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Healthcare Change Turbulent Environment, 21

A Team-Based Roadmap for Healthcare Change in a Turbulent Environment: A Longitudinal Study of a Not-for-Profit Hospital Transitioning into a For-Profit Organization

Abstract

This longitudinal action research describes how a 50-person management staff, led by a committed chief executive officer (CEO), was able to successfully implement a team-based structure and strategy to achieve a radical change from a non-profit hospital to a for-profit organization over a 12 year period. Many of the issues addressed and practical steps taken to establish a team-based leadership model for the new organizational template are described.

Organization development models, diagnosis, intervention, and specific practices to bring about a successful transition are discussed. Seven principles are presented that contain “The Lessons Learned” from the longitudinal organizational systemic change intervention.

Key words : healthcare change; turbulent environment; organization development; diagnosis; intervention.

The Business of Healthcare: Class Five Turbulence Remains

Significant changes are continuing in the healthcare industry. Hospitals are clustering into multi-institutional groupings, the population is aging, and Americans are spending more on healthcare (Korman and Mujtaba, 2020; Berman, Naik, & Winslow, 2006). Hospitals are experiencing dramatically increasing debt and expense at the same time that inpatient admissions and government and private insurance reimbursements are declining. Healthcare leaders face major internal and external demands for change complicated by the structure of the healthcare industry itself (Fairfield & Wagner, 2004). Leadership in healthcare demands a response to these rapidly changing conditions. Society expects hospital executives to develop new strategies for growing admissions, achieving higher patient care standards, and reducing expenditures in the midst of financial and insurance coverage declines (Berman, et al., 2006).

The U.S. health care delivery system is on the verge of reform yet again. Reimbursement and care delivery models are poised for significant overhaul with the goal of improving the quality, safety, and efficiency of care. Healthcare organizations were preparing for changes under health care reform, meaningful use requirements, and were awaiting the decision of the Supreme Court regarding the Affordable Healthcare Act. Healthcare leaders know all about dealing with change, and they must adapt on the individual, organizational, and industry levels just to survive. Is this becoming a complex healthcare issue that is unnavigable?

Altman and Gurvis (2006) remark, “One does not have to be a medical expert to know that the healthcare system in the United States is unequivocally broken and broke” (p. 19). Issues of access and affordability place the industry directly in the midst of the current political debate. The healthcare system is likely to remain broken without leaders who are courageous, visionary, charismatic, and skilled in dealing with complex organizational change (2006). Altman and Gurvis (2006, p. 20) suggest the following:

The system will not be healed without excellent individual and collective leadership. Strong, capable individual leaders who are courageous, visionary, charismatic, and skilled will be needed. However, it will take a lot more than heroic individual efforts to make significant headway with this vexing and complex challenge. Our belief is that the development of leadership talent and of processes that support collective leadership is part of the solution.

Healthcare organizations are experiencing a demand to transform to meet the expectations of society, consumers, and governmental agencies, and to incorporate the latest advances in technology (Berman et al., 2006). Intense competition, reductions in reimbursements, mergers, and requirements to restructure and re-engineer for cost efficiency have exerted enormous pressure on healthcare organizations (Cunningham, 2002). As the magnitude and rate of change are predicted to accelerate, organizations must be able to successfully anticipate and manage their approach and process to change (Griener, Cummings, & Bhambri, 2003). Attempting radical change is a complex endeavor as it involves the “transformation of the organization” (Greenwood & Hinings, 1996, p. 1023), much like the one undertaken in this study.

In the case of the hospital, that is the subject of this longitudinal action research study, the CEO and his team were attempting a radical planned change by moving from being a non-profit hospital to a for profit organization. These changes were brought about by both internal forces and by external market conditions. In general, we know that:

…radical change in an organization occurs when there is a shift from one template to another (in the case of privatization there is an anticipated shift from a public sector, bureaucratic template to a private sector template) (Voges, Tworoger, and Bendixen, 2009, p. 10).

After 50 years of leadership research in more than 1,000 studies, what has merged is the need to fully understand and develop oneself to “discover where to use one’s leadership gifts to serve others” (George, Sims, McLean, & Mayer, 2007, p. 130). Hospitals are trying to prove their merit based on compliance with national, state, and local regulations as well as to positive trend lines in surveys, management dashboards and balanced score cards. These accomplishments are important yet not sufficient evidence of the leadership needed by hospitals and the communities they serve (Hoffman, 2009). For this study, leadership is viewed as a “process of influence in which one person is able to enlist the support of others in the accomplishment of a common task” (Chemers, 2000, p. 27). Hospital executives with a clear understanding of how they function, perceive, interpret, and make decisions on perceptions may provide more targeted and intentional leadership for periods of organizational change. Provost (1993) suggests those with an awareness of their style are more effective at their profession. By helping increase self-understanding about style, type, typical responses, and needs during change, leaders may proactively prepare for and lead organizational change (Barger & Kirby, 2004).

Research from the Center for Creative Leadership sample of 34,899 leadership effectiveness evaluations completed between 2000-2009 from people working in the healthcare sector identified the “most important priority for leadership development in the healthcare sector is to improve the ability to lead employees and work in teams” (“Addressing the leadership gap in healthcare,” 2011, p. 5). The pressure remains on hospital leaders to be more transparent, to protect and empower both patients and staff, and physician, to improve clinical outcomes, and to demonstrate proper stewardship of limited resources (Hoffman, 2009).

Bisbey, Reyes, Traylor, and Salas (2019) report that team training contributes to improved performance, reduced errors, and even saving lives. Their research highlights the salient role of multidisciplinary collaboration in response to real-world problems.

Purpose

The purpose of this action research study is to present longitudinal data that charts patient satisfaction, employee engagement, and physician satisfaction during a 12 year time period. “Longitudinal studies of culture change and change in performance on such measures as patient satisfaction would be a valuable contribution to the literature” (Meterko, Mohr & Young, 2004, p. 497). This research study will add to the body of knowledge about how effective leadership and teamwork strategies can be effectively employed during radical template change. Studies of this type are needed to help develop models for organizational culture change that “supports better patient care” (Meterko, Mohr & Young, p. 498). The results serve as the structure to examine leader-follower relationships during organizational change, to analyze similarities and differences, and reach informative conclusions about leadership styles that result in better outcomes during organizational change (Hammer, Reynierse, & Komisin, 1996; Musselwhite & Ingram, 2003).

This study strives to document one hospital’s successful 12 year change effort that resulted in increased patient satisfaction and employee engagement. In addition, this study provides healthcare leaders with an additional model for change during highly turbulent times (Musselwhite & Ingram, 2003; Barger & Kirby, 2004; Meterko, Mohr & Young, 2004).

