Quality Assurance in Healthcaer Systems

Applying Quality Improvement

The American health system has sophisticated care delivery capability, featuring complex technology and very committed providers. However, serious questions exist regarding quality, performance, and value. The health care system accounts for the largest sector of the economy. Americans currently spend almost $2.5 trillion per year on health care, comprising approximately 17.6% of the total gross domestic product (Centers for Medicare and Medicaid Services 2011). This is the highest level of per capita spending in any country of the world. Despite this level of spending, the United States does not have the best health status measures or indices. Moreover, individuals receive approximately one-half of the services that should be delivered when they visit health care organizations (McGlynn et al. 2003). Approximately 25% to 35% of the services delivered have no effect on the outcome. Evidence suggests that many treatments and services are provided when less expensive care options would yield comparable results (Orszag and Ellis 2007).

The focus of the acute care sector is delivering individual care services with the primary goal of restoring health and caring for sick and dying persons. The public health sector focuses on communities with the goals of protecting health, enhancing health promotion, and improving the health of the general population.

Critics assert that the health care industry is ineffective and inefficient. Effectiveness means achieving high-quality results, whereas efficiency is defined as maximizing outcomes while minimizing costs. For example, from a financial perspective, hospitals are better off being full rather than empty. Physicians are paid when they interact with patients, independent of their health status. The delivery system is biased toward delivering services, independent of their value.

Questions regarding value and performance have been directed at the public health system. Approximately 5% of health care expenditures are made for public health services. The rest are directed to hospitals, physicians, and prescription drugs. Lifestyle issues such as poor nutrition and inadequate exercise have resulted in an obesity epidemic involving approximately 40% of adults, and 20% of American adults routinely use tobacco products. These two public health issues alone put tremendous upward pressure on health care spending. It is now estimated that three-quarters of all health care expenditures are made for chronic diseases that are related to diet (US Department of Agriculture 2011).

QI programs might be used to address several problems that have just been described. A review of treatment protocols could identify opportunities for procedural changes. A review of service delivery might reveal gaps in applications of existing service standards. A review of outcomes could help to identify unneeded treatments or services. Reviewing current programs has the potential to identify less expensive options. An analysis of treatment and service activities or needs might suggest potential modifications to the existing goals of restoring health and caring for sick and dying persons. Reviewing how the salaries of physicians and other care providers are determined might lead to changes in professional responsibilities and compensation that are more closely linked to the health status of their patients.

Analyzing the programmatic goals of public health might identify programs that have limited utility or uncover opportunities for new services. Such activities might lead to savings that could be reallocated to yield better results or improve productivity.

Although QI programs have great potential, they are not universal panaceas. Research has highlighted several risk factors for obesity in the American population. Inappropriate nutrition and inadequate exercise are two important examples. Modifying these behaviors will require more personal commitment and effort rather than organizational activities. The experience gained with addressing tobacco usage may provide some guidance that can be generalized to other personal activities that contribute to less than optimal health.

Case Study Resolution

After thinking for a few moments, Dr. Lombard turned to Elizabeth and said, “Have you ever considered a career in management? The field needs people with inquisitive but open minds. After learning some fundamentals, you should have options. Before you make a commitment for additional training, let me give you something to read. After you have finished the material, come back, and we will continue this conversation.”

“Thanks,” Elizabeth said as Dr. Lombard handed her a copy of this book.

Periodicals

Books

Web Sites

• • Academy of Management: http://www.aomonline.org
• • American Health Information Management Association: http://www.ahima.org
• • American Society for Quality: http://www.asq.org/
• • Applied Systems Thinking: When Smallpox Becomes a Threat Again: http://www.pegasuscom.com/aar/model3.html
• • Centers for Disease Control and Prevention Syndemics Prevention Network: http://www.cdc.gov/syndemics/
• • Institute for Healthcare Improvement: http://www.ihi.org/
• • Journal of Healthcare Management: http://www.ache.org/PUBS/jhmsub.cfm
• • National Institute of Standards and Technology, Baldrige National Quality Program: http://www.nist.gov/baldrige/
• • One Health Initiative: http://onehealthinitiative.com/
• • Robert Wood Johnson Foundation: http://www.rwjf.org/
• • Society for Human Resource Management: http://www.shrm.org
• • Systems Thinking: http://www.answers.com/topic/systems-thinking
• • Systems Thinking: http://thesystemsthinker.com/

The Legislative Branch

At the national level in the United States, laws originate in the US House of Representatives or the Senate. Laws approved by the House or Senate move to the other body. If identical bills are approved, the law moves to the President for approval or veto. If the bills are not identical, a conference committee comprised of members from the House and Senate constructs a compromise bill, which is then processed through the two bodies. A two-thirds vote of the legislative branch (House and Senate) can override a Presidential veto. Similar processes guide most state legislatures.

