Health care organizations are situated within larger social systems and are affected internally by changes in the socioeconomic and political environment. Successful adaptation and continued competitiveness in the industry requires the ability of organizations to deal with uncertainty, pressures, and change. Nurses as leaders need skills in organizational analysis to ascertain their organization’s capacity for adaptation and to assist in strengthening this capacity. An organizational analysis must come from the perspective that health care organizations are complex and there is a need to consider different facets of the organization in order to arrive at a holistic assessment as demonstrated in this paper.
Health Care Organizations in the 21st Century
Modern health organizations have become are complex in order to address the increasing complexity of patient needs brought on by demographic changes in ways that fulfill society’s expectations. Professional silos have to be overcome to give way to collaboration, and traditions need to be challenged through research that enables evidence-based practice (Plesk & Greenhalgh, 2001). External regulations and accrediting organizations also pose pressure to meet quality benchmarks and standards. At the same time, there are often resource limitations. Adapting to internal and external pressures requires changes in ways of thinking and doing (Wheatley, 1993). A major challenge to transforming organizations in this manner includes ingrained beliefs, norms, traditions, and mental models that make up the organizational culture and psyche. Inappropriate leadership styles, low organizational readiness to change, and ineffective approaches to change are also hindrances to adaptation. Adaptation is possible when these challenges are overcome.
Overall Description of the Organization
The Virginia Commonwealth University (VCU) Medical Center is a 1,125-bed regional referral center that is also an academic hospital. Its mission is to “preserve and restore health for all people, to seek the cause and cure of diseases through innovative research, and to educate those who serve humanity” (VCU Medical Center, 2015). It abides by the philosophy of providing excellent care despite challenges and to foster prevention. The organization’s values include service, trust, attitude, and respect. Based on the latest annual report, the hospital’s goal is to become the safest health system in the state and the country (VCU Medical Center, 2013).
The organization’s mission and values are alive and well. In terms of patient care performance, the hospital was the recipient of the 2014 American Hospital Association (AHA) Quest for Quality Prize in recognition of exemplary leadership and innovations in the areas of quality improvement and patient safety (MCU Medical Center, 2013). For the past 4 years, it has been recognized as the best hospital in Richmond by the U.S. News and World Report. It is a Magnet hospital with a 3-star rating on patient experiences (Medicare, 2015). The hospital has also actively sought Joint Commission (JC) certification for its services with the most recent being comprehensive stroke care (MCU Medical Center, 2015).
According to Schein, the definition of culture includes the assumptions learned in the process of coping that help predict feelings and behaviors (Bellot, 2011). Norms, traditions, and sacred cows as well as the organizational climate and culture of learning are also aspects of culture.
For members of the organization, the assumption is that change is necessary in order to adapt to internal and external pressures and also to achieve personal, professional, and organizational growth (VCU Medical Center, 2013). This belief conforms to the truths that organizations are dynamic with change and adaptation as innate capabilities (Plesk & Greenhalgh, 2001; Wheatley, 1993). Based on experience during the early years of health care reform, the organization remained stable and majority of change projects were successful because change was welcomed by leadership, a behavior mirrored by employees. Another assumption stemming from past experiences of change is employee autonomy in problem-solving and decision-making consistent with shared governance (VCU Medical Center, 2015). For instance, workplace issues in the nursing department are resolved by nurses. This freedom generates empowerment and satisfaction and has contributed to motivation, commitment, and innovation. It is therefore the freedom that gives rise to self-organization within complexity and chaos (Plesk & Greenhalgh, 2001; Wheatley, 1993).
Norms, Traditions, and Sacred Cows
Team-work and interdisciplinary collaboration are norms at the hospital (VCU Health Systems, 2014). For instance, QI projects aimed at fulfilling CMS criteria was often the product of collaboration among nurses, physicians, and other allied health professionals through a committee system. Hierarchy between nursing and medicine is non-existent as QI projects spanning different disciplines can be led by nurses. Collegiality is also a norm and reinforced by mentorship that is encouraged by the hospital’s Professional Edge Program (VCU Medical Center, 2015). Open communication is a norm as well as shown during staff meetings and consultations.
