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9/15/2015
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ORGANIZATIONAL STRUCTURE
AND
ORGANIZING CARE
NSC 440
OBJECTIVES
Identify different organizational structures in
healthcare
Describe common methods of organizing care
within a healthcare organization.
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ORGANIZATIONAL STRUCTURE
Organizational structure refers to the way in which a group is
formed, its lines of communication, and its means for
channeling authority and making decisions.
Formal structure—division of work, framework for authority,
responsibility and accountability—visible and planned.
Informal structure—socially blurred lines of authority—
hidden and unplanned.
ORGANIZATIONS
Organization can be considered a social system.
Social Systems are established to carry out specific
purpose; important to accomplish work an individual can’t
carry out alone.
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SYSTEMS
SUB-SYSTEM SUPRA-SYSTEM
Internal Environment
Production
Managerial
Maintenance
Adaptive
Supportive
EXTERNAL ENVIRONMENT Public policy
Competitors
Health care financing
Technology
Health research and education
Health status/health promotion
Public Health
SYSTEMS THEORY
System—organized coordination of united parts forming a
unitary whole to accomplish a set of goals
Composed of interrelated parts
Arrangement of parts results in a unified whole
Open or closed
Open—interact internally and with the environment
Closed – only interacts internally; does not interact with the
environment
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SYSTEMS THEORY
“Parts” of system
Input—staff, patients, materials, financial resources,
supplies and equipment
Throughput—processes performed to create product
Output—product of health care system—restored health,
dignified death, research or education
Feedback loop—maintains the system—channels
information to allow the system to monitor outputs and
adjust inputs and throughputs required
ORGANIZATION STRUCTURE
Organizational chart – depicts only formal relationships
Span of control – number of employees one manages
Managerial Levels – Top, middle, and first-line managers
Centrality – location of a position on the organizational chart
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INFRASTRUCTURE DESIGN
Organizational structural design is one of the
critical challenges facing all healthcare
institutions.
No one approach to organizational design seems
to dominate across the healthcare industry at the
present time.
NEW ORGANIZATIONAL
INFRASTRUCTURE IS NEEDED TO:
Streamline services
Improve efficiency
Increase collaboration
Improve quality
Decrease costs
Improve communication
Better focus resource allocation
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TYPES OF ORGANIZATION STRUCTURE
Tall or vertical
Bureaucratic—small span of control can lead to an
inefficient, top-heavy organization
Hierarchical arrangement
Decision making from top down
Communication may be distorted due to the multiple
layers
Board of GovernorsDirector of Medical Affairs Executive Administrator
Chief of Staff Administrator
Board of Trustees
Revised: 1/4/06
Shriners Hospitals for Children - Lexington
Organizational Chart
Executive
Secretary
Director of
Patient Care
Services
Director of
Performance
Improvement
Director of
Human
Resources
Director of
Fiscal
Services
Management Information Systems
Business OfficeOR/CSR
PACU
Inpatient Unit/EPACU
Medical Office/Care Coordination
Graphic Arts
Radiology
Infection Control/ Employee Health
Hospital Education
Medical Library
School Services
Plant Operations
Environmental Services
Clinical Laboratory
Nutrition Services
Motion Analysis Laboratory
Recreational Therapy
Occupational Therapy
Director of Rehabilitative Services
Physical Therapy
Prosthestics & Orthotics
Tony Lewgood
Administrator
Chester Tylkowski, MD
Chief of Staff
H. I. Stroth, Jr.
Chairman of the Board
HIM/ Patient Registration
Volunteer Services
Materials Management
PBX
Pharmacy
Community Relations
Assistant
Chief of Staff
Director of
Research
Development
Director of
Research
Administration
Staff Physicians Resident Staff
Executive
Secretary
Physician
Assistants
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TYPES OF ORGANIZATION STRUCTURE
Flat Organizational design
Remove hierarchical layers
Decentralizing the organization
More authority and decision making occurs where the work
is being carried out
However, if a Manager’s span of control is to large (too
many people reporting to a single manager) delays can
occur in decision making, problem solving, and critical
thinking.
