Assignment

4 Organizational Behavior—Macro

Learning Objectives

After reading this chapter, you should be able to:

• Identify and define the types of groups found in business organizations.

• Summarize the principal theories of group dynamics.

• Analyze group performance and effectiveness.

• Discuss the role of physicians as stakeholders in health organizations.

• Apply evidence-based management principles to health organizations.

• Compare functional and dysfunctional organizations.

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Section 4.1Introduction to Organizational Behavior—Macro

Staff and Executive-Level Teams Are Fundamentally Different A motivational poster frequently found in managers’ offices displays a team of rowers to illustrate the concept of people working together; a popular offering from the Art of Rowing company is titled Team- work: Together We Achieve More. When most people on a team are doing similar jobs, the rowing metaphor is very apt. However, executive-level teams are different:

Executive teams are more like baseball teams. Sure, they are all wearing one uni- form and following one game plan, but sometimes they work alone (as in the case of a batter), sometimes they work in pairs (pitcher throws to catcher, or shortstop and first baseman collaborate in a double play) and only seldom do they all get in on the action.. . . Don’t expect a team at that level to feel the same way your depart- ment level team does. You’re not all in the same boat. So figure out the game plan, play your position, and keep your head up to spot your chances to support your teammates. (Davey, 2012, p. 1)

When one thinks of the ideal executive- level team, a better metaphor might be a company softball team—which can include both men and women of varying ages and ethnicities. However, company softball teams are seldom good at playing softball; many are formed to encourage camaraderie among the players and sup- porters, thereby strengthening working relationships and organizational com- mitment. Organizations need and value talented individuals who can work col- laboratively with others; being a “team player” is an important attribute for success in almost every type of job. Since much of the clinical and administrative work in health organizations is done in groups or teams, it is important for health care professionals to understand the work- ings of, participate in, and lead teams.

Critical Thinking and Discussion Questions 1. What have you learned from participating in a department or management team? 2. How important is team camaraderie among executives in health care organizations?

4.1 Introduction to Organizational Behavior—Macro Chapter 3 focused on the individual behavior in organizations. This chapter focuses on group behavior and discusses how organizations achieve their goals by coalescing the skills and efforts of individuals into groups and networks. Organizational behavior researchers and practitioners study behaviors within and between groups, both formal

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Section 4.2Group Dynamics

and informal. Formal groups are officially designated to fulfill certain functions and accomplish specific tasks. Within the category of formal groups are command groups and task groups. Command groups are the building blocks of the organization’s struc- ture. They are specified in the organization chart and include the executives, managers, supervisors, and the people who report to them. Task forces, also called task groups, are temporary groups charged with solving a problem or responding to an opportunity. Stakeholders are groups and organizations that have a vested interest in the organiza- tion. Informal groups are naturally formed groups of people who work together or who are drawn together on the basis of friendship or shared interests. Although they are not officially sanctioned or recognized by the organization, they strongly influence its work- ings (Ivancevich & Matteson, 2002). Successful health care management requires skill in managing individuals, groups, and stakeholders.

4.2 Group Dynamics Cartwright and Zander (1968) define group dynamics as “a field of inquiry dedicated to achieving knowledge about the nature of groups, the laws of their development, and their interrelations with individuals, other groups, and larger institutions” (p. 120). They note that this subunit of organizational behavior became an identifiable field in the United States in the late 1930s and has four distinguishing characteristics:

1. An emphasis on theoretically significant empirical research, based on effective experimental design, careful observation, reliable measurement techniques, and statistical analysis of data performed according to accepted social science research methods.

2. Interest in the dynamics of group life and observed relationships, in order to discover general principles concerning what conditions produce what effects and how certain properties and processes depend on others.

3. Interdisciplinary relevance, incorporating and contributing ideas from and to sociology, psychology, anthropology, political science, and other social sciences.

4. Potential applicability of findings to professional and business practice, in order to provide a sounder scientific basis for practitioners in a variety of group set- tings and organizations.

While groups and teams are terms often used interchangeably in the literature, there are some important distinctions between them. Groups consist of two or more individuals who interact with each other and share a common purpose or affiliation. A team is a type of group; all teams are groups, but not all groups are teams. In business a team is a group whose members work together on a specific project or are responsible for a specific organizational function. While there may be a designated team leader, teams collectively assume responsibility, set goals, develop plans, and divide the work. “In order to be a team: (1) individuals’ actions must be interdependent and coordinated, (2) each member must have a specified role, and (3) members must share common task goals or objectives” (Ivanitskaya, Glazer, & Erofeev, 2009, p. 109).

Group dynamics, as the name implies, deals with changes that occur when people interact. The following section highlights three important theoretical contributions to the study of

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Section 4.2Group Dynamics

group dynamics in the workplace. The first, roles, places the individual in context among peers, superiors, and subordinates and also defines his or her function in the organization. The sections on group process and intergroup behavior deal with group development and group behavior toward other organizational groups.

Roles

A key construct of psychology is the role an individual plays in a given situation, which serves a specific purpose and involves a set of shared expectations. For example, nurses are the primary caregivers of patients in a hospital. In business others in the organization and the profession establish expectations for a given role. For a nursing supervisor, these others would include direct reports, the boss, fellow supervisors, patients and their fami- lies, and the nursing educational, professional, and licensing organizations.

Benne and Sheats (1948) developed functional role theory based on behavioral patterns they observed among individuals in many different small-group interactions. Some indi- viduals performed task roles, which involved completing a job and accomplishing an objective. Others performed maintenance roles, which were social in nature, focusing on process and relationships. Still others performed individual roles to help the group accomplish its goals. Whetten and Cameron (2011) noted that two types of roles, task facilitating and relationship building, were both important contributors to group per- formance. Most people, whether group members or leaders, tend to emphasize one role over the other. While at certain times one role may predominate, effective groups need to strike a balance between task-facilitating and relationship-building roles. Tushman (1977) described individuals whose roles primarily involve interactions and communications with external stakeholders as holding boundary-spanning roles, such as compliance or government-relations officers in a health organization. Another type of role common in large-scale or high-tech health organizations is that of horizon scanning, which involves identifying new and evolving interventions or technological advances, as well as ana- lyzing their potential impact on the health care industry generally and the organization specifically (Sun & Schoelles, 2013). Whetten and Cameron (2011) categorized a number of unproductive behaviors that inhibit group work as blocking roles, and emphasized the importance of managerial proficiency in developing, participating in, and leading groups.

Theory in Action: Management Behavior and Group Roles

Here are common behaviors of each role type, with examples of statements to illustrate group leader behaviors or, in the case of blockers, to deal with them effectively (Whetten & Cameron, 2011).

Task-Facilitating Roles • Giving directions: “Let’s start by brainstorming ideas.” • Seeking information: “What do the licensing regulations specify?” • Giving information: “Here are the regulatory specifications.”

(continued)

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Section 4.2Group Dynamics

Theory in Action: Management Behavior and Group Roles (continued)

• Elaborating: “To add to Joe’s comments. . .” • Urging: “We need to win this bid to make our revenue target next year.” • Monitoring: “Who will be lead staff with accountability for each task we’ve identified?” • Analyzing process: “Some members seem to have checked out on this project.” • Reality checking: “Can we really meet this deadline?” • Enforcing: “We’re getting off track; let’s focus on what we have to decide today.” • Summarizing: “Here is what I understand are our next steps, and who is lead staff for

each.”

