Organizational structure is comprised of the policies and practices that define roles (descriptions of activities expected of incumbents in job positions), reporting relationships and work flow in the organization. In most organizations, structure is formally documented in organizational charts, job descriptions, and compilations of policies and procedures. Roles typically are grouped into departments or divisions, which are hierarchically arranged. Grouping roles into separate departments based on the professional education of the incumbents, such as departments of medicine, nursing, and pharmacy, makes interprofessional teamwork harder, as discussed in Chapter 5 on healthcare administration. Organizational structures can be modified to promote effective teamwork.

A third task of senior leaders is to provide key organizational resources for team-based activity. These organizational resources can make it easier for teamwork to thrive. Teams need resources for information and communication flow and for training and education, among other activities.

The 3 tasks that define the senior leader’s role in relation to teamwork serve well to categorize the competencies needed by senior leaders. Senior leaders need to be able to perform the 3 tasks, each of which requires certain competencies.

COMPETENCIES FOR SENIOR LEADERS

Regina Simpson, MSN, MBA, was still feeling her way into her new job as CEO of Rockaway Heights Hospital, a position she had attained 3 months ago. The organization was missing something, but she couldn’t put her finger on it. Everybody she talked to seemed to want to do the right thing—they generally were very caring, hardworking professionals. Surveys by the Human Resources Department showed that employees, with the possible exception of nurses, generally were happy to be at Rockaway Heights. But hospital performance was poor, and she had been hired to fix that. “Culture of safety” scores for the hospital were in the lower quartile compared to national norms. The governing board was concerned that the hospital was losing market share to competitors in the large metropolitan market area of Rockaway Heights, particularly in cardiac services, orthopedics, and obstetrics. “Minute clinics,” staffed with nurse practitioners, and urgent care centers were popping up all over the town. Rockaway Heights usually was last on the scene for new programs, like the minute clinics, urgent care centers, and the new palliative care program announced yesterday by a competitor hospital.

The Rockaway Heights Hospital employed over 200 physicians, but Ms. Simpson understood that they didn’t always work well with other physicians in the community. Nurses were angry over a failed effort to gain Magnet recognition for the hospital, an effort that many physicians and administrators opposed, or at least did not openly advocate. And some of the senior leaders of the organization seemed content to keep their heads down and worry about their own departments rather than the organization as a whole.

Create and Sustain a Team-Based Organizational Culture

Poor organizational performance often has its genesis in poor organizational culture. Ms. Simpson is right to wonder about the root causes of poor performance at Rockaway Heights Hospital. She can begin by assessing the culture of the organization, the first of 5 competencies to create and sustain a team-based culture (Table 18–2).

Assess the Organizational Culture

If senior leaders are interested in improving the culture of their organizations, they must first understand the existing culture of the organization. Likely, if leaders have been in the organization for a year or more and have been listening, they have a good handle on “the way we do things around here” and the values and beliefs that underlie those typical ways or patterns. However, if leaders are new to an organization, like Ms. Simpson in the vignette, they can accelerate their learning by targeted examination of the cultures of their organizations.

Organizational culture, or underlying beliefs and assumptions, can be diagnosed by examining the artifacts of culture, including stories and myths, rituals and ceremonies, formal organizational vision and value statements, heroes and heroines, logos, physical facilities, and commonly used metaphors for the organization. All of these indicators of culture are directly observable. For example, members of the organization may refer to it as a “well-oiled machine” or a “three-ring circus,” perhaps reflecting an emphasis on order in the well-oiled machine and a tolerance of autonomy in the three-ring circus. Another sample indicator of culture is stories about the organization. The founder of the organization, and the founder’s values, may be presented as a heroic figure in stories, as Dr. William Worrall Mayo and his 2 sons are represented in the history of Mayo Clinic.

Social psychologist Edgar Schein suggests investigating organizational culture more deeply by identifying tacit or unspoken assumptions, which may vary from beliefs formally espoused by the organization in documents and announcements to employees and the public (Schein, 2009). An organization may claim to promote teamwork in its formal value statement, for example, but leaders may not work actively to support it. Employees may be quite cynical about the degree to which teamwork is supported and may behave inconsistently with that value. To uncover tacit assumptions, Schein recommends that senior leaders conduct individual and group interviews, rather than relying on large surveys. The interviews allow leaders to probe more deeply into differences between behavior and espoused values. Hopefully Ms. Simpson, in the preceding vignette, will spend much of her time talking to individuals and small groups rather than relying on hospital-wide surveys for insights into the culture of Rockaway Heights Hospital.

Another fairly obvious fact to those in healthcare settings is that strong sub-cultures, such as cultures of the different health professions, are present in healthcare delivery organizations. The sub-cultures have different underlying beliefs and assumptions. Ms. Simpson will need to be alert to identifying and working with those sub-cultures at Rockaway Heights. In her institution, acknowledging differences among the nursing, physician, and administrator sub-cultures would be an obvious initial step.

