Healthcare Administration 5Discussion 1

CHAPTER 6

Organizing and Staffing

CHAPTER OBJECTIVES

• Define the basic management function of organizing and identify the steps in the organizing process.

• Define the key concepts of hierarchy, chain of command, splintered authority, and concurring authority.

• Identify the factors that shape the span of management.

• Differentiate between line and staff relationships, and identify basic line and staff relationships.

• Describe the dual pyramid organization arrangement found in healthcare authority patterns.

• Identify the basic patterns of departmentation.

• Introduce the concept of the matrix organization and define the applicability of this apparently contradictory concept.

• Identify patterns of organizational flexibility: temporary agency, contractual outsourcing, and the use of independent contractors and consultants.

• Identify the principles involved in developing an organizational chart.

• Describe the elements of a job analysis.

• Introduce job descriptions, including their uses and the elements necessary in their development.

• Describe the job rating and classification system.

• Identify the content and uses of the management inventory.

• Describe the role and activities of the professional practitioner as consultant.

Organizing is the process of grouping necessary responsibilities and activities into workable units, determining the lines of authority and communication, and developing patterns of coordination. It is the conscious development of the role structures of superior and subordinate, line and staff. The organizing process stems from several underlying premises:

• There is a common goal toward which work effort is directed.

• The goal is articulated in detailed plans.

• There is a need for clear authority–responsibility relationships.

• Power and authority elements must be reconciled so that individual interactions within the organization are productive and goal directed.

• Conflict is inevitable but may be reduced through clarity of organizational relationships.

• Individual needs must be reconciled with and subordinated to organizational needs.

• Unity of command must prevail.

• Authority must be delegated.

THE PROCESS OF ORGANIZING

The immediately identifiable aspects of the organizing process include clear delineation of the goal in terms of scope, function, and priorities. For example, will a healthcare institution focus on acute care for inpatients or comprehensive care, including outpatient care and home care? Will the organization expand its services through decentralized locations and active outreach programs?

The development of a specific organizational structure must be considered. What degree of specialization will be sought? Specialization is a major feature of healthcare organizations; it is dictated and shaped in part by the specific licensure mandates for each health profession. The manager must assess the question of line and staff officers and units. A major organizational question concerns the division of work. What will be the pattern of departmentation? The development of the organizational chart, the job descriptions, and the statements of interdepartmental and intradepartmental workflow systems must be assessed and implemented as part of the management function of organizing. Finally, the changes in the internal and external organizational environment must be monitored so that the organizational structure can be adjusted accordingly.

In summary, the basic steps of organizing are these:

1. Goal recognition and statement

2. Review of organizational environment

3. Determination of structure needed to reach the goal (e.g., degree of centralization, basis of departmentation, committee use, line and staff relationships)

4. Determination of authority relationships and development of the organizational chart, job descriptions, and related support documents

FUNDAMENTAL CONCEPTS AND PRINCIPLES

Relationships in formal organizations are highly structured in terms of authority and responsibility. The resulting hierarchy—that is, the arrangement of individuals into a graded series of superiors and subordinates, authority holders, and rank-and-file members—constitutes one of the most obvious characteristics of formal organizations. A pyramid-shaped organization tends to result from the development of a hierarchy ( Figure 6–1 ).

The authority and responsibility that can be observed in the hierarchy constitutes a distinct chain of command, also referred to as the scalar principle: the chain of direct authority from superior to subordinate. It was long maintained that strict unity of command—the uninterrupted line of authority from superior to subordinate so that each individual reports to one and only one superior—was fundamental to hierarchical relationships in organizations. It was seen as essential to have a clear chain of command showing who reports to whom, who is responsible for each individual’s actions, and who has authority over each worker. In situations of mandatory reporting, critical events, and similar matters, it is important that this set of relationships (i.e., who has the responsibility to report—and to whom) be well established and stated with clarity.

Although unity of command is the usual practice, an alternative is reflected in split-reporting relationships in which a single subordinate reports to two or more superiors. Split-reporting relationships are proliferating as healthcare organizations merge into larger organizations or join together in health systems. It is not at all uncommon to find, for example, a single manager over the same functions at two sites who is therefore answerable to two different site administrators. Such combinations have occurred out of economic necessity, and many of them make sense in terms of operating efficiency and optimal utilization of management capability. This efficiency can be put at risk, however, as the absence of unity of command can create a new set of problems.

FIGURE 6–1 Pyramidal Hierarchy

The individual who reports to two superiors is put in the position of having to balance the two reporting relationships. If either superior is inflexible or overly demanding, the stage is set for subordinate burnout as the individual attempts to reconcile conflicting demands. Much of the determination of whether a split-reporting relationship works lies beyond the reach of the individual. Even the most highly capable subordinate can be rendered frustrated and ineffective by two superiors who have not coordinated their demands and expectations or who have tried to have their way with the subordinate at the expense of the other superior.

Also, a split-reporting relationship more than doubles the communication demands on the subordinate manager. Not only does the manager have to communicate regularly with two superiors, but he or she must do so in a manner that attempts to provide coordination between the needs of the two superiors.

Split reporting may generate potential conflict when managers differ in their interpretation or application of policy. For example, one manager may readily give liberal leave in bad weather or allow early closing before a holiday, whereas another manager may have a stricter interpretation of such practices. The employee in this situation is caught in the middle of an ambiguous situation.

Split-reporting relationships may be necessary under certain circumstances, but they should always be entered into with full awareness and consideration of the problems that may be encountered. The concept of unity of command should not be abandoned without good reason and without planning to meet the increased communication needs of the alternative arrangement.

The authority delegated to any individual must be equal to the responsibility assigned. This principle of parity—that responsibility cannot be greater than the authority given—ensures that individuals can carry out their assigned duties without provoking conflict over their right to do so. In developing policies and documents that support the organizational chart, managers must avoid contradicting this principle. At the same time, managers cannot so completely delegate authority that they become free of responsibility. This is reflected in the principle of the absoluteness of responsibility; authority may (and must) be delegated, but ultimate responsibility is retained by the manager. This, in turn, is the basis of the manager’s right to exercise the necessary controls and require accountability.

Normally, managers have adequate authority to carry out the required activities of their divisions or units without recourse to the authority possessed by other managers. Two situations occur, however, in which the authority of a single manager is not sufficient for unilateral decision making or action. Occasionally, because the work must be coordinated and because there are necessary limits on each manager’s authority, a problem cannot be solved or a decision made without pooling the authority of two or more managers. These problems of splintered authority are overcome in three ways: (1) the managers may simply pool their authority and make the decision or solve the problem, (2) the problem may be referred to a higher level of authority until it reaches a single manager with sufficient authority, or (3) reorganization may be done so that recurring situations of splintered authority are eliminated. Such recurring situations sometimes require adjustment in the delegation of authority.

Concurring authority is sometimes given to related departments to ensure uniformity of practice. For example, the packaging department of a manufacturing company may not change specifications without the agreement of the production division. A computer systems manager in a healthcare setting may be given concurring authority on any data element changes, although this is the primary responsibility of the health information practitioner, to foster compatibility throughout the information processing function. Concurring authority, as a control and coordinating measure, can be a normal part of the routine checks-and-balances system. Splintered authority and concurring authority are the natural consequences of the division of labor and specialization that make it necessary to coordinate the authority delegated to different managers.

Maintaining unity of command in disasters and emergency situations has received particular attention over the past several years. In 2003, the National Incident Management System was implemented as part of a nationwide Homeland Security initiative. One feature of this system is the concept of unified command, a mechanism wherein a command team, which consists of representatives from various response agencies, develops a collective set of strategies. This process takes into account that different responding groups (e.g., police, fire companies, emergency medical response personnel) have differing jurisdictions and responsibilities. Within the structure of unified command, incident commanders from each agency coordinate their efforts. A lead agency or team will have primary authority and responsibility, with the other groups deferring to them. The lead agency or team could change as the situation changes and a different skill set or jurisdictional authority becomes the preferred one (e.g., a fire company hands off a situation to police; an emergency first responder team hands off the care of injured patients to an advanced field triage team). Healthcare organizations are adopting similar organizational patterns in their disaster planning, both internal and external.

THE SPAN OF MANAGEMENT

If authority is to be delegated appropriately, consideration must be given to the number of subordinates a manager may supervise effectively. Four terms are used to refer to this concept: span of management, span of control, span of supervision, and span of authority. Stated another way, the span of management is the number of immediate subordinates who report to any one manager. It is essential to recognize that the number of individuals whose activities can be properly coordinated and controlled by one manager is limited.

There is no ideal span of management. A span of 4 or 5 subordinates at higher levels and a span of 8 to 12 at the lower levels have sometimes been suggested. Many modifying factors shape the appropriate span of management for any authority holder, however. These factors include the following:

• Type of work. Routine, repetitive, and homogeneous work allows a larger span of management.

• Degree of training of the worker. Those workers who are well trained and well motivated do not need as much supervision as a trainee group; the more highly trained the group, the larger the span of management may be.

• Organizational stability. When the organization as a whole, as well as the specific department, is stable, the span of control can be broader; when there are rapid changes, high turnover, and general organizational instability, a narrower span of control may be needed.

• Geographical location. When the work units are dispersed over a scattered physical layout, sometimes even involving separate geographical locations, closer supervision is necessary to control and coordinate the work.

• Flow of work. If much coordination of workflow is needed, there is a corresponding need for greater supervision and a narrow span of control.

• Supervisor’s qualifications. As the amount of training and experience of the supervisor increases, the span of control for that supervisor may increase as well.

• Availability of staff specialists. When staff specialists and selected support services, such as a training, human resources, or development department, are available, a supervisor’s span of management may be increased.

• Value system of the organization. In highly coercive organizations, a supervisor may have a large span of management, because there is a pervasive system to help ensure conformity, even to the extent of severe punishment for deviation from the rules. In contrast, in a highly normative organization, there may be an emphasis on participation in planning and decision making and a resultant complexity in the communication process; thus a smaller span of management may be appropriate. In healthcare organizations (traditionally normative settings with respect to the professional worker), the span of management may be large because the healthcare professional is a specialist within an area and does not always require close supervision.

As an example, the span of management in a laboratory department is shown in the partial organizational chart in  Figure 6–2 . In this figure, one can trace the chain of command from each supervisor in the department back up to the chief executive officer.  Figure 6–3 , depicting the relationships in a physical therapy department, illustrates other ways of depicting organizational relationships.

LINE AND STAFF RELATIONSHIPS

The terms line and staff are key words in any discussion of organizing. In common usage, staff refers to the groups of employees who perform the work of a given department or unit. The director of nursing speaks of the nursing staff, the chief dietitian discusses the dietary/food service staff, and the physicians who practice in a hospital are referred to as the medical staff.

FIGURE 6–2 Partial Organization Chart Illustrating Span of Management (following from President/CEO through Vice President/Ancillary Services and Director, Laboratories)

FIGURE 6–3 Physical Therapy Department Organizational Chart

In management literature, a differentiation is made between line and staff departments or officers. Line refers to those workers who have direct responsibility for accomplishing the objectives of the organization, and staff refers to those employees who help the line units achieve the objectives. In a healthcare organization, direct patient care units are considered to perform line functions, and all other units are listed as staff services. The problem with this distinction becomes apparent when it must be applied to such units as the dietary, supply chain division, or housekeeping and environmental services. Are these functions any less essential to the operation of a healthcare organization than a direct patient care unit? Some authors prefer to list such units as service departments, reserving the term “staff” for a specific authority relationship.

The concept of line and staff was inherited by management theorists from the military of the 1700s and 1800s. An examination of a typical military encounter during this era makes it easier to conceptualize the notions of line and staff. The soldiers literally formed a line; the immediate commanding officers were those who commanded the line—that is, line officers. The actual fighting of the battle was the duty of these troops and officers. In turn, these troops and officers were assisted by staff officers and other units that provided logistical support, supplies, and information. The idea carried over as formal bureaucratic organizational theory developed in the 1800s.

The Relationship of Line and Staff Authority

The term staff also connotes a certain kind of authority relationship. Again, the original usage of the term was derived from the military, in which the staff assistant pattern was developed as a means of relieving commanders of details that could be handled by others. The staff officer was an “assistant to” the commander, and this assistant’s authority was an extension of line authority.

Line authority is based on a direct chain of command from the top level of authority through each successive level of the organization. A manager with line authority has direct authority and responsibility for the work of a unit; the line manager alone has the right to command others to act. A staff assistant provides advice, counsel, or technical support that may be accepted, altered, or rejected by the line officer.

Functional authority is the right of individuals to exercise a limited form of authority over the specialized functions for which they are responsible, regardless of who exercises line authority over the employees performing the activities. For example, the information services staff is responsible for developing and implementing a specific computerized data collection system. The unit manager has functional authority over processing input documents, although these documents may be originated and completed by workers in other units, such as the admission office, business office, nursing service, or health information management. A human resources officer may be charged with monitoring organizational compliance with affirmative action programs or labor union contracts; the advice of such an officer cannot be rejected or altered arbitrarily by a line officer.

A manager may hold a staff position. Such an individual may be the designated officer in charge of a support department, such as the legal or human resources department. Yet this manager may also have charge of one or several workers within the unit and would exercise line authority within that unit. Organization charts, job descriptions, and similar documents should contain clear statements as to the nature of each position: whether it is a line or staff position, what kind of authority it possesses, and what its area of responsibility includes.

Line and Staff Interaction

Various types of staff arrangements may be developed to channel line and staff interaction. As noted earlier, one basic mode of interaction is to designate a staff member as the personal assistant to an individual holding office in the upper levels of the organization. This position should not be confused with that of an assistant department head or assistant manager, who generally shares in direct line authority. Managers in the upper levels of the organization may have several assistants, each carrying out highly specialized tasks. When there is only one position of assistant, this individual’s work may be general, varied, and determined by the needs of the superior officer. The style of interaction may be highly personal, as when the staff assistant is seen as an alter ego of the line officer. When such a staff member indicates a point of view, a desired action, or a preferred decision, other members of the organization recognize that this individual is reflecting the opinion and wishes of the line officer.

A full department that gives specialized assistance and support frequently has a general staff. The relationship between staff and line personnel is less intimate than the assistant relationship. The work tends to be technical and highly specialized (e.g., the work of logistical staff in the military).

A third aspect of line and staff relationship is the organizational arrangement of the specialized staff. Specialized staff members (or departments in a large institution) give highly specialized counsel, such as that provided by engineers, architects, accountants, lawyers, and auditors. Finally, as noted, departments can be arranged in terms of direct line entities, assisted by support or service units.

The Contractual Management Team

There is a growing practice of using a contractual management team in place of the direct-hire chief executive and/or chief operating officer and some key department manager positions (e.g., director of nursing). The board of trustees hires, on contract, an outside individual or team to take over, for some period, the executive functions in the organization. The board has directly given this individual or team authority to make necessary changes and maintain regular operations. The reasons for using an outside group include necessary restructuring due to downsizing or mergers, need for turnaround measures, and preparation for a merger or for disinvesting by the original sponsoring organization. These expert outsiders identify and implement necessary changes, absorb any hostility from workers and clients, and deal with overcoming the resulting demoralization. They may be in residence for several months or years, depending on the reasons for using them. More than consultants who merely make recommendations, these individuals are empowered to implement.

THE DUAL PYRAMID FORM OF ORGANIZATION IN HEALTH CARE

Healthcare institutions are characterized by a dual pyramid form of organization because of the traditional relationship of the medical staff to the administrative staff. The ultimate authority and responsibility for the management of the institution is vested in the governing board. In accordance with the stipulations of licensure and accrediting agencies, the board appoints a chief executive officer and a chief of medical staff, resulting in two lines of authority. The chief executive officer is responsible for effectively managing the administrative components of the institution and delegates authority to each department head in the administrative component. Within the administrative units, there is a typical pyramidal organization with a unified chain of command.

Physicians and dentists are organized under a specific set of bylaws for the governance of the medical and dental staff. With governing board approval, the chief of the medical staff appoints the chief of each clinical service. Physicians and dentists apply for clinical privileges through the medical staff credentials process and receive appointment from the governing board. A second pyramid results from this organization of the medical staff into clinical services, with each having a chief of service who reports to the chief of the medical staff.

In an effort to consolidate authority and clarify responsibility, the top administrative levels of a healthcare organization may be expanded to include a central officer to whom both the administrator and the chief of the medical staff report. In some institutions, however, there may be no permanent medical staff position that corresponds to the position of chief executive officer on the organizational chart. The elected president of the medical staff may fill this role when there is no organizational slot for a medical director per se.

It is important to determine the precise meaning of titles as they are used in a specific healthcare setting. The following titles are commonly used:

• Chief of staff. This is the officer of the medical staff to whom the chiefs of medical and clinical services report. The chief of staff is appointed by the governing board.

• Chief of service. Each chief of service is the physician–director of a specific clinical service (e.g., chief of surgery) and is the line officer for physicians who are appointed to that specific service.

• Department chairperson. The chairperson of a department is the director of a specific clinical service in an academic institution, such as a teaching hospital. (This title may be used as an alternative to “chief of service” in this type of setting.)

• Medical director. This is a position in a line authority structure. It is sometimes seen as the counterpart of the chief executive officer for the medical staff.

• President of the medical staff. The president is the presiding officer for the medical staff and is usually elected for a year. In the absence of a full-time medical director, this individual serves as coordinating officer for the medical staff.