Health organizations and their interest groups, such as professional associations, can be directly involved in proposing legislation and participating in hearings on health laws. Large health organizations and associations frequently employ communications or lobbying specialists to engage in this activity. Key groups in the legislative process are the committees of the US House and Senate that process health laws under consideration. The Senate Finance Committee and the House Committee on Ways and Means, which have jurisdiction over Medicare and Medicaid legislation (described in more detail later in this chapter), are two key committees. Legislative committees often hold public hearings on controversial proposals. The hearings give health organizations opportunity for input. Similar processes at the community and state levels provide opportunities for influence on state and local laws as well.

Influencing the Policy Process

To further influence public policy in the health care arena, managers can develop or participate in coalitions of like-minded individuals and advocate for their viewpoints before, during, and after the legislative process. Longest (2010) suggests five stages at which public policy can be influenced:

• 1. Agenda setting stage
• 2. Legislation development stage
• 3. Rulemaking stage
• 4. Policy operation stage
• 5. Policy modification stage

To help establish agendas, managers can urge their organizations to define and document problems, develop and evaluate solutions, and lobby politicians. Members of health organizations can participate in drafting legislation and testifying at legislative hearings. At the rulemaking stage, health organizations can provide formal comments on draft rules and serve on rulemaking advisory bodies. At the policy operation stage, health organizations can share their knowledge and concerns with policy implementers. Finally, managers and others, including consumers of health organization services, can document the case for modifying laws and regulations through communication to government of their experiences and evaluations of laws and regulations.

Health Information Technology Support and Security

Health information technology has been targeted by recent legislation designed to modify existing policies and practices. These efforts have been driven by the slow adoption of information technology by organizations in the health sector and the fragmented delivery system in the United States. Health care service providers have begun to implement a wide range of different brands of information systems. Information systems are often selected for their financial advantage to the purchasing organization rather than considering their utility to customers, clients, or patients. A consequence of this approach is that individuals who use different provider organizations often do not have integrated health records.

To address these issues, recent changes in health policies have supported investment in information technology and standardization of the diverse technologies so that they can be interconnected. A National Coordinator for Health Information Technology was mandated by the Health Information Technology for Economic and Clinical Health Act (HITECH Act). This legislation was included in the American Recovery and Reinvestment Act (ARRA) of 2009. The Office of the National Coordinator is responsible for promoting a nationwide health information technology infrastructure that improves health quality and reduces costs. The ARRA also authorized nearly $20 billion over 5 years to assist physicians in adopting electronic health record (EHR) technology. Beginning in 2015, physicians not using EHRs will be penalized in their Medicare payments.

Privacy and security of health data are of critical concern to US health policy, again related to the many different sources of health information already in existence. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 set standards for the security of certain protected health information. Health care providers and supportive personnel in a variety of settings now receive training on enforcement of the HIPAA guidelines. Privacy and security continue to be critical national policy issues in implementation of a health information technology infrastructure.

Access to Health Services

As noted earlier, the federal Medicare health insurance program and the joint federal–state Medicaid health insurance program have served elderly and disadvantaged populations for decades in the United States. A major expansion in the federal role in access to health services occurred in 2010, with the Patient Protection and Affordable Care Act. The law unfolds over the 2010–2014 period. The constitutionality of the law is being challenged in the courts as this book is written, with undetermined outcome.

Immediate effects of the Patient Protection and Affordable Care Act include a prohibition on denial of health insurance coverage for children due to preexisting conditions and requirements for full coverage of selected preventive services in health insurance plans. Later effects include an individual mandate for health insurance—individuals not covered by government insurance programs must maintain health insurance or pay a penalty. Access to affordable insurance will be increased through the use of health insurance exchanges operating in each state. Minimum standards for health insurance policies will be introduced. The law also funds a major expansion of Community Health Centers, which largely serve inner city poor populations, and increases payment levels to rural health care providers. Providers (primarily hospitals and clinicians) are given incentives to join in community-based accountable care organizations (ACOs). ACOs are integrated groups of providers responsible to care for a population of Medicare enrollees who are rewarded for reducing costs and improving quality.

Quality Improvement

US health policy is strongly behind efforts to improve the quality of health services, with increased expectations that health organizations will report and enhance the quality and value of their services. This trend is demonstrated by several provisions of the Patient Protection and Affordable Care Act. This legislation requires increased linkages between Medicare payments and quality outcomes. The Act establishes a Patient-Centered Outcomes Research Institute that is independent from the government. The Institute will examine the relative effectiveness of different medical treatments. The HITECH Act requires physicians to document clinical quality measures.

