Healthcare Administration Capstone Discussion 3

CHAPTER 9

Training and Development: The Backbone of Motivation and Retention

CHAPTER OBJECTIVES

• Acknowledge the importance of and necessity for employee orientation programs and ongoing training and development activities.

• Relate orientation, training, and development to the management functions of planning, organizing, directing, and controlling to employee motivation.

• Identify the components of effective employee orientation programs.

• Recommend an approach to communicating standards of conduct and behavior to new employees.

• Identify the components of employee training programs.

• Explore the availability of resources for training and development activities.

• Identify the components of the clinical affiliation/clinical practice program and contract.

EMPLOYEE DEVELOPMENT

It is a fundamental responsibility of every manager to endeavor to shape and enhance the behavior of employees so that they possess the necessary knowledge, skills, and attitudes to fulfill their assignments according to the policies, rules, and regulations of the institution. Advances in technology necessitate continual retraining of experienced employees to perform new and altered tasks. Training and staff development are the fundamental means by which behavior can be improved to meet the immediate and long-range needs of the institution.

Training and development are ongoing activities, beginning with the orientation of a new employee and continuing throughout the employee’s tenure with the organization. Participation in formal orientation and training programs must be documented for each employee, with copies of all reports provided to the employee for personal use and placed in the official personnel record of each employee.

Relationship of Training and Development to the Basic Management Functions

The need for sound orientation and training flows from several considerations. The mission and values of the organization usually include a commitment to quality. Certain organizational policies and practices usually reflect the intent and expectation that internal development—that is, promotion from within the organization—is the norm. Concurrently, the organization continuously seeks to meet its external mandates, which include requirements for appropriate orientation and training. The licensing and accrediting agencies include in their surveys and site visits reviews of such programs. Also, labor contracts may contain explicit provisions for training programs and related benefits, such as compensatory time for training programs attended at off-site locations. With the increased attention being paid to succession planning and the continuity of operations, cross-training for key positions has become yet another reason for managers to develop appropriate training programs.

Quality improvement programs and risk management oversight both require proper orientation and training. Management concerns such as employee evaluation or performance review, assessment of productivity measures, and the operation of merit and bonus pay programs all require—if only out of fairness to employees—that all workers be properly oriented and trained for their jobs.

The employee who knows what is expected and how to completely perform the work is likely to be a productive employee who experiences job satisfaction. When employees are generally satisfied, complaints, grievances, and job turnover decrease accordingly. The management team further assists employees in their personal development and their growth on the job by making additional training possible—for example, through tuition reimbursement benefits, release time for educational purposes, additional stipends for incidental costs (books, fees, travel), and so on.

As a practical matter, training is necessitated by the need for workers who possess specific knowledge and skills. When the labor pool in the area does not provide a ready source of specially trained support staff, managers must engage in planned training to meet their staffing needs.

ORIENTATION

A sound beginning for each newly hired employee provides a positive atmosphere of mutual expectation between the employee and management. Ideally, the formal orientation will be brief, highly focused, and completed on the worker’s first day of employment or as soon as possible thereafter. Orientation is a responsibility shared by the department head, the human resources department, and other designated specialists such as those in employee health and safety, information technology services, and public relations. The orientation program elements common to all employees are ordinarily developed and coordinated by the human resources department. Information and special practices associated with a specific department—that is, a departmental orientation—is the responsibility of that department’s manager.

General Orientation

The typical content of a general orientation program includes the following information:

• A brief history of the organization along with explanation of its mission and its vision

• The institution’s ownership form, mode of governance, and administrative structure

• An overview of the various departments and services

• A review of specific employee policies, including:

○ Drug, alcohol, and substance abuse considerations

○ Sexual harassment

○ Nondiscrimination issues

○ Conflict of interest prohibitions and gifts

○ Dress codes

○ Use of computers, accessing the Internet, using electronic mail (e-mail)

○ Computer security and passwords

○ Privacy and confidentiality of all aspects of patient care

○ Security, fire and safety, and disaster plans

○ Infection control

○ Review of the organization’s disaster plan

An additional portion of the general orientation ordinarily consists of a review of employee benefits, with direct assistance provided to new employees in signing up for such benefits. If workers are covered under a specific labor union agreement, the provisions of the applicable contract are explained at the general orientation.

The outline of the contents of a typical general orientation to a healthcare provider organization appears as Exhibit 9–1.

Departmental Orientation

The departmental orientation aspect of the new employee orientation is customized to the individual worker. The mission and goals of the department are shared. The departmental organizational chart, including names as well as job titles, is made available. The manager pays particular attention to acquainting the new worker with the other employees who will likely share common duties and work space. Preferably the manager will have made prior arrangements with an established member of the group to act as a “buddy” to the new employee to facilitate the transition into this new work environment.

EXHIBIT 9–1 General Orientation Contents and Checklist

The following checklist is initiated in General Orientation, following which it will be permanently retained in the employee’s personnel file. It is to be completed and submitted to the Human Resources representative at the conclusion of General Orientation.

Employee Name (please print)

___________________________________________________________________

Affiliate or Division (if applicable)

___________________________________________________________________

Department

___________________________________________________________________

Orientation Topics (Initial to indicate completion of each topic)

______ Organization’s mission, vision, and values

______ Organization’s history and structure

______ Overview of operations: how all departments work together

______ Bloodborne pathogens/tuberculosis control

______ Compliance mandate: standards of conduct

______ Confidentiality of patient-related information

______ Cultural proficiency: diversity awareness

______ Domestic violence and its signs

______ Electrical safety and the Safe Medical Device Act

______ Emergency preparedness (disaster plan)

______ Fire safety

______ Hazardous communications and the right-to-know law

______ Improving organizational performance

______ Risk management

______ Incident reporting

______ Infection control

______ No-smoking policy

______ Patient rights

______ Professional misconduct

______ Security management and crime watch

______ General age-specific competencies

______ Use of the organization’s property and systems

______ Internet, e-mail, and social media use

______ Introduction to personnel policy and procedure manual

______ Received identification badge

______ Completed and submitted confidentiality statement

______ Received and reviewed employee handbook and submitted signed receipt

Departmental policies, procedures, work standards, and productivity monitors, if any, are highlighted, with the understanding that these will be explained in detail during the formal training period. Issues relating to patient safety and privacy are reiterated, and the confidentiality statement is again reviewed and signed by the employee (if this has not already been done at time of hire or at the general orientation). So oriented, the new employee is ready for the transition to the training phase.

The outline of one possible departmental orientation schedule appears as Exhibit 9–2. The departmental orientation may vary from one department to another depending on the  nature of any given department’s work.

Of Special Concern: Standards of Conduct and Behavior

An organization’s code of ethics is reflected in its standards of employee conduct and behavior, which in turn are usually published in complete form in a personnel policy and procedure manual and in summary fashion in an employee handbook. Certain behavioral expectations should be emphasized with every new employee, and the new-employee orientation presents the best opportunity for doing so.

Conflict of Interest

An organization’s employees ordinarily retain the right to engage in outside business or financial activities as long as these activities do not interfere with the complete performance of their duties. It is necessary for the working healthcare professional to avoid both actual conflict of interest and any behavior that creates the appearance of conflict of interest. The issue of appearance is important; a perceived conflict may not in fact be real, but to the perceiver, perception is reality.

A conflict of interest occurs when one’s loyalty becomes divided between job responsibilities and some outside interest. A conflict of interest may be perceived when an objective observer of one’s actions has cause to wonder whether the actions are motivated solely by organizational concerns or by external concerns.

Conflict of interest is the area of ethical concern likely to emerge most often in the management of a department. Some of the following guidelines apply to employees at all levels, whereas some are most pertinent to specific employees (e.g., purchasing agents). Because many of these considerations affect employee behavior, they are important to every department manager. Whether you are a manager or nonmanager:

• Never place business with any firm in which you or your family or close outside associates have an interest.

• Derive no personal financial gain from transactions involving the organization unless the organization is advised of—and approves of—your potential benefit.

EXHIBIT 9–2 Department Orientation Contents and Checklist

This form is to be initiated by the department manager or other designated individual for each new employee’s department-specific orientation. Please complete the form and submit it to Human Resources following orientation; the completed form will be retained in the employee’s personnel file.

Employee Name (please print)

______________________________________________________________________________________

Affiliate or Division (if applicable)

______________________________________________________________________________________

Department

______________________________________________________________________________________

Orientation Topics (Manager, preceptor, or instructor should initial on completion of each topic)

_____ Welcome, tour of department, introduction to staff

_____ Department fire and life safety requirements

_____ General safety rules, specific hazards, personal protective equipment

_____ Infection control practices, if applicable

_____ Review of job description and performance expectations

_____ Reporting incidents and emergencies

_____ Department’s role in emergency or disaster

_____ Age-specific competencies, if applicable

_____ Work hours, schedules, time reporting, absence reporting

_____ Dress code

_____ Parking

_____ Employee health department and annual health review requirement

_____ Pay rate, pay cycle, pay increase policy, performance appraisal process

_____ Telephone use and paging process

_____ Grievance procedure and progressive discipline process

_____ Continuing education, mandatory requirements

_____ Other considerations (if any) unique to the employee’s position

______________________________________________________________________________________ I have reviewed the foregoing topics with my supervisor (or preceptor or instructor) during my orientation.

_______________________________________________________________________ Employee Signature

I have reviewed this employee’s completed orientation form.

_______________________________________________________________________ Supervisor Signature

• Conduct all aspects of a personal business venture outside of the organizational environment and on nonwork time. This guideline is regularly violated and often implicitly condoned by management through failure to address the offending behavior. For example, soliciting orders for cosmetics, food containers, jewelry, and so on during work hours is in violation of ethical standards. Also, using the organization’s equipment to make photocopies for a part-time activity or other outside interest is similarly in violation.

• In situations in which you have the authority to hire or so recommend, do not employ relatives.

• Do not solicit, offer, accept, or provide any consideration that could be construed as conflicting with the organization’s business interests, such as meals, gifts, loans, entertainment, or transportation.

• Do not accept gifts exceeding the maximum value established by the organization (limits may exist in amounts up to perhaps $50 but are commonly lower). Never accept gifts of cash in any amount.

• Safeguard patient and provider information against access or use for financial gain by unauthorized interests.

If in doubt, disclose the situation and seek resolution of an actual or potential conflict of interest before taking what might later be seen as an improper action. Questions concerning potential conflicts of interest can usually be addressed with the organization’s human resources department.

Finally, in many organizations managers and professionals are asked to sign a conflict-of-interest statement, indicating either the presence or absence of potential conflicts. This statement is usually the same as that executed by members of the board of directors.

Use of Organizational Assets and Information

It is the responsibility of all employees to protect the assets of the organization against loss, theft, and misuse. Neither may the organization’s property be used for personal benefit, nor may it be loaned, sold, given away, or disposed of in any manner without appropriate authorization.

The organization’s assets are intended for use for business purposes only during legitimate employment. Improper use ordinarily includes unauthorized personal appropriation or use of tangible assets such as computers and copiers and other office equipment, medical equipment, vehicles, supplies, reports and records, computer software and data, and facilities. Intangible assets such as intellectual property; trademarks and copyrights; and proprietary information, including computer programs, confidential data, business plans, and such must be protected as vigorously as tangible property.

It also is necessary to protect patient property and information in accordance with established policies requiring patient information to be shared only with those who are authorized to receive it and have a legitimate need for it.

The responsibility for protection also extends to proprietary information entrusted to the organization by vendors, referral sources, contractors, service providers, and others. This standard includes the requirement to use only legally licensed computer software, with the use of bootleg or pirated software considered illegal as well as unethical.

Concerning information, an organization’s ethical standards of conduct may set forth the following principles:

• It is prohibited to disclose proprietary information to anyone external to the organization, whether during or after employment, except as specifically authorized.

• All organizational property and information in employees’ possession must be surrendered on termination of employment.

Referral Practices

The laws governing Medicare, Medicaid, and other federally sponsored programs prohibit payment in any form in return for the referral of patients. The federal antikickback statute imposes criminal penalties for knowingly and willfully seeking or receiving payment for referring patients. The kinds of payments prohibited by the statute include kickbacks, bribes, and rebates. The Self-Referral Law (known as the Stark law) prohibits physicians holding a financial interest with an entity providing any designated health service from referring Medicare and Medicaid patients to that entity. The law also prohibits billing federal healthcare programs for items or services ordered by a physician who has a financial relationship with the billing entity.

These and additional considerations may be incorporated in an organization’s ethical standards of conduct in the following manner:

• No employee shall solicit, receive, offer to pay, or pay remuneration of any kind in exchange for referring or recommending referral of any individual to another person, department, or division of the organization for services or in return for the purchase of goods or services to be paid for by a federal program.

• No employee shall offer or grant benefits to a referring physician or other referral source to secure the referral of patients or patient business.

• No physician shall make referrals for designated health services to entities in which the physician has a financial interest through either ownership or a compensation arrangement.

• No physician shall bill for services rendered as a result of an illegal referral.

Political Activity

An organization’s code of conduct often includes an expectation that employees who participate in political activity will ensure that they are not doing so as representatives of the organization. There is, in fact, a legal prohibition against political activity by not-for-profit hospitals and nursing homes, and participating in political activity can jeopardize the employer’s tax-exempt status.

Employee Privacy

Although personnel files remain the property of the employer, the organization will have a privacy policy limiting access to these files to those persons having a legitimate need for the information. The policy will usually state that personnel information will be released externally only on employee authorization or in response to a subpoena or other legal order.

Patient Confidentiality

Records relating to or concerning individuals to whom the organization is providing or has provided service should be held in the strictest confidence. It is a violation of the ethical code of conduct to reveal patient information to anyone outside of the organization without the express written authorization of the patient (or the patient’s guardian, administrator, or executor), or a court order or other appropriate legal instrument. Within the organization, patient information is to be retained in confidence and revealed on a need-to-know basis only.

Employee Relationships

The following is a suggested model for the portion of an organization’s ethical standards of conduct addressing relationships with employees:

Every employee will be treated and judged as an individual on the basis of individual qualifications without regard to race, gender, sexual orientation, religion, national origin, age, disability, veteran status, or other characteristic protected by law. This pledge extends to all areas of the employment relationship, including hiring, promotion, benefits, training, and discipline.

[The organization] will conscientiously observe all federal, state, and local laws and regulations applicable in any way to the employment relationship.

[The organization] is committed to providing a work environment in which employees are free from harassment, sexual or otherwise. No employee will be made to feel uncomfortable in the work environment through exposure to coarse, profane, or sexual language or derogatory comments.

Employees are encouraged to express themselves freely and responsibly through established channels and procedures. Complaints will be treated as confidential information and will be revealed only to those who need to know as part of a process of investigation or resolution. Interference, retaliation, or coercion by any employee against an employee who registers a concern or complaint will not be tolerated.

We will observe the standards of our professions and exercise judgment and objectivity at all times. Significant difference of professional opinion will be referred to the appropriate management for prompt resolution.

We shall show respect and consideration for one another regardless of position, status, or relationship.

Contemporary Concerns: E-mail and the Internet

The use of e-mail and the Internet by business has been becoming more widespread for a number of years, and it is clear that their use will likely continue expanding for some years to come. These technologies have also been experiencing widespread personal use; in fact, their use in the personal realm may well be growing considerably faster than their business applications. The phenomenon of social networking has taken off to an extent that far exceeds the expectations of all but an optimistic few. Just as e-mail has always been able to do, social networking can and does intrude on business.

No modern business technology is more misused and abused than e-mail. E-mail is even more problematic than the next most misused and abused business technology, the photocopier. Many photocopiers, as we all know but frequently choose to ignore, handle a significant volume of non-business copying, ranging from cartoons, jokes, and recipes to announcements, schedules, and newsletters for outside organizations. E-mail not only carries a high volume of nonbusiness material, but—unlike the photocopier—also carries business information that is communicated in slapdash, generally careless fashion that frequently serves more to raise questions than to convey information.

If you have to spend one-third to one-half of your e-mail time sorting through unimportant communications and personal information before getting into pertinent messages, many of which you must then interpret or question before passing along or acting upon, then your e-mail is out of control. The discussion on communication offers specific guidelines for the business use of e-mail.

E-mail and the Internet have facilitated significant increases in efficiency in a number of activities, but they have also given life to a number of practices that are contrary to reasonable expectations of employee conduct. In other words, these modern computer-based conveniences are highly susceptible to abuse. For this reason, it is necessary to establish rules for their use.

Policy

Each organization should develop a formal policy governing the use of its Internet facilities, including e-mail systems, clearly stating that these technologies are to be used for business purposes only by employees and other authorized users and they are subject to the following standards and requirements.

Internet

Only authorized employees are allowed Internet access and then only for valid business reasons. Assigned account numbers and access codes are personal to each user and must not be shared with others. Management reserves the right to deny or terminate access to the Internet at its own discretion.

Employees do not have an expectation of privacy with respect to their use of the organization’s Internet facilities. Any and all messages, data, images, or other information received, transmitted, or archived using the Internet facilities may be accessed, copied, and used by systems administrators and management. Also, any messages, data, or images may be disclosed to legally entitled third parties such as regulators, law enforcement agencies, and courts. The organization reserves the right to monitor, log, and filter Internet access by employees.

Prohibited uses of Internet facilities include, but are not limited to, the following:

• Viewing, displaying, copying, or communicating libelous, threatening, or sexually explicit material, material that fosters a hostile work environment, or material that fosters discrimination of any kind as defined in the Civil Rights Act of 1964 and subsequent antidiscrimination laws

• Supporting an outside activity, whether a commercial venture, charitable or political cause, or other private undertaking

• Developing personal home pages

• Recreational “surfing” during work hours

• Playing games

Electronic Mail

All employees are advised that e-mail is available within the organization for business use only. Transmitting jokes, cartoons, recipes, personal messages, and other non-business-related information constitutes misuse of the organization’s communications capacity and misuse of work time.

All users of e-mail should also be aware that in spite of individual accounts and passwords, an individual’s e-mail can be readily accessed by unauthorized persons and may also be subject to monitoring internal to the organization. There is no expectation of e-mail privacy; all e-mail messages are potentially public.

Social Networking Media

These personal platforms of social interaction present a challenge concerning the right of an individual to free self-expression versus the organization’s need to uphold its mission and its public image. A few considerations come to mind. Yes, one has a right to free speech, but at the work site, issues such as the protection of patient privacy or the maintenance of a nonhostile workplace for employees must be addressed. How far can the employer go to limit the use of off-duty action, using personally owned devices? Certainly the generally accepted standards of ethical and professional behavior continue to be the expected norm. The use of the organization’s logo, badges, identification insignia, or symbols is another area where limits would be set. Orientation and training focusing on maintaining a nonhostile workplace could include a discussion of the impact of negative comments made about ethnic, religious, and similar sensitive topics on one’s social networking site. When a person chooses to make these attitudes public, they are, in fact, public and could be used as examples of how he or she is potentially biased. When an employee is under consideration for advancement, the information and views posted in these forums may well be included in the assessment.