Once leaders understand the organization’s existing culture, they have a better grasp on the challenge they face, as well as levers for change. Changing a culture is difficult and painstakingly slow. Values and assumptions take years to develop and to change. They cannot be imposed by senior leaders (Kouzes and Posner, 2012, p. 66). To accelerate the change process, senior leaders need to draw on the strengths of the existing culture rather than starting over with a blank slate (Katzenbach et al, 2012; Schein, 2009). In most healthcare organizations, there are underlying assumptions, beliefs, and past accomplishments to celebrate, honor, and reinforce. Most healthcare professionals are committed to serving the best interests of patients, for example. And most health professionals value respect and collaboration among the members of their own profession. In both cases, there is an organization-wide strong foundation for promotion of the core values.

Emphasize Teamwork Values

What key underlying assumptions and beliefs generate teamwork in organizations? We note 4 values that help improve the interprofessional teamwork culture—collaboration, respect, patient focus, and innovation.

First, senior leaders should aim to establish collaboration as “the way we do things around here.” Maximizing collaboration means considering everyone in the organization to be a valued contributor to the organizational mission, including those lowest in the formal hierarchy (for example, clerks and custodians). The preference for collaboration as a way to get things done can be explicitly promoted by top management in ways that will be discussed later, but first collaboration needs to be established as a priority and explicit value of the organization.

Another organizational value that is foundational to teamwork, as covered in several other chapters, is respect, in particular, respect for members of other professions. Hammick and colleagues (2009, p. 23) argue that interprofessional teamwork requires that individuals hold 5 values, all of which relate to respecting others:

1. Respect for everyone in the collaborative team

2. Confidence in what you know, what you do not know, and what others know

3. A willingness to engage with others rather than taking a detached view of proceedings

4. A caring disposition toward your colleagues

5. An approachable attitude and showing a willingness to share what you know as a means to the best possible outcome for the user of your service

Mutual respect allows for the knowledge bases of the different professions to be optimally used for the benefit of patients. The importance of respect as a primary value in health services delivery also has been noted recently in relation to establishing a culture of safety (Leape et al, 2012a; 2012b). Disrespect is signaled in healthcare organizations by such actions as disruptive behavior, humiliation of nurses, students, residents, and others, and dismissive treatment of patients, such as not providing information needed to make informed decisions. To demonstrate that respect is expected, organizations can adopt a zero-tolerance policy for abusive behavior by team members, letting everyone in the organization know that shouting at colleagues, relentless personal criticism, harsh treatment of subordinates, and other forms of abuse will not be ignored or accepted—and then taking action when instances of abuse occur even if they are rare.

A third critical organizational value is patient focus. Senior leaders should repeatedly and effectively convey that the patients’ interests (as defined by the patients) are the primary interests of the organization. This is not just a priority (which can change over time) but a permanent core value of the organization. If team members perceive that profit or market share or personal power or other interests are more important than patient service and quality of services, they will become cynical and disengaged.

A fourth component of an interprofessional teamwork culture in most organizations is that innovation is supported. Effective teams discover new and unexpected ideas and solutions. If those ideas and solutions are not valued by the larger organization, team members become dispirited and disengaged from the change process. If organizations do things the way they have always been done, teams will have more difficulty being successful (Whelan, 2013, p. 8).

All 4 of these values are present to some extent in healthcare organizations. Often it is the responsibility of leadership to highlight and accentuate these values rather than others—to “shine light on them.” In the vignette earlier, Ms. Simpson could engage individuals and small groups in discussions about the degree to which collaboration, respect for other professionals, patient focus, and innovation are exhibited in behaviors of hospital employees and affiliated clinicians.

Hire and Promote for Teamwork Values

Business consultant Jim Collins popularized the importance of “getting the right people on the bus” before embarking on an organizational change journey (Collins, 2001, pp. 41-64). Because many personal values are deeply held, some individuals will find it hard to change them. If individuals are unable to embrace teamwork values, and they serve in roles where teamwork is expected, they may need to depart or to work in areas where teamwork is not important. In the long run, hiring and promoting people who embrace and demonstrate teamwork values eliminates the need to remove some individuals from the organization.

Collins also notes that discharging employees can be more difficult in the social sector than the business sector, as many social sector organizations are not-for-profit or public entities, and some have significant proportions of unionized employees (Collins, 2005). Decisions to terminate employees can be anguishing and costly, but necessary, in order to alter culture. If removing employees is difficult, rigorous application of early assessment—the typical probationary period for employees—is even more critical. As it is impossible to know a new hire fully at the outset, testing and assessing for teamwork values are essential in the early months of employment.