As of 2008, 26 states had enacted mandatory reporting laws requiring provider organizations to report instances of serious adverse events that occurred in hospitals on an annual basis (US Department of Health and Human Services 2008). In most states, root cause analysis is required to develop action plans for preventing similar events.

A movement to accredit public health departments, formally launched in 2011, is another example of the growing inclusion of quality improvement in US health policy. The Public Health Accreditation Board is dedicated to advancing the continuous quality improvement of state, local, tribal, and territorial public health departments.

Emergency Preparedness

Government is heavily involved in health policy for emergency preparedness. At the national level, the US Department of Homeland Security, established by the Homeland Security Act of 2002, and one of its units, the Federal Emergency Management Agency, develop and deploy national strategies for prevention and response to emergencies, including terrorist attacks and natural disasters. States and many localities have similar emergency preparedness units, and health managers should be familiar with their organization’s responsibilities to the community, state, and federal governments during emergencies.

Prevention and Health Promotion

US health policy has gradually increased recognition of the importance of prevention and health promotion. Building on the Healthy People initiatives, which set national health goals for 1990, 2000, 2010, and 2020, the Patient Protection and Affordable Care Act of 2010 creates a $15 billion Prevention and Public Health Fund and a council to develop and promote stronger national prevention, health promotion, and public health strategies. As already noted, the Act also creates requirements for health insurance plans to cover selected preventive services.

Another area of growing health policy concern is health disparities. Health disparities are population-specific differences in health. Many different populations are affected by disparities including racial and ethnic minorities, residents of rural areas, women, children, the elderly, and persons with disabilities. The Minority Health and Health Disparities Research and Education Act of 2000 authorized several US Department of Health and Human Services programs to address disparities. The Patient Protection and Affordable Care Act of 2010 expands services to low-income populations, broadens initiatives to increase racial and ethnic diversity in the health care professions, and strengthens cultural competency training for health care providers.

Systems Thinking about the Policy Context for Management

Most health organizations tackle complex challenges to improve patient or population health. The health challenges inevitably have a health policy component, creating long-term interdependence between health organizations and health policies. As health policies change, so do the roles of organizations.

A good example of this connectedness over time is the health challenge of tobacco control. For several decades in the United States in the 1900s, tobacco control was not viewed as a salient health policy issue. Individualistic values and the American free enterprise economic system combined to limit the creation of policy interventions to control the use of tobacco. Tobacco users were free to make their own choices to use tobacco, and tobacco manufacturers were free to pursue profit.

Eventually, accumulating research on the negative health effects of tobacco on users and the harmful impact of secondhand smoke on nonusers, along with the huge cost of tobacco-induced illness to health insurance programs, altered health policy to promote decreased use. Individual-level interventions such as telephone quit lines and nicotine substitutes emerged. Community-level and population-level interventions, including bans on smoking in public places, higher taxes on tobacco products, and warning labels on tobacco products, were implemented. Successful suits against tobacco companies by state governments reflected changing health policy and resulted in large endowments for tobacco use prevention campaigns and research. Over time, a multitude of stakeholder organizations emerged, including government (e.g., the National Cancer Institute, Centers for Disease Control and Prevention) and private organizations (e.g., Robert Wood Johnson Foundation, American Cancer Society, Campaign for Tobacco-Free Kids).

As a whole system, the changes in tobacco health policy reflect the interdependence of private nonprofit organizations, researchers, government, consumers, and product manufacturers. Whole systems thinking about tobacco control involves reducing duplication of effort among disparate programs, encouraging multipartner efforts, developing better evidence on the effectiveness of tobacco control efforts, and integrating research and practice (National Cancer Institute 2007). The whole systems approach to tobacco control is a constructive attempt to address the pluralistic and fragmented health system, the incremental nature of policy change, and the complexity of most health challenges.

Case Study Resolution

Returning to the discussion about electronic health record systems, Madeline began to speak. “Financial efficiency is important, but, in my opinion, customers or clients should come first. If we opt for efficiency, the organization and owners benefit. If we install a system that can interact with other electronic health systems in the region, our costs will be marginally greater. However, the people that we serve will benefit. The increase in customer satisfaction and goodwill should more than offset the extra cost. The federal government has recognized the value of integrated record systems, too. We should check into that.”

“I agree,” replied Sandra.