Another aspect of social networking simply falls under the heading of rude behavior. At a meeting, when one or more attendees are sending or receiving instant messages, the message to the rest of the group is simple: these individuals do not value the interaction of the group and are being disrespectful of the other attendees’ time. In addition, these individuals, either inadvertently or by design, might be sending information about the proceedings to someone outside the room. As a general rule, employees should use electronic devices so that all those in their presence may feel psychologically safe.

TRAINING

An organized, formal training program designed to meet certain objectives is the most effective method of changing the behavior of employees. To establish such a program, the manager and those individuals involved in the organized training activities must (1) identify training needs, (2) establish training objectives, (3) select appropriate methods and techniques, (4) implement the program, and (5) evaluate the training outcomes. (See Appendix 9–A for excerpts from a training program designed for release of information specialists.)

Identification of Training Needs

The manager reviews various aspects of the work, including individual employee performance, to determine training needs. Such detailed review might include the following elements:

1. Comparison of specified job requirements (as stated in the job descriptions) with current or new employee skills.

2. Analysis of performance ratings. Where are workers having difficulty meeting accuracy or productivity standards? Where are errors concentrated? Is there a pattern of difficulty in some technical aspects of the work?

3. Analysis of personnel records and reports. Is there a pattern of lateness, absenteeism, accidents, safety violations, client complaints, or equipment damage?

4. Analysis of short- and long-range plans. These often indicate the need for training in new procedures or in skills for dealing with new client groups.

5. Analysis of current trends and changes in laws, regulations, accreditation standards, and new technologies. When new regulations or standards are promulgated (e.g., the False Claims Act required reporting) or new technological support becomes available (e.g., a new software program), retraining is required.

6. “Just-in-time” training. In rare circumstances, a group of workers might be pulled from their regular work and posted to a work situation where immediate, specific training is needed. Examples of these circumstances include blizzard or hurricane preparations, when patients need to have appointments canceled and rescheduled. A team of workers would receive the necessary training to make these calls, assess the patients’ concerns and needs, and make the new appointment. Another example of the use of “just-in-time” training is a situation in which all visitors must be screened or rerouted, such as during a pandemic. The screening team would receive instructions appropriate to the changing situation, perhaps as often as every 2 or 3 hours.

EXHIBIT 9–3 Analysis of Grievances (May to October)

A director of health information systems used an analysis of grievances over 5 months (Exhibit 9–3), a quarterly audit of the storage and retrieval function (Exhibit 9–4), and a 4-year long-range plan excerpt (Exhibit 9–5) to determine training needs. The first aspect of this overall analysis focused on the question: is this a systems problem or a training problem? Notice that six incidents in Exhibit 9–3 involved work standards and procedures, indicating a systems problem. Then notice that there are several incidents that indicate a specific training need—for example, a worker who is unable to meet work standards, the series of misfiles in the storage/retrieval area, and the supervisor and the uneven application of department policy.

The audit of the storage and retrieval system (Exhibit 9–4) leads the manager to review the system itself (dual system for historic reasons, available space and possible overcrowding, lighting, general “housekeeping”). The manager then notes that there are specific training needs—to make certain that the workers understand the two different filing systems and to review safety and ergonomics to prevent injury.

The short- and long-range plans for the organization and the department (Exhibit 9–5) provide yet another series of training needs. For example, as the healthcare organization undergoes its expansion of specialties (home care, hospice, sports medicine), there will be a need to train the health information specialists in the related aspects of documentation, coding, and registries appropriate to those services. There is a training need that is still conditional: the continuing implementation of the electronic health record, which depends on external mandates and regulations to implement this system. The manager would revisit the long-range plan periodically as training needs become certain.

EXHIBIT 9–4 Audit of Storage and Retrieval System: Legacy Files (July to September)

Percentage of misfiles—active records; terminal digit, color-coded system:

Percentage of misfiles—legacy records; terminal digit, color-coded system:	14%
Percentage of missing or incorrectly placed outguides:	11%
Percentage of loose reports misfiled in records:	8%
Percentage of “permanently lost” records:	4%
Percentage of records unavailable at time of appointment: (appointment request had clear patient ID)	33%

Number of Accidents/Incidents

Falls from ladder:	3
Back strain—moving/accessing boxes of emergency room reports:	1
Eye injury—hit in eye by falling outguide:	1
Bruised hip due to file cabinet drawer jammed open:	1

Other Problems Noted

20% turnover rate

All employees in unit = entry level

Poor “housekeeping” in inactive area; active storage = okay

Active storage area: terminal digit and color coded

Inactive storage area: middle digit and different color-coded record jackets

EXHIBIT 9–5 20×1–20×5 Long-Range Plans (excerpt)

Organizational Expansion:

Sports medicine outpatient clinic—juvenile sports injuries	July 20×2
Participation in regional telemedicine program	July 20×2
Affiliation with local university’s college of health professions	September 20×2
Home care and hospice program	July 20×3
Adolescent crisis day care program	January 20×4
Contract with regional industry-on-site clinic	January 20×4

Departmental objectives (in addition to plans stemming from organizational expansion):

Conversion to EHR: continuing development until completion in 20×4 (dependent on status or regulations and technology for EHR)

Move to new building—Campus #2 January 20×5

Once training needs have been identified, the manager must establish the objectives for the program. The objectives should be written in measurable terms and should state the specific outcomes to be achieved at the conclusion of the training program. For well-established, performance-related outcomes, the training objectives are specific and stated in measurable terms, because the desired results can be factually determined through recordkeeping. Written objectives serve as the fundamental guide for organizing the program and evaluating the desired outcomes.

This type of training objective is stated in stylized language. Usually each objective contains the following elements:

• The statement of the main focus (what is to be demonstrated or stated).

• The level of mastery or an acceptable performance level (e.g., “error-free” or “with 100% accuracy”). When mastery-level performance is adopted, a realistic time limit to obtain mastery (e.g., after a certain number of practice sessions) may be stated.

• Any conditions, such as use of specific regulations or use of designated equipment.

• A time frame or performance standard, which may be presented in stages, with an initial phase of untimed performance followed by progressively increased performance levels until the work standard is met.

These training objective elements may be stated in whole or in part at the beginning of the training design for each unit and need not be repeated. For example, the various activities or processes that the trainee carries out must be in “accordance with the specified policies and procedures.” Having stated this condition initially, the training specialist need not repeat it for each learning objective.

A second type of training objective focuses on affective matters—namely, values and attitudes. Their measurement is less tangible, so a performance level would not usually be stated. Exhibit 9–6 is an example of a training program that emphasizes the underlying values of patient privacy and dignity. Workers who are not involved in direct patient care could benefit from such a program in that their own understanding of the importance of their behind-the-scenes work will be increased. Direct patient care providers, who sometimes feel burdened by the “paperwork” requirements, could be given this opportunity to take a fresh look at how their documentation and review efforts foster a climate of positive values.

A third type of training objective is that associated with patient and family education. Examples include program offerings to such groups as parents of autistic children, family caregivers for patients with Alzheimer’s disease, and support groups for a specific clinical situation. The objectives of this type of educational offering include the following:

EXHIBIT 9–6 The Health Record: Mirror of Dignity, Privacy, and Patient Participation

The content of the health record reflects the important quality-of-life indicators of patient dignity, privacy, and participation in the treatment/care process. The policies and practices associated with health record systems and functions support these considerations. Review of institutional policies and practices provides both management and caregivers with a tool for assessing commitment to these values. Participants in this training session will have an opportunity to increase their understanding of the underlying values that find expression in the documentation and review processes. Specific attention will be devoted to the following topics:

1. Quality of Life: Indicators of Patient Care

2. The Health Record: Mirror of Dignity, Privacy, Choice, and Participation

a. Patient rights documents

b. Consent for treatment

c. Guardianship and power of attorney

d. Use/access of one’s own financial recourses (as in a long-term care facility)

e. Patient care plans, with specific emphasis on patient and family participation

f. Supportive care plans in end-of-life situations

g. Activities therapy plans, including the specific expression by the patient about declining to participate in some activities

3. Health Information Processes and Practices

a. Relationship of these processes and practices to the protection and enhancement of privacy and dignity

b. Specific practices:

i. Release of information

ii. Correlation of financial/billing information and documentation

iii. Timely and thorough review of documentation during the inpatient stay and at time of discharge

4. Audit Topics

a. Privacy and dignity: compliance with external directives and the organization’s mission and core values

b. Participation by patient in healthcare decisions: comparisons of patient expressions of wishes and values with elements in the plan of care

c. Compliance with end-of-life (“living wills”) directives

1. Providing information about community resources

2. Enabling participants to use support services

3. Coming to terms with the limits and the possibilities associated with the given clinical situation (e.g., stroke or breast cancer survivor)

4. Strategies for dealing with individuals (including family and neighbors as well as the general public) who are not familiar with special needs associated with a given clinical situation (e.g., an autistic child)

A measurable outcome would not be included in a general program offering, but when such training is part of the patient care plan, monitoring of progress would be included.

Training Module Content

Detailed content is developed for each sequence of the training module when the training plan focuses on performance outcomes in job-related training. The manager takes care to use materials consistent with professional standards. Materials made available from professional associations are reliable and up-to-date. There is an advantage to using such resources: these training materials represent best practices and widely accepted methods. They have been developed and vetted by teams of experts and supported by research. They are revised on a regular basis to reflect changes in requirements. The testing materials have been developed by experts in testing design. The materials reflect the body of knowledge required for certifications at various levels.

The manager augments these standardized materials with information specific to the organization. Finally, the manager sequences the training modules in logical order. For example, a training module on the release of information would follow a training module on the Health Insurance Portability and Accountability Act (HIPAA).

Training Methods and Techniques

The manager has many training methods available to achieve the desired outcomes. The methods most often used are profiled next.

Job Rotation

Job rotation is a popular approach to staff training and development. Under a rotational scheme, job assignments may last anywhere from 3 to 6 months. This approach gives an employee the opportunity to acquire the broad perspective and diversified skills needed for professional and personal development. Job rotation can also be used to introduce new concepts and ideas into the various units within the department and to help individual employees to think in terms of the whole program rather than their immediate assignments.

Job rotation also supports the concept of cross-training. In cross-training, employees working in different jobs that are comparable in pay grade and skill level are trained in each other’s jobs. This provides the manager with increased flexibility in covering positions in times of absence or fluctuating demands, and it provides employees with variety in their work and the opportunity to learn and grow.

Formal Lecture Presentations

The lecture method is one of the oldest techniques used in training and development programs. The fundamental purpose of the lecture is to inform. The lecture format saves time because the speaker can present more material in a given amount of time than can be presented by any other method. The lecture should be supplemented by visual aids, however, or the results are likely to fall short of the instructional goals. During the lecture, employees are passive. Outside disturbances or mental wanderings frequently distract individuals and render the lecture ineffective.

Seminars and Conferences

The major purpose of seminars and conferences is to allow for the exchange of ideas, the discussion of problems, and the formulation of answers to questions or solutions to problems. The opportunity for employees to express their own views and to hear other opinions can be very stimulating. Employees who actively participate are more committed to decisions than they would be if the solutions were merely presented to them. Remember that true and lasting learning occurs in direct proportion to the amount of individual involvement in the discussion process.

Role Playing

Acting out situations between two or more persons is a training method used successfully with all levels of employees. Interviewing, counseling, leadership, and human relations are a few of the content areas in which role playing has been used. By playing the roles of others, employees gain valuable insight not only from their own actions, but also from the comments of observers.

Committee Assignments

Through committee assignments, employees can explore topics or problems to gain a broader or new perspective, experience situations involving the resolution of different ideas, learn to adjust to someone else’s viewpoint, and practice reaching decisions. Committee assignments also offer opportunities for employees to assume positions of leadership that they would not otherwise have.

Case Studies

Based on the premise that solving problems under simulated conditions enables employees to solve similar problems in actual work situations, the case study method requires employees to become actively involved in problem-solving situations, either hypothetical or real. The case studies used in developing problem-solving skills should be carefully selected and pertinent to the job so that their use meets the training and development requirements of the employees.

Program Implementation

Throughout the implementation phase, the physical and psychological environment must be constantly monitored. For example, the time schedule, the learning environment, and the pace need to be checked periodically.

The primary consideration in any training program is the establishment of a time schedule to provide the greatest educational impact possible without reducing work output or, in healthcare institutions, patient care. The training program and the methods to be used should be announced well in advance. This approach allows everyone involved sufficient lead time to arrange individual schedules so that work assignments can be adequately covered during the employee’s absence.

The arrangement of the room in which the training is to occur can either promote or handicap the process of learning. It is important to ensure that each participant can see and hear each member of the group. The traditional classroom setting in which the “teacher” sits in the front of the room and the participants are seated in neat rows should be avoided whenever possible, because it creates a stiff and formal atmosphere. One of the best arrangements for a training session is to put the tables in an open-ended rectangle, with chairs placed only on the outside perimeter. In addition, the room should be well lighted and adequately ventilated.

The pace and timing of each session are also important during the implementation phase of a training program. The function of pace is to maintain interest; therefore, the pace should be quickened when interest begins to wane, or it should be slowed if individuals are having difficulty absorbing content. A training session should not last longer than 2 hours. In fact, a 1-hour session is believed to produce better results. If a 2-hour session is necessary, a break should be allowed at the midpoint. Common sense and individual attention spans dictate how long adults accustomed to active work can be kept relatively immobile.

Evaluation of Outcomes

Probably the most difficult aspect of a training program is evaluating the outcomes to determine whether they are or are not what was desired. This difficulty arises because there are no concrete and precise measuring tools for assessing changes in behavior and attitudes. Outcomes must be measured indirectly and conclusions based on inference. The evaluation is not just a single act or event but an entire process. Evaluation is made easier, however, if objectives have been clearly stated in measurable terms.

A before-and-after comparison may be a useful way of evaluating change. If the manager and those individuals involved in the training program assess the behavior factors they wish to change before training and examine the same factors after training has been concluded, they can determine if a change occurred.

For material of a factual nature, where precise knowledge should be demonstrated, fact tests are used. More commonly, however, trainees are evaluated through performance tests. Each trainee has activities to carry out; these are drawn from the usual work of the job. The final evaluation may be carried out in stages: practice activity, followed by real work activity under immediate supervision, followed by real work activity with diminishing levels of immediate supervision.

The evaluation brings the training process full circle. Each trainee has been given specific objectives to attain, appropriate didactic and practice materials have been explained, and practice activities with appropriate feedback and correction have been provided. The evaluation, therefore, consists of determining the trainee’s capacity to perform the work outlined in the job description and specified through the detailed policies and procedures of the department.

Resources for Training

The manager should endeavor to provide timely and thoroughly developed training materials. The cost of training materials and the time to be expended are also factors to consider. The manager can use to advantage the many programs developed by professional associations. For example, the American Health Information Management Association has developed training programs for coding, making it easier for health information department employees to enhance that particular skill set. Distance learning is yet another option in which both technical and professional-level courses are readily available.

Some topics are common to several disciplines, thus enabling the management team to share resources and split the cost over multiple groups of employees. The training material for HIPAA implementation represents one such training program that is suitable for interdepartmental use.

Training, while desirable as well as necessary, can be costly. Budget decisions and justification for such expenditures may be systematized by reviewing training resources against a set of criteria. Exhibit 9–7 reflects such an assessment. Good, solid justification of necessary training activity is essential. Surely every department manager has heard executive management consistently praise the value of training when conditions are at least stable financially. Nevertheless, when a financial crunch arises and it is necessary to reduce expenditures, the education and training budget is often one of the first areas cut.

Addressing Diversity

It is highly probable that the majority of healthcare managers will be called on to manage increasingly diverse work groups. The diversities encountered in the workforce may be rooted in ethnicity, religion, race, gender, or social differences, but in the work organization all of these areas of difference have been gathered under the term cultural diversity or just simply diversity. This term represents a broad range of differences, also implying, for example, differences in values, assumptions, expectations, and needs.

EXHIBIT 9–7 Budget Justification for Training Resource

Title of Resource:	Confidentially Speaking: Keeping Patient Information Private
Sponsor:	Norton and Collins, Inc.

Target Population:

• New employees of Health Information Services

• Students accepted for clinical internship in Health Information Services

• Employees needing a refresher course in basic principles

Job Skill:

Fostering and maintaining confidentiality of patient information

Cost:

• Two-part video:	$104.00
• Shipping and handling:	$11.00
• Total cost:	$115.00

Additional notes:

1. Video can be reused within the department.

2. Video can be loaned to other departments.

3. Video content has been reviewed by experts in the field of HIPAA compliance.

4. Content meets continuing education approval by national association.

Labor projections continue to advise organizations that in the early decades of the 21st century, the majority of new entrants into the workforce are likely to be women, minorities, and immigrants. This has become true in a number of areas of health care.

It is reasonable to assume that the majority of people are most at ease around others who look, think, and act as they do. However, these days rarely do people of a single cultural group populate an entire function, department, or organization. Rather, it is common to find most employee populations culturally mixed to some extent. Lack of understanding of the differences between and among cultures gives rise to difficulties for the manager, often indicating the need to train managers and staff in matters of diversity.

Workplace tensions can arise from failure to recognize or understand cultural differences, and these tensions can cause interpersonal conflict, reduced productivity, absenteeism, turnover, and charges of discrimination and other legal complaints. In addition, communication problems arise from language and literacy concerns related to individual background, and other issues develop from lack of cultural awareness and respect.

In the workforce in general, it is now and will become increasingly more necessary to interact with people who have different values and beliefs. Increasing diversity in the workforce is unavoidable, especially in health care. In health care, diversity is present at all working levels. Although in health care, diversity is greatest in the entry-level positions in housekeeping, nursing assistance, and food service, it is also significant in professional areas such as nursing service.

Recognizing Differences

In the absence of knowledge of cultures other than our own, people incline toward stereotypes in their thinking about others. Although stereotypes are usually superficial or simply wrong, they nevertheless tend to influence thinking and decision making.

A manager should be able to respect each employee as an individual and hold all employees to the same standard of job performance. Yet in the one-to-one relationship between manager and employee, the manager must recognize individual differences that are culturally based. A few examples of differences one may encounter as a manager are:

• In some cultures, prolonged, direct eye contact is acceptable, whereas in others it is considered rude and improper.

• People from some cultural backgrounds believe it is disrespectful to offer opinions or suggestions to a superior (potentially quite frustrating to the manager who wants employee input).

• Workers from some cultural backgrounds are uncomfortable with being singled out in any way, even for praise.