Relationship-Building Roles • Supporting: “Your root-cause analysis was spot-on!” • Harmonizing: “Let’s just agree to disagree about this; we don’t need to agree on every

point to move ahead.” • Relieving tension: “I haven’t had this much fun since my last root canal!” • Confronting: “Maria, this is your department’s domain, so you need to assign staff to

complete this part of the job.” • Energizing: “I can’t believe how much we’ve accomplished so far!” • Developing: “Jerry, I know this is a new area for your department but Ruben will help

you; he’s done a lot of similar projects.” • Building consensus: “Let’s list the things we have agreed to so far.” • Empathizing: “I know it’s stressful to have such a lot to do in such a short time.”

Blocker Roles • Dominating: “Remember, this is a group project; we need everyone’s ideas.” • Overanalyzing: (a) General: “We need to avoid analysis paralysis”; (b) Specific:

“Hilary, will you please summarize your concerns in no more than 1 page for the next meeting?”

• Stalling: “Folks, we need to make a decision on this today.” • Disengaging: “Charlie and Lisa, you haven’t said anything and I know you have

opinions about this.” • Overgeneralizing: “Is the issue that Oscar raised as much of a problem for other

people?” • Faultfinding: “Let’s keep an open mind as everyone presents their ideas.” • Premature decision making: “Are we jumping to a solution here?” • Presenting opinions as facts: “Do you have any data or facts to support that

statement?” • Rejecting: Include instructions prior to the meeting: “Please type out on separate sheets

of paper your idea(s) for resolving issues 2 through 5 and bring them to the meeting.” • Pulling rank: “We need to hear more from the people who will be doing the work.” • Resisting: “Let’s concentrate on how we can move forward on this project.” • Deflecting: “We’re getting off track here, let’s focus on the main points.”

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Section 4.2Group Dynamics

Group Process and Phases

Educational and research psycholo- gist Bruce Tuckman became well known following the publication of a short article in 1965 in which he proposed a four-stage linear process of group development: Forming, storming, norming, and perform- ing. Hare, Borgatta, and Bales (1965) argued that since group members will seek a balance between accom- plishing the task and building rela- tionships with fellow group mem- bers, it becomes a repetitive cyclical process as the group moves from storming, norming, and performing, as illustrated in Figure 4.1 (Smith, 2005). Understanding dynamics of the group developmental process is par- ticularly important for health profes- sionals participating in or leading the multidisciplinary teams so common in health organizations.

1. In the forming stage, groups organize themselves and test each other to establish boundaries for both task and relationship behaviors. It is also during this stage that leadership and dependency roles are established.

2. The storming stage involves some conflict or polarization as members com- pete for leadership or to control the group’s direction, which disrupts task requirements.

3. In the norming stage, members develop feelings of identification and cohesive- ness with the group as they put aside their personal agendas, adopt new roles, and commit to new behaviors as group members.

4. In the performing stage, the interpersonal structure becomes the vehicle for accomplishing the task activities as members recognize the importance of group goals, develop pride in identity, and direct their energies as a group to accom- plishing the task.

In 1977 Tuckman and Jensen added a fifth stage, adjourning, since not all groups are ongoing. This stage can be a stressful process because it involves loss and the termina- tion of roles (Smith, 2005). Coppola (2008) argues that an additional preparation stage is important, especially in hospitals and other large, complex organizations. The informing

Figure 4.1: Group development phases

Early group dynamics researchers developed a four-phase developmental model that included the phases of forming, storming, norming, and performing.

Source: Smith, M. K. (2005). Bruce W. Tuckman—forming, storming, norming and performing in groups. The Encyclopaedia of Informal Education. Retrieved August 15, 2013, from infed website: http://infed.org/mobi /bruce-w-tuckman-forming-storming-norming-and-performing-in-groups

Forming

Storming Norming Performing

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Section 4.2Group Dynamics

stage begins with an initial (written or verbal) notification of or invita- tion to membership when a new team is officially designated or when new team members join an existing structural (command) team where members rotate in and out. During this stage the member(s) form opin- ions about both the mission of the team and its other members. Figure 4.2 displays the team development phases as a six-stage process that includes informing and adjourning.

Often, one of a new manager’s first assignments is to lead a newly formed or existing group. Understanding the developmental group processes will assist managers in maximizing output; it will also prepare them to lead more complex interdisciplinary groups as their careers progress, such as a hospital committee required by the Joint Commission or staffing a

board of directors committee. Ledlow and Coppola (2014) suggest strategies for health man- agers to employ at each of the six stages of group development, as summarized in Table 4.1.

Table 4.1: Group developmental stages and management strategies

Stage Strategy Additional considerations

Informing • Officially notify each member of appointment to the group

• Formally present group goals, measurable objectives in a bounded time frame

• Communicate in person with group members

• Allow a reasonable time period (15 to 30 days) between notification and first required meeting

• Known desire of members to be or not be in the group

• Skill set, track record in prior groups

• Personality dynamics between group members

Forming • Hold a “kick-off meeting to:

1. Outline group roles 2. Clarify goals and

objectives 3. Establish time line

with milestones and deliverables

• Challenge of allowing time for group development pro- cess within time constraints for task completion

Figure 4.2: Tuckman, Jensen, and Coppola’s

group development phases

Groups develop over time in a series of stages that include preparing to work together and bringing their work to a close.

Norming

Storming

Adjourning

Forming

Performing

Informing

(continued)

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Section 4.2Group Dynamics

Stage Strategy Additional considerations

Storming • Encourage constructive pro- fessional discourse

• Resist temptation to intervene prematurely

• Push to develop a new collective idea that reflects input from all group members

Norming • Recognize that group has developed a unique per- spective of the task to be accomplished

• Work with nonnorming mem- bers to encourage them to support group norms

• Better to remove or replace obstinately noncooperative members

Performing • Thank group members • Recognize individual

contributions

• Know contributions of each member and use this knowl- edge for staff development to build on strengths

Adjourning • Document the process and save the output

• Recap lessons learned

1. Best practices 2. Opportunities for

improvement

• Disseminate knowledge gained to other segments of the organization

• Acknowledge that people will miss some aspects of the group’s work and time with each other

• Use learnings to build knowledge-management and organizational-learning systems

Source: Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health care professionals: Theory, skills, and applications (2nd ed.). Burlington, MA: Jones & Bartlett.

Intergroup Behavior

Industrial psychologists Blake, Shepard, and Mouton (1964) found in their studies of group dynamics that members of a group who strongly identify with the group will feel obli- gated to conform to its norms and positions and to uphold their group’s positions against other groups. Acting in ways contrary to their own group position would be regarded as disloyal to the group, whereas holding fast to it would be considered highly effective behavior as a member or leader. Each group within an organization has its own goals, yet these groups are interdependent with each other. When organizations encourage groups to compete with each other and reward them on a relative basis with group incentive plans, the groups perceive defeat of the other groups as necessary to achieve their objectives, and a power struggle ensues. The researchers proposed three sets of assumptions about inter- group disagreement and identified mechanisms of intergroup conflict resolution for each.