Team training refers to a systematic set of learning initiatives that target and build teamwork KSAs (Salas et al., 2008). Today, team training is one of the more robust areas of teams’ research, boasting extensive practical implications such as playing a role in reducing patient mortality in health care (Hughes et al., 2016). Its success has likely resulted from science’s being shaped over the years by the unique perspectives of psychologists across an array of disciplines and key players in industry who championed their research, used their tools, and demonstrated their impact. The objective of this article is to describe the multidisciplinary research effort that built a science around team training by responding to problems in the medical industry workplace and beyond.

Background

This study contributes to the base of knowledge on leading organizational change in the hospital setting. By helping increase understanding about typical responses, and needs during change, leaders may proactively prepare for and lead organizational change (Musselwhite & Ingram, 2003; Barger & Kirby, 2004). Each individual leader possesses unique motivators and satisfiers that influence their approach to working with others during organizational change. Using multiple organizational development methods and approaches to accommodate the differing communication and information requirements benefits the organization during periods of change.

Action research is related to specific organizational change issues such as leadership, decision making, and planning (Jessup, 2002). Each individual possesses unique motivators and satisfiers that influence their approach to organizational change. In order to make Carl Jung’s theory of psychological types more understandable and useful in people’s live, according to Hutton (1998, p. 3),

The essence of the theory is that much seemingly random variation in behavior is actually quite orderly and consistent, being due to the basic difference in the way individuals prefer to use their perception and judgment.”

The changes in healthcare strategy and structure have been accompanied by changes to human resources practices such as decreased loyalty to employees, altered career opportunities, increased stress, bullying, workplace mobbing, and even putting pay at risk (Mujtaba, Cavico and Senathip, 2020; Mujtaba and Senathip, 2020). So, how are employees coping with the difficult and changing times facing a healthcare corporation? How do you improve employee morale in the face of budget cuts, layoffs, shorter length of stay, and decrease in qualified staff, carefully monitored supplies, and an unpredictable census? How do you build high performance during times of change? How do you offer unequaled quality of care in this environment? These are the major challenges facing every healthcare system in the United States.

Methodology

Since the problems in healthcare are many and the solutions are complex, action research has been used in healthcare to take a more holistic view of the problems in context (Meyer, 2000; Bates, 2000). Action research is research in which “the researchers work explicitly with and for people rather than undertaking research on them” (Meyer, 2000, p. 178). This type of research combines theory and practice in a way that is participatory, consists of democratic processes and pursues practical solutions to problems (Meyer, 2000; Brydon-Miller, Greenwood and Magurie, 2003; Rapoport, 1970).

Action research was introduced in the U.S. in the 1940’s by Kurt Lewin, and has recently reemerged (Cummings and Worley, 2015). It attempts to test theory by applying it in the field, thus allowing the researcher to have a more nuanced view of the theory’s application. The researcher works collaboratively with the subjects who have superior knowledge of the specific problem solving context to share with the researcher. Through effective dialogic organizational development process, this often results in a solution appropriate for the context (Marshak, 2013; Bushe and Marshak, 2008/2009). It also ensures that when the researcher is no longer there, the knowledge base remains in the employees who participated in the process. This embeds the knowledge in the organization facilitating the change process during challenging times such as the Covid-19 pandemic (Sarwar, Maqsood, and Mujtaba, 2021; Korman and Mujtaba, 2020).

Our action research project was conducted and extended across many years of a turbulent time period, both in which to participate and to facilitate change, while the hospital was transitioning from a non-for-profit status to a for-profit organization. Participation allowed the results to be observed, altered in process, and linked to theory.

We begin with the history of the organization that created a need for solutions and the leaders across departments and functions who worked together to develop a structure to improve teamwork. We offer an authentic and at times poignant view of the process that incited action and breakthroughs through team partnerships. Next, we detail the theoretical drivers behind the process using OD tools and interventions and the hands-on approach of investigating how we turn a team of experts into an expert team. We discuss the spectrum of team training over time.

The Organization and its Environment

Colorado is a state where the pressures and conflicts between doctors, hospitals, managed care companies, and insurance companies regularly make the evening news. Hospitals are being challenged to deliver quality care in a fiscally responsible manner as dramatically altered reimbursement structural changes occur (Mathis, 1990). Within this setting of complex social, medical, and financial changes this hospital has developed and applied a model that successfully connects leadership, teamwork, organizational culture, and performance. After the first two years of the hospital’s organizational change effort, they received recognition as a finalist from the RIT/USA TODAY Quality Cup Award for Teamwork.

Hospital History

The Medical Center was founded in 1945 by a group of local Jewish community leaders who wanted to create a hospital that was free of discrimination and open to doctors and patients of all creeds, races, and origins. The Hospital opened for patients in March 1949. In 1996, the Medical Center became a part of a 50/50 joint venture owned by HCA (Hospital Corporation of America) and a local Health Foundation, a non-profit organization.

The hospital is a general medical and surgical hospital with 271 beds. Well known as hospital institution and landmark for 60 years, the Medical Center has earned a reputation as a "Baby Hospital" while becoming a leader in comprehensive women's services, internal medicine, endoscopy, heart and vascular care, orthopedics and total joint replacement, bariatric surgery, sports medicine, and aesthetic surgery. With origins in Jewish teachings, traditions and community, the founders built the hospital to "serve the need of every creed." By offering a high level of expertise and service across all disciplines, this facility has truly become a destination hospital, attracting patients from throughout state and around the world.

Mission Statement

The mission of this healthcare organization is as follows: “Foremost in our hearts and minds is the commitment to our patients. Therefore, we assume responsibility for everything that affects their care.” Furthermore, the mission statement states that:

· We acknowledge our fellow employees, physicians, board members and volunteers as the source of our success.

· We welcome and respect the diversity of our patients, employees, and physicians.

· We value honesty and integrity in all that we do.

· We are a compassionate community that strives for excellence.

· With origins in Jewish teachings, traditions and community, these core values have emerged and developed over the first 50 years. Together, we affirm our past and create our future.

The Competitive Healthcare Environment

Like many freestanding not-for-profit hospitals, this healthcare facility could no longer compete in the new marketplace of managed care. The board realized they would eventually have to close their doors and thus chose to sell to a for profit healthcare chain. This change in ownership and the resulting change in the environment, particularly from non-profit to profit based, had a major effect on the staff of the hospital.

Many of the staff had been employed at the hospital for ten, twenty, and even thirty years. They remained due to the unique identity of the hospital even though only a small percentage of the staff and patients were Jewish. At the time of the transition, the staff felt they had lost their identity, core values, and the psychological contract between employer and employee had been violated. A change to the delicate balance of the employment relationship had been unilaterally imposed, with more being demanded of the employees for a dramatically altered set of outcomes. Morale among these employees was at a new low.

The organization’s reputation for excellence was challenged in the community. The employees were grieving a loss that was very real for them. Hospital staff, more than most employees in other professions, work for the spirit and energy of the people they serve. They deal with life and death on a daily basis, making split second decisions in a world where unpredictability leads to both miraculous recoveries and unforeseen deaths. Their compensation is important, yet the real meaning of their lives comes from the intrinsic nature of their work and service. A maintenance worker, when asked what he liked about his job, remarked that he liked being a healthcare worker. He went on to explain that his job was to keep the electrical power on. The patients’ lives were in his hands as much as they were in the hands of the surgeons. If the power and life-maintaining equipment went down, even for the briefest period of time, patients could die.