• Workers from some cultural backgrounds will point out their own successes with pride, whereas others will remain silent no matter how successful; to them, self-praise or self-promotion is not acceptable behavior.

• In some cultures, physical touching or entering another’s close personal space is acceptable, but in some it is not.

• Some male workers from certain cultures may be extremely ill at ease reporting to a female manager.

These and other factors add up to numerous individual differences that a manager may have to account for in relating to each individual member of a work group.

In the Manager–Employee Relationship

All employees should be expected to adapt to the reasonable requirements of the job and the workplace as necessary, but they always bring their individualism to the job as well. The effective manager always remains aware of individual differences and respects these differences in the relationship with each employee.

It is also to the manager’s advantage to become familiar with applicable aspects of antidiscrimination laws. In reacting to culturally based individual differences, it is sometimes possible to unintentionally enter into discriminatory practices out of ignorance of the law.

What about Diversity Training?

Every healthcare employee, and especially every healthcare manager, stands to benefit by attending a sound cultural diversity program and making a determined effort to learn about the cultures prevalent in a department or organization. The manager must not only successfully relate to each employee but also must deal with the interactions between and among employees to ensure that equal treatment, opportunity, and respect exist for all. It seems at times like a nearly impossible task to treat all employees alike regarding observance of policies while recognizing and adjusting for cultural differences among employees.

Along with the term cultural diversity, one is also likely to hear of cultural competence or cultural proficiency. Diversity itself must be prevalent and valued before one may be considered culturally competent or culturally proficient. Thus, in promoting the need to value diversity, the organization is encouraging the process of including the perspectives of underrepresented, nondominant groups to ensure they have a voice in the organization.

The shape and substance of any particular organization’s diversity training will depend considerably on the cultural mix within the organization. There are, however, a few general guidelines to keep in mind when considering diversity training:

• As with total quality management and other organization-wide undertakings, diversity training must have the visible participation and support of top management. Many potentially beneficial programs have withered and died because top management either did not provide visible support or provided token support at the start before backing away.

• Anecdotal evidence suggests that the most effective diversity training programs are those conducted by outside providers engaged for that purpose. When presented by insiders, there is sometimes the perception that the division or department presenting the program is advancing its own agenda.

• The presenters of the most effective programs should be seen as more or less culturally neutral. That is, no single underrepresented group should be seen 

might perceive that this group is simply advancing its own agenda.

• Even highly successful diversity training should be repeated or reinforced periodically. For many participants, such training is counter to lifelong beliefs, attitudes, and prejudices that cannot be erased or altered by a one-time presentation or program.

It is clear that in the coming few decades, the more effective organizations will be those that successfully manage workforce diversity and tap the maximum potential that each employee has to offer.

MENTORING

Professional practitioners may find themselves in the special teaching role of mentor. Mentoring is a process in which a more experienced and usually older person guides and nurtures a younger or less experienced employee. The mentoring relationship may be informal and limited—for example, in the instance of a senior practitioner encouraging a visiting student during the student’s part-time job. Alternatively, the relationship may be formal and limited, as in the relationship of the clinical supervisor during training rotation or in assisting with thesis supervision. The relationship may then become informal and ongoing, as in a partnership of interest, leading to shared projects, copresenting at workshops, and coauthoring papers.

Network

A network is a group of individuals who communicate through formal and informal channels and willingly promote one another for mutual benefit. The network members trade services, ideas, recommendations, and “tips” to further their own development and success. The various state and national professional associations are examples of networks.

Peer Pals

Peer pals boost one another’s careers by sharing information and strategies. They share one another’s strengths and weaknesses because they are on the same developmental level.

CLINICAL AFFILIATION/CLINICAL PRACTICE PROGRAM AND CONTRACT

Healthcare organizations typically include education and research in their mission. In developing their client base, managers include healthcare practitioners who are in training. These clients are identified in the clientele network (Chapter 3) as secondary clients whose needs are important and deserving of attention. Practitioners-in-training also become a source of potential employees, thus helping the managers in their recruitment outreach. Supervising practitioners-in-training is part of managers’ leadership role as well; they are effective role models through their support of the educational efforts of colleges, universities, and specialty training programs. Managers recognize the importance of clinical rotation because of their own experience as students. They appreciate and understand the professional association/credentialing requirements that include clinical practice.

Organizational Responsibility and Coordination

There is on-going interaction among peer professionals about shared interests and concerns. The need for clinical rotation is one recurring topic. The initial discussion of, and request for, developing a clinical rotation sequence often starts at this informal level. Formal responsibility and coordination are the next steps, usually involving the chief academic officer of the healthcare facility. This executive-level manager develops policies and procedures, including legal guidelines, for accepting student practitioners in the clinical setting. The department manager determines the availability of the department for specific kinds of rotations, their length, and their scope. When an agreement has been reached between the academic institution and the healthcare site, department managers prepare their employees for the presence of a student observer/participant. This manager assumes responsibility for on-site supervision of the student. The academic institution maintains responsibility for students as well. For example, the outline and description of the content and sequence of the clinical rotation is developed by the academic department, and the assignment of a grade for the coursework is the responsibility of the faculty.

Elements of the Clinical Affiliation Agreement

There are a number of considerations about placement of a student in the clinical site. Although these formalities may seem bureaucratic, their purpose is the mutual protection of the healthcare organization, its patients and workers, and the academic institution and its students. The affiliation agreement is developed to address aspects of the training and typically includes the following elements:

1. Organizational name of the parties to the agreement.

2. Length of agreement. A certain number of students (n) are accepted for a specific time period (e.g., September l–November 30) for the particular activities associated with the clinical rotation. The names of the students are listed.

3. Stipulations of trainee status. Students are not employees or independent contractors, even if they are receiving a stipend. They are not eligible for any fringe benefits, unionization eligibility, or workers’ compensation. A student should sign a statement indicating this so that there is no misunderstanding.

4. Stipends or support (e.g., room and board, meal plan). If either is provided, either by the academic institution or the healthcare organization, the tax consequences to the recipient are the responsibility of the recipient.

5. Liabilities. The healthcare organization restricts its arrangements with academic institutions, accepting students only if the academic institution carries proper insurance to cover field placement of its students. Furthermore, a student receives orientation about the healthcare organization’s policies, procedures, and rules about standards of conduct; use of social media; protection of patient privacy; and confidentiality provisions about patient care interactions. The privacy of the employees is also emphasized. The use of organizational assets and information, prohibition about political activity, and similar limits on behavior are included in the initial briefing. A student must sign a confidentiality agreement, pledging to maintain confidentiality about the site, the patients, and the workers.

6. Removal from clinical placement. The healthcare organization reserves the right to have students recalled by the educational institution if they do not carry out the agreed-on activities or behave in a nonprofessional manner.

7. Intellectual property and copyright considerations. Reports, computer software development, data, photographs, and images and similar material covered by the usual concept of intellectual property become the property of the healthcare organization. Students shall be permitted to use such material in their academic reports, without identifying patients, workers, or the organization. Subsequent use of the material shall be covered by the usual understandings of intellectual property and copyright considerations. The director of affiliations of the healthcare organization coordinates the requests for such approval.

8. Designated contacts. The academic institution shall provide the name and title of the faculty coordinator for clinical placement. The healthcare organization provides the name and title of the department manager who is accepting the supervision of the student while on-site.

9. Contract. This is dated and signed by the officials from each party to the agreement.

EXERCISE: WHAT TO DO WHEN BUDGET CUTTING THREATENS TRAINING?

Any department manager who has been through a financial belt-tightening exercise has undoubtedly collided with one of the fundamental contradictions encountered in organizational life: top management’s verbal support of training and its importance, followed, when budget trimming becomes necessary, by the early reduction or elimination of training funds. You are to explain why this fundamental contradiction exists, and describe which arguments you might use in defense of your education budget.

Also, many people tend to view all expenditures in terms of costs versus benefits; education comes up short in their eyes by very nearly defying cost–benefit analysis. In defense of your education budget, which the budget director has said must be reduced by half or more, you are to do the following:

• Develop an argument for keeping as much of your education budget as possible.

• Describe how you would go about attempting to measure the results of education.

CASE: THE DEPARTMENT’S “KNOW-IT-ALL”

Several weeks ago, physical therapist Willis Patrick said to his boss, Glen Jones, director of physical therapy, “Glen, the way that we develop the budget in this department doesn’t make much sense. We just take last year’s actual expenses and stick an inflation factor onto it and make some other guesses. We really ought to be budgeting from a zero base, making every line item completely justify itself every year.”

Glen said something about simply following the instructions issued by the finance department and doing it the way all the managers were told to do it. He pursued the matter no further.

A few days later Willis approached Glen, saying, “Don’t you think the way we do performance appraisals ought to change? Surely most smart managers know it’s better to evaluate employees on their anniversary dates than all at once, the way we do it now.”

Glen again answered to the effect that he was simply doing what he had to do to comply with the policies and practices of the organization. They discussed the matter for perhaps 5 minutes. Although Glen was not going to start working to inspire change in the performance appraisal system, he nevertheless felt led to concede that Willis had brought up a number of good points. It struck Glen that his employee was idealizing an appraisal system in almost textbook terms; it seemed flawless in theory, but Glen had been through enough actual systems to be able to recognize a number of potential barriers to thorough practical application.

In the ensuing 2 to 3 weeks, Willis had more and more to say to Glen about how the organization should be managed. In fact, it took Willis only a matter of days to get beyond generalized management techniques such as budgeting and appraisals and start offering specific advice on the management of the department.

Glen quickly came to realize that he could count on Willis to offer some criticism of most of his actions in running the department and most of administration’s actions in running the hospital. Glen did not appreciate this turn in his relationship with an otherwise good employee. Glen had always seen Willis as an excellent physical therapist, perhaps somewhat opinionated but not to any harmful extent. Recently, however, he had come to regard Willis as a sort of conscience, a critical presence who was monitoring his every move as a manager.

The worsening situation came to a head one day when Willis attempted to intercede in a squabble between two other physical therapy employees. When Glen entered the situation, he proceeded to criticize Glen’s handling of the matter in front of the other employees.

Glen took Willis into his office for a private one-on-one discussion. He first told Willis that although he was free to offer his suggestions, opinions, and criticisms regarding management, he was never again to do so in the presence of others in the department. Glen then asked Willis, “It seems that lately you have a great deal to say about management and specifically about how I manage this department. Why this sudden active interest in management?”

Willis answered, “Last month I finished the first course in the management program at the community college, a course called Introduction to Management Theory. Now I’m in the second course, one called Supervisory Practice. I know what I’m hearing—and quite honestly, it’s pretty simple stuff—and when I see things that I know aren’t being handled right, I feel that I have an obligation to this hospital to speak up.”

Glen ended the discussion by again telling Willis that he expected all such criticism and advice to be offered in private and never again in front of other employees. Overall, the conversation did not go well; more than once Glen felt that Willis’s remarks were edging toward insubordination. Because of the uneasy feeling the discussion left with him, Glen requested a meeting with the hospital’s vice president of human resources.

After describing the state of the relationship between him and Willis in some detail, Glen spread his hands in a gesture of helplessness and said, “I’m looking for advice. Apparently on the strength of a course or two of textbook management, this guy suddenly has all the answers. What can I do with him?”

Questions

Questions

1. If Willis does, indeed, act as though he has all the answers, what can Glen do to encourage modification of this attitude?

2. If you were Willis, how should you best proceed in applying your newly acquired knowledge of management? Explain and provide an example.

3. What are the possible reasons behind Glen’s growing aggravation with Willis? List a few possible reasons and comment on the validity of each.

Appendix 9–A

Training Design: Release of Information

BACKGROUND INFORMATION AND NEEDS ASSESSMENT

The department manager completed a thorough review of the release of information function as part of a quality improvement study. The study included the following areas of focus:

1. Risk management study: HIPAA breach prevention with more than satisfactory compliance.

2. Review of licensure and accrediting standards: no problem area identified; no plan of correction required.

3. Turnover rate in the unit: 30% higher than the department as a whole.

4. Management inventory review: potential problem identified. No one is cross-trained for the release of information (ROI) positions; no one has been promoted internally to ROI positions for the past 4 years.

5. Productivity standards: adequate to above average for most functions except those associated with in-person and telephone requests, with only an 80% level achieved by workers.

6. Patient/client satisfaction survey results: reflected significant dissatisfaction with ROI responses to in-person and telephone requests. Typical comments included the following: “it was confusing—all those details; how are we supposed to know the rules?,” “I felt like I got the run-around; it was overwhelming ... all those details,” and “worker was very impersonal; kept referring to the policy. It all seemed like a huge mess of red tape to me.”

7. Worker satisfaction survey results: reflected satisfaction with most working conditions. Workers felt well-trained in the technical functions of their work but expressed concerns at being “put on the spot,” “feeling bullied by aggressive or upset clients who did not understand the consent and fee requirements,” and “feeling badly that they could not help the patient/client who clearly had a pressing need for the requested information.” They felt poorly trained to deal with difficult situations and expressed the desire to transfer out of this area of work because of this stressful aspect.

8. Focused study: determined which kind of request and what steps in the process were generating the most difficulty. Findings showed that, with the success of the regional health information exchange, information for continuing care was not problematic. The gradual implementation of the electronic health record and the related portal-access processes were satisfactory. The three areas of concern, reflected in both patient and worker surveys were these:

a. The fee structure and its application

b. Release of information for records of deceased patients

c. Dealing with one-to-one interactions with upset or angry clients

THE REDESIGN OF THE TRAINING PROGRAM CONTENT

In light of the background findings and needs assessment, the manager added an initial phase of training to emphasize the value and importance of the ROI function. With the assistance of the social service department and the human relations department, the manager developed a training module for communicating with distressed patients/clients. This initial phase was then followed by the technical training module (see below).

Phase One: Valuing Our Mission—Valuing Your Role

The objectives are to assist the trainee in understanding and valuing the overall mission: service to the patients/clients and their role in this process. To emphasize the interpersonal nature of the work, this presentation is made in a small group setting; the manager presents the key points in a discussion format rather than as a formal lecture. Role playing is used to provide the trainees with interactive experience reflecting the challenging aspects of dealing with difficult situations. Key points include the following:

• Identifying examples of difficult situations, such as a client who needs information immediately because:

○ He or she is late in filing a benefits claim and will miss the final deadline.

○ He or she is receiving bill collection notices from the hospital for failure to pay.

○ He or she needs immediate assistance relating to disability claim or workers’ compensation claim and has no other means of support.

○ He or she is eligible for special program assistance (e.g., learning disability) but the deadline for providing support information is next week.

○ He or she is a family member of a recently deceased patient but is not the executor of the estate and does not understand why he or she cannot have information.

• Acknowledging the conflict experienced by worker who wants to help but must follow the designated procedures. Small-group discussion of this topic: when you are the perceived source of the “red tape” and your role in offsetting the impersonal aspects of formal organizations.

• Valuing the worker’s role as facilitator in assisting patients/clients in navigating the system.

COMMUNICATION IN STRESSFUL SITUATIONS

A social service or human relations specialist presents information about communication in such situations. This is applied to the common situations (identified above) through role playing. After the completion of Phase One, the trainee continues with learning the technical aspects of the work (Phase Two). An excerpt of a training design for processing written requests follows.

Phase Two—Release of Information Functions

• Purpose

• Overall training objective

• Assumptions

• Resources

• Training sequence and performance level

• Methods

Purpose

This training module is designed to enable the trainee to perform the release of information duties as delineated in the job description and prescribed in detail in the applicable policies and procedures.

Overall Training Objective

The objective is to gain the ability to process written requests for release of information from the patient health record maintained by this facility.

• In accordance with the healthcare organization’s policies and procedures as well as applicable federal and state laws and accrediting standards

• With 100% accuracy

• Within the established time frames and priority indications

• Within the work standards parameters

Assumptions

1. The trainee meets the job qualifications except for knowledge and skill in release of information.

2. The trainee has successfully completed the training modules for:

○ Computer competency in job-related heath information systems software utilization

○ Privacy and confidentiality, including HIPAA, ARRA, and HITECH

○ Overview of release of information function

○ Patient health record content and sequence

3. There is a comprehensive policy and procedure manual for release of information.

4. There are validated work standards.

Resources

During this training process, the trainee will use

1. The release of information policy and procedure manual, including the reference grids for the following items:

○ Authorization requirements and examples

○ Content and format of acceptable authorizations

○ Fee schedule and transmittal forms

○ Cover letters and sample responses

2. Software for tracking and completing each request

3. Fictitious requests and health records

Training Sequence and Performance Level

The training sequence is based on the steps described in the procedure manual. The trainee learns to process standard requests, followed by nonstandard requests.

1. The trainee processes a standard request by performing each step with 100% accuracy, then proceeds to the next step.

2. After having demonstrated the ability to complete each separate step, the trainee processes a standard request through the complete cycle with 100% accuracy.

3. The trainee processes a nonstandard request by performing each step with 100% accuracy, then proceeds to the next step.

4. After having demonstrated the ability to complete each separate step, the trainee processes a nonstandard request through the complete cycle with 100% accuracy.

5. After having demonstrated the preceding abilities, the trainee is given a mix of standard and nonstandard requests to process with 100% accuracy within the work standards parameters.

Methods

An in-basket exercise is used to introduce the material. Lecture and demonstration are used to explain each step.

CHAPTER 10

Adaptation, Motivation, and Conflict Management

CHAPTER OBJECTIVES

• Address the necessity for properly and thoroughly integrating each individual employee into the organization and describe the common techniques of integration.

• Introduce the theories that address present-day employee motivational concerns and provide the manager with insight into the conditions and circumstances that inspire employees to perform.

• Specifically address the motivational concerns arising in conjunction with reengineering, reorganizing, and other practices resulting in downsizing of the workforce.

• Develop an understanding of the origins of conflict, especially in the organizational setting, and describe how to address conflict constructively.

• Describe the essential need for discipline within the organization and introduce the concept of progressive disciplinary action, differentiating between problems of performance and problems of conduct relative to rules and policies.

• Briefly examine the role of the collective bargaining agreement (union contract) in the avoidance of and as necessary the control of conflict.

ADAPTATION AND MOTIVATION

To get work done efficiently and effectively, managers must motivate workers and assist them in their adaptation to organizational demands. Individuals must fit into the organizational framework. There is a close relationship between the manager’s concern for employee motivation and the adaptation activities and controlling function of the manager. The worker who fits into the organization and who values an assigned role is likely to be motivated more readily than one who does not experience such feelings of belonging. In turn, when workers fit into the organization, the need to control or modify activity or behavior through disciplinary action is reduced.