Table 4.1: Group developmental stages and management strategies (continued)

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Section 4.2Group Dynamics

1. If intergroup disagreement is considered inevitable and permanent, the operating assumption is that it must be resolved in favor of one or the other group, either by a power struggle or by a third party arbiter—or left to resolve itself.

2. If intergroup disagreement is not considered inevitable but agreement is not possi- ble, conflict can be resolved by reducing the interdependence between groups and allowing or encouraging the groups to act more independently from each other.

3. If achieving agreement and maintaining interdependence are both considered possible and necessary to organizational functioning, conflict may be resolved by group actions to (a) maintain surface harmony, (b) bargain or compromise, or (c) make a genuine effort to address fundamental points of difference between groups (Blake et al., 1964).

Alderfer (1987) notes the importance of intergroup relationships to explain group behav- iors in larger organizations. He distinguished between identity groups and organizational groups, which are comparable to informal and formal groups. Identity group members share some common characteristic (e.g., age, ethnicity, gender) and have shared experi- ences (e.g., alumni, professional degree), and as a result they have similar perspectives on life and work. Members are assigned to organizational groups based on the organiza- tion’s division of labor and authority structure. Identity group and organizational group membership is frequently related. For example, a majority of executives in health orga- nizations are older white males who often share prior work or educational experiences and similar hobbies such as golf; clinicians who trained in the same institution often work together in other organizations during their careers. Intergroup theory proposes that both organization and identity groups affect members’ intergroup relations and thus shape beliefs and behaviors.

Teams

Teams are widespread in health organizations because the clinical and administrative staff need to work together closely to meet the needs of their patients, customers, or members. There are teams based on discipline (such as those composed exclusively of physicians or nurses) or hierarchical position (such as the governing body/board of directors, executive team/chief team, directors/unit leaders council, etc.). Multidisciplinary teams are used extensively for quality-improvement initiatives.

Permanent and Temporary Teams Interdisciplinary teams are organized to perform a particular function involving the work of several operational units; if the functions are ongoing, the teams are designated as committees. Committees have permanent standing, elected or appointed member- ship, and provisions for alternate representatives. In some committees members have time-limited terms of office. In other committees membership is automatically assigned to the position; for example, the quality-improvement committee of a hospital typically includes the chief of the medical staff and the director of nursing or their delegated

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Section 4.2Group Dynamics

physician or nurse representatives. Staffing committees is a key health administration role and helps support clinicians or senior executives.

Theory in Action: Typical Health Organization and Hospital/Health-System Board Committees

Some typical health organization committees with ongoing responsibilities and a brief description of their function are:

• Utilization Review—patient-care management case reviews, medical-management process analysis

• Clinical Documentation Review—monitoring of documentation adequacy • Risk Management—liability exposure and overall safety assessment • Infection Control—physical facility and patient-care process monitoring to prevent and

deal with infection • Patient Safety—adverse event case analysis, care-process improvement to prevent

adverse events • Quality Improvement—proactive patient-care and business-process improvement • Professional Development—individual and group skill enhancement and training • Credentials—clinical credential assessment, verification and monitoring • Patient/Health Plan Member Grievance Review—complaint assessment and

adjudication

At the governing body level, hospital and health-system boards commonly do much of their work through committees. A 2013 survey by the American Hospital Association’s Center for Healthcare Governance found that over half had committees for finance (83%), quality (75%), executive (68%), governance and nominating (61%), and audit and compliance (51%) (Gamble, 2013).

Task forces are temporary teams organized as needed to solve a particular problem or complete a specific project. These teams are time limited, have specific and strategic objec- tives, and disband when the problem is resolved or the project is finished. Often there is a work product such as an accreditation self-study or a revised policy and procedure manual. Examples of health organization task force functions and work products include:

• Accreditation or licensing application or renewal • Policies and procedures—development or update • Event planning: Holiday party, charitable activity, organizational anniversary

celebration • Space planning (for a move or facility renovation) • Technology transitions—planning and implementation (e.g., electronic medical

records) • Customer service initiatives involving significant business-process changes • Feasibility studies for new business ventures or programs • Pursuing an award such as the Baldrige prize for quality, magnet hospital designa-

tion, or five-star Medicare health plan rating

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Section 4.2Group Dynamics

Cross-Functional Teams Many organizations create customer teams in response to increased market competition and customer demands for better service coordination. Managed health care systems have resulted in the creation of ever-larger economic bargaining units among both payer and care delivery organizations as evidenced by health plan mergers and acquisitions and hospital system affiliations. These large customers (mega health plans and multihospital systems) expect not only lower prices but also knowledge of their business and rapid responsiveness to their needs; they often demand a single point of contact for inquiries and service. In such an environment, a coordinated approach to business development and customer relations is essential and typically involves people from marketing, finance, information systems, and operations on the team. The cross-functional team members possess the competencies needed to achieve an optimal outcome, such as winning a new contract or improving customer satisfaction and regulatory or accrediting agency ratings.

Theory in Action: Ten Tips for What Not to Do as a Team Manager

Parker (1994) offers a David Letterman–style “Top 10 List” of practices to avoid when managing cross-functional teams.

10. Don’t listen to any new idea or recognition from a team. It’s probably not a good idea since it’s new and comes from a team.

9. Don’t give teams any additional resources to help solve problems in their area. Teams are supposed to save money and make do with less. Besides, they will probably just waste more time and money.

8. Treat all problems as signs of failure and all failures as a reason to disband teams and downgrade team members. Teams are supposed to make things better, not cause you more problems.

7. Create a system that requires lots of reviews and signatures to get approvals for all changes, purchases and new procedures. You cannot be too careful these days.

6. Get the security department involved to make it difficult for teams to get information about the business. Don’t let those team members near any computers. You don’t want them finding out how the business is run.

5. Assign a manager to keep an eye on teams in your area. Tell the teams that he or she is there to help facilitate (teams like that word)—but what you really want these managers to do is control the direction of the teams and report back to you on any deviations from your plan.

4. When you reorganize or change policies and procedures, do not involve team members in the decision or give them any advance warning. This will just slow things down and make it difficult to implement the changes.

3. Cut out all training of team members. Problem solving is just common sense anyway, and besides, all that training really accomplishes is to make a few consultants really rich.

2. Express your criticisms freely and withhold your praise and recognition. Teams need to know where they have screwed up so that they can change. If you give out praise, people will expect a raise or reward, and you don’t want that.

1. Above all, remember you know best. That’s why they pay you the big bucks. Never forget that (pp. 210–211).

Source: From Parker, G.M., Cross-functional teams: Working with allies, enemies & other strangers. © 1994 John Wiley and Sons Inc. Reprinted by permission.

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Section 4.3Group Performance and Effectiveness

Virtual Teams Advances in electronic communication technology have encouraged the formation of vir- tual teams in many organizations and some entirely virtual organizations as well. As the use of virtual work teams grew, both organizations and workers realized that virtualiza- tion had both benefits and drawbacks. At International Business Machines (IBM), an early adopter, more than 45% of its 400,000+ employees and independent contractors work remotely; however, employees joke that the company’s initials stand for “I’m by myself” (Johns & Gratton, 2013). Marissa Mayer made headlines when she was named CEO of Yahoo! in July 2012 at age 37, when she was 6 months pregnant with her first child; she sparked a firestorm of controversy 7 months later by eliminating the company’s long- standing telecommuting programs. Mayer argued that employees needed to be physically present to create a unified organization. Yahoo!’s share price increased by more than 70% in Mayer’s first year in office, although the company’s revenue rose at a much slower rate than its competitors in the digital advertising industry (Efrati & Silverman, 2013).

