Organizational Theory
Consider the following scenario in an Emergency Department at
Queens Hospital Center and what you might do as a public health consultant to
improve patient care:
“Currently 83 percent of
patients at the Queens Hospital Center emergency room are treated and
released. They wait six to eight hours for treatment. The goal is
to decrease waiting time and the number of walkouts and to improve care and
patient satisfaction. Current Procedure: (1) Patient seen by triage
nurse. (2) Patient sent to registration. (3) Patient waits to be
seen by physician. (4) Patient sent for any necessary lab or x-ray.
(5) Patient waits for test results to be reviewed by MD. (6) Patient
treated, discharged, or admitted.”6
This scenario would be a challenge to any public health
consultant. Success at the task would most likely depend on how well the
consultant grasped some basic principals about organizations.
An organization is “a structured social system consisting of
groups of individuals working together to meet some agreed-on objectives."2
Organizational theory (OT) is the study of organizations for the benefit of
identifying common themes for the purpose of solving problems, maximizing
efficiency and productivity, and meeting he needs of stakeholders.
Broadly OT can be conceptualized as studying three major subtopics: individual
processes, group processes and organizational processes.2
Why is OT important for public health professionals? Since
organizations pervade the field of public health: from free clinics to refugee
crisis support teams to research institutions, an understanding of
organizations and how they work, helps public health professionals to be more
effective participants in and leaders of organizations.
This paper will try to accomplish the enormous task of summarizing
major concepts in organizational theory. The three broad concepts that
will be explored include: individual processes, including motivation
theory, personality theory, and role theory; group
processes includingworking in groups/communication, leadership,
and power and influence; and organizational processes,
as it relates to organizational structure, and organizational
culture. In the process a rudimentary introduction to select
organizational models will also be presented.
Since the hope of the paper is to make OT relevant to work in the
public health field, efforts have been made to end the discussion of each broad
topic with a discussion of that topic’s relevance to practice. Following
the last section, organizational processes, a suggested solution to the
scenario presented at the beginning of the paper, will be provided.
Individual Processes
Motivational Theory
What makes us do the things we do? Why would two
individuals, in similar circumstances, choose two different options? The
answer, in part, is motivation. Motivation drives behavior; it is the
force behind an individual’s decision to commit or not commit to certain acts
or behaviors. The elements that make up what we call motivation are complex,
unique for each individual, and generally dynamic through time.
Handy suggests that motivation is the intersection of assessed
need and the likelihood or nature of results.6 An individual
calculates an “E” (energy, enthusiasm, effort) the product of need, and
prediction for liklihood of acheving the desired results. When a person
enters into a contract with an organization some calculation will be made in
regards to the individual’s “E” put forth. Organizations also put forth
an “E”, either by resources alone (salary), or by other items such as prestige
and stature. This exchange sets the limits of a physical and “psychological
contract” between the organization and the person. The psychological
contract can be defined as the shared and unshared expectations between the
individual and the organization based on initial agreements and the
individual’s motivation calculations. When both parties see the
psychological contract clearly, (i.e., when it is fully understood and
acknowledged by both parties), the motivation of the individual becomes
transparent.
Motivation theory tells us a few things about managing groups of
people. First, in order to find successful ways to change people’s
behaviors in an organization you must understand the terms of the psychological
contract for those individuals. When you understand the terms by which a
person joins an organization, you can better secure meeting that demand and
hopefully sustain an “E” input over time. If, however, an organization
changes its “E”, or increases demands on the individual, “E” will change
according to the person’s motivation calculation. Management must
carefully consider how to maintain or adjust the psychological contract in
order to keep that person a productive member of the team. This may mean
an increase in salary or manpower and/or increased managerial
responsibilities.
Role Theory
The roles we carry shape the way we see ourselves and help to
define the behaviors we should exhibit, and those we should not. Roles
also help us to communicate responsibilities and set expectations for
appropriate responses from others. In an organization roles can help to
clearly define boundaries between individuals and locis of power.
Adjusting to or meeting role expectations can however create problems. Role
ambiguity is one such problem. Role ambiguity occurs when either
the focal person or others around him/her are unclear about the nature or
expectations of a role. Role ambiguity can plague employees endeavoring
to successfully attain and maintain new responsibilities or goals. On the
other hand, a person may not reach role objectives due to overloading of
responsibilities or under utilization of talents and abilities. Role
conflict may arise when two roles intersect creating tension or difficulty
fulfilling one or both roles. For example, when a mother returns to work
and attempts to maintain breast-feeding. Management may not support the
amount of time taken during the day to pump milk, leaving the mother at a
hazard of not meeting both role expectations fully. Role
incompatibility may occur when the expectations/nature of the role is
clear but is incompatible with other roles or a person’s sense of self.
