Goals

Try answering this true-or-false question:

Question:The primary goal of any health- care organization is to keep people healthy, restore them to health, or assist them in dying as comfortably as possi- ble. True or false?

Answer:False. The previous statement is only partially correct. Most healthcare organizations have several goals, some more immediately apparent than others.

What other goals could a healthcare organiza- tion possibly have? The following are some examples:

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^Survival. Organizations have to maintain their own existence, a goal that is threat- ened when, for example, the organization fails to meet the Joint Commission on Accreditation of Healthcare Organizations’

standards or is unable to collect money owed by its clients.

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Growth. The chief executive officers (CEOs) of many organizations also want to help their organizations grow by expand- ing into new territories, adding new servic- es, and bringing in new clients.

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Profit.For-profit organizations are expect- ed to return some profit to their owners.

Not-for-profit organizations have to be able to pay their bills and to avoid getting into too much debt. Even this is sometimes difficult for an organization.

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Status. The leaders or owners of many healthcare organizations also want to be known as the best in their field, for exam- ple, by having the best open-heart surgeon, having “top-notch” nurses, or providing the most attractive patient rooms and views in town.

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^Dominance.Some organizations also want to drive others out of the healthcare busi- ness or gobble them up, surpassing the goal of survival and moving toward dominance of a particular market by driving out the competition.

These additional goals are not as often dis- cussed in public as the first, more lofty state- ment of goals in our true-or-false test.

However, they still drive the organization, especially the way the organization handles its finances and treats its employees.

These goals may have profound effects on every one of the organization’s employees, nurses included. For an example, let’s return to the story of Hazel Rivera. Why did she receive a less favorable rating than her friend Carla?

After comparing ratings with her friend Carla, Hazel scheduled another meeting with her nurse manager to discuss her evaluation.

The nurse manager explained the rating:

Hazel’s care plans were very well done, and she genuinely appreciated Hazel’s efforts to make them so. The problem was that Hazel had to be paid overtime for this work accord- ing to the union contract, and this had reduced the amount of overtime pay the nurse manager had available when the patient care

load was especially high. “The corporation is very strict about staying within the budget,”

she said. “In fact, my rating is higher when I don’t use up all of the budgeted overtime hours.”

When Hazel asked what she could do to improve her rating, the nurse manager offered to help her streamline the care plans and man- age her time better so that the care plans could be done during her shift.

Structure

The Traditional Approach

Virtually all healthcare organizations have a hierarchical structure of some kind (see Box 7–1). In a traditional hierarchical structure, employees are ranked from the top to the bot- tom as if they were on the various steps of a ladder (Fig. 7–1). The number of people on the bottom rungs of the ladder is almost always much greater than the number at the top. The president or CEO is usually at the top of this ladder; the maintenance crew is usually at the bottom. Nurses fall somewhere in the middle of most healthcare organiza- tions, higher than the cleaning people, aides, and technicians but lower than physicians and administrators.

The people at the top of the ladder have authority to issue orders, spend the organiza- tion’s money, and hire and fire people. Much of this authority is delegated to people below them, but they retain the right to reverse a decision or regain control of these activities whenever they deem it necessary.

The people at the bottom have little author- ity and usually no part in deciding how money is spent or who will be hired or fired but are responsible for carrying out the directions from people above them on the ladder. The people at the bottom are not entirely without power or the ability to influence people high- er up on the ladder, however. Without the people at the bottom of the ladder, the organ- ization could not function. If there was no one at the bottom, the work of the organization would not get done. The people at the top depend on the people lower on the ladder to get most of the work done.

More Innovative Approaches

There is much interest in restructuring organ- izations, not only to save money but also to 88 ❖ Essentials of Nursing Leadership and Management

make the best use of a healthcare organiza- tion’s most valuable resource, its people. This begins with hiring the right people. It also involves providing them with the resources they need to function and the kind of leader- ship that can inspire the staff and unleash their creativity (Rosen, 1996).

