Health Care Organizations and Environments

Transcription

1 Question 1: What are the key responsibilities of the governing board (GB) in health care organizations? Answer 1: First, GBs are responsible for formulating organizational ends. That is, they are responsible for establishing a vision from which mission and associated organizational objectives grow. Second, GBs have a responsibility to ensure suitable performance from senior executives, including selecting a competent CEO. This is a difficult task given the complexity of HCOs. Third, GBs are responsible, ultimately, for the quality of patient care. The credentialing of practitioners and granting privileges is a gate-keeping function of the GB. Seeing that protocol is adequate to address quality, utilization, and risk, management issues must be approved by the GB. The board must review outcomes of care reports and decide competency issues as part of improving patient satisfaction. Fourth, the GB is responsible for the finances and financial performance. In integrated systems, this responsibility broadens significantly with managed care contracts covering different forms of delivery. A poorly vetted contract can spell doom for the system. The fifth area of GB responsibility is one for self. That is, those who govern are responsible for doing so in an effective, efficient, and ethical manner. Fulfilling this responsibility includes establishing and maintaining appropriate by-laws to guide the governance process, selecting GB members who can serve well and seeing that they do, and ensuring that processes for evaluating GB performance and for member development are in place and properly functioning. HCOs and health systems (HSs) differences are mostly scope and complexity. The primary difference is HSs have more boards, and there is a significant challenge getting them to work together. Question 2: What is the chief executive officer's (CEO) relationship to the governing board? Answer 2: CEOs assemble and organize resources and develop the system to carry out GBapproved programs and policies. CEOs also provide information to the GB so it can develop policy, monitor implementation, and oversee results. The CEO's performance should be assessed regularly and systematically by the GB; specific recommendations should result from this process. Performance should be measured against predetermined objectives mutually identified and accepted by the CEO and GB. A traditional CEO assessment scheme using performance levels in specific accountabilities requires negotiation and is a type of management by objectives with bilaterally established performance objectives. In addition, GBs 1

2 always measure CEO performance by negative developments. Consistent with the philosophy of W. Edwards Deming, GBs should not set objectives that CEOs meet without giving them sufficient authority and resources. The four most common areas for hospital CEO evaluations are financial performance; vision and other leadership qualities; physician relations and integration; and fulfillment of the strategic plan. Employment contracts for CEOs are increasingly common, and are in terms of employment, including severance. CEOs "walk a fine line" as they focus GB members' expertise and encourage interest, dedication, and enthusiasm, but simultaneously dissuade direct participation in internal operations. GB members undercut the CEO's authority and subordinates are frustrated and confused theses conditions are likely to adversely affect efficiency and effectiveness when they intervene in operations. Interference is forestalled by GB job descriptions and clarification of roles and activities by GB member orientation and education. The CEO should be present at meetings and many are voting members. Issues involving CEO conflict of interest should be avoided. Personal ties between the CEO and GB members may give the CEO excessive influence and lessen objectivity. Conversely, there are advantages when the CEO is a voting member of the GB. Two of the most important advantages are enhanced communication and participation in policy development. It is also important that the GB evaluate its own performance. First, it must demonstrate accountability for its actions and resource utilization. The GB can identify criteria for monitoring progress and delineating steps to obtain and use feedback to ensure further improvement after selecting targets for improvement. Question 3: Which external and internal environments of the HCO may adversely affect managerial problem solving abilities? Answer 3: The variables imposed by the environment may be uncontrollable and affect the feasibility of alternatives, and constraining implementation of the solution selected. Legal, political, economic, cultural, stakeholder, and competitive forces are always externally present. A requirement to obtain a certificate of need for facility expansion or a new service constrains alternatives. High local unemployment with loss of employer-paid health insurance adversely affects revenues and increases bad debt, and unfunded federal mandates and regulations constrain health systems with a 2

3 managed care component. Changes in Medicare-Medicaid payments may limit the organization's ability to add technology and equipment. Internally, organizational objectives may restrict alternatives that can be considered. Influential but less precise is organizational culture the way of doing business. Its characteristics can limit problem solving. Managers in a reactive culture are unlikely to select bold solutions. Similarly, managers in an action-oriented culture tend to act quickly, with less preparation. Finally, any alternative that is considered must be consistent with the HCO's culture. Organizational structure may limit the authority to implement needed changes within departments. The absence of technology may eliminate another. For instance, physical plant layout may preclude changing patient and material flow, union contracts may constrain job definition and design, and the computer system may not allow online connection to nursing units. Another influence that is essential for change is acceptance by peers and superiors. Involving others in problem solving is influenced by how important their acceptance is to implementation. The degree of informal influence needed to affect some change may mean a compromise on objectives to affect any change at all. Question 4: What are the advantages and disadvantages of the centralized and decentralized models of governance structures? Answer 4: In an HCO with a centralized governance structure, decisions can be made more quickly, the time that managers must spend on governance interactions is minimized, and the system GB is encouraged to focus on strategic issues. Offsetting this, however, is the fact that a centralized governance structure limits the number of stakeholders that can serve on the GB. The advantages of the decentralized governance structure include that it permits the system GB to push details to subordinate GBs, subordinate GBs may be closer to and can focus on local community or HCO issues, and decentralization permits a greater number of stakeholders to serve on a GB. Among the disadvantages is the fact that multiple boards can contribute to confusion, conflict, and in extreme circumstances even gridlock over roles and responsibilities. They can consume significant amounts of management time in GB interactions, and may slow the decision-making process, especially if subordinate GBs insist on focusing on their interest at the expense of those of the HCO. Question 5: What is the role and function of hospital senior management? 3