Adaptation to Organizational Life

Two specific conditions that exist as a result of organizational structure illustrate the need for an explicit management process to help integrate the individual into the organization:

1. The need to offset the effects of decentralization

2. The need to coordinate the many individual functions that result from departmentation and specialization

Overall goals and policies are established at the highest levels of the organizational hierarchy, but the actual work is carried out at every level. Occasionally, conflicting directives, or what seem to be conflicting directives, are issued from the central authority.

Additionally, the number of individuals who enter the organization and the different manner in which these individuals react to the complexities of organizational life must be taken into consideration. These individuals not only have different values, different personalities, and different life experiences, but they also belong to other organizations, some of which may have values that compete and even conflict with the values embodied in the workplace. Some of the patterns of accommodation to organizational life may be functional for the organization but dysfunctional for the individual. Potential conflict must be offset, and the personality mixes of workers and clients must be melded into smoothly functioning interpersonal relationships.

Techniques for Fostering Integration

Events and conditions should be anticipated as fully as possible, and the courses of action to be taken for designated categories of events and conditions should be described. Authorization of the course of action applicable to any category may be permissive; it may spell out several series of steps from which the employee can choose. To prevent undesirable actions from arising, sanctions or penalties should be established for those who commit these offenses. The policy manual, the procedure manual, the employee handbook, the medical staff bylaws, and the licensure laws for the various health professionals are all routine management tools for guiding behavior and fostering integration.

Work Rules

Rule formulation has generally been accepted as a management prerogative embodied in the control function. Work rules are related to motivational processes because they contribute to a stable organizational environment. They serve several functions in an organization:

• They create order and discipline so that the behavior of workers is goal oriented.

• They help unify the organization by channeling and limiting behavior.

• They give members confidence that the behavior of other members will be predictable and uniform.

• They make behavior routine so that managers are free to give their attention to nonroutine problems.

• They prevent harm, discomfort, and annoyance to clients.

• They help ensure compliance with legislation that affects the institution as a whole.

The organization has a positive duty to protect both clients and workers with regard to health, sanitation, and safety. In addition, it must seek to prevent behavior that has the potential of alienating or offending clients. Because they deal with patients and their families in stressful situations, healthcare organizations have specific obligations in this area.

Incentives and Sanctions

Both incentives and sanctions can be used to induce compliance. Incentives are bonus pay, merit increases, and special time off. Sanctions are demotion, suspension, and written reprimands. An essential element in any system of sanctions is the development of adequate feedback mechanisms and correction where needed. Employee evaluation and training processes can provide feedback and correction on a routine basis.

Selection

Managers may increase the likelihood of worker satisfaction with the organization by developing recruitment and selection strategies to enhance this possibility. By recruiting from groups with a positive predisposition toward the organization, such as students in training rotations at the organization, managers will be able to attract employees who already value the organization’s mission. When an organization has a long-standing relationship with its surrounding community and is recognized as “the best place to work,” managers are able to recruit and select individuals who are accustomed to the presence and practices of the organization. The more selective an organization is, the more effective the involvement of its members tends to be. Their commitment to organizational values is deeper, and they need fewer external controls.

In recruiting members, the highly selective organization should try to appeal to an audience composed of individuals who are favorably disposed toward the values of the organization, even at the preselection stage. Recruitment information may indicate, either implicitly or explicitly, the need to conform.

Training

Workers who are unsettled because of rapid changes in work processes, or potential employees who have been out of the workforce, will benefit from an active, well-publicized training program geared toward these needs. For example, their technical skills can be modified so that they will perform the work according to the specific procedures unique to the organization. Orientation programs have been developed in hospitals to familiarize professionally trained individuals (e.g., technologists) with particular routines. Businesses often use rotating management internships to foster integration of newly graduated management majors. Training that enhances internal transfer and promotional opportunity is yet another motivational tool.

Identification with the Organization

Managers tap into the human need to belong by using tangible expressions of organizational identity to help foster identification with the organization. Recall the early stages in the life cycle of an organization: a well-developed expression of mission is reflected in a motto, a logo, or some other readily identifiable symbol. A manager seeks to use these icons as sort of internal advertising telling employees, “You are a part of this excellent organization.” The manager uses these simple but effective means of building up identification with the organization—yes, the coffee mug, the cap, and the T-shirt are all small but effective means of keeping the organization and its mission at the forefront. They are used because they work. The development of a sense of identification is good for the organization, but it can also be good for each individual.

The Work Group

An employee’s particular mindset is continually reinforced by his or her work group. Through the work group, the individual becomes assimilated into the organization—or is perhaps prevented from being properly assimilated. In addition to the formal prescriptions regarding work activities, informal patterns of behavior arise among members of the group. The individual learns the unwritten rules as well as interpretations of the written rules. The informal organization of the work group also satisfies an essential human need—the need to belong. Nonconformity with group norms could lead to expulsion from the group, which would eliminate a vital source of information and communication as well as an arena in which to air conflicts that stem from the formal organizational role demands.

THEORIES OF MOTIVATION

On the one hand, the manager seeks to develop a workforce that fits the organization; on the other hand, the manager must remain aware of the basic needs of the workers. The art of motivating is built on this recognition of human needs. Motivation is the degree of readiness or the desire within an individual to pursue some goal. The function of motivating or actuating is essentially a matter of leading the workers to understand and accept the organizational goals and to contribute effectively to meeting these goals. In motivating or actuating, the manager seeks to increase the zone of acceptance within the individual and to create an organizational environment that enhances the individual’s will to work. As self-motivation increases, the need for coercive controls and punishment decreases.

Bases of Motivation

Needs are the internal, felt wants of an individual (they are also referred to as drives and desires). Incentives are external factors that an individual perceives as possible satisfiers of felt needs.

A manager may gain insight into aspects of motivation in several ways:

• Observation of existing work situations

• Review of cultural expressions concerning work

• Studying the work of management theorists who have addressed the concept

Observation of Existing Work Situations

Consider the response in your work setting to these two basic questions: Why do the employees (including you) work? Why do they work in this specific setting? The answers surface quite readily. One employee might say, “I work because I need the money. I need money to procure basic goods and services for daily life and for those additional items that constitute ‘the good life.’” Another might give as the reason, “I don’t really have to work but I want to keep involved; this work is meaningful to the community and it gives me a reason to get out of the house and be around people.” Attractive and necessary fringe benefits might be the magnet for still other workers—the college tuition benefit for a worker or a member of the family, health insurance coverage, special discounts on pharmacy products, or day care for dependent children or aged parents.

In answering the question “Why work at this specific organization?”, workers might offer a variety of responses. “Everyone in our family started out here; it is our tradition,” says one worker. Another might indicate he or she is feeling stuck, even trapped: “It’s the only place that is hiring right now and we can’t relocate, so here we are for now; we will move on when there is opportunity.” “It is a résumé enhancer,” states a new entrant into the workforce. “It is the place to be if you want to be on the cutting edge of practice,” says another. Yet another person might belong to the sponsoring religious or fraternal organization and enter the workforce of its organizations because of this affiliation. As noted earlier, attractive fringe benefits, including flexible work schedules, may be the main source of attraction.

When managers sort through these reasons, they can readily see a mix of internal and external motivators they can then use to enhance worker satisfaction. The satisfied, motivated worker more readily contributes to the organizational mission than the dissatisfied or indifferent employee.

Cultural Expectations about Work

Another avenue for considering work and motivation is the study of cultural expectations about work. These cultural attitudes are readily expressed in classic literature, art, and drama. They are evidenced in music—everything from coal miners’ roots music lyrics, to seafaring chanteys, to 9-to-5 contemporary offerings. Television and movies represent the full range of the work setting, presenting both the comical and the dramatic aspects. One can identify repeated themes: the worker as hero, the manager as remote, the team as valuable, or the work setting as uplifting or repressive. Such cultural influences seep into everyone. The management team remains aware of this potential and develops positive motivational practices to offset what is negative and enhance what is good.

Motivational Theories

In reviewing published works concerning theories of motivation, a manager will see that studies of motivation tend to deal with several broad questions: What satisfies human needs? And, therefore, what satisfies workers’ needs? When one or several basic needs are met, what is the next level of motivators to be activated? Is motivation internal to the worker, part of our basic human makeup, dependent on external practices, or a combination of all these factors? Undertaking individual research into the various available theories of motivation can provide the manager with insight into a number of aspects of employee behavior.

PRACTICAL STRATEGIES FOR EMPLOYEE MOTIVATION

Motivation may be described as the drive, impetus, or initiative that causes an individual to direct his or her behavior toward satisfaction of some personal need, using “need” in the broader sense of the word to describe something one pursues because its attainment represents fulfillment of a sort. Considering motivation in this light, we might question whether it is possible for anyone to “motivate” another human being to do anything or pursue anything.

It is, in fact, not strictly possible to motivate another person. The best that can be done is to create the circumstances under which an individual can become self-motivated. It is much like the old saying, “You can lead a horse to water but you can’t make it drink.” One can create what would seem to be ideal conditions and structure seemingly perfect circumstances, but these alone provide no guarantee of successful employee motivation because there is no way of making someone respond appropriately if the person does not care to respond. Most people in work organizations are subject to the same overall collection of needs, but the mix of needs—that is, the differing emphasis on the various needs that drive an individual—may vary greatly from person to person. In brief, what “motivates” one person may have little or no effect on another individual. This necessitates generalizing to some extent and recognizing that any particular motivational strategy may work with some people and fail to work with others who are similarly situated.

Motivators

The true motivating forces, or at least the strongest of the genuine motivating forces, are to be found in the work itself and are all describable as opportunities. The genuine sources of motivation are the opportunity to:

• Accomplish or achieve and be recognized for doing so

• Acquire new knowledge

• Do work that is both challenging and interesting

• Do work that is meaningful or that makes a societal contribution

• Assume responsibility

• Be involved in determining how the work is done

The foregoing opportunities are likely to include the primary motivators for a great many employees, provided that these employees are at least nominally satisfied with the environmental factors surrounding their employment—that is, the potential dissatisfiers.

Dissatisfiers

The potential dissatisfiers are the environmental factors that exist in all aspects of an employee’s relationship with the organization. They generally do not motivate workers, but they can easily lead to employee dissatisfaction if they are not maintained at a level acceptable to the employee. These potential dissatisfiers can be grouped in five categories:

1. Salary administration, primarily the perceived overall fairness of salaries and benefits

2. Potential for promotion and growth and the extent to which this is or is not present

3. Personnel policies, or how each employee is treated both as an individual and relative to other employees

4. Working conditions and the extent to which they promote well-being relative to what is expected

5. Communication in all of its forms, including knowledge of the organization’s plans and prospects, regular feedback on performance, individual confidentiality, and higher management’s responsiveness to employee questions and concerns

Motivational Strategies

The first four of the five dissatisfiers listed previously have much to do with the overall organization and are perhaps mostly beyond the control or direct influence of the department manager. The final one on the list, communication, depends in part on the organization’s policies and practices but also depends to a considerable extent on the individual manager’s behavior. Any specific motivational strategy must take into account the relative strength of potential dissatisfiers, so it might be said that an initial—and continuing—motivational strategy is the maintenance of the environmental factors so as to minimize their potential effects as dissatisfiers. Other active motivational strategies that might be used include the following:

• Performance appraisal. Making full use of the organization’s performance appraisal process, preferably including self-appraisal participation and faithfully including appraisal interviews, serves a number of communication needs and can also provide recognition for work well done (only very rarely is it not possible to convey something positive in an appraisal). However, the formal appraisal done annually or perhaps semiannually is not enough; the manager should dispense praise when earned and in general maintain an ongoing communicating relationship with each employee.

• Job rotation, job enrichment, and job enlargement. These strategies generally involve expanding or enlarging jobs or rotating duties. Such actions provide employees with the opportunity to gain new knowledge and can serve to inject increased interest and challenge into the work.

• Delegation. Related to the foregoing strategy concerning job expansion, proper delegation well administered can provide employees with added interest and challenge, the chance to acquire new knowledge, and the opportunity to take on increased responsibility.

• Awards and honors. Employee awards and honors programs provide visible recognition that can go a long way toward satisfying some employees’ needs for recognition and appreciation. Such programs often include “Employee of the Month” and “Employee of the Year” selections.

• Career ladders and parallel-path progression systems. Such systems provide the opportunity for capable individuals to advance themselves professionally without necessarily seeking entry into management, thereby satisfying a continuing need for learning, growth, status, and recognition.

• Incentives and bonuses. Although it may be argued that in and of itself money is not a particularly strong motivator, it nevertheless looms large as a driving force for some workers. Often the monetary value of an incentive or bonus does not count nearly as strongly as the act of achievement. For some employees, it can truthfully be said that the money becomes primarily the “score” in the quest for accomplishment.

• Employee participation. Allowing employees to participate in establishing or revising methods, procedures, and processes is potentially one of the strongest individual motivators. In addition to involving the employee in determining how the work is done, doing so provides increased responsibility, adds interest and challenge, and promotes the acquisition of new knowledge.

Motivation in Critical Incidents

From time to time, an organization experiences difficult situations in which workers, along with management, may experience a sense of defeat. By way of example, consider the long-term care facility with a history of excellence. Year after year, it passes the licensure review with flying colors. Then there is one unfortunate incident: a caregiver fails to report a patient-to-patient altercation until 2 days after the incident. This omission is noted by the on-site surveyors, who flag the organization for the incidence of patient abuse. The staff is devastated because they have taken such matters seriously and have had no prior instances.

A second example of a difficult situation stems from ever-increasing external regulations: the organization works diligently to comply with these requirements, only to find more regulations to follow. The current emphasis on disaster rehearsal to the point of failure is well meaning, but down in the trenches, it is hard to be enthusiastic when one is set up to fail.

A third example may be found in the difficult situation of budget freezes or cuts. There may be a season of dry promotions, no raises, and cutbacks in fringe benefits. Yet despite these measures, the worker is expected to give full effort.

A fourth example occurs when one or a few caregivers commit extensive fraud in billing. This serious infraction attracts extremely bad publicity for the facility. Other workers may bear the brunt of this criticism in their community and social settings: “Oh, you work at that place—was your department involved in the fraud?”

In each of these situations, particular attention must be given to motivational practices, starting with fostering a climate of trust. Trust is enhanced by transparency: “Yes, this happened. Yes, this is what management did about it. Yes, here is information you can share with others.” Timely and accurate information, the presence of feedback, and the encouragement of all workers that things are going well—these are all motivational strategies that are appropriate for critical incident situations.

APPRECIATIVE INQUIRY

Appreciative inquiry (AI) represents yet another tool that can be used in critical situations, because it helps shift the focus back to the good done by the employees. AI is an approach to organizational change and development that begins with examination of what is working well and appreciation, through active recognition and expression, of the best of the individual and the group or organization’s experience. Developed in the mid-1980s by Dr. David Cooperrider, Suresh Srivastva, and their colleagues at Case Western Reserve University, AI has been applied in a variety of organizational settings, including large federal agencies such as the Department of Health and Human Services, business ventures, and professional associations.1

The Appreciative Inquiry Process

When a manager uses the AI approach, the focus is on the values and mission of the organization and the positive experiences of the individual members of the organization. In the healthcare setting, this can be broadened to include client or patient groups as well as the professional, technical, and support staffs. The operative assumption is the understanding that something—perhaps even many things—are working well. These positive experiences are explicitly recalled and actively noted as successes. Using these positive accomplishments, the group then builds on them to envision improvements. A set of goal statements is developed, or updated, based on the newly energized vision of the organization’s efforts.

By way of example, consider the difference in two methods of dealing with patient safety, risk management, and incident reporting and review. In a more traditional approach, the emphasis is on the number, causes, and characteristics of the problems relating to patient safety—for example, number of falls, medication errors, or misdiagnoses. In an AI approach, the emphasis is on the goal of making this organization the safest possible environment for patients, staff, and visitors. The review process would still include specific data such as those noted earlier. However, the data would be cast in the context of all the care that is given without mishap. Specific problem areas will usually decrease simply as a result of positive efforts at improvement of safety practices.

Motivational Aspects of Appreciative Inquiry

Appreciative Inquiry is a planning process which, by its very nature, includes motivation through positive reinforcement of that which is good. The process diffuses potential conflict because the best results of both individuals and departments or divisions are emphasized. Cooperation and enthusiasm for participation are enhanced.

Managers have many opportunities in their ongoing work to apply AI. Consider, for example, the usual concerns associated with preparation for outside surveys and reviews, such as accreditation or licensure inspections. The preparation of the survey report necessarily involves fact gathering. Instead of using the mindset that many vague problems will come to light, the management team could start by reaffirming the organization’s best practices, noting them, and then isolating those areas needing improvement. Consider a report prepared by a consultant. The areas of compliance, which represent the majority of the day-to-day practices, are clearly listed, following which the areas needing improvement are identified.

Another situation of potential concern and conflict is associated with periodic labor contract negations. Typically, each party brings to the table its list of concerns and demands. Using an AI approach, however, the starting point would be a reflection of those areas of management–labor relations and those provisions of the contract that have enhanced the accomplishment of the organization’s mission.

When an organization as a whole, or a group within an organization, has experienced much change and yet another major change must be absorbed, AI can be used to coalesce the positive energy needed to carry on. For example, the implementation of the Health Insurance Portability and Accountability Act regulations involved major changes affecting budgeting, vendor selection, collection, processing, and release of patient care information. In taking on this challenge, the health information manager and the professional association as a whole recalled its long-standing commitment to privacy and confidentiality with the concomitant successes in these areas. These managers were easily motivated to take leadership roles in implementing these new requirements regarding confidentiality and security of patient care information.

Using the AI approach, a manager carries out an employee performance review using as a starting point the employee’s assessment of the work and his or her contribution to the department’s mission. The manager would invite the employee to identify all the areas where he or she is performing well and then discuss those areas where performance could be improved.

Using the framework of AI, a manager continually seeks to take advantage of opportunities to express public appreciation for all that is going well. The customary declaration of a week highlighting one or another department is an example of this practice. The nomination of employees as “Employee of the Month” or similar recognition events reflect an AI attitude. The celebration of milestones in a professional organization’s life cycle is yet another opportunity to reflect on past accomplishments, leading to emphasis on future endeavors.

MOTIVATION AND DOWNSIZING 2

Reducing labor cost is usually the most common goal of reengineering or reorganizing or other organizational restructuring efforts that result in “downsizing” (i.e., the reduction of the workforce). A considerable amount of thought and effort are required in structuring and implementing a staff reduction in a manner that will be as fair as possible to all concerned while supporting the organization’s primary responsibility for delivering quality health care. However, the effort associated with downsizing cannot end simply when the employees who have been identified for separation have been released. For those at all levels who remain with the organization—and in essentially all workforce cutbacks, the people who remain are far more numerous than those who leave—the implementation of a reduction-in-force (RIF; sounds like “riff” in the language of human resources management) is the beginning of a completely new work situation in what will, and what in fact must, become an altered organization culture. Although many will tend to seek a “business as usual” state of affairs following a staff reduction, they will find that this is not possible.

