by Kathryn Barzilai
Consider the following scenario in an Emergency Department at Queens Hospital Center and what you might do as a public health consultant to improve patient care:
“Currently 83 percent of patients at the Queens Hospital Center emergency room are treated and released. They wait six to eight hours for treatment. The goal is to decrease waiting time and the number of walkouts and to improve care and patient satisfaction. Current Procedure: (1) Patient seen by triage nurse. (2) Patient sent to registration. (3) Patient waits to be seen by physician. (4) Patient sent for any necessary lab or x-ray. (5) Patient waits for test results to be reviewed by MD. (6) Patient treated, discharged, or admitted.”6
This scenario would be a challenge to any public health consultant. Success at the task would most likely depend on how well the consultant grasped some basic principals about organizations.
An organization is “a structured social system consisting of groups of individuals working together to meet some agreed-on objectives."2 Organizational theory (OT) is the study of organizations for the benefit of identifying common themes for the purpose of solving problems, maximizing efficiency and productivity, and meeting he needs of stakeholders. Broadly OT can be conceptualized as studying three major subtopics: individual processes, group processes and organizational processes.2
Why is OT important for public health professionals? Since organizations pervade the field of public health: from free clinics to refugee crisis support teams to research institutions, an understanding of organizations and how they work, helps public health professionals to be more effective participants in and leaders of organizations.
This paper will try to accomplish the enormous task of summarizing major concepts in organizational theory. The three broad concepts that will be explored include: individual processes, including motivation theory, personality theory, and role theory; group processes including working in groups/communication, leadership, and power and influence; and organizational processes, as it relates to organizational structure, and organizational culture. In the process a rudimentary introduction to select organizational models will also be presented.
Since the hope of the paper is to make OT relevant to work in the public health field, efforts have been made to end the discussion of each broad topic with a discussion of that topic’s relevance to practice. Following the last section, organizational processes, a suggested solution to the scenario presented at the beginning of the paper, will be provided.
What makes us do the things we do? Why would two individuals, in similar circumstances, choose two different options? The answer, in part, is motivation. Motivation drives behavior; it is the force behind an individual’s decision to commit or not commit to certain acts or behaviors. The elements that make up what we call motivation are complex, unique for each individual, and generally dynamic through time.
Handy suggests that motivation is the intersection of assessed need and the likelihood or nature of results.6 An individual calculates an “E” (energy, enthusiasm, effort) the product of need, and prediction for liklihood of acheving the desired results. When a person enters into a contract with an organization some calculation will be made in regards to the individual’s “E” put forth. Organizations also put forth an “E”, either by resources alone (salary), or by other items such as prestige and stature. This exchange sets the limits of a physical and “psychological contract” between the organization and the person. The psychological contract can be defined as the shared and unshared expectations between the individual and the organization based on initial agreements and the individual’s motivation calculations. When both parties see the psychological contract clearly, (i.e., when it is fully understood and acknowledged by both parties), the motivation of the individual becomes transparent.
Motivation theory tells us a few things about managing groups of people. First, in order to find successful ways to change people’s behaviors in an organization you must understand the terms of the psychological contract for those individuals. When you understand the terms by which a person joins an organization, you can better secure meeting that demand and hopefully sustain an “E” input over time. If, however, an organization changes its “E”, or increases demands on the individual, “E” will change according to the person’s motivation calculation. Management must carefully consider how to maintain or adjust the psychological contract in order to keep that person a productive member of the team. This may mean an increase in salary or manpower and/or increased managerial responsibilities.
The roles we carry shape the way we see ourselves and help to define the behaviors we should exhibit, and those we should not. Roles also help us to communicate responsibilities and set expectations for appropriate responses from others. In an organization roles can help to clearly define boundaries between individuals and locis of power.
Adjusting to or meeting role expectations can however create problems. Role ambiguity is one such problem. Role ambiguity occurs when either the focal person or others around him/her are unclear about the nature or expectations of a role. Role ambiguity can plague employees endeavoring to successfully attain and maintain new responsibilities or goals. On the other hand, a person may not reach role objectives due to overloading of responsibilities or under utilization of talents and abilities. Role conflict may arise when two roles intersect creating tension or difficulty fulfilling one or both roles. For example, when a mother returns to work and attempts to maintain breast-feeding. Management may not support the amount of time taken during the day to pump milk, leaving the mother at a hazard of not meeting both role expectations fully. Role incompatibility may occur when the expectations/nature of the role is clear but is incompatible with other roles or a person’s sense of self.