As in other businesses, a growing number of administrative profession- als in health organizations are telecom- muting. Managers in these organiza- tions recognize that new work models bring new challenges, and it is not easy to achieve a balance between the independence and freedom of vir- tualization and the camaraderie and opportunities for collaboration in a traditional office setting. Finding or creating new ways to provide a sense of community can mitigate worker isolation, avoid alienation, and foster team collaboration (Johns & Gratton, 2013).

4.3 Group Performance and Effectiveness Teams are an integral element of health organizations’ administrative infrastructure. Effec- tive teams are like flocks of geese: Both have interdependent members who care for and support each other and are more efficient working together than alone. Members rotate as leaders and help each other when one falters or is distressed.

Benefits and Costs of Teams

Considerable research has demonstrated the benefits of teams for both the organization and the individual: Enhanced communication, higher productivity and satisfaction, and decreased turnover (Buchbinder & Thompson, 2012).

Blend Images/John Fedele/Getty Images

A virtual team meeting via video chat saves time and money.

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Section 4.3Group Performance and Effectiveness

Teams maximize the organization’s human resources, for in teams, each member learns to be more effective through the coaching, help and leader- ship of all the other members. All members, not just the individuals, feel success and failures alike. Because failures are not blamed on individual members, they have the courage to take more risks in a team setting and more ideas are forthcoming. The greatest lesson learned by team members is: Teams consistently outperform individuals. And the second greatest is: Individuals may be considered for career advancement as a result of broad- ening their knowledge of the organization and acquiring teamwork skills. (Costa, 2009, p. 315)

Katzenbach and Smith (1993), in their best-selling business book, The Wisdom of Teams, present the following findings to support their fundamental premise that teams and orga- nizational performance are inextricably connected.

• “Real teams” are jointly responsible for specific results that the company perfor- mance ethic demands. They emerge and operate best when management makes clear and strong performance demands and holds them accountable for results.

• High-performing teams are rare, mainly because few teams elicit the high degree of personal commitment that distinguishes members of high-performing teams from people on other teams.

• Teams integrate, rather than replace, formal hierarchical structures and processes. • Teams integrate performance and learning by defining performance goals and

developing the skills needed to achieve them. • Teams are increasingly the primary unit of performance for organizations, essen-

tial for the speed and quality that customers in all types of industries expect.

There are, however, significant costs of teamwork. The greatest cost is the staff time spent in meetings and the associated opportunity costs (how that time might be better spent). Other costs include time spent in arranging, scheduling, and recording meetings; travel or communication expenses for in-person or virtual meetings; and expenses for food, travel, and accommodations. There are also psychic costs associated with having to work with other people, such as delayed decisions, loss of autonomy, and pressure to compromise (Buchbinder & Thompson, 2012).

Health administrators therefore need to weigh the costs and benefits of forming teams under varying circumstances, since whether a team or individual approach is most appro- priate depends on the nature of the problem, the goal to be achieved, and the skill of the team leader (Maier, 1967). Generally, teams are most useful in situations requiring mul- tiple skills, a variety of perspectives, broad experience, and a free flow of communication (Whetten & Cameron, 2011).

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Section 4.3Group Performance and Effectiveness

Dysfunctional Teams

Not all teams function successfully. Patrick Lencioni (2002) has identified five dysfunc- tions of teams that prevent them from performing effectively. Table 4.2 compares the prin- cipal characteristics of dysfunctional and well-functioning teams.

Table 4.2: Functional and dysfunctional teams

Attribute Dysfunctional teams Functional teams

Trust In the absence of trust, team members are unable to be genuinely open with each other about their mistakes and weaknesses.

Team members feel free to ask for or offer help.

Conflict Failure to establish a founda- tion of trust creates fear of conflict, so that team members cannot frankly and passionately debate ideas, and fail to resolve the issues about which they disagree.

Productive conflict enables a team to produce the best pos- sible solution in the shortest amount of time, then move on to the next important issue.

Commitment Lack of healthy conflict results in lack of commitment, since team members have not openly expressed their opinions. The quest for certainty about the correctness of a decision can paralyze a team and undermine members’ confidence in their ability to make any decisions.

Seeking consensus is not necessary; reasonable people can support a decision they do not agree with as long as they perceive that their opinions have been heard and seriously considered.

Accountability Lacking commitment to a clear plan of action, team mem- bers avoid accountability and hesitate to confront their peers regarding counterproductive actions and behaviors.

Members of great teams dem- onstrate their respect for each other by holding them account- able for performing at a high level.

Results Failure to hold each other accountable leads to inattention to results when team members put their individual needs or the needs of their work unit above the collective goals of the team.

Great teams want to achieve the goals they set and the results to which they commit.

Source: Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass.

Teamwork in health organizations is often very challenging, especially in large, complex organizations with members from different professional groups. Forming and leading a great team is hard work, but the results are worth the effort.

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Section 4.3Group Performance and Effectiveness

Web Field Trip: Mind Tools Team Effectiveness Assessment

Go to http://www.mindtools.com/pages/article/newTMM_84.htm. Answer the 15-question assessment for a team in which you are a leader or participant.

1. Analyze your responses and identify your areas of strength and weakness. 2. How will you use what you learned from this assessment to become a more effective

group leader?

Groupthink

Yale University research psycholo- gist Irving Janis (1971) developed this concept from research on the actions of President John F. Kennedy’s cabi- net toward Cuba. After concluding that Cuban president Fidel Castro was working on behalf of the Soviet Union, in late 1961 Kennedy autho- rized a clandestine brigade of Cuban exiles to invade the island. The Bay of Pigs fiasco, as it became known, failed within days and was an embarrass- ing defeat for the Kennedy adminis- tration. A few months later, the same team handled the Cuban missile cri- sis brilliantly. After aerial reconnais- sance photographs revealed Soviet missiles under construction in Cuba, the administration boldly confronted Soviet premier Nikita Khrushchev while avoiding armed conflict (U.S. Department of State, n.d.).

Janis (1971) reviewed hundreds of documents on the Bay of Pigs invasion attempt and other unsuccessful government and military leadership team decisions and made a sur- prising discovery: Each group of high-level leaders and officials displayed the same type of social conformity that psychologists had routinely observed in studies of groups composed of students and the general population. Janis called this phenomenon groupthink, defined as

remaining loyal to the group by sticking with the policies to which the group has already committed itself, even when these policies are working out badly and have unintended consequences that disturb the conscience of each member . . . when concurrence-seeking becomes so dominant in a cohesive ingroup that it tends to override realistic appraisal of alternative courses of action. (p. 157)

Henry Burroughs/AP

The Kennedy administration’s 1961 Bay of Pigs fiasco is a prominent example of groupthink.

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Section 4.3Group Performance and Effectiveness

Groupthink Signs and Signals Behavioral symptoms of groupthink typically arise during the norming stage of the group developmental process, but they can develop at any time. Signs and signals of groupthink include:

1. Illusion of invulnerability: Members feel their group or organization is too smart, powerful, or rich to be wrong or to experience defeat.

