
Form a strategic vision	The strategic vision should be clear and concise enough for the core coalition to understand the purpose for the change in just a few sentences. Long, dragging reasoning for the change will disengage an audience and potentially sabotage the positive outcome a manager is reaching for. Mulholland (2017) suggested that if the coalition is unable to succinctly describe the vision, then staff buy-in is less likely to occur.
Get everyone on board	It is time to spread the word. This is a crucial time in the change process because not only is the word about the change spreading, but managers are inviting feedback, positive or negative, to the table. Responding to feedback is a key driver in getting staff on board with the change process. By empathizing with their concerns and providing timely feedback that addresses apprehension towards the change or provides ongoing positive feedback to supporters, managers and leaders can decrease resistance to change that may occur later.
Remove barriers and reduce friction	Removing barriers to change is a vital step. It ensures that hurdles are removed even before they occur. Identifying staff needs in order to ensure a smooth transition is a necessary element in Kotter’s theory. Needs are often based on the change that is occurring. For example, the implementation of a new medication administration system will require adequate staff training on the new system. By providing a variety of classes on the new administration system, employees can get comfortable with the system before it is implemented on the unit. In addition to the classes, key managers and leaders can provide extra help and manpower during the transitional stage to guide employees when problems may arise. Identifying budgetary flexibility to increase manpower during the rollout phase can decrease tension and frustration.
Generate short-term wins	Motivation and recognition are key drivers to help the organization embrace the change. Managers and leaders should plan to acknowledge the individuals and groups who have embraced the change. This encourages continued complacency and promotes a culture where employees feel valued for their work.
Sustain acceleration	Meeting goals that were set at the beginning of a change initiative does not mean that goal attainment should cease. Organizations must continually evaluate the change process and the initiative put into place. When goals have been accomplished, create new ones for which employees can strive. This provides an ongoing path for success, rather than just a finish line at the end of a race.
Set your changes in stone	Setting your changes in stone sets the new status quo. This can be done formally, through the documentation of change processes, as well as through recognition of key members who helped make the change process happen.

Note: Adapted from "8 Critical Change Management Models to Evolve and Survive," by B. Mulholland, 2017, located at https://www.process.st/change-management-models/

Nudge Theory

The nudge theory is different from the other models previously presented in that there is no actual model that it follows. Instead, this theory utilizes the concept of "nudging" as the basic principle to perform certain tasks that would inspire or encourage employees to work towards a common vision. According to  Merriam-Webster's, to nudge (2018) is to "gently push." Thaler, the developer of this theory, suggested that nudging helps to make the process easier and more effective by paving the way for employees (Mulholland, 2017); however, the gentle pushes are only as effective as the individual presenting them. Because this theory is quite equivocal and broad in nature, it is often used as a tool with a more advanced management model to help increase the effectiveness of employee engagement (Mulholland, 2017).

Some of the most basic principles of nudging include clearly defining upcoming changes, remaining empathetic and viewing changes from a frontline view, presenting evidence that supports changes, offering change as a choice, listening to feedback, limiting obstacles, and focusing on short-term wins (see Table 4.2).

Table 4.2

Principle of Nudge Theory

Principle	Description	Application as It Applies to Barcode Scanning for Medication Administration
Clearly define changes	Communication is imperative when any change occurs. It is important to clearly define any changes, utilizing various methods of communication (meeting, e-mail, flyers, etc.), and to gain the support of employees in the process. By engaging employees in the change process, an easier transition is likely to occur.	Introduce nursing staff to the application of barcode scanning ahead of time. Allow a forum in which staff can provide feedback on experiences or systems utilized in the past that would help engage them in the process of determining which scanning device to use.
Remain empathetic	Always view changes through the eyes of those who will be directly affected and determine ways that the changes can be implemented that are most desirable to them. This will enhance the transition process.	Understanding that resistance to this new medication administration record may occur, identify with the anxiety or apprehension that nurses may have moving forward. For example, would the implementation of this method add more time to the medication administration process? Will this new system delay the process in administering emergent medications? These types of concerns should be anticipated and addressed during the planning phase.
Present evidence	When presenting change to employees, be sure to provide substantial evidence about performance trends to identify why the change is necessary. Trends at the local level (within the organization itself), as well as national trends can provide employees with some different viewpoints.	To place more value on the need for the change, present staff with evidence regarding medication errors and near misses within the facility and provide ways that the new system will prevent these errors from occurring. To ensure substantial evidence is presented, provide a national overview of medication errors and the improvement of patient outcomes after the implementation of the scanning device.
Offer change as a choice	While choice may not always be an option, using a passive approach can help employees feel like a choice was presented. This principle is highly reliant on the previously established principles, including clearly defining changes, remaining empathic, and presenting evidence. If those principles were not approached well, then resistance to change and negative behaviors regarding change may occur here.	After clearly communicating the introduction of the barcode scanning system, addressing anticipated concerns, and presenting valid and indisputable evidence, provide employees with a forum where they can support or oppose the change. Mulholland (2017) suggested that the efficient presentation of evidence and focus on employees will ensure a supportive attitude towards the change that would have employees embracing it, rather than opposing it.
Listen to feedback	Feedback is a valuable tool to utilize in the change process. Employees should be allotted time and various forums to provide feedback and relay concerns. Addressing feedback not only eases the transition into the change, but also makes employees feel heard and appreciated.	Be sure to listen to what the staff has to say regarding the implementation of the new scanning device. Although you may have addressed anticipated concerns while employing the principle of remaining empathetic, other concerns may arise in the planning and rollout phases. Concerns must be clearly addressed and personalized as much as possible.
Limit obstacles	Be sure a continuous pattern of assessing and reassessing the changes before, during, and after implementation is determined. This process will help to identify potential obstacles or roadblocks that employees may face in the change process, which may inherently have an effect on their engagement. Addressing concerns on a continuous basis will decrease resistance and promote a smoother adaptation to the change.	Keep up with continuous updates on the technology being used. Ensure that there is a good process in place that ensures system compatibility is always addressed and the most recent versions of the scanning software is available.
Focus on short-term wins	Keep the momentum going and celebrate those who have embraced the change, as well as organizational milestones. This helps employees feel valued for the hard work they put in to make the change successful.	Continually provide employees with updated stats on medication errors and improved patient outcomes. To increase engagement and productivity, recognize whole units, as well as individual employees, for meeting organizational goals applied to the scanning process.

