1. Organizational Structure Nursing Care Delivery Systems

2. Objectives At the completion of this module, the learner will be able to: –Distinguish between the different types of organizational structures –Identify skill mix most suitable for organization type –Relate differences in nursing care delivery modalities

3. Health Care Organizations Acute care hospitals, long-term care providers and rehab facilities have traditionally been classified as institutional providers. Characteristics that differentiate institutional providers from other healthcare organizations are: –Types of services provided (general or specialty) –Length of direct care services provided Acute : less than 30 days Long-term: greater than 30 days –Ownership –Teaching status –Accreditation status

4. Ownership Three basic ownership forms: –Public institutions: provide health care services under the support and/or direction of local, state, or federal government (VA hospitals, State charity facilities) –Private non-profit (voluntary agencies) Controlled by voluntary boards or trustees and provide care to a mix of paying and non-paying patients Excess revenue is redirected back into the organization for maintenance and growth Required to provide care to patients regardless of their ability to pay Historically been exempt from paying taxes Examples include Our Lady of the Lake

5. Ownership For Profit organizations –Referred to proprietary or investor-owned –Operate with the intent to make a profit by providing healthcare services to individuals who can afford to pay for services Third-party payers (organizations such as private or public insurers who provide healthcare insurance coverage) –Owners may be individuals, partnerships, corporations or multisystems (Example: Oschner)

6. Teaching Status Academic health centers – directly affiliated with a school of medicine and at least one other health professional school (ex.. Tulane) Affiliated teaching hospitals –those that provide only a clinical portion of a medical school teaching program (OLOL; Baton Rouge General) Care is usually more costly at teaching hospitals; however, care is usually better because of access to technology and research Usually receive reimbursement from the government to cover additional costs

7. Accreditation An organization is accredited by an external body as having the structure and process necessary to provide high quality care An example is Joint Commission

8. Consolidated Systems Consolidated systems are organized along five levels: –Large national hospital companies –Large voluntary affiliated systems –Regional hospital systems that cover a defined geographical area –Metropolitan based systems –Special interest groups that own and operate units organized along religious lines, teaching interests, or related special interests that drive their activities

9. Networks Heath care markets with 100,000 or more residents are generally served by one to three health care networks Follow one of three organizational models: –Public utilities: organized and governed like public utilities (the water dept) –For profit businesses –Loose alliances – loosely connected “virtual” networks that emulate integrated health systems through contracts and linked systems

10. Economic Forces Driving the Development of HC Organizations Increasing number of uninsured patients Decreasing reimbursement threaten the economic viability of healthcare organizations

11. Social Forces Driving Development Focus is changing from illness to health (wellness) Increasing demand by individuals that they participate in designing their own health care plans

12. Demographic Forces Driving Development An aging society and increasing percentage of people without the financial resources to access care Inability of communities to provide ready and economic access to needed health care services

13. Organizational Theory The analysis of how organizations and their component parts act and interact. Based on determining the effectiveness of organizations achieving their purpose

14. Systems Theory The individual components of any system interact with each other and with their environment Important to know the role of nursing within the health care system and how the role impacts the “system”

15. Organizational Foundations Mission –Reason for the organization’s existence –Influences the design of the structure –Identifies the organization’s customers and the types of services offered. –Within health care organizations, there is an organizational mission statement and each department has a mission statement (i.e., nursing) –Should be used as the guiding framework for decision making

16. Organizational Foundations Vision –The goal that the organization wishes to achieve –Conveys an inspirational view of how the organization wishes to be viewed in the future –Usually very brief.. One or two phrases or sentences

17. Organizational Foundations Philosophy –Expresses the values and beliefs that members of the organization hold about their work, the people they serve, and themselves. –A nursing philosophy statement states the beliefs of nurse managers and staff as to how the mission will be achieved

18. Organizational Culture The mission, vision, and philosophy shape and reflect the organizational culture A reflection of the norms or traditions of the organization and is demonstrated by the behaviors that illustrate the values and beliefs Can be effective and promote success and positive outcomes or can be ineffective and result in disharmony, dissatisfaction, and poor outcomes for patients, staff and the organization

19. Characteristics of Organizational Structures Classified by the characteristics of: –Complexity: division of labor, specialization of labor, number of hierarchical levels, and the geographical dispersion of units –Formalization: degree to which the organization has rules, stated in the terms of policies that define a member’s function –Centralization: the location where a decision is made Decentralized: decisions are made at or close to the patient-care level Centralized: decisions are made at the top of the organization

20. Healthcare Organizations Classified according to profit status –Not for profit: All money made by the organization is put back into the organization (build new buildings, buy new equipment, etc); –Profit: owned by a corporation; money earned goes to stock holders Also classified by ownership –Publicly owned: owned by the government –Privately owned: owned by a corporation or group of stockholders

21. Organizational Structures Bureaucratic: –Are formal and have a centralized and hierarchical command structure (chain of command) –Clear division of labor and well-articulated and commonly accepted expectations for performance –Rules limits variation in worker’s performance –Communication and decision making flows from top to bottom, which limits workers’ automony –Like a factory line. Each employee has a certain job to perform. Focus is on efficiency, not necessarily quality –Decision making and authority can be described by: Line functions: involve direct responsibility for accomplishing the objectives of a nursing dept (direct care personnel) Staff functions: assist those in line functions (staff development, researchers, etc)

22. Organizational Structures Functional structures –Arrange departments according to specialty –Departments with similar functions report to common manager (have a VP for nursing, finance, human resources, etc) –Tends to support professional expertise but delay decision making. Decisions made have to be made by a higher administrator.

23. Organizational Structures Service-Line Structures (Product Lines) –The functions necessary to produce a specific service or product are included in an integrated organizational unit under the control of a single manager. For example…cardiology service line –Benefits include coordination of services, expedited decision making and clarity of purpose –Limitations include increase expense associated with duplication of services, loss of professional or technical affiliation and lack of standardization

24. Organizational Structures Matrix: –Complex and designed to reflect both function and service –Manager responsible for a service reports to both a functional manager and a service or product line manager –Facilitates internal efficiency and effectiveness through the promotion of cooperation among disciplines –a combination of bureaucratic and flat; teams or committees are used to carry out the work

25. Organizational Structures Flat: –Delegation of decision making to the professionals doing the work –Present in Magnet facilities –Few levels of management; authority is given to those who are performing the job (shared governance) –Hybrid: an organization that has characteristics of several different types of structures

26. Shared Governance Organizations that allow nursing staff autonomy to govern their practice Accountability forms the foundation for designing professional governance models. To be accountable, authority to make decisions is essential. The management and administrative level serves to coordinate and facilitate the work of the practicing nurses. Been shown to improve nurses’ job satisfaction, enhance productivity, and improve retention

27. Trends in Healthcare Organizational Structures Moving away from hierarchical management structures to flat structures Changing from formal channels of communication to free access of information Changing from a specified division of labor to empowerment of employees Moving from division and simplification of tasks to enrichment of work through performance of multiple tasks and expansion of knowledge Changing from simple organizations to a more complex, integrated organization

28. Reference Yoder-Wise. P.S. (2011). Leading and Managing in Nursing (5 th Edition). St. Louis: Mosby