2. Rationalization: Members discount warnings and other signals that their think- ing is incorrect.

3. Morality: Members’ belief in the inherent morality of their group and the right- ness of their position leads them to ignore the ethical consequences of their decision.

4. Stereotypes: Members consider opponents too weak, stupid, or corrupt to deal effectively with whatever the in-group decides to do and dismiss disconfirming information by discrediting its source.

5. Pressure: Group leaders and members apply direct pressure to any member who expresses doubts about the proposed course of action or who questions the assumptions on which it is based.

6. Self-censorship: Members suppress misgivings and doubts, deciding that they are not relevant and should be set aside.

7. Illusion of unanimity: Members assume that not speaking in opposition indicates agreement with the group’s position.

8. Mind guarding: Members protect the group leader and fellow members from adverse information that would disrupt the consensus, such as objections or questions from “outsiders”— even highly respected experts.

The author’s experience during the 1980s in a nonprofit hospital system executive team meeting illustrates groupthink in health care organizations. The corporate director of marketing and planning presented her plan for an integrated marketing approach by the system’s member hospitals as a cost-effective way to promote the hospitals in their respec- tive communities and compete with the erosion of market share and doctor defections to for-profit hospitals chains in the region. The CEO of the flagship hospital stated, “I refuse to engage in any form of advertising; it’s not dignified, and it’s unethical for a nonprofit religious hospital to use its funds in this manner. Besides, everyone knows we provide the best quality care and have the best physicians. They lure patients with false advertising and doctors with kickbacks. If we adopt their tactics, we stoop to their level.” The senior- level leadership team ignored the marketing director’s rejoinder that advertising was just one small part of the overall plan and that the physician relations program did not and would never involve payment for admissions. After some murmuring, discussion of the plan was tabled; it did not appear on the executive council agenda again until the flagship hospital CEO was on vacation.

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Section 4.4Stakeholder Dynamics

Groupthink Remedies To counteract groupthink, Janis (1971) offers the following suggestions based on the suc- cessful actions taken by the Truman administration’s Marshall Plan team for post–World War II European economic recovery as well as the actions of the Kennedy cabinet in peace- fully resolving the Cuban missile crisis:

• Assign the role of critical evaluator to at least one team member, who will encour- age the group to consider both pros and cons of any proposed course of action.

• Leaders should refrain from expressing their opinions or expectations at the beginning of a group discussion.

• Set up subgroups of team members or outsiders to develop and debate indepen- dent proposals.

• Require each team member to seek input from members of their organizational units and report back to the group.

• Invite one or more outside experts to each meeting to hear and critique core members’ views.

• Assign at least one team member to play devil’s advocate whenever the agenda calls for an evaluation of policy alternatives. In contrast to the critical evaluator’s neutral stance, this member’s role is to make opposing arguments.

• Hold a “second-chance” meeting at least 1 day after the group reaches a pre- liminary consensus, where all members are encouraged to express their second thoughts about the decision.

Taking these actions will help ensure that team decisions in health organizations are well formed, carefully considered, vigorously debated, and thoughtfully adopted.

An illustration of groupthink often used in management classes is the Abilene Paradox (http://www.crmlearning.com/abilene-paradox), which recounts the story of a Texas family that made a long, hot, and unpleasant drive to Abilene for dinner. They all would have pre- ferred to stay home, but each agreed because they felt the others wanted to go (Harvey, 1988).

4.4 Stakeholder Dynamics Health care organizational stakeholders and their relationships are especially complex and involve many players and forces. These individuals, groups, and organizations are linked together by cooperative economic exchanges as well as legal and regulatory rela- tionships. Table 4.3 lists the major types of health organization stakeholders and briefly describes their primary characteristics (White & Griffith, 2010).

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Section 4.4Stakeholder Dynamics

Table 4.3: Principal attributes of health organization stakeholders

Stakeholder Principal attributes

Owners Vary according to whether the organization is a not-for-profit or for-profit corporation, or a federal, state, or local government agency

Customers, buyers, and payers Patients and families, differentiated by age, gender, clinical need, and language prefer- ence; employers, health insurance and other types of payers differentiated by company and type of coverage

Suppliers and workers Direct patient-care providers differentiated by professional credentials; many other types of employees; contract providers; sup- pliers of goods and services; and volunteers who support and supplement the efforts of workers in myriad ways

Regulators and advocates Government agencies (federal, state, and local); accrediting bodies; trade and profes- sional associations; lobbying groups; unions; consumer associations; community groups; competitors; and other organizations influ- encing health organization transactions and operations

Source: White, K. R., & Griffith, J. R. (2010). The well-managed healthcare organization (7th ed.). Chicago: Health Administration Press.

Health organization stakeholders include individuals and groups within and exter- nal to the organization. Employees, including managers and executives, are internal stakeholders. There are also interface stakeholders, which function both externally and internally; for health care organizations these groups would include the medi- cal staff, the governing body, and stockholders in the case of for-profit organizations. External stakeholders for health care organizations include patients, community orga- nizations, insurers, vendors, competitors, employers, labor unions, and regulatory and accrediting bodies (Ledlow & Coppola, 2014). Sometimes stakeholders are individu- als; more often they are groups. Figure 4.3 illustrates a generic model of stakeholder- organizational relationships.

Stakeholder Management

Health organization leaders must thoroughly understand the function and role of stake- holders to determine which are relevant to their organizations and then assess which are potential partners or allies and which are potential threats. Stakeholders have their own

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Section 4.4Stakeholder Dynamics

interests and agendas, which may align or conflict with that of the health organization, and they all make demands on the organization to some degree. Balancing the demands of multiple stakeholders pursuing dif- ferent interests and seeking to influ- ence the organization to act in ways that further their agendas is a major challenge for health organization leaders—especially when conflicting responsibilities to patients, governing bodies, professional staff, employees, and community pose ethical dilem- mas (Levey & Hill, 1986). Achiev- ing this balance is part of the larger challenge of delivering high-quality care while simultaneously increas- ing access to health care services and reducing costs; to achieve one objective often involves a trade-off in another area. Thus, health organiza- tion leaders are hard-pressed to sat- isfy their various stakeholder groups in terms of what these stakeholders most value in terms of access, cost, and quality (Coppola, Erckenbrack, & Ledlow, 2009).

Stakeholder analysis is a widely used method in health organizations to understand how different stakeholders influence the organizational decision-making process. As part of the strategic planning process, it is especially useful in generating knowledge of relevant individuals, groups, and organizations in order to understand their interests, agendas, interrelationships, resources, and vulnerabilities (Brugha & Varvasovszky, 2000). When stakeholder representatives are willing to forthrightly state the positions of their organiza- tions and share these with other relevant stakeholders, organizational leaders can engage in a more transparent and productive relationship with stakeholders. Unfortunately, this situation rarely occurs, so it is often necessary to conduct interviews, focus groups, or sur- veys to discern stakeholders’ true intentions or to accurately predict their actions.

Interface stakeholders present the biggest challenge in stakeholder management, since they interact with the organization across boundaries. With the increase in integrated delivery systems and new organizational structures, the number and types of these stake- holders are increasing. Managers need to identify the key stakeholders and understand their interests and agendas in order to develop and sustain successful relationships with them (Dansky & Gamm, 2004).