Note: Adapted from "8 Critical Change Management Models to Evolve and Survive," by B. Mulholland, 2017, located at https://www.process.st/change-management-models/

The ADKAR Model

The ADKAR change management model is a well-known tool used by leaders and managers to encourage and promote individual change in order to meet organizational goals (Prosci, 2018). ADKAR is an acronym for awareness, desire, knowledge, ability, and reinforcements, which are the guiding principles for this model. It has been successfully used to promote personal change, as well as organizational change, by addressing key elements that may be hindering personal or organizational forward movement.

Each of the five elements in this model is essential to address in order to work toward a positive outcome.  Awareness is the ability to identify the need for change. Employees must be able to recognize the "why" behind the change as the initial driver to accepting the change. Leaders and managers have a significant influence on awareness and can be the driving force behind whether employee buy-in or awareness occurs. Good justifying evidence must be presented to validate the need for change and for employees to become aware of its necessity. This leads into addressing the  desire for change, which can be challenging. Here, leaders and managers must be able to meet the emotional and logical needs of employees in order to gain their desire to make change happen (Mulholland, 2017). Mulholland (2017) further suggests that without winning over both the emotional and logical sides of employees, total buy-in will most likely not occur. Some of the most effective ways to meet this need are to provide substantial evidence that is relevant to the employees themselves and relate how the change affects the employees' current positions. As with any change, it is important to listen to and genuinely respond to feedback and concerns in order to help employees find value in the process.

The next step in the ADKAR process is  knowledge. This involves arming employees with the information needed to make change happen. Clear steps and direction are needed to guide employees and to give them all the resources they need to reach the final goal or destination. Prosci (n.d.) suggested that, "in order to effectively change, you need to know how" (p. 10). After learning how to achieve a particular goal or implement a particular change, it is time to show off skills learned. This refers to  ability, and it involves coaching and support from key leaders and managers within the organization. This is extremely important because without supporting the change in practice itself, unsuccessful outcomes will most likely occur.

Finally,  reinforcement refers to the positive recognition of short-term wins and serves as an accountability strategy for managers and leaders. Prosci (2018) mentioned that the lack of reinforcement will lead to employees reverting to old habits or behaviors. This last step is essential to the overall future success of the change implemented and the vision of the organization. Without proper support and recognition of achievement, all the hard work put into the previous steps may go to waste.

Figure 4.4

ADKAR Model

Leaders and managers have an integral role in organizational change management. Choosing the model that would best fit an organization's needs is imperative in the change process; however, this should be secondary to recognizing the influence that leaders and managers have on staff. Without the proper individuals to deploy the vision and change, the change process will be difficult to implement.

Organizational Systems: Open vs. Closed System

Organizations function on either an  open system  or a closed system. An open system is one in which there is good internal and external environment exchange of information and feedback in order to promote positive change and meet the needs of stakeholders locally, regionally, nationally, or even globally. The  internal environment  refers to the organization itself, while the  external environment  refers to a variety of individuals or organizations that can influence the way an organization practices (McNamara, 2005). Examples of external environmental influences include individuals or organizations that have political, technological, or societal impacts (McNamara, 2005).

Working with an open system that has porous boundaries where efficient exchange occurs in order to improve services or products leads to a more open and accepting culture. This is because the organization seeks constant feedback from outside influences in order to adapt to changing environments and to meet organizational goals. This differs from the closed system, in which organizations have hard boundaries where little information exchange occurs. Closed systems are unhealthy systems that often remain stagnant, leading to poor organizational culture (McNamara, 2005).

In order for organizations to be open systems, they seek feedback from a variety of avenues in order to meet organizational goals. The main concepts of an open system include inputs, processes, outputs, outcomes, feedback, and, finally, goals. Figure 4.5 provides an overview of the open system of an organization.

Figure 4.5

Overview of the Open System of an Organization

Note. Adapted from  Field Guide to Consulting and Organizational Development, by C. McNamara, Minneapolis, MN: Authenticity Consulting, LLC, 2005.

Operational Processes in Health Care Management

Within health care, managers must be aware of the  organizational processes  that can be impacted daily. Whether working in upper management, directing departments and managers, or working in middle management, overall success can be determined by supervising staff and daily productivity along with efficient deployment of essential organizational processes. These processes, including  planning ,  decision making,   delegation ,   coordination ,   communication , and   evaluation , have a direct effect on employee engagement, which can influence the culture of a particular unit or even a whole organization. As already established, positive working cultures increase how employees practice and have a direct effect on patient satisfaction and patient outcomes.

