M4 Assignment 1 Discussion

International Journal of Arts & Sciences,

CD-ROM. ISSN: 1944-6934 :: 5(7):423–447 (2012)

Copyright c© 2012 by UniversityPublications.net

LEADERSHIP-STRUCTURE- CULTURE AND PROPOSED CHANGE IN

INTERNAL MEDICINE DEPARTMENT OF MGMC (MAHATMA

GANDHI MEDICAL CENTER)

Pratiksha Gurnani

California State University Los Angeles, USA

As Professor Serge Zelnick often said during his lectures, change is tough, but it presents us

with an opportunity. Creating and managing change can be a real challenge, and ingrained

cultural attitudes are often barriers to change. In this study, I have focused on several key

questions that are important not only for the Mahatma Gandhi Medical Center (MGMC) but

also for every health care organization: What type of organizational structure exists right

now—that is, how are responsibility and authority assigned? What kind of culture exists in the

organization at this time? Which types of leadership behaviors and approaches are common in

this organization? In speaking about leadership, I also focus on the concept of business ethics

because I believe leadership is directly connected with ethical issues. Information technology

(IT) infrastructure is also a key to success, so I have considered IT as well. Correct use of

power and decision making are two of the most important ingredients for effective leadership.

Many organizations and leaders have failed or underperformed because of poor decision

making. (Kreitner, 2009, Beaufort B. Longest, FACHE and Hurt Darr 2008). Power and

decision making are integral parts of effective leadership and how they are distributed within

the internal medicine departmental system. I have used one of the two decision-making

models—classical and administrative. To analyze leadership within the department, I have

used a behavioral style theory of leadership and a situational theory of leadership. Based on

my analysis, I have made some suggestions for more effective leadership, which will

contribute to four important goals: (a) patient safety, (b) clinical quality, (c) staff–patient

satisfaction, and (d) financial stability. Proposed changes about leadership and future

strategies will contribute to cost effectiveness and better medical outcomes.

Keywords: Organizational structure, Effective leadership, Leadership behavior, Ethical

issues, Proposed change.

1. The Current State of Health Care in the United States

The founder of Dell computers once said, “Our business is about technology, yes. But it’s also

about operations and customer relationships”. (Solve Problem- Don’t Manage Them). Can we

say the same thing about the healthcare business? We cannot. In a typical business a direct

relationship exists between a product or service and suppliers and consumers; in health care the

normal law of supply and demand is disrupted. The health services are supplied directly to

consumers, but the payment for those services is not given directly by those consumers. The

payers for those services are either employer or the government or any other third party.

The Patient Protection and Affordable Care Act is an attempt to create a consumer-centered

health care system. However, as a part of U.S. health care, we are in transition and face an

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uncertain health care future. Our health care system is moving from pay for procedure to pay for

performance, meaning we have started taking baby steps toward eliminating medical errors and

improving the poor quality of health care.

The United States spends more money on health care than any other developed nation, and

different studies give ample reasons for these relatively high costs (Boffey P. ,2012, January 21

): (a) little willingness to ration medical technology or services; (b) high medication prices; (c)

higher prices charged by U.S. doctors and hospitals as compared to anywhere else within the

world ; (c) negative response to managed care; (d) high administrative costs; (e) higher percentile

of total gross domestic product (GDP) spent on health care , which translates into a high per

person cost; (f) medical model of delivery, with limited emphasis on disease management or

prevention; (g) practice variation for providing the medical services i.e. overuse and underuse of

services; (h) fear of lawsuits, resulting in defensive medicine (unnecessary tests); (i) high

malpractice premiums; (j) imperfect markets, where supply is stronger than demand and demand

is not sensitive to changes in price; (k) third-party payment mechanisms that shield consumers

from price; (l) payment by procedure; (m) no government price regulation; (n) little emphasis on

primary care practice and emphasis on specialization as result, more costly hospital stays; (o)

U.S. physicians lag far behind other developed nations in using electronic health records, which

can help to avoid costly errors and duplications; and (p) vast increase in specialists as compared

to the increase in primary care physicians.

According to a study published in the Journal of the American Medical Association, as few

as 2% of medical students are choosing to step away from radiology, ophthalmology,

anesthesiology, and dermatology or similar high-prestige and competitive specialties to pursue

general internal medicine (Chen, 2009).

The reasons specialists dominate the health care landscape include (Dr. Zelman, 2010):

(a) availability of information and procedures; (b) little restraint on consumer demand to see

specialists with the most up-to-date technology; (c) high incomes; (d) excellent medical

education, organized and controlled by specialists; (e) hospital-focused training; (f) focus on

intensive procedures and tertiary care; and (g) prestige among colleagues.

Medical specialization has increased the volume of intensives and invasive surgeries,

resulting in higher costs, over utilization of services and poor quality of care. Specialist-oriented

care has received all the focus, and little attention has been paid to disease prevention. (Zelman,

2010).

To reduce the imbalance between primary care physicians and specialists, a collaborative

team approach needs to be implemented. This approach leads to better patient outcomes and

more job satisfaction. Primary care physicians are the source for providing high-quality and

efficient care for patients. Some solutions to the shortage of primary care physicians would be to

create incentives for them to enter primary care, to have hospitals train them and direct them

toward primary care, and to increase the prestige associated with primary care. Market pressures

allow the drive for lower costs to generate more demand for primary care physicians (Pear,

2011).