Hospital managers struggled with meeting the conflicting challenges of quality, efficiency, cost effective delivery, and customer satisfaction. Hospitals traditionally have passed on costs to either the payers or the patients. They, like a regulated telephone company, knew little of the world of cost savings and competition. The managers were now spending more time looking at budgets and staffing patterns than patient care issues. They, like the doctors, were forced to spend more time thinking about the economics of patient care than patient care.

Similar to many healthcare leaders, when the chief executive officer (CEO) was hired as CEO of this hospital in 1997, he came to a hospital where employee morale was dropping, patient care declining and hospital maintenance suffering. The hospital that had been the “rose” of the region was losing its reputation for excellence. The facility was immersed in a myriad of issues due to increased penetration of managed care, declining resources, and financial restrictions and limitations. Some of the doctors were dissatisfied and decided to establish a competitive hospital on their own. To do it cheaper and quicker was the daily challenge for every department. This was a class five rapid—intense, fast, and unforgiving. This was the kind of turbulence that can destroy a company. Additionally, the patient acuity was increasing exponentially, meaning the patients being admitted were increasingly ill and in more jeopardy. To restore quality, productivity and profitability in an organization confronted by such relentless changes requires a potent strategy—a high velocity approach with the promise to mobilize the organization into a high performance team (Barker, 1992).

The CEO’s goal was to make the hospital a first class hospital again and his strategy was organizational transformation and culture change through TEAMS. Acting as a change agent, the CEO had determined the “readiness for change” within the organization (Armenakis, Harris & Mossholder, 1993, p. 681). A culture of teamwork in hospital settings has been correlated to patient satisfaction and ultimately to the performance of the organization per Meterko, Mohr and Young (2004). The CEO recognized this as the only way to leverage the talent of the organization and once again achieve excellence. Organizationally speaking the rules had changed and the situation demanded a redesign into new forms to replace the classical hierarchical work cultures fettered by rigid bureaucracies.

At this time, team-based structures were surfacing across all industries. It was a hot management topic. Sometimes, teams were successful and sometimes not. Too frequently people complained that teams were a good idea but usually did not achieve the desired results. Yet, team structure and leadership might have been just the fit for achieving effective performance in this unique and complex environment, as public pressure, and stakeholder expectations to provide accessible high quality, cost conscious service continued (Gottlieb, 1990). Teamwork is a framework used for culture change in healthcare for the improvement of patient care (Rose, Thomas, Tersigni, Sexton, & Pryor, 2006). It did not take a rocket scientist to make teams work. It required perseverance, integrity, a plan, a willingness to learn while doing, and unwavering optimism (Kotter, 1996).

“The US Healthcare system requires radical, not incremental change” (Waldman, Smith, and Hood, 2003, p. 5). Systems thinking were required. The organizational change model that was followed consisted of system wide focus of diagnostics and assessments and targeted interventions implemented in phases through teams to positively impact the culture of the hospital (see Figure 1 for the transition phases).

Figure 1 - Organizational Change Model Transition Phases

OD Intervention Model, Phases, and Intervention

OD Model

In an OD program, the emphasis is placed on a combination of individual, team, and organizational relationships (Brown, 2011). Through a five stage process centered on an action research model, the focus is to drive continuous improvement throughout the entire organization impacting all functions and elements for increased effectiveness.

1. The first stage is to obtain perspective from external environment in order to detect the need for change. The need for change could be from growth or decline as well as technological, social, or competitive changes.

2. Once the need for change is established the second stage is to develop the practitioner-client relationship. During this stage, the importance is in establishing a relationship of trust within the organization that will undertake the change initiative. This will enable the practitioner to have open communication with key stakeholders to best evaluate the situation to later implement the necessary change program (Brown, 2011).

3. The third stage is the diagnostic process where the practitioner and the client analyze the information gathered that was essentially designed to identify the problem that is currently causing the issue. “A weak, inaccurate, or faulty diagnosis can lead to a costly and ineffective change program” (Brown, 2011, p. 14).

4. The action plans or interventions come in the fourth stage to implement the necessary changes through effective planning, organizing, leading, and controlling management functions. Of course, the purpose of the final stage is to measure the results.

5. Stage five centers on ensuring that the change program delivered the results that the organization and the practitioner set as the desired outcomes. In this final stage, modifications can be made if the change program is not delivering as promised or in sharp contrast stay the course if the results are being produced by the organization (Brown, 2011).

OD Approach to Change

Action research involves collecting information about the organization, feeding this information back to the client system, and developing and implementing action programs to improve system performance (Ali, 2011). Using Brown’s (2011) five stage model of change the process involved establishing a need for change and then applying fundamental knowledge of OD.

As presented in Figure 2, the integrated approach to change are structural, technological, and behavioral (Brown, 2011). The structural approach focuses upon changing the organizational design through adjustments to the lines of authority- moving from a hierarchical to team based problem-solving, communication, and decision making arrangement. The technological approach involves new computer systems and equipment. The behavioral approach emphasizes the people and human assets.

Figure 2 - OD Strategy: An Integrated Approach to Change

Note: Organizational Change Strategy. Adapted from Donald Brown (2011) in Organizational Development. (8th ed.). Saddle River, NJ: Pearson.

OD Interventions

A series of OD interventions based upon the stream analysis took place from 1998-2011 supporting an integrated approach to change. The OD practitioners and the leaders of the organization jointly diagnosed and planned these interventions over a 12 year period (see Table 1).

Table 1 - OD Interventions: Stream Analysis across the Years of the Study

The OD processes and tools from Table 1 facilitated team development not as an additive function of individuals becoming more effective team players but an entirely different capability (Wageman, Nunes, Burress, and Hackman., 2008). The OD interventions emphasized collaborative leadership and effective teamwork to successfully fulfill the vision of the organization. These interventions helped teams focus on improving patients, physicians, employees, and community experiences to transform current services and practices to better serve all stakeholder groups (Hawkins, 2010, 2017). Specifically, the OD tools and methods were organized into three clusters designed to provide structure and create a common language:

1. Inquiry and diagnostic instruments – psychometric instruments used to explore personal and interpersonal relationships on the team and among the teams; team appraisal questionnaires, and instruments including a team 360=degree feedback tool.

2. Exploration and action techniques were used during leadership meetings and off site advances (versus retreats) for exploring team dynamics and functioning to enable better collaboration and learning.

3. Alternative approaches to foster team innovation and creativity were applied using appreciative inquiry and solution focused practices.

The overall goal of the OD based approach was to develop collective transformation leadership that was built on the structure of teams. Applying the teams’ learning and wisdom by working together across disciplines, roles, borders, and self-interests in a way that had not been attained previously (Thorton, 2016). The core teams delivered value as measured by the patient, physician, employee, and community surveys conducted during the period on the interventions. In addition, the team member surveys provided a qualitative measure of the impact of the team organizational structure.

