HLTH 4100 Week 3 Organization Structure Analysis Example

Reading the Hospital's Organization Chart for What It Speeds Up and What It Blocks: A Structure Analysis of Emergency Admissions

Student Name

Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

Instructor Name

Month Day, Year

Reading the Hospital's Organization Chart for What It Speeds Up and What It Blocks: A Structure Analysis of Emergency Admissions

The Chart as Published

The hospital's organization chart, posted on the intranet, shows the president at the top with four vice presidents reporting to her: the chief nursing officer, the chief medical officer, the chief financial officer and the vice president of operations. Under the chief nursing officer sit directors of emergency services, medical-surgical nursing, critical care and women's services, each with nurse managers for individual units. Under the chief medical officer sit the medical staff departments and, by contract, the hospitalist group. Environmental services and transport sit under operations. House supervisors, who manage the hospital overnight and on weekends, report to the chief nursing officer. Bed placement has no box of its own. This analysis reads the chart for one process, moving admitted patients from the emergency department to inpatient beds, and asks what the structure speeds up and what it blocks.

What the Structure Speeds Up

Functional structures, in which people are grouped by specialty, are good at work that stays inside a function (Mintzberg, 1979). The chart groups nurses by unit and units by specialty, which supports clinical expertise and clear supervision. Within a medical-surgical unit, the nurse manager can quickly change staffing, adjust assignments or address a safety problem, because everyone involved reports to her. Similarly, the emergency department director controls everything inside the emergency department: triage, treatment rooms, staffing. Work that begins and ends inside one box moves quickly.

What the Structure Blocks

An emergency admission does not stay inside one box. It begins in the emergency department, depends on a hospitalist group that reports through the medical side, requires a bed on a unit under a different director and needs cleaning and transport from operations. Four boxes, under three vice presidents, must coordinate for every admission. The chart provides no point below the vice presidents where anyone has authority over the whole path. The emergency department director cannot require a unit to accept a patient. The unit nurse manager is accountable for her own unit's safety and staffing, not for emergency department boarding. The house supervisor has some authority at night but not during the day.

Lawrence and Lorsch (1967) described this as the problem of differentiation and integration: as organizations divide work into specialized units, they need deliberate integrating mechanisms to coordinate across them, and the more different the units, the more integration they need. Our hospital has differentiated well and integrated poorly.

Span of Control and Its Effects

The chart also shows spans of control that affect the process. The emergency department director oversees about 120 staff through two managers, while each medical-surgical nurse manager oversees about 60 staff on a single unit. The chief nursing officer has eight direct reports, including all directors and the house supervisors. Wide spans at the director level mean that cross-unit problems, such as a dispute about accepting a patient, rarely reach anyone with authority to settle them during the day. They are settled, slowly, by negotiation between charge nurses.

The Informal Structure

The chart does not show the informal structure, which is where admissions are actually negotiated. In interviews, three charge nurses described calling the emergency department back to ask for more information, waiting for a nurse to finish a task before accepting a patient or holding a bed for an expected transfer from the intensive care unit. Each is a reasonable decision for the unit. Together, they add up to the median 95 minutes the acceptance step takes. Informal norms, such as accepting admissions only after shift change is complete, are widely followed and appear in no policy. The chart describes formal authority; the informal structure describes how that authority is actually exercised (Scott & Davis, 2007).

What Staff Say About the Chart

When I showed the chart to five staff members and asked who was in charge of getting admitted patients upstairs, the answers differed. An emergency department nurse said the house supervisor. A charge nurse said the emergency department. A hospitalist said nursing. The nurse manager of a medical-surgical unit said that no one was, exactly, and that it worked out through phone calls. The last answer is the most accurate reading of the chart. When people who work inside a structure cannot agree on who owns a process, the structure has left that process to negotiation, and negotiation takes time.

The same exercise at the comparison hospital, done by phone with two colleagues, produced the same answer from both: the bed manager. A single, agreed answer to that question is one sign that a structure has an integrating role that works.

How the Comparison Hospital Integrates

The comparison hospital in our system has the same functional chart with one addition: a patient flow department under the chief nursing officer, with a bed manager on duty 24 hours a day. The bed manager has written authority to assign any admitted patient to any appropriate open bed and to require the receiving unit to accept within 30 minutes, with an escalation path to the director if a unit objects. This is an integrating role in the sense Lawrence and Lorsch described: a position whose job is to coordinate across differentiated units. It sits in a box of its own and has authority over the whole path, which our chart lacks.

What the Analysis Suggests

The structure analysis suggests that the admission delay is a design problem, not a performance problem among charge nurses, who are making reasonable decisions within their own units. Two changes would address it. First, create an integrating role with authority over bed placement, as the comparison hospital has done, placed where it can act across all units. Second, change what unit managers are accountable for, adding emergency department boarding time for their admitted patients to their dashboards, so that the people who control the bottleneck see its effects. Either change alone would help; together they would redraw the chart around the path patients actually take.

References

Lawrence, P. R., & Lorsch, J. W. (1967). Organization and environment: Managing differentiation and integration. Harvard University, Graduate School of Business Administration.

Mintzberg, H. (1979). The structuring of organizations. Prentice-Hall.

Scott, W. R., & Davis, G. F. (2007). Organizations and organizing: Rational, natural, and open system perspectives. Pearson Prentice Hall.