Periodicals

Books

Web Sites

• • Agency for Healthcare Research and Quality: www.ahrq.gov/
• • Health Disparities, Centers for Disease Control and Prevention: http://www.cdc.gov/omhd/Topic/healthdisparities.html
• • Health Information Privacy: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
• • Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009: http://www.hhs.gov/recovery/reports/plans/onc_hit.pdf
• • Healthy People: http://www.healthypeople.gov/2020/default.aspx
• • Henry J. Kaiser Family Foundation: http://www.kaiseredu.org/
• • Homeland Security Act of 2002: http://www.dhs.gov/xabout/laws/law_regulation_rule_0011.shtm
• • National Academy for State Health Policy: www.nashp.org/
• • National Association for Public Health Policy: www.naphp.org/
• • National Healthcare Disparities Report, 2003: http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm
• • Patient Protection and Affordable Care Act of 2010: http://www.healthcare.gov/law/introduction
• •INTRODUCTION

  Although managers oversee structures and processes, they must manage people to achieve success. A successful manager must understand people and the ways they interact. Formal organizational structures influence interactions and friendships among employees who work within them. Interpersonal and intergroup factors affect organizations. Groups establish and reward their own patterns of behavior. Group norms are often highly fluid, and conflict and politics play a part in group and individual behaviors. However, simply understanding will not change people’s behavior. Successful managers must be familiar with different methods for shaping the behavior of individuals and the groups to which they belong.

  INFORMAL GROUPS

  Informal groups exist within most formal organizations. These are often peer groups. In health organizations, informal peer groups often form around professional identity, based on the distinctive cultures of professions like nursing, pharmacy, and medicine, or around work role, such as secretary. Each informal group has its own norms for status and prestige that have implications for managers. Peer groups provide four benefits for members. They satisfy complex needs, offer emotional support, help to shape personal identities, and assist in meeting personal goals.

  Research has shown that employees who work alone often find their jobs to be unsatisfying (Festinger, Schacter, and Back 1950; Mayo 1946; Roy 1960). The organizational cost of this lack of satisfaction can be measured in terms of low productivity, excess rates of absenteeism, and high turnover rates. Personal self-image is derived, in large measure, from social feedback. A group provides its members with norms (guidelines) for correct behavior. The correctness is not necessarily aligned with organizational policies and expectations, but rather in terms of group norms.

  Groups usually refer to aggregations of small numbers of individuals. A classic definition is provided by Berelson and Steiner (1964, 47):

  • A group is an aggregate of people, from two up to an unspecified but not too large a number. These individuals associate with each other in face-to-face relations over an extended period of time. They differentiate themselves in some regard from others around them. Finally, they are mutually aware of their membership in the group.

  Group membership is often related to both technology and the pace of work. Some level of psychological or physical closeness and an opportunity to communicate must exist before people can form mutually satisfying groups. Sayles and Strauss (1966) described the progression of group development and how informal patterns of behavior (group norms) evolve. Employee groups often begin with friendships based on contacts at work, equipment used, or common interests. These groups arise within organizations. However, once these groups are established, they develop lives of their own. At this point, groups are often independent of the working situations from which they emerged.

  This process is dynamic and self-generating. Increasing opportunities for interaction tend to create favorable sentiments toward fellow group members. In turn, these attitudes become the foundation for an increased variety of activities that are not related to job duties. Increased opportunities for interaction reinforce group solidarity. The group becomes something more than simply a collection of people. It develops norms or customary behaviors. It evolves a set of stable characteristics that become very difficult to change or modify. In other words, groups become organizations.

  Identification with a group is important. Most individuals have difficulty in holding out against the weight of an otherwise unanimous group judgment even when the group is clearly in error (Maslow 1943). In organizational settings, groups can assist individuals to solve specific problems and to protect them from making mistakes. Individuals prefer to receive guidance, advice, and assistance from peers rather than supervisors or managers. As a bonus, the ability to render assistance often becomes a source of prestige for the giver. Nonconformity with group norms is usually punished by withholding acceptance.

  Members of many professional groups are able to differentiate themselves on the basis of clothing or other signs of group membership. Physicians frequently display stethoscopes prominently around their necks or wear surgical scrubs outside of a hospital. Nurses often wear their nursing school pins as decoration on clothing other than uniforms. Most group members use professional jargon as a means of establishing and maintaining group identity.

  Informal channels of communication also develop within groups (Fallon, Covitch, and Rothenberg 1974). Informal channels are independent of formal, organizational channels. They tend to be both effective and long lived. Individuals use them to discuss ideas, discoveries, and common problems. Informal channels tend to be much more efficient than formal channels of communication. Data travel more rapidly over informal channels.