Analysis and Discussion: The “Lessons Learned”

Today, the teams at the hospital have been in existence for 12 years. The leadership teams have survived many challenges and changes in personnel. The hospital leaders and staff have accomplished an organizational transformation that has led them to excellence. The team methodology offered an approach to increase quality and profit and to restore the positive and purposeful spirit across the organization. A team approach is appropriate where interdependencies exist, where there is an organization-wide application of teams as a strategy, and where the systems support teams (Katzenback & Smith, 1993). “Collaboration among individuals or groups in a culture means working together at a significantly higher level than cooperation (Rose et al., 2006, p. 438).

Table 2 provides the engagement data from 1998 to 2011 for our study in this hospital, which shows a significant 17% increase in employee involvement in the spirit and purpose of this healthcare organization. As such, it can be concluded that any successful change and transition from a non-profit to a for-profit hospital must include a large percentage of the organization’s employees at all levels.

Table 2 - Employee Engagement Survey Overall Satisfaction Summary

*Note: Gallup conducted surveys during the study period.

Strategic Organizational Health Outcome

The core teams have been in place in various iterations for 12 years. What have they attained? What is the value added for all of the training, consultants, and employees’ time?

Selecting the appropriate outcome measures of organizational change efforts remains challenging, particularly when corporate culture is studied (Waldman et al., 2003). In this research study, the formation and development of team-based leadership structure, the focus and work of these teams led to measureable achievements in patient satisfaction, physician satisfaction, and employee engagement. Financial data, while studied, is subject to many “outside” variables that impact the financial outcomes.

Tables 3 and 4 present the results of the relevant metrics and key performance indicators of the team-based results-oriented strategy regarding satisfaction of physicians, nurses, and patients. For example, Table 3 shows that physician satisfaction survey results from which shows a positive and sustained trend in this longitudinal study.

Table 3 - Physician Satisfaction Survey Results Summary

Note: Surveys conducted by Data Management and Research, Inc.

Tables 4 - Patient Satisfaction Survey Results Sample During the Study Years

The Hospital Consumer Assessment of Healthcare Providers and Systems’ (HCAHPS) patient satisfaction survey results demonstrated an overall rating of the facility 73%, which increased year over year. In 2007, HCAHPS’ first national, standardized, and publicly reported survey of patients’ perspectives of care was implemented. They participated for the following reasons:

· It’s the right thing to do.

· Hospitals that do not participate will not receive the 2% annual payment update from CMS.

· In the future the annual payment update will likely be tied to how well a hospital performs on HCAHPS.

· When we excel, we can prove it and attract more patients.

Table 5 - Comparison of Gallup and HCAHPS Survey Elements

In terms of overall performance regarding the hospital’s budget over the 12-year period, financial data were analyzed as either “Did not meet budget”, “Met budget”, or “Exceeded budget”. As can be seen from Table 6, this hospital met or exceeded budget for most of the years, with the exception of one year during 2006.

Table 6 - Hospital Financial Performance: Performance to Budget Summary

Year Performance to Budget*

1 Exceeded budget

5 Met budget

6 Did not meet budget

8 Exceeded budget

9 Met budget

19 Met budget

11 Exceeded budget

*Note. Actual fiscal results cannot be presented due to propriety nature of the data.

Our study demonstrates that while employee engagement is very important and essential for success, there are many other functions (such as employee and patient satisfaction, financial outcomes, etc.) that all managers, employees and consultant must assess and track in order to bring about positive and goal-oriented changes in the organization, while increasing the probability of retaining the diverse and talented employees (Delapenha, Espinosa, Fabre, Lemon, Gibson, and Mujtaba, 2020; Udechukwu and Mujtaba, 2007). As a result of this longitudinal study for over 12 year period, we have compiled a list of various lessons that were learned. As such, the following principles and concepts are some of the lessons learned and provide insights into how the transformation was achieved.

Principle #1: For teams to be successful, begin with training.

Historically, in the spring of every year, the management staff held a retreat. The usual format was as a reward ceremony, a speaker or two, socializing and recreation--the typical off-site perk for management. In the spring of 1997 an experienced management consultant was brought in to do a three-day learning retreat instead (Hutton Consulting Services, 1997).

Instead of calling it a retreat, the CEO called it an Advance. The CEO believed in the power of words by creating the metaphors. They learned about Systems Thinking, Chaos Theory, team dynamics and how to better communicate with each other. They completed the Myers-Briggs Type Indicator and analyzed the results. They read Peter Senge’s (1990) book—The Fifth Discipline. They committed to move the culture toward a systems oriented shared leadership learning organization.

To begin to institutionalize the cultural transformation every manager was placed on a team after their initial team training. Six teams were formed: The Patient Satisfaction Team, The Employee Satisfaction Team, The Physician Satisfaction Team, The Community Satisfaction Team, The Values and Tradition Team, and a Core Team made up of the leaders and facilitators of each team to whom all the teams would be accountable. Managers could join any team they wished as long as it was not related to their regular job duties. For example, a manager whose job involved working with the doctors could not join The Physician Satisfaction Team.

Each team was given the task of forming a charter, developing a vision and mission statement, as well as establishing norms for operating. A team leader was chosen to lead the meetings and a facilitator was chosen to facilitate the meetings. The team members were taught team processes and team dynamics (Yeatts & Hyten, 1998), including the following:

· How to hold productive meetings, e.g., having an initial check in by members, an ice breaker exercise, a structured agenda, a timekeeper?

· How to fully participate?

· How to solicit feedback e.g., recap at the end where every member expresses how they felt about the meeting?

· How to hold each other accountable for coming on time and not leaving early?

· How to confront each other about their feelings and observations?

Each team was encouraged to be creative and to challenge the existing system and underlying assumptions in pursuit of achieving excellence in their particular area. Explicit permission was given to experiment with new ways of doing things and to take risks.

This is the part of teamwork that rarely gets the attention it deserves. For a team to function efficiently and effectively there must be a foundation for team success which involves determining goals and an understanding of the mission, setting strategies, and determining processes that will be put in place (Mathieu & Rapp, 2009). The organization must show commitment to the teams by providing resources, training, support, and authority. The individual members must be interested in the team and its mission, and the teams must have the knowledge, skills, resources, and commitment to achieve their goals. As in any endeavor, effective planning creates a foundation for success.

Principle #2: There must be an underlying value system and vision for the training.

The CEO knew what very few CEOs know about teams -- you have to have a philosophy and a vision that you believe in, teach, and continuously communicate. This CEO identified a vision of personal mastery and organizational excellence, a sense of value in teamwork, systems thinking, and a goal to become a learning organization. He desired to help people find the power within and help them to achieve their own goals in providing excellence to simultaneously achieve the same goal of excellence for the hospital.