What Follows Downsizing?

A significant downsizing will forever alter many employees’ beliefs and attitudes concerning their employment. Consider the following:

• For many years, healthcare workers saw reductions occurring in other industries in their communities while feeling relatively safe against the likelihood of ever being laid off. For a long time, many felt certain that health care, as an absolutely essential service, would remain untouched by the economic concerns that plagued other industries.

• Many healthcare workers long enjoyed a sense of employment security that has now been severely damaged.

• Healthcare workers have been awakened to the fact that health care is now subject to many of the external forces that plague other industries. That is, there are forces beyond their control that are causing permanent changes to health care.

The immediate responses to a healthcare organization’s downsizing can include the following:

• Many employees may initially—and permanently, if positive steps are not taken—feel more like they are a “cost of doing business” rather than valued members of a work organization. They come to view themselves as simply another commodity that the organization will probably purchase less of in the future.

• Employee commitment to the organization will tend to erode as perceived employment security is diminished.

• Employee morale will be automatically reduced.

• Some key staff the organization desires to retain may resign to seek employment in environments they may perceive as more stable, further negatively affecting the morale and outlook of those who remain.

• Managers, with their thinking still governed by former ways of doing things, may try to compensate for lost staff by increasing the use of overtime and temporary help. They will experience additional frustration as controls are placed on hiring and on the use of overtime and temporaries.

In the time immediately following downsizing, there is a severe risk of cost reduction’s becoming universally perceived as a higher priority than people. It is true that cost control is an essential element of survival; the healthcare organization that cannot adapt to financial reality will not survive to employ anyone. People, however, still remain the driving force. It is people working together who must bring the organization into line with financial reality, yet the same organization’s continued existence then and forever will depend on serving people.

What must follow downsizing is a revitalization of the remaining workforce. An organization cannot and should never attempt to simply lay off a number of employees and call on those who remain to close ranks and continue as before. All who remain have a more difficult and more responsible task looming before them, and the organization’s top management should endeavor to give all of the support and assistance that can reasonably be provided in making the transition to a leaner, more purposefully directed organization.

The Necessity of Reducing the Workforce

Although the scenarios have differed to some extent from state to state, healthcare provider organizations across the nation have been experiencing reductions in revenue from most payment sources or revenue increases that fall short of covering increasing operating costs. Further significant revenue shortfalls will likely be occurring because of additional limitations placed on reimbursement levels by most payers. The simple fact of the matter is that the healthcare system is being forced by external circumstances to continually deliver the best of care while holding down increases in costs. Because the demand for service remains as high as ever and, in many respects continues to grow, the system is called on to accomplish more results with limited resources.

One may hope that realistic cost-containment activities, pursued as a normal course of business, would help an organization avoid or at least lessen a major financial crunch. However, the problem remains the same regardless of its immediate magnitude, and it must be dealt with. The communication issues are difficult enough when faced squarely with realistic data on a year-to-year basis; they become all the more difficult when the workforce has long been conditioned to believe that nothing serious is amiss.

In brief, when downsizing is planned and before the cuts occur, the workforce must be given every opportunity to understand why this is going to happen. The more openly the employees have been treated all along and the more frankly they have been advised of the organization’s real circumstances on a continuing basis, the easier it will be to communicate why.

Any downsizing, while preferably designed and recommended by senior management and the medical staff leadership and approved by the board of directors, should proceed after all other reasonable efforts to reduce costs have been explored as follows:

• All realistic short-term savings opportunities should be identified and implemented.

• Before the actual reduction occurs, maximum effort should be expended to reduce staff through attrition by freezing hiring in most positions and, as much as possible, transferring current employees into areas of greatest need.

• Overtime should be severely curtailed, essentially reserved for true emergencies only and approvable by only a select few. Also, the use of temporary help should be curtailed (along with overtime, agency temporary help can tend to increase under staff reduction pressure if not closely monitored).

• Supply inventories should be reduced to levels conforming to the true needs indicated by reduced levels of activity.

It must be stressed that no matter how much cost-control effort precedes downsizing, the reduction itself is never the end of the process. For the organization’s continued financial viability and effectiveness, it becomes the job of all employees to pursue continuous cost control in concert with continuous quality improvement if the organization is to prevail as a quality provider of health care.

The Employees Who Remain

A RIF instantly establishes two different groups of employees: those who leave and those who remain. Except in rare instances, those who remain far outnumber those who leave. Judging from many of the healthcare staff reductions that have occurred in recent years, it is not unusual for the “survivors” to outnumber those leaving by eight, nine, or ten to one.

Management must recognize that the manner in which it deals with the reduction’s survivors has a considerably greater bearing on the organization’s future than how the terminations related to the RIF have been addressed. Those who have departed are gone, probably forever, but the survivors are there and are critical to the organization’s future.

Stress and stress-related fear among those who remain following a layoff is natural, predictable, and essentially universal throughout the organization. A fully understandable feeling among survivors is the fear that they may be the next to go. To counter this fear, some top managers have essentially promised that “this is it—no more layoffs” or allowed employees to believe that the condition is only temporary and that employees will most likely be called back. Any belief in either of these scenarios must not be encouraged; more than a few managers who have promised “no more layoffs” have been severely contradicted by worsening reality.

It becomes necessary to unite the survivors into a forward-moving team and to motivate them to work harder in a leaner, more efficient, and yet initially a completely alien situation. Through a concentrated and continuing communication program, the survivors of the reduction need to learn:

• Why they remain and what will be expected of them, why the old organization is gone forever, and how they can help shape the new organizational culture that will be emerging

• That as the survivors of the reduction they are among the best in their occupations and that is essentially why they are still in place

• That a future in which continually doing more with less will remain critical to organizational survival and continued employment

Immediate and Natural Reactions to Downsizing

The issues emerging in the wake of downsizing are all essentially “people” issues. The major issues that surface usually include the following:

• The short-term loss of talent in the form of productive employees the organization would wish to retain. At special risk are valuable “free-agent” employees, those professional and technical workers whose primary loyalty is to an occupation and whose movement between and among organizations may be governed more by labor market circumstances than by ties to a specific organization.

• An immediate drop in productivity, precisely at a time when productivity increases are needed for the sake of long-term survival. This occurs because morale has dropped and employees are preoccupied with issues of security and concern for their future.

• Increases in the use of sick time, healthcare benefits, on-the-job accidents, medication errors, and other lapses in quality. These are often experienced during and after downsizing, again because of employees’ concern for their employment.

Employee Motivation Following Downsizing

Under normal circumstances—without the direct prospect of a reduction in the workforce and with each employee’s reasonable expectation of continued employment—job security and wages are not particularly active motivating forces. Rather, as noted earlier, they are potential dissatisfiers; as long as wages and job security are perceived as “reasonable,” the concern for them is largely secondary. However, when these are disturbed—when raises are eliminated, for instance, or when security is perceived as threatened—these become factors in heightening employee dissatisfaction, which in turn negatively impacts motivation.

It becomes necessary to help the surviving employees reestablish a sense of equilibrium with their altered surroundings and achieve a relative sense of security. An employee who may come to work each day wondering “Will I be next?” will be neither effective nor productive. As long as an employee is preoccupied with personal survival, individual productivity will decline at the time its improvement is needed more than ever.

It is necessary to communicate with employees fully, completely, and repeatedly until they understand that:

• Nobody—neither the organization nor a labor union—can absolutely guarantee continued employment.

• A certain amount of stress is inevitable regardless of what management does following downsizing, but stress can be energizing as well as debilitating and can serve as a spur to improvement.

• A future emphasis on improved productivity is essential to survival as an organization.

• Employees’ aggregate job performance is the organization’s best survival guarantee, and as far as individual employees are concerned, their performance is their own best job security.

The most potent motivating forces—perhaps the only true long-run motivating forces—are inherent in people’s work. These forces are, of course, the opportunity to learn and grow, to do interesting work, to contribute, and to feel a sense of accomplishment and worth. However, these motivators can work only when employees are able to feel relatively secure and reasonably compensated. Management needs to provide conditions under which all employees can become self-motivated and then act on that belief.

Attendant to employees’ motivational needs, the organization might also consider the creation of incentive programs and other flexible rewards to encourage and acknowledge innovation, commitment, and enhanced productivity. Overall, top management should at all times let employees know what is expected of them and tell them exactly how this desired behavior will be rewarded.

Changes in Managers’ Roles

Any significant downsizing is bound to include the elimination of some management positions or the combination of selected management positions. In the presence of a generally flatter management structure, managers and their superiors are both likely to find their roles enhanced. They will essentially assume new roles, roles that are more challenging and that require more direct decision making.

The individual who directly supervises others will be the organization’s primary conduit for communication with staff. At each management level, the manager is always a critical link in the movement of information up and down the chain of command. The first-line manager is the primary communicating link between each direct reporting employee and the rest of the organization. As the one member of management who the employee knows best and the one whose role it is to be the employee’s communicating link, the manager influences the attitudes and outlooks of a significant portion of the organization. Thus as the individual employee views the manager, so too is he or she likely to view the organization. In other words, if a manager of 15 people is seen as distant, uncommunicative, and uncaring, then 15 people are likely to see the total organization as distant, uncommunicative, and uncaring. Because the size of direct reporting work groups generally increases following downsizing and flattening of the organization, the influence of the individual manager becomes even more significant.

Some of the manager’s key concerns after downsizing are:

• The need to be conscious of the employee’s motivational needs and to work to control turnover both immediately and over the long term.

• The need to function as a strong advocate for the staff—to achieve the best for those who must leave as well as for those who remain.

• The need to begin preparing to work with the survivors, helping them to internalize the dramatic change well before the reduction is fully implemented.

• The need to actively encourage employee participation more than ever before, stressing involvement and drawing all possible employees into the decision-making processes. More than ever, the supervisor’s focus needs to be “we,” never “I” or “you.”

• The need to develop and use employee teams to the maximum possible extent.

• The need to communicate, communicate, communicate at all times, remaining in touch with employees’ fears and concerns even when some of the answers have to be “We simply don’t know yet, but we’ll keep you informed.”

CONFLICT

Conflict is an inevitable component of cooperative action, and the effects of conflict are felt by all participants in organizational life. Indeed, in a sense organizational life largely consists of carefully orchestrated conflict, so much so that one of the classic functions of a manager is to ensure coordination, which includes promoting cooperation and minimizing conflict.

Dictionary definitions of conflict use terms such as “variance,” “incompatibility,” “disagreement,” “inner divergence,” and “disturbance.” Conflict is basically a state of external and internal tension that results when two or more demands are made on an individual, group, or organization.

The Study of Conflict

The manager and healthcare practitioner must understand the phenomenon of conflict within organizations so that they can make it acceptable, predictable, and therefore manageable. Conflict must be accepted as an inevitable part of all group effort. The causes of conflict are found primarily in the organizational structure, with its system of authority, roles, and specialization. The clash of personal styles of interaction can be analyzed so as to deal more effectively with such clashes.

Conflict can be accepted as an element of change, a positive catalyst for continual challenge to the organization. Aggression may be accepted and channeled to foster survival. If conflict is not channeled and controlled, it may have negative effects that impede the growth of both the individual and the organization.

In certain situations, conflict may clarify relationships, effect change, and define organizational territories or jurisdictions. When there has been an integrative solution, resulting from open review of all points of view, agreement is strengthened and morale heightened. Conflict tends to energize an organization, forcing it to keep alert, to plan and anticipate change, and to serve clients in more effective ways.

ORGANIZATIONAL CONFLICT

Managers can assess organizational conflicts by using a theoretical model, which frees them from the bias created by their own immediate involvement in the conflict. By analyzing conflict in a relatively objective manner, a manager can deal with it more positively and more easily. The following is a basic model for such an analysis:

1. The basic conflict

a. Overt level

b. The hidden agenda

c. The source of conflict

2. The participants

a. Immediate and primary participants

b. Secondary participants

c. The audience

3. The provision of an arena

4. The development of rules

5. Strategies for dealing with organizational conflict

Exhibit 10–1 is an example of the use of this model.

EXHIBIT 10–1 Conflict Model with Example

The Basic Conflict
Overt issue	Habitual lateness and/or absenteeism of employee
Hidden agenda	Growing employee resistance to managerial authority
Sources	Human need versus organizational need Organizational structure
Participants
Immediate	Unit supervisor and employee
Secondary	Chief of service, personnel director
Audience	Other employees with similar problems with work schedule, other managers with similar employee disciplinary problems, and higher levels of management who monitor organizational climate
Arena	Grievance procedure
Rules	Work rules related to attendance, procedures for filing grievances
Strategy	Limitation of conflict to unit members

The Basic Conflict

Overt Level

As a starting point, the manager analyzing a conflict describes the obvious problem. This process of naming the conflict elements provides focus and clarifies the issues that are at stake. Examples include the following problems:

• Habitual lateness by an employee

• Delays in transport of patients from inpatient services to physical therapy or occupational therapy services

• Lack of clarity about job responsibilities

• Delays in treating patients, causing patients to wait unduly for their appointments

The Hidden Agenda

Although the overt issue may be the true and only substance of the conflict, there is sometimes another area of conflict that constitutes a hidden agenda. This hidden agenda may be the true conflict, or it may be an adjunct issue. The process of naming the conflict and describing its elements helps bring to light any hidden agenda that may exist.

Conflict issues are buried for several reasons. For instance, they may be too explosive to deal with openly, or subconscious protective mechanisms may prevent a threatening subject from surfacing until the individual in question has a safe structure and the necessary support to deal with it. Within an institution, the climate may not be appropriate for accepting conflict, or organizational resources may be insufficient to deal with it.

The subtleties of intraorganizational power struggles cause certain aspects of conflict to remain hidden. Individuals may choose to obscure the real issue as a means of testing their strength, of determining points of opposition before plunging ahead with an issue, or of checking the intensity of opposition. Periodic sparring over issues that never seem to be resolved is a clue to the existence of a hidden agenda. For example, the hospital budget issue of billing a medical group practice for certain administrative services may surface each year and be subjected to temporary resolution. The root of the problem is not the allocation of money, but rather the creation of a new institutional structure. As a consequence, organizational control of outpatient services is at stake.

The Sources of Conflict

The definition of a conflict should indicate its primary sources: competition for resources, authority relationships, extraorganizational pressures, and so on. As discussed earlier, organizational conflicts are ultimately due to the individuals who participate in organizational activities.

The Nature of the Organization

Organizations with multiple goals face competing and sometimes mutually exclusive demands for available resources. A hospital, for example, must safeguard against malpractice claims through active risk control management, yet it must also contain costs. The rules, regulations, and requirements imposed by the many controllers of the organization identified in the clientele network may be a source of conflict. Shifting client demand and changes in the degree of client participation in the organization may lead to conflict when an increase in the allocation of resources for one group is a loss for another. The authority structure is another clue to potential conflict; members of coercive organizations are more frequently in conflict with the organization than are members of normative institutions.

The Organizational Climate

An emphasis on competition as a means of enhancing productivity, as in the use of the “deadly parallel” organizational structure or the use of a reward system that emphasizes competition among individuals or departments, may cause conflict. The intentional overlap and blurred jurisdiction of units can produce continual jockeying for organizational territory. Competition for scarce resources may be sharp, with resulting conflicts, coalitions, and compromises. The subtleties of an institution’s power struggles, the shifting balance of power (e.g., a growing union movement), and the need to demonstrate power constitute another facet of organizational climate. Denial of conflict is a potential source of trouble, because it removes a safe outlet for the resolution of conflict before it becomes a serious problem.

The Organizational Structure

The complex authority structure of healthcare organizations (i.e., a dual track of authority coupled with an increasing professionalism among the many specialized workers) creates situations of potential conflict. Professional practitioners, such as nurses, physical therapists, clinical psychologists, and social workers, are trained to assess patient needs and to take actions within the scope of their licensure or certification; however, their ability to make decisions is limited by the hierarchical organizational structure. This problem is compounded when the individual practitioner has a legal duty to act or refrain from acting that is in direct opposition to the hierarchical system, such as when a nurse refrains from giving a medication that would be harmful to the patient even when the physician has (inadvertently) ordered such a dosage.

Physicians, in holding staff appointments, find themselves required to shift regularly from their roles as independent practitioners when functioning outside the healthcare facility to more limited roles as members of the organizational hierarchy. This regular role shift may also be required of the physical therapist, nurse practitioner, or occupational therapist who functions as an independent agent in private practice and at the same time participates in the patient care process as a staff member of a healthcare institution.

Conflict may also arise from specialization within the organizational structure when individuals attempt to carry out their assigned activities. For example, the social worker might seek to place a patient in a long-term care facility, but the utilization review coordinator must impose strict guidelines in terms of days of care allotted under certain payment contracts. The health information manager must develop a system of record control, although many users of records find it more practical to retain records in restricted areas of their own. The purchasing agent must comply with certain regulations on deadlines, budget restrictions, and auditing procedures in spite of individual needs. Specialization within the complexities of bureaucratization leads to frustration, misunderstanding, and conflict.

Superior–subordinate relationships constitute another area of potential conflict. The organizational chart is, in fact, a suppression chart that specifies which positions have authority over and literally suppress other individual jobs or units. The legitimacy of a leader’s claim to office is continually assessed. The power, prestige, and rewards built into the hierarchical system all represent gain for some and related loss for others. The erosion of traditional territory associated with line management results from activities clearly intended to remove some authority from line managers. These activities include client or worker involvement in decision making.

The process of management by objectives, in which workers are directly involved in setting and assessing objectives, commands much attention for its motivational value. Also, streamlined processes, such as central number assignments or patient bed assignments, have much merit as systems improvements, and a central pool of patient aides, assistants, and transporters is an alternative to assignment by department. Yet each of these processes erodes the distinct territory of one or several managers, whose ability to make decisions is affected by such changes. Increased specialization in some technical areas leads to a more frequent use of functional specialists. Although the line manager retains authority, the specialist must be included in the planning and decision-making process; the line manager is no longer the sole agent in charge.

Unions may move into management territory in several areas relating to personnel management and direct work assignment. In the collective bargaining process, the nature of the work, who will do it, and how much will be done may be issues. Union gains may be management losses.

Individual Versus Organizational Needs

Human needs and values must be welded into the organizational framework. A large number of clients and workers enters the organization, and they have different values, experience, motives, and expectations. The degree to which each individual internalizes the values of the organization and accepts a primary identity derived from the institution varies greatly. Individuals who do not participate directly in the accomplishment of organizational goals or in the institutional authority structure tend to identify less with the organization and view its demands less favorably than those who participate more fully in direct, goal-oriented activities.

