Today’s organizations face many challenges with changes in health-care technology, reimbursement, and practice.
The organizational leader’s jobs are to formulate an organi-zational culture and climate that is supportive of the vision, mission, and values of the organization. One main point to strive for is autonomy for the nursing staff. The culture should provide the members opportunities to grow and develop within their profession, such as with shared gover-nance practice models and magnet status. Both affect nurses and how they will function within the organiza-tional structure. The culture surrounding magnet status is one of care centers, with leaders who work with the staff to plan and evaluate the organization’s services to meet the needs of the community.
Magnet status allows the nursing staff to participate and share in the development of policies and procedures through committees detailing research, practice, and edu-cation. Quality care and indicators are a part of all perform-ance appraisal processes and patient satisfaction surveys.
The overall nursing structure includes autonomy, collabora-tion, and delegation as key processes within the nursing philosophy. Nurses participate in all levels of decision mak-ing within the shared governance model. Organizations strive for excellence and ensure this within all of the services and activities offered. This philosophy is threaded through-out within the vision, mission, and values.
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departments, and communication tends to be slow as it travels through this type of a system. This type of structure is noted for its subdivision and special-ization of labor. Advantages to this type of structure are that managers have a narrow span of control and can maintain close supervision of their employ-ees. A disadvantage is that there may be a delay in decision making due to the many layers of people that the decision must pass through to get to the top administrative level. It predisposes leaders to an autocratic style of leadership because many deci-sions must go to the top of the organization or the higher-level supervisor for an answer.
FLAT/DECENTRALIZED STRUCTURE
The decentralized structure is flat in nature, and organizational power is spread out throughout the structure (Fig. 4-3). There are few layers in the reporting structure, and managers have a broad span
of control. Communication patterns are simplified, and problems tend to be addressed with ease and efficiency at the level at which they occur.
Employees have autonomy and increased job satis-faction within this type of structure. A disadvantage is the broad span of control, which may make it hard for management to process information quickly and efficiently for the employees. This is especially true for decisions that need to span the whole structure.
Management at all levels takes on a greater sense of responsibility within this structure, so education across teams is important. Managers may be super-vising areas with which they are not familiar or have limited working experience.
AD HOC/ADHOCRACY STRUCTURE
The organic or adhocracy structure of organi-zation is an open, free-form system. This system has resulted from behavioral research based on job 50 Understanding Organizations
Chief Administrator
Inpatient Outpatient
Two Three
One
Two Three
One
Inpatient Outpatient
Two Three
One
Two Three
One
Inpatient Outpatient
Two Three
One
Two Three
One Vice
President-Patient Services
Vice President-Nursing Services
Vice President-Business
FIGURE 4-2 Bureaucracy.
Nursing Administrator
Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Maternity
Supervisor
Pediatric Supervisor
Surgery Supervisor
FIGURE 4-3 Decentralized structure.
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satisfaction and efficiency. This type of structure is used with specialized teams to complete a specific task. From an organizational perspective, the entire organization consists of specialized teams, each assigned to complete a specific task. The major dis-advantage of this type of structure is the lack of a formal chain of command. The teams work together, but when problems are encountered there is no assigned person within the structure on whom they can rely for resolution.
MATRIX STRUCTURE
The matrix structure is a combination of two struc-tures, consisting of the product (output) and the function, linked into one structure. The function consists of all of the activities and duties needed to produce an end product, and the product is the result of the function. The structure works to bal-ance the function and service of the organization into one operational outcome. The functions are the tasks required to complete the product. The man-ager of the product division works with the manman-ager of the function division, creating two lines of authority, accountability, and communication. The team approach is incorporated, and there is a decrease in the number of formal rules for this type of structure. Issues with the matrix structure include the vague chain of command and goal vari-ation between the two structures. This type of struc-ture implements the use of resources efficiently.
STRUCTURES SPECIFIC TO HEALTH CARE As health-care organizations continue to change and reorganize services to meet the needs of the cus-tomer, so will the look of the structure. Many ser-vices are changing and becoming more accessible for the patient entering the complex health-care arena.
Integrated Health-Care System
Integrated health-care systems can be defined as innovative, patient-centered hospital delivery sys-tems that continuously improve quality and use resources cost-effectively (Effken & Stetler, 1997).
This type of system evolved as a result of changes in reimbursement and managed care. An integrated health-care system is a network of structures com-bined into one to provide better continuity of care
for patients in the most applicable setting. The net-works share the risks associated with the cost to provide care to the patients (McCarthy, 1997). By providing services in the most appropriate setting, the costs can be contained, which allows for a bet-ter patient outcome.
The push for an integrated system stems from the need to improve the quality of care within organizations, to reduce costs associated with health care, and to ensure patient/customer satis-faction (Wolf, Hayden, & Bradle, 2004). The single hospital of yesterday is now a component of a much larger system, offering a wide range of services for the consumer. Integrated health-care systems attempt to keep costs down and keep dollars for care within their own systems. This type of consol-idation also assists and prepares for managed com-petition. One example of a cost control measure includes redesigning practice to serve the organiza-tional and patient needs better. Management sys-tems look collaboratively at patient care and outcomes of care. It is important for nurses to know and understand how these systems work and what can be done to enhance them.