Although all authority flows from the governing board, there are two distinct chains of command—one in the administrative structure and one in the medical sector. Furthermore, in matters of direct patient care, the attending physician exercises professional authority; thus, a single employee not only may be subject to more than one line of authority but also may have professional authority. Line officers in the administrative unit may find that their authority is limited in some areas because of the specific jurisdiction of medical staff committees, such as the pharmacy and therapeutics committees. The director of the physical therapy department, for example, may report to a committee of physicians of the active medical staff, which limits the authority mandate of this line manager. Because of the dual pyramid structure, much coordination is needed.

BASIC DEPARTMENTATION

The development of departments is a natural adjunct to the specialization and division of labor that are characteristic of formal organizations. Departmentation overcomes the limitation imposed by the span of management. The organization, through its departments and similar subdivisions, can expand almost indefinitely in size. Departmentation facilitates the coordination process, as there is a logical grouping of closely related activities.

Basic departmentation may be developed according to any one of several patterns:

1. By function. Because it is logical, efficient, and natural, the most widely used form of departmentation groups all related activities or jobs together. This permits managers to take advantage of specialization and to concern themselves with only one major focus of activity. Hospital departments are usually developed according to function (e.g., the finance office and the health information management, human resources, environmental services, maintenance, and dietary departments).

2. By product. All activities needed in the development, production, and marketing of a product may be grouped for purposes of coordination and control. This pattern of departmentation is used in business and industry where one or a few closely related products are grouped. It facilitates the use of research funds, the use of specialized skills and knowledge, and the development of cost control data for each product line. Functional departmentation may be an adjunct of product departmentation.

3. By territory. In business, the marketing process may be developed according to geographical boundaries. In service organizations, a decentralized pattern based on customer or client groupings may be appropriate. In some healthcare organizations, territorial departmentation is used because funding stipulations designate specific catchment areas or require coverage of certain population centers. Local needs, such as participation of clients and prompt settlement of difficulties, may be accommodated more easily through departmentation by territory. Grouping by geographical territory is a common element in outreach programs and home care services, because it fosters efficient movement of personnel to client locations.

4. By customer. Departmentation may be based on client needs. Specialty clinics in health care tend to follow this pattern. Government programs frequently focus on a specific client need, partly in response to the lobbying of interest groups. Specific examples of customer departmentation include special maternal and infant care programs, the Veterans Administration, and programs for migrant workers. A university may have components such as day, evening, and weekend divisions, as well as continuing education programs, to accommodate the needs and interests of differing student populations.

5. By time. Activities may be grouped according to the time of day they are performed. This pattern, which is usually based on the use of shifts, is common in manufacturing and similar organizations in which the activities of a relatively large group of semiskilled or technical workers are repetitive and continue around the clock. Organizations that provide essential services throughout the day and night use this pattern, usually in conjunction with functional departmentation.

6. By process. Technological considerations and specialized equipment usage may lead to departmentation by process. This is similar to functional departmentation in that all the activities involving one major process or some set of specialized equipment are grouped. In healthcare organizations, the formation of radiology and clinical laboratory departments is an example of departmentation by process as well as by function.

7. By number. Departmentation may be accomplished by assigning certain duties to undifferentiated workers under specific supervision. This form of departmentation is used when many workers are needed to carry out an activity. Its use is relatively limited in modern organizations, but it was traditional in early societies, such as tribes, clans, and armies. Organizing by sheer number may be used in such activities as house-to-house soliciting campaigns and membership drives. Unskilled labor crews may be organized in this pattern.

Orphan Activities

Certain activities may not merit grouping into separate departments, and there may be no compelling reason to place them in any specific location in the organization. Yet these orphan activities must be coordinated and interlocked with all others. The “most use” criterion is followed to resolve the question of organizational placement. The major department that most often uses or needs the service absorbs it. Other units that need the service obtain it from the major department to which it has been assigned.

Patient transportation in a hospital involves such a set of activities. These services are used by the physical therapy, occupational therapy, and radiology departments, among others, but overall coordination is assigned to the inpatient nursing units because one central placement is needed for these groups of workers. As another example, in small nursing homes one worker often performs several activities on a limited basis, such as general maintenance activities, running errands, and transporting patients to appointments with private physicians. The individual with these responsibilities may report to a central manager, such as the director of nursing, because the director or a delegate is present on all shifts. This arrangement provides coordination and control of the activities.

Deadly Parallel Arrangements

In an alternative organizational pattern, the higher levels of management establish dual organizational units for the purposes of control or competition. As a control device, the parallel arrangement permits comparison of costs, productivity, and similar parameters. Competition may be enhanced, if this is desired as a means of motivation, because productivity and performance can be compared.

SPECIFIC SCHEDULING

The determination of specific coverage of key functions through specific scheduling, usually by shift, is an essential aspect of organizing.  Exhibit 6–1  provides an example of the development of coverage based on workflow. A mix of full-time and part-time workers and overlapping shifts at times of high volume demand in the workflow are essential considerations in developing this particular plan, which reflects the needs of a large group practice with a hard copy record system in use while it gradually implements an electronic health record system.

EXHIBIT 6–1 Specific Scheduling by Shift: Health Information Services

Planning Premises

1. Clinic days and hours

Monday through Friday 8:00 A.M. to 7:00 P.M.

Scheduled appointments and walk-ins

Saturday and Sunday 8:00 A.M. to 4:00 P.M.

Primarily walk-ins; occasional scheduled appointments

2. Tasks and deadlines (based on operational goals for department)

Pull and deliver charts for appointments for chart availability 1 hour before clinic opening.

Pull and deliver charts for walk-ins within 15 minutes of call for chart.

Refile charts within 2 hours of return by clinic (pick up and return of charts scheduled every 2 hours).

File late and continuing care reports within 2 hours of receipt.

3. Special task

Search for charts unavailable or not found on first attempt. Perform this task at 8:00 A.M., 12:00 P.M., and 2:00 P.M. weekdays.

4. Full-time equivalents (FTEs) needed

Eight (to be full-time employees)

5. Number of floaters needed to provide vacation, holiday, and sick-time coverage Two FTEs, to consist of four part-time positions assigned as needed based on vacation, holiday, and sick-time experience.

Monday Through Friday

7:00 A.M. to 3:00 P.M. Shift: Two FTEs

Search for charts missing or not found on initial attempt.

Pull and deliver charts for walk-ins throughout shift.

Pick up and return charts to file, 2-hour rotation.

Pull charts for next day’s clinic appointments.

9:00 A.M. to 5:00 P.M. Shift: Two FTEs

Pick up and return charts to file, 2-hour rotation.

Pull charts for next day’s clinic appointments.

Process late and continuing care reports.

Search for charts missing or not found on initial attempt (for late afternoon and early evening clinic appointments).

Pull and deliver charts for walk-ins 3:00 P.M. to 5:00 P.M.

3:00 P.M. to 11:00 P.M. Shift: Two FTEs

Pull and deliver charts for evening clinic walk-ins.

Pick up and return charts to file, 2-hour rotation.

Process late and continuing care reports.

Carry out quality control audit of files.

Saturday and Sunday

8:00 A.M. to 4:00 P.M. Shift: One FTE per day

Pull and deliver charts for walk-ins.

Pick up and return charts to file, 2-hour rotation.

Process late and continuing care reports.

Carry out quality control audit of files.

FLEXIBILITY IN ORGANIZATIONAL STRUCTURE

Managers, in their role as change agents, continually seek ways to respond to change in the external and internal organizational environment. It may be necessary to adjust traditional organizational patterns because of advances in modern technology, increases in workers’ technical and professional training, the need to offset employee alienation, and the need to overcome the problems inherent in decentralized, widely dispersed units. In addition, managers must take into account certain characteristics of today’s workforce: the two-wage earner family, the single parent, and the worker who is also caretaker of an elderly family member. These workers need a modicum of flexibility such as that provided in flexible hours, telecommuting, and similar alternatives to on-site work.

In general, functional departmentation has been predominant, and there has been a strong emphasis on unity of command. When technical advice or assistance was needed, staff roles were developed to assist the line managers. When intraorganizational communication and cooperation among several units were needed, the committee structure was used. Three alternative temporary or permanent organizational patterns allow managers to retain the benefits of these traditional practices and to reduce some of their disadvantages: (1) the matrix approach, (2) temporary departmentation, and (3) the task force. These approaches may supplement the traditional organizational structure or, in the case of the matrix approach, supplant it.

Matrix Organization

Matrix organization, a design that involves both functional and product departmentation, is used predominantly to provide a flexible and adaptable organizational structure for specific projects in, for example, research, engineering, or product development. This pattern is also called grid or latticework organization and project or product management. The matrix of organizational relationships involves a chief for the technical aspects, an administrative officer for the managerial aspects, and a project coordinator as the final authority. This dual authority structure is a predominant characteristic of the matrix organization and stands in distinct contrast to the unity of command in the traditional organizational pattern.

Workers are essentially borrowed from functional units and temporarily assigned to the project unit. Rather than designating line and staff interactions, the developers of the matrix pattern seek to create a web of relationships among technical and managerial workers. Multiple reporting systems are developed and communication lines are interwoven throughout the matrix.

Participants in the matrix organizational pattern tend to be highly trained, self-motivated individuals with a relatively independent mode of working. These functional personnel are grouped together according to the needs dictated by the phase of the project that has been undertaken. In the matrix arrangement, workers receive direction from the technical or the administrative chief as appropriate, but it is assumed that they have the ability to develop the necessary communication and work patterns without specific direction in every aspect. The project coordinator has the traditional responsibilities of guiding the technical and administrative groups and of developing the basic channels of communication and lines of coordination; however, there may be none of the detailed stipulations that are commonly associated with the highly bureaucratic traditional organizational pattern. In the healthcare organization, a matrix organization frees nurses, physical therapists, occupational therapists, and other direct patient care professionals from some of the relatively rigid elements of formal organization.

Temporary Departmentation

The temporary department or unit reflects a management decision to create an organizational division with a predetermined lifetime to meet some temporary need. This lifetime may be imposed by an inherent, self-limiting element, such as funding through a defense contract or private research grant. Although the predominant organizational structure may be modified periodically, there is an implicit assumption that the basic unit will remain substantially unchanged for the life of the organization. The use of the term “temporary” may be somewhat misleading; temporary departmentation usually reflects an organizational pattern that will exist for more than a few months, as an activity limited to only a few months’ duration would be placed under the category of special project or task force rather than temporary departmentation. The temporary department may exist for several years (i.e., for the life of a research grant), although there is no set rule.

The development of a new product (i.e., the calculation of comparative cost data, product development, and marketing) may be placed under a temporary department assigned to carry out the necessary research development and marketing within a specific period. A team of workers with the necessary specialized knowledge may be assembled under the jurisdiction of the temporary department, deadlines set, necessary accounting processes developed, and related functions delineated.

In businesses and institutions with defense contracts or research grants, temporary departmentation provides the necessary organizational structure without interfering with the establishment’s normal efforts. Equipment is purchased and workers hired with special funds designated for that purpose. These workers are not necessarily subject to the same pay scale, fringe benefits, union contracts, and similar regulations as are regular employees. The manager must make it clear to these workers that their jobs are temporary, limited to the life of the contract or grant. There should also be a clear understanding about worker movement into the main organizational unit: is this employee eligible for such movement with or without having accrued seniority and similar benefits? Patients who receive full or partial subsidy for their care in a healthcare institution under a special research grant or project should be informed about the limited scope of the project, and their options for continuity of care about the life of the project should be explained.

Temporary Agency Services

Staffing flexibility may also be achieved or enhanced through the use of temporary help from agencies that specialize in supplying trained personnel to cover short-term needs. “Short-term” in this sense is ordinarily construed as a period not exceeding 6 months. The employees engaged under an arrangement with a temporary help agency are employees of the agency, not the utilizing organization.

There are several advantages to the use of agency “temps.” The organization is spared the effort and expense of recruiting, hiring, training, and separating employees who will be in the workforce for perhaps only a few weeks. Also, in many instances, these temporary employees come trained in the basics of the job and require only specific departmental orientation. Although the organization pays something of a premium in that the rate for a temp includes the person’s pay and benefits and the agency’s profit, the temp alternative is often more economical than paying overtime premium to regular staff to cover the need. There are in health care, however, some marked exceptions to this claim of economy in health care. Professional staff such as registered nurses, physical therapists, and a number of others are always more costly as temporaries than regular staff. Presently the reasons for engaging professional temps have little or nothing to do with “short-term needs”; the key reasons for today’s use of professional temps are the shortage of adequate staff and the attendant difficulties experienced in recruiting critically needed personnel.

It should be stressed that temporary help arrangements need to be limited to a period of less than 6 months. Federal law requires that anyone working for an organization for a period exceeding 6 months must be considered an employee for purposes of earning credit toward retirement. Some nonhealthcare organizations’ past practices—often involving laying off employees and hiring them back as “temporaries” at lower rates of pay and with fewer benefits and the inability to accrue retirement credit—were seen as a deliberate strategy to avoid certain costs.

In any event, a temporary engagement that has extended beyond the 6-month guideline should be examined closely for alternative ways of meeting the need. The key criterion for the appropriate use of temporary staff is the short-term nature of the need. In the healthcare setting especially, the prolonged use of temps to meet a continuing need is never as economical as engaging permanent staff.

Outsourcing

Outsourcing is the process of having certain services that could be provided internally performed by agencies or individuals external to the organization. Outsourcing has been an actively used alternative in manufacturing industries for many years. It is common in manufacturing for a company to rely on external suppliers to provide it with various components made to the company’s specifications. In fact, what we now know as outsourcing probably began in manufacturing in the manner just described, although the label “outsourcing” is considerably newer than the activity itself.

Many of the decisions favoring outsourcing are made for economic reasons. Quite simply, if a service can be obtained externally for less than the cost of providing it internally, outsourcing may be considered a preferred alternative (providing, of course, that the external source meets all of the organization’s quality requirements).

Often the economic decision favoring outsourcing is driven by volume considerations. Should there not be enough of a particular activity required to justify hiring and staffing to perform it (e.g., some specialized task requiring just a few hours each week), outsourcing may be the logical alternative.

Outsourcing decisions may also hinge on the presence or absence of particular skills or capabilities. For example, a large healthcare organization may have its own in-house legal counsel, whereas a smaller organization will outsource all of its legal work to an external law firm. Or perhaps a group practice that is having difficulty keeping up with medical transcription because of position vacancies or abnormally high volume of dictation will farm out some of its transcription work to an external service.

In recent years, outsourcing has become a “hot-button” issue with many Americans. More and more activities have been farmed out not just to suppliers external to an organization but to suppliers outside the country. Some businesses have taken this approach in an effort to reduce their operating costs or improve their competitive positions; in tough economic times, some have seen outsourcing as enhancing their chances of survival. Regardless of why outsourcing is undertaken, however, it frequently leads to the loss of jobs. Foreign outsourcing invariably means lower costs for various products and services and fewer jobs in the domestic economy.

Nevertheless, for the modern healthcare organization, outsourcing has its legitimate uses. Outsourcing is often essential for acquiring services that cannot be provided on an in-house basis, and it is sometimes the most economical means of addressing a temporary need.

Contracted Services

The general heading of outsourcing includes the use of contract management services and the use of independent contractors. Under contract management, the entirety of a particular service associated with the organization is managed by or perhaps provided in full by an external organization that specializes in that service. Probably the two most common hospital and nursing home services provided under contract management are food service and housekeeping, although in one setting or another essentially every conceivable service has been contracted out by some healthcare organizations. Contract management may involve management alone or the complete provision of the service. At one particular hospital, for example, an external firm supplies the management of food service while the rank-and-file food service workers remain hospital employees; at the same hospital, housekeeping is provided by an external firm using its own staff with no involvement of hospital employees.

The use of so-called independent contractors has received considerable government attention over the past couple of decades. Generally, to qualify under Internal Revenue Service (IRS) guidelines as an independent contractor and thus be paid as a supplier rather than as an employee, a worker is required to demonstrate a level of independence not commonly found in an employer–employee relationship, as evidenced by the following principal factors:

• The worker personally invests in facilities and equipment that are used in performing the services.

• The worker can expect to either make a profit or experience a loss from the activity (other than because of simple nonpayment for services provided).

• The worker provides services for two or more unrelated clients or customers within the same period of time.

• The worker makes services available to any or all potential clients or customers on a regular and consistent basis.

It is the presence of the foregoing conditions that the IRS will look for in assessing the nature of the relationship in which an external service is provided. Using an independent medical transcriptionist as an example, if Ms. Jones acquired her own equipment and offers transcription services to a number of organizations including Hospital A, chances are she will be considered an independent contractor. If, however, Ms. Jones is performing transcription for Hospital A only and working in her home using equipment largely or completely provided by Hospital A, she will be considered an employee of Hospital A. And as an employee Ms. Jones must be on the payroll of Hospital A with all that such a status implies (various personnel expenses for the hospital, and withholding taxes and such for Ms. Jones).

The use of independent contractors may generate cost savings because of the elimination of personnel expenses associated with training, physical space requirements, unemployment compensation, and other aspects of direct employment. However, the healthcare organization department that makes use of independent contractors must have consistently applied guidelines governing such working relationships.  Exhibit 6–2  provides a set of sample guidelines for contract specifications for independent contractors using, for illustrative purposes, guidelines applied in arrangements with an outsourced dictation–transcription service.

elecommuting

If our hypothetical Ms. Jones of the foregoing example does all or most of her work at home, serving only Hospital A and using some Hospital A’s hardware and software, she may be considered a telecommuting employee.