Solutions to Previous Conflicts

New problems may arise from solutions to previous conflicts. The use of compromise as a strategy in dealing with conflict tends to leave all participants somewhat dissatisfied. At the next opportunity, one or more participants may seek to reopen the issue in an attempt to regain what was lost, particularly if the loss was acute. The loser may build up resources and enter into an active state of aggression when such resources have been accumulated, such as a nation defeated after a war (e.g., Germany after World War I). When there is a consistent denial pattern, the conflict may “go underground” for a time, then emerge again with greater force. Again, managers should realistically examine the negative consequences of conflict resolutions so as to minimize their recurrence.

The Participants

The immediate participants in the conflict can be identified readily as the individuals or groups caught in the open exchange.

The secondary participants are the individuals called in to take an active role, such as persons at the next level of the hierarchy. A manager may consult with a senior official to whom the individual involved in the conflict reports or with a staff adviser, such as a labor relations specialist. A unit manager may be required in some instances to refer conflict to the next level for resolution, as in some grievance procedures. In the case of a unionized employee, a representative of the union, such as a shop steward, may be involved. A “neutral” party may be called in by both sides in a labor dispute (e.g., a mediator or an arbitrator). Occasionally, a manager may consult informally with certain “marginal” individuals, such as those in the department or organization who have an overlapping role set, a supervisor whose domain spans several activities, a client who is also on an advisory committee, or another department head who has faced similar situations. Because they link groups, these individuals are sought out to test a potential solution or to obtain information and even advice.

A third category of participants may be classified as the audience. This category may include the following:

• The clients. If the conflict is overt and severe, the clients may turn to other organizations for the necessary services so as to avoid the conflict. Uncertainty may cause tension within this group, however, and clients may become active participants. A client group alienated from the institution may develop its own system to meet its needs.

• The public at large. This group may seek action through recourse to some government agency, and an agency’s intervention into the conflict may take the form of additional regulation of the organization. The conflict may be brought into the public arena; for example, a labor dispute may be taken to court. The net effect of intervention by some agent on behalf of the public at large is the opening or broadening of the conflict, which removes it from the immediate control of the original parties to the dispute.

• A potential rival or enemy. While one group and its opponents are absorbed in conflict, a third group whose energies are not drained by conflict may seek to expand its services and attract the clients of the groups locked in the dispute.

• Individuals or groups with similar complaints. Some observers may seek to press a similar claim if “the right side” wins. In the case of employee unrest, a labor organizer may consider more active unionization attempts. Independent practitioners who seek greater autonomy in the practice of health care may monitor changes in organizational bylaws or state licensure regulations and find gains made by one individual or group of practitioners to be the catalyst needed to obtain similar gains. In malpractice cases, jury awards are monitored and publicized. As the basis for a certain kind of claim is expanded through a trend in court decisions, more individuals may advance their cases. Without extensive publicity of the benchmark cases, this basis of claim might not have arisen. A worker who sees another worker win a concession from the manager about some work rule will more readily press a similar claim.

• The opportunist. Some individual or group may seek to enter the conflict as champion or savior. Such action may be undertaken by individuals seeking to raise themselves to leadership positions.

In many cases, members of the audience not only cheer and jeer, but they also become active participants, thereby expanding the conflict in terms of the number of individuals or groups who must be satisfied in any solution.

Conflict should be resolved at as low an organizational level as possible. The facts are better known by the immediate participants, who are able to communicate directly. Also, because the number of participants is limited, agreement on a solution may be more easily obtained. Top levels of management should be involved only rarely in conflicts within the organization, because their involvement might give undue weight to the problem, establish precedent, and force the setting of policy that escalates resolutions to a higher level. The resources of top management should generally be reserved for critical issues.

The Provision of an Arena

The development of a safe, predictable, and accessible arena tends to create a sense of security and to keep the problems from becoming diffuse. The aggrieved know where to turn and what to do to seek redress. The provision of an acceptable arena is also efficient. The individuals involved give their attention to it in a highly structured manner, and it establishes clear boundaries to the conflict: It is legitimate to bring issues of conflict to this place, through this structure, at these designated times. The court system and legislative debate are such arenas in the larger society. In organizations, arenas include the structured grievance process for employees (Exhibit 10–2), the appeals process for the professional staff member seeking staff appointment, or the complaint department for customers. Committees in which multiple input is invited are also common arenas for the resolution of conflict.

The Development of Rules

Rules serve to limit the energy expended on the conflict process. The provision of rules has a facesaving and legitimizing effect; it is permissible to disagree, equal time is guaranteed, and each point of view is aired. The rules also provide a basis for the intervention of a referee or neutral party. The rules may be developed to allow a cooling-off period so that the issues can be put in perspective.

EXHIBIT 10–2 Excerpts from Grievance Procedure

Any grievance that may arise between the parties concerning the application, meaning, or interpretation of this Agreement shall be resolved in the following manner:

Step 1: An employee having a grievance and his Union delegate shall discuss it with his immediate supervisor within five (5) working days after it arose or should have been made known to the employee. The Hospital shall give its response through the supervisor to the employee and to this Union delegate within five (5) working days after the presentation of the grievance. In the event no appeal is taken to the next step (Step 2), the decision rendered in this step shall be final.

Step 2: If the grievance is not settled in Step 1, the grievance may, within five (5) working days after the answer in Step 1, be presented in Step 2. When grievances are presented in Step 2, they shall be reduced to writing on grievance forms provided by the Hospital (which shall then be assigned a number by the Department of Human Resources at the Union’s request), signed by the grievant and his or her Union representative, and presented to the Department Head and the Department of Human Resources. A grievance so presented in Step 2 shall be answered in writing within five (5) working days after its presentation.

The time frame given by the rules reduces uneasiness, because participants are assured of a legitimate opportunity to present the issues. Conflict remains under control.

Strategies for Dealing with Organizational Conflict

Two strategies for dealing with conflict are opposite in nature: limitation and purposeful expansion. A manager assesses a conflict situation and makes a judgment. Is the wiser course of action one in which the conflict is allowed to become greater? With this approach, there is the risk that the organization could lose control as conflict is widened, and it is unlikely that both sides will be reinforced equally. Conflict is best kept private, limited, and therefore controllable. Yet there might be an advantage to conscious expansion. The underlying purpose of the intentional expansion of conflict is to demonstrate its immediate effect on the clients or the public, who in turn will bring pressure on the opposing party to end the dispute. The immediate involvement of the client group is sought in the hope that it will act as a catalytic factor, forcing quick resolution. For example, a teachers’ union may go on strike at the beginning of a school year, a coal miners’ union may strike during the winter, and traffic officers may conduct a slowdown or job action during the height of the Fourth of July traffic to the shore.

The routinization of conflict is an additional strategy wherein conflict is accepted as a normal part of organizational life. Thus, the conflicts are anticipated. Certain conflicts are identified and contingency plans are developed. For example, a strike plan is developed in anticipation of possible conflict arising at the conclusion of a contract cycle. Such an event may be short-lived, with more of a symbolic value as a kind of catharsis as a biennial event. The energy associated with such conflict is brought to the surface and played out in a scripted fashion; it is predictable and therefore manageable. Other strategies for the routinization of conflict include, for example, co-optation, strategic leniency, preformed decisions through policy and procedure development, and the selection of individuals who fit the organization.

In addition to such conscious strategies, a manager should make use of the general principles of sound organization. When used properly, these principles bring about stability and reduce conflict. Known policies and rules, sufficient orientation and training of members, proper authority–responsibility designations, and clear chains of command and communication—all of these practices foster cooperation and mutual expectation, with the attendant reduction of undue conflict.

Finally, awareness of “burnout” and programs to prevent it can contribute to the reduction of conflict and enhance motivation. Such programs are discussed in another section.

DISCIPLINE

The attitudes, emotions, and motivations of each employee within an organization affect not only the degree to which goals and objectives are attained but also influence the behavior of other employees. The manager of any unit or department must be concerned with the conduct or behavior of all employees within that unit or department. A manager’s guidance of a work group is best supported and facilitated by: (1) establishing reasonable standards of conduct, or work rules, and informing employees of these standards, and (2) enforcing all rules consistently and humanely.

The word discipline has acquired different and sometimes less-than-favorable connotations over the years. In the military context, the word is usually associated with order, consistency, and unquestioning obedience. In the context of the work organization, however, the word is strongly associated with the use of authority, and it carries the disagreeable connotation of punishment. However, a brief foray into the origins of the word reveals that discipline comes from the same root as disciple and as such actually means “to teach so as to mold.” Thus at one time, teaching was the primary intent of discipline, the process of shaping or molding the disciple. Nevertheless, for the most part, in the context of the work organization, people have come to associate discipline—and therefore disciplinary action—with punishment.

Although much disciplinary action necessarily includes elements of punishment, its primary objective must never be punishment itself. Rather, the principal purpose of disciplinary action should be correction of behavior. Therefore it is a requirement of disciplinary action that for all but the most serious infractions, the transgressing party be afforded the opportunity to correct the offending behavior. The obvious exceptions are those instances of behavior that are sufficiently serious to prompt “correction” by removing (that is, terminating) the offenders without a second chance. These exceptions arise in a relative minority of disciplinary situations; for the greatest part, disciplinary action is properly directed toward correcting errant behavior.

In addition to using disciplinary action to improve employee behavior, at times it can help motivate employees so they become self-disciplined and thus more effective in the performance of their jobs. However, no matter how skillfully it is applied, disciplinary action will always carry something of a negative connotation for many employees, so in the long run calling attention to correct behavior is more effective in promoting self-discipline and cooperation than calling attention to incorrect behavior. In other words, disciplinary action is necessary and has its place, but praise ultimately proves more powerful in inspiring acceptable performance and behavior. Even in an organization where employees exhibit a high degree of independence and self-discipline, a manager must occasionally apply disciplinary action of some kind because rules have been broken.

At this stage of the discussion, it is necessary to make a distinction between two kinds of employee problems with which the manager may be confronted: problems of performance and problems of conduct or behavior. When a manager speaks of taking disciplinary action, he or she is talking of addressing problems of conduct or behavior—that is, problems that involve the breaking of rules or the violation of policies. In addressing these kinds of problems, although it is usually his or her purpose to correct the errant behavior, the process frequently involves “warnings” of various kinds. Thus, the process can acquire a negative connotation and be perceived as including “punishment.” Most, if not all, problems of conduct or behavior involve violations that are willful or that at least result from carelessness or indifference. Such violations are considered the fault of the perpetrators.

Problems of performance are an entirely different matter. The warnings, suspensions, and other measures described within a progressive disciplinary process are inappropriate for problems of performance. Such problems, which usually encompass an employee’s failure to meet the minimum expectations of the job, are not considered willful violations of rules. Therefore, problems of performance must be addressed through counseling and retraining as necessary, using a process that is entirely corrective in nature and not punitive in any respect. The progressive disciplinary process, then, is applicable only to problems of conduct or behavior and not to problems of performance.

Distasteful as the application of disciplinary action may be, it is the manager’s responsibility to act promptly, firmly, and consistently when action is called for. Disciplinary action should follow the misconduct as closely in time as possible. The only significant reasons for ever delaying disciplinary action even briefly are to allow tempers to cool, perhaps to investigate a situation and decide how to proceed, or to take the time and opportunity to secure a private one-on-one meeting with the offending individual. Every instance of disciplinary action must be treated as a confidential matter, handled in private; it is, quite bluntly, nobody’s business but that of the offending employee and the manager.

Progressive Disciplinary Action

Several steps constitute the progressive disciplinary process. Not all of these steps will be applicable in all instances; at which step the process is entered and how many steps are applied will depend on the nature of the specific infraction. The steps comprising a complete progressive disciplinary process are described next.

Counseling

The initial step taken to address a number of kinds of noncritical errant behavior should be counseling. In a one-to-one meeting with the manager, the employee should be told the nature of the perceived problem, why it is a problem (or how it can become a problem), what the rules are concerning this behavior (with specific reference to handbooks and policy manuals), what the possible consequences of this kind of behavior are, and within what period of time correction is expected. This should be accomplished without reference to any kind of “warning”; it is simply an important, job-related discussion between manager and employee.

The manager should document each counseling session. Some organizations use a specific form for documenting counseling sessions, but a simple handwritten note retained in departmental files should be sufficient.

Oral Warning

Repeated problem behavior following counseling should be addressed using the more formal early stages of the progressive disciplinary process, specifically the oral warning. The oral warning stage, often regarded as involving a “counseling” session itself, should be used only after the employee has failed to respond to informal counseling.

EXHIBIT 10–3 Record of Oral Warning

Employee Name __________________________________ ID No. __________

Department ____________________________________ Hire Date _________

Job Title and Grade ______________________________ Job Date __________

Infraction or incident; policy reviewed and discussed:

 

Dates of counseling sessions or discussions concerning the same policy:

 

The employee must take the following action:

 

Employee Signature ________________________________ Date ___________

Manager Signature _________________________________ Date ___________

This record will be maintained in departmental files. If further action is required for the same offense, it will be forwarded to Human Resources for inclusion in the personnel file.

The oral warning should be documented by the manager, preferably on a form created for that purpose. Exhibit 10–3 presents an example of a simple oral warning form.

Often someone will argue that if the “oral” warning is documented, it is actually a written warning. It may seem so, but the difference between a written warning and an oral warning lies in what goes into the employee’s personnel file. The record of an oral warning should be retained in department files; it should go into the official personnel files only as part of a subsequent warning for the same kind of behavior.

One might logically ask that if it is truly to be an “oral” warning, why document it at all? This is done because the oral warning is a step in the published progressive disciplinary process. When an employment relationship breaks down and legal problems result, it can become necessary to provide evidence that every step in the process was followed.

Written Warning

The written warning follows the oral warning as necessary, with this documentation automatically included in the employee’s personnel file. Exhibit 10–4 is an example of a written warning form.

EXHIBIT 10–4 Written Warning

Employee ___________________________________ Name ID No. __________

Department ____________________________________ Hire Date __________

Job Title and Grade _______________________________ Job Date __________

Infraction or incident; policy reviewed and discussed:

 

Dates of previous actions related to the foregoing:

 

The employee must take the following action:

 

Employee Signature ___________________________________ Date __________

Manager Signature ____________________________________ Date __________

This record puts the employee on notice that additional violations will result in more serious disciplinary action such as suspension without pay or discharge.

An employee whose improper behavior has not been corrected following counseling, oral warning, and written warning is in a position in which failure to change is likely to lead to loss of income via suspension and perhaps eventual loss of employment. By this stage, the manager and the employee have been together on the subject of the employee’s behavior problem at least three or more times. It is time for the manager to bring other resources into the process.

Before Suspension

Before proceeding to the suspension step, the manager should consider referring the employee to one of two available sources of assistance: the employee health service or the human resources department. If in any of their numerous contacts, the employee has given the manager reason to believe that he or she may be experiencing health problems of any kind, a referral to the employee health service is in order. If the problem appears to possibly lie in the employee’s attitude or in other difficulties unrelated to health, the referral should be to human resources. In the ideal system, the human resources department will include an employee relations specialist or employee ombudsperson, but in the absence of such specialists, most human resources generalists can fill the employee relations role.

This referral puts the employee in contact with someone who may be able to point the way toward resolution of some underlying problem. Also, a knowledgeable person other than the manager is brought into the process, and this new participant may be able to get through to the employee where the manager could not. This step provides the employee with a more distinct opportunity to correct the problem behavior. Also, the involvement of human resources can be helpful in instances in which tension or strain exists between the department manager and the employee.

Suspension and Discharge

If the referral step described previously proves unsuccessful, suspension without pay, which in many systems ranges from 1 to 5 days, may follow. Eventually, discharge will likely be necessary if nothing up to and including suspension without pay is successful in changing behavior. Exhibits 10–5 and 10–6 are examples of forms used to document suspension and discharge, respectively. However, a well-functioning referral program for employee behavior problems will significantly reduce the use of the clearly punitive steps of suspension and discharge.

XHIBIT 10–5 Suspension Without Pay

Employee Name __________________________________ ID No. ___________

Department ______________________________________ Hire Date ___________

Job Title and Grade _______________________________ Job Date ___________

 

Infraction or incident, and rule or policy reviewed and discussed:

 

Previous Disciplinary Actions:

Date:

Action Taken:

 

Suspended for ____ days from the above date. Report back on regular shift on ____.

 

Or

 

____ Time off waived by manager for the following reason (waiver does not lessen the severity of the action):

 

Employee Signature ______________________________________________ Date ___________

Manager Signature ______________________________________________ Date ____________

This is a final warning. Failure to respond appropriately may result in discharge.

EXHIBIT 10–6 Notice of Discharge or Dismissal

Employee Name ____________________________________________ ID No. ___________

Department ______________________________________________ Hire Date ___________

Job Title and Grade ________________________________________ Job Date ___________

 

Your employment is being terminated for the following reasons:

 

Previous Disciplinary Actions:

Date:

Action Taken:

 

____ Check here to indicate whether the employee desires an exit interview to discuss benefits status. If this opportunity is declined, continuation-of-benefits information will be mailed to the employee’s home address.

 

Employee Signature _______________________________________________ Date ____________

Manager Signature ________________________________________________ Date ____________

There is an important point to address concerning suspension without pay. Note that in Exhibit 10–5, the manager has the option to waive the time-off requirement of a suspension. The manager is permitted to use this option on occasions when the enforced time off for a suspension would leave an important job untended or an area critically understaffed. However, the employee must be strongly advised that waiver of time off does not lessen the severity of the disciplinary action as far as the official record and future actions are concerned.

The manager who believes there is cause to discharge an employee should take the case to the human resources department for thorough review before initiating action. Given the legal environment of the times, most organizations today require human resources or administrative review and concurrence for most discharges. This review is conducted to determine whether all bases have been covered from a legal perspective and whether the record clearly demonstrates that the employee was given the opportunity to correct the inappropriate behavior. Because of the time required to accomplish it, this review serves another extremely important function in ensuring that no employee is ever fired on the spot or otherwise terminated in the anger of the moment.

Some severe infractions must, of course, be dealt with as they occur. However, immediate firing is never the answer. The offending employee should instead be sent home on indefinite suspension pending investigation and resolution.

Not all kinds of infractions will require the application of all the foregoing steps. A mild infraction, such as tardiness (within a few minutes of starting time) may, if it becomes chronic, eventually require all of the steps described previously. A more serious infraction, such as sleeping on duty, may call for a written warning or suspension on the first violation and discharge on the second violation.

The organization’s human resources department ordinarily provides guidance for determining the severity of disciplinary action for specific infractions. Differences exist among organizations as to which kind of action applies to which sort of infraction, but guidelines might include the following:

• For typical minor infractions such as chronic tardiness, absenteeism, or perhaps discourtesy, the progression might consist of first, oral warning; second, written warning; then 1-day suspension; then 3-day suspension; and finally discharge.