Organizations need to acknowledge that its employees manage many roles and that problems or conflicts can arise since role conflicts create tensions that can change the ability of the individual to reach their goals. Organizations should be sure to support their team members in meeting new roles by giving time for transition, or offering training and support. In addition, when role conflict arises the organization can nurture employee’s ability to relieve tension by allowing time to devote to caring for roles outside the office. An example of this may be support for a breast pumping station in the office and management support of breaks for pumping.
Personality is the unique and enduring traits, behaviors and emotional characteristics in an individual.3 Personality can either aid or hinder meeting work goals dependent on fit. For example, perhaps the best well know personality types are Type A vs. Type B. Type A personalities are competitive, impatient, seekers of efficiency and always seem to be in a hurry. Type B personalities are laid back and possess more patience and emotional stability, but tend to be less competitive. In a work environment Type A’s tend to be more productive in the short term and pursue more challenging work. However, they also have a greater tendency towards health risks and are less likely than Type B’s to be in top executive positions.3
The later fact might be suprising. Why would Type A’s tend to be in top executive positions more frequently than Type B’s? Daniel Goleman might suggest that the difference in performance by classic Type A vs. Type B personalities is less due to fixed personality traits as they are for propensities to grasp the concept of emotional intellect (EQ).4 Unlike IQ, EQ is the “capacity for recognizing our own feelings and those of others, for motivating ourselves, and for managing emotions well in ourselves and our relationships.” (Refer to Appendix A for a presentation of Goleman’s EQ Emotional Competence Framework.)
Another possibility is that these trends are less the product of an innate character as it is the interaction of experience, personality and circumstance. If this is the case, a person’s ability to work in groups or propensity for certain types of work may be task and time dependent, but can be changed with motivation and effort.
Organizations can play a role in developing their staff for success. Workshops, seminars, even book clubs that focus on developing EQ an strengthen organizational success. Allowing for a diverse set of experiences, with appropirate support can maximize and expand the capabilities of each employee.
Do motivation, role theory and personality factor into our day-to-day experiences in an organization in a significant way? Three theorists would suggest individual processes are very important to the success of any organization. The Human Resource Model, as developed by the contributions of Likert in 1967, McGregor in 1960 and Argyris in 19573,6,8, proposes that the individual is the most important, indeed the central consideration for maximizing the success of an organization. According to The Human Resource Model each employee as an untapped well of creativity, talent and motivation, and the success of an organization depends on how well human resources are tapped. As an employee is placed in an environment where they becomes the originator and leader of their work, the organization’s goals and their individual goals become one. When organization goals are internalized the indiviudal’s satisfaction increases, as well as the amount of motivation to be efficient and productive. Therefore the motivation of the employee is key because talent and creativity flows when the person is motivated to do so by internalization of organizational goals.7
According to the human resource model, the challenge of growth and productivity in an organization is the challenge of assisting human resources in reaching their maximum potential. The multiple dimensions of individual processes, the calculation of motivation, role development and development of innate talent and abilities, are all factors that must be considered seriously and channeled appropriately for acheving success.
Leadership is an important topic that is discussed at length in Chapter 14 of the On-Line Textbook. Please refer to that chapter for an in depth discussion of this topic.
One needs only to superficially examine the tabloids and other media outlets to see the action of power and influence: Movie stars promoting everything from prostate exams to weight reduction pills or popular health guru’s preaching cures for all ills. These individuals, and others like them, wield great power and influence. Within the walls of an organization, power and influence also make an impact on individuals and groups. Although one may often think of power and influence in terms of how it is abused, it can also be used to do positive work within an organization to drive production and to meet goals. To that end we will consider its role within organizations and implications for change.