EXHIBIT 6–2 Guidelines for the Use of Contractual Services

Contracts with incorporated contractual services should be approved by the Human Resources Division and should include the following elements as a minimum:

• HIPAA-compliant confidentiality and security measures

• Accept dictation from land-line phone systems, PC microphones, handheld digital recorders

• Document distribution by secure line fax, secure e-mail, remote print

• Electronic editing and signature

• Tracking system for each document, from beginning of recording through document received

• Customized format

• Ninety-nine percent error-free guarantee

• STAT capability

• Access to listen or view transcriptions 24/7 (365 days/year)

• 24/7 support center (365 days/year)

• Turnaround time of (n) hours

• Conform with nationally accepted billing method principles

Telecommuting is an employment arrangement in which a person who is on the organization’s payroll works an agreed-on or perhaps regularly scheduled amount of time each week at home or some other external location with the support of the appropriate equipment and services. As a flexible workstyle option, telecommuting is a significant step beyond what is often called “flextime.” A telecommuter works in a setting other than the traditional office or shop and is supervised by means other than management provided by an immediately present supervisor.

Whether they work full-time or part-time, telecommuters are regular employees on the payroll of the organization. They are decidedly not independent contractors or freelancers who are paid per piece or per job and excluded from employee benefits, and they do not conform to the criteria by which the IRS defines independent contractors.

Telecommuting is never appropriate for employees whose primary duties involve direct interaction with clients or customers, and it is inappropriate for people who work on team undertakings that require regular employee interaction. And even if a particular job’s duties would seem to lend themselves to telecommuting, such an arrangement should never be considered for employees who have yet to prove themselves as reliable self-starters.

Telecommuting cannot be a hit-or-miss proposition. It requires a consistent policy delineating the rules for its use, specifying:

• Where the telecommuter can work: whether just at home or at other sites as well

• Work status: whether full-time or part-time

• When one can work: whether the employee sets the hours, the organization sets the hours, or the employee is allowed to flex around required “core” hours

• Technology required: whether what is needed is determined by the telecommuter or designated by the business

• Work space: compliant with the Health Insurance Portability and Accountability Act (HIPAA), with security of confidential data

In developing a telecommuting policy, it is best to secure the input of not only affected managers but also some of the likely telecommuters. The telecommuting policy should require that any such arrangement be described by specific objectives, detailed results expected, and methods for measuring accomplishments.

For certain kinds of activities, telecommuting has been practiced for years. For example, traditional telecommuting arrangements have included data entry, customer billing, and medical transcription. However, possibilities for telecommuting include most jobs that are performed independent of other people and those that do not require high-cost specialized equipment. Many jobs can lend themselves to telecommuting as long as the arrangement can satisfactorily serve the needs of all concerned.

The individual in a telecommuting situation stands to benefit from reduced travel time and fewer transportation concerns, comfort of work environment and dress, freedom from interruptions, possibly flexible hours, and in some instances relief from child care concerns. Some professional and technical employees find that on telecommuting days they are more available for telephone consultation than when they are in a busy office environment. The organization frequently gains productive efficiency and is often able to reduce expenses and save energy and in general reduce the strain on facilities and services. In fact, some organizations have adopted telecommuting as a means of avoiding the addition of more space. Telecommuting can also aid in recruiting and retaining employees.

Telecommuting is not likely to succeed with the occasional employee who is unable to cope well with isolation from coworkers and the absence of traditional supervision. And the manager who is constantly—or, at the other extreme, never—checking up on the unseen employee will not do well with telecommuting employees. Managers inexperienced with telecommuting often fear they will not be able to monitor employee activities sufficiently, perhaps feeling they cannot effectively manage people who are not under their full-time direct supervision. Thus the manager of telecommuters must necessarily manage by results, using goals, objectives, and quotas.

Before going forward with any telecommuting arrangement:

• Check with counterparts at other organizations of comparable size and complexity about their experiences with telecommuting.

• Be certain the desired arrangement is consistent with the organization’s personnel and business systems (e.g., time reporting, payroll).

• If unionized employees are potentially involved, sound out the union concerning its stand on telecommuting and bring union officials into the process early.

Needless to say, a great many employees would likely jump at the opportunity to work at home. However, telecommuting should never be adopted simply because some employees want to do it. Telecommuting should be seriously considered only if doing so would seem to make good business sense.

THE ORGANIZATIONAL CHART

The management tool used for depicting organizational relationships is the organizational chart. It is a diagrammatic form, a visual arrangement that depicts the following aspects of an institution:

1. Major functions, usually by department

2. Relationships of functions or departments

3. Channels of supervision

4. Lines of authority and of communication

5. Positions (by job title) within departments or units

There are numerous reasons for using organizational charts:

• An organizational chart maps major lines of decision making and authority, so managers can review it to identify any inconsistencies and complexities in the organizational structure. The diagrammatic representation makes it easier to determine and correct these inconsistencies and complexities.

• An organizational chart may be used to orient employees, because it shows where each job fits in relation to supervisors and to other jobs in the department. It shows the relationship of the department to the organization as a whole.

• The chart is a useful tool in managerial audits. Managers can review such factors as the span of management, mixed lines of authority, and splintered authority; they can also check that individual job titles are on the chart so it is clear to whom each employee reports. In addition, managers can compare current practice with the original plan of job assignments to determine if any discrepancies exist.

Certain limitations are inherent in the rather static structure presented by organizational charts, and these limitations can offset some of the advantages of using the charts:

• Only formal lines of authority and communication are shown; important lines of informal communication and significant informal relationships cannot be shown.

• The chart may become obsolete if not updated at least once a year (or whenever there is a major change in the organizational pattern).

• Individuals without proper training in interpretation may confuse authority relationship with status. Managers whose positions are placed physically higher in the graphic representation may be perceived as having authority over those whose positions are lower on the chart. The emphasis must be placed on the direct authority relationships and the chain of command.

• The chart cannot be properly interpreted without reference to support information, such as that usually contained in the organizational manual and related job descriptions.

Types of Charts

There are two major kinds of organizational charts: master and supplementary. The master chart depicts the entire organization, although not in great detail, and normally shows all departments and major positions of authority. A detailed listing of formal positions or job titles is not given in the master chart, however. Each supplementary chart depicts a section, department, or unit, including the specific details of its organizational pattern. An organization has as many supplementary charts as it has departments or unit

The supplementary chart of a department usually reflects the master chart and shows the direct chain of command from highest authority to that derived by the department head. The master chart usually shows the major functions, whereas the supplementary chart depicts each individual job title and the number of positions in each section, as well as full-time or part-time status. Additional information, such as cost centers, major codes, or similar identifying information, sometimes appears on the charts.

General Arrangements and Conventions

The conventional organizational chart is a line or scalar chart showing each layer of the organization in sequence ( Figure 6–4 ). In another arrangement, the flow of authority may be depicted from left to right, starting with major officials on the extreme left and with each successive division to the right of the preceding unit. The advantage of this form stems from its similarity to normal reading patterns. A circular arrangement, in which the authority flows from the center outward, is sometimes used; its advantage is that it shows the authority flow reaching out and permeating all levels, not just flowing from top to bottom.

FIGURE 6–4 Organizational Chart of a Hospital

FIGURE 6–5 Special Relationships: Consultant in Advisory Role

Certain general conventions are followed when an organizational chart is drawn. Ordinarily, line authority and line relationships are indicated by solid lines, and staff positions are indicated by broken or dotted lines. In  Figure 6-5 , the position of health information consultant has a staff relationship to the administrator, which is, accordingly, shown by a broken line. Sometimes the staff relationship is indicated by a small “s” with a slash mark setting it off from the job title.

Occasionally, a special relationship is indicated by surrounding an entire unit or even another organization with broken lines and leaving it unconnected to any line or staff unit. Such a unit is included in the organizational chart to call attention to the existence of a related, auxiliary, or affiliated organization. This technique is used in  Figure 6–4  to indicate the relationship of the teaching institutions affiliated with the hospital

Preparing the Organizational Chart

If the chart is prepared during a planning or reorganization stage, the first step is to list all the major functions and the jobs associated with them. The major groupings by function then are brought together as specific units—for example, all jobs dealing with health information services or with patient identification systems, all jobs dealing with physical medicine and rehabilitation, or all jobs dealing with information processing and computer activities. If there is a question about the proper placement of one or several functions, managers can derive significant information by asking the following questions:

• If there is a problem, who must be involved to effect a solution?

• Do the supervisors at each level have the necessary authority to carry out their functions?

• If a change in systems and procedures is needed, who must agree to the changes?

• If critical information must be channeled through the organization, who is responsible for its transmission throughout each unit of the organization?

As an aid in developing the organizational chart, it is useful to prepare a simple tabulation showing the following information:

1. Job title

2. Reporting line: supervised by whom (title)

3. Full-time or part-time

4. Day, evening, or night shift

5. Line or staff position

The inclusion of the incumbent’s name is optional for this worksheet preparation, although names may be useful in a subsequent managerial audit of the department in which the manager is comparing present practice with the original plan. The use of names as the basic means of developing the chart could be misleading, however, as it may block managers’ thinking, causing them to describe organizational relationships as they are rather than as they should be. It may be best to show names only on a staffing chart that is prepared after the organizational chart has been developed.

After obtaining the necessary information about work relationships, shifts, supervisory needs, and span of management factors, managers develop the final chart, using the general conventions for depicting organizational relationships. A support narrative or a section of the organization’s manual can be developed to give additional information.

THE JOB DESCRIPTION

The duties associated with each job should be determined by the needs of the department. Frequently, jobs evolve as duties are assigned to an employee. These jobs are accumulations of tasks rather than products of prior planning. Some form of control is necessary to keep assignments within intended limits. To provide this control of the various work assignments, the duties and responsibilities of each job should be set forth in written form. This helps ensure that employees’ concepts of their duties will be consistent with those of the manager and with the needs of the department.

In every formal organization, there are job descriptions/position profiles to cover all jobs. To fill the various positions with the appropriate employees, it is necessary to match the jobs available in the department with the individuals. This can be done only with the help of job descriptions, which are written objective statements defining duties and functions. Each job description includes responsibilities, experience, organizational relationships, working conditions, and other essential factors of the position.

If a specific position is part of the continuity of operations plan, or if team participation is an essential component of the position, these expectations should be clearly stated.

Job Analysis

Preceding the development of a job description, there should be a thorough job analysis that serves as a single source for the various uses to be made of information concerning a specific job. In addition to providing all of the information necessary for the development of the job description, the job analysis serves a variety of other uses, including performing a job evaluation (establishing an appropriate pay grade for the job), developing recruiting specifications, conducting employee orientation and education, and planning for staffing requirements. Reminder: not every element will apply to every job; the job analysis pattern is, however, applied to every job so that comparison and classification of jobs is possible. Typical content includes the following:

• Job responsibilities: details of work, frequency of action (e.g., routine, periodic, emergency), any other distinguishing features (e.g., on-call duties) (note percentage of time spent on each duty)

• Level of supervision: working under direct supervision or independently, with only periodic review of work by second-level supervisor or department manager

• Supervisory responsibilities: providing direct supervision (indicate job titles and numbers of employees supervised); providing direct training and supervision of students on affiliation rotation (indicate if duties include employee evaluation, discipline, and/or hire-or-fire decisions as well as if duties include orienting, training, coaching, scheduling, developing, counseling, and measuring performance of [n] employees)

• Consequences of errors:

○ Are errors easily detected and remedied?

○ Are errors difficult to detect, with long-range consequences?

○ Is the work performed independently?

○ Could a serious error occur in direct patient care?

• Confidential data: having limited access or full access to patient records, financial information, or review committee proceedings (e.g., infection control reports, safety reviews, audits, credentialing reviews, employee evaluations, labor contract background information)

• Mental and physical demands and effort: having various physical abilities, such as (1) lifting and supporting patients (n pounds) and (2) lifting and pushing equipment (n pounds; indicate type of equipment); ability to walk and stand throughout the work day, to tolerate prolonged sitting throughout the work day, to maintain calm demeanor when faced with agitated or demanding clients, and to drive an automobile; having visual and aural acuity

• Environment/working conditions: routine office environment; indoors; no major exposure to noise, infections, or hazards (identify these [e.g., exposure to infections, high noise levels, outdoor work in extreme weather conditions]); telecommuting option; travel requirements; shift work (permanent or rotating); site rotation (regular or occasional)

• Preparation and training: entry level requirements only (e.g., high school diploma or equivalent), advanced training (e.g., master’s degree in a specific field of study), certification as specialist in a specific area, graduation from an approved/accredited training or educational program, computer skills, language and degree of fluency in specific language

A specific advantage of the use of a job analysis is that a single job analysis can sometimes serve as a template for a family of jobs. Consider, for example, a job analysis of perhaps six pages in length for “registered nurse (RN).” This thorough job analysis would be written to be descriptive of all RN positions in the organization, with all duties or groupings of duties described in general terms. Related to this master job analysis, there may be any number of one- or two-page job descriptions addressing the specific variations of RN, such as RN, Emergency Department; RN, Medical/Surgical; RN, Operating Room; and so on.

At one time or another, all of the information gathered via a thorough job analysis will be relevant to some important application information it contains in a concise manner.

Job Description Content and Format

The format of a job description should present the information in an orderly manner. Because there is no standard format, job descriptions vary with the type of facility and with the size and scope of the department. The following format, along with some sample wording, is suggested as a guide:

• Job title. The job should be identified by a title that clarifies the position. The inclusion in the job title of such words as “director,” “supervisor,” “senior,” “staff,” or “clerk” can help to indicate the duties and skill level of the job. Examples of job titles that indicate such specificity are Physical Therapist—Vestibular and Balance Program Coordinator, and Health Information—Coding and Reimbursement Clinical Specialist; Certified Documentation Improvement Practitioner; and Voice Recognition Editor.

• Immediate supervisor. The position and title of the immediate supervisor should be clearly identified. This information reflects the organization chart. For managerial positions, include information about succession plan responsibility.

• Job summary. A short statement of the major activities of the job should indicate the purpose and scope of the job in specific terms. This section serves principally to identify the job and differentiate the duties that are performed from those of other jobs. Sample wording might be:

This is a clerical position in the health information service of an acute care facility affiliated with a medical school and a research institution. This full-time, day-shift position is under the direct supervision of the Assistant Health Information Administrator. The work is performed with relative independence and any exceptions to policy should be referred to the unit supervisor.

• Job duties. The major part of the job description should state what the employee does and how the duties are accomplished. The description of duties should also indicate the degree of supervision received or given.

• Job specifications. A written record of minimum hiring requirements for a particular job comes from the job analysis procedure. The items covered in the specifications may be divided into two groups:

1. The skill requirements include mental and manual skills, plus personal traits and qualities, needed to perform the job effectively:

○ Minimum educational requirements

○ Licensure or registration requirements

○ Experience expressed in objective and quantitative terms, such as years

○ Specific knowledge requirements or advanced educational requirements

○ Manual skills required in terms of the quality, quantity, or nature of the work to be performed

○ Communication skills, both oral and written

2. The physical demands of a job may include the following:

○ Physical effort required to perform the job and the length of time involved in performing a given activity

○ Working conditions and general physical environment in which the job is to be performed

○ Job hazards and their probability of occurrence

The date of latest revision is provided at the end of the description.

Exhibit 6–3  is a sample job description. Human resources manuals and professional association publications are excellent sources of job description content and wording.

EXHIBIT 6–3 Excerpts from a Typical Job Description: Clerical Position

Job Summary

This is a clerical position in the health information service of an acute care facility affiliated with a medical school and a research institution. This full-time, day-shift position is under the direct supervision of the Assistant Health Information Administrator. The work is performed with relative independence and any exceptions to policy should be referred to the unit supervisor.

Job Duties

1. Receives visitors to the department, processes their requests by routing them to appropriate supervisors, assists requestor as needed, and schedules appointments

2. Processes reports from dictated media and/or from rough draft and transcribes according to prescribed format

Job Specifications

1. Fluency in English language, both oral and written expression

2. Ability to create final copy, from both dictation and handwritten copy, error-free minimum of 70 words per minute

3. Minimum of high school diploma or its equivalent and at least 1 year of secretarial experience or successful completion of postsecondary secretarial school

Note flexibility in requirement 3; this fosters a nondiscriminatory approach to hiring, giving flexibility to the manner in which an individual may qualify for the position.

In some institutions, job specifications are organized as a separate record because the information is not used for the same purpose as the information contained in the job description. The specifications receive the most usage in connection with the recruitment and selection of employees, as this part of the job description defines the qualifications that are needed to perform the job. Job evaluations and the establishment of different wage and salary schedules are other functions that depend on the data contained in the job specifications.

Job Rating and Classification

Before employees are selected and hired, the organization develops a job classification. This classification is based on the results of the job rating process. In job rating, each set of functions within each unit of the organization is analyzed using some set of common denominators. In health care, these variables include complexity of duties; error impact; contacts with patients, families, and other individuals both within and outside of the organization; degree of supervision received; and nature of duties, ranging from unskilled to highly technical and professional. Mental and physical demands as well as working conditions may also be assessed because these variables may make a job different from seemingly similar positions in the organization.