Figure 4.3: Stakeholder-organizational

relationships

An understanding of stakeholder-organizational relationships is essential to stakeholder management.

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n er

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g B ody

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lators/Advocates Custo me

rs /B

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a y e

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Suppliers/W orkers

Organization

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Section 4.4Stakeholder Dynamics

Physician Relations

Physicians are key interface stakeholders who can interact across organizational bound- aries to manage a variety of internal and external stakeholders. In addition to practic- ing medicine, physicians may serve on hospital, medical group, and health plan commit- tees; on medical school faculties; on governmental planning or advisory committees or review boards; as consultants to pharmaceutical, medical device, and other health care organizations; and as expert witnesses in legal actions. In these various roles they can be valuable sources of organizational business intelligence. Physicians also represent the organization to the external environment and thereby contribute positively or negatively to the organization’s reputation and image, particularly with respect to clinical outcomes and quality-performance indicators reported to and reviewed by insurers and regulatory and accrediting agencies. Most importantly, physicians represent their organizations to patients; as patient care managers, they are the principal source of both the medical care and the information about the care that patients receive.

Since stakeholder relationships directly impact an organization’s financial performance, an important function for health organization executives is to help physicians, as interface stakeholders, develop and maintain strong positive connections with their mutual key stake- holders of patients, insurers, and regulatory and accrediting agencies. To do this involves assessing specific physician behaviors about patient communications, adherence to insur- ance clinical and administrative protocols, and compliance with regulatory and accrediting agency data collection and reporting requirements (Malvey, Fottler & Slovensky, 2002).

Theory in Action: Training Physicians as Group Leaders

An example of how health organizations might help physicians with patient communications is to offer them training in group facilitation and education skills. Group patient visits are an emerging trend in a growing number of medical practices today and have been proposed as one way to deal with anticipated increases in demand for medical care by newly insured patients under the ACA.

The percentage of practices offering group visits grew from 6% to 13% between 2005 and 2010 and includes some of the nation’s leading medical groups such as the Cleveland Clinic and Harvard Vanguard Medical Associates (Park, 2013). Cleveland Clinic nurses note that shared medical appointments have improved patient access, outcomes, and patient satisfaction. For chronic conditions, patient education is repetitive and time-consuming yet necessary; group visits are a much more efficient way to provide this education. They allow providers to devote more time to patients and encourage patients to learn from each other how to manage their conditions. Additionally, the group visit model allows nurse practitioners to serve as primary care providers by leading patients in group discussions and evaluating their current health status (Bartley & Haney, 2010). Physicians who move into management positions will benefit by acquiring skills in group leadership.

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Section 4.4Stakeholder Dynamics

Strong positive relationships with physicians are essential to health organizations in almost every sector of the industry. Pressures to do more with fewer resources make it more difficult to maintain the trust and respect that are essential building blocks of posi- tive relationships. As a result, relationships with physicians are becoming more adver- sarial than collaborative. This situation often negatively impacts workplace morale and patient care and increases the risk of litigation and its associated costs (Yamada, 2009).

Under conditions of steadily increasing economic pressures to deliver high-quality care at affordable costs, physicians and administrators today must (a) document in increasingly precise and standardized ways how they are meeting quality standards and (b) break down and justify their service charges to increasingly demanding and sophisticated purchasers of care. These pressures drive efforts for health organization alignments with physician groups. However, achieving successful alignment is difficult for administrators and physi- cians alike, since their training and professional orientation predispose them to different ways of working. Physicians and nurses operate from a clinical framework, advocating at the individual level for patients and families, while managers are trained to look at population-level health status and organization-wide issues. Health administration edu- cation emphasizes working collaboratively with employees and colleagues, while clinical care education focuses on development of individual skills and competencies (Buchbinder & Shanks, 2012). Research on hospital-medical staff collaborations and the effectiveness of interdisciplinary teams shows that conflicts between physicians and hospital staff (includ- ing nurses) are often due to physicians’ refusal to embrace teamwork (Weber, 2004).

The ACA has strong financial incentives designed to encourage closer physician- organization alignment through formation of clinically and administratively integrated delivery systems called accountable care organizations (ACOs), as discussed in Chapter 2. Integration offers physicians opportunities to access greater financial resources and focus on practicing medicine while remaining independent members of their medical group or independent practice association. To succeed, integrated arrangements require structures and processes for administrators and physicians to jointly set goals, develop strategies, make decisions, and resolve conflicts. Studies of successful physician-integration efforts found that trust was considered the critical success factor in establishing the cooperative relationship necessary to make these processes work, and identified these indicators of trust-based relationships (Zuckerman et al., 1998):

• frequent, open, and candid communication, both formal and informal; • willingness to share and explain relevant clinical, financial, and performance data; • demonstrated management competence—responsiveness, following through on

actions, and delivering on promises; and • placement of physicians in management and governance positions.

There are varying degrees of physician alignment, ranging from loosely structured con- tractual agreements to those in which the physicians become salaried employees of either the hospital/health system or a separate integrated services–delivery organization. Hos- pitals and health systems were eager to acquire and manage physician practices during the 1990s, but many of these acquisitions turned out to be expensive mistakes: Hospitals did not know how to manage medical practices, and many physicians were less hardwork- ing and productive as employees than they had been as independent practitioners. Today hospitals recognize the need to carefully evaluate physician practices before acquiring

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Section 4.5Organizational Misbehavior and Dysfunction

them and to employ experienced medical group administrators to manage them (Aston, 2013). Professional services agreements in which the physician remains employed by the practice allow physicians to more closely align with a health system without becoming an employee. Various practice services agreement models enable hospitals and health sys- tems to realize financial benefits without incurring the legal obligations and financial risks of an employer (Reiboldt & Greeter, 2013).

4.5 Organizational Misbehavior and Dysfunction Organizations, like individuals, can behave in ways that are counterproductive, self- defeating, and even pathological. Researchers have found that organizational dysfunc- tion reflects problems with the leadership of the organization and, to a lesser extent, with managers at lower levels. This chapter concludes by discussing the diagnosis, prognosis, and treatment of organizational dysfunction.

Theory in Action: Crime Does Not Pay

Some cases of organizational misbehavior are so flagrant that they make front page headlines, such as the saga of Richard Scrushy. Trained as a respiratory therapist, Scrushy quickly rose to top management and in his early 30s founded the HealthSouth Corporation to deliver a wide range of outpatient rehabilitation services. The company soon went public and rapidly expanded into sports medicine and workers’ compensation, despite repeated lawsuits and settlements with Medicare and private insurers claiming fraudulent billing practices. Scrushy enjoyed and flaunted the company’s success, earning millions of dollars and traveling and living in high style. He was widely admired as a brilliant businessman—until he was indicted for securities fraud.

Although all five of the HealthSouth chief financial officers who worked for him were found guilty and sentenced to prison terms, Scrushy was acquitted. However, a few months later Scrushy was convicted on unrelated charges and spent about 5 years in prison. Once revered as a Wall Street wonder, today Scrushy is a poster boy for greed who was profiled in a 2009 episode of the CNBC series American Greed.

Diagnosing Organizational Misbehavior and Dysfunction

Seldom is organizational misbehavior by health organization executives so clearly patholog- ical. More often organizational dysfunction reflects egotism and groupthink, when highly intelligent people display poor judgment. It can also result when leaders are unable to

• clearly articulate the organization’s vision, values, goals, and culture; • engage and motivate employees; • develop meaningful reward systems; and • effect needed changes (Graber, 2009).