Planning

In the planning process, managers must set performance targets and determine a clear path for how those targets will be reached (Buchbinder & Thompson, 2010). Planning is often influenced by current health care trends and national goals set forth by regulating and other health care agencies. Many times, these goals are determined through research and the application of evidence-based practices. For example, individuals who present to the emergency room with an ST-elevation myocardial infarction (STEMI) are proven to have better outcomes when then they are diagnosed and treated in the cath lab within a certain amount of time (time is based on whether or not fibrinolysis was administered in the field). In order to meet this goal to ensure the best outcome for the patient, managers within the emergency department and cath lab must be able to formulate and disseminate clear protocols for the staff to take when STEMI cases appear. By planning and identifying a clear path to reach the STEMI protocol target, managers can ensure their staff is able to meet the goal and patients are given the best opportunity for a positive outcome.

Decision Making

Decision making is one of the most critical tasks within health care management. Managers must have efficient decision-making skills that allow them to assess how their decisions will affect patients, staff, and the organization. It involves making decisions based on both benefits and drawbacks and determining how to ensure the best possible outcomes ensue (Buchbinder & Thompson, 2010). Guo (2008) suggested that the DECIDE model (see Figure 4.6) for the decision-making process can help health care managers determine the best possible solution.

Figure 4.6

DECIDE Model

Note. Adapted from "DECIDE: A Decision-Making Model for More Effective Decision Making by Healthcare Managers," by K. Guo, 2008,  Health Care Manager, 27(2), 118-127.

Delegation

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Delegation, also known as directing, involves guiding or motivating subordinates to complete particular tasks. It is important to note that effective leadership is necessary in the delegation process (Buchbinder & Thompson, 2010). In order for managers and leaders to maintain smooth operations within their particular unit, a clear understanding of the delegation process is necessary.

In health care, delegation is often associated with the scopes of practice for licensed individuals. While national standards for delegation in health care are noted, every state contains specific guidelines regarding the delegation process. In nursing, the Nurse Practice Act (NPA) is the primary resource for the delegation process at the state level. The National Council of State Boards of Nursing (2016) determined five key components that should be included in the delegation process. This is often referred to as the "five rights of delegation" (see Table 4.3).

Table 4.3

The Five Rights of Delegation

Quality	Description
Right Task	. Action falls within the individual's job description and scope of practice. . Policies or procedures provide clear nursing guidance, along with expectations and limitations. . Proper training to complete the task is provided and documented.
Right Circumstance	. Consideration of delegated activities must be made based on patient's status (stable, unstable). . Any changes in patient's condition should be directly reported to the licensed nurse. . Before additional delegated activities can be communicated, the licensed nurse must reassess the patient and situation for appropriateness.
Right Person	. The individual performing the delegated task must have the appropriate training and knowledge, per the policy and procedures.
Right Directions and Communication	. Delegation should be specific to the situation and patient. . Clear and direct communication regarding delegated tasks should take place. . Time for questions or clarification should be allowed. . If the delegate is not comfortable or is unsure of the task or procedure, the delegate has a right to refuse based on lack of knowledge and training. . Any changes or modifications to the task must be cleared with the licensed nurse prior to implementation.
Right Supervision and Evaluation	. Two-way communication should take place during and after the delegated task. . The licensed nurse is responsible for evaluating patient outcomes and for ensuring that tasks are completed in a timely and efficient manner. . The licensed nurse should ensure that proper documentation is charted regarding the delegated activity and patient's status before, during, and after the delegated activity took place.

Note. Adapted from "National Guidelines for Nursing Delegation," by the National Council of State Boards of Nursing, 2016,  Journal of Nursing Regulation, 7(1), p. 8.

Coordination

Coordination, or organizing, is an essential role for nurse managers in health care. Coordination involves ensuring the overall design of the team efficiently produces increased productivity and positive patient outcomes. It further involves "determining positions, teamwork assignments, and distribution of authority and responsibility" (Buchbinder & Thompson, 2010, p. 20). Often times, organizing and re-organizing occurs based on current or predicted health care trends. For example, the team nursing model, originally developed after World War II in response to a nursing shortage and lack of continuity of care, has been increasingly used in particular health care units today in order to promote efficiency. This team approach has led to greater job satisfaction and retention of nurses (Campbell, 2017). Based on trends and research, nurse managers can determine whether this approach would best meet their particular unit's needs and should restructure the care approach based on their findings.

Communication

Communication is a key component to improving operational processes in health care management. Proactive communication leads to better health care outcomes.  “Communication does not only involve disseminating information, but also requires active listing and validation of concerns or feedback.”Nurse managers must be able to deploy efficient communication techniques that promote a two-way reciprocating effect. In other words, communication does not only involve disseminating information, but also requires active listing and validation of concerns or feedback. In fact, Kim and Oh (2016) suggested that health care organizations must foster effective communication and maintain an environment that not only encourages open communication, but also values feedback. By promoting an environment that encourages and models efficient communication, managers can increase engagement, lessen anxiety and stress, and promote higher employee satisfaction, all of which lead to greater patient outcomes (Kim & Oh, 2016).

Evaluation

To ensure that health care units or organizations are moving forward in the operational process, it is important that evaluation occurs. Evaluation can be addressed toward one individual or a group. For example, the individual performance of nurses and other health care staff are often reviewed on an annual basis. This evaluation process allows managers to highlight strengths or weaknesses of an individual's performance. The process provides an opportunity for staff to see how their performances are contributing, or possibly hindering, the goals of the organization or unit. It also provides a forum in which they can provide feedback on their perception of the working environment.