4 Answer 5: The American Hospital Association identified six responsibilities of senior management: 1. Executive management should initiate and motivate organizational mechanisms to ensure that the hospital has effective organizational structures and processes. The organizational plan must identify the role of the CEO with the GB and the medical staff that clearly assigns responsibilities for specific programs and services. 2. Executive management is expected to infuse the mission and philosophy of the institution into the entire organization. This function requires the CEO to understand the relationships between hospital philosophy and the goal of improving the health status of the community. 3. Executive management should assume primary responsibility for ensuring that members of the hospital are kept informed about public policy and environmental issues and their effects on the hospital. Executive management must take the initiative to work with community organizations. 4. Executive management should take the initiative in ensuring that the hospital has a broadly-based strategic planning program. This strategic plan is ongoing in daily management by focusing on short- and long-term goals and adjusting them as community and hospital needs change. 5. Executive management should assume responsibility for the cost-effective management of the hospital's resources. This responsibility requires a commitment to provide the most economical and highest quality services possible, in keeping with available resources. 6. Executive management should provide a work atmosphere that recognizes the vital importance of human resources to the health organization. The provision of a positive work performance implies a moral and ethical commitment to the needs of people, a concern for their health status and quality of life, and a commitment to fostering respect and satisfaction for all. Question 6: What is the art of management? Answer 6: Management is the drama of organizational life to make people capable of joint performance in a common venture. Drama in organizational life is a form of action, whether verbal or nonverbal components of communication. The art of management in the drama of organizational life is about character and practice and application based upon 4

5 knowledge and desired results. Management is operationally focused on performance acts which have results both within the organization and outside, in society. Performance in management may be an act, face-to-face, or apart from the participants who may be stakeholders, employees, or satisfied customers. Managers are the basic resource of performance and drama in organizations, for they have the responsibility for contribution. The tools of the art of management are strategies and techniques, commonly known as management science. These tools are for specific functions, such as cost accounting, inventory control, maintenance scheduling, money management, and quality control. The performance of the manager defines the usefulness of management science tools for risk taking, expectations, and measurement of results. The management science is practiced by industrial engineers, operations research specialists, or staff persons who are technical specialists who draw upon economics, social sciences, or physical sciences to assist the manager in making judgments between different courses of action. These are tools of significant importance for contribution. To use these tools is not to practice science, because there are no natural laws of science in management. Management is performance acts expressed through a series of actions involving practice and application toward a common venture. Question 7: What do managers do? Answer 7: Henri Fayol said managers perform four functions: plan, organize, coordinate, and control (Griffith, 2002). Whether or not managers actually consciously perform these four functions is a matter for debate. Managers might find themselves responding to the pressures of the job, forced to do many jobs superficially, unable to delegate enough, and verbally communicating with never enough time. What management is can be analyzed systematically. Management is a social discipline dealing with social institutions and the behavior of people. It is mostly about human difficulties or problems whether the organization is a church or a software company. Performance or action is essential if there are to be satisfied customers, clients, or patients. Managerial action is the art of performance. The art form relates to the quality process or performance of the social institution in achieving quality results and a satisfied customer. Managers may not be conscious of form as art but they know good quality actions can increase employee and stakeholder satisfaction. 5

6 The Characterization of Action The basic resource of any organization is human behavior and through its actions displays the values or character of the organization. The integrity of the organization is the sum total of its human beings' actions and responses, or drama. The organizational life is a matter of persuading, talking, shouting, politicking doing. The essence of conduct is actions, relationships, communications, and interactions which form the character or integrity of the entity. In the successful organization, the boss' integrity of character is not a learned skill at work but a sense of what is right and wrong as manifested in action by him- or herself and other managers. The art of management is about integrity in the practice and application of knowledge based upon desired outcomes. Reference Griffith, J. R., & White, K. R. (2002). The well-managed healthcare organization (5 th ed.). Chicago: AUPHA Press. 6