Organizations need to acknowledge that its employees manage many
roles and that problems or conflicts can arise since role conflicts create
tensions that can change the ability of the individual to reach their
goals. Organizations should be sure to support their team members in
meeting new roles by giving time for transition, or offering training and
support. In addition, when role conflict arises the organization can
nurture employee’s ability to relieve tension by allowing time to devote to
caring for roles outside the office. An example of this may be support
for a breast pumping station in the office and management support of breaks for
pumping.
Personality Theory
Personality is the unique and enduring traits, behaviors and emotional
characteristics in an individual.3 Personality can either aid
or hinder meeting work goals dependent on fit. For example, perhaps the
best well know personality types are Type A vs. Type B. Type A
personalities are competitive, impatient, seekers of efficiency and always seem
to be in a hurry. Type B personalities are laid back and possess more
patience and emotional stability, but tend to be less competitive. In a
work environment Type A’s tend to be more productive in the short term and
pursue more challenging work. However, they also have a greater tendency
towards health risks and are less likely than Type B’s to be in top executive
positions.3
The later fact might be suprising. Why would Type A’s tend
to be in top executive positions more frequently than Type B’s? Daniel
Goleman might suggest that the difference in performance by classic Type A vs.
Type B personalities is less due to fixed personality traits as they are for
propensities to grasp the concept of emotional intellect (EQ).4
Unlike IQ, EQ is the “capacity for recognizing our own feelings and those of
others, for motivating ourselves, and for managing emotions well in ourselves
and our relationships.” (Refer to Appendix A for a presentation of
Goleman’s EQ Emotional Competence Framework.)
Another possibility is that these trends are less the product of
an innate character as it is the interaction of experience, personality and
circumstance. If this is the case, a person’s ability to work in groups
or propensity for certain types of work may be task and time dependent, but can
be changed with motivation and effort.
Organizations can play a role in developing their staff for
success. Workshops, seminars, even book clubs that focus on developing EQ
an strengthen organizational success. Allowing for a diverse set of
experiences, with appropirate support can maximize and expand the capabilities
of each employee.
Discussion
Do motivation, role theory and personality factor into our
day-to-day experiences in an organization in a significant way? Three
theorists would suggest individual processes are very important to the success
of any organization. The Human Resource Model, as developed by the
contributions of Likert in 1967, McGregor in 1960 and Argyris in 19573,6,8,
proposes that the individual is the most important, indeed the central
consideration for maximizing the success of an organization. According to
The Human Resource Model each employee as an untapped well of creativity,
talent and motivation, and the success of an organization depends on how well
human resources are tapped. As an employee is placed in an environment where
they becomes the originator and leader of their work, the organization’s goals
and their individual goals become one. When organization goals are
internalized the indiviudal’s satisfaction increases, as well as the amount of
motivation to be efficient and productive. Therefore the motivation of
the employee is key because talent and creativity flows when the person is
motivated to do so by internalization of organizational goals.7
According to the human resource model, the challenge of growth and
productivity in an organization is the challenge of assisting human resources
in reaching their maximum potential. The multiple dimensions of
individual processes, the calculation of motivation, role development and
development of innate talent and abilities, are all factors that must be
considered seriously and channeled appropriately for acheving
success.
Group Processes
Leadership
Leadership is an important topic that is discussed at length in
Chapter 14 of the On-Line Textbook. Please refer to that chapter for an
in depth discussion of this topic.
Power and Influence
One needs only to superficially examine the tabloids and other
media outlets to see the action of power and influence: Movie stars promoting
everything from prostate exams to weight reduction pills or popular health
guru’s preaching cures for all ills. These individuals, and others like
them, wield great power and influence. Within the walls of an
organization, power and influence also make an impact on individuals and
groups. Although one may often think of power and influence in terms of
how it is abused, it can also be used to do positive work within an
organization to drive production and to meet goals. To that end we will
consider its role within organizations and implications for change.