• For more serious infractions, such as conducting personal business on work time, unexcused absence, or failure to report for work when scheduled, the progression might consist of written warning for the first offense, then 3-day suspension, and finally discharge.

• For still more serious infractions such as insubordination, falsification of records, or violation of confidentiality, the complete progression might consist of a written warning for an initial offense and discharge for a second offense.

• For the most serious infractions, there is no progression; these incidents call for discharge on the first and only offense. Typical serious infractions include theft, fighting on the job, possessing or using alcohol or illegal substances on the job, bringing weapons onto the premises, deliberate destruction of property, and absence without notice for three consecutive scheduled days (considered job abandonment).

Heading Off Infractions Before They Occur

The manager who observes an employee apparently headed toward a point where disciplinary action will be necessary is advised to introduce counseling before true progressive discipline is necessary. For example, if the manager sees that a particular employee is developing a poor attendance record and is closing in on the point at which disciplinary action is called for, the manager should address this problem via counseling with the employee before such action is necessary. It is the unfeeling manager who, observing that an employee is approaching the point where disciplinary action is necessary, will allow the circumstances to continue until action is unavoidable. It is better by far for both manager and employee to use counseling in an effort to head off the problem before it fully develops.

Appeal Procedure

Numerous organizations use appeal procedures to address employee complaints about work-related matters. Such matters can include, for example, disciplinary actions, performance evaluations, and decisions based on specific interpretations of policy. A typical appeal procedure might include the following steps or some variation of them. The time frames given are simply what one organization might specify.

• An employee with a complaint should first address the issue with the immediate supervisor.

• If the employee is not satisfied with the supervisor’s response, within a week of the meeting he or she may complete a simple appeal form (obtained from human resources) and schedule a meeting with the appropriate department head (the manager to whom the supervisor reports). If the department head is the immediate supervisor, this step and the following step are omitted.

• Within 2 weeks the department head will review all facts and circumstances, investigating as necessary, and render a decision in writing on the appeal form.

• If not satisfied with the department head’s response, the employee may take the appeal to the member of administration to whom the department head reports. As in the previous step, within 2 weeks the administrative representative will render a decision in writing.

• If the employee remains unsatisfied with the response, the appeal is then taken to the director of human resources, who will convene a three-party ad hoc appeal committee consisting of one staff employee, one management employee, and one human resources representative. Within 2 weeks this committee will submit a confidential recommendation to the director of human resources.

• As necessary, the director of human resources will review the complaint and recommendation with administration or legal counsel for legal or other significant implications. Once cleared at this level, the recommendation becomes final and binding.

• The employee does, of course, have external options for appeal, such as the Equal Employment Opportunity Commission and the State Division of Human Rights. However, if the organization’s representatives have applied the appeal procedure honestly and impartially, the chances of a successful external challenge are severely limited.

Grievance Procedure

The word appeal was used throughout the foregoing procedure to differentiate the process from that which might be embodied in a collective bargaining agreement (union contract). Collective bargaining agreements invariably use the term grievance in the same sense that appeal might be used in a nonunion context. As in the nonunion appeal process, a union grievance procedure uses several steps that take the complaint up through succeeding levels of consideration. The essential differences arise from the involvement of union officials and perhaps outside arbitrators or mediators.

One form of grievance procedure is presented in Appendix 10–A, Sample Collective Bargaining Agreement. In that document, Article Fifteen covers the grievance procedure.

THE LABOR UNION AND THE COLLECTIVE BARGAINING AGREEMENT

Since the National Labor Relations Act was amended in 1975 to remove the exemption of not-for-profit hospitals, workers in healthcare organizations have been permitted by federal law to organize into labor unions. The specific exemption of not-for-profit hospitals had been in place since 1947, so between 1947 and 1975 the only active union organizing that occurred in not-for-profit institutions was that made possible by the labor relations laws of a few states.

The typical collective bargaining agreement reflects management’s and the union’s efforts to contain and control conflict and provide a framework for the resolution of disagreement. Appendix 10–A contains a typical collective bargaining agreement. The entire agreement is included in this appendix to provide the complete context of the formal relationship between employer and union. However, with specific reference to conflict both actual and potential, attention is called to the following articles:

• Articles Six and Seven, in which the contracting parties agree to the limitation of conflict during the life of the agreement

• Articles Fourteen and Fifteen, which provide for the orderly resolution of disciplinary actions and complaints by employees against management

• Articles Eight through Twenty, which address the specifics of working conditions, hours of work, benefits of employment, and other employment-related matters in a manner intended to provide clear guidelines for practice and, therefore, to avoid conflict or minimize the chances of conflict occurring

Although some members of the healthcare organization, especially managers and professionals, may find a collective bargaining agreement restrictive because of the apparent limitations it places on actions of various kinds, the overall clarity of the provisions in a well-written contract, plus the fact that the contract has been negotiated by management and workers together, so that both sides “own” the agreement, can sometimes foster positive organizational relationships. When the occasional conflict does occur, the provisions of the contract can guide its resolution.

LABOR UNIONS IN HEALTH CARE: TRENDS AND INDICATORS

At present, the healthcare industry is not significantly unionized, with approximately 7.2% of all eligible nonmanagerial employees in all healthcare settings working under union contracts as of the end of 2013, up slightly from 7.0% as of the end of 2012.3 Approximately one-fourth of the country’s hospitals have some unionized staff, but in a great many instances these unions are limited to specific groups and do not represent total employee populations. Overall, union representation in health care is substantially less than in all other industries; the strongest union penetration involves public sector employees at about 35.3% of eligible workers, as compared with 6.7% of eligible workers in the private sector.3 At the same time, however, indicators suggest that union penetration in health care is trending upward.

Numerous union attempts to secure representation seem on the surface to have resulted in a surprisingly high percentage of union victories. However, it is misleading to compare numbers of union elections with union victories; many elections are called off by unions or otherwise not pursued if circumstances suggest that the unions are likely to lose.

Why is unionization presently increasing in health care, and why do some of the unions seem to be concentrating on healthcare employees? Consider the following factors:

• Healthcare employment is large and growing. Health care has long since passed manufacturing and is presently second only to government in number of employees. Large groups of nonunionized employees attract union attention.

• Health care has for several years been in an especially unsettled state. Mergers, acquisitions, closures, systems formation, and various downsizing activities have resulted in layoffs or displacements of employees as healthcare delivery patterns have changed. This unsettled state renders many employees susceptible to union overtures.

• Health care was once considered by many to be essentially recession-proof, but that is no longer the case. With all of the changes occurring in health care, employees have seen many of their fellow workers laid off as a result of the effects of the aforementioned circumstances plus the ever-tightening web of financial constraints placed on the healthcare system. There are now fears concerning job security where no such fears existed in the past.

• In numerous hospitals, cutbacks in staffing have raised nurses’ concerns over both the safety of patients and the well-being of nurses themselves. Complaints about the effects of long shifts, extra shifts, and mandatory overtime have driven some nurses closer to unions, and the nurses’ unions have taken up these staffing issues on their behalf.

Many of the foregoing circumstances, plus healthcare employees’ concerns for other employment-related matters, are reflected in the issues emerging prominently in union contract negotiations. The industry is seeing—and for a while should continue seeing—discussions, disputes, and demands addressing the following issues:

• Job security, as new patterns of care delivery continue to evolve and uncertainty concerning continued employment prevails.

• The employer’s share of the cost of employee health insurance. As health insurance rates continue climbing, employers are endeavoring to shift a greater portion of these costs to employees—a move strongly resisted by employees and unions.

• Pension plans and associated employer contributions to them, as organizations continue to abandon defined-benefit plans and increase their reliance on defined contribution plans, such as 401(k) plans.

• Staffing levels, especially from nurses but possibly from other professional groups as well.

• Pay rates, which are always a source of contention, although in many instances these concerns may be secondary to some of the other issues.

Unions of all stripes—in health care and elsewhere—have begun working together to push a national legislative agenda. Within health care, three unions have joined together to put forth a single front in support of a new legislative agenda. These efforts have included support of the proposed Employee Free Choice Act.

The Employee Free Choice Act, introduced as a legislative bill in congress in 2009, proposed to amend the National Labor Relations Act to bypass the secret ballot representation election if the majority of eligible employees sign a petition or authorization card. Union opponents expressed concern that the peer pressure, harassment, and coercion that can accompany an open petition could enable unions to rapidly make progress in unionizing the healthcare industry. Also, the bill would have required employers and unions to enter binding arbitration to produce a contract no later than 120 days after a union is officially recognized. The bill would also have increased penalties on employers who discriminate against workers for union involvement. The Employee Free Choice Act has not become law and for all practical purposes is tabled and unlikely to go forward any time soon, if at all.

CASE: A MATTER OF MOTIVATION: THE DELAYED PROMOTION

Background

With considerable advance notice, the director of health information management (HIM) resigned to take a similar position in a hospital in another state. Within the department it was commonly assumed that you, the assistant director, would be appointed director; however, a month after the former director’s departure, the department was still running without a director. Day-to-day operations had apparently been left in your hands (“apparently,” because nothing had been said to you), but the hospital’s chief operating officer had begun to make some of the administrative decisions affecting the department.

After another month had passed, you learned “through the grapevine” that the hospital had interviewed several candidates for the position of director of health information management. Nobody had been hired.

During the next few weeks you tried several times to discuss your uncertain status with the chief operating officer. Each time you tried, you were told simply to “keep doing what you’re now doing.”

Four months after the previous director’s departure, you were promoted to director of HIM. The first instruction you received from the chief operating officer was to abolish the position of assistant director.

Instructions

1. Thoroughly analyze and describe the likely state of your ability to “motivate” yourself in your new position. In the process, comment to whatever extent you feel necessary on your level of confidence in the relative stability of your position and explain how it might affect your performance.

2. Describe the most likely motivational state of your HIM staff at the time you assumed the director’s position, and explain in detail why this state probably exists.

CASE: CHARTING A COURSE FOR CONFLICT RESOLUTION—“IT’S A POLICY”

Background

The setting is an 82-bed hospital located in a small city. One day an employee of the maintenance department asked the supervisor, George Mann, for an hour or two off to take care of some personal business. Mann agreed, and he asked the employee to stop at the garden equipment dealership and buy several small lawnmower parts that the department required.

While transacting business at a local bank, the employee was seen by Sally Carter, the supervisor of both human resources and payroll, who was in the bank on hospital business. Carter asked the employee what he was doing there and was told the visit was personal.

On returning to the hospital, Sally Carter examined the employee’s time card. The employee had not punched out to indicate when he had left the hospital. Carter noted the time the employee returned, and after the normal working day she marked the card to indicate an absence of 2 hours on personal business. Carter advised the chief executive officer (CEO), Jane Arnold, of what she had done, citing a long-standing policy (in their dusty, and some would say infrequently used, policy manual) requiring an employee to punch out when leaving the premises on personal business. The CEO agreed with Sally Carter’s action.

Carter advised Mann of the action and stated that the employee would not be paid for the 2 hours he was gone.

Mann was angry. He said he had told the employee not to punch out because he had asked him to pick up some parts on his trip; however, he conceded that the employee’s personal business was probably the greater part of the trip. Carter replied that Mann had no business doing what he had done and that it was his—Mann’s—poor management that had caused the employee to suffer.

Mann appealed to the CEO to reopen the matter based on his claim that there was an important side to the story that she had not yet heard. Jane Arnold agreed to hear both managers state their position.

Instructions

1. In either paragraph form or as a list of points, develop the argument you would be advancing if you were in George Mann’s position.

2. In similar fashion, thoroughly develop the argument you would advance if you were in Sally Carter’s position.

3. Assuming the position of the CEO, Jane Arnold, render a decision. Document your decision in whatever detail may be necessary, complete with explanation of why you decided in this fashion.

4. Based on your responses to Questions 1 to 3, outline whatever steps—policy changes, guidelines, payroll requirements, or something else—you believe should be considered to minimize the chances of similar conflict in the future.

NOTES

1. David L. Cooperrider, Peter F. Sorensen Jr., Diana Whitney, and Therese F. Yaeger, eds. Appreciative Inquiry: Rethinking Human Organization Toward a Positive Theory of Change (Champaign, IL: Stipes Publishing, 2000).

2. Portions of this section are adapted from C. R. McConnell, The Effective Health Care Supervisor, 8th ed. (Burlington, MA: Jones and Bartlett Learning, 2015), Chapter 25, “Reengineering and Reduction in Force,” 466–472.

3. Union Members, 2013, News Release, Bureau of Labor Statistics, USDL-14-0095, January 24, 2014.

Appendix 10–A

Sample Collective Bargaining Agreement

(Fictitious in all respects—for training use only to illustrate various aspects of contract agreement)

ARTICLE	CONTENT	PAGE
One	Intent and Purpose	2
Two	Recognition	3
Three	Union Security	3
Four	No Discrimination	6
Five	Management Rights	6
Six	Union Activity	7
Seven	No Strike; No Lockout	8
Eight	Hours of Work and Overtime	9
Nine	Rate of Pay; Shift Differential	10
Ten	Probationary Employees	12
Eleven	Seniority; Layoffs and Promotion	12
Twelve	Safety and Health	17
Thirteen	Resignation	17
Fourteen	Discipline and Discharge	17
Fifteen	Grievance Procedure	18
Sixteen	Arbitration	20
Seventeen	Holidays	21
Eighteen	Vacation	23
Nineteen	Sick Leave	25
Twenty	Leave of Absence	26
Twenty-One	Insurance and Pensions	26
Twenty-Two	Terms of Agreement	27

COLLECTIVE BARGAINING AGREEMENT BETWEEN JGL MEMORIAL HOSPITAL AND THE CLERICAL AND TECHNICAL HOSPITAL EMPLOYEES’ GUILD OF GREATER NEW CITY METROPOLIS, AFL-CIO AND ITS AFFILIATE LOCAL 123B

This agreement dated January 4, 20N1, to be effective as of February 1, 20N1, is entered into between JGL MEMORIAL HOSPITAL (herein called the “Hospital”) and Clerical and Technical Hospital Employees’ Guild of Greater New City Metropolis AFL-CIO AND ITS AFFILIATE Local 123B (herein called the “Union”).

ARTICLE ONE: INTENT AND PURPOSE

1.1 Whereas, the Hospital is engaged in furnishing an essential public service vital to the health, welfare, and safety of the community and more particularly of the patients seeking and receiving service at the hospital; and

Whereas, both the Hospital and its employees have a high degree of responsibility to provide such services without interruption of this essential service; and

Whereas, both parties recognize this mutual obligation, they have entered into this Agreement to promote and improve the mutual interests of the Hospital and its employees and to establish and maintain cooperation and harmony between the Hospital and its employees;

Now, therefore, in consideration of the mutual promises and obligations herein assumed, the parties agree as follows:

ARTICLE TWO: RECOGNITION

2.1 The Hospital recognizes the Union as the sole collective bargaining Agency for all technical and clerical workers including messengers, mailroom workers, unit clerks, clerks and clerk typists, secretaries, and other technical workers as certified in the State labor relations board certification of December 11, 20N1.

2.2 The Unit specifically excludes supervisors, temporary workers, casual workers, and students.

2.3 Part-time work employees who work 20 or more hours per week shall be covered by the terms of this agreement on completion of the probationary period.

2.4 The number of part-time employees shall not exceed 5% of the total number of bargaining unit employees in each department as of February 1, 20N1. Temporary employees and students and independent contractual employees may not be hired for a period longer than 4 months per job per year.

ARTICLE THREE: UNION SECURITY

3.1 It shall be a condition of employment that all employees of the Hospital covered by this agreement who are members of the Union in good standing on the effective date of this agreement shall remain members in good standing and those who are not members on the effective date of this agreement shall, after the 60th day actually worked, following the date of signing this agreement, or its effective date, whichever is later, become and remain members in good standing in the Union. It shall also be a condition of employment that all employees covered by this agreement and hired on or after the date of signing or its effective date, whichever is later, shall, after the 60th day actually worked following such date, become and remain members in good standing in the Union.

3.2 The failure of any employee to become a member of the Union at the required time shall obligate the Hospital, on written notice from the Union to such effect and to the further effect that Union membership was available to such employee on the same terms and conditions generally available to other members, to forthwith discharge such employee. Furthermore, the failure of any employee to maintain his Union membership in good standing as required herein shall, on written notice to the Hospital by the Union to such effect, obligate the Hospital to discharge such employee. Following such notification to the Hospital, the employee shall be given a period of not more than 30 days during which he shall be given an opportunity to reestablish his membership in good standing with the Union.

3.3 The Union agrees that the payment of regular monthly membership dues and initiation fees shall constitute membership in good standing.

3.4 The Hospital shall for the term of this Agreement deduct union dues and initiation fees from such employees who are members of the Union and who individually and voluntarily notify the Hospital through written authorization to the Hospital for deductions from any wage paid to such employee. The Hospital agrees to make such deductions on the first payday of each month or at such other time as both the Hospital and the Union shall mutually agree and shall remit such monies promptly to the designated officer of the National Union. The Hospital shall supply the Union with a list of those employees for whom deductions were made and the amount of deductions per current month.

3.5 The Hospital will furnish the Union each month with the names; addresses; Social Security numbers; classification of work; dates of hires; names of terminated employees, together with their dates of termination; and the names of employees on leave of absence and specific kind of leave of absence. Employees shall promptly notify the Hospital of changes in their names and addresses.

3.6 The Union shall indemnify and save the Hospital harmless against any claims, demands, suits, and other forms of liability that may arise out of action taken or not taken by the Hospital for purposes of compliance with these provisions.

ARTICLE FOUR: NO DISCRIMINATION

4.1 There shall be no discrimination against or for an employee because of race, color, creed, national origin, political belief, sex, age, Union membership, or nonmembership by the Hospital or by the Union.

ARTICLE FIVE: MANAGEMENT RIGHTS

5.1 Unless expressly included in this Agreement, nothing herein contained shall be construed to limit the Hospital’s right to exercise the functions of management under which it shall have, among others, the right to employ, supervise, and direct the working force; to discipline, suspend, and discharge employees for just cause; to transfer and lay off employees because of lack of work; to require employees to observe reasonable work rules and regulations not inconsistent with this Agreement; to determine the extent to which its properties, equipment, and facilities shall be maintained and/or operated or shut down; to introduce new or improved methods and/or procedures; to determine the services to be rendered to patients and the schedules of maintaining such services; and otherwise to manage or conduct the facility, provided that these provisions shall not be used for the sole purpose of depriving any Hospital employee of work. The above rights are not all inclusive, but indicate the type of matters or rights that belong to and are inherent to Management. Any of the rights, power, and authority the Hospital had prior to entering this collective bargaining agreement are retained by the Hospital except as expressly and specifically abridged, delegated, granted, or modified by this Agreement.