When developing a job description, it is useful to compare the draft of the description with the job rating scale specific to the organization. From this “dry run,” changes in actual wording may result so that the final expression of job duties and related conditions matches the categories or factors to be assessed. Without such correlation between the job rating scale and the job description’s wording, inequities could be fostered. Similar jobs could receive different ratings based on a lack of proper wording in a particular job description.

Ideally, the overall job rating process contains safeguards against discrepancies; ideally, the human resources manager makes such job rating information available to unit managers. It is still the duty and prerogative of line managers to take active steps in these matters and anticipate the job rating process.

In addition to the overall job classification, the wage and salary and fringe benefit package may be predicated on information gained in the job description or job rating process. Another key to success in developing useful job descriptions is to assess the written document for its adequacy in conveying information about the factors used in job rating and wage and salary considerations.

Two additional outcomes of the job classification that concern the manager are the determinations made for exempt and nonexempt positions under the Fair Labor Standards Act (FLSA) and the applicability of a union contract in terms of jobs included in a particular bargaining union. In both of these cases, information about supervisory activity is critical. Thus, there is another benchmark against which to measure the adequacy of the job description. Does it contain sufficient information to justify inclusion—or exclusion—of a job in terms of overtime pay and related FLSA provisions? Is the nature of the job clearly delineated in terms of rating as skilled or unskilled, technical or professional, for purposes of union contract applicability?

Recruitment

Certain steps in the recruitment process involve information derived from the job description. Internal job posting may involve the placement of the complete job description in a specified location, such as on an employee bulletin board. Potential transfer employees essentially participate in a self-selection or rejection process as they read this job description. They can take the opportunity to assess such practical aspects of a job as shift work or weekend coverage requirements in terms of their availability to work such hours.

The physical, mental, or technical demands of the job also may sway the potential transfer employee to reconsider applying for a position. Then, too, the job description may have the effect of encouraging applicants. Does the job description contain enough information to help prospective employees make such a preliminary determination?

Those involved in the preliminary selection interviews, usually members of the human resources department, need sufficient information about all the jobs in the institution to carry out initial screening. The unit managers must convey, through the job description, key points of information about duties, responsibilities, and qualifications. It is important to note that the unit manager is the individual most familiar with the work of the unit. This information must be conveyed in a way that it can be understood by persons who are not involved in the unit or department on a daily basis.

Awareness of the wide audience who will use the job descriptions will help the manager write them in understandable form. The unit manager may find it useful to try out the wording of a job description on another manager. Does the wording convey enough information for this person, familiar with the healthcare setting but not necessarily familiar with the details of the specific department, to form a basic idea of the job?

The Final Selection Process

A major use of the job description occurs during the selection process as the candidate is matched to the job. During the selection interview, information about the duties, responsibilities, and qualifications is conveyed. One sensitive overlay to the selection process, which includes all aspects of the interview, testing, and physical examination, is strict avoidance of discriminatory practices, even inadvertent discrimination.

When the job, as summarized in the job description, is the focus of the interview, it is easier to avoid the pitfalls of interviewing that could suggest discriminatory practices. Thus, with a job description that spells out such expectations as weekend coverage, shift work availability, and similar requirements, the manager and prospective employee can deal with that set of expectations without the manager probing in any way into such questions as days of religious observance, arrangements for child care, and other topics that are off-limits for direct inquiry. The emphasis is on the job as it is described.

Job qualifications and mental, physical, and technical demands become the objective measures of candidate suitability when they are derived from job duties. These in turn foster a positive climate of compliance with nondiscriminatory practices.

For example, if the job duties include frequent routine interaction with patients in need of emergency care and the patient population involved is non-English speaking, a qualification of fluency in a specific language is not discriminatory. If the unit manager can tie each qualification to one or more job duties, the likelihood of discriminatory practices in the employment selection process is diminished. Sometimes it may seem that one is stating the obvious, such as ability to read, write, speak English (or some other language) with ease, hear, see, and lift—so why spell these out? These elements are specified in detail when they are true requirements. The purpose of the job description, with its explicit requirements, is to provide all parties with necessary information about the job so that there is no misunderstanding later.

Another method to use in making a dry run of the job description that helps the manager determine the level of detail needed under the foregoing conditions is working with human resources management using a sample of applications that have been received over some period of time. How does the manager’s job description hold up? On what basis would the manager hire, or not hire, a particular individual in light of the job description as it is written?

Employee Development and Retention

At each point of employee development, activities focus on the work to be done within each job. Orientation and training programs take on greater meaning as they are tailored to specific job duties and qualifications. Training outcomes can be stated in terms of the trainee’s ability to perform the duties. This is another step toward objective evaluation of candidates.

Job descriptions also provide a focus for performance evaluations. Has the worker accomplished the duties and responsibilities made known in the job description? Error correction, retraining, and, if necessary, disciplinary action are carried out in the context of the job for which the individual was hired. In cases of grievance, emphasis is given to the worker’s accomplishment of the job duties, with the presumption that these have been made known to the worker. A comprehensive, up-to-date job description is a valuable management document in such cases.

Finally, in cases of illness or injury under review by workers’ compensation groups or agencies such as the Occupational Safety and Health Administration (OSHA), the basic determination of job relatedness is made using the job description.

Following is a summary of uses of the job description. How would the manager’s current descriptions hold up when scrutinized in relation to each of these applications?

Summary of Uses of the Job Description

The job description does the following:

• Fosters or contributes to overall compliance with legal, regulatory, contractual, and accrediting mandates

• Serves as a basis for job rating, job classification, and wage and salary administration

• Serves as a basis for determining exemption or inclusion under provisions of the FLSA and collective bargaining agreements

• Provides information to prospective employees and to employer representatives during the recruitment and selection process

• Serves as a basis for orientation and training programs at the time of initial selection, transfer, or promotion

• Serves as a basis for performance evaluation, error correction, retraining requirements, and grievance determinations

• Provides information to determine eligibility for claims under workers’ compensation groups, OSHA, and similar programs

Jobs, like the organizational structure of a hospital, are dynamic in nature. Changes in the size and nature of the organization, the introduction of new equipment, or the employment of new treatment techniques—to mention only a few factors—have a definite influence on the duties and requirements of jobs. Thus, the manager and the employees of a department must review the description of each job on a periodic, regular schedule (at least once a year). The document should be dated when it is first prepared, redated when it is reviewed, and again redated when it is revised. An up-to-date accurate job description is essential when the human resources department recruits applicants for a job or when the manager hires new employees, appraises the performance of existing employees, and attempts to establish an equitable wage and salary pattern within the department.

THE MANAGEMENT INVENTORY

Part of planning and organizing involves the assessment of current and projected staffing needs. One tool for gathering such information is the management inventory, a simple, factual listing of each specific job; name of the incumbent; and any relevant notation. Notation would include such known factors as: (1) an employee who has given 3-month notice of intent to retire; a summer intern leaves in late August; an employee who has requested and has been granted family leave time starting on September 1, with a planned return date of December 15; and an employee who has provided manager with military reserve duty dates, including a 2-week span in mid-July. Managers also include training level accomplished or needed, cross-training indications, changes upcoming because of system change, and phasing out of certain functions. The management inventory is, of course, a highly confidential document used for planning purposes. It is compiled from information given to the manager; managers may not inquire into personal matters that might infer age or sex discrimination.

THE CREDENTIALED PRACTITIONER AS CONSULTANT

Because the contemporary healthcare organization is frequently involved in new patterns of organization, the credentialed practitioner is sometimes called on to be an external consultant or independent contractor. Consultants offer advice and counsel and carry out professional activities within the scope of their competence and licensure. Consultative arrangements generally fall into three categories:

• One-time-only arrangements wherein the consultant carries out an in-depth assessment of current practices or assists in development of a major project. For example, an occupational therapist might assist the management team of a long-term care facility with its plan to open an adult day care service. The occupational therapist would typically identify and describe the range of activities for the occupational therapy unit’s services; calculate and determine the pattern of staffing needs for the unit; and identify equipment and space needs, along with layout considerations.

• Initial survey with implementation. In this instance the consultant and the healthcare organization’s representatives agree that the professional practitioner will remain under contract to implement the initial findings. Using the example given previously, the occupational therapist would be given the mandate to contact vendors; compare vendor bids; and, with the organization’s approval, select the equipment and oversee its placement.

• Ongoing maintenance of project or program. In this arrangement, the professional practitioner agrees to provide continuous service over some specific, and usually prolonged, period of time. For example, a physical therapist is hired to upgrade the in-service training program at an industrial health clinic. Having developed an overall training plan, based on the facility’s needs, the physical therapist commits to a plan to provide the in-service training on a regular basis—for example, one day per month for the upcoming year.

THE INDEPENDENT CONTRACTOR

When the professional practitioner is hired to provide regular, ongoing services for a protracted period of time (as in the third example in the previous section), the relationship of the practitioner to the contracting organization may fall into the category of independent contractor. Both parties to such an arrangement need to review pertinent federal and state laws and regulations regarding independent contractor status. Particular attention should be given to the Internal Revenue Code’s definitions of independent contractors. Regulations set forth in HIPAA contain specific provisions concerning privacy and confidentiality requirements for business partners and independent contractors. Professional liability insurance provisions, workers’ compensation laws, collective bargaining agreements, and similar labor-related mandates need review as to their applicability to the particular arrangements.

GUIDELINES FOR CONTRACTS AND REPORTS

Whether fulfilling the role of consultant or independent contractor, the professional practitioner works under written contract and provides formal reports to the administrative coordinators of the facility. Following are guidelines for the content of contracts and reports.

The Contract

The professional practitioner, working with a properly qualified attorney, would develop a contract specific to the given situation. The contract typically includes at least the elements of a clear statement of parties to the contract, the period covered, services to be provided, fees and payment schedule, ownership of materials, privacy and confidentiality of patient and business information, and provisions for termination of the contract. An attorney would provide the appropriate level of detail and additional provisions necessary for a sound agreement.  Appendix 6–A  is a detailed excerpt from a contract between a health information specialist who provides ongoing services to a long-term care facility.

The Written Report

The consultant provides the administrative coordinators with periodic written reports, formal and detailed in their content. Following are guidelines for such reports:

1. Consultant reports are formal business records and, as such, must be retained by both the consultant and the organization for the required retention period for such business records. See the specific state laws and federal tax laws governing the retention period.

2. Consultant reports are subject to inspection and review by licensing and accrediting agencies and by third-party payment auditors. The report, therefore, should be complete, formal, and accurate.

3. Keep the report focused on compliance with required licensure, accreditation, and professional practice standards. Include both positive and negative findings. A useful practice, and one that also motivates the recipients to continue to strive for excellence, is to list the positive findings first, followed by the heading “Areas Needing Improvement.”

4. Provide specific recommendations for each topical area needing improvement. For example, suggest the content of an in-service training program on the topic or provide sample forms or procedures.

5. Prioritize the findings in order of importance. To prioritize findings:

○ Priority Class One: Address any practice that has potential for direct harm to the patient. An example in health information documentation would be contradictory physician orders concerning medications. This finding would be reported orally to the nursing staff as soon as it is identified by the consultant. The written report, as follow-up, would contain the formal recommendation for corrective practices, with the notation that an oral report was made to the nursing staff in a timely manner.

○ Priority Class Two: Address any practice for which the facility received a citation in the last external survey or auditor review, with particular attention to the practices for which a plan of correction was filed with state or federal agencies. Also, address any practice having repeat citations over the past several years, even if the current survey showed full compliance for the immediate year.

○ Priority Class Three: Address any practice that is out of compliance with:

♦ State licensure requirements. For example, mention record retention practices that do not meet the state’s required retention period.

♦ Federal conditions of Medicare. For example, cite any failure to update the patient plan of care according to the required time frames.

♦ HIPAA regulations. For example, note any failure regarding the disclosure of patient information without appropriate consent.

♦ Accrediting standards (if the facility participates in an accreditation program). For example, address the failure to document interdisciplinary progress notes according to suggested standards.

♦ Generally accepted principles of professional practice. For example, mention failure to put complete patient identification on each page of the hard copy record or on each data entry for an electronic record.

Appendix 6–B provides an example of a cover letter, a formal report with priority indications, and a project timetable.

EXERCISE: CREATING ORGANIZATIONAL CHARTS

For a work organization and a specific department or function with which you are familiar, create two organizational charts—a master chart for the organization overall and a supplementary chart depicting the structure and arrangement of the specific department or function. (If you have no familiarity with an actual work organization, invent an organization and department in chart form using the chapter’s material for guidance.) Use these charts to answer the following questions:

1. Is the organization more appropriately described as centralized or decentralized? Why?

2. Which management position appears to have the broadest span of control in terms of number of direct reporting employees? Why?

3. What is the longest single departmental chain of command in the organization, and how many levels does it consist of?

4. Assuming that dramatic losses of business activity have necessitated reorganizing, revise the original master chart for the organization overall to “flatten” the organization by at least one level in two principal chains of command.

EXERCISE: DEVELOPING A JOB DESCRIPTION

Select a healthcare profession or occupation and write a job description for it. It will be most helpful to use an occupation in which you have worked or for which you are preparing. Following completion of the job description, prepare a condensed description of that job in less than one-half page that could be used for recruiting purposes.

Appendix 6–A

Sample Contract for a Health Information Consultant

Note: The following example is not intended as legal advice. The professional practitioner who plans to enter into consultant activity should consult an attorney for the development of a contract appropriate to the specific situation.

CONSULTANT AGREEMENT FOR HEALTH INFORMATION SERVICES

Parties to the Agreement: The parties to this agreement are Emma Dean, MS, RHIA, Consultant (referred to as Consultant), and The Gabriels Continuing Care Center (referred to as Gabriels Center), Anywhere, Anystate. As a licensed continuing care facility in this state, Gabriels Center is governed by the applicable state and federal laws and regulations.

Effective Date: February 1, 2017. This agreement continues in effect until one of the parties chooses to terminate it by providing a written notice to that effect 1 month prior to the termination date.

Independent Contractor: Consultant’s status is that of an independent contractor. Consultant is not an employee or agent of Gabriels Center. Consultant is not a participant in any benefits program, labor contract agreement, or any other program offered by this facility. Consultant is not a designated officer in the continuity of operations or succession plan of the facility.

Professional Competence: Consultant agrees to provide formal, written evidence of professional competence as defined by the national credentialing body for health information practice. This documentation shall be provided at the inception of this contract and on an annual basis (on the anniversary date of this contract) thereafter.

Scope of Service: Consultant’s activities are limited to the skilled care, assisted living, and personal care components of Gabriels Center as currently configured.

Terms of Payment: The fee for services is ($_____) per quarter. A 5% increase shall be made at the beginning of each new year of the contractual relationship if this contract remains in effect. This increase shall be effective on the anniversary date of the initial contract. Consultant, as an independent contractor, is responsible for Social Security contributions and any applicable withholding tax or contribution as required by federal, state, and local taxing authorities. Consultant will present a written bill for services rendered for each quarter. This bill must be filed within five working days of the conclusion of the quarter. A quarterly written report must be filed at the same time. Gabriels Center agrees to pay Consultant within five working days of the receipt of the quarterly bill and report. This is the whole and entire reimbursement.

Confidentiality: Consultant agrees to keep confidential any and all information about Gabriels Center’s operations and practices and to follow HIPAA-compliant practices. Reports shall be filed with the designated official contact of the center.

Ownership of Materials: Consultant agrees to develop materials such as, but not limited to, policies, procedures, forms, job descriptions, and training programs for use by Gabriels Center in its skilled and assisted living components. These materials become the property of Gabriels Center. Gabriels Center agrees to limit their use solely to these levels of care as currently configured. Gabriels Center agrees not to sell or distribute the materials to any other component or entity. Gabriels Center agrees to obtain Consultant’s permission to use the materials in any other manner. The consultant retains the right to use the same or similar materials without facility identification.

Responsibilities: Consultant will review the health information services and the healthcare documentation practices of the skilled care, assisted living, and personal care components of Gabriels Center.

Consultant will make at least quarterly site visits and remain available by telephone and/or electronic messaging.

The specific duties are listed in the attached Key Activities of the Health Information Consultant. Consultant will make formal, oral reports to the chief executive officer or designate at the conclusion of each quarter at a mutually agreed-on time and date. A formal, written report shall be filed within five working days of the conclusion of the quarter. One interim written report per quarter shall be made at a mutually agreed-on date.

Entire Agreement: This is the full and entire agreement as stated in these terms and signed by both parties on the date listed below. This agreement may be amended in writing with both parties signing and dating the acceptance of the changes.

Chief Executive Officer	Emma Dean, MS, RHIA
The Gabriels Continuing Care Center	Health Information Consultant
Date: February 1, 2017	Date: February 1, 2017

KEY ACTIVITIES OF HEALTH INFORMATION CONSULTANT (ADDENDUM TO FEBRUARY 1, 2017, CONTRACT)

Consultant shall oversee the health information system (HIS) and documentation practices for the skilled and assisted living and personal care components as follows:

1. Identify applicable federal and state laws and regulations and generally accepted principles of health information practice. Assess the degree of compliance with these regulations and recommend improved practices associated with areas needing upgrading. Assist the management team in preparing for periodic federal and state reviews and related plan of correction development.

2. Monitor proposed changes in applicable federal and state laws and regulations; monitor trends in health information practices and provide the management team with this information.