Influence is the action or force by an individual that modifies
another person’s activity or behavior. Power is the force behind
influence to make it effective.6 There are three fundamental
principles regarding power. First, for power to be wielded it must have
an identifiable and credible source; power would have no bearing on individuals
without evidence to show that it can be used. Sources of power are
those substances, physical or not, that can be mobilized to have
influence. There are at least five broad sources of power: resource,
position, expert, personal and negative power. Resource power derives
from the control of wealth and resources: for example, the boy who owns the
soccer ball gets to say if there will be a game. Position power is
the power identified with fulfilling certain roles. A Chief Executive
Officer easily wields decision-making power because it stems from his
appointment responsibilities. Expert power is the power
arising from knowledge and experience. Personal power is
the innate charisma a person may possess, a type of magnetism.
Finally negative power is the ability to not do
something, and in so doing prevent another person(s) from gaining what they
want.
Second, power is a balance between both parties. Both the
person commanding influence and the person on whom the power is being exerted
commands power, the later commanding at least negative power. Finally,
power is relative. Power can be exerted only when those to whom you are
trying to wield power recognize the source of it. Take for example the
conundrum a professor of the arts would be in trying to guide decisions made by
a Medicare policy review board. His credibility as leader is diminished
because the professional source of power stems from expertise in the arts not
public policy.
Once a power source (or sources) are established, influence must
be communicated through recognizable methods. Each method chosen
predisposes individuals to certain types of responses. Depending on how
individuals respond, their new behavior may or may not be sustainable over
time. Influence methods include, but are not limited to: the use of force
and coercion, rules and procedures, exchange (bargaining, negotiating),
persuasion/logic, and ecology.6 An example of ecology would be
changing the environment people are in. Chatty employees moved to
different floors will quickly influence their behavior by changing the amount
of talking that can be done in the workday.
If the goal of power and influences is to increase productivity
and the quality of services delivered by changing employee behavior, then the
central measurement of outcome success is individual response. Depending
on sources of power, certain individual responses are more desirable for
organizational strategy because of the way they correlate with sustainability
of the response over time. Compliance is the agreement to a behavior
because of force – the “I have to” response. This implies the lack of self-initiated
behavior because the person “has to” rather than “wants to”. Generally
compliance will be the result of methods of force, rules and procedure and
sometimes exchange methods, and must be maintained with continual
supervision. Unlike compliance, identification and internalization have
some degree of acceptance of the new behavior, however the sustainability of
the behaviors are not the equal. Identification is a behavior
adopted out of a desire to please or admiration for the person wielding the
power. The manager exerting this type of power has great magnetism but
must constantly be present for the behavior to continue. The organization
becomes dependent on the power figure, making the employee action not
sustainable independently. Internalization is for most situations the
most desirable response because it is independent of the source of influence
and is self-sustaining.6
Working in Groups
In the 1930’s and 40’s a set of experiments were done at the
Western Electric’s Hawthorne plant.6 The initial round of
experiments involved a select group of female employees, whom constructed
telephone equipment, placed in a variety of environments (changes in lighting,
quota demands, rest period frequent and duration) in order to measure their effect
on productivity. To their astonishment, the research team found that the
environment had little to no effect on productivity. In all simulated
environment changes the level of productivity increased, and once back in their
original environments the production level of the employees continued to remain
at higher than pre-experiment levels. The team hypothesized that the
major cause for increased productivity was the relationships formed between the
employees and between the employees and the management.
A second round of experiments were conducted on male employees
that involved in wiring and smoldering of telephone equipment at the same
plant. No change of environment was made as in the first experiment,
except to place the men under observation. The research team found what
they called the “Hawthorne Effect”8: Regardless of quota set
by the company, the empoyees neither under nor overproduced. In addition,
work output was equal for all members of the group. The research team
hypothesized that the workers created informal groups between themselves and
their superiors, which tightly regulated production in order to maintain a
group identify where no man excelled beyond the others.
This well-known experiment demonstrated for the first time in a
controlled setting the role of informal groups on productivity, and that the
effects of group culture in work environments could have positive or negative
consequences.
Outside of the informal groups created by employees,
administrators form groups in order to meet organization goals. The
nature of these types of groups also deserves some discussion. Motivation
for utilizing groups may include: (1) improved decision-making, (2). More risk
taking, (and therefore presumably more innovation), and (3). Satisfying the
need of individuals to be in a group.6
Groups, like children, go through stages of growth.
According to Handy, there are four stages of growth: forming, storming, norming
and performing.6 As managers you must be sensitive to the
needs of the group at each stage in order to help the group reach its goals
successfully. In the forming stage relationships are being built through
the establishment of goals, role definition and time-line formation.