Popular press releases highlight that the overall health coverage for Americans has been

improved dramatically over the last century. However, subsets of the population, including

people with lower socio-economic status, racial and ethnic minorities experience poor health

outcomes and problems with accessing quality healthcare services. As a result of recent health

care chaos, more than 50 million Americans are uninsured.

Leadership-Structure- Culture and Proposed Change ... 425

1.1. My Experience as a Help Line Counselor

I have been working as a volunteer help line counselor with the New York state consumer-

assistance program. The organization provides services such as free health- and insurance-

coverage information and advice to the uninsured, assistance in getting health coverage or the

best alternative according to the client’s situation, instructions on how to use health insurance

once the client is enrolled, assistance in getting the best care possible, and assistance in filing a

complaint with state regulators. Every week approximately 500 calls are answered and many

more voicemails. According to the different eligibility criteria for public health insurance

programs, every uninsured American should be able to take advantage of at least one option, but

very few people fit the criteria; the rest have to go with the charity care option. People become

frustrated when they try to get coverage through the public health insurance program (PHI),

because they are often just slightly over the eligible income limits for public health insurance

program and therefore not eligible. One client said, “I feel that I am getting penalized for

working because my friend, who doesn’t have a job, has coverage and I do not!” Another said, “I

have been eagerly waiting to get a reduction in my unemployment benefits so that I can get the

PHI coverage.” Many more stories can be told, but the point is that, even with low-income

subsidy programs, charity care facilities, special care programs, and better coverage and lower

premiums, PHI has been facing many difficulties in accomplishing its mission. Both private and

public options for coverage have a significant drawback: the first option is not affordable and the

second not available to many people. Meanwhile, Americans without health care are drowning

and going bankrupt, and no one is throwing out any life preservers.

Dr. Victor Fuchs, an emeritus professor of economics and health research and policy at

Stanford University, said “If we solve our health care spending, practically all of our fiscal

problems go away, and if don’t then almost anything else we do will not solve our fiscal

problems’” In his view, what is needed is a major change that comes once in a decade, perhaps,

or even just once in a generation. (Kolata, 2012).

The reason why I have mentioned about the current state of our health care and about my

experience is to drag the attention towards the required change in order to solve our health care

crisis. The change with new health age will contribute to cost effectiveness and better medical

outcomes. To execute the change successfully, the key ingredient is effective leadership.

2. MGMC and Its Internal Medicine Department

I am going to use the fictitious name of the hospital throughout the paper. The name I have

chosen for the hospital is Mahatma Gandhi Medical Center (MGMC). As I am going to talk

about effective leadership styles and some proposed changes for those styles, the best suitable

name came in my mind was Mahatma Gandhi who led the whole nation with his unique

leadership style. For my study, the department I chose vaguely is the Internal medicine

Department of MGMC.

MGMC was one of the first medical centers in the entire United States and in the Northeast.

MGMC is located on a 15-acre campus in a large city. Many people in the area are still aware of

MGMC’s reputation for handling a multitude of medical issues. In 1988, MGMC became a

private, nonprofit organization, and in the late 1990s, it was approved as a core teaching affiliate

with one of the schools of medicine in this large urban area, as well as with the College of

Osteopathic Medicine. MGMC provides services to the local inner-city community. MGMC

provides X beds, as well as every health need to the multicultural population it serves, from high-

426 Pratiksha Gurnani

tech infant care or adult surgery to inpatient rehabilitation. MGMC’s stated mission is

“enhancing life by offering health-care services with compassion” Its four-pillared vision and

goal is to provide patient safety, clinical quality, employee satisfaction, and financial stability.

2.1. Programs and Services within MGMC

MGMC has different types of programs and services (figure2) such as child and adolescent

behavioral health services; comprehensive spine institute; women’s health center; emergency

services; general pediatric center; heart institute; imaging center; eye care; nursing services,

outpatient physical therapy center; outpatient rehabilitation center; wound prevention services;

rehabilitation services; internal medicine; emergency medicine; dentistry and oral maxillofacial

surgery; behavioral health services; auxiliary services; and so forth.

2.1.1. Internal Hospital Structure

The organizational structure tells us about efficiency, effectiveness, and coordination within the

organization, as well as how staff is organized to get the job done. Figure1 shows the hospital ‘s

triad organizational structure.

Figure 1. Triad organizational structure of MGMC.

Leadership-Structure- Culture and Proposed Change ... 427

Figure 2. Programs and Services within the hospital

MGMC was the only hospital within the market area and nearby counties to be recognized with the prestigious Magnet Award granted by the American Nurses Credential Center’s Magnet

Recognition Program® in 2008. The hospital was named to Modern Healthcare’s 2011 list of 100 Best Places to Work in Healthcare. (100 Best Places to Work in Healthcare, 2011, August 22). The hospital has been recognized by the magazine as being an outstanding employer in the

health care industry on a national level. For the press release, the president and CEO of MGMC said that “we view this achievement as one more step in our campaign of ‘enhancing life’ and our journey to becoming one of America’s best hospitals.”