The interrelated nature of each person’s role and how everyone working with each other is critical to success was deemed extremely important. Departmental barriers had to be removed. A new perception of the hospital had to be communicated and internalized. Only by trying new things and learning from each other would they be able to succeed. Collaboratively, the core values were developed by the hospital managers. These values were to be used to guide them in making decisions on a day to day basis as well as serve as a driver and filter for the long term decisions.

It was a requirement that every manager be a team member in addition to his/her regular duties. One either accepted these core values or needed to. Each team would meet every week for at least an hour and a half and would be accountable for producing measurable results. To support the framework for culture change to a team-based structure, one should remember that “collaboration results from shared understanding of issues, open communication, mutual trust, and tolerance of differing points of view” (Rose et al., 2008, p. 438).

Principle #3: There must be ongoing development and coaching of teams.

Management teams, similar to sports teams, need the assistance of ongoing coaching for their development (Coutu & Kaufman, 2009). You cannot simply provide instructions and put them on the field without someone to coach them. In a survey of 140 coaches 48% are hired to facilitate transition and 12% to address derailing behaviors according to Coutu and Kaufman (2009). The CEO set out to hire a coach for the teams and he knew something that very few know about coaches—they have to share your value system to be effective. He interviewed several consultants and each time he would ask if they had read the Fifth Discipline, or knew Chaos Theory, or knew their Myers-Briggs type. Each time he would hear something resembling the following comment: “Oh yes, I’ve heard of that, but now let me tell you about this great program that we have that is the newest, the best and greatest etc.” He continued the interviewing process until he identified a group that were experts in teamwork and shared his value system. After much discussion about experience, values, and approach, the CEO hired a consulting group to provide ongoing coaching for the teams (The Xaos Group, 1998). The consultants were psychologists, well versed in team dynamics and development.

The consultants provided coaching for the teams in real time. Too often consultants are brought in for training but they never get the opportunity to observe the teams at work. This can be equated to teaching the plays but missing execution at the practice. The best learning always occurs in the practice and the games, not in the locker room. During the first year, the primary consultants were in attendance on an almost weekly basis. As the teams developed, their physical contact became less frequent but never as infrequent as to cause a disconnect between the consultants and the actions being implemented at the hospital. They came with enough frequency to build and maintain trust with the employees. Both consultants led the Advances, while providing one-on-one coaching, and helped resolve the inevitable conflicts. They served as resources to the CEO, executive team, and all of the manager teams. They acted as coaches or guides rather than consultants and were wholly committed to the success of the hospital. They did not think for them but rather they learned to think with them to achieve goals and solve problems, “consistent with Center for Creative Leadership’s principles of effective coaching for helping leaders develop clarity of purpose, balance reflection with action, and highlight accountability for results” (VanVelsor, McCauley, & Ruderman, 2009, p. 129).

The culture of individualism existed in this hospital for many reasons, clinical versus nonclinical, medical versus nursing, business versus patient care, for profit versus not for profit, role, history, hierarchy, and title (Bate, 2000). The central challenge was to transform the culture to one common culture of accountability that is focused on the shared goal of patient care. The change required here was “big change and this is a collective effort involving multiple actors” (Bate, 2000, p. 500). The team structure, relationships, and skills training were parts of the overall organizational development effort and supported the dramatic change in the culture.

Principle #4. Sometimes a new face lends renewed energy to the project.

After two years of process coaching, the CEO hired a quality focused consultant to supplement the coaching (The Robbins Group, 1999, 2000). This individual was knowledgeable about reengineering, statistical processing, and quality techniques and tools. This consultant taught them how to identify who their customers were and how to define operational excellence. They were instructed on the use of descriptive statistics, fishbowl diagrams, histograms, run charts, scatter diagrams, control charts, Pareto charts, and surveys to collect and analyze data.

After four years, another process-oriented coach was brought in to work with the teams (Human Dynamics, 2000). The coaching team comprised of coaches with diverse expertise who worked together to make a smooth transition. The teams were benefiting from a new perspective and new energy. The initial coach felt that his impact was diminishing due to the fact that he had taught them most of what he knew. Too often companies retain consultants because of their knowledge of the organization and the comfort level that was created between the consultant and the organization. The question of whether the consultant has additional new information for the organization is overlooked.

The coaching continued as the new consultant became involved in developing the talent of the teams. Coaching is an ongoing activity for now, not a one-time opportunity. Coaches need to pay attention to the process, watching team dynamics and activities, analyzing its effectiveness, and determining what is missing, while identifying the obstacles and limitations to high performance. Team results are to a great extent shaped by group process as much as natural talent (Huszczo, 1996). Even highly competent and committed team members cannot achieve high performance if they are off target and unsynchronized. The constant diagnosis and examination of the team’s internal operations is required for the teams to successfully use their resources, make decisions, and solve problems (Nash, 1999).

Principle #5: There is more to learn than you ever first imagined.

In the spring of 1998, it was time for the next annual managers’ Advance. This off-site meeting was named The Advance to the Summit (The Xaos Group, 1998). The Advances continued from 1998 to the 2011 and are institutionalized in the organizational culture. The CEO started by taking all of the managers to the IMAX presentation of the climb to Mt. Everest. He gave them Margaret Wheatley’s book, Leadership and The New Science. The off-site meetings focused less on didactic teaching and more on experiential learning. In experiential learning, team members created metaphors and engaged in activities that served as the basis for learning. People received instant feedback on their ideas and behavior. The teams came together to experience success and failure. They created team names and team cheers. They gave each other one-on-one feedback. The learning and insights gained were not possible at the off-site before because the defenses were less and the spirits high. The managers reached a new level of teamwork that they could not have envisioned when this journey began.

In 1999 the Advance continued. This year they read Leadership Jazz by Max Dupree. Experiential learning and risk taking were encouraged. A fireside chat to bring out unresolved issues led to healthy conflict and constructive strategies of conflict management were practiced (The Xaos, Group, 1999).

In 2000, they held the meeting at a rural off-site location in the mountains. This year there were no hairdryers, no hotel bar, and no nearby shopping. It was just the team members in a corporate conference center in the middle of the Colorado Rockies. They continued to grow with an “Orienteering” outdoor experience and a High Ropes Course. They read Tuesdays with Morrie and talked extensively about living, dying, and the meaning of their lives (The Xaos Group, 2000).

Throughout the Advances they maintained ongoing commitment to self-awareness through the use of instruments such as the MBTI Form q, MBTI for Teams, FIRO-B, Change Style Indicator, and the Conflict Lens. Team functioning and dynamics were examined with the Campbell/Hallam Team Development Survey to develop action plans to augment performance.

The sharper the insights into each individual, the better the odds were of achieving high performance. “Healthcare organizations are social groups who pursue common purpose, share values and beliefs, and therefore possess a common culture” (Waldman et al., 2003. p. 6). The intentional training development of the leadership teams provided more than superficial understanding and appreciation of their colleagues and their abilities and tried to reframe their vulnerabilities into positions of strength. The teams looked for preferences, areas of expertise, and placed people in the right places and positions. Teams thrown together in a haphazard manner might have required recasting. At each off-site, the teams challenged themselves to learn more and risk more. They did not just ask their consultants to design an off-site. They took ownership and worked utilizing a collaborative approach to design meaningful presentations and experiences. The teams were transitioned into a foundation of strength in the effort toward high performance.