3. Prepare and periodically update the following documents:

○ Policy and procedure manuals

○ Forms design for hard copy and electronic data capture

4. Analyze and review each component of the health information system and the documentation practices of the facility:

○ Patient identification

○ Creation and maintenance of official health record

○ Data entry and dictation–transcription/voice recognition editing

○ Record retention, storage, and retrieval

○ Coding and reimbursement support

○ Support data and studies for patient care reviews, quality improvement studies, and management use

○ Release of information

5. Participate in staff development and in-service training:

○ Annual presentation of documentation standards to professional staff

○ Training program for new HIS employees

○ Annual training program for each HIS employee

6. Assist management in the development of:

○ Staffing pattern

○ Job descriptions

○ Space allocation and equipment acquisition

○ Budget preparation

7. Participate in the patient care review committee and the emergency preparedness committee:

○ Recommend items for consideration

○ Provide support materials for items under consideration

○ Attend regularly scheduled meetings

End of listing of key activities as of February 1, 2017.

6–B

Sample Cover Letter and Report

Background information for this fictitious setting:

1. State-licensed as a continuing care facility; last licensure survey was December 20, 2016

2. Privately owned and sponsored by a nonprofit corporation

3. Medicare certified under applicable provisions

4. Fiscal year: July through June

5. Components:

○ Independent Living: 100 units; average length of stay: 8 years

♦ Eighty percent of residents move to the assisted-living or skilled unit when one of these levels of care is needed

○ Assisted Living: 50 units; average length of stay: 3 years

♦ Ninety-five percent of residents move to the skilled care unit when this level of care is needed

○ Skilled Care: 90 units; average length of stay: 1.5 years

○ Personal Care: 30 units; average length of stay: 3 years

○ Annual discharges average 45, including 25 discharges to acute care; 10 discharges from skilled care, returning to the assisted living unit; 10 deaths (natural causes)

6. Health Information Services (HIS): There is no full- or part-time credentialed practitioner. The consultant was hired on February 1, 2010, and remains under contract.

7. Expansion plans: The facility is considering the addition of an adult day care unit, a memorycare/dementia care unit, and a home care service for the independent living unit.

COVER LETTER

July 5, 2017

Bernard Downey, Chief Executive Officer

The Gabriels Continuing Care Center

253 Main Street

Anywhere, Anystate 00999

Dear Mr. Downey:

I have enclosed the written report and bill for the April–June 2017 quarter. The report reflects my findings and recommendations about the health information services (HIS) of the skilled and assisted living components of your center.

As we discussed at our June 30 meeting, I will continue the regularly scheduled duties and responsibilities as outlined in the current contractual agreement. As we agreed, we will meet on July 12 to update and expand this contract to reflect my involvement in the plans for the adult day care program, the home care project, and the development of the personal health record for the independent living unit. We also agreed to give additional efforts to the following topics:

• Review and update of all HIS job descriptions and titles

• Participation in a focused study of pattern of care and related documentation for short-term, postacute care admissions versus balance-of-life admissions

• Special review of documentation and reporting of suspected elder abuse, including involuntary seclusion in the personal care unit

• Focus on efforts to regain Five-Star Medicare rating

• Focused review of pattern of admission from, and readmission to, acute care facility for same diagnosis within (n) days

• Focused review of pattern of care for patients with advance directives who are, nevertheless, transferred to acute care

• Thorough review of record retention policy and practice, with particular attention to legacy hard copy records from the 2007 merger of three facilities, along with planned destruction of all hard copy records for which the mandatory retention period has been met

If you have any further question about these findings, please do not hesitate to contact me.

Sincerely,

Emma Dean, MS, RHIA

Health Information Consultant

Enclosures: quarterly report and bill for period ending June 30, 2017

QUARTERLY REPORT: HEALTH INFORMATION SERVICES

April 1, 2017–June 30, 2017

Report filed on July 5, 2017

Dates of Site Visits and Primary Activities

April 13: Continuing review of systems and documentation

Attended Emergency Preparedness committee; presented updated version of the portable emergency file for individual residents

May 10: Continuing review of systems and documentation

Training program for new coder

May 16: Continuing review of systems and documentation

In-service training program on documentation requirements; presented to professional staff

June 28: Attended Emergency Preparedness committee; finalized updated version of portable emergency file

June 28: Completed suggested response to Plan of Correction

Met with chief executive officer to review quarterly report and discuss additional activities regarding the Center’s expansion

Persons Interviewed During Site Visits

Chief executive officer, director of finances, director of nursing, director of social services, consultant occupational therapist, consultant physical therapist, staff activities therapist, health information staff

Key Activities

1. Licensure review preparation: assisted with preparation for annual licensure review, completed report sections relating to HIS, developed suggested Plan of Correction responses for the deficiencies noted at the December 20, 2016, site visit by state agency

2. Monitoring of proposed changes in legislation and regulation and trends: assisted in the development of an in-service training program concerning medical identity theft prevention, assisted risk management and nursing service in development of a procedure for providing photo identification for residents who are admitted to the local hospital or who receive care at the local hospital’s clinic. I reviewed compliance with the licensure agreements associated with computer software in the HIS; no breaches were identified. I proposed the development of a project for the implementation of the personal health record for the independent living unit. This project will be discussed during the next quarter; the consultant’s agreement will be amended to reflect this involvement.

3. Policy and procedure manual development: the section of release of information was updated to reflect the changes associated with the newly implemented computerized system.

4. Participation in staff development and in-service training: annual presentation to professional staff on core data/documentation requirements was given on May 16. The preliminary information on the photo identification issues was also presented at this session. On-the-job training of the HIS coder was given during the week of May 12–16.

5. Committee participation: attended meetings of Emergency Preparedness Committee on April 13 and June 8 to develop an updated version of the portable emergency file for residents

6. Review of HIS: Each component of the HIS was reviewed.

Patient identification: The comprehensive system is in place; 100% accuracy noted; each patient has full identification, documented at admission and updated at least quarterly Practice needing improvement: some frail, elderly patients have used, and continue to use, a familiar name (“nickname”) and that is the name to which they most readily respond. (Examples: Sarah Smith uses Sally as her familiar name; Jonathan Michael Lake uses Mike.) This familiar name should be added to the identification information, noting that it is the familiar and preferred name as used by the resident. The full legal name should, of course, be listed. Discussion of these issues is appropriately included at admission and in the patient care plan conference. Suggestion: confer with legal counsel and risk management to develop an appropriate policy and procedure.

Priority Class One: residents could become confused and/or agitated when they are addressed using only a formal name.

Creation and maintenance of an official health record: A formal health record was readily located for each resident. In all but two cases, there were no data entry errors within the records. In two cases, residents with the same first and last name (but different middle names and dates of birth) were mixed. The contents of these two records were promptly corrected under the supervision of the director of nursing.

Practice needing improvement: proper data entry; attention to accuracy of identification and data entry

Priority Class One: potential harm to resident

A second issue was noted: the creation of “shadow charts.” The physical therapy, occupational therapy, and social services departments have created their own full-scale health record; the content of these records duplicate some portions of the official health record, and some information in the “shadow chart” is not included in the official record.

Practice needing improvement: elimination of “shadow charts”

Priority Class Three: the applicable laws and regulations indicate that there is one official health record.

Coding and reimbursement: A 10% sample of coding was carried out, giving attention to completeness, accuracy, and timeliness. Completeness and accuracy met the required standard, but there is a delay in timely coding due to staff absence associated with illness and vacation. This affects the reimbursement process, causing delay in that system.

Practice needing improvement: timely coding through provision of alternate staff to carry out this function when regular staff is absent

Priority Class Three: reimbursement schedules require timely submission of billing information.

Storage and retrieval: During the month of May, the closed (inactive) files from 2001 to 2011 were moved to another location because of renovations to the former storage area. The new location is a temporary one—the storage shed on the upper campus. This storage area does not meet the privacy, security, and protection requirements. The records are in boxes in the same space as items for the craft and yard sale fund-raising events, there is only a padlock on the door, there is no sprinkler system, and access is not restricted. Before similar actions are taken in the future, and before remedial action is taken now, it is necessary to check with the HIS consultant to ensure compliance with laws, regulations, and best practice.

Practice needing improvement: relocation of records to secure environment; recommended removal to a commercial storage facility that meets record storage requirements or cull these records for destruction if the retention period has been satisfied.

Priority Class Three: applicable laws and regulations require secure storage.

A second issue was noted: The records from the 2016 discharges due to death were not found in the central storage and retrieval unit. These records had been inadvertently kept with the patient care review committee files. They were subsequently retrieved and placed in their proper location.

Practice needing improvement: review and enforce the procedure for the return of records after committee review.

Priority Class Three: applicable laws and regulations require secure storage.

7. Review of health information documentation: These findings are based on the results of the routine reviews done at time of admission, patient care plan conference, transfers within levels of care, and discharge. An additional 10% sampling was carried out. Overall, there is continuing improvement in documentation practices. However, the following areas need attention:

Patient care plan: The initial care plan and the first two updates are adequate; there is only limited update of the plan reflecting changes in care when a major episode occurs (e.g., bed rest or other restrictions due to a fall). Activities therapy plans are not updated to reflect the circumstances of a resident’s increased impairment due to physical or cognitive diminishment. The plan of care for final weeks of care when a patient is close to death is not fully reflective of palliative care, review of healthcare directives, and family conference.

Physical examination: Approximately 20% of residents do not have their annual physical examinations completed within the mandated time frames.

Transfer support documents: Approximately 10% of residents do not have up-to-date transfer support data entries available at the time of transfer. The average delay in providing these documents was 2 days.

In addition to the routine review of documentation, three special studies were carried out. The findings were presented to the Patient Care Review committee and were made part of the minutes of that committee:

• Restraint-free protocol compliance

• Adequacy of consent for treatment and for release of information

• Adequacy of data entries/documentation at time of transfer into the Center and at discharge to another facility

CHAPTER 11

Communication: The Glue That Binds Us Together

CHAPTER OBJECTIVES

• Provide a working definition of communication.

• Address the manager’s critical role in employee communication.

• Review the common means of communication used in the work setting.

• Provide guidelines for the proper use of electronic mail (e-mail).

• Examine the components of individual and small-group communication, including verbal (oral) and nonverbal communication.

• Enumerate the essential components of successful interpersonal communication.

• Review a number of means of fostering, enhancing, and improving interpersonal communication and overcoming barriers to individual communication.

• Provide guidelines for personal improvement in using written communication in its various forms.

• Present the fundamentals of organization communication, including both formal and informal communication.

• Differentiate between formal and informal communication in the organizational setting.

• Review the commonly encountered barriers to effective communication in the organizational setting.

A COMPLEX PROCESS

It is necessary to begin this chapter with an important disclaimer: what follows is no more than a once-over-easy treatment, an effort to hit the high spots of a topic of extreme importance to every manager—professional or otherwise. Each heading and subheading in this chapter could be the subject of an entire book in its own right and yet leave much unaddressed. We have endeavored here to provide an introduction to the basics of communication within the healthcare organization as experienced from the perspective of the individual manager.

In a relatively large healthcare organization—for example, the average hospital—decisions are frequently presented as orders or instructions, and members whose activities are affected are expected to comply with those edicts. Organizational roles may be specialized, and much communication occurs through relatively formal channels such as memos, policies, procedures, or regulations.

In a relatively small organization such as a group medical practice of fewer than 20 employees, the communications environment may be considerably different. In the small organization, work roles overlap and are likely to be far less specialized. In this setting, communication is less formal and the opportunity for the direct sharing of information is greater than in a large organization. Formal communication in the small organization may be minimal. The single factor of size can influence the quality and kinds of communication employed within an organization.

There are, however, many factors other than organization size to consider. Communication is a complex process, requiring particular skills on both individual and group levels. Also, as an individual interacts with more and more people, the overall complexity of the interactions increases. Whether considered in an individual or organizational context, communication is a far more complex process than many at first imagine. Therefore, to be optimally successful, communication requires considerably more conscious effort than most people give to it.

Communication may be described as the exchange of ideas, thoughts, or emotions between or among two or more people. It may be literally described as the transfer of meaning or, in a somewhat broader sense, the development of mutual understanding. Concerning the transfer of meaning, the intent is to take information that exists in a specific form in one person’s mind and ensure that it is duplicated in another’s mind. In the broader sense, the development of mutual understanding, the intent is for two or more people to share whatever information they have about a specific subject and arrive at an agreed-on meaning, whether that meaning is an opinion, a decision, or a course of action.

From the perspective of the individual manager, communication in the organizational setting ranges from the highly informal to the strictly formal, from on-the-run spoken remarks to structured presentations, from quick e-mail or voice mail messages to formal reports, and from one-on-one contacts to the necessity to address large groups. In other words, as experienced by the individual manager, communication in the organizational setting can occur in nearly any form or format.

COMMUNICATION AND THE INDIVIDUAL MANAGER

Many of the problems encountered in communicating with others arise because the majority of human beings take their communications capacity for granted. After all, communication is basic to all human activity. Except when asleep, most people are usually in one of four fundamental communicating modes: talking or writing (i.e., sending information out) or reading or hearing (i.e., receiving information). Note that the fourth mode is identified as hearing rather than listening, suggesting the source of a great many problems and misunderstandings—one can hear without truly listening. In any case, one who is awake is in one of the four fundamental communicating modes, with hearing being the “default” mode.

Whether in the workplace or any place, people cannot function adequately without communicating. For the individual manager, communication in any of several forms is essentially constant. Consider communication in the context of the essential management functions of planning, decision making, organizing, staffing, directing, coordinating, and controlling. Once formulated, plans mean nothing unless they are communicated; once made, decisions never see implementation unless they are communicated in some form. Likewise, to be complete, organizing, staffing, coordinating, and controlling all require communication. Also, the basic function of directing is itself largely communication. Truly, communication holds everything together.

In his or her day-to-day activities, the manager must be involved in communication in one form or another for the following reasons, among others:

• Receiving orders, instructions, and direction from above

• Delivering orders, instructions, and direction to employees

• Coaching, counseling, and disciplining employees as necessary

• Interviewing and selecting candidates for employment

• Relating to managers and employees of other departments

• Relating to patients, visitors, clients, customers, vendors, and others from outside as necessary

• Reporting to higher management on departmental activities

• Responding to questions and requests coming from any of a number of sources

Depending on the situation, the manager’s communication under the foregoing various circumstances might be spoken or written, or formal or informal. In addition, it might make use of any of several common communications practices or media, which are described (along with the significant advantages and disadvantages of each) in the following subsections.

Face-to-Face

Face-to-face interaction is potentially the strongest means of communication available to the manager. The word “potentially” is appropriate here, however, because far too many face-to-face contacts are neither efficient nor effective. Properly used, the face-to-face contact has some important characteristics going for it. A message is transmitted not only in words but also with vocal tone and facial expression and other body language. Because it occurs in the here and now, the opportunity for feedback is immediate; questions and answers can flow back and forth until understanding is achieved. Properly used, the face-to-face contact is the most effective means of fulfilling most of the communication needs that arise during the workday: it appeals to multiple senses, offers immediacy of feedback and response, and ensures the maximum likelihood of establishing mutual understanding.

The disadvantages of this method are few. Face-to-face contact is frequently more time-consuming than other means because it involves bringing the parties together physically. Because it is immediate, there is always some risk of instant disagreement. Also—and this may be a minor consideration in most instances but once in a while can become extremely important—there is no physical record resulting from the conversation unless positive steps are taken to create one.

The Telephone

As an aid to business communication, the telephone offers several advantages. A telephone call provides for immediate feedback and response; views can be exchanged, and mutual understanding can be achieved without delays between messages. A message comes through not only as words themselves but also as vocal tone and general manner of speaking. And for many purposes, the telephone is faster than most other means.

Consider, though, what is lost in using a telephone call instead of meeting face-to-face. What can often be a significant part of one’s “message”—facial expressions and other body language—are completely lacking. Because one’s body language is not always communicating the same message as the words one uses, the telephone call is generally less reliable than the face-to-face conversation. Also, unless a record is deliberately created or a call is recorded, there is no record of the transaction.

Voice Mail

Voice mail represents the telephone call with one critical omission: immediacy of feedback and response, extremely important in interpersonal communication, is absent. A clear advantage of voice mail, when it is frequently accessed, is speed of transmission; a message is quickly left in a voice mail box, and the originator moves on to other matters. (Undoubtedly some also see it as an “advantage” to speak to a voice mail system rather than a live person; when delivering bad news, criticism, or something controversial, many a caller is happy to simply “drop it and run.”) One clear advantage of voice mail is that many issues can be successfully addressed via messages and responses without the parties having to connect directly.

One disadvantage, of course, lies in having to wait for someone to respond to a message. Also, as noted, there is no immediacy of feedback and response, so voice mail is a still weaker means of communication than the telephone. Again, there is no record unless positive steps are taken to create one.

Letters and Memos

When a communication takes the form of a letter or memo, everything has been removed except the words themselves. There is no vocal tone, facial expression, or body movement; there is no immediacy of feedback and response. The words are made to carry the entire message, so to do so with reasonable accuracy the words must be well thought out. The primary advantage of a letter or memo is the creation of a record that can be read again, shared with others, and retained in a file. Also, the permanent record is often important because of legal implications.