Influence is the action or force by an individual that modifies another person’s activity or behavior. Power is the force behind influence to make it effective.6 There are three fundamental principles regarding power. First, for power to be wielded it must have an identifiable and credible source; power would have no bearing on individuals without evidence to show that it can be used. Sources of power are those substances, physical or not, that can be mobilized to have influence. There are at least five broad sources of power: resource, position, expert, personal and negative power. Resource power derives from the control of wealth and resources: for example, the boy who owns the soccer ball gets to say if there will be a game. Position power is the power identified with fulfilling certain roles. A Chief Executive Officer easily wields decision-making power because it stems from his appointment responsibilities. Expert power is the power arising from knowledge and experience. Personal power is the innate charisma a person may possess, a type of magnetism. Finally negative power is the ability to not do something, and in so doing prevent another person(s) from gaining what they want.
Second, power is a balance between both parties. Both the person commanding influence and the person on whom the power is being exerted commands power, the later commanding at least negative power. Finally, power is relative. Power can be exerted only when those to whom you are trying to wield power recognize the source of it. Take for example the conundrum a professor of the arts would be in trying to guide decisions made by a Medicare policy review board. His credibility as leader is diminished because the professional source of power stems from expertise in the arts not public policy.
Once a power source (or sources) are established, influence must be communicated through recognizable methods. Each method chosen predisposes individuals to certain types of responses. Depending on how individuals respond, their new behavior may or may not be sustainable over time. Influence methods include, but are not limited to: the use of force and coercion, rules and procedures, exchange (bargaining, negotiating), persuasion/logic, and ecology.6 An example of ecology would be changing the environment people are in. Chatty employees moved to different floors will quickly influence their behavior by changing the amount of talking that can be done in the workday.
If the goal of power and influences is to increase productivity and the quality of services delivered by changing employee behavior, then the central measurement of outcome success is individual response. Depending on sources of power, certain individual responses are more desirable for organizational strategy because of the way they correlate with sustainability of the response over time. Compliance is the agreement to a behavior because of force – the “I have to” response. This implies the lack of self-initiated behavior because the person “has to” rather than “wants to”. Generally compliance will be the result of methods of force, rules and procedure and sometimes exchange methods, and must be maintained with continual supervision. Unlike compliance, identification and internalization have some degree of acceptance of the new behavior, however the sustainability of the behaviors are not the equal. Identification is a behavior adopted out of a desire to please or admiration for the person wielding the power. The manager exerting this type of power has great magnetism but must constantly be present for the behavior to continue. The organization becomes dependent on the power figure, making the employee action not sustainable independently. Internalization is for most situations the most desirable response because it is independent of the source of influence and is self-sustaining.6
In the 1930’s and 40’s a set of experiments were done at the Western Electric’s Hawthorne plant.6 The initial round of experiments involved a select group of female employees, whom constructed telephone equipment, placed in a variety of environments (changes in lighting, quota demands, rest period frequent and duration) in order to measure their effect on productivity. To their astonishment, the research team found that the environment had little to no effect on productivity. In all simulated environment changes the level of productivity increased, and once back in their original environments the production level of the employees continued to remain at higher than pre-experiment levels. The team hypothesized that the major cause for increased productivity was the relationships formed between the employees and between the employees and the management.
A second round of experiments were conducted on male employees that involved in wiring and smoldering of telephone equipment at the same plant. No change of environment was made as in the first experiment, except to place the men under observation. The research team found what they called the “Hawthorne Effect”8: Regardless of quota set by the company, the empoyees neither under nor overproduced. In addition, work output was equal for all members of the group. The research team hypothesized that the workers created informal groups between themselves and their superiors, which tightly regulated production in order to maintain a group identify where no man excelled beyond the others.
This well-known experiment demonstrated for the first time in a controlled setting the role of informal groups on productivity, and that the effects of group culture in work environments could have positive or negative consequences.
Outside of the informal groups created by employees, administrators form groups in order to meet organization goals. The nature of these types of groups also deserves some discussion. Motivation for utilizing groups may include: (1) improved decision-making, (2). More risk taking, (and therefore presumably more innovation), and (3). Satisfying the need of individuals to be in a group.6
Groups, like children, go through stages of growth. According to Handy, there are four stages of growth: forming, storming, norming and performing.6 As managers you must be sensitive to the needs of the group at each stage in order to help the group reach its goals successfully. In the forming stage relationships are being built through the establishment of goals, role definition and time-line formation. Quickly groups move into the storming phase, where roles, procedures and goals are questioned. It is vital at this stage that conflicts be resolved effectively and efficiently. In the third phase, norming, members establish a formal or informal set of rules and procedures for group members to incorporate into their work. Open communication is vital for the norms defined to be accepted and uniformly applied. Only when the forming, storming and norming phases are completed will groups be able to move into a performing stage of growth.