Group performances can also be evaluated on a predetermined basis, such as daily, weekly, monthly, quarterly, annually. For example, core measures are a set of standardized practices that have been determined as best practices by a collaboration of regulating agencies, but mainly led by the Centers for Medicare & Medicaid Services (2017). Core measures exist for several different types of health care agencies and are often evaluated for treatment compliance on a monthly or quarterly basis. The evaluation provides organizations with an overview of performance regarding top health-related issues and whether their organization is meeting national standards.

Continuous Quality Improvement

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Continuous quality improvement  involves the continuous effort of organizations, including groups and individuals working in and with the organizations, in improving services or products to meet the needs of customers. In health care, continuous quality improvement is essential for organizations to keep up with increased demand for health care, constant practice changes, and increasing health care standards of the nation; however, organizations must be aware that the application of continuous quality improvement on services alone will not achieve improved health outcomes. In fact, McCalman et al. (2018) suggested that only 10% to 20% of improvement is contributed to the enhancement of health care performance. Therefore, continuous quality improvement within health care must involve the unceasing development of structured processes that involve  interdisciplinary teams  within an organization to contribute to decisions made to improve health outcomes (McCalman et al., 2018). Interdisciplinary teams should work at a multitude of levels within the organization, as well as with other health care and regulating agencies, to ensure optimal health care outcomes.

Lean Six Sigma in Healthcare

The application of continuous quality improvement not only contributes to better patient outcomes, but also improves processes and culture within an organization. This is extremely important in health care to ensure that staff are engaged in the improvement process in order to achieve better patient outcomes. Lean Six Sigma in Healthcare uses a five-step approach to achieve process improvement and to improve the patient experience. The process—define, measure, analyze, improve, and control (DMAIC)—can be used in a variety of situations to improve processes and is specifically designed to promote quality improvement (American Society for Quality, 2018). This process is an ongoing cycle that health care organizations can implement to incorporate a disciplined method for long-term solutions (Berardinelli, 2012). Figure 4.7 outlines the DMAIC process and what occurs in each stage.

Figure 4.7

The Lean Six Sigma DMAIC Process

Note. Adapted from the "Six Sigma Explained" post by Khirin, from May 10, 2010, on the PanYa blog at http://khiripet.blogspot.com/2010/05/six-sigma.html

The DMAIC process may be used in the health care setting to improve the patient experience by making sure the organizational processes are consistently delivering desired results. However, it is important to note that this process is not a method to implement best practices; instead, it is a method to discover them (Berardinelli, 2012). Each phase builds upon the previous one to establish best practice outcomes.

Performance and Data-Driven Decision Making for Health Care

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The health care industry is an ever-changing global market that strives to provide quality, efficient care at manageable costs. As day-to-day operations often focus on providing quality services with desirable patient satisfaction rates and positive patient outcomes, several tactics are used to determine the efficiency of the services provided. These tactics involve gathering data, in multiform, to measure the different aspects of care relating to quality and finance. Data collection and analysis is the most efficient way to determine changes a health care organization needs to incorporate in order to improve processes. The IBM Corporation (2013) further stated that organizations "must treat data as a strategic asset and put processes and systems in place that allow them to access and analyze the right data to inform decision-making processes and drive actionable results" (p. 2). Agencies that regulate health care agencies have put several tools and initiatives into place to promote performance and data-driven decision making for health care. Select tools and initiatives are further reviewed in this section.

AHRQ – Quality Indicators for Health Care

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The Agency for Healthcare Research and Quality (AHRQ) is an organization that strives to impact health care delivery positively by using data and research to drive change. In fact, the mission of the AHRQ is to generate "evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used" (AHRQ, 2017, para. 5). The AHRQ originally developed  quality indicators  to allow states to assess the inpatient quality care of hospitals, but it was not too long after its introduction that hospitals began to use quality indicators to drive up personal performance and to compare their performance to other like facilities within the community and state. In addition, quality indicators have been used as a tool to determine areas needing improvement and change within organizations (Jones et al., 2014).

The AHRQ has created four indicator groups for health care agencies to use to improve services and care provided. These indicators include prevention quality indicators, inpatient quality indicators, patient safety indicators, and pediatric quality indicators (AHRQ, n.d.e). Further review of each indicator, along with how they are used to measure quality, is further examined in Table 4.4.

Table 4.4

AHRQ Quality Indicators

	Prevention Quality Indicators (PQI)	Inpatient Quality Indicators (IQI)	Patient Safety Indicators (PSI)	Pediatric Quality Indicators (PQI)
Data Measure	Data collected in the inpatient setting, particularly at the time of discharge, to determine the relationship between outpatient ambulatory care services (access to care, compliance, follow up, etc.) and hospital admission rates (AHRQ, n.d.d)	Data collected in the inpatient setting that measures inpatient mortality for certain procedures and medical conditions; the use, overuse, underuse, or misuse of procedures; and evidence relating the impact of procedure volume on mortality rates (AHRQ, n.d.a)	Data collected in the inpatient setting to measure the potential risks and complications and adverse events associated with surgeries, procedures, and childbirth (AHRQ, n.d.b)	Data collected in the inpatient setting, particularly at the time of discharge, to determine the impact of exposure to the health care system has on pediatric patient outcomes. Data is used to determine areas needing change, related to inpatient pediatric care, at the system and provider levels (AHRQ, n.d.c)
Examination and Implementation	. Screening Tool . Used to check primary care access in the community . Determines need for more community services relating to primary care . Allows health care and regulating agencies focus on disease prevention, rather than disease-oriented care (AHRQ, n.d.d)	. Identifies potential problem areas in the inpatient setting . Assesses quality of care in the hospital setting . Identifies mortality indicators relating to conditions or procedures that have variance results in health care . Measures utilization procedures and efficiency of use . Measures volume of procedures that may impact positive and negative patient outcomes by increased or decreased use (AHRQ, n.d.a)	. Provides hospitals with data relating to potential adverse events needing further investigation . Assesses the incidence of adverse events or complications in the hospital setting to determine similarities with like events . Determines complications that may denote patient safety risks and events . Compares data, at the regional level, to determine patient safety events that impact a larger area (AHRQ, n.d.b)	. Determines the effects that exposure to the health care system has on pediatric patient outcomes . Allows health care systems and providers to adjust care to promote better patient outcomes . Determines need for increased primary care services . Determines community outpatient support that focuses on prevention (AHRQ, n.d.c)