The principal disadvantage, as already noted, is the absence of all the dimensions of an effective communication except the words themselves. Another disadvantage lies in time; it invariably takes longer to write an effective letter or memo than to use most other means. Other disadvantages include the dislike of writing shared by many in the workforce and the carelessness with which so many apply the written word.

Written communication is addressed further in a later section of this chapter.

E-mail

E-mail has probably become the most actively used means of message transmission, for messages both from person to person and from individuals or groups to other individuals or groups. In some respects, however, it is one of the weaker means of communication available. Response to an e-mail is generally faster than response to a letter or memo, but as with letters and memos, e-mail is dependent on words only. And often—although certainly not always—e-mail messages are prepared with considerably less care than their paper counterparts and are thus more susceptible to misinterpretation.

E-mail is rapid as far as message transmission is concerned, and feedback can—but does not reliably—occur quickly. There is also the availability of instant messaging, which can offer very nearly the same advantages as the telephone call except for the voice.

Other aspects of e-mail are addressed later in this discussion of communication.

Consideration of the characteristics of these several communication methods provides some guidance for structuring one’s communications according to need. That is, the means chosen for a particular communication may be governed by the following considerations:

• The time available—that is, how quickly resolution is needed

• The importance of the issue

• The complexity of the issue

• The sensitivity of the issue

• The need for negotiation or problem solving

• The need for documentation (a paper trail)

VERBAL (ORAL) COMMUNICATION

Spoken communication, which may be correctly referred to as either “oral” or “verbal” communication, is of critical importance in all aspects of health care. The understanding of the thoughts and ideas of others is essential to the delivery of quality patient care. The principal parts of a verbal exchange are the voice, the content of the message and response, and the method used to transmit the information. The voice conveys emotions; the tone used for delivery, the use of silences, the choice of words, the accents and intonation, and the speed of delivery are all factors in a verbal exchange. 1  Some of these factors (such as voice quality) are genetic, and certain others (such as speed of speech) are cultural. Health practitioners must also understand that their professional education has trained them to express ideas in a selective fashion.

The unconscious aspects of verbal communication are frequently overlooked. Conscious information is volitional because the speaker is aware of the content, direction, and reasons for the exchange. In greetings, information sharing, confrontations, and discussions, for example, the speaker can identify the reasons for the communication. However, there may be unconscious motives behind a given verbal communication, such as thoughts, aspirations, desires, anxieties, fears, or emotions that influence behavior but are hidden from the person’s conscious thoughts. A slip of the tongue is an example of an unconscious verbalization. 2

Nonverbal Communication

Nonverbal communication is included in the discussion of verbal communication because the two are inseparable parts of many interpersonal exchanges. Composed of movements, gestures, expressions, and silences, nonverbal communication may or may not be an important accompaniment to verbal communication. People may not speak, yet ideas may be exchanged. Although telephone conversations, for example, are largely dependent on the voice alone, intonation and silences frequently convey information beyond the spoken words. Two people who share a “knowing” look while waiting for a third have shared an idea without uttering a word.

Nonverbal communication can have both conscious and unconscious aspects. Conscious information is available for analysis and scrutiny. Unconscious thoughts also influence behavior, but these thoughts, feelings, or emotions are not part of the person’s awareness. Analysis of the content of thoughts is difficult because the forces are hidden.

Body language, which lies at the heart of nonverbal communication, is a series of conscious or unconscious postures that convey information to others. Many studies, both popular and scholarly, have been undertaken to explore this form of communication. Some popularized versions seem to convey the belief that gestures are universal; in reality, most gestures are culturally bound. A nod of the head may mean “yes” in one society yet mean “no” in another. Interpretations of human gestures, expressions, silences, and body movement must be rendered cautiously. It is best to check perceptions with the other person.

Communication levels can be clearly portrayed in a matrix.  Table 11–1  is based on the Johari Window, which was developed by Joseph Luft and has appeared in many group dynamics texts and courses in the past 20 years. 3

Communication Distance

E. T. Hall discussed four levels of distance that are used by humans during communication. 4  His research was based on observations and interviews with middle-class adults from the northeastern seaboard of the United States. These crude observations are merely a first attempt to develop approximate categories. The four distance zones are as follows:

1. Intimate distance (from 1 to 18 inches). Individuals are involved in lovemaking, wrestling, or comforting or protecting each other.

2. Personal distance (from 11/2 to 4 feet). Individuals can hold or grasp each other. Visual images are distorted, but they begin to normalize as the person moves to arm’s length.

3. Social distance (from 4 to 12 feet). Individuals are less intimate. Voice level is normal, and conversations can be overheard. Impersonal business is conducted at this distance, but the interaction becomes more formal as the persons involved move toward the 12-foot distance.

4. Public distance (from 12 to beyond 25 feet). Voice volume is increased, and details about the person are not noticed. Verbalization is formal.

Components of Communication

Communication includes four principal components: initiation, transmission, reception, and feedback. For communication to occur, there must be a sender, someone who begins the interaction. Initiation, which includes the preparation for the interaction, might begin on a nonverbal level and move to a verbal exchange. Transmission is the movement of the communication from one party to another; it depends on verbal and nonverbal sharing methods. Reception is the manner in which the message is received. The receiver’s perception shapes the way in which a message is decoded and acted on. To ensure that the sender and the receiver are truly sharing ideas, the receiver offers feedback, which is a verbal or nonverbal signal that acknowledges the message. Acknowledgments include modification, suppression, or nonacceptance of the information.

Interpersonal communication depends on assumptions, perceptions, feelings, past experiences, and present surroundings. Although people frequently talk, communication may prove taxing and difficult. People must transcend personal and cultural barriers that obstruct their understanding of an exchange.

Methods of Improving Communication

Communication is improved by observing, attending, responding to requests, and checking information. Each of these strategies depends on an objective analysis of an exchange.

Observation is the activity of perceiving events, objects, and people. Skilled observers are objective and can separate their own inner world from outside reality. Accurate observation is dependent on self-knowledge, because inner reality can make someone “see” an event that did not occur. An event can be “real” in the mind of the person who really wants to “see” it.

Attending helps people hear or see events as they are. During a conversation, instead of planning their next remark, those who are attending direct their energy toward listening or empathizing with the other person. Attending is also referred to as active listening.

Responding is the behavior an individual selects to address the needs or requests of the other person. The behavior may be verbal or nonverbal, and the quality of the response shapes the remainder of the communication. If a person asks for the time and receives a pleasant answer, that person may decide to continue the exchange. In contrast, unpleasant replies may inhibit further communication.

Active listening can also help an individual decode less obvious requests. Sometimes a sender makes an indirect request, which may be symbolic or may indicate unconscious desires. A perceptive listener should try to “hear” the request and bring the buried topic into the conversation. For example, Allie asked Mary for her pathology notes. Mary responded by saying that she would be glad to duplicate the notes, and she began to rummage in her purse. Allie handed Mary a tissue. Mary seemed grateful and quickly wiped her nose. Allie then handed Mary some money to cover the cost of duplicating the notes. A less perceptive listener may have mistaken Mary’s action as a hint for payment or as a rejection of the request. In reality, Mary’s nose was running, and she was distracted for a minute while she attended to it.

Communication is also improved by checking information. Listeners can check information by matching their perceptions of a situation with the sender’s intention. In the preceding example, Allie could have asked Mary if she needed a tissue. Listeners can examine the validity of their perceptions by paraphrasing the sender’s message and asking for feedback.

People must be aware of symbols that may be archetypal, cultural, or idiosyncratic. 5  A symbol can be almost anything that is used to represent something else. Archetypal symbols are shared by humans and extend back in history; for example, a circle means unity throughout the world. Cultural symbols are specific to a subgroup (e.g., a thumb extended upward means a victory or a good job). Idiosyncratic symbols are specific to an individual or small group. Symbolic meanings contribute to the variety and breadth of communication by forcing listeners to move beyond their personal understanding of gestures, body movements, expressions, and silences.

Personal Tools to Foster Communication

There are six personal tools to be applied in promoting interpersonal communication:

1. Authenticity: the ability to be true to one’s own feelings

2. Acceptance of feelings (based on authenticity): the acceptance of feelings of others by people who accept their own feelings

3. Disclosure: the ability to share feelings, both positive and negative, with others (honest people are able to share information openly)

4. Empathy: the ability to project one’s own personality onto another person (this promotes understanding)

5. Caring: the desire to help others on an individual and collective level 6

6. Humor: the ability to identify situations as ludicrous, comic, or happy 7

All six tools require the integration of personal needs with goals and actions.

Communication Barriers

Communication can be blocked by internal or external forces. Internal forces, including both conscious and unconscious thoughts, may preclude listening, sharing, and caring so that the meaning of the exchange is confused and misinterpreted. Conscious behaviors that limit communication include facial expressions that are perceived as negative or inappropriate (e.g., smiling when reprimanding a subordinate), body postures that are perceived as rejecting or critical of the person (e.g., folding one’s arms over one’s chest although expressing a desire to share ideas), verbalizations that interrupt the flow of the exchange (e.g., saying “Terrific!” or “Great!” every time a speaker pauses), and interruption or disruption of the speaker’s thoughts (e.g., changing topics abruptly, such as interrupting a request for assistance with a comment about football scores).

External forces may also impede communication. Distractions, such as noise, motion, and confusion, may compromise the quality of an exchange. The context for a communication may either add to or subtract from the interaction. For example, a crowded room with flashing lights and loud music is designed for sensory stimulation, not verbal communication. In this environment, intimate conversations are taxed and labored; communication is limited to nonverbal cueing.

Speaking to Groups

Much of a department manager’s verbal communication—surely an overwhelming majority for most first-line managers—involves one-on-one, face-to-face interchanges with individuals or with collectives of perhaps two or three people at most. There are, however, regularly occurring needs for the manager to address larger groups, such as an entire department or perhaps the organization’s management group. Speaking before groups is unavoidable, yet some managers who do very well in face-to-face situations experience considerable problems with addressing groups. This is unfortunate because public-speaking ability is extremely important to the career-minded manager who wishes to advance in an organization.

The following story suggests the value of a manager’s capacity for public speaking. To afford all managers with some development opportunity, the administrator of a small community hospital established the practice of rotating the chairmanship of the monthly meeting of the facility’s 24 or 25 managers. Given a broad outline, each manager would develop a specific agenda and chair the meeting, making the month’s announcements and calling on other participants as needed. It was believed that experience with speaking and with leading meetings could be acquired as painlessly as possible in this friendly, familiar setting in which everyone knew one another.

On the day when the supervisor of the hospital’s small business office was to chair the meeting, she called in sick. Having missed her turn, she was assigned the next month’s meeting; that time she scheduled a day off for personal business. When spoken with privately by the administrator, she admitted her intense fear of public speaking. When asked how she conducted department meetings, she pointed out that with just three employees other than herself a department meeting was more like four friends getting together. She declared she could not possibly address a group as large as the management team. Over the following few weeks she resisted all of the administrator’s efforts to get her some assistance in overcoming her fear. She claimed that the mere thought of speaking to a group made her physically ill.

Shortly thereafter, the hospital’s board of directors voted in favor of a merger with another, slightly larger, community hospital. Most department managers from the two facilities were put in the position of having to compete for the resulting single position for each combined department. The process involved having each pair of managers prepare proposals describing how they would administer the combined department; each proposal was to be presented orally before the administrators and senior managers of both facilities, a group of five or six in total.

As one might expect at this point in the story, the supervisor who feared speaking was not chosen to head the combined department. She did everything possible to duck the appearance, and, when essentially trapped into it, delivered a brief, stammering start before excusing herself, pleading illness.

The person who was chosen as the department head was actually her equal in education and qualifications and had less experience. Yet the fearful speaker accepted a staff position in the combined department in the knowledge that she would probably never return to management.

At the very least, every group supervisor and department manager will have to conduct meetings of his or her own staff. In most organizations, it is also likely that from time to time one will also have to present a proposal or deliver an oral report to a management team or perhaps even to an administrative group or board of directors. Any person who dodges assignments that involve speaking had best appreciate that doing so is decidedly a career-limiting practice.

It should not be news for many readers to learn that fear of public speaking is both common and widespread; it is one of the most frequently encountered fears in the population at large. However, it may be news to most to learn that the majority of individuals who regularly, capably, and comfortably speak before groups of people once struggled with this same fear. To be sure, some natural speakers may be encountered now and then—fortunate individuals who never had reservations about addressing many people at one time. But these natural speakers are a minority. Most people who regularly speak in public had to overcome a certain amount of apprehension about doing so.

To offer an all-encompassing shortcut to a subject that rates an entire book by itself, the keys to success in public speaking are preparation, practice, and repetition. Preparation should always go without saying; there are not a great many speakers who can go in cold and simply “wing it,” especially on an important topic. Preparation—knowing what one will say and how it will be said—helps moderate the uneasiness felt by the new speaker. Practice simply makes sense, at least for the inexperienced speaker; it also helps quell the new speaker’s apprehensions. The most significant key, however, is repetition. For most people, the more public speaking you do, the better you become at it; also, the more speaking you do, the less fearful you become about speaking. Getting started requires preparation and practice, and getting better and becoming less fearful and more confident require preparation and repetition.

The Meeting

Meetings, particularly those of smaller groups, are where most managers acquire their early experience in both speaking to groups and leading discussions. For convenience, we can consider the department manager’s meetings as being of two kinds: staff meetings and general meetings (all others). Staff meetings are those the manager convenes with his or her own employees. General meetings include problem-solving meetings or meetings held for various other purposes with people from a variety of departments or activities.

The Staff Meeting

The manager has considerable flexibility in determining how and when staff meetings are scheduled, how they are conducted, and what is covered at them. Some managers find it advisable to bring the staff together on a weekly basis; some do so monthly and occasionally even less frequently. Staff meetings may take different forms: Sometimes it is necessary for the manager to carry most of the meeting for providing information and updates, sometimes it is appropriate to have each staff member report on his or her recent activities, and sometimes one or two staff members will provide most of the meeting’s substance. Regardless of frequency or form, however, some fundamentals should be observed:

• Employees should expect staff meetings to occur on some regular, planned frequency (except for the occasional emergency meeting).

• Staff meetings should occur; there should be only a few special circumstances under which a meeting is skipped or canceled. (For activities in certain professional areas, regular meetings—and minutes thereof—are a requirement of regulatory and accreditation bodies.)

• Staff should be advised that meetings will start on time, that starting will not be delayed for the sake of latecomers, and that information will not be repeated for latecomers.

• Meeting length should be limited, holding to specific starting and quitting times. Ending early is fine if all pertinent business has been transacted, but ending late should occur only under exceptional circumstances and then as seldom as possible.

• The meeting leader—assuming that this person is the department manager—should not dominate the meeting but rather make every effort to secure employee participation.

• If decisions are made or specific subsequent actions are required, they should be committed to writing.

The General Meeting

Every manager should expect to become involved in specially scheduled meetings held for a variety of purposes—information sharing, exploratory discussion, problem solving, and so on—as both meeting convener and participant. Specific guidelines for calling and holding such meetings are as follows:

• Define the issue or problem and determine whether a meeting is truly required. Depending on the number of people who must be involved, the required timing, and other means of communication available, it might be possible to avoid a meeting. The most efficient meeting is the meeting that never takes place.

• Determine a goal for the meeting, deciding what must be accomplished. It is necessary to be able to identify what one desires from the meeting—the solution to a problem, a group decision, the group’s acceptance of an idea, or whatever.

• Select the participants, taking care to include the people who have the necessary knowledge of the topic and those who have the authority to commit to a solution, if this is necessary.

• Give participants sufficient advance notice—no last-minute surprises that create conflicts—and distribute needed materials, if any, along with the initial notice (it is highly inefficient to wait until meeting time to provide handout material pertinent to the meeting).

• Make certain a proper meeting area is secured well in advance of the meeting; it can be highly frustrating to have a bunch of people ready to meet with no place to gather.

• Prepare an agenda. It need not be elaborate; a brief list of points to cover will usually suffice.

• Start the meeting on time and reiterate its purpose. Describe up front what you wish to accomplish and by what time you expect to end the meeting.

• As meeting leader, do not lecture or otherwise dominate the meeting. Encourage participation by all; stimulate discussion.

• Do not let any particular participants monopolize or dominate the meeting; likewise, if possible do not allow anyone to remain silent the entire time.

• End with a decision, a plan, a schedule of subsequent activity, or whatever concrete results come of the meeting.

• Arrange for the production of meeting minutes, if necessary, or otherwise ensure that significant results are documented.

• If a follow-up meeting is necessary, if at all possible get it scheduled before the participants leave. If it cannot be scheduled then, schedule it as soon as practical.

WRITTEN COMMUNICATION

The Importance of Written Communication

Written communication is essential to the conduct of business in any organization. Some ways of doing business require that letters and memoranda pass between individuals and organizations, and in spite of advances in electronic record storage there remain many needs for filed hard copy. Also, written copy of various kinds must be produced and maintained for purposes of satisfying legal, regulatory, and accreditation requirements.

Many people who work in the delivery of health care can attest to the volume of writing required of them. Complaints about “paperwork” are common and widespread, and there is undoubtedly much more paper generated than is truly needed. Nevertheless, much of the written material that is produced is inescapable; hard copy documents of various kinds will remain in existence for the foreseeable future.