FLATTENED ORGANIZATIONAL
STRUCTURE
CEO
Board of
Directors
FinanceClinical
Front-line Staff
Front-line Staff
CEO
VPs
Assistant VPs
Directors
Managers
CEO
VPs
Directors/Managers
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TYPES OF ORGANIZATION STRUCTURE
Shared Governance Organizational Design
Flat type of organization structure
Group structures—Governance Councils; Professional
Practice Models
Gives nurses more control over their practice
Research supports that shared governance improves staff
nurse’s satisfaction with work environment
Changes the traditional management roles
SHARED GOVERNANCE STRUCTURE
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TYPES OF ORGANIZATION STRUCTURE
Matrix
Formal vertical and horizontal chain of command
Less formal rules
Fewer levels of hierarchy
Designed to focus on both product and function
Centralized decision making
Disadvantage of Matrix
Decision Making can be
slow due to level of
information sharing
Produce confusion and
frustration due to dual-
authority
MATRIX MODEL
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TYPES OF ORGANIZATION STRUCTURE
Service Line Organization
Organized around care areas
Care centered organizations—i.e.. Women's & Children's,
Cancer, Cardiac
Similar to matrix
Smaller in scale than bureaucratic
SERVICE LINE
Service Lines should have a balanced focus in
multiple areas including :
Patient care protocols– e.g. evidence-based medicine
order sets
Clinical outcome measures– e.g. mortality, readmissions,
infection rates
Enhanced patient experience– e.g. time to be seen,
provider satisfaction, overall satisfaction with services
Process efficiency– e.g. cost of care, resource utilization
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SERVICE LINE IMPLEMENTED IN HOSPITALS
Volume Increased
Net Revenue
Increased
LOS Decreased
Patient Satisfaction
Increased
ORGANIZATIONAL STRUCTURES
Current research suggests that changing an organization’s
structure in a manner that increases autonomy and work
empowerment for nurses will lead to more effective patient
care.
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MANAGEMENT AND LEADERSHIP ROLES
Evaluates the organizational structure frequently to determine
if changes need to be made to improve efficiency,
effectiveness, and quality.
Uses committees to facilitate group goals
Fosters a positive organizational culture
Promotes participatory decision making and shared
governance to empower subordinates
Clarifies unity of command when there is confusion
ORGANIZING PATIENT CARE
Total Patient Care or Case Method Nursing
Oldest model
Nurses assume total responsibility during their time on
duty
Assigned to patient as a case—private duty nursing
Early 1900’s most care performed in home, hospital
reserved for poor or acutely ill
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ORGANIZING PATIENT CARE
Total Patient Care or Case Method Nursing
ORGANIZING PATIENT CARE
ADVANTAGES DISADVANTAGES
Provides high autonomy and
responsibility
Patient assignment is simple
and direct
Patient receives holistic and
unfragmented care during
nurse’s shift
Each shift nurse can alter
care regime, which could
cause confusion for the
patient
Nurse needs to be skilled
enough to provide total care
Nurse may only focus on
his/her shift and trending
may not occur (failure to
rescue)
Total Patient Care or Case Method Nursing
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ORGANIZING PATIENT CARE
Functional Nursing
After WW II—nursing shortage utilized ancillary
people in care delivery
Care broken up into functions
Provided care through tasks rather than assigned
to individual patients
ORGANIZING PATIENT CARE
Functional Nursing
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ADVANTAGESDISADVANTAGES
Tasks are completed quickly
– efficiency
Little confusion of what
needs to be done
Cost effective – may
decrease the number of RNs
to patient ratio (OR and LTC)
Lead to fragmented care
Low job satisfaction (not
challenged)
Focus on tasks and not
outcomes
Requires more supervision of
unlicensed care givers
ORGANIZING PATIENT CARE
Functional Nursing
ORGANIZING PATIENT CARE
Team or Modular Nursing Team Leader----nursing staff---patients
Democratic relationship—no more than 5 people on a team
Team Leader:
Responsible for knowing the condition and needs of all the patients