Principle #6: Sustained commitment is the hardest thing to achieve and embed.

The difficulties in gaining and maintaining commitment to achieve long-term success in radical change in a healthcare organization was addressed in general by Narine and Persaud (20003). They state that it is difficult to maintain long-term change momentum resulting in culture change. They state that each healthcare organization will be influenced by its specific characteristics as we illustrate in this organization.

True commitment is often not fully understood by many CEO’s. It is easy to get people energized for a short period of time, but how can it be sustained? This is why the newest and latest organizational interventions are attractive to practitioners. It is new, exciting, and easier to accomplish. Commitment takes creativity, follow-up, and a desire to fully achieve the vision. Matters of morale, trust, and loyalty cannot be ignored. The question is how do you get commitment and subsequently how do you sustain it? The corporate culture change at the hospital occurred through carefully structured and consistently applied development and training of the hospital leaders to obtain sustainable results (Waldman et al., 2003).

You sustain commitment by the process described above. You must keep your vision and values in front of your employees every day of the year. The most successful corporations are those whose leaders know how to continually repeat the vision. Scott McNeally of Sun Microsystems, Steve Jobs of Apple, and Jack Welch of General Electric are all are leaders who remained consistently committed to a vision and values. The CEO, the executive committee and the Values and Tradition Team forged this statement for the hospital: Foremost in our hearts and minds is the commitment to our patients. Therefore, we assume responsibility for everything that affects their care. We acknowledge our fellow employees, physicians, and board members as the source of our success.

It is the spirit of this statement that is spoken and acted upon on a daily basis at the hospital. “Therefore, we assume responsibility for all their care,” directs all of their decisions. It is their guiding principle. In the beginning of the entire process, when the coach spoke to the managers about the teams’ assignments he acknowledged to them that they were in effect just given a major assignment to do in addition to them already over packed jobs and duties. They all related well to this observation. Some were skeptical; most were enthusiastic. They were waiting for something to guide them through the rapid changes that were taking place—something to capture their spirit and ignite their feelings about the work of the team.

The coach had to ensure that they were on board emotionally and not just showing up. After three years he asked them what they thought of the team concept. They replied:

It is instilled a sense of pride and security in a chaotic and turbulent industry. …I believe teams will make the difference between being a hospital and a high performing organization. …It makes you feel connected and unified with a purpose. …One of my proudest moments was at a management meeting. It was a really great meeting. People were volunteering, happy, and talking.

Tom B. who had come back to the hospital after an absence could not believe who we had become since he had left. We are a whole new organization in 18 months. …I see the difference between our team meetings and other meetings I go to. How comfortable and effective we are. We had another consultant come in who was totally focused on getting things done—e.g., the slide show, the data, etc. He did not want to hear how the staff felt. We told him this is not how we do it here. I have 120 people in my department he had impacted and he had to know how they feel, because in the end this is how they will operate. This was a whole new concept for him.

We take the time to process when we have a conflict rather than backstabbing. …The behind the back chatting is gone. And I used to do it. It is no longer tolerated. We call people on it when they talk behind each other’s back. … It is more enjoyable now. We have gone through a lot. Initially it was hard. Now we are getting comfortable….It helped internalize and clarify roles and titles…Now with the teams I feel we can handle a crisis. … My morale was down. It gave me new life blood.

And Problems unresolved are no longer acceptable. …We now hand off the baton in the relay. We do not just lay it on the table and see if someone picks it up. We all take responsibility to see that there is a hand off and that the next person moves ahead. … We have learned to take the time upfront in all we do to avoid problems later. …Teams are what will sustain our system and our gains. Other programs get a quick blip and then regress. We see it as organic and not a one-time event. …We can implement ideas. This is the key. Many others have ideas but never figure out how to implement them. …It has gotten us focused on key areas that will make the hospital a viable hospital. … Others have isolated tactics and programs. We come from core beliefs and values. This will sustain us.

These are comments that every training department and consultant wishes to hear but rarely does. These managers “got it” and “used it.” The genius was not in just putting people in teams but in giving them a model, training and education, and ongoing support. The new attitude at the hospital can be summed up by one manager who remarked, I have never felt so proud and bonded so quickly to a place. Something is right about it. The hospital is a model for others to emulate.

There is strong evidence that employee attitude affects corporate culture and vice versa. Morgan and Ogbanna (2008) remark that “researchers have challenged the top management dominated organizational culture” (p. 39). The team-based leadership structure that evolved in this hospital involved over 50 leaders across the organization, including directors, managers, and physicians, and not just the five top executives. The lasting organizational culture change in this setting represented a mixture of subcultures, from business professionals, clinical managers, medical doctors, and nurse managers. Integrating multi-perspectives in the organizational culture change from the beginning facilitated a “multiple culture configuration” of different healthcare professional subgroups (Morgan & Ogbanna, 2008, p. 44).

Principle #7: In the end, it will be the results that matter most.

Identify the operational improvements that are most urgently needed. The idea is not to minimize the importance of intangible factors, as they are vital to the long-term success of the organization. Emphasize the factors that lead to the bottom line or that contribute directly to competitive positioning. For commitment, trust, loyalty, and morale are inextricably linked to team performance and accomplishment. Both the tangibles and intangibles are needed to achieve strategic health. The teams need to understand their responsibilities, state their performance goals, keep monitoring the goals, and providing necessary course corrections (Huszczo, 1996). As noted by Waldman et al., (2003), “focusing on system outputs, not interim outputs of component elements has implications for healthcare” (p. 8). Understand the systemic impact of the corporate culture and its relationship to multiple factors such as patient care, physician satisfaction, and employee engagement, which as this hospital knows, occurs when the patient is foremost in their hearts and minds, that is when healthcare can become a business first and foremost too.

Testimonials

In this study, we were able to achieve many qualitative testimonials from the participant leaders and some of are highlighted here. For example, a Nurse Manager mentioned that, “The hospital leadership experience has meant a great deal to me. During the last three years I have laughed, cried, been angry, and exhilarated by the experiences at Rose. The most important thing I learned is the value of self-evaluation and introspection. In an organization that is striving toward excellence. It must first begin within each person.”

Another Nurse Manager explained that “Until I experienced leadership at Rose, I never knew:

· My vision would become my most sacred possession.

· Values could be verbs, not just nouns.

· As a leader, I am a servant.

· What feedback was, much less how to put it into practice?

· That patients and physicians are my customers.

· How to be a role model, much less have the confidence to try.

· The power of a thank-you.

· That I could get Goosebumps driving into a parking garage.”