ARTICLE SIX: UNION ACTIVITY

6.1 Except for Union activity expressly provided for in this agreement, no employee shall engage in any Union activity, including the distribution of literature, which could interfere with the performance of work during working time or in working areas at any time.

6.2 Union representatives (or designees) shall have reasonable access to the Hospital for the purpose of administering the provision of this agreement, provided they obtain clearance from the designated Hospital official, who shall not unduly restrict such access.

6.3 The Hospital will provide bulletin boards for Union use for the purpose of posting only Union notices. Such bulletin boards shall be located at places readily accessible to the employees’ place of work. The Union will be permitted to post on these boards such notices of a noncontroversial nature, copies to be submitted to the Labor Relations manager prior to posting.

6.4 The work schedules of employees elected as Union Delegates shall be adjusted so far as practicable as to permit attendance at regularly scheduled meetings after normal working hours, provided the Hospital’s operations shall not be impaired. The Union shall give reasonable notice to the Labor Relations manager of such regularly scheduled meetings and the names of such delegates.

ARTICLE SEVEN: NO STRIKE; NO LOCKOUT

7.1 During the terms of this agreement, neither the Union nor the employees shall engage in any strike, sit-down, sit-in, slow-down, cessation, stoppage, interruption of work, boycott, or other interference with the operations of the Hospital.

7.2 The union, its officers, agents, representatives, and members shall not in any way, directly or indirectly, authorize, assist, encourage, participate in, or sanction any strike, sit-down, sit-in, slowdown, cessation or stoppage or interruption of work, or other interference of the operations of the Hospital, or ratify, condone, or lend support to any such conduct or action.

7.3 Should any strike, slow-down, picketing, or other curtailment, restriction, or interference with Hospital functions or operations occur that the Union has not caused or sanctioned either directly or indirectly, the Union shall immediately:

(a) Publicly disavow such actions by the employees or persons involved.

(b) Advise the Hospital in writing that such action has not been caused or sanctioned by the Union.

(c) Post notices on the Union bulletin boards stating that it disapproves of such actions and instruct the members to return to work immediately.

(d) Take such other steps as would reasonably ensure renewed observance of provisions of this Article.

7.4 The Hospital shall have the right to discharge or otherwise discipline all employees or the Union on their behalf without having recourse to the grievance procedure and arbitration, except for the sole purpose of determining whether an employee participated in the prohibited action.

7.5 During the terms of this Agreement, the Hospital shall not engage in any lockout of any employee.

ARTICLE EIGHT: HOURS OF WORK AND OVERTIME

8.1 A period of 8 hours shall constitute a regular day’s work, and 40 hours shall constitute a regular week’s work in any one day or in any one week. A work day is defined as the continuous 24-hour period beginning at the employee’s regular starting time.

8.2 All work performed by an employee in excess of 40 hours in any 1 week shall be paid for at the rate of time and one-half.

8.3 The Hospital shall distribute and allot overtime work to best suit the efficient operation of a department and will make every reasonable effort to distribute in a reasonable way the overtime work equitably among the employees of the department in which the overtime occurs, provided the employee is qualified to perform the work.

8.4 All employees shall receive a 1-hour paid lunch period, which shall be counted as time worked. The Hospital will schedule this lunch period.

8.5 There shall be no pyramiding or duplicating of overtime rates. Hours compensated for at overtime rates under one provision of this Agreement shall be excluded as hours worked in computing overtime under any other provision. When two or more provisions requiring the payment of overtime rates are applicable, the one most favorable to the employee shall apply.

8.6 Employees shall be required to work overtime when assigned for the proper administration of the Hospital’s operations.

ARTICLE NINE: RATES OF PAY; SHIFT DIFFERENTIALS

9.1 Job classifications and rates of pay and progression in existence on the day of this agreement are set forth in Attachment A, which is made part of this agreement.

9.2 If during the term of this Agreement new job classifications are established or substantial changes are made in existing job classifications covered by the bargaining unit, the Hospital will put the new or changed job classification into effect and establish a rate of pay therefor. Such rate will be discussed with the Union in advance, with the objective of obtaining its agreement. The Hospital may then install the rate with or without agreement; when installed after agreement, no grievance may be filed with respect to the rate. If installed without agreement, the employee(s) affected or the Union may within 30 days present a grievance protesting the rate if that rate does not bear a proper relationship to existing rates. If no grievance is filed within the 30 days or if the grievance is settled, the new rate will become part of Attachment A (wage scale) and shall not be subject to challenge under the grievance procedure.

9.3 Full-time employees working on a shift that begins on or after 3:00 P.M., and before 4:00 A.M., shall be paid a shift differential of (n amount) per hour. An employee who is entitled to a shift differential for work on his regular shift shall receive the shift differential for overtime hours that are an extension of the regular shift. A shift differential shall not be paid when employees are authorized to exchange shifts temporarily for personal reasons.

9.4 A shift differential shall not be gained or lost as a result of an extension of a shift caused by overtime.

9.5 If an employee is regularly assigned to a shift receiving a shift differential, the differential shall be included in calculating the employee’s vacation, holiday, and sick leave pay.

ARTICLE TEN: PROBATIONARY EMPLOYEES

10.1 New employees and those hired after a break in continuity of service of more than 6 months will be regarded as probationary employees until they have actually worked 60 days and will receive no continuous service credit during such period. During this period of probationary employment, probationary employees may be disciplined, laid off, or discharged as exclusively determined by the Hospital, and the Hospital shall not be subject to the grievance and arbitration provision of this Agreement.

Continuing employees who apply for and are accepted into another job/position are considered probationary employees for 25 working days. See Article 11.9 for related stipulations.

10.2 The rate of pay for new employees and those hired after a break in continuity of service of more than 6 months shall be the hiring rate for the job. The rate of pay for continuing employees shall be the grade level rate of pay.

ARTICLE ELEVEN: SENIORITY; LAYOFFS AND PROMOTIONS

11.1 Seniority is defined as an employee’s length of continuous regular full-time Hospital service last date of hire. Employees who were hired the same day shall have their seniority established by lot and carried subsequently on the seniority list.

11.2 Seniority is computed from the day of last hire, on completion of the probationary period delineated in Article Ten.

11.3 Seniority shall accrue

(a) During any authorized leave of absence with pay

(b) During an authorized leave of absence without pay because of personal illness or accident for a period of 6 months or less, or maternity leave for a period of 1 year

During military service, as provided by federal law, an employee will not accrue, but will not lose, seniority during an authorized leave of absence without pay.

11.4 An employee will lose seniority when he

(a) Voluntarily terminates his full-time employment

(b) Is discharged for cause

(c) Willfully exceeds the length, or violates the purpose, of an authorized leave of absence

(d) Is laid off for a period of 6 months or the length of the employee’s service with the Hospital, whichever is less

(e) Fails to report in accordance with a notice for recall from layoff within 48 hours of the time specified in the notice sent by certified mail to the last address furnished to the Hospital by the employee. The Hospital shall send a copy of the notification to the Union.

(f) Fails to report for recall to the assigned job

An absence from work for three consecutive work days without notice or permission shall be deemed a voluntary resignation.

11.5 An employee who is or has been promoted or transferred out of the bargaining unit and who is later transferred back into the bargaining unit by the Hospital shall be credited on returning to the bargaining unit with the seniority he would have had if he had remained continuously in the bargaining unit.

11.6 In the event of a layoff in a department, temporary employees shall be laid off first, then probationary employees, then regular part-time employees, and then regular full-time employees on the basis of their Hospital-wide seniority. In the event a full-time permanent nonprobationary employee is scheduled to be laid off from a department, he or she may either bid for a posted vacant position in accordance with the provisions of Section 7 or displace another employee within the department of equal or lesser grade on the basis of Hospital-wide seniority, provided he has the ability to perform said job within 25 working days. The immediate department manager shall determine the employee’s acceptability.

11.7 Employees on layoff shall be recalled as follows:

(a) To a position, if open, previously held successfully in department by the employee regardless of place on the recall list

(b) In reverse order of layoff on a Hospital-wide basis to other open positions with the following provisions:

1. Employees may not upgrade from the recall list.

2. The employee must be acceptable to the hiring supervisor.

3. The employee must have the ability to perform the open position. The hiring supervisor shall determine the employee’s acceptability for that position during the applicable probationary period for a newly hired employee in that grade level.

4. When probationary or part-time employees are laid off, they shall have no recall rights.

11.8 Promotional opportunities

(a) Openings for bargaining unit positions shall be posted for five (5) work days.

(b) Employees within a department will be given preference for promotion to a higher-paying job in the department.

(c) All bids must be submitted in person and in writing to the Office of Human Resources within the five (5) work days.

(d) An open position shall be defined as a position that has been posted and for which no acceptable bidders have been found.

(e) An employee who has been promoted in pay grades six (6) to ten (10) shall not be eligible for further promotion for six (6) months.

(f) An employee who has accepted a promotional opportunity shall have twenty-five (25) working days to prove that he or she can perform in the new position.

(g) An employee who has accepted a promotional opportunity and fails the probationary period shall return to his or her previous position. If this position has been filled, the employee may be offered an open equivalent position. If none is available, the disqualified employee shall be laid off, subject to recall according to the provisions of Section 11.7.

11.9 The rate of pay during the probationary period is that of the grade level of the job.

ARTICLE TWELVE: SAFETY AND HEALTH

12.1 The Hospital agrees to provide reasonable safeguards on the premises for the health and safety of its employees. Two employees from the bargaining unit mutually agreed on by the Hospital and the Union shall serve on the Hospital Safety Committee.

ARTICLE THIRTEEN: RESIGNATION

13.1 An employee who resigns shall give the Hospital 2 weeks advance written notice.

13.2 An employee who fails to give such notice or whose employment is terminated shall forfeit unused vacation time, provided it was physically possible for the employee to give such notice.

ARTICLE FOURTEEN: DISCIPLINE AND DISCHARGE

14.1 No employee who has completed his probationary period shall be discharged or disciplined without just cause. If disciplinary action becomes necessary in the interest of proper operation of the Hospital, care of the patients, and general employee welfare, such actions of the Hospital shall be subject to the grievance procedure. The Hospital agrees to furnish copies to the Union of disciplinary notices resulting in suspension or discharge of an employee.

14.2 Any grievance resulting from action taken as outlined in the preceding section must be filed in writing according to the grievance procedure outlined in Article Fifteen.

ARTICLE FIFTEEN: GRIEVANCE PROCEDURE

15.1 Any grievance that may arise between the parties concerning the application, meaning, or interpretation of this Agreement shall be resolved in the following manner:

Step 1. An employee having a grievance and his Union delegate shall discuss it with his immediate department head within five (5) working days after it arose or should have been made known to the employee. The Hospital shall give its response through the department head to the employee and to this Union delegate within five (5) working days after the presentation of the grievance. In the event no appeal is taken to the next step (Step 2), the decision rendered in this step shall be final.

Step 2. If the grievance is not settled in Step 1, the grievance may, within five (5) working days after the answer in Step 1, be presented in Step 2. When grievances are presented in Step 2, they shall be reduced to writing on grievance forms provided by the Hospital (which shall then be assigned a number by the Office of Human Resources at the Union’s request) signed by the grievant and his Union representative, and presented to the Department Head and the Department of Human Resources. A grievance so presented in Step 2 shall be answered in writing within five (5) working days after its presentation.

Step 3. If the grievance is not settled in Step 2, the grievance may within five (5) working days after the answer in Step 2, be presented in Step 3. A grievance shall be presented in this step to the Office of Human Resources. The Office of Human Resources shall hold a hearing within five (5) days and shall thereafter render a decision in writing within 5 days.

15.2 Failure on the part of the Hospital to answer a grievance at any step shall not be deemed acquiescence thereto, and the Union may proceed to the next step.

15.3 An employee who has been suspended or discharged, or the Union on his behalf, may file within five (5) business days of the suspension or discharge a grievance in writing in respect thereof with the Office of Human Resources at Step 3 of the foregoing Grievance Procedure. Any prior written warnings applicable to the employee shall be mailed to the Union by the Hospital within five (5) working days after the employee is notified of his or her discharge.

15.4 All time limits herein specified shall be deemed to be exclusive of Saturdays, Sundays, and holidays.

15.5 Any disposition of a grievance from which no appeal is taken within the time limits specified herein shall be deemed resolved and shall not thereafter be considered subject to the grievance and arbitration provisions of this Agreement.

15.6 A grievance that affects a substantial number of a class of employees may initially be presented at Step 2 or Step 3 by the Union. The grievance shall then be processed in accordance with the Grievance Procedure.

ARTICLE SIXTEEN: ARBITRATION

16.1 A grievance that has not been resolved may, within ten (10) working days after completion of Step 3 of the Grievance Procedure, be referred for arbitration by the Hospital or the Union to the American Arbitration Association for resolution under the Voluntary Labor Arbitration Rules of the American Arbitration Association then prevailing.

16.2 The fees and expenses of the American Arbitration Association and the arbitrator shall be borne equally by the parties.

16.3 The award of an arbitrator hereunder shall be final, conclusive, and binding on the Hospital, the Union, and the employees.

16.4 The arbitrator shall have jurisdiction only over grievances after completion of the Grievance Procedure, and he or she shall have no power to add to, subtract from, or modify in any way any of the terms of this Agreement.

ARTICLE SEVENTEEN: HOLIDAYS

17.1 The following days are recognized as paid holidays for full-time and part-time employees who have completed their first 25 working days of employment:

New Year’s Day	Martin Luther King, Jr. Day
Memorial Day	Labor Day
Independence Day	Thanksgiving Day
Christmas Day

Two additional days that may be scheduled in accordance with the employee’s preference.

17.2 The additional days shall be taken at a mutually agreeable time and shall be requested in writing at least five (5) working days in advance. Once scheduled, these days shall not be canceled by an employee without the consent of the Hospital. These additional days must be taken within the calendar year and are not cumulative.

17.3 Employees shall receive their regular rate of pay for each holiday observed, provided they are on active pay status.

17.4 To be eligible for holiday benefits, an employee must have worked the last scheduled work day before and the first scheduled work day after the holiday (or the day scheduled in place of the holiday) except in the case of accident or illness preventing employee from working. The Hospital may require a written certificate from a physician or other proof.

17.5 If a holiday falls during an employee’s regularly scheduled day off, the employee shall receive an additional day off or an additional day’s pay, as the Hospital may decide.

17.6 If an employee is required to work on a holiday, he shall be compensated at 21/2 times his regular rate of pay for time worked or shall be given a compensatory day off at regular rate of pay, as determined by the Hospital. An employee shall not be considered as working on a holiday if the shift he is working started prior to the holiday.

17.7 If the holiday falls during an employee’s vacation, he shall receive an extra day’s pay or an extra day off with pay, as the Hospital shall decide.

ARTICLE EIGHTEEN: VACATION

18.1 Employees shall be granted vacation with pay according to the following schedule; vacation pay rate will be at the current straight hourly rate, including shift differential, for the number of hours indicated.

Period of Uninterrupted Service	Vacation Pay
One (1) year	10 working days	80 hours
Five (5) years	12 working days	96 hours
Six (6) years	13 working days	104 hours
Seven (7) years	14 working days	112 hours
Eight (8) years	15 working days	120 hours
Nine (9) years	16 working days	128 hours
Twenty (20) years	20 working days	160 hours

18.2 Employees whose vacations occur during a period in which a holiday occurs shall receive an extra day’s pay for the holiday, or an extra day off with pay, as the Hospital shall decide.

18.3 Employees must take their vacations during the 12-month period following their vacation eligibility year. No vacations may be carried over and employees will not be compensated for vacation time not taken. No part of an employee’s scheduled vacation may be charged to sick leave.

18.4 Vacations shall be scheduled by the Hospital, in order to meet the staffing needs of the Hospital. Insofar as practicable, vacations will be granted to meet the requests of employees. Employees in each department with the greatest seniority shall have first choice of vacation period. The Hospital maintains the right to limit the number of employees permitted to be on vacation at any one time. The Hospital reserves the right to change the vacation schedule as needed.

18.5 Employees shall submit their vacation request to their Department Head in writing at least 2 weeks before date of desired period of vacation.

18.6 On written request 2 weeks in advance, an employee will be paid his or her vacation pay before starting vacation.

18.7 Employees who give 2 weeks’ notice of voluntary termination and employees terminated involuntarily shall be entitled to accrued vacation pay.

ARTICLE NINETEEN: SICK LEAVE

19.1 “Sick leave” is defined as the absence of an employee from work by reason of illness or accident that is not work connected or is not compensable under the workers’ compensation laws of the state. Full-time workers are paid for an 8-hour day; part-time workers are paid for a 4-hour day.

19.2 Eligibility and Benefits. An employee who has completed his probationary period is eligible for one (1) day of sick leave earned at the rate of the said day for each full month of continuous service retroactive to his date of hire but not to exceed a total of 10 days for any 1 year. As of July 1 of each year, employees with at least 1 year of service shall be credited with 10 days of sick leave.

19.3 Unused sick leave may be accumulated up to a maximum of 150 days. Unused sick leave will not be compensated on termination.

19.4 Pay for any day of approved sick leave shall be paid at the employee’s regular rate of pay.

19.5 Employees with accumulated paid sick leave will continue to earn vacation while out on paid sick leave. Holidays falling within an employee’s paid sick leave will be treated as a holiday, and a sick leave day will not be charged to that day. An employee cannot receive both holiday pay and sick leave pay for the same day.

19.6 To be eligible for the benefits of this Article, an employee must notify his or her supervisor at least 1 hour before the start of his regularly scheduled work day unless proper excuse is presented for the employee’s inability to call. The Hospital may require written certification by a physician or other proof of illness or accident. Employees who wish to return to work after sick leave may be required to be examined by a physician designated by the Hospital before returning to work.

ARTICLE TWENTY: LEAVE OF ABSENCE

20.1 Maternity leave, military leave, funeral leave, and jury duty shall be the same as described in the Employee Handbook (November 20N1 revision) and shall remain in effect and may not be reduced during the life of this contract.

ARTICLE TWENTY-ONE: INSURANCE AND PENSION

21.1 The provisions for life insurance, health and accident insurance, pension plan, and related benefits outlined in the Employee Handbook (November 20N1 revision) shall remain in effect and may not be reduced during the life of this agreement.

ARTICLE TWENTY-TWO: TERMS OF AGREEMENT

22.1 This Agreement constitutes the entire agreement between parties until and including January 20, 20N3, and shall continue in full force and effort from year to year thereafter unless and until either of the parties hereto shall give to the other party notice in accordance with applicable law, but in no case less than 60 days prior to expiration of the contract. Such notice shall be given in writing.

IN WITNESS THEREOF, the parties hereto have hereunto set their hands and seals.