Just as many professionals and managers resist speaking in public, so do many frequently resist writing. Thus, many professionals and managers who resist writing chores do not write especially well. It could perhaps be argued forever whether some dislike writing because they are not especially good at it or whether they are not especially adept at writing because they dislike it. This problem is often compounded by widespread dislike of writing because it seems to consume more time than many wish to devote to it. The resulting resistance to writing is such that any number of professionals and managers will write a letter or memo only when absolutely necessary and even then will react to the pressures of time and write something once through and send it on its way.

The biggest problem concerning writing in business is not that it takes too much time but rather that it is allowed to consume too little time. Writing well requires more time and effort than simply dashing something off to get it sent and out of the way. Writing well requires editing and rewriting—admittedly time-consuming activities but activities that will usually pay for themselves in improved understanding and fewer problems of misinterpretation. Anyone who regularly communicates in writing should heed the words of Blaise Pascal: “I have made this letter rather long because I have not had time to make it shorter.”

E-mail: Helpful, but the Source of Many Problems

Email has become today’s most misused and abused business technology. It carries a high volume of nonbusiness material, and it tends to carry business information in a generally careless fashion that frequently does more to raise questions than convey information.

Appropriate use of e-mail requires attention to the handling of both that which is received and that which is sent.

In addressing incoming e-mail, heed these guidelines:

• First be attentive to deleting rather than reading. In most instances, a quick look at the subject line along with one’s knowledge of the sender will indicate whether a message should be read in full or discarded at once.

• Become familiar with frequent senders and know what they are likely to be sending. There has never been, and there will never be, a beneficial technology that does not have a downside: the downside of the personal computer is its appeal to some users as more of a toy than a tool. Learn where many of the important messages come from and who is likely to be sending junk.

• Similar to the age-old advice about handling each incoming piece of paper only once, try dealing with each e-mail message once and only once. On reading a message, reply to it, forward it, delete it, or store it in an electronic folder. Messages should not be allowed to accumulate; they fill up the inbox and increase the chances of importance messages getting lost in the clutter.

In sending an e-mail message, follow these guidelines:

• Use a clear, understandable subject line that tells the addressee in a few words what to expect of the communication.

• Write, edit, and rewrite each message as though it were an important letter or memo (more on this to follow).

• Inform employees of the proper business use of e-mail and train them in proper handling of incoming mail. Consider reminding employees that e-mail is not as private as they might believe; messages are regularly misdirected accidentally, and it is easy for some computer users to tap into others’ e-mail. It helps to imagine that any particular message could conceivably become as public as a bulletin-board notice. Your e-mail messages are never truly private; most organizations must archive all e-mails transmitted on company equipment or servers.

Concerning the seemingly prevalent “casual” (or, less euphemistically, “sloppy”) use of e-mail, it often seems that e-mail brings out the worst in many writers of business communications. E-mail is such a readily available and easily usable means of interpersonal communication that it is easy to overlook its relatively severe shortcomings. When speaking with someone in a face-to-face interchange, in addition to words, one has the benefit of facial expression, vocal tone, and immediacy of feedback. Even in a telephone conversation, there is vocal tone and immediacy of feedback. However, an e-mail message is like a letter or memo in that all that is available to carry the message are words someone must read.

Misunderstandings abound because so many users simply “dash off” messages without using the care they might apply to letters or memos. Some who would never allow a letter to go out containing obvious errors think nothing of e-mailing unedited ramblings devoid of capitalization and normal punctuation and overflowing with misspellings and incorrect terms.

Editing a letter takes time. Although this task is often ignored, it is not ignored nearly as often as editing an e-mail message. What’s different about an e-mail message that causes its writer to forget the need to edit and clarify? Perhaps it is the seeming immediacy of e-mail, the feeling it provides of talking directly to someone via the computer screen. But it is easy to forget that the key element present in dealing with someone face-to-face, with the immediacy of feedback, is missing in e-mail. Feedback is delayed, and all too often it becomes necessary to trade messages back and forth to achieve the appropriate transfer of meaning. It is far better to edit and rewrite—and certainly spell-check—before sending each message. Clarity of content is most likely to accompany clarity of presentation.

E-mail is perhaps best thought of as one of a subset of tools in that versatile toolkit known as the personal computer. Like any good tool, to retain its usefulness it must be kept in good order and used for its intended purposes only.

Memos and Letters *

Letters and memoranda are essential—and unavoidable—in the operation of any business or other organization. To many people who work in various healthcare settings, it often seems that more than enough paperwork is already required without adding more by creating documents in addition to necessary charting, covering the organization legally, and responding to external requirements. However, even though the paper volume seems almost overwhelming at times, much of this paper is nevertheless necessary. Many organizations function quite well in spite of hefty amounts of paperwork, but just try to run an organization completely without paper.

Any written communication serves one or more of several important functions. Specifically, a given written communication may be used to advise (or inform), explain, request, convince, or provide a permanent record. Letters and memos may be used for any one or a combination of these purposes.

No matter how well it is written, any letter or memo possesses a serious drawback: it is essentially a one-way communication, providing no opportunity for immediate feedback. The individual who writes a letter or memo is unable to amend, correct, clarify, or defend what is being written based on the reactions of the audience.

Because of the one-way nature of a letter or memo, the need for clarity in writing becomes critical. However, clarity is an attribute frequently lacking in written communications in the organizational setting.

This section offers some guidelines for communicating more clearly via letter or memorandum. However, although these guidelines will help improve the clarity of one’s writing, following a few pages of advice in a work such as this book is unlikely to make a person become a “good” writer. To become a writer of effective business communications, two things are needed: (1) the desire to write better letters and memos and (2) the help provided by practically oriented teachers of business writing and good references on writing.

*  Portions of this section were adapted from Charles R. McConnell, The Effective Health Care Supervisor, 8th ed. (Chapter 19, “Communication: Not by Spoken Words Alone”) (Sudbury, MA: Jones and Bartlett Publishers, 2015), pp. 347–360.

Numerous books on writing techniques are available, but the writer who wishes to use one single straightforward reference should turn to The Elements of Style by William Strunk, Jr., and E. B. White. This short volume contains more solid, usable advice per page than any other book on writing available.

For better letters and memos, conscientious use of the following guidelines will improve your writing in a minimum amount of time.

Write for a Specific Audience

A particular letter or memo may be going to one person, or it may be intended for several people. Before writing, the writer must decide to whom, specifically, the missive is to be directed. The person for whom the message is primarily intended is the primary audience. However, there may also be a sizable secondary audience—others who will receive, read, and perhaps make use of the communication.

Many managers write as though they believe that anyone picking up a particular document will completely understand its contents. Targeting a specific audience is a difficult task at best, however, and it becomes nearly impossible in the presence of a sizable secondary audience, including people of widely varying backgrounds and different degrees of familiarity with the subject.

Write specifically for the primary audience. No person can successfully write for everyone. If there is difficulty identifying the primary audience, it is necessary to sift through the likely recipients of the message with one question in mind: who of all these people needs this information for decision-making purposes? Often the primary audience will be a single person, but it could just as well be two, three, or more people. For example, a nursing supervisor writing about the need for a specific change in departmental policy would likely be making all of nursing management aware of the issue, but it would be the supervisor’s immediate superior—the director of nursing service—who would be the primary audience because this is the person who wields the decision-making authority concerning departmental policy. In contrast, if the director of nursing service is releasing a new policy with which all supervisors are expected to comply, then the memo announcing the policy will have all supervisors as its primary audience.

Use what is known about the primary audience in deciding how to structure a message. Can it be on a friendly, first-name basis? Must it be a formal letter, or will a brief, casual note suffice? Does this person prefer detail, or would a concise overview be enough? Let knowledge of the primary audience suggest how to communicate.

Avoid Unneeded Words

Understanding and exercising one simple concept—that of the “zero word”—will go a long way in removing excess words from one’s writing. Every word in a given piece of writing can be placed in one of three categories: necessary, optional, or zero. A necessary word is essential to getting the basic message across. An optional word, as the name suggests, can be used at one’s option to qualify or modify a necessary word or phrase. A zero word contributes nothing and should be removed.

Consider the following sentence:

Mary is certainly an exceptionally intelligent woman.

This sentence contains only three necessary words: Mary is intelligent. Note, however, that even with all zero words and optional words removed, what remains is still a sentence.

The word exceptionally is the only optional word in the sentence. It may well make a difference in what you are trying to communicate to say that “Mary is exceptionally intelligent” rather than simply “Mary is intelligent.” Although this is perfectly acceptable, it is necessary to watch out for the excess use of such modifiers and qualifiers; after a while, they not only become tiresome but also lose much of their impact.

The example sentence includes three zero words: certainly, an, and woman. At least they are zero under normal circumstances, assuming that Mary is a woman. The word an is there for structural reasons, and certainly is certainly unnecessary, because in terms of what the writer is trying to convey, Mary either is or is not intelligent, and certainly does not make that judgment any more binding. Zero words abound in most business writing, but they are relatively easy to get rid of with conscientious editing.

Almost any sample of business writing will yield at least a few zero words. If in doubt about a word, try the sentence without it. If the sentence remains a sentence and continues to convey the intended message, the word is probably a zero word. One can usually find a surprising number of zero words, among which are often many uses of the, that, of, and other simple words.

Unnecessary words are often used in phrases of several words, where they do the work that could be done by one or two words. This is especially common in business correspondence in which some phrases have reached cliché proportions. Consider these examples:

• The use of “due to the fact that” when one can simply say “because”

• Saying “be in a position to” when all that is needed is “can”

• Saying “in the state of California” when “in California” says the same

• Using the stuffy “with reference to” when the job can be done by “about”

Such phrases are to be avoided; they simply add bulk without adding clarity. In fact, such words not only fail to add clarity, but they also can actually harm the message by surrounding and obscuring the real meaning.

Use Simple Words

Almost every technical and professional field has its own jargon, with jargon defined as “the technical terminology or characteristic idiom of a special activity or group.” However, this is the second definition of jargon appearing in several dictionaries—the first is “confused unintelligible language.”

It is one thing for a laboratory technologist to write to an audience of other laboratory technologists; in this instance one can get away with the free use of the language of the field. It is another thing to write to all employees of the healthcare organization simultaneously; this audience usually includes highly educated, specialized professionals; unskilled and semiskilled workers; and numerous levels in between these two extremes. Also, an organization’s staff includes people in many different but medically related fields, all of which have their own “languages.”

Medical and technical professionals are among the worst offenders when it comes to sprinkling correspondence with jargon. The excuse that the writing is “in the language” of a field should not allow one to cut across departmental lines to any considerable extent. As already suggested, technologist-to-technologist communication may be a safe channel for the use of jargon. In contrast, technologist-to-finance director is a channel calling for a completely different approach. Again, consider the primary audience in preparing to write.

Edit and Rewrite

During editing and rewriting, zero words, roundabout phrases, and other verbal stuffing should come out of the intended correspondence. Few pieces of writing cannot be improved by careful editing or rewriting. Most people—and this statement includes professional writers—cannot go from thought to a completely effective finished message in a single pass. In fact, professional writers do much more editing and rewriting than do most writers of day-to-day business correspondence. This reveals the problem: much of what is wrong with our writing is wrong simply because not enough time and effort are put into it. As the Pascal quotation cited earlier suggests, it usually takes more time to write a shorter letter than it does to write a longer one.

Anyone who might think that better writing is too time consuming should think also of the cost of misunderstanding. Many a manager has had to spend valuable time and effort smoothing out some problem that developed because a written message was misunderstood. Many memos can be edited in the time it takes to solve a couple of knotty problems arising from missed communication.

Change Old Habits

In their day-to-day writing, many people are unconsciously still trying to please English teachers of years gone by. Throughout several decades of the 20th century, students were taught to write letters that sounded as if they were lifted from a Victorian secretarial handbook.

Most of what has been said up to this point is “legal” in terms of long-standing English usage. However, many practices that are acceptable (and even improve) business writing today would previously have been guaranteed to get users into trouble with the teacher.

Be Friendly and Personal

Feel free to use personal pronouns in letters and memos. People use I, you, and we when they are speaking to each other, so why not use them when writing? Many people were taught to avoid personal pronouns, and this warning sticks with them. Students were once taught never to say I. But for clarity and directness, I is far preferable to archaic affectations such as the undersigned or the author.

Most letters and memos should strive for a conversational tone. Once this is achieved, correspondence will be direct, friendly, and personal.

Use Direct, Active Language

Ask direct questions when the situation warrants it. Some writers may have been taught to go out of their way to avoid questions and thus say things like, “Let me know whether you will attend.” It is much more direct to ask, “Will you attend?”

Statements should be kept in the active voice, avoiding the likes of “The contract was signed by your representative.” How much cleaner it is to say, “Your representative signed the contract.”

Use Contractions

It is preferable to use contractions such as don’t, wouldn’t, can’t, shouldn’t, and so on, even though this usage in business was long discouraged. Contractions contribute to the natural, conversational tone one should be working to achieve. Even so, many writers of business correspondence squeeze the contractions out of their writing without realizing what they are doing. The result is a formalistic style, stilted and stuffy, that merely serves to create more distance between writer and reader.

Write Short Sentences

Although it is difficult to set firm guidelines for sentence length, consider that any sentence much longer than 20 words is edging into questionable territory. Some teachers of business writing have suggested 20 words as maximum sentence length, and others suggest that 14 or 15 words as the maximum. Regardless, it is safe to say that the longer the sentence, the more opportunities there are for misunderstanding.

Forget Old Taboos about Prepositions and Conjunctions

It is likely that most people were repeatedly and sternly warned against committing two terrible transgressions: ending a sentence with a preposition and starting a sentence with a conjunction.

A story is told about Winston Churchill and the rule concerning prepositions. When reminded it was improper to end a sentence with a preposition, Churchill replied (paraphrased but retaining the point), “This is something up with which I shall not put.” An extreme example, for sure—but it cleanly illustrates how far out of the way the writer may be led in search of so-called structure. Go ahead and say, “This is something I won’t put up with.”

A surefire way to lose points with some teachers is to begin sentences with conjunctions, especially and and but. Fortunately, this archaic prohibition has been successfully shattered by professional writers. Of course, if every other sentence in a letter begins with and, the writer has created a different kind of monster. However, the freedom to open a sentence in this manner can help avoid long sentences and needless repetition.

Say It and Stop

Avoid starting a letter by repeating what was said in the letter being answered. Also, avoid opening with standard stuffing such as “In response to your letter of the ...”

Simply state the message. If the point of the letter is to tell a potential supplier that the bid was rejected, do not spend two paragraphs describing the evaluation process and building the rationale for the “no” to be delivered in paragraph three. Deliver the answer in the opening paragraph, preferably in the first sentence. Then go on to explain why, if necessary.

Having delivered the message and explained it as necessary, do not spend another paragraph or two winding down by repeating what has already said. Simply say it—and stop. Also, watch out for standard closing lines that mean little or nothing. It may be quite all right to say, “Call me if you need more information”; this statement is thoughtful and shows interest. But avoid phrases such as “We trust this arrangement meets with your complete satisfaction.” If the reader is not completely satisfied, the writer is likely to hear about it.

Consider also the use of the collective we in the foregoing example. Few words are more likely to make a letter more impersonal to a reader than one who is made to feel that the communication is coming from a crowd. The we has its place—for instance, when writing to someone outside the organization and speaking on behalf of the organization. However, rather than being organization-to-person or organization-to-organization communications, most of one’s writing will consist of person-to-person messages. As long as the thoughts are your own and yours is the only hand pushing the pen or tapping the keys, say I.

Sample Letter: Wrong and Right

Following is the text of a letter sent to a number of hospital chief executives by the director of a regional office of a state health department:

Dear Administrator:

I would like to call your attention to Section 702.4 (c) of the State Hospital Code, which requires nosocomial infections in hospitals be reported immediately to the Regional Health Director.

We have recently experienced several hospital outbreaks in this region, which have not been reported to this office by the hospital. It is recommended that you review Section 702.4, Infection Control and Reporting, of the State Hospital Code so that you understand what your responsibilities are regarding increased incidence of hospital infections or disease due to chemical or radioactive agents or their toxic products in patients or persons working in the hospital.

In counties where there is an organized county or city health department or a Commissioner of Health, it is also required that a report of communicable be made immediately to the County or City Health Commissioner. In the unorganized counties or districts, a report must be made to the District Health Officer immediately. This is no way eliminates or excuses the hospital from reporting immediately to the Regional Health Director.

Please note that failure to report nosocomial infections is a violation of Section 702.4(c) of the State Hospital Code. Violations of the Code are subject to penalty. In the future, such violations will leave us no alternative but to recommend that appropriate sanctions be taken against a hospital for violation of this section of the State Hospital Code.

Very truly yours, Regional Health Director

It is certainly possible to correctly extract the true message from this letter, although a telephone call or two might be necessary before a recipient would feel comfortable about its meaning. Also, there is no denying the scolding tone and the threat contained in the letter (with threats of sanctions or punishment of some kind seemingly incorporated in a great many communications from government agencies).

Now consider how the text of the letter could read if more thoughtfully written:

The State Hospital Code calls for the reporting of nosocomial infections to the Regional Health Director as soon as they are discovered. However, several recent outbreaks in this region have not been reported.

Please review Section 702.4 of the Code (Infection Control and Reporting) concerning your role in helping to control infection or disease resulting from the exposure of patients, staff, or others to chemical or radioactive agents or their toxic products.