Note. Adapted from various quality indicators from the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services on its website at www.qualityindicators.ahrq.gov/

Managed Care: Initiatives to Reduce Cost and Improve Health Resource Utilization

Prior to the introduction of  managed care  in the 1980s through 1990s, health care costs were rising at a rapid rate. The rise in costs directly affected the ability of individuals and families to attain health care coverage due to increased premiums from health care cost inflation (Staton, 2002). In the past decade, many advancements toward bettering managed care to reduce costs and improve health resource utilization through  utilization management  have been made. Utilization management provides payers, whether private insurance companies or public organizations such as Medicare and Medicaid, to assess the need and appropriateness of services on a case-by-case basis (Speights, 2015).

To help reduce cost, managed care organizations (MCOs) were formed. Managed care organizations contract with a set of health care providers and facilities to provide a variety of health care services at managed and contracted rates. The three main types of managed care organizations are the  health maintenance organization (HMO) , the  preferred provider organization (PPO) , and the  point of service (POS) plan . Each of these managed care organizations utilizes specific guidelines that allow patients to seek health care through predetermined avenues. It is through this management that health care costs are maintained or reduced and appropriate care is provided.

The health maintenance organization (HMO) is the most restrictive, yet often most affordable, of the three types of managed care organizations. It often refers to a set network of physicians, hospitals, and insurance companies that fall under or are closely affiliated with the same organization (Nguyen, 2009). For example, Kaiser Permanente, a well-known HMO, offers coverage and services to its clients to be seen within the Kaiser Permanente network. Although clients are able to access the care they need, more steps may be required to seek specialized care. Often, individuals with HMO plans must first see a primary care physician from within the HMO network to obtain a referral to a specialist or other provider (Speights, 2015). Patients with HMOs have the least amount of out-of-pocket expenses when compared with other managed care organizations.

The preferred provider organization (PPO) works with a little more flexibility than the health maintenance organization. Patients have the flexibility to seek care outside of the preferred network, but a higher  deductible  is often necessary. In addition, providers contract to receive lower rates for services in exchange for more referrals (Nguyen, 2009). The benefits of this plan, for both patients and providers, make it the most appealing of the three types of managed care organizations.

The point of service (POS) plan uses an integration of benefits noted in the HMO and PPO plans. Patients with POS plans seek care from providers within the network, but providers do not specifically belong to set hospital systems (Nguyen, 2009). While of the POS plan does require patients to have a primary care provider, similar to the HMO, patients are able to seek out-of-network services, although out-of-pocket expenses tend to be higher for out-of-network services.

Pay-for-Performance Model – Models Intended to Improve Health Care Performance and Accountability

Pay-for-performance  models have grown tremendously over the past decade, as a result of increased health care costs and decreased quality and satisfaction of health care services. The implementation of these models was meant to steer away from the  fee-for-service  concepts where providers, individuals, and systems were being paid regardless of quality and satisfaction (Baird, 2016). The pay-for-performance models were meant to hold providers accountable for services provided and ensure that quality of care was a top priority in the health care field. Some examples of these models include the hospital value-based purchasing program, the physician value modifier program, the hospital readmission reduction program, and the physician quality reporting system (Baird, 2016). Figure 4.8 further reviews six key financial metrics for value-based purchasing.

Figure 4.8

Value Based Purchasing Metrics

Note. Adapted from "Surviving Value-Based Purchasing in Healthcare: Connecting Your Clinical and Financial Data for the Best ROI," by B. Brown, 2014, Salt Lake City, UT: Health Catalyst.

Although these models have the patients’ and the health care system’s best interest in mind, some challenges are also associated with their use (Baird, 2016). For example, if a patient at an inpatient facility is discharged with a prescription for which the patient has an undiagnosed allergy, should the hospital be responsible for the patient’s readmission if an anaphylactic reaction occurs? Further, factors that may skew performance results include complexity of cases, vulnerable populations, access to follow-up care, and continuity of care (Baird, 2016). Although, these factors are taken into consideration, the overall goal and focus of the pay-per-performance models is to ensure that patients and payers were provided with appropriate, cost-effective care. The establishment of this system has placed more responsibility on providers to meet quality health care standards.

Technology and Data Analytics

To control costs and ensure higher quality of care and better patient outcomes are achieved, a shift has been made from disease-oriented care to preventative care. More focus is being placed on determining how to promote health maintenance and manage chronic disorders before they become too complex to manage efficiently (Ghosh, Basu, & Bhaduri, 2011).  Analytics , which is "a discipline that applies mathematical sciences to data in order to answer what, why, when and how questions" (Ghosh et al., 2011, para. 6), has been used to foster preventative care through predictability and prevention. The shift to promote preventative care and health management has helped to reduce health care costs and allows providers to focus more on early care management, rather than treat complex and chronic issues.