Duties—assign team members, teaching, and coordinating activities
Use of less skilled—LPN, NA’s
Changed over time—recently has returned by name of care pairs—only two people
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ORGANIZING PATIENT CARE
Team or Modular Nursing
ADVANTAGES DISADVANTAGES
Allows members to contribute
their own special expertise or
skills
Team has autonomy on how
tasks will be completed
Requires excellent
communication and leadership
skills
Care can be fragmented and
confusing to patient
Can have blurred lines of
responsibility leading to errors
ORGANIZING PATIENT CARE
Team Nursing
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ORGANIZING PATIENT CARE
Primary Care
Marie Manthey—model initiated in 1960’s-1970’s
Similar to Total Patient Care
24-hour responsibility for plan of care and
coordination of care
Associate Care Nurse—assist primary nurse on off
shifts
Expensive and resource intensive
ORGANIZING PATIENT CARE
Primary Care
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ADVANTAGES DISADVANTAGES
Improved coordination of care
throughout the continuum
Outcome focused, not just
task related care
Relationships developed
between primary nurse and
patient/family
Can be used with Team
Nursing design as well
Increase job satisfaction of
Primary Nurse
Requires skill set of Primary
Nurse – if inadequate, poor
outcomes can occur
Requires excellent
communication between care
givers
Facilities consider it
expensive, usually structured
with all-RN staff
ORGANIZING PATIENT CARE
Primary Care Nursing
ORGANIZING PATIENT CARE
Case Management
Case management is a collaborative process of
assessment, planning facilitation and advocacy for
options and services to meet an individual’s health
needs through communication and available resources
to promote quality cost-effective outcomes (Case
Management Society of America, 2002).
Disease Management is
population-based.
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ORGANIZING PATIENT CARE
Case or Disease Management
Collaboration of interdisciplinary care delivery
Critical pathway development; Care Maps
Do not deliver direct patient care
Divided up in service lines or chronic conditions
Promote quality of care because is focused on
patient outcomes
Cost-effective
ADVANTAGES DISADVANTAGES
Decrease patient LOS, cost
and prevents readmissions or
denials of patient stays
Outcome focused and
reflects best practice
Improves coordination of care
across the continuum
(inpatient and outpatient)
Focuses on prevention and
early disease detection, not
just acute care
Requires highly trained
nurses
If case load too high, do not
see benefit
Financial impact should not
be at patient expense
ORGANIZING PATIENT CARE
Case or Disease Management
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Clinical Nurse Leader (CNL) or Clinical Nurse
Specialist (CNS)
Advanced generalist or specialist with Master’s
degree
Provides clinical leadership at the point of care (can
be unit-based or service line)
Coordinates and assume responsibility for outcome
and evidence-based practice
Collaborates with interdisciplinary team
Identifies risk-analyses strategies and resources
needed
ORGANIZING PATIENT CARE
ADVANTAGES DISADVANTAGES
Highly trained and skilled, mentor young nursing staff
Can work both clinical and business spheres
Change agent
Provide individual case management as well as population disease management
Develop critical pathways and multidisciplinary action plans (MAPs)
Require higher salary to
recruit
Limited number MSNs
ORGANIZING PATIENT CARE
Clinical Nurse Leader
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ORGANIZING PATIENT CARE
Medical Care
Providers
Clinical
Nurse
Leader
Clinical
Care
Sphere
Business
Sphere
Ancillary
Services
Research
Technology
Financial
Services
Marketing
Community
Awareness
Business
Planning
Evidence-base
Practice
Outcomes
Management
Leadership and Management Functions in Organizing
Patient Care
Activities must be organized based on resources, people,
materials, and time
Responsible for selecting and implementing a patient care
delivery system that facilitates unit goals
Periodically evaluates the effectiveness of the organizational
delivery of care model
Ensures the delivery care model advances the practice of
professional nursing
ORGANIZING PATIENT CARE
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QUESTIONS?