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Section 4.5Organizational Misbehavior and Dysfunction

Manfred Kets de Vries (2003) of the international INSEAD business school faculty developed a typology of five types of neurotic organizations based on the typical and repetitive behav- ior patterns of their leaders and managers and the effects of these behaviors on the organiza- tion’s employees. Each style has its strengths and weaknesses, as displayed in Table 4.4.

Table 4.4: Neurotic organization leadership style summary

Style Description Illustrative example

Strengths Weaknesses

Dramatic Driven by the need to impress and gain atten- tion. Leaders are highly charis- matic, act boldly, are undeterred by risk, and take controversial stands.

Richard Branson, Virgin Airlines

Strong entrepre- neurial spirit

Decisions may become too centralized; leader may micromanage.

Suspicious General atmo- sphere of distrust and paranoia; hyperalertness for problems and enemies.

J. Edgar Hoover, Federal Bureau of Investigation

Knowledge and aware- ness of external threats and opportunities

Punitive poli- cies; encourages subterfuge and information hoarding.

Compulsive Preoccupied with rules; exhaustive evaluation proce- dures. Relation- ships defined by control and acquiescence.

John Akers, IBM Efficient opera- tions, strong ana- lytics, thorough problem-solving approach

Risk of analysis paralysis.

Detached Cold, unemo- tional; lack of involvement; indifference to praise or criti- cism; intolerance of dependency.

Howard Hughes, Hughes Corporation

Open to ideas and influence from people at all levels and outside the organization

Leadership vacuum induces managers to create individual fiefdoms.

Depressive Inactivity, pas- sivity, powerless- ness, insularity; lack of confi- dence in ability to effect changes.

Many government- sector organizations

Consistent inter- nal processes

Focus on mainte- nance of internal processes; can become detached from the marketplace.

Source: Kets de Vries, M. (2003). Organizations on the couch: A clinical perspective on organizational dynamics. Retrieved August 19, 2013, from INSEAD Faculty & Research website: http://www.insead.edu/facultyresearch/research/doc.cfm?did=1321

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Section 4.5Organizational Misbehavior and Dysfunction

Organizational Dysfunction Prognosis

Leaders in dysfunctional organizations often struggle to understand why people in the orga- nization continue to behave in counterproductive ways that result in poor strategic deci- sions, ineffective execution of strategy, factionalized management teams and business units, hiring mistakes, inadequate succession planning, and low productivity. Too often, however, they blame others for their own lack of communication and problem-solving skills.

Organizations that are in a state of decline or experiencing rapid and unsettling change display a variety of similar dysfunctional characteristics when they lose resources (rev- enue or market share) and employees, which Cameron (1994) identified as the “dirty dozen” (p. 183):

1. Decision making is centralized, as employee empowerment is constrained. 2. Long-range planning is neglected in favor of focusing on short-term survival and

crisis management. 3. Tolerance for risk taking and learning from mistakes decreases. 4. Employees become more resistant to change in order to protect themselves from

loss of jobs, benefits, and perks. 5. Morale drops as employees become suspicious and angry. 6. Special interest groups become more visible and outspoken. 7. Across-the-board cutbacks are used to minimize organizational resistance. 8. Organizational leaders lose credibility with subordinates. 9. Organizational competition for shrinking resources leads to conflict and

infighting. 10. Information, especially bad news, is suppressed rather than passed up the

hierarchy. 11. Teamwork declines as employees focus on individual performance and rewards. 12. Leaders are blamed for organizational uncertainty and decline.

Astute professionals will be aware of and alert to these warning signs of organizational dysfunction and take steps to address them promptly to prevent further deterioration and improve organizational functioning.

Organizational Dysfunction Treatment

The remedy for organizational dysfunction is evidence-based management, which involves using leadership practices supported by solid research. Walshe and Rundall (2001) observed that just as clinicians have been slow to adopt an evidence-based approach to their own practices, so have health care managers: They also tend to overuse ineffective interventions and underuse effective ones. Shortell (2006) named ineffective health managerial decision making as a significant contributor to the quality deficiencies, excessive costs, and overall underperformance of the U.S. health care system. A later study by Kovner and Rundall (2006) found that improving the quality of management decision making received little attention, even when a management mistake results in significant harm to patients or financial loss, such as the failed merger of Stanford University and University of California hospitals that cost $176 million over a 29-month period. Health-system leaders believed that their organizational cultures promoted the use of evidence-based decision making— but their definition of evidence consisted mostly of personal and anecdotal experience,

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Section 4.5Organizational Misbehavior and Dysfunction

information from Internet sites, and advice from consultants or services such as the advi- sory board. None reported any oversight or regular review of the decision-making pro- cesses in their organizations.

Health organization executives and managers have been reluctant to acknowledge their mistakes for the same basic reasons that prevent clinicians from doing so: They are embar- rassed and do not want to lose face with colleagues. They may also lack financial or staff resources or time to adequately research, analyze, or monitor the effects of a decision, or they may be under pressure from superiors, medical staff or regulatory agencies. Some executive decisions seem reasonable at the time they are made but turn out badly. Further- more, it often takes a long time before it is clear that a specific decision is not working out as planned. Hoffman (2002) urges health organizations to encourage managers to disclose and learn from their mistakes by taking the following actions:

• Establish and obtain governing board approval for a managerial disclosure policy based on criteria such as legal risk, regulatory agency requirements, board man- dates, and ethical considerations.

• Analyze the root causes of the problem, the decision-making process, and its consequences.

• Discuss the analysis with the management team to determine how best to avoid repetition of a similar error, such as: 1. articulating lessons learned, 2. developing new or modifying existing policy, 3. changing the decision-making process, and/or 4. developing new or modifying training activities.

• Learn more about how to handle management mistakes from case studies of other health organizations and national professional development organizations’ educational programs.

• Incorporate questions or discussions of mistakes and lessons learned into execu- tive, managerial, and supervisory performance reviews.

Cohen (2011) makes a business case for use of evidence-based human-capital manage- ment practices in health care organizations where at least 60% of budgets are allocated to labor costs and notes the financial benefits of such practices for staff recruitment, selec- tion, development, and retention. For example, a poor executive hire could cost the orga- nization 6 to 10 times that individual’s annual earnings. Pfeffer and Sutton (2006) recom- mend that managers relentlessly seek new knowledge from both inside and outside their companies and industries so that they can keep updating their skills and knowledge, just as medical professionals must do.

Because clinicians and health administrators have different professional cultures, research orientations, and decision-making styles, evidence-based practice concepts need to be translated from the clinical to the management arena (Walshe & Rundall, 2001). “Until both components are in place—identifying the best content (i.e., EBM [or evidence-based medicine]) and applying it within effective organizational contexts (i.e., EBMgt [or evidence-based management])—consistent, sustainable improvement in the quality of care received by US residents is unlikely to occur” (Shortell, Rundall, & Hsu, 2007, p. 673). The following case study describes the use of evidence-based medi- cine and management to improve patient safety.