Meaningful use  refers to the use of and exchange of information on electronic health records (EHRs) in a meaningful manner among health care providers, insurers, and patients to ensure quality and continuity of care. Regulating agencies, such as Medicare and Medicaid, developed this incentive program to improve patient care and encourage providers to use data acquired from electronic health records in a meaningful way to reduce health care costs and increase health care quality. This is the primary way that analytics are captured in health care to turn data into relevant and useful information that can be used to lower cost of care and increase quality (Ahier, 2018). These data are also used to determine best treatment options and preventative measures that can be applied when delivering patient care. The three stages of meaningful use are provided in Figure 4.9.

Figure 4.9

Meaningful Use Stages

The use of technology and analytics in health care have contributed to remarkable transformations in health care delivery and health care costs over the past decade. The Office of the National Coordinator for Health Information Technology (n.d.) prepared a significant executive summary that outlines the overall goals of health information technology in improving the quality of health care and containing costs. The vision of the Office of the National Coordinator for Health Information Technology (ONC), as expressed in the executive summary to its report, "Federal Health IT Strategic Plan 2015-2020," is to provide "high-quality care, lower costs, a healthy population, and engaged individuals" (ONC, n.d., p. 5) by improving "the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most" (ONC, n.d., p. 7). Figure 4.10 outlines the goals of the report and objectives for reaching those goals to contribute to a better health care delivery system.

Figure 4.10

Federal Health IT Goals

Note.  Reprinted from "Federal Health IT Strategic Plan 2015-2020," prepared by the Office of the National Coordinator for Health Information Technology Office of the Secretary, United States Department of Health and Human Services.

Patient Advocacy and Social Justice

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Nurses play an important role in ensuring that quality and safe care is provided to patients and that safe practices are implemented to achieve the best patient outcomes possible. To be advocates and practice  social justice , nurses must be armed with the knowledge and values that empower them to voice concerns and contribute to positive changes in their immediate environment; however,  advocacy  often encounters barriers in a culture where nurses feel powerless. In fact, research performed by Oliveira and Tariman (2017) indicated that the number one barrier to advocacy was lack of support from administration. An environment that does not support its nurses through education, training, and debriefing of high-risk practice behaviors may lead to increased errors, decreased accountability, and poor patient outcomes.

Achieving Effectiveness with Quality

Practicing a culture of safety within health care is essential to improving quality of care and decreasing errors (Agency for Healthcare Research and Quality, 2018). A shift from individual blame to the practice of identifying why and how errors occurred has created several opportunities for organizations to address errors in a matter that would prevent them in the future. This type of culture has eased its way into health care, but not without pushback. Often, when errors occur, accountability or blame needs to ensue to justify the error, rather than determining the potential causes to prevent the error from occurring again in the future. One mechanism adopted by many health care organizations to prevent this reactionary behavior is  just culture , which utilizes an intricate algorithm that allows risk management investigators to determine whether an error was due to human error, negligent conduct, reckless behavior, intentional rule violations, or malicious behavior (Marx, 2001). The outcome of the investigation is what allows managers to determine the best plan of action to take. While several just culture algorithms are available, the following is an example of an algorithm that determines the severity of the error and the action plan (see Figure 4.11).

Figure 4.11

Just Culture Algorithm

Note. Adapted from "Just Culture Algorithm Flowchart," by Masrani, 2005, located on the Flowchart in Word website at http://flowchart.ghkates.com/just-culture-algorithm-flowchart/

It is important to note that algorithms, such as the one provided in Figure 4.11, can be used in situations other than when an error has occurred. Near misses, including incidents that never reached a client and incidents that did reach a client but did not cause harm, can be reviewed using the just culture algorithm or any root cause analysis tool that could effectively investigate the reason for the near miss. Further, the investigation of near misses can determine changes or needs relating to hospital policies and procedures or staff education. The information learned after a root cause analysis is completed should be disseminated appropriately in case study form, along with any changes or variances to current policies or procedures to decrease or prevent the potential of harm occurring in the future.

In addition to ensuring that a culture of safety is established in relation to errors and near misses, conflict resolution strategies must also be established within organizations. Nursing leaders and managers must be able to develop conflict resolution strategies that can be beneficial in difficult situations.

Conflict , which is a simple or complex disagreement between two or more individuals or groups, is a very natural part of human behavior; however, it is the ability to resolve conflict that creates safe environments where individuals do not feel threatened by those around them. Poorly managed conflict leads to poor cultures, unengaged staff, and poor patient outcomes (Johansen, 2012). In fact, The Joint Commission (2008) released a sentinel event alert stating that "intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments" (para. 1). Table 4.5 further outlines suggested actions The Joint Commission (2008) published to avoid conflict and promote a safe working environment.