A Food Services Manager explained that “I have worked at 8 healthcare facilities in the last 13 years. Through the interaction within our teams and, at the Advances, I feel we have broken down traditional barriers between nursing and ancillary departments which has led to improved responsiveness and patient satisfaction. The improvement in my life has been that I have found a facility and leadership team that I want to be part of for years to come.”

Finally, an Information Services Manager explained that “One of the true benefits for me has been the focus on being a learning organization. Readings, dialogue, and putting what I have learned into my day-to-day operations has been challenging and rewarding. Until three years ago, I had been managing, now I am experiencing leadership. It’s a whole new experience to have administrators that see the value I offer and are willing to put time, effort, and dollars into my growth.”

Conclusion

This longitudinal action research study reported how one hospital, rocked by turbulent times and a move from non-profit to for-profit organizational structure succeeded in negotiating a radical change initiative. Meterko, Mohr and Young (2004) called for longitudinal studies to be done to provide much needed information about change efforts in the hospital industry.

This paper contributes to the body of knowledge about how leadership and a team-based culture can be used to improve patient satisfaction, employee engagement, physician satisfaction, and overall organizational performance. Furthermore, it provides an additional model for healthcare leaders as they attempt to guide their organizations through environmental complexity and change. Meterko, Mohr and Young (2004) noted that most work in this area is cross-sectional in nature and studies of the type reported in this paper are needed to better understand how the strategies impact performance metrics. In addition, the study describes how an entire management staff led by a committed CEO was able to use a team-based leadership strategy to achieve a changed organizational culture, increase leadership potential, improve quality of care, employee, physician, and patient satisfaction, and fiscal performance.

The study provides an example of the integration between theory and practice that underscores the need for multiple perspectives to solve the complex problems faced by teams. We see this integration as an implication of team training because the team-based intervention was built with an applied approach by the organization in the healthcare industry in conjunction with trained psychologists and coaches. Not only did the practical nature of team training make an impact, but the multidisciplinary teams serve as a testament to the effectiveness of diverse team composition and the power of teamwork in itself (Bisley et al., 2019; Salas et al., 2008). It may not be easy to work with others who subscribe to different (sometimes opposing) perspectives, yet the implications of team training demonstrate the positive impact on patients, physicians, employees, and the community.

The limitations of this study include the fact that a single hospital was studied and the experiences may not be generalizable to other hospitals of a different size or composition. Another limitation was that the patient satisfaction and employee engagement surveys were self-reported and may not be an accurate reflection of the attitudes held by respondents. Finally, the respondents in the patient satisfaction survey may be more satisfied than those who chose not to respond.

Compliance with Ethical Standards

· Conflict of Interest. The authors have declared that they have no conflict of interest.

· Ethical Approval. All procedures performed in this study were in accordance with ethical standards.

· Informed Consent. Informed consent was not necessary for this study.

· Funding information. There is no external funding for this research.

References

Ali, A. (2011, July 28). A Model for Organizational Development [Web log comment]. Retrieved from http://organizationaldevelopments.blogspot.com/2011/07/model-for-organizational-development.html

Altman, D., & Gurvis, J. (2006, March–April). Riding out the storm in the healthcare system. Leadership in Action, 26 (1), 19–22.

Armenakis, A.A., Harris, S.G. & Mossholder, K.W. (1993). Creating readiness for organizational change. Human Relations, 46(3), 681-704.

Barger, N. J., & Kirby, L.K. (2004). Introduction to type and change. Palo Alto, CA: Consulting Psychologists Press.

Barker, Joel. (1992). Bridging the leadership gap in healthcare. The Healthcare Forum Journal, 35, 49-64.

Bate, Paul. (2000). Changing the culture of a hospital: from hierarchy to networked community. Public Administration, 78(3) 485-512.

Berman, D., Naik, G., & Winslow, R. (2006, July 12). Behind $21 billion buyout of HCA lies a high stacks bet on growth. The Wall Street Journal, 20, 1.

Bisbey, T. Reyes, D., Traylor, A, and Salas, E. (2019). Teams of Psychologists Helping Teams: The Evolution of the Science of Team Training. American Psychological Association, 74(3), 278–289. Link: http://dx.doi.org/10.1037/amp0000419

Brown, D. (2011). An experiential approach to organizational development. (8th ed.). NY: Prentice Hall.

Brydon-Miller, M, Greenwood, D, & Maguire, P. (2003). Why Action Research? Action Research, 1(1), 9-28.

Bushe, G.R., & Marshak, R.J. (2008). The Postmodern turn in OD. OD Practitioner, 40(4), 9-11.

Bushe, G. R., & Marshak, R. J. (2009). Revisioning organization development: Diagnostic and dialogic premises and patterns of practice. The Journal of Applied Behavioral Science, 45(3), 348–368.

Center for Creative Leadership. (June, 2011). Addressing the leadership gap in Healthcare. Retrieved from http://www.ccl.org.

Chemers, M.M. (2000). Leadership research and theory: A functional integration. Group Dynamics, Theory, Research and Practice, 4(1), 27–43.

Coile, R.C. Jr. (1990). The mega trends - and the backlash. Healthcare Forum Journal, 33, 37-41.

Coutu, D., & Kauffman, C. (2009). What can coaches do for you? Harvard Business Review, 87(1). 91-97.

Connors, E. J. (1990). Reflections on leadership in health care: A conversation with Max DePree. Hospital and Health Services Administration, 35, 309-320.

Cummings, T. G., and Worley, C. G. (2019). Organizational Development & Change, 11th edition. Southwestern Cengage Learning: Mason, Ohio.

Cunningham, C. (2002, December). Readiness for organizational change: A longitudinal study of workplace, psychological and behavioral correlates. Journal of Occupational & Organizational Psychology, 75(4), 377–392.

Delapenha, C., Espinosa, C., Fabre, J., Lemon, P., Gibson, N. and Mujtaba, B.G. (August 2020). The SAS Institute’s Human Resources Practices in Diversity and Inclusion. Journal of Human Resource and Sustainability Studies, 8(3), 249-265. DOI: 10.4236/jhrss.2020.83014. Link: https://www.scirp.org/journal/paperinformation.aspx?paperid=102082

Fairfield, K. D., & Wagner, R. F. (2004). Whose side are you on? Interdependence and its consequences in management of healthcare delivery. Journal of Healthcare Management, 49(1), 17–29.

Fitzgerald, C., & Kirby, L. (1997). Developing leader: Research and applications in psychological type and leadership development. CA: Davies and Black Publishing.

Gauthier, A. (1994). Strategic Priorities. In Senge, Kleiner, Roberts, Ross & Smith, The Fifth Discipline Fieldbook. NY: Doubleday/Currency.

George, B., Sims, P., McLean, A., & Mayer, D. (2007, February). Discovering your authentic leadership. Harvard Business Review, 129-138. Reprint R0702H. www.hbr.org. Link: https://hbr.org/2007/02/discovering-your-authentic-leadership

Griener, L., Cummings, T., & Bhambri, A. (2003). When new CEOs succeed and fail: 4D theory of strategic transformation. Organizational Dynamics, 32(1), 1–16.