Quickly groups move into the storming phase, where roles, procedures and goals
are questioned. It is vital at this stage that conflicts be resolved
effectively and efficiently. In the third phase, norming, members
establish a formal or informal set of rules and procedures for group members to
incorporate into their work. Open communication is vital for the norms
defined to be accepted and uniformly applied. Only when the forming,
storming and norming phases are completed will groups be able to move into a
performing stage of growth.
A few thoughts on groups remain. As discussed in the
leadership chapter of the On-Line Textbook, groups by anticipating the needs of
the group, leaders can moitvate acitivites according to the stages the group is
in. During the forming and storming stages leaders should assist group
members by encouraging participation and viable communication. Leaders
are key in maintaining group stability through effective negotiation during the
storming phases. As the group matures, reaching the norming phase the
leaders should practice foresight, promoting the next level of action by
introducing effective evaluation methods and standard setting adjustments as
necessary.
Perhaps one of the greatest challenges for working in groups is
the element that can be its greatest strength, diversity. Those who have
studied groups acknowledge that diversity in certain combinations can be key to
success. RM Belbin1 agrees, finding that teams do not
need brilliance but balance for success. Specific character roles, noted
in appendix B, can provide the recipe for success.
Discussion
Working in groups are building blocks for meeting organization goals.
Managers should consider ways to develop leadership in team members.
Training for versatility in leadership styles through workshops could encourage
this growth. Encouraging self-growth through concepts of EQ or even
Covey’s Seven Habits of Highly Effective People2 can
also provide the groundwork for leadership growth by mastering interpersonal
skills. Managers should also be proactive about identifying and
cultivating talent of his/her staff. When committees must be formed
managers can help select individuals to create groups that have the balance of
personalities and talents to maximize the likelihood of success.
Each manager must also consider diversifying their own talents by analyzing
spheres of social competence and goals though which to improve these abilities,
but also seeking to diversity sources of power and methods of influence.
For example in an environment that is strictly managed with rules and
procedures, implementing a democratic process can broaden influence by
example. This method however would require a great deal of time, effort
and must be approached with focused investment.
Organizational Processes
Organizational Structure and Design
If we were to look at any organization from a bird’s eye view we
could observe its structure and design. In the biological sciences
structure defines function, so too for human organizations. Important
concepts to consider in the studying of organizational structure are the flow
of information and sources of power. Consider the following diagrams:
In figure 1A all information flows through the CE either directly
(before intersecting with a non-CE sphere) or indirectly with 1-2 intersections
preceding. In this environment power is very well centralized and
communication well controlled. Figure 1B is a variation of a
centralized model. The managerial style in this model is more functional
with formalized relationships. These organizational structures work best
when the task is uniform, and predetermined and environment pressures are
lessened; such as if a company has cornered and market and or has a stable
product. In health care this might occur when a large tertiary care center
that has cornered the market for a city or isolated region.
In contrast, consider figure 1C where the division of duties is
highly specialized leading to two separate functional units. In this
model work and the division of duties is highly specialized so power is widely
distributed. Communication flows in a centralized fashion within units,
but no one unit controls all communication or has all power, making power decentralized.
This model may serve best in the situation where innovation and the ability to
respond to environmental change quickly is key.
The challenge for all managers will be to balance the need for
uniformity with the demands for diversity. Uniformity guarantees ease of
control and supervision, ease of integrating work of multiple subgroups or
teams (such as between offices) and economy since it is easier to pay for and
maintain one system rather than many (one type of form verse multiple
forms). However the environment in which the organization is based, and
for which the product is being delivered, is constantly changing making it
unpredictable. Organizations must than manage responses to these changes-
diversifying their processes and thinking.
Organizations may tend to seek too much uniformity, following the
classic futile fight against the law of entropy- that all things move towards
greater disorder. An organization should recognize the many demands for
diversity classify their importance and decide on which to pursue, maximizing
the cost of diversity with the achievement of goals carefully.5
Open Systems Theory (OST) has integrated these conflicting
pressures. According to OST organizations live within dynamic
environments and are shaped by them. The organization is an organism with
external (resource availability, changes of needs and demand) and internal
(employee characteristics, adaptation to organizational change teams and
individuals) environmental influences. The organization evolves according
to the pressure exerted by these sources and therefore is evolving by successful
adaptation within this dynamic, changing and an open system. The
challenges to managers are to identify appropriate sources of influence by
prioritizing them, and to guide successful adaptation by the organization.7
Organizational Culture
Organizational culture is “a cognitive framework consisting of attitudes,
values, behavioral norms, and expectations shared by the organization’s
members.”9 Organizational cultures help to establish a sense of
identity for employees within the organization and therefore can facilitate
comfort and a greater likelihood of internalizing organization goals.