  Managers assign duties and job responsibilities to individuals and teams. In theory, managers should only be concerned that assigned tasks are effectively and efficiently accomplished. However, other forces and factors can and do emerge. Individuals usually like or dislike the people with whom they work; they are rarely neutral. These feelings often lead people to establish communication links and perform activities with others in a variety of informal and usually unplanned patterns. Astute managers must understand and interact with these patterns to be optimally effective.

  The need for affiliation and group membership has been well established. However, after groups have been established, many individuals become competitive and want to be perceived as having a higher status than their peers. Most people talk about equality, but as George Orwell (1946) wrote, “Some want to be more equal than others.” Sets of unwritten rules about expected conduct frequently define prestige and status. Subtle differences in status begin to emerge as informal groups become established.

  Two classes of factors are relevant to status: external and internal. External factors refer to attributes that are brought to the workplace from the outside. These commonly include age, gender, race, education, and seniority. Internal factors may be created consciously when senior management establishes and defines an organization. Internal factors often include titles, job descriptions, perquisites, offices, work schedules, mobility, and methods of evaluation. The title “Doctor” may sufficiently differentiate physicians from other employees of a health care organization. It does not perform this function in a university setting. Within many organizations, traditional indications of power and prestige are usually encountered: office size, windows and their view, access to executive dining rooms, and reserved parking.

  Effective managers understand informal groups. If a group’s basic attitude toward an organization is positive, informal expectations can greatly assist management. This is particularly important when managers strive to enroll employees in improvement projects and in the pursuit of stretch goals. Managers experience difficulties when the goals or structures of the formal organization conflict with those of informal groups. This can occur when management’s evaluation of positions or jobs does not correspond with the opinions of group members. When this occurs, managers must select between one of two extreme positions. The first is to rearrange the formal organization, including policies and procedures, to accommodate the desires of an informal group. The second is to change the norms or composition of the informal group. Compromise is easier to accomplish. This type of conflict is less common in professional settings than in blue-collar environments. Nevertheless, managers must be alert for it and seek methods of resolution that will have a minimal impact on accomplishing organizational goals and objectives and on the employees involved.

  CONFLICT

  When resources must be shared or collaboration is needed to offer or deliver services (that is, when interdependence is high), the parties involved must establish relationships with each other, crossing boundaries that exist between individuals and among groups. Stress and conflict frequently accompany such interactions. Three distinct types of conflict are of interest to professional managers: interpersonal, intergroup, and specialist versus generalist.

  Interpersonal Conflict

  Interpersonal conflict is the least important but most exaggerated type of friction. Managers often blame organizational problems on individual personalities or general worker incompetence. The traditional psychological explanation for interpersonal conflict is frustration. Individuals who feel ignored or undervalued seek alternative methods to overcome their frustrations. In this process, they disrupt the normal activities of an organization. Poorly structured formal channels of communication frequently contribute to interpersonal conflict.

  Organizational structure defines the flow of communications. A conscientious manager with employees who have interpersonal problems will benefit from a review of the organization’s structure and patterns of work flow. Individuals resent communications that flow in only one direction. Similarly, workers are slow in adjusting to unexpected changes in routine that they cannot control.

  Unpredictability can result from technological innovations as well as from changes in organizational structure and policy. Stress is increased and employees become aggravated if organizational changes alter their informal status from what was previously accepted. Stress is amplified when change is unilaterally imposed without prior notice or consultation or if individuals perceive no functional or technological reason for changing. When changes are necessary, prudent managers inform employees early in the process and, if feasible, allow them to participate in decisions that affect their jobs or working conditions.

  Intergroup Conflict

  Intergroup conflict develops when clusters of employees belonging to different informal groups must interact with each other. Groups can be categorized as apathetic, erratic, strategic, or conservative. Apathetic groups are least likely to exert concentrated pressure on management. Their members are usually not very cohesive, and any group leadership is widely distributed. Erratic groups display inconsistent behavior toward management. Strategic groups tend to be shrewd and calculating when applying pressure. They never tire of objecting to unfavorable management decisions or seeking loopholes in contract clauses or existing policies that will be beneficial to them. They continually compare their benefits to those of other informal groups within the organization. Conservative groups are composed of elite members who are secure and powerful. They typically possess skills that are critical to their organization.

  The success of informal groups that bargain with management reflects the internal strength or cohesion of the group. Cohesion assists the members who are pursuing group goals. Cohesion has six dimensions: homogeneity, communication, isolation, size, outside pressure, and group status. Homogeneity reinforces a basic reason for the existence of many groups. Individuals seek out others who are like themselves. Group members with different backgrounds and interests are frequently ineffective in promoting their own particular agendas. Competition between individuals usually reduces group cohesion; unified group membership increases it.