Make Teamwork Highly Visible

Cultivating a culture of teamwork requires visible demonstration of the use of teams by top leadership. Putting the middle and lower reaches of an organization in teams is not enough to create successful team-based organizations (Harris and Beyerlein, 2005, p. 152). Teams must “cascade” throughout the organization. Having teams at all levels of the organization models and reinforces the team concept. Thus, the top management group must become a team. They need to “walk the talk” of teamwork by using teams, particularly interprofessional teams and teams including patients and family members, to do their own work in the organization. They need to demonstrate teamwork in the culture change effort itself by being widely inclusive, particularly of the clinician and patient populations. Top leaders are watched and noticed by clinical professionals, as well as by junior leaders, so role modeling by top leaders is critical.

Under-communication of basic messages is a primary reason that change efforts lose steam or fail (Kotter, 1996, pp. 85-100). Kotter’s advice to senior leaders for communicating a change vision is relevant to creating a teamwork culture: (1) keep the message simple, avoiding jargon, (2) use metaphors, analogies, and examples that people can visualize, (3) promote the message in multiple forums, both formal and informal, (4) repeat the message over and over, (5) lead by example, (6) address any inconsistencies (for example, that teamwork may cost more), and (7) listen to feedback, including questions and suggestions. Senior leaders can repeatedly communicate the desirability of using teams for many (but not all) tasks in delivering care and managing the organization. They can communicate the clear expectation that teamwork and collaboration will be used. They can communicate continually about the goal of creating a teamwork culture, the activities to achieve it, and the progress made.

To make teamwork visible, senior leaders need to be proactive in demonstrating successes from the use of teamwork. Senior leaders can demonstrate pride in teams by tying team identity to the organization’s identity. This means celebrating team successes publicly and widely disseminating their accomplishments. Senior leaders can tell stories about individuals who lead or contribute to successful teams. They can create organizational awards for team performance, for example, for improvements in safety measures in clinical units of the organization, making sure that, as with any award, the selection criteria are transparent and the selection process is fair. Small and symbolic awards still can be quite meaningful, and celebrations need not be costly. Team members appreciate knowing that the organization recognizes their collaborative efforts.

Relate Effectively to Clinicians

Senior leaders cannot promote interprofessional teamwork without connecting to the professionals who comprise teams. Some senior leaders, whether they have a clinical background or not, shy away from associating with clinical professionals and understanding clinical processes. This makes it less likely that they can serve as role models or connect with clinicians. Of all the professions involved in interprofessional teams, administrators particularly need to strive to engage the clinical culture. Overcoming the traditional divide between administrative processes and clinical processes in many healthcare organizations, discussed in Chapter 5 on healthcare administration, requires that administrators learn enough about clinicians and clinical processes to engage clinicians and patients as equal partners on interprofessional teams. By the same token, clinical professionals need to connect proactively with administrators and understand administrative functions to be constructive partners on management teams.

Create and Sustain a Team-Based Organizational Structure

After 6 months of exploration, Ms. Simpson, CEO of Rockaway Heights Hospital, concluded that the Rockaway Heights organizational culture needed serious revamping and that she would focus on “innovation through collaboration” as a theme of her leadership tenure. She appointed 3 leadership task forces, with a variety of representatives, including clinical professionals and patients, to study the feasibility of opening new ventures or redesigning services in the areas of cardiac services, orthopedics, and obstetrics. Ms. Simpson talked about innovation through collaboration at every chance that she got, and she hired a new Director of Marketing to spread the concept throughout the organization and community.

A year later, the marketing campaign was in full gear. The governing board had given its formal endorsement of the marketing effort. The tagline, “innovation through collaboration” was attached to most of the hospital’s internal communications and several advertisements, and the 3 task forces received some positive publicity in the community. Three of the more traditional senior leaders in the organization had left to pursue other opportunities, at the urging of Ms. Simpson.

However, Ms. Simpson was having trouble delivering on her vision of innovation through collaboration. The 3 task forces had finished their work and had been disbanded, though Ms. Simpson continued to meet with key physician leaders in the orthopedics, cardiac services, and obstetrics areas. The task force reports were awaiting review at the board level, and the reports included some interesting ideas. The orthopedics task force, for example, had recommended designing an orthopedics center with the whole range of related services, including physical therapy and some radiology and other diagnostic services, in a single physical facility, jointly run by the hospital and a large group of orthopedists in the community. But employees in the organization were expecting more and expecting it faster. They were starting to grumble about the “all talk, no action” administration. Senior leaders who were not part of the cardiac services, orthopedics, or obstetrics areas were feeling excluded from the action and were worried that their jobs were in jeopardy. Ms. Simpson knew that she needed to push further, and quickly.

An organizational culture without corresponding organizational structures and resources that reflect and reinforce the culture invites frustration and discord. Senior leaders need to execute on the promise of a new vision and values by redesigning organizational structures and providing key resources. Altering structures to support teamwork begins with conceptualizing the organization as a cluster of interacting teams. This competency and the 5 others needed for creating a team-based structure are listed in Table 18-3.

Stay updated, free articles. Join our Telegram channel

Join