Table 4.5

Actions to Resolve Conflict and Promote Safe Working Environments

Educate Team Members	Provide all team members, regardless of position, with education on professional behavior and basic business etiquette.
Hold Staff Accountable	Hold staff accountable for modeling behaviors associated with the code of conduct, regardless of position or authority. Treat staff equally and approach inappropriate behavior with respectful and thoughtful conversation, rather than reactionary behaviors.
Establish Conflict Management Policies and Procedures	Put policies in place that outline the courses of action for intimidating or disruptive behavior.
Provide Training and Coaching	Provide all leaders and managers with effective conflict resolution training and cultural assessments that promotes relationship building and collaboration among an interdisciplinary team.
Support Surveillance and Progressive Discipline	Provide feedback in a nonconfrontational manner that encourages staff members to reflect on behaviors and make changes to reflect more appropriate manners. Provide clear feedback regarding potential disciplinary action if repetitive behavior occurs.
Conduct Interventions	Determine the effects that intimidating and disruptive behaviors have on staff. Provide necessary support to care for staff that may be affected physically or mentally through intimidating or disruptive behavior.
Encourage Interprofessional Dialogue	Promote communication workshops that provide proactive dialogue among staff from all disciplines.
Document	Document intimidating or disruptive behavior and always seek assistance from human resources specialists, as needed.

Note. Adapted from "Sentinel Event Alert: Behaviors That Undermine a Culture of Safety (Issue 40), by The Joint Commission, 2008.

The Quality and Safety Education for Nurses

The acronym QSEN stands for the Quality and Safety Education for Nurses. QSEN was established by the Robert Wood Johnson Foundation to provide nursing faculty with the most essential competencies that would prepare future nurses with the knowledge, skills, and attitudes (KSAs) needed to promote quality and safety in health care (QSEN Institute, 2018). The project was implemented in three phases between 2005 and 2012 to determine the top competencies to establish, pilot the competencies in select nursing programs, and establish the competencies as necessary items needed in nursing education programs. The six competencies defined as being imperative to in nursing education are  patient-centered care ,   teamwork  and   collaboration ,  evidence-based practice ,  quality improvement ,  informatics , and  safety  (QSEN Institute, 2018). To drive the program initiatives, the University of North Carolina at Chapel Hill School of Nursing and the American Association of Colleges of Nursing worked hand in hand to develop, pilot, and implement the project and disseminate the results and curriculum design strategies to academic organizations throughout the United States (QSEN Institute, 2018). It is the establishment of QSEN and early education and identification of quality and safety standards that continues to prepare new generations of nurses to provide quality and safety care.

Reflective Summary

Health care is a vital part in establishing healthier communities in the United States. It ensures that the services rendered, in a multitude of settings, provide well-established, efficient care that creates a sense of safety and trust among the customers being served; however, the culture of safety and focus on quality care must first be established within organizations for providers and health care workers to treat and care for the communities they serve efficiently. The integration of proper structures, decision-making processes, and competencies set forth by regulating agencies can help organizations establish well-tuned cultures that enhance health care experiences and place greater trust and respect in the system.

Key Terms

ADKAR Model: A change management model that uses awareness, desire, knowledge, ability, and reinforcements to promote personal change, as well as organizational change, by addressing key elements that may be hindering personal or organizational forward movement.

Advocacy: The action of supporting or pleading for a cause or proposal.

Analytics: The application of data analyzation used to foster preventative care through predictability and prevention in health care.

Centralized Decision Making: Key individuals within an organizational structure who have decision-making power.

Collaboration: Two or more people working together toward a common goal; in a health care setting, this work is meant to provide safe, quality care to patients in a nonthreatening environment.

Communication: Interpersonal sharing of information and/or feelings are exchanged in verbal and nonverbal methods.

Conflict: A simple or complex disagreement between two or more individuals or groups.

Continuous Quality Improvement: The ongoing efforts of organizations, including groups and individuals, working in and with the organizations to improve services or products to meet the needs of customers.

Coordination: Ensuring the overall design of the team efficiently produces increased productivity and positive patient outcomes.

Culture: Traditional beliefs and values shared among a group of people.

Decision Making: The act of determining a particular route of action to take, which may impact self, individuals, or groups of individuals in the process.

Decentralized Decision Making: Power to make decisions is spread among a group of individuals.

Deductible: The amount an individual must pay for services prior to an insurance plan providing compensation coverage.

Delegation: The use of personnel to accomplish a desired task by allocation of responsibility and authority under the guidelines set forth by regulating health care boards at the state and national level.  Divisional Organization: An organization is separated into divisions and decision making is decentralized to each divisional unit.

Entrepreneurial Organization: Organizational structure that focuses on central leadership in which a limited number of managers over a flat structure have decision-making authority and maintain power over how the business is run.

Ethical Standards: A determined set of principles that depicts the values and morals of an individual or organization and drives fair decision making and actions.

Evaluation: The assessment or reassessment of a particular person or group, task, or performance that determines the efficiency or inefficiency of a particular process.

Evidenced-Based Practice: The integration of clinical expertise, the most up-to-date research, and patient’s preferences to formulate and implement best practices for patient care.

External Environment: A variety of individuals or organizations, not directly related to an organization itself, that can influence the way an organization practices.

Fee-for-Service: Reimbursement for services provided by a provider or health care system regardless of quality or satisfaction.

Health Maintenance Organization (HMO): A type of health insurance plan in which the individual enrolls for a predetermined fee for services from a preset list of providers and facilities; care delivered by providers not on the preset list will result in no compensation from the insurance company to the provider or facility. The individual requires a referral from the individual’s primary care provider for any other provider or services. For example, to have coverage for a visit to a dermatologist, the individual must have the primary provider’s approval via a referral.

Horizontal Structure: An organizational structure in which power is shared and staff are given more decision-making power.

Informatics: The collection and analyzation of data that are used to improve health care documentation and services.

Innovative Organization: Organizational structure in which  the decision-making process is highly decentralized, consulting a diverse range of talent in order to produce innovative and cutting-edge results.

Interdisciplinary Teams: Several members of a health care team working together.