Greenwood, R. & Hinings, C. (1996). Understanding radical organizational change: Bringing together the old and the new institutionalism. The Academy of Management Review, 21(4), 1022-1054.

Hawkins, J. (2011, 2017). Transformational coaching, in the Complete Handbook of Coaching. eds F. Cox, T. Bachkirova and D. Clutterbuck. Sage: London

Hoffman, P. (August, 2009). No easy answers. and Healthcare H&H .com. Retrieved from http://www. H&H.com/

Huszczo, Gregory. (1996). Tools for team excellence- Getting your team into high gear and keeping it there. CA: Davies-Black Publishing.

Hughes, A. M., Gregory, M. E., Joseph, D. L., Sonesh, S. C., Marlow, S. L., Lacerenza, C. N., and Salas, E. (2016). Saving lives: A metaanalysis of team training in healthcare. Journal of Applied Psychology, 101, 1266–1304. Link: http://dx.doi.org/ 10.1037/apl0000120

Hutton, C. (1997, 1998). Hutton, Consulting. FL: Boca Raton.

Jessup, C.M. (2002). Applying psychological type and “gifts differing” to organizational change. Journal of Organizational Change Management, 15(5), 502–511.

Jung, C.G. (1923). Psychological types. Princeton, NJ: Princeton University Press.

Katzenbach, J. R., Smith, D.K. (1993). The Wisdom of Teams. MA: Harvard Business School Press.

Korman, K. and Mujtaba, B.G. (August 2020). Corporate Responses to COVID-19 Layoffs in North America and the Role of Human Resources Departments. Reports on Global Health Research, 3(2), 1-17. DOI: 10.29011/2690-9480.100122 Link: https://www.gavinpublishers.com/articles/review-article/Reports-on-Global-Health-Research/corporate-responses-to-covid-19-layoffs-in-north-america-and-the-role-of-human-resources-departments

Kotter, John. (1996). Leading Change. MA: Harvard Business School Press.

Marshak, R. J. (2013). Leveraging language for change. OD Practitioner, 45(2), 49-55.

Mathieu J. & Rapp, T. (2009). Laying the foundation for successful team performance trajectories: The role of team charters and performance strategies. Journal of Applied Psychology, 94(1), 90-103.

McLagan, P. & Nel, C. (1995). The age of participation- New governance for the workplace and the world. CA: Berrett-Koehler Publishing.

Meterko, M., Mohr, D., & Young G. (2004) Teamwork culture and patient satisfaction in hospitals. Medical Care, 42(5), 492-498.

Meyer, J. (2000, January 15). Using qualitative methods in health related action research, BMJ, 320, p. 178-181.

Morgan, P. I., & Ogbonna E. (2008). Subcultural dynamics in transformation: A multi-cultural perspective study of healthcare professionals. Human Relations, 61(1), 39-65. Doi: 10.1177/0018726707085945

Mujtaba, B. G., Cavico, F. J., and Senathip, T. (2020). Strategies for Personal, Organizational and Professional Leadership Success. Scientific Journal of Research & Reviews, 2(3), 1-10. DOI: 10.33552/SJRR.2020.02.000538. Link: https://irispublishers.com/sjrr/volume2-issue3.php

Mujtaba, B. G. and Senathip, T. (2020). Workplace Mobbing and the Role of Human Resources Management. Business Ethics and Leadership, 4(1), 17-34.

Musselwhite, W. C. & Ingram, R. P. (2003). Change style indicator facilitator guide. Greensboro, NC: Discovery Learning Press.

Nash, Susan. (1999). Turning team performance inside out – team types and temperament for high –impact results. CA: Davies-Black Publishing.

Narine, L. & Persaud, D.D. (2003). Gaining and maintaining commitment to large-scale change in healthcare organization. Health Services Management Research, 16, 179-187.

Provost, J. (1993). A casebook: Applications of the Myers-Briggs Type Indicator® in counseling (2nd Ed.). Gainesville, FL: CAPT, Inc.

Rapoport, R. N. (1970). Three Dilemmas in Action Research. Human Relations, 23(6) 499-513.

Robbins, William (1999, 2000). Robbins Group. TX: Austin

Rose, J. S., Thomas, C. S., Tersigni, A., Sexton, J.B., Pryor, D. (2006, August). A leadership framework for cultural change in health care. Journal of Quality and Patient Safety, 32(8), 433-442.

Salas, E., Diaz Granados, D., Klein, C., Burke, C. S., Stagl, K. C., Goodwin, G. F., & Halpin, S. M. (2008). Does team training improve team performance? A meta-analysis. Human Factors, 50, 903–933. Link: http://dx.doi.org/10.1518/001872008X375009

Sarwar, A., Maqsood, U., Mujtaba, B. G. (2021). Impact of Job Insecurity due to COVID-19 on the Psychological Wellbeing and Resiliency of Food Delivery Personnel. International Journal of Human Resource Studies, 11(1), 24-44. DOI: http://dx.doi.org/10.5296/ijhrs.v11i1.18075. Available at: http://www.macrothink.org/journal/index.php/ijhrs/article/view/18075

Senge, Peter. (1990). The Fifth Discipline. NY: Doubleday

Seymour, P. & Frost, D. (1998, 1999, 2000, 2001). The Xaos Group. CO: Colorado Springs.

Thorton, C. (2016). Group and team coaching; The secret life of groups. London: Routledge, Taylor, & Francis Group

Udechukwu, I. I. and Mujtaba, B. G. (2007). Determining the probability that an employee will stay or leave the organization: a mathematical and theoretical model for organizations. Human Resource Development Review, 6(2), 164-184. DOI: 10.1177/1534484307300239. Online at: http://hrd.sagepub.com/cgi/content/abstract/6/2/164.

Van Eyende, D. F. & Trcuker, S.L. (1996). Personality patterns of healthcare and industry CEOs: similarities and differences. Healthcare Management Review. 21, 87-95.

Van Velsor, E., McCauley, C., Ruderman, M. (2010). The Center for Creative Leadership handbook of leadership development. (3rd Ed.). San Francisco, CA: Jossey-Bass

Voges, K. E., Tworoger, L. C. & Bendixen, M. (2009). The role of organizational template in radical change. Journal of Applied Management and Entrepreneurship, 14(3), 27-48.

Wageman, R. (2001). How leaders foster self-managing team effectiveness. Organizational Science, 12(5), 559-577.

Wageman, R. Nunes, D, Burruss, J., & Hackman, J. (2008). Senior leadership teams. HBR Press.

Waldman, J., Smith, H., & Hood, J. (2003). Corporate culture. The missing piece of the healthcare puzzle. Hospital Topics, 81(1), 5-10.

Wheatley, Margaret. (1995). Leaderships and the New Science. MA: Harvard Business School Press.

Yeatts, Dale, E. (1998). High-Performing self-managed work teams. CA: Sage Publications.

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