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Section 4.5Organizational Misbehavior and Dysfunction

Case Study: Improving Responses to Medical Errors With Organizational Behavior Management

A 146-bed general acute care community hospital in southwest Virginia conducted an assessment of patient safety needs and the various organizational behavioral management techniques used by hospital managers in response to the nine most frequently reported patient safety events. The most frequently reported category of patient safety events (errors) was procedure/ treatment variance, and the least effective management responses were to witnessed falls. The organizational behavioral management intervention therefore selected managers’ follow-up responses to procedure/treatment variance and witnessed falls as targets.

Managers first received the results of the needs assessment, then were instructed to (a) respond to the two targeted event types with corrective-action communication combined with individual and group behavior-based feedback and (b) use positive recognition to support behavior that prevented harm, including reporting events. For the 3-month intervention period, researchers Cunningham and Geller (2011) reviewed 361 patient safety event follow-up descriptions, with a total of 527 interventions that achieved the following results:

1. Reports of targeted event types increased in the first month of intervention, then decreased in subsequent months, indicating that the intervention increased employees’ sensitivity to the need to report close calls and learn from them.

2. The two targeted events displayed opposite trends in impact scores associated with managers’ follow-up actions during the intervention phase. The impact scores for follow-up behaviors for procedure/treatment variance increased sharply in the first month, then gradually declined in the next 2 months. In contrast, impact scores for follow-up behaviors for witnessed falls increased slightly in month one, then sharply in subsequent months.

3. Managers significantly increased use of individual and group feedback during the intervention phase and decreased use of no intervention, a significant improvement in the management of patient safety errors. Especially significant was the increased use of group feedback.

4. Participating managers and health care workers expressed positive perceptions of the intervention techniques used and related outcomes. Managers received summaries of the monthly events and intervention follow-up reports at monthly managers’ meetings and were encouraged to share them with their employees. Intervention perception survey results found that both managers and workers perceived an increase in managers delivering praise for behaviors to prevent harm than delivering reprimands for errors.

This study demonstrates the benefits of applying an evidence-based intervention strategy by teaching health care managers to (a) communicate more effectively in follow-up responses to patient safety events, (b) more carefully document their follow-up actions to learn what intervention behaviors do most to promote patient safety, and (c) provide group rather than individual feedback when appropriate. This intervention demonstrably improved patient safety and offers a model for managers in other organizations to follow.

Reflection Questions: 1. How does the trend in impact scores for managers’ follow-up actions reflect the Haw-

thorne effect? 2. Why was the increase in managers’ use of group behavior-based feedback important? 3. What would you recommend to sustain the use of the intervention strategy?

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Section 4.6Summary and Resources

4.6 Summary and Resources

Chapter Summary Much of the work in organizations is done by teams of people rather than individuals. Organizations need talented individuals who can work collaboratively with others. Being a team player is an important attribute for success in most jobs, and being able to lead a team effectively is a critical success factor for managers and leaders.

There are many different types of groups—formal and informal, permanent and tempo- rary, structural and functional. An understanding of group dynamics and processes helps managers effectively channel and coalesce the skills and efforts of their subordinates for maximum productivity and performance. Not all employees are natural team players, so managers also need to know how to deal with negative individual and group behaviors.

High-performing teams are results oriented, with managers who set clear performance expectations and hold them accountable. Effective team managers establish a climate of trust, so that team members can be open with each other when asking for or offering help. They also encourage and manage constructive conflict, so that members of the group can frankly debate their ideas and consider a wide range of solutions. Without a free exchange of ideas, team members will lack commitment to the plan of action or fall victim to group- think, a condition that occurs when group loyalty prevents members from expressing their doubts about or opposition to an apparent consensus decision.

Health organizations have many different stakeholder groups with which they interact and which have a vested interest in the organization. Stakeholders’ interests may align or conflict with those of the organization, so balancing their demands is a major challenge and responsibility for organizational leaders. Developing and maintaining positive rela- tionships with physician stakeholders is a critical success factor for leaders of most health organizations, as is attention to the experience of patient stakeholders.

Just as physicians are increasingly expected to make deliberate and thoughtful use of the current best clinical evidence when making treatment decisions, so should health admin- istrators use management practices that are supported by solid research. In addition, health organizations should create conditions that encourage leaders and managers to acknowledge and learn from their own and others’ mistakes.

Critical Thinking and Discussion Questions 1. What are examples of task and maintenance roles for health organization group

leaders, and why are both roles important? 2. Can a group leader streamline the group development process? 3. How can managers help a task force end on a positive note? 4. How can managers hold teams accountable for results? 5. Why is lack of conflict a sign of a dysfunctional team? 6. Identify the key internal, interface, and external stakeholders for a general acute

care hospital. 7. Give an example of evidence-based management.

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Section 4.6Summary and Resources

Key Terms

Abilene Paradox (Harvey) An agreement to a group decision that none of the group members desires, but each member thinks the other members of the group prefer the decision.

adjourning The final stage of group development process, when the group disbands after task completion.

blocking roles Behaviors that hinder a group from accomplishing its goals.

command groups Groups specified in the organization chart; members are respon- sible for a specific function.

committees Formal groups that have per- manent standing within the organization’s administrative structure, regular meetings, and elected or appointed members, often with specific terms.

evidence-based management Manage- ment practices based on effectiveness sup- ported by research.

evidence-based medicine Clinical care practices based on effectiveness supported by research.

external stakeholders Members of groups outside the organization, such as custom- ers, suppliers, and regulators.

formal groups Groups officially desig- nated by the organization to fulfill certain functions and accomplish specific tasks.

forming The first stage in group devel- opment process, when groups organize themselves and establish boundaries for task and relationship behaviors.

functional role theory (Benne and Sheats) The observation that individuals in small groups played task roles, maintenance roles, or individual (blocking) roles.

groupthink (Janis) Remaining loyal to a group position even when the policies are not working out or the members have misgivings about the position.

identity group A group in which mem- bers share a common biological character- istic or experiences.

independent practice association A medical group formed as an economic bargaining unit in a managed care delivery system.

individual roles Behaviors that help a group accomplish its goals.

informal groups Naturally formed groups of people who work together or who are drawn together on the basis of friendship or shared interests.

informing A group process preparation stage that involves an invitation to mem- bership and prospective group members forming opinions about the purpose of the group and its members.

interface stakeholders Stakeholders that function both internally and externally, such as the medical staff, governing body, and stockholders of for-profit corporations.

internal stakeholders Employees, includ- ing executives and managers.

maintenance roles Roles that are social in nature, focusing on process and relationships.

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Section 4.6Summary and Resources

neurotic organizations Organizations that are characterized by counterproduc- tive behaviors that impede achievement of organizational goals.

norming The third stage of group devel- opment process, when members develop feelings of cohesion and adopt new roles as group members.

organizational behavior management Intervention techniques designed to improve managerial effectiveness.

organizational groups Groups to which members are assigned based on the organi- zation’s division of labor and its authority structure.

performing The fourth stage of group development process, when members focus their energies on accomplishing the task for which they are responsible.

role A key construct of psychology; the shared social expectations of how an indi- vidual behaves in a given situation.

stakeholders Individuals, groups, and organizations that have a vested interest in the organization.

storming The second stage of group development, when members compete for leadership or to control the group’s direction.

task force A temporary group charged with solving a problem or responding to an opportunity.

task roles Roles that are involved with completing a job and accomplishing an objective.

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