  Group members must be able to talk with each other. A lack of privacy and opportunities for discussion hinders group development. Both researchers and cartoonists have noted this when they discuss cubicles. The widely used partitions of contemporary offices are less expensive than permanent walls. They also tend to reduce group development and solidarity. Isolating all group members from other workers promotes group solidarity, whereas isolating group members from each other reduces group solidarity. Small departments tend to be more closely knit than large ones, because larger groups tend to have fewer opportunities for informal communication and are more heterogeneous. This encourages fractionation of informal groups into smaller cliques. This has the effect of creating new small groups that offer more opportunities for membership and interaction.

  When organizations exert pressure on employees, communication among peers (lateral communication) tends to increase. Concurrently, communications between different levels of management (vertical communication) tend to decrease. Personal differences among group members are minimized when presented with the threat of a common danger such as a tough supervisor. Strong management policies toward workers may encourage the formation of strong informal groups to resist the pressure.

  Specialist versus Generalist Conflict

  The increasingly complex nature of contemporary health organizations, the use of complex technological tools and concepts, and the need to increase productivity have contributed to the emergence and importance of specialists. By definition and training, these individuals have advanced skills and specific knowledge. When supervisors lack these technical skills, they must carefully manage their subordinates. Managers must rely heavily on specialists to be successful in their own supervisory positions.

  In contrast is the generalist. This is an individual who knows something about many positions but frequently not enough to displace a specialist. A generalist may not be a member of the specialists’ group due to a lack of esoteric knowledge. A generalist usually has less job security. A generalist may have to use means other than technical knowledge to succeed. Often this translates to relying on the output of subordinates or politics. Subordinates are often unable to go to their supervisor for assistance with technical problems. This can lead to resentment and feelings that the boss is incompetent. This chain of events was initially suggested almost a half century ago: The most symptomatic characteristic of a modern bureaucracy is the growing imbalance between ability and authority (Thompson 1963).

  It is interesting to note the role reversal of specialists and generalists in contemporary health agencies or organizations. In clinical care situations, generalists often have greater value to managed care systems than do specialists because they are the gatekeepers. Yet, they continue to be paid at lower rates than specialists.

  Disputes over jurisdiction or turf have historically been common in service organizations as different specialty groups tried to decide which one would assume the responsibility for leading a particular initiative or program. The historical result has been an informal arrangement known as a consultation. In addition to providing specialized expertise, consultation serves an organizational need, allowing individuals to tread on the turf of others in a legitimate fashion. The contemporary reality is that members of the same organization often provide consultations to each other, thus reducing turf infringements.

  Constructive Conflict

  Conflict can be a constructive force in organizational life. In fact, suppressing conflict can create a significant barrier to improving internal processes and the quality and value of goods, services, and programs. If employees (and managers) fear retribution for delivering bad news or correcting their superiors, opportunities for improvement will be missed.

  Conflict among individuals and groups can be identified and constructively addressed by encouraging honesty and frankness, within the bounds of organizational values of respect and integrity. Compromise and collaboration are two options for the processing of constructive conflict (Thomas 1977). Compromise requires that each side give up something for a solution that is not ideal for either party but that both parties are willing to accept in the interests of the organization. Collaboration requires more creativity, because it involves new ideas that are appealing to both parties (win–win solutions). Managers should encourage the identification of conflict around important issues and the development of compromise or collaborative solutions. Guidelines for improving collaboration among individuals and organizations in a broader sense (beyond conflict management) are covered elsewhere (Chapters 12 and 13) in this book.

  Other common ways of processing conflict are competition (letting both sides battle to resolve an issue or disagreement, with the most powerful usually winning), accommodation (one side surrenders), and avoidance (both sides allow the conflict to fester). Although none of these three options sounds ideal on the surface, there are conditions when each should be used (Thomas 1977). For example, competition may be necessary when there is not time to compromise or collaborate. Avoidance may be advisable for trivial issues. Accommodation may be useful when harmony and stability are especially important. Experienced managers use all five options for managing conflict, depending on the specific situation.

  POWER AND POLITICS

  Organizations, including those in the health care and public health sectors, are infused with politics. Organizational politics involves the use of power to get things done in the organization. Managers are inevitably involved in organizational politics, particularly if they pursue a change and improvement agenda.