Traditions include the provision of excellent services as validated by the recognition of the hospital by award or certification bodies. Discovery and innovation are also traditions borne out of research activities that are expected of the various disciplines. Recognizing and rewarding exemplary employee or unit performance are traditions as well (MCV Foundation, 2013). A sacred cow is the preoccupation with finding research evidence to support clinical practice that can sometimes be regarded by the staff as having more weight than patient preferences or clinical experience. It is an area that is currently needs balancing in order to further increase patient satisfaction ratings.
The organizational climate can be described as dynamic, innovative, and bold because the hospital strives to be a leader in the industry and does so through research and innovations that require risk-taking. The climate is also supportive as evidenced by collegiality, teamwork, positive communication styles, and reward systems. Furthermore, the organization assists members in attaining work-life balance through employee wellness programs (VCU Medical Center, 2014). Successful quality improvements, such as those that enabled better performance in stroke care (MCU Medical Center, 2015), and nomination as one of the top 100 places to work in healthcare (Fields et al., 2013) attest to employee commitment, engagement, and buy-in.
Culture for Learning
Regarding Senge’s elements for a learning organization (Al-Abri & Al-Hashmi, 2007), MCU Medical Center has all 5. Systems thinking is demonstrated in the way that QI issues are addressed collectively at the department or interdepartmental levels. Personal mastery is evident in nurses’ participation in decision-making reflecting that their input is solicited by leaders. The use of mental models is manifested by the development of a professional nursing model that guides the provision of nursing care and clinical decision-making (MCU Medical Center, 2015). Meanwhile, shared vision is implied by the alignment between goals, culture, budget, structures, processes, and activities. The establishment of committees and interdisciplinary collaboration for the design and implementation of QI projects attest to team learning.
Predominant Leadership Style
As the hospital leaders admitted, the goal of zero adverse patient events is a very ambitious but clear vision (MCU Medical Center, 2013). However, leaders continually communicate their trust in and foster the capability of employees with high expectations that this capacity will eventually lead to a level of care which patients truly deserve. This regard for employees is evident in the “About Us” section of the hospital’s website and its annual report. Relating performance to patients in this manner promotes altruism that often leads to employees exceeding expectations. Support and recognition of employees’ outstanding performance are also characteristics of transformational leaders. Finally, a positive attitude towards change modeled by senior leaders motivates employees to follow. These aspects highlight transformational leadership style as described by Giltinane (2013).
Level of Greatness of the Organization
Based on Collins’ (2006) work, the organization has a high level of greatness at Level 3 or disciplined action. Investments are being made not for stop gap measures that address only the tangible aspects of a problem but for changes that create a lasting impact such as fostering employee capability and culture and values compatible with continuous quality improvement. Time, effort, and resources were channeled to educating and training more than 12,000 employees to support the patient safety goal (MCU Medical Center, 2015). This approach is also consistent with creating order through disseminating information (Wheatley, 1993). In the nursing department, a professional practice model was developed first to establish a framework for quality improvement. This approach also conforms to establishing a pattern in what seems to be chaos (Wheatley, 1993) and creating internalized rules to govern complexity (Plesk & Greenhalgh, 2001). Rather than relying solely on new technologies to deter medical errors, this painstaking, flywheel approach ensured that people and practices first support the patient safety goal.
Readiness for Change
Based on Weiner’s (2009) theory of readiness for change, the organizational culture, previous organizational restructuring in line with QI, and past experiences with change in the context of QI as described above are contextual factors to readiness. The overarching vision to be the safest hospital that is reflected in the professional nursing model as well as established research and successful QI activities towards this end, also described above, also support change commitment and efficacy. What remains for the organization to do is to enhance change implementation through continued practice. A DNP’s role in sustaining readiness is to foster self-reflection for the organization to continually learn from change experiences, improve future responses to change, and socialize new members into the change culture. A DNP must also consider the results of systems analysis to determine the forces supporting change commitment and efficacy as well as barriers to change in order to create a future improvement plan that sustains the strengths and overcomes the barriers.
Health care organizations are complex and exist within a fluid external environment. An organization’s adaptability is manifested in successful change projects and can be determined through an organizational analysis. Organizational culture, namely the assumptions, norms, traditions, and sacred cows as well as organizational climate and culture of learning, are important considerations to the ability to weather change. An organizational analysis can establish baseline level of greatness and readiness of change that DNPs, as nursing leaders, should consider to ensure that plans for improvement sustain and enhance these baseline qualities.
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