Increasingly, people recognize that organi- zations need to be not only efficient but also adaptable and innovative. Organizations need to be prepared for uncertainty, for rapid changes in their environment, and for rapid, creative responses to these challenges. In addi- tion, they need to provide an internal climate that not only allows but also motivates employees to work to the best of their ability.

They need to stop thinking, to paraphrase Parker and Gadbois, of the managers as the brains of the organization and employees as the muscle (2000, p. 428).

More innovativeorganizations have adapt- ed a more organic structure that is looser, more flexible, and less centralized than the traditional hierarchical structure. In these organically structured organizations, deci- sions are made by the people who will imple- ment them, not by their bosses or by their bosses’ boss.

The organic network emphasizes increased flexibility of the organizational structure, decentralized decision making, and autonomy for working groups or teams. Once rigid department or unit structures are reorganized into autonomous teams made up of profes- sionals from different departments and disci- plines, each team is given a specific task or function to carry out (e.g., a hospital infection control team, a child protection team in a community agency). These teams are respon- sible for their own self-correction and self- control, although they may also have a designated leader. Together, team members make decisions about work assignments and how to deal with any problems that arise. In other words, the teams supervise and manage themselves.

Supervisors, administrators, and support staff have different functions in an organic network. Instead of spending their time observing and controlling other people’s work, they become planners and resource people. They are responsible for providing the conditions required for the optimal function- ing of the teams and are expected to ensure that the support, information, materials, and budgeted funds needed to do the job well are available to the teams. They also provide

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BOX 7–1

WHAT IS A BUREAUCRACY?

Although it seems as if everyone com- plains about “the bureaucracy,” not every- one is clear about what a bureaucracy really is. Max Weber defined a bureaucrat- ic organization as having the following characteristics:

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Division of Labor:Specific parts of the job to be done are assigned to different individuals or groups. For example, nurses, physicians, therapists, dietitians, and social workers all pro- vide portions of the health care need- ed by an individual patient.

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^Hierarchy:All employees are organ- ized and ranked according to their degree of authority within the organi- zation. For example, administrators and directors are at the top of most hospital hierarchies, whereas aides and maintenance workers are at the bottom.

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Rules and Regulations:Acceptable and unacceptable behavior and the proper way to carry out various tasks are defined, often in writing. For example, procedure books, policy manuals, bylaws, statements, and memos prescribe many types of behavior, from acceptable isolation techniques to vacation policies.

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Emphasis on Technical

Competence:People with certain skills and knowledge are hired to carry out specific parts of the total work of the organization. For example, a com- munity mental health center will have psychiatrists, psychologists, social workers, and nurses to provide differ- ent kinds of therapies and clerical staff to do the typing and filing.

Some degree of bureaucracy is charac- teristic of the formal operation of virtually every organization, even the most deliber- ately informal, because it promotes smooth operations within a large and complex group of people.

Source: Weber, M. (1969). Bureaucratic organiza- tion. In Etzioni, A. (Ed.). Readings on Modern Organizations.Englewood Cliffs, N.J.: Prentice-Hall.

more coordination between the teams so that the teams are cooperating rather than block- ing each other, working toward congruent goals, and not duplicating effort.

Very large organizations can also be sepa- rated into functional divisions that operate as though they were smaller, independent organ- izations. This reduces complexity and allows each division to be better integrated when the integration of the organization as a whole becomes virtually impossible because of its great size, complexity, and diversity. However, communication among divisions can become more difficult. This is a downside of organic structure. If not done well, there is a potential for creating chaos and confusion instead of creativity (Senge et al., 1999).

Organic networks have been compared to spider plants with their central cluster and off- shoots (Morgan, 1997). Each cluster could represent a discipline (e.g., nursing, social work, occupational therapy) or a service (e.g., psychiatry, orthopedics). For example, Figure 7–2 shows an organic network for a wellness center. Each cluster represents a separate set of services. A client might use just one or all of them in developing a personal plan for wellness. Staff members may move from one cluster to another, or the entire configuration of interconnected clusters may be reorganized as the organization shapes and is shaped by the environment.