  Power derives from formal authority, control over resources (which often comes with authority), expertise, and certain personal characteristics and social networks of individuals. Authority refers to legitimate power—power that is viewed as appropriate by the individual who holds power and by those subject to the power. In organizations, legitimacy is usually conveyed by formal documents such as a position descriptions, policies, and rules. In the absence of formal policies, those with power often create ad hoc rules. A decision made using ad hoc rules is either an interpretation of existing (standing) policies or is made because no explicit guidelines exist. In organizations built around authority, decisions are transmitted from managers to subordinates, who then implement them. If subordinates choose to disobey, then they will incur sanctions or pay a price for this privilege. Subordinates may obey because an individual holds a particular position or office, and power is perceived as emanating from the position (authority). Most cultures teach that individuals ought to obey both laws and persons of legitimate authority.

  Another source of power for managers is control over rewards and punishments. Positive rewards make individuals feel good. They can also provide desirable options or objects such as money, status, prestige, position, special treatment, or advancement. Negative rewards (sanctions) tend to be given along a continuum of increasing degrees of coercion with repeated applications. For example, if an individual does not react to a verbal suggestion, at the next occurrence, the warning typically is repeated and accompanied by a written document. A fine or suspension may follow if suggestions or orders continue to be ignored. Expulsion is the ultimate sanction. Managers can use rewards and punishments, including the outplacement of opponents, to advance the organization’s agenda (Pfeffer 2010).

  Expertise is a particularly common source of power in health organizations, and sometimes it is more important than formal position. Certain highly respected practicing clinicians or scientists may have more influence over their peers than do other clinicians or scientists appointed to formal positions. It is important for managers to cultivate relationships with respected, powerful individuals regardless of formal position.

  Social networks are another basis of power outside the hierarchy of authority. An individual’s connections with powerful others, whether based on culture, training, religion, or other factors, can give that individual power in organizational decision making. Astute managers keep a wide range of connections themselves and seek out employees who are widely connected.

  Finally, personal characteristics can add to one’s power base in organizations, depending on the organizational and societal culture. In some cultures, gender (usually male gender) historically has been a source of power. Charisma, or the projection of positive energy and enthusiasm, is another personal characteristic that often yields power to the holder.

  Constructive Politics

  Constructive politics among individuals and groups can be used in organizations to move controversial issues to decision points and to advance the agenda of the organization. Constructive politics means using power in ways that are moral, open, and caring, where all participants follow the same rules or guidelines (Bolman and Deal 2008). In most workplaces in the United States, for example, it is not ethical to use gender or religion as a source of power. Constructive politics would not include giving more power to individuals based on their gender or religion.

  Constructive politics requires that power be exerted in the interests of organizational goal achievement. Effective managers use constructive politics to pursue the goals of their unit and the organization. Four competencies of constructive politics are useful for managers: setting agendas, anticipating resistance, networking and building coalitions, and bargaining and negotiating (Bolman and Deal 2008).

  Using the power to set agendas is critical for managers interested in improving organizations and creating new value for consumers in products and services. The default agenda for many organizations involves maintaining the status quo. Managers can be proactive about seeking improvement both in their departments and the larger organization by making sure that organizational performance issues and improvement opportunities get raised and addressed at critical meetings.

  Mapping the political terrain enables managers to forward their agendas more successfully. Anticipating and addressing resistance in advance of important decision-making forums is particularly useful. Likely opponents to action items can be co-opted, or enrolled in the process of change, by seeking their help and developing informal relationships with them. Proposals for change can be altered to accommodate opponents’ suggestions, if the suggestions improve the idea or only marginally damage it.

  Networking and building coalitions recognize that power derives in part from mass and that individuals seldom succeed alone in organizations. Ideas for improvement need sponsors in other departments and at higher levels of the organization. Effective managers develop coalitions of supporters for their ideas before exposing the ideas to widespread testing.

  Bargaining and negotiating are final competencies of the constructive organizational politician, because getting something is often preferable to getting nothing or to imposing your will but losing the commitment of those imposed upon. Bargaining and negotiating skills are similar to those involved with collaboration and compromise, including a willingness to truly listen to and engage in dialogue with adversaries, to separate issues from personalities, and to be creative about innovative, win–win solutions when parties disagree (Fisher, Ury, and Patton 2011).

  The essence of politics is achieving compromise or collaboration and getting results. Organizations constantly seek positive results. Politically astute managers understand the dynamics of groups and their rules of behavior. They use them for the benefit of their entire organization. This may involve establishing closer working relationships with informal leaders to improve the output of a group. Alternatively, it may mean promoting some group goals to generate support for a desired organizational goal. This must be done within permitted discretionary limits and guidelines. It may also involve working behind the scenes to create environments and situations in which their subordinates are allowed to shine. The possibilities are limited only by organizational guidelines, personal ethical standards, and individual imagination.