MGMC was also a big winner in the governor’s charity care funding plans for 2011. The governor announced an increase of $60 million in charity care funding next year, to treat the

uninsured.

428 Pratiksha Gurnani

Emergency medical services (EMS) at MGMC have been named an Innovation Hero in the

Healthcare Heroes awards program. Most important, these innovations have helped EMS set a

new standard for saving lives—in response time and the economical infusion of technology.

Using new technology and training, (Hudson county health care news, 2012, February 10).

Any hospital performance depends on four areas: patient’s safety, clinical quality, employee

satisfaction, and financial stability. The CEO of MGMC believes that the hospital performance is

pretty well right now; it will be even better. In fact, their goal is to be a world class health care

system.

As per my research I would say patient’s safety, clinical quality, employee satisfaction, and

financial stability can’t be graded without examining the organizational structure, cultural

dimensions, and the leadership style and behavior. The coming sections of the paper will talk

more about hospital performance support issues.

3. Question and Answer Session with Residents

The program director and the chief resident believe that MGMC offers a perfect field for internal

medicine training for a multi-ethnic resident staff, with emphasis on hands-on experience and

proximate patient care. The residents are growing into competent board-certified internists under

the guidance of well-qualified faculty representing a wide spectrum of specialties.

For better assessment, I asked first- and second-year residents a series of questions about the

department. I have listed some of answers here in this chapter and the other answers are

mentioned as bullet points in later chapters.

Pinkie

I heard that organization has been facing a sudden increase in patient load compared to past

years. What is the reason? How is your department managing this patient flow?

Resident1

Well, it is true at a certain level that some of the departments are facing a heavier patient load

compared to previous years. There can be two reasons for that: Patients are feeling the

improvement in services, in clinical quality, as well as patient safety and satisfaction. The second

reason can be that, within the market area, there are two hospitals that are in financial crisis, so

naturally they can’t maintain the quality of health care. Managing patient flow is teamwork

performed by self-motivated, young, hardworking, and efficient resident groups; a fully

supportive administrative department; and a well-qualified, enthusiastic faculty. All these people

are the strengths of the program. Furthermore, the program director makes a supreme effort to

create a warm, nurturing atmosphere in which to promote a “family atmosphere” among the

house staff and faculty.

Pinkie

During my degree program in health care management, I have learned that uninsured and

underinsured patients account for a large part of hospital expenditures. How are you handling

this situation as a team?

Leadership-Structure- Culture and Proposed Change ... 429

Resident2

Yeah, that’s true. Even though we are getting a huge amount of funds from the state just for

treating the uninsured, that’s just not enough to treat the uninsured and to maintain financial

stability as well. However, we are not just treating illness; we are more focused on the cause and

on preventative care. For the patients with multiple chronic medical conditions, we have free

health promotional programs per week, per month, and sometimes per year, which help them

keep healthy even with chronic conditions. We motivate and educate these patients through our

health prevention and health promotional collaborative approaches and help them to improve

their health and the quality of life. We have monthly community events in which our staff gives

free assistance and guidance to those who need to enhance the quality of health and life: for

example, monthly mammogram events, free diabetes camps, nutritional camps, the biggest loser

program, guidance for ostomy, epilepsy, etc. As a team, we are trying to give better care at lower

cost and lower utilization. I would say that, through the effective steps of evidence-based

practice management, a vibrant mentor system, and an open-door policy to the program

director’s office, where we get all the answers to our dilemmas, we have gained the leadership in

community-based health interventions.

Pinkie

Do you have any idea about the occupancy rate within your department? Do you have excess or

unused bed capacity within your department? What is the average waiting time for emergency

room visits?

Resident 1

No, the department of internal medicine never has unused beds. In fact, the department is facing

a higher occupancy rate that is above the limit. There is no chance for unused bed capacity. I

would say that the average waiting time between patient sign-in and initiation of care within ER

is around 95 to 100 minutes. The internal medicine department has a well maintained nurse–

patient ratio, which affects ER waiting time.

Pinkie

As it says on the main web page, the organization is doing well right now in four areas: (a)

patient and staff safety, (b) clinical quality, (c) patient satisfaction, and (d) financial stability.

What do the residents think about this? And what are the steps taken within your department to

be better or the best within these four areas? Please rate your department from 1 to 5 based on

customer satisfaction, decreased operating costs and financial stability, productivity

improvement, and enhanced competitive position.

Resident2

During the orientation of residency program; I read a quote by Watson Wyatt, which affected my

heart very deeply. Here it is: “Organizations, where staff understands organizational goals,

typically achieve 24% greater returns.” As I said earlier, the internal medicine department of

MGMC has an innovative and forward-thinking curriculum, which includes objective examples;

430 Pratiksha Gurnani

self-motivated young, hardworking, and efficient resident groups; a fully supportive

administrative department; and a well-qualified, enthusiastic faculty. All of them together are the

strengths of the program. Furthermore, the program director makes a supreme effort to create a

warm, nurturing atmosphere. As a team, we all are working hard to decrease operating costs,

improve productivity, and enhance competitive position. The department empowers the

providers to become leaders by promoting inclusion and respect to improve quality, safety, and

efficiency. Not only the department, I would say, but the whole hospital has improved its

position in financial stability compared to previous years. Moreover, MGMC achieved Quality

Nursing Leadership with the Magnet status in 2008. So, I would say, the whole hospital

gradually is doing better in all areas.