A few thoughts on groups remain. As discussed in the leadership chapter of the On-Line Textbook, groups by anticipating the needs of the group, leaders can moitvate acitivites according to the stages the group is in. During the forming and storming stages leaders should assist group members by encouraging participation and viable communication. Leaders are key in maintaining group stability through effective negotiation during the storming phases. As the group matures, reaching the norming phase the leaders should practice foresight, promoting the next level of action by introducing effective evaluation methods and standard setting adjustments as necessary.
Perhaps one of the greatest challenges for working in groups is the element that can be its greatest strength, diversity. Those who have studied groups acknowledge that diversity in certain combinations can be key to success. RM Belbin1 agrees, finding that teams do not need brilliance but balance for success. Specific character roles, noted in appendix B, can provide the recipe for success.
Working in groups are building blocks for meeting organization goals. Managers should consider ways to develop leadership in team members. Training for versatility in leadership styles through workshops could encourage this growth. Encouraging self-growth through concepts of EQ or even Covey’s Seven Habits of Highly Effective People2 can also provide the groundwork for leadership growth by mastering interpersonal skills. Managers should also be proactive about identifying and cultivating talent of his/her staff. When committees must be formed managers can help select individuals to create groups that have the balance of personalities and talents to maximize the likelihood of success.
Each manager must also consider diversifying their own talents by analyzing spheres of social competence and goals though which to improve these abilities, but also seeking to diversity sources of power and methods of influence. For example in an environment that is strictly managed with rules and procedures, implementing a democratic process can broaden influence by example. This method however would require a great deal of time, effort and must be approached with focused investment.
If we were to look at any organization from a bird’s eye view we could observe its structure and design. In the biological sciences structure defines function, so too for human organizations. Important concepts to consider in the studying of organizational structure are the flow of information and sources of power. Consider the following diagrams:
In figure 1A all information flows through the CE either directly (before intersecting with a non-CE sphere) or indirectly with 1-2 intersections preceding. In this environment power is very well centralized and communication well controlled. Figure 1B is a variation of a centralized model. The managerial style in this model is more functional with formalized relationships. These organizational structures work best when the task is uniform, and predetermined and environment pressures are lessened; such as if a company has cornered and market and or has a stable product. In health care this might occur when a large tertiary care center that has cornered the market for a city or isolated region.
In contrast, consider figure 1C where the division of duties is highly specialized leading to two separate functional units. In this model work and the division of duties is highly specialized so power is widely distributed. Communication flows in a centralized fashion within units, but no one unit controls all communication or has all power, making power decentralized. This model may serve best in the situation where innovation and the ability to respond to environmental change quickly is key.
The challenge for all managers will be to balance the need for uniformity with the demands for diversity. Uniformity guarantees ease of control and supervision, ease of integrating work of multiple subgroups or teams (such as between offices) and economy since it is easier to pay for and maintain one system rather than many (one type of form verse multiple forms). However the environment in which the organization is based, and for which the product is being delivered, is constantly changing making it unpredictable. Organizations must than manage responses to these changes- diversifying their processes and thinking.
Organizations may tend to seek too much uniformity, following the classic futile fight against the law of entropy- that all things move towards greater disorder. An organization should recognize the many demands for diversity classify their importance and decide on which to pursue, maximizing the cost of diversity with the achievement of goals carefully.5
Open Systems Theory (OST) has integrated these conflicting pressures. According to OST organizations live within dynamic environments and are shaped by them. The organization is an organism with external (resource availability, changes of needs and demand) and internal (employee characteristics, adaptation to organizational change teams and individuals) environmental influences. The organization evolves according to the pressure exerted by these sources and therefore is evolving by successful adaptation within this dynamic, changing and an open system. The challenges to managers are to identify appropriate sources of influence by prioritizing them, and to guide successful adaptation by the organization.7
Organizational culture is “a cognitive framework consisting of attitudes, values, behavioral norms, and expectations shared by the organization’s members.”9 Organizational cultures help to establish a sense of identity for employees within the organization and therefore can facilitate comfort and a greater likelihood of internalizing organization goals. Organizational culture also provides a status quo and maintains stability in processes, communication and role interaction.