Internal Environment: The communication, feedback, and practices that occur within an organization that affects the way an organization functions.

Just Culture: Safety culture concept focusing on system issues that result in unsafe behaviors, yet holds the individual employee accountable to avoid reckless or risky behaviors and human error. Error or near miss analysis are based on the type of behavior associated with the error and not the severity of the event.

Kotter's Theory: A theory of change management that inspires the development of process improvement by focusing on the individuals who will make the change occur.

Lewin's Change Management Model: A change management model that utilizes three specific stages (unfreezing, making change, refreezing) to identify processes needing revision, implement changes to support revision with the least amount of resistance, and establish a new status quo.

Machine Organization: Focuses on centralized power, but this structure differs from the entrepreneurial organization in that a tall hierarchy characterizes its decision-making process.

Managed Care: The delivery of health care services that focuses on decreasing health care costs and managing health care utilization so patients can receive affordable and appropriate care at reduced rates.

Meaningful Use: Government standard regarding the electronic exchange of patient information among health care providers, insurers, and patients for enhanced efficiency, safety, quantity, and quality of information sharing.

Mission Statement: Stated organizational purpose that is recognized and integrated into professional practice.

Nudge Theory: A change management theory that utilizes the concept of "nudging" as the basic principle to perform certain tasks that would inspire or encourage employees to work towards a common vision.

Open System Theory: Good internal and external environment exchange of information and feedback in order to promote positive change and meet the needs of stakeholders locally, regionally, nationally, or even globally.

Organizational Change Management: The process of change and the ability to help people adapt to change in order to meet transformational goals within an organization.

Organizational Culture: The values, beliefs, or behaviors that are displayed within a particular organization.

Organizational Processes: Processes, including planning, decision making, delegation, coordination, communication, and evaluation, that have a direct effect on employee engagement and organizational culture.

Organizational Structure: The manner in which organizations delegate decision-making power and management to help run the business on a day-to-day basis.

Patient-Centered Care: The involvement of patients and their families in actively participating in health care decisions to promote collaborative decision making regarding care.

Pay-for-Performance: Meant to hold providers accountable for services provided and ensure that quality of care is a top priority in the health care field by reimbursing or penalizing providers for care that does not meet predetermined standards.

Planning: Setting performance targets and setting clear paths for how those targets will be reached.

Point of Service (POS) Plan: Patients seek care from in-network providers, but providers do not belong to a set health care system. Further, patients can see out-of-network services at higher deductible rates, but still need to have a primary care physician noted.

Preferred Provider Organization (PPO): A type of health insurance plan in which the individual enrolls for a predetermined fee for services from a preset list of providers and facilities; care delivered by those not on the preset list may result in no or less compensation from the insurance company to the provider or facility.

Professional Organization: Tall organizational structures that have decentralized decision-making powers. Often, experienced and skilled individuals with various academic backgrounds participate in the decision-making process at various levels.

Quality Improvement: A systematic and formal approach to collecting, analyzing, and disseminating data in order to improve services or products that a business renders.

Quality Indicators: Standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.

Shared Values: The principles and beliefs on an organization that support a positive working culture and guide behaviors of all staff, regardless of position.

Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.

Stakeholders: Person or persons both involved and directly affected by plans, actions, and outcomes. Person with a vested interest or personal stake in the outcome.

Status Quo: Latin term meaning "the existing condition"; identifies the current practice standards.

Teamwork: The action of two or more people working together to reach a desired outcome efficiently and effectively.

Utilization Management: The collection and assessment of data relating to health care services and treatment to ensure that services provided to patients are appropriate for care and timely in duration.

Vertical Structure: An organizational structure that implements a top-down approach in which managers, at various levels, are tasked with directing staff and the services or goods provided. Power or decision making depicts a pyramidal flow with one person in charge at the top and several levels of managers below.

Values: The beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group.

Vision: An aspiration or a plan for the future.

References

Agency for Healthcare Research and Quality. (n.d.a). Inpatient quality indicators overview. Retrieved from http://www.qualityindicators.ahrq.gov/Modules/iqi_resources.aspx

Agency for Healthcare Research and Quality. (n.d.b). Patient safety indicators overview.  Retrieved from http://www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx

Agency for Healthcare Research and Quality. (n.d.c). Pediatric quality care indicators.  Retrieved from http://www.qualityindicators.ahrq.gov/Modules/pdi_resources.aspx

Agency for Healthcare Research and Quality. (n.d.d). Prevention quality indicators overview.  Retrieved from http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx

Agency for Healthcare Research and Quality. (n.d.e). Quality improvement and monitoring at your fingertips. Retrieved from http://www.qualityindicators.ahrq.gov/Default.aspx

Agency for Healthcare Research and Quality. (2017). About AHRQ. Retrieved from https://www.ahrq.gov/cpi/about/index.html

Agency for Healthcare Research and Quality. (2018). Culture of safety.  Retrieved from https://psnet.ahrq.gov/primers/primer/5/safety-culture

Ahier, B. (2018). From meaningful use to meaningful analytics.  Retrieved from https://www.healthcatalyst.com/meaningful-use-to-meaningful-analytics

American Society for Quality. (2018). The define measure analyze improve control (DMAIC) process. Retrieved from http://asq.org/learn-about-quality/six-sigma/overview/dmaic.html

Baird, C. (2016, March 8). Top healthcare stories for 2016: Pay-for-performance [Blog post]. Retrieved from https://www.ced.org/blog/entry/top-healthcare-stories-for-2016-pay-for-performance

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