I would rate the department for customer satisfaction as 2, decreased operating costs and

financial stability as 3, productivity improvement as 4, and enhanced competitive position as 4.

Pinkie

I believe quality of care affects financial status of an organization and financial status of the

patient as well. What are the strategies your department is using to face challenges for enhancing

quality improvement?

Resident1

I hear pay for performance is the best way to improve quality of care, but, unfortunately, our

hospital is a charity care hospital, so the providers would not get paid that way. Strategies

include residents’ electives, by which they have been taught important quality-improvement (QI)

and error-reduction techniques and strategies. The QI improvement department is part of the

strategy: It takes care of all the departments’ quality and takes creative steps to improve quality.

The QI department is handled by consultants, physicians, and registered nurses. The QI team

keeps an eye on utilization management and error rates. They keep track of medical errors and

the misuse, underuse, and overuse of services and unnecessary tests and procedures and send us

the report with warnings and necessary steps we need to take to improve the clinical quality. A

third strategy is our quality-focused mission, vision, and culture development, which are already

here.

4. Leadership and the Four Pillars of Success

Leadership is the process of inspiring, influencing, and guiding others to participate in a common

effort (Kreitner, 2009) and the art of selecting and persuading people to work toward a common

vision and goal (Longest, 2008). Leadership is categorized into two types as follows:

• Leadership type 1: Formal leadership is the process of influencing others to pursue official

organizational objectives (Kreitner, 2009).

• Leadership type 2: Informal leadership is the process of influencing others to pursue

unofficial objectives that may or may not serve the organization’s interests (Kreitner, 2009).

Leadership-Structure- Culture and Proposed Change ... 431

A match between the leader’s style, behavior, and the situation leads to leadership effectiveness.

Situational factors include the job performed, the workplace culture, and the overall

environment.

4.1. The Evolution of Leadership Theory From the 1950s to the 1990s

Figure 3. The Leadership Evolution. From Kreitner, R. (2009). Management, 11 th

edition.

The trait approach (1900s–1950s) encompasses the idea that leaders are born, not made. The

focus of early leadership research has been to find personal traits distinguishing leaders from

followers. Later studies of leadership characteristics led to the conclusion that there are a few

general traits associated with effective leadership, such as self-confidence, stress tolerance,

emotional maturity, and integrity—but no trait or set of traits by itself guarantees leadership

effectiveness. Both the situation and the skill level of a leader have much to do with a leader’s

effectiveness. The situational approach encompasses the idea that leaders are made, not born.

(Kreitner, 2009)

I have used the behavioral-style and situation-based theories of leadership for my analysis.

Based on the results of that analysis, I have made some effective leadership recommendations in

the next chapter. Because of the current state of the health care system, the Internal Medicine

Department is not in a position to rely solely on theories, still based to the results some key

recommendations can be taken into consideration.

4. 2. Behavioral Style Theory of Leadership

The Blake and McCanse Leadership Grid is one of the best styles of leadership theory. The grid

represents Ohio State dimensions and Michigan dimensions of employee orientation and

production orientation. The grid has nine possible positions along each axis, creating 81

positions into which a leader’s style may fall. The grid shows the dominating factors in a leader’s

thinking regarding how to get results. The five key positions are focused on the four corners of

432 Pratiksha Gurnani

the grid and a middle-ground area.

Figure 4. The Blake & McCanse Leadership Grid. From Kreitner, R. (2009). Management, 11 th

edition.

On X Axis: Concern for Production

The desire to achieve greater output, cost-effectiveness, and profits.

On Y Axis: Concern for People

Promoting friendships, interpersonal relationships with co-workers, trust-based accountability,

and self-esteem for the individual.

4.2.1 Within the Leadership Grid Styles (Figure4)

(1, 9) Country Club Leadership. Primary/high concern for people; secondary/low for

production. Within the grid, leader’s concern is high for people’s needs and feelings and low for

direction and control, so production suffers.

(9,1)Authoritarian/Compliance Leadership. Primary/high concern for production;

secondary/low for people. People in this category believe that, to have productive and efficient

workplaces, employees’ needs should always be secondary. Leaders within this grid are

autocratic and have strict work rules, policies, and procedures. They believe that punishment is

the most effective tool to motivate employees.

(1, 1) Impoverished Leadership. Secondary/low concern for production; secondary/low

concern for people. Leaders within this grid position are mostly ineffective. They have neither

high concern for getting the job done nor for creating a work environment that is satisfying and

motivating. As a result, the workplace is full of disorganization, dissatisfaction, and disharmony.

(5, 5) Middle-of-the-Road Leadership. Moderate concern for production and for people to

maintain the status quo. Leaders within this style try to balance between two competing

concerns. Within this style neither production nor people needs are fully met. Leaders who use

this style settle for average performance and often believe this is the most anyone can expect.