Culture is enforced in a number of ways, such as by ceremony, symbols and language. Ceremonies that commemorate employees demonstrating “excellence” as evidenced by exemplifying organizational values demonstrate in front of a large audience those values to be celebrated while also reinforcing them. Symbols, such as mission statements or encouragement slogans can constantly reinforce the vision the organization wants each individual to be guided by. Special language can also help to define a culture and allow an individual to identify with it.
The presence of culture demands uniformity. Managers must consider the consequence of paradigm shifts and plan in detail implementing changes. Implement new paradigms require the complete support of the administration, and should be able to address the needs of the employee working body.
The two major organizational processes do not stand diaposed end of organizational theory in practice. In fact, organizational structure and culture must reflect one another in order to reinforce the goals and mission of the organization. Imagine an international refugee mission seeking to initiate programs for maternal child wellness in which people at the front lines aren’t in the community with the individuals divvying the resources. Although the goal of the organization values may be to respond to the needs of the community, administers, isolated from certain staff (organizational structure) leads to the inability to reach goals.
Refering back to the scenario presented at the start of the paper, Queens Hospital hospital wants your input on how to improve the Emergency Department’s patient care, and to maximize efficiency and quality. Utilizing OT there are a few questions we might want to ask to diagnosis the problem.
Staff related issues: How well does staff feel supported and able to pursue work related issues. What are staffing levels? Are these ratios sufficient for patient workload? If staffing levels are low this can contribute to the problem of efficiency and quality. If this seems likely to be a problem, further questions should include: What is staff turn over, and what is the wait time for obtaining new staff? How well are human resources retaining staff, what are the problem areas? What are the incentives motivating work participation, and what pools are applicants are applying? Whom, what talents and skills do we want to aim for?
Organizational Issues: How well do the different units of care delivery fit with one another? For example if the laboratory was contracted out to a lab three miles away, the hospital may be limited by the time it takes for blood to be collected, transported, analyzed and transported back. This process may also be on a schedule, (on the hour or half hour) which then adds the wait time for transportation. An in-house lab staff might be considered, although cost of overhead and staffing would have to be considered for its cost. What also is the climate in the organization, are works overall satisfied, dedicated, feel empowered to deliver excellent care? Has the organization build and supported a culture of excellence?
Where is decision-making centralized, and what would be the benefits and disadvantages of diversifying sources of power? In light of the patient population needs, what types of problems are most commonly seen? Uniform vs. diversity pressures help to guide modes of action. If a lot of non-acute conditions are presented to the hospital we might want to consider the utilization of an Urgent care model ancillary to maintaining the ER for acute conditions.
Consider other more "acute" conditions as well: What glitches to the staff frequently comment as a problem? Maybe the computer system is archaic and redundant. Maybe there are frequent errors in obtaining and reporting labs, consults, and obtaining patient records. One glitch could create a myriad of small, but recurrent problems, troubling staff and overall efficiency of the practice.
We will assume that acute issues, and staff related issues are not the problem, since resolving them would be self-explanatory. We will consider only adjustments in organizational structure and design for the sake of relevance to the topic of OT. I suggest that Queens Hospital consider a new model of care delivery, in which the Emergency Department diversifies to a decentralized model of management and adds new modes for care delivery. The new process would look something like this: When a patient enters the hospital they are seen immediately by a Triage nurse. The nurse has the option, after registration is complete, to one of three routes: the nurse can channel a patient through the traditional method, to be seen by Emergency room physicians according to priority. The nurse can also decide to transfer non-acute patients to urgent care center (an initiative of this hospital or a close center), or to initiate pre-approved protocols for common illnesses, (such as asthma) prior to visitation from the physician.
Utilizing this model has a few advantages. By increasing the structural complexity, patients can have treatment initiated and completed at a faster rate. This not only allows the hospital to see more patients, but it will improve patient satisfaction. Redesigning job roles and responsibilities may also increase the motivation of staff by maximizing their control of patient care. Nurses can more effictively utilizie their triage skills and doctors can focus on patients with conditions or complications that require their skill and training.