Organizational culture also provides a status quo and maintains stability in
processes, communication and role interaction.
Culture is enforced in a number of ways, such as by ceremony,
symbols and language. Ceremonies that commemorate employees demonstrating
“excellence” as evidenced by exemplifying organizational values demonstrate in
front of a large audience those values to be celebrated while also reinforcing
them. Symbols, such as mission statements or encouragement slogans can
constantly reinforce the vision the organization wants each individual to be
guided by. Special language can also help to define a culture and allow
an individual to identify with it.
The presence of culture demands uniformity. Managers must
consider the consequence of paradigm shifts and plan in detail implementing
changes. Implement new paradigms require the complete support of the
administration, and should be able to address the needs of the employee working
body.
Discussion
The two major organizational processes do not stand diaposed end of
organizational theory in practice. In fact, organizational structure and
culture must reflect one another in order to reinforce the goals and mission of
the organization. Imagine an international refugee mission seeking to
initiate programs for maternal child wellness in which people at the front
lines aren’t in the community with the individuals divvying the
resources. Although the goal of the organization values may be to respond
to the needs of the community, administers, isolated from certain staff
(organizational structure) leads to the inability to reach goals.
Review of Case Study
Refering back to the scenario presented at the start of the paper,
Queens Hospital hospital wants your input on how to improve the Emergency
Department’s patient care, and to maximize efficiency and quality.
Utilizing OT there are a few questions we might want to ask to diagnosis the
problem.
Staff related issues: How well does staff feel supported and
able to pursue work related issues. What are staffing levels? Are
these ratios sufficient for patient workload? If staffing levels are low
this can contribute to the problem of efficiency and quality. If this
seems likely to be a problem, further questions should include: What is
staff turn over, and what is the wait time for obtaining new staff? How well
are human resources retaining staff, what are the problem areas? What are
the incentives motivating work participation, and what pools are applicants are
applying? Whom, what talents and skills do we want to aim for?
Organizational Issues: How well do the different units of care
delivery fit with one another? For example if the laboratory was
contracted out to a lab three miles away, the hospital may be limited by the
time it takes for blood to be collected, transported, analyzed and transported
back. This process may also be on a schedule, (on the hour or half hour)
which then adds the wait time for transportation. An in-house lab staff
might be considered, although cost of overhead and staffing would have to be
considered for its cost. What also is the climate in the organization,
are works overall satisfied, dedicated, feel empowered to deliver excellent
care? Has the organization build and supported a culture of excellence?
Where is decision-making centralized, and what would be the
benefits and disadvantages of diversifying sources of power? In light of
the patient population needs, what types of problems are most commonly
seen? Uniform vs. diversity pressures help to guide modes of
action. If a lot of non-acute conditions are presented to the hospital we
might want to consider the utilization of an Urgent care model ancillary to
maintaining the ER for acute conditions.
Consider other more "acute" conditions as well: What
glitches to the staff frequently comment as a problem? Maybe the computer
system is archaic and redundant. Maybe there are frequent errors in
obtaining and reporting labs, consults, and obtaining patient records.
One glitch could create a myriad of small, but recurrent problems, troubling
staff and overall efficiency of the practice.
We will assume that acute issues, and staff related issues are not
the problem, since resolving them would be self-explanatory. We will
consider only adjustments in organizational structure and design for the sake
of relevance to the topic of OT. I suggest that Queens Hospital consider
a new model of care delivery, in which the Emergency Department diversifies to
a decentralized model of management and adds new modes for care delivery.
The new process would look something like this: When a patient enters the
hospital they are seen immediately by a Triage nurse. The nurse has the
option, after registration is complete, to one of three routes: the nurse
can channel a patient through the traditional method, to be seen by Emergency
room physicians according to priority. The nurse can also decide to transfer
non-acute patients to urgent care center (an initiative of this hospital or a
close center), or to initiate pre-approved protocols for common illnesses,
(such as asthma) prior to visitation from the physician.
Utilizing this model has a few advantages. By increasing the
structural complexity, patients can have treatment initiated and completed at a
faster rate. This not only allows the hospital to see more patients, but
it will improve patient satisfaction. Redesigning job roles and
responsibilities may also increase the motivation of staff by maximizing their
control of patient care. Nurses can more effictively utilizie their
triage skills and doctors can focus on patients with conditions or
complications that require their skill and training.
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