Leadership-Structure- Culture and Proposed Change ... 433

(9, 9) Team Leadership. High concern for production; high concern for people

(commitment, trust, and teamwork). According to the Blake and Mouton model, this style is the

pinnacle of managerial styles, and managers perform best using a (9, 9) style. The grid proposes

that, when both people and production concerns are high, employee engagement and productivity

increase accordingly. This model offers only a framework for conceptualizing a leadership style;

it does not address the qualities that make an effective leader or which leadership style should be

applied.

4.2.2 Results based on survey

Using the questionnaire (Appendix 1) associated with the Leadership Grid, 2 team members

asked anonymously fill out the survey (Appendix 2) regarding the team leader’s leadership style.

The corresponding score to each of the questions are listed in the grid ; the average scores were

calculated for all questions relating to both the “concern for people” and the “concern for task”

categories. The results included a “concern for people” average of 5.1 and a “concern for task”

average of 5.00. So the resulted position within the grid is (5, 5.1) (Figure 5).

Figure 5. Plotted Position of Leadership Style within the Grid.

Based on the descriptions listed by Blake and McCanse, resulted style (5, 5.1) is called

“middle of the road” style. A leader with this style is called “compromiser,” “average

performer,” and “keep balance between people and task” (Bass, 1990).

The reason why the Blake and McCanse Leadership Grid was chosen to analyze the

leadership style of the team leader was due to its simplicity and efficiency in obtaining a specific

leadership style based on the observations of people who report directly to the team leader. It

would have been more effective if the leader was asked to fill out the survey about himself in

order to compare his own assessment of his leadership style to the answers ascertained from the

team members.

Within the Blake and McCanse Leadership Grid, the goal should be the position (9, 9) which

means team leadership If will be the result employee engagement, quality improvement, and

financial stability will increase accordingly.

434 Pratiksha Gurnani

4.3. Situational Leadership Theory

Based on the results from the Blake and McCanse leadership grid, I have chose Robert House’s

Path Goal theory to identify the qualitative position of the team leader. This theory is also known

as the path-goal theory of a leader’s effectiveness, or the path-goal model. The theory is derived

from expectancy motivation theory. The path-goal model can be classified both as a contingency

and a transactional leadership theory. The original theory (1971) says that a leader’s behavior is

contingent on the satisfaction, motivation, and performance of his or her subordinates. (Kreitner,

2009). The leader’s job is to assist followers in attaining their goals and to ensure that their goals

are compatible with the overall objectives of the group or organization.

The revised version (1996) adds more focus on group participation, in which the participants

are more intelligent and knowledgeable. (Kreitner, 2009) Path-goal theory assumes that leaders

are flexible and they can change their styles according to situations. According to the path-goal

theory, a leader’s effectiveness depends on two classes of contingency variables:

• Environment contingencies are outside the control of the employee (e.g., task structure,

formal authority system, and the work group).

• Employees contingencies are the personal characteristics of the employee (e.g., focus of

control, experience, and perceived ability). Personal characteristics determine how the

environment and leader’s behavior are interpreted.

Figure 6. Relationship between leadership Style and Effect in Various Situations. From Kreitner, R. (2009).

Management, 11 th

edition.

Leadership-Structure- Culture and Proposed Change ... 435

The path-goal theory implies that the same leader can display any or all leadership styles,

depending on the situation. The theory proposes that leader behavior will be ineffective when it

is redundant to sources of environmental structure or incongruent with subordinate

characteristics. The theory assumes that effective leaders can enhance employee motivation

through three different means: (1) clarifying the individual’s perception of work goals, (2)

linking meaningful rewards to goal attainment, and (3) explaining how goals and desired rewards

can be achieved.

This theory consistently reminds leaders that they need to help their teams to fulfill their

goals and objectives in efficient and effective ways (Kreitner, 2009, pp. 48, 53).

4. 4. Differences between Power and Authority

Power is the important ingredient for an effective leadership recipe. Before I talked about the

power distributed within the department, I would like to show the relationship between power

and authority. Figure below shows the relationship between the two.

Figure 7. Relationship between power and authority. From Kreitner (2009).

Power: The ability to marshal the human, informational, and

material resources to get something done.

• Power is central to effective leadership and can be

achieved through coercion.

• Power can reinforce authority.

• A prime source of power is the possession of

knowledge. A person with knowledge is oftentimes able to use that

knowledge to directly or indirectly influence the actions of others.

• Power affects decisions, behavior, and situations.

• Empowerment: Making employees full partners in

the decision-making process and giving them the necessary tools and

rewards.

• Threats to empowerment: dishonesty,

untrustworthiness, selfishness, and inadequate skills.

Authority: Authority is about who you are

as a person, your character, and the influence you have

built with people.

• Authority tends to be granted

through assent.

• Authority is one of the primary

sources of power.

• Sources of authority can come

from a position (such as duties and responsibilities)

delegated to a position holder in a bureaucratic

structure.

• For example, a CEO of the health

care organization has the authority to order a product

design change, or a police officer has the authority to

arrest an offender of the law.

4.4.1 Differences between power and authority according to Kreitner (2009)

4.5 Comment Bullets on Power as per Question Answer Session

Following are the bullets from the question-answer session regarding ‘the power’ within internal

medicine department.

436 Pratiksha Gurnani

• According to the team members, punishment power is used the least within the department.