The services offered can include a combination of any of the following: hospital, clinics, home health, community health, school nursing, long-term care, and rehabilitation services. When ser-vices vary like this, it is known as vertical integration, which provides a range of health-care services across the life span (Newhouse & Mills, 1999). When the integrated system consists of a chain of similar services, such as all hospitals or clinics, this is known as horizontal integration.
TYPES OF HEALTH-CARE SERVICES
There are three types of health-care services on the health-care continuum. Integrated systems often provide all three types. The shift to managed care has also changed the focus from secondary and ter-tiary care to primary health care. Primary health care prioritizes the importance of health promotion and illness prevention. This is the first line of defense for health care. Examples of health-care services provided in primary care include physician visits, immunization clinics, mammography, and teaching and education for clients. Primary health care covers services that prevent illness. Secondary health-care services focus on treating disease
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through intervention. The patient has a health alteration and seeks treatment to improve the cur-rent state of health. Secondary health-care settings include the acute care setting, such as inpatient hos-pitals, surgical centers, and birthing centers.
Tertiary health-care services focus on the restora-tion and rehabilitarestora-tion services for patients with chronic health-care needs. The goal is to maintain the current state at the best possible level of health.
Health-care settings include long-term care facili-ties, hospice, and rehabilitation centers.
Managed care is the umbrella term that is used to address the financing and risk management for services provided in integrated health-care systems.
Managed care unites the financing groups with the providers of care. The goal of managed care is to establish programs that benefit all key participants, including the insurance companies and the physi-cians. The push for managed care was evident as the health-care industry continued to become more complex and difficult for patients to maneuver and understand. Intensifying these concerns was the increase in cultural diversity served by the private sector (Valanis, 2000). The managed care model is the only health-care delivery model formulated from market and customer response, as compared with government and legislative initiatives (Kelly-Heidenthal, 2003; Liberman & Rotarius, 2001).
Managed care involves a prepaid mechanism, which means that a predetermined dollar amount is established to cover the cost of the health-care serv-ice. Care that is rendered is selective and requires prior authorization. There are many types of man-aged care products in use currently. The most com-mon is the health maintenance organization (HMO). The HMO plan offers health care for its members for a fixed prepaid amount. An enrolled group of patients participates in the plan, and the provider is considered an employee. The provider receives a fixed payment for the services from the subscriber and assumes the financial risk. The advantage of a managed care program is cost reduc-tion. There is a gatekeeper for the patient, usually the primary care physician. The gatekeeper’s role is to oversee and coordinate services for the patient in the mix of the system. A disadvantage to managed care includes limitations to specialized care needs;
some organizations are profit-driven and limit their services. Patients in health care today are dis-charged quicker and sicker, with only limited ser-vices available outside of the acute care setting.
Professional Practice Models
In organizations where nurses are employed and valued, management has developed and imple-mented opportunities for professional, autonomous nursing practice. Shared governance is defined as
“structures… based on a set of principles about the relationship between the worker and the work-place” (Porter-O’Grady, 2003, p. 251). The push was for decentralized nursing leadership and deci-sion making for profesdeci-sional nurses. Such a struc-ture is based on the values of interdependence and accountability for nursing practice. The objective is to empower the nursing staff through involvement in decisions that affect their specific work areas (Erickson, Hamilton, Jones, & Ditomassi, 2003).
The outcome from implementation of a profes-sional practice model is that nurses have control of their nursing practice. Nursing staff participates in nursing committees that cover topics such as education, community involvement, research, qual-ity control, and staffing, scheduling, and hiring practices.
The uniqueness of this structure is that nurses gain control and autonomy over their professional nursing practice. Governance models are designed to link values and nursing practice beliefs to achieve quality care (Anthony, 2004). There are more opportunities to be involved in decision making and have a voice within the organizational structure. As the nursing staff members serve on the various committees, they plan and organize the care of the patients and establish standards for nursing care based on research and evidenced-based practice.
MAGNET STATUS
The American Academy of Nursing (AAN) began to review and identify as magnet hospitals those hospitals that had solid organizational structures and a decentralized, open management style. This concept became popular in the 1980s in rela-tion to professional practice model concepts. The goal of the magnet organization was to demon-strate autonomous nursing practice through self-governance, appropriate staffing, clinical expertise, and clinical ladder career opportunities (Upenieks, 2003).
To obtain magnet status, hospitals demonstrate that the structure in place is exemplified through a professional practice model that promotes excel-52 Understanding Organizations
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lence in nursing. Compliance with the identified standards must be demonstrated at all levels of nursing care within the organization (McClure, Poulin, Sovie, & Wandelt, 1983). Multiple days of onsite evaluations to assess organizational magnet-ism are conducted by the accrediting organization, American Nurses Credentialing Center, to deter-mine if magnet status can be awarded. Status is awarded for 4 years. To achieve magnet status, there must organizational and nursing leadership linkages. There are 14 criteria necessary to obtain magnet status:
1. Quality of nursing leadership 2. Organizational structure 3. Management style
4. Personnel policies and programs 5. Professional models of care 6. Quality of care
7. Quality improvement 8. Consultation and resources 9. Autonomy
10. Community and the hospital 11. Nurses as teachers
12. Image of nursing
13. Interdisciplinary relationships 14. Professional development