  OTHER WAYS TO INFLUENCE ORGANIZATIONAL DYNAMICS

  Among other managerial options for increasing influence with employees is development of personal participation and interest in the careers of employees. Successful managers and supervisors help to promote the careers of their employees. This involves ongoing training that is delivered at formal and informal venues. Managers should project clear career paths for their employees. Within the limits of opportunity allowed by an organization, formal career paths should exist. Successful managers understand that helping subordinates and peers to succeed will reflect positively on themselves.

  Effective managers motivate their employees to think about problems they may encounter before they occur. As workers develop competence on their jobs, their self-esteem improves. Employees also learn to expect and receive respect from supervisors and peers. Successful managers promote good attitudes about the organizations in which they lead. Further, they continually review various aspects of their organization or department so that they can identify and address problems before they become insurmountable. Effective supervisors discuss the details of a new program or project in advance rather than allowing interns or inexperienced employees to look foolish at meetings involving senior executives.

  Successful managers stress the need for quality and reinforce the importance of good customer service. They also regularly reward examples of quality and good customer service. If recognized and rewarded, employees will internalize the need for quality and the values of excellent customer service.

  A final class of options for influencing organizational dynamics involves altering the existing formal structure of an organization. Such modifications may involve changes in authority, job duties, or responsibilities; modifying formal communication channels; and remodeling and upgrading the physical conditions of work.

  Traditional management theory states that the goal of managers is to achieve common objectives within their units, using available resources within an allotted amount of time. However, this view of management is changing. Experts are urging that managers also have more input into the development of organizational mission, strategy, and objectives and seek out and use any and all available resources within an organization (Rainey 2009). Other experts (Foster 2009; Gorenflo 2010; Hoyle 2007; Institute of Medicine 2001) have noted the importance of quality and customer service in the role of the manager.

  Consistent with this expanded view of the management role, contemporary managers must assume the task of absorbing and preventing stress. An important goal is to balance change and challenge with the need for some degree of organizational equilibrium. It is a managerial responsibility to design and adjust the working relationships of individuals so structural problems do not interfere with the effective performance of an organization. Frequently, simple changes of job responsibilities can resolve minor problems.

  Finding an appropriate placement for a problem employee can be beneficial for both the sending and receiving groups. Simply handing an unwanted employee to someone else will generate a group or organizational reputation that is likely to outlive the individual doing the dumping. Managerial success can be improved by encouraging and maintaining open and appropriate communications between associates (laterally) and supervisors and subordinates (vertically). Observers have noted that poor managers are characterized by either very high or very low levels of interaction relative to the usual level for a given position and organization (Richardson 1961). Effective managers tend to spend a significant amount of time responding to their subordinates and associates. As a result, they are more readily available and receive more contact from their subordinates (Rainey 2009).

  An important element of any manager’s duties is planning and modifying the structure and flow of work to minimize any stressful patterns or factors that may deter effective performance by individual workers. This may involve placing organizational or physical buffers or barriers. If there are obvious external differences in the behavior or working conditions of two groups, it is sensible to limit interactions to the telephone, e-mail, or other electronic media. A manager must maintain a comfortable rhythm in the flow of work among subordinates. This may involve scheduling, sheltering, or coaching subordinates. Workloads should be equitably designed and distributed. In the current climate of task specialization and electronic isolation, managers all too often react to the pressures of senior organizational leaders by demanding increased output from their employees. Successful managers are careful not to routinely expect levels of production from their employees that they would be unwilling or unable to produce themselves.

  CONCLUSION

  The rhythm and cadence of work, as well as the administrative processes by which they are controlled, are fundamentally important for organizational success. Organizations have been characterized as being a system of relationships (Chapple and Sayles 1961). Organizing tasks involves applying systems thinking and using appropriate technologies. Every organization is a unique collection of processes, procedures, policies, controls, formal authority structures, and managerial techniques. Among related units of organizations, it is unusual that changes in sentiment precede changes in activities or organizational rearrangement. Technology and organizational structures must be modified before group norms and values are likely to be successfully changed or altered.

  This chapter has outlined various patterns in interpersonal and intergroup relations in organizations. Many careers have been devoted to understanding and describing group dynamics and behavior. In addition to understanding their subordinates and peers, effective managers understand the organizational forces that exist in local working environments. Table 7–1 summarizes several lessons for dealing with personal and group dynamics in organizations. Being willing to listen to both subordinates and superiors, communicating through multiple methods, being open to innovation, and using constructive conflict and politics should result in both effective and rewarding experiences as a manager.

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