According to Kreitner (2009) & Beaufort B. Longest (2008) excessive power may create the

rebels. So there should be least use of punishment power. The more we move toward

excessive or coercive power the more we experience resistance.

• The team believes that the expert power is used the most within the department. The team

believes expertise, special skills, or knowledge can influence the whole team. As jobs

become more specialized employees increasingly dependent on experts to achieve the goals.

• The team believes the team leader has expert qualities to lead with effective power source.

5. Comment Bullets on Rest of the Issues as per Question-Answer Session

5. 1. Cultural Dimensions & the Strength of Culture

Following are the bullets from the question-answer session regarding cultural dimension within

internal medicine department

• Organizational culture is the collection of shared beliefs, values (goals, priorities), buildings,

logos, rituals, stories, myths, and jargons that creates a common identity and sense of

community. Strong culture means better performance. Organizational culture is social glue

that binds an organization’s members together. (Kreitner, 2009).

• The internal medicine department’s culture is considered as the identity of the team.

• The team priorities are mission, vision and four pillars of goals.

• Department of Internal Medicine is proactive who believes to take opportunities; relationship

oriented and future oriented.

• The providers have been taught to be vision focused, treating the cause; not just the illness &

keep balance between testing and treatment.

5.1.1 The Strength of the department cultural dimensions:

• Patient confidentiality.

• Transparency of information.

• Frequency of communication.

• Habit of co-operation & mutual respect.

• Clinical quality and community based patient centered care.

• Promote internal integration, diversity & external connectivity.

• Evidence based teaching and practicing of medicine.

Proper training and education is given to enhance & overcoming the cultural dimensions.

5. 2. Information System

Following are the bullets from the question-answer session regarding information system within

internal medicine department.

Leadership-Structure- Culture and Proposed Change ... 437

• There is no fully integrated real-time visual display of all patient activity that is accessible

across all touch points right now.

• What is accessible: Patients reports, lab results, CT--scans, X-ray reports, previous

admissions medical records.

• What is not accessible: History, progress notes, and consults.

• However, EMR will be mandatory in health care world from 2012; it will take some time to

implement fully integrated EMR within their system.

• After the full implementation of Electronic Medical Record (EMR), the changes will be (1)

improving patient outcome (2) preventing healthcare errors, to reducing the operating costs

(3) improved sharing of patient information and medical histories.

• All these changes will be a huge benefit to all parties who are related to the department as

well as the organization.

5. 3. Ethical Hot Spots

Following are the bullets from the question-answer session regarding ethical hot spots within

internal medicine department.

• The team does believe that ethical behavior is the core part of their organization.

• They have been taught during the orientation that ethics are not a federal or state laws or

culturally accepted rules.

• The “House Staff Manual” has given the clear ethical guidelines for the different situations.

The providers have to follow the guidelines and they are not allowed to behave based on their

feelings.

• Patient confidentiality is their culture as well as part of the organization ethics too.

• Patient safety and clinical quality comes first in the list of organizational ethical behavior.

• Every organization has ethics specialist who plays a role in top management’s decision-

making process. The team believes that the hospital has better taken care by ethics

specialists.

• Even though organization and department both have to invest more in ethical training, ethical

behavior affects positively on staff motivation, consumer satisfaction & financial stability.

5. 4. Decision Making

Every organization grows, prospers, or fails as a result of decisions made by its leaders and

managers. The selection of a decision-making model depends on a manager’s personal

preferences, risk, uncertainty, and ambiguity. (Kreitner, 2009)

Following are the bullets from the question-answer session regarding decision making within

internal medicine department.

• Department of internal medicine empowers the providers to become leaders by promoting

inclusion and respect.

• Whole team takes part in the process of decision making for an important issues but the

actual decision is taken by the leader.

• Sometimes decisions have to be taken under situational pressure, under risk factor,

uncertainty or certainty.

438 Pratiksha Gurnani

• Team tries to find best suitable option according to the situation at that time; they think about

pros and cons of the alternatives; they avoid jumping on final conclusion very fast.

• The providers need to take immediate decisions to fight with illness, disease and death every

day so any theoretical model with ideal situations and ideal goal won’t be a good option.

I would like to differentiate the characteristics of two models so that we can determine the best

decision-making model for the Internal Medicine Department, as well as other facilities where

emergency situations can occur. The differences between the two decision making models are

shown below:

Leadership-Structure- Culture and Proposed Change ... 439

After reviewing the characteristics of both models, I would say the bounded rationality

model would be the best choice for the department, where the providers have to face the

challenges of life-and-death situations, resolve problems using intuition, and consider human and

environmental limitations.

6. Conclusion

Einstein’s definition of insanity is doing the same thing over and over and expecting different

results. The focus of department should be more on proposed changes and recommendations in

the areas of structure, culture, and leadership rather than on awards. Consistently making small

changes will eventually change the culture.

7. Proposed Changes and Recommendations

Because of its strong culture and structure, it will be difficult to implement a change in

leadership style for the Internal Medicine Department of MGMC. Even though change is

difficult, it is necessary for the department. Effective leadership is critical to organizational

success. There is no right or wrong answer for leadership effectiveness; it is a matter of

cautiousness. I believe leadership can be taught, as well as learned. The department’s leadership

needs to be more polished with some proposed changes.