If your community has a Department of Health, your timely report should go to the local Commissioner. If you have no local health department, your report should go directly to the District Health Office.

Please assist us in ensuring that Section 702.4 of the Code is observed as intended. Your cooperation will be appreciated.

Why should the author have bothered to edit and rewrite the original letter? One good reason for doing so is for clarity. In its rewritten form, the letter is far less likely to be misunderstood. Also, the scolding and threatening have been removed; there is always the opportunity to communicate more sternly later with recipients who might remain noncompliant. And consider this as well: the text of the original letter contains 230 words, and the rewritten version contains 126 words. This amounts to a reduction in length of 45%. Not only is the rewritten letter clearer, but there is also less to read. Is this at all important? It has been estimated that most business documentation contains anywhere from 25% to 100% more words than are actually needed. This suggests that the 2-inch-thick stack of documentation in the manager’s inbox need be only 1 to 1.6 inches thick if properly written.

Time spent editing and rewriting is time well spent in making a message more readily understood while greatly reducing the chances of misunderstanding.

Formal Writing and Reporting

Letters and memos constitute a significant percentage of most managers’ writing chores. However, it may occasionally be necessary or desirable to tackle larger writing tasks such as informational or analytical reports, educational presentations, speeches, or perhaps even journal articles.

Many elements of the personal, direct style preferred for correspondence are applicable to other writing. For instance, some speeches or educational presentations can, and should, be handled with the same personal touch. However, some additional rules apply in writing more structured material such as formal reports, and still more rules apply when writing for publication in trade magazines or professional journals.

A thorough treatment of the topic of report writing is beyond the scope of this book. If you need to author a formal report, obtain a manual or handbook on the subject and do some studying, paying particular attention to outlining schemes if the report in question is likely to be lengthy. Also, be aware of the advisability of using one of the commonly recommended report formats, one that calls for a tight summary of objectives, conclusions, and recommendations early in the report.

Whether you are writing a letter, memorandum, or formal report, never lose sight of the fact that the initial step in preparing to write anything is to get a clear image of the intended audience, both primary and secondary.

COMMUNICATION IN ORGANIZATIONS

Considering that communication between two people may be difficult at times, and small-group communication may frequently be taxing, the task of communicating with a large group may at first seem overwhelming. As bureaucracies began to emerge at the dawn of the 20th century, when industrialization promoted the growth of large organizations, the need to develop complex communication patterns became more pressing as organizations added more and more members. Put simply, communication had to keep pace with production. The resulting strategies to increase organizational communication can be divided into two categories: formal and informal.

Formal Communication

Verbal

An organization is a stratified social system with a hierarchy of roles. The roles are arranged according to the degree of power and status assigned to each, and the assignment is based on the goal-oriented needs of the organization. Formal communication is sanctioned by the organization and is shared along communication channels established by the hierarchy of roles. The arrangement of roles determines the direction of the communication.

Formal communication is directional. The four traditional channels of communication are upward, downward, diagonal, and lateral ( Table 11–2 ).

Formal verbal communication in organizations takes place through orderly channels. The exchanges are directional and promote organizational goals, such as a verbal exchange of orders or instructions. Department meetings can also be formal. An aide who wants to register a complaint must go through a series of formal channels; the aide cannot walk into the president’s office and discuss the grievance.

Table 11–2 Examples of Directionality
Four Channels	Examples
1. Upward	Staff person communicating with supervisor
2. Downward	Staff therapist giving orders to an aide
3. Diagonal	Head of Social Work conferring with patient registrar in Admissions
4. Lateral	Nurse sharing night orders with another nurse

Because the size of organizations precludes face-to-face interaction among the majority of group members, they must rely on less personal means of communication (e.g., written and transmitted communication). Common examples include goal statements, policy and procedure manuals, directives, direct mailings to employees, inserts in pay envelopes, mass e-mail communications, organizational bulletins, newsletters, magazines, bulletin boards, posters, and handbooks.

Nonverbal

The use of space is a form of nonverbal communication. The goals of the organization determine the location and quality of space assigned to group members (who may resist adjustments and reassignments). The way that furniture is arranged, the selection of ornaments, and the care given to the space all reflect the values of the group. If an organization has an elaborate waiting room and sloppy offices, it can be inferred that the company is more interested in its public face.

The arrangement of furniture can stimulate or stifle communication. Managers rely on spatial relationships to strengthen their communication. For example, asking for a raise while the manager looks over a desk is more difficult than asking while both parties are seated next to each other.

Informal Communication

Because informal communication is not sanctioned by the social system, it may or may not promote the goals of the organization. Informal communication is not directional; it may—and frequently does—circumvent formal channels. Informal communication is frequently anonymous, and more often than not sources cannot be verified.

Informal communication, such as small talk and gossip, may not be accurate. Even so, the use of informal communication should not be neglected. Managers can use this type of communication to determine the success of formal communication patterns. Rumor and gossip, although inaccurate, may gauge the feelings of group members. Perceptions about events can also be examined. Informal communication is a barometer of the organization, because information can travel at a fast rate. Future events may be foreshadowed by listening to information communicated informally.

Informal communication within the organization may be accurately described by a single familiar term: the grapevine. This may perhaps be more accurately described as the communications network of the informal organization. Every organization has a formal structure of relationships governing relationships within the workplace. In addition, every person in the organization has a number of informal channels of communication, relationships with friends, acquaintances, and others with whom one might speak. Furthermore, many of the relationships partially define the informal organization, with the implied structure being based on numerous interactions between and among people.

The informal organization is at work, for example, when two or three employees happen to stand out from the group, perhaps even speaking for others, although they have no official standing. This effect is also evident when a single manager is regarded as senior by the work group over a number of others at the same level because of longevity or perhaps because of strength of personality or some particular trait or combination of traits. In brief, interpersonal relationships and people’s regard for one another describe the informal organization, which is at best a phantom structure that is always shifting and realigning.

People will talk. The grapevine is not required by management, and it is certainly not controlled by management. It runs merrily back and forth across departmental lines and rapidly changes its course. The grapevine is dynamic but unreliable. It carries a great deal of misinformation, but it is in the organization to stay.

It is best to remain acutely aware of the grapevine. Tune in, listen to what it is carrying, and learn from it. A manager is likely to be isolated from some of the bits and pieces the grapevine carries, or at least miss a few things until they have been around awhile. How much one hears is frequently dependent on how well one relates with employees, peers, and others.

When tuned in to the grapevine, a manager will inevitably hear some things that he or she knows are simply not correct. A manager who hears something that is disturbing or inappropriate should check it out if possible. Each manager is responsible for setting the facts of the story right whenever the opportunity to do so presents itself. One must be sure, however, to have the story straight—do not heap more speculation onto a growing rumor.

The grapevine sometimes possesses the distinct advantages of speed and depth of penetration. Some bits of news can travel through the organization at an astonishingly rapid rate and often reach people who would never think to read a bulletin board or look at an employee newsletter. The grapevine can carry the good as well as the bad, and because it will always be around, it is best to feed it some real facts whenever possible so it will have something useful to carry.

Tools for Improving Communication

A number of formal and informal tools can be used to promote communication within the organization. Assessment instruments require analysis of the conscious and unconscious goals of group members. Some can be used to assess individual interaction styles, members’ perceptions of one another, perceptions of leadership, roles that members play relative to one another in the work group, and members’ feelings about the organization. Group members complete questionnaires, and the results are compared and discussed. The goals of the members are compared with the goals of the leaders. The results are discussed in nonthreatening ways. Strategies for promoting change can be generated in the group.

Sometimes group communication becomes so difficult that outside experts are brought in as facilitators to resolve the issues. Professional facilitators are trained in a number of disciplines, including business, psychology, education, and sociology.

Barriers to Communication in Organizations

A number of obstacles can block communication or distort the goals of organizational exchanges:

1. Language. There may be a lack of common understanding of certain important terms. The use of slang, jargon, or technical language can create problems.

2. Unconscious motives. Personal thoughts, ideas, and emotions not readily available for examination may cloud a group’s ability to perceive or interpret events. A group may share a collective mentality that may not be based on real events. Such collective thought has been shaped by emotions.

3. Psychological factors. Past experience and ideas impinge on the communication process. Feelings such as mistrust, fear, anger, hostility, or indifference may shape group perceptions.

4. Status. Real or perceived differences in rank, socioeconomic status, or prestige may detract from the communication process. People develop preconceived notions about others and act on their preconceptions instead of reality.

5. Organizational size. The larger the social system, the greater the number of communication layers. Each layer provides an opportunity for additional distortion.

6. Logistical factors. Groups may lack the time, place, or space to communicate clearly. Feedback may be neglected because it is difficult to collect.

7. Overstimulation. Members may be bombarded with so many events that they are unable to process any more information. People who are stressed must be managed carefully so they are not additionally burdened.

8. Cultural clashes. One group may misinterpret another’s ideas because of a difference in cultural factors, such as age, socioeconomic status, the region of birth, and education level.

9. Organizational structure. Communication may be blocked by the structure of the communication channels. One person’s role may serve as a bottleneck for open communication. In another instance, roles may overlap, and some groups may not receive the information that they need.

10. Phase in the life cycle of the organization. Communication may be taxed during the organization’s developmental stage. In later stages in the life cycle, the old channels may not have been adapted to new situations. Sometimes organizations rely on one type of communication and ignore other methods.

Special Consideration: Directional Flow Barriers

Communication within a work organization moves downward with far greater ease than it moves upward. The downward channels of communication are largely controlled by management and tend to be exercised at management’s option. Letters and memoranda to employees, general e-mailings to employees, employee meetings and staff meetings, informational stuffers in paycheck envelopes, bulletin boards (except for occasional boards placed solely for employee use), policy and procedure manuals, most newsletters and employee newspapers, and public address systems all represent downward channels of communication controlled by management. Perhaps the most potent downward channels reside in the vested authority that each level of management has over its subordinates; in any vertical relationship in the chain of command, the person higher in authority is seen as exerting the greater measure of control in the communication that occurs within the relationship.

When a bit of information is set in motion in any of the downward channels, barring occasional breakdowns in flow, it moves as does anything moving from higher to lower—as though readily assisted by gravity. Moving a message up the chain of command, however, is often like attempting to make a physical object rise in spite of gravity. One can, of course, make an object rise in spite of gravity, but doing so requires the effort of lifting it plus whatever extra effort is required to overcome gravity. The same is true of communication: it usually requires a bit of extra effort to make a message travel upward against the normal downward-flowing tendency of organizational communication.

To obtain communication from employees, the manager can, and indeed should,  through techniques such as proper delegation, build in requirements for all reasonable forms of employee feedback. If an employee clearly understands that he or she is to report to the manager on a given matter at a given time, then reporting usually takes place. It is likely that a large part of the effective group manager’s time is consumed in the basic management function of controlling—ensuring, through regular follow-up and correction, that work is getting done as intended. This function requires employee feedback.

Despite such efforts, the manager can never secure all of the most valuable information by mandating feedback. Information that frequently remains hidden from the manager can include both personal and work-related employee problems. It can also include difficulties employees experience with management and coworkers, problems understanding or adhering to certain policies and practices, ideas for improvement that employees may not know how to structure or transmit, complaints about treatment from the organization, and numerous other indications of unmet needs. These kinds of information may be essential, or at least helpful, to the manager in running the department. Yet the manager may obtain such information not through mandate but rather by being visible and available to the employees and by earning the trust and confidence of the employees to the extent that they will volunteer such information.

Thus, the manager may ordinarily communicate downward at will because of position in the hierarchy. In contrast, employees can communicate upward effectively only if the manager makes it possible for them to do so.

ORDERS AND DIRECTIVES

The manager’s role is to direct the employees toward achieving the goals and objectives of the department and the institution. Regardless of the leadership style used, the manager must issue orders and directives to convey what must be done. The terms orders and directives may be used interchangeably, although orders has a more autocratic tone.

Giving orders is a major function of the manager’s day-to-day operation of the department. Too often it is taken for granted that every manager knows how to give orders. Unfortunately, this is not true. The manager must remember to convey to the employees what is to be done, who is to do it, and when, where, how, and why it is to be done. At times, some of the components are implied or omitted. As an example, consider this order: “Effective July 1, John Doe will be the Senior Physical Therapist of the Amputee Service.” This statement answers the what, who, when, and where but omits the how and why.

Verbal Orders versus Written Orders

The form of an order depends on the situation. The verbal (actually, oral) order is the most frequently used. Because it is given on a one-to-one basis with immediate feedback possible, the manager can observe the employee’s reaction, ask questions, and appraise the degree of understanding. Disagreements can be handled immediately. Observation of the employee’s body language provides additional feedback.

When permanence is important, written orders are more appropriate. This form is most effective when information is to be disseminated to employees as a group. Written orders are more carefully thought through, because there is less opportunity for explanation. The use of long sentences, excessive adjectives, and involved word patterns should be avoided. The written order also carries a degree of formality not present in the verbal order. It is difficult, however, to keep written material up-to-date and impossible to clear up obscure meanings.

Making Orders Acceptable and Effective

The issuing of effective orders requires attention to timing as well as to language. Planning to issue an order involves content, format (oral or written), and the manner in which the order is actually issued. When there is rapport between manager and employee, a simple request may be suitable; an implied order is sometimes given with the same informality. When certain action must be taken, precision is involved, and misunderstanding must be avoided; the written, direct order is the best method. The sense of command may be foreign to many managers, yet commands may be needed on some occasions, such as emergencies. Although policies, work rules, and procedures may not be considered orders, they do set required courses of action as determined by management.

Because a critical aspect of the manager’s function is communicating, effort must be applied to making orders acceptable and effective. Acceptability is enhanced by the general processes of leadership that the manager has developed over time. In effect, the manager prepares the employees in many ways so that when orders are actually given, they are normally both acceptable and effective in terms of essential communication.

CASE: THE LONG, LOUD SILENCE

Background

As the director of health information management who was recently hired from another organization, it did not take you long to discover that morale in your new department has been at low ebb for quite some time. As you undertook to become acquainted with each of your employees, you quickly became inundated with complaints and other evidences of discontent. Most of the complaints concerned problems with administration, the financial division, and the records-related practices of physicians, but there were also a few complaints by staff about other members of the department and a couple of thinly veiled charges concerning health information services personnel who “carry tales to administration.”

In listening to the problems, it occurred to you that there were a number of common threads running through them and that a great deal of misunderstanding could be cleared up if the gripes were aired in open fashion with the entire group. You then planned a staff meeting for that purpose and asked all employees to be prepared to air their complaints—except those involving other employees by name—at the meeting. Most of the employees seemed to think such a staff meeting was a good idea, and several assured you they would be ready to speak up.

Your first staff meeting, however, turned out to be brief. When offered the opportunity to air their gripes, no one spoke.

This result—silence—was the same at your next staff meeting 4 weeks later, although in the intervening period you were steadily bombarded with complaints from individuals. This experience left you frustrated because you regarded many of the complaints as problems of the group rather than problems of individuals.

Instructions

1. Describe in detail what you believe you can do to get the group off dead center and to open up about what is bothering them.

2. Describe how you might approach the specific problem of one or more of your employees carrying complaints outside of the department—that is, “carrying tales to administration.”

3. Describe several means of organizational communication at your disposal that you believe might be applied in helping to address this department’s problems.

CASE: YOUR WORD AGAINST HIS

Background

You and six other department managers are at a meeting chaired by your immediate superior, the vice president for patient services. The subject of the meeting is the manner in which members of this group, as well as other supervisors and managers, are to conduct themselves during the present union organizing campaign.

The vice president makes a statement concerning one way in which all managers should conduct themselves. You are surprised at what he says because earlier that day you read a legal opinion describing this particular action as probably illegal.

You interrupt the vice president by saying, “Pardon me, but I don’t believe it can be done quite that way. I’m certain it would leave us open to an unfair labor practice charge.”

Obviously annoyed at being interrupted, the vice president says sharply, “This isn’t open for discussion. You’re wrong.”

You open your mouth to speak again, but you are cut short by an angry glance.

You are absolutely certain that the vice president is wrong. He had inadvertently turned around a couple of words and described a “cannot do” as a “can do.” Unfortunately, you are in a conference room full of people, and the document that could prove your point is in your office.

Instructions

Describe in detail any options you believe you can pursue in an effort to set the matter straight for all parties who received the wrong information as well as with the vice president, while incurring the minimum possible public disfavor by the vice president.

NOTES

1 . Evelyn W. Mayerson, Putting the Ill at Ease (Hagerstown, MD: Harper & Row, 1976), 1–36.

2 . Sigmund Freud, A General Introduction to Psychoanalysis, trans. Joan Riviere (New York: Washington Square Press, 1964), p 40.

3 . Joseph Luft, Group Process (Palo Alto, CA: National Press Books, 1963).

4 . E. T. Hall, The Hidden Dimension (Garden City, NY: Anchor Books, 1966), 113.

5 . A. C. Mosey, Three Frames of References for Mental Health (Thorofare, NJ: Charles B. Slack, 1970), 52. Taken from J. Mazer, G. Fidler, L. Kovalenko, and K. Overly, Exploring How a Think Feels (New York: American Occupational Therapy Association, 1969).

6 . Naomi I. Brill, Working with People (Philadelphia: J. B. Lippincott, 1973), 31–46.

7 . V. M. Robinson, Humor and the Health Professions (Thorofare, NJ: Charles B. Slack, 1977).