Litmus Test Questions for Team Leaders to Enhance Leadership Capabilities

• What values should guide my actions as a leader?

• How do I best set examples for others?

• Am I playing favorites and self-interested things first?

• When things are unpredictable, how do I articulate my vision of the future?

• How do I improve my ability to motivate my team toward a common goal?

• How do I promote an environment for more innovation and risk taking? (Kouzes & Posner,

2002, p. xxiv).

I would like to recommend some key points for effective leadership based on the results

(appendix 2) of the leadership theories: (a) Blake and McCanse Leadership Grid (b) House’s

path-goal theory, and the ratings from the question and answer rounds for a modern trait profile

of leadership.

7. 1. Recommended Key Points for Effective Leadership Based on Both Theories

• Effective leadership can be achieved by the combination of transactional, transformational,

and charismatic approaches.

• These combinational approaches should be building commitment to the mission, effective

task accomplishment, focus on higher productivity and higher performance, higher employee

effort, higher satisfaction, strong personal commitment toward goals, and assertiveness and

self-confidence.

• Improve internal abilities to motivate team members through Maslow’s theory of motivation

and Management By Objective (MBO).

440 Pratiksha Gurnani

• Find something positive to say about your department that makes you different from the

other departments and for which you and your team are passionate.

• Balance between effectiveness and efficiency by monitoring the use of utilities and resources

while achieving the goals and objectives.

• Focus should not be solely on the quality of health care system output but also on health care

input.

• Try to be outspoken and soft spoken.

• Make oral presentations of written work.

• Team involvement in problem-solving, task forces, and decision making.

• Send out notices of accomplishment to top management, as well as seek opportunities to

increase name recognition.

• Expand contacts with senior personnel and create a network of professional people within

and outside the organization (Bock, 2006, pp. 16–17).

• Learn to practice reverse mentoring that helps upper management to learn about workplace

issues from junior mentors. (Cawood, 2011).

7. 2. Future Strategies for Improvement

For continual improvement in the areas of safety, quality, patient–staff satisfaction, and financial

stability, these important strategies should be implemented:

• Quality structure

• Learning organization

• Control system

• Motivational approaches.

7.2.1. Quality structure

Quality structure should be built with (a) a quality committee or governing body, (b) quality

coordination of care group, (c) clinical services group, or (d) decision support teams.

7.2.2. Learning organization

A learning organization is an organization skilled at creating, acquiring, and transferring

knowledge and modifying its behavior to reflect new knowledge and insights (Kreithner, 2009,

p. 46).

Peter Drucker said this about learning organizations: “The need for learning organizations is

due to the world becoming more complex, dynamic and globally competitive.” (Kreithner, 2009,

p. 46)

Stages of Organization Learning: (a) Cognition: learning new concepts; (b) Behavior:

developing new skills and abilities; and (c) Performance: getting something done

Critical Learning Skills: (a) solving problems; (b) experimenting; (c) learning from

organizational experience/history; (d) learning from others; (e) transferring and implementing

that knowledge; (f) changing behaviors according to the knowledge (Kreithner, year, p. 243).

Leadership-Structure- Culture and Proposed Change ... 441

Litmus Test Questions for Checking Whether the Department is an Effective Learning

Department or Not

• Is there any learning agenda or benchmark for the department?

• Is the department avoiding repeated mistakes?

• Is the department capturing critical knowledge before key people leave from the hospital or

department?

• Is there any encouragement for learning and knowledge sharing?

• Is there any encouragement for risk taking?

• Are employees empowered?

• Are there any post planning meetings?

According to the litmus test and the questions and answers with residents, I would say the

Internal Medicine Department is a type of learning organization, meaning it is not a perfect

learning organization, with all the critical skills and stages. The department lacks some important

key skills for learning organization. For an ideal learning organization, I would suggest

concentrating more on critical skills rather than on stages. If the department improves its skills,

the stages would automatically follow. The leader should place more focus on the step-by-step

process of skill improvement.

Some Suggestions for an Ideal Learning Environment in MGMC

• Willingness to change.

• Post action review meetings, in which key questions should be discussed, such as what the

plan for action was, what did the team do, where was the gap, what actions should be taken

the next time.

• Take actions to increase speed of learning than the competition.

• Benchmark key points for learning environment, learning process, and leadership that foster,

inspire, and motivate to accomplish goals.

• Evidence-based practice and lifelong learning.

• Open communication in external environment with free expression of opinions.

• Maintain healthy formal relations with staff through mutual respect and involvement in

decision making.

• Utilize the opportunities to learn and gain knowledge.

• Share knowledge throughout the organization via reports, information systems, informal

discussions, site visits, education, and training.

• Solve problems with learned experiences and gained knowledge.

• Experiment and implement the best results.

7.2.3. Control System

Control is any process that directs the activities of individuals toward the achievement of

organizational goals. (Zelnick, S. 2009). Control is taking preventative or corrective actions to

keep things on track. Purpose of the control function is to get the job done despite environmental,

organizational, and behavioral obstacles and uncertainties.

442 Pratiksha Gurnani

Some Suggestions for Effective Control System

The Internal Medicine Department of MGMC is in need of an effective control system through

which potential benefits can be maximized and dysfunctional behaviors minimized. An effective

control system will keep track of:

• Average patient waiting time.

• Injuries per 100 days.

• Patient satisfaction survey.

• Completeness and accuracy of clinical notes.

• Responsibility for identifying and evaluating risk.

• Safety and security and quality-improvement activities.

• Promote environment for more innovation, risk taking, evidence-based practice, and

prevention. (Zelnick S.2009)

7.2.4. Motivational Approach

There is a direct relation between workforce motivation and organizational success; the

leadership of the Internal Medicine Department lacks this important leadership behavior. I would

suggest improving the abilities of the leaders to motivate team members by using (a) Maslow’s

theory of motivation and (b) management by objective (MBO).

• Maslow’s Motivational Model for Leaders and Learners. Abraham Maslow developed

the famous theory of motivation, which is about understanding the needs that people have

and want to satisfy. Maslow’s hierarchy of needs pyramid shows five important categories of

needs. Everyone has some priority of these needs and if they are not alleviated in the related

sequence, he or she cannot think about something else. As one goes from bottom to top on

the pyramid, the needs become more complex. A team leader should motivate people and

create a work environment where the needs of everyone can be satisfied with good job

performance.

Figure 8. Maslow’s Pyramid of Needs. (Beaufort B. Longest, FACHE & Hurt Darr , 2008).

Leadership-Structure- Culture and Proposed Change ... 443

• Management by Objective (MBO). The very first outline of MBO was given by Peter

Drucker. Peter Drucker was a writer, management consultant, and self-described social

ecologist. He is one of the best known and most widely influential thinkers and writers on the

subject of management theory and practice. In 1959, Drucker coined the term knowledge

worker. This term shifted the entire focus of management thought to productivity-output and

away from work-effort input. He is known as the “father of management.” (Kreithner, 2009)

He introduced concepts such as cooperation between labor and management, decentralization

of management, and viewing workers as resources rather than costs. His emphasis on the

results of managerial actions and goals rather than the supervision of activities was a major

contribution.

b.1 The Characteristics of MBO

• MBO believes in comprehensive Management System based on measurable and participative

set objective.

• It is Popular in both private and public organizations.

• It is primarily used as a tool for (i) Strategic planning; (ii) Employee motivation; (iii)

Performance enhancement.

• Intentions for the Implementation.

• To improve communication between employees and management,

• Increase employee understanding of company goals

• Focus employee efforts upon organizational objectives

• Provide a concrete link between pay and performance.

• Core Factor within MBO system: Emphasis on the results achieved by employees rather

than the activities performed in their jobs.

b.2 The MBO Cycle

• Setting long-range company objectives in such areas as sales, competitive positioning,

human resource development, etc by top management team for the coming year. These goals

are passed on to the next layer of management and can be broken down further into goals for

different departments, eventually into goals for individual employees.

• Developing action plans by managers.

• Periodic review.

• Performance appraisal.

b.3 Strengths of MBO System:

• Three common components for all MBO systems.

• They require specific, difficult, and objective goals.

• The goals are not usually set unilaterally by management but with the managers’ and

subordinates participation.

• The manger gives objective feedback throughout the rating period to monitors progress

towards the goals.

444 Pratiksha Gurnani

At a minimum, a successful MBO program requires each employee to produce five to ten

specific, measurable goals.

• MBO blends planning and control into a rational system of management.

• MBO can have a very positive effect on an organization’s performance.

• Employees get strong input to identifying their objectives, time lines for completion,

• MBO forces an organization to develop a top-to-bottom hierarchy of objectives.

• MBO includes ongoing tracking and feedback in the process to reach objectives.

• MBO emphasis end results rather than good intentions or personalities.

• MBO encourages self management and personal commitments through employee

participation in setting objectives.

• Employees can receive no rewards or all available rewards depending on their performance.

The CEO reviews each employee’s pay recommendation, which is based on a self- and

managers performance evaluation. (Prabu V., 2009)

Even though MBO has some weaknesses, it has some strong key points, which encourage

companies to implement for getting better results in the areas of strategic planning, employee

motivation, and performance enhancement. I believe above motivational approaches will help to

increase clinical quality, employee satisfaction and financial status.

Acknowledgments

I would like to dedicate the result of my hard work to all my well-wishers: God Almighty, my

parents, my husband, my in-laws, and my friends. This paper would not have been possible

without the guidance and help of several individuals who contributed their valuable assistance in

the preparation and completion of this advanced field study. I would like to express my utmost

gratitude and appreciation to my dissertation advisers, Professor Serge Zelnick and Dr. Steve

McGuire, for their unselfish and outstanding support and their patience and encouragement while

I was completing this study. I am especially grateful for Professor Zelnick’s vast knowledge in

the field of managing health care organizations. Thank you both for your prompt replies to my

emailed questions. I would also like to express my appreciation to the International Journal of

Arts & Sciences publications team for giving me the opportunity to share my research.

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Appendices

Appendix 1: Questionnaire For analysis

Leadership-Structure- Culture and Proposed Change ... 447

Appendix 2: Results & Grid Position of team leader

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