Chapter 2 Organizational Structure of Health Care Copyright © 2017, Elsevier Inc. All rights reserved.

Leadership Structure in Health Care  Organizational structures of most health care organizations focus on oversight, efficiency, and stakeholder satisfaction.  Health care institutions are organized according to lines of authority, power, and communication.  Structures are defined as centralized or decentralized. Copyright © 2017, Elsevier Inc. All rights reserved.2

Integrative Structures in Health Care  Health care systems organized to provide care throughout different transitions of care  Institutions partnered or merged with other facilities to provide broader care  Integrative structures provide increased efficiency and financial stability of services  May be vertically or horizontally integrated Copyright © 2017, Elsevier Inc. All rights reserved.3

Organizational Structures  Visualized by an organizational chart  Centralized organization is a typical hierarchy with a chain of command and top-down decision-making  Flat organization removes the hierarchal layers, allowing authority for action at the point of service Copyright © 2017, Elsevier Inc. All rights reserved.4

Functional Structures  Arrange services and departments according to what they do  Departments with similar functions report to a common manager or vice president  Advantage: Supports professional expertise  Disadvantage: Departments become separate entities with little interaction Copyright © 2017, Elsevier Inc. All rights reserved.5

Product Line Structures  Functions necessary to produce a specific service are brought together into an integrated unit under the control of a single manager  Advantage: Coordination of all services within a specialty and similar focus  Disadvantage: Increased expense caused by duplication of services Copyright © 2017, Elsevier Inc. All rights reserved.6

Matrix Structures  Combine both function and product line structures in an integrated service structure  Manager of a unit responsible for a service reports to a functional manager and a service manager  Requires a collaborative relationship between the service and functional managers Copyright © 2017, Elsevier Inc. All rights reserved.7

Integrated Structures  In integrated health care systems, providers provide care across the continuum for a particular patient population.  Preventive care is inherent in this structure, with primary care providers, not the hospital, at the center of the structure.  Goal is to keep people healthy.  Hospitals, delivery systems, and health care workers are brought together under one umbrella.  Disadvantages: High overheads and potential internal power struggles. Copyright © 2017, Elsevier Inc. All rights reserved.8

Major Types of Care Delivery Systems  Method used to deliver care to patients  Determines the nurses’ authority for clinical decision-making and outcomes  Fundamental elements of any care delivery system:  Clinical decision-making  Work allocation  Communication  Management  Coordination  Accountability Copyright © 2017, Elsevier Inc. All rights reserved.9

Total Patient Care  Care responsibility does not extend beyond the shift.  One nurse assumes accountability for the complete care of a group of patients for the shift.  Advantages  All care is given by an RN  High patient satisfaction  Reduces the need for supervision  Disadvantages  May not be cost effective due to increased need for RNs  Some nurses believe some tasks could be done safely and effectively by others with less skill Copyright © 2017, Elsevier Inc. All rights reserved.10

Functional Nursing  Work is allocated according to specific tasks and technical skills.  Charge nurse identifies and assigns work during shift.  Medication nurse, dressing nurse, treatment nurse, etc., are assigned specific tasks.  Assignments are oriented to accomplishing tasks.  This model is more efficient during staff shortages. Copyright © 2017, Elsevier Inc. All rights reserved.11

Functional Nursing (Cont.)  Advantages  Large number of tasks can be completed in a shift  Can mix staff classifications  Efficient financially  Staff members can be trained to master one task  Disadvantages  Charge nurse is only one with total view of patient  Decreased patient satisfaction  Decreased nurse satisfaction  Fragmented communication  Fragmented accountability  Lack of holistic care Copyright © 2017, Elsevier Inc. All rights reserved.12

Team Nursing  Uses a group of staff members led by a nurse to provide care  Team composed of health care workers with a diversity of skills, education, licensure, and ability  RN evaluates and supervises team members who provide care Copyright © 2017, Elsevier Inc. All rights reserved.13

Team Nursing (Cont.)  Advantages  Facilitation and overseeing of novice nurses  Smaller group of patients allows for increased quality of care than functional nursing  Team leader has knowledge of patient needs and coordinates care  Disadvantages  Increased time needed to communicate  More expensive due to increased number of staff needed  More time needed to supervise, coordinate, delegate  Can lead to omissions in care  Most educated staff act as supervisors and not in direct delivery of care Copyright © 2017, Elsevier Inc. All rights reserved.14

Modular Nursing  A variation of team nursing  Based on physical layout — usually smaller patient “pods” or patient care areas  Nurses stationed near the patients  A group of nurses and staff members are assigned to a group or “cluster” of patients  Advantage: Ease of working in environment  Disadvantage: Need to have consistent numbers of staff members in each group Copyright © 2017, Elsevier Inc. All rights reserved.15

Primary Nursing  Primary nursing is a one-to-one approach to patient care.  Assigned nurse has 24-hour responsibility for delivery, implementation, evaluation, and coordination of care for the patient.  Primary nurse works with nurses on other shifts to coordinate all care for the patient and family.  Primary nurse develops and evaluates the plan of care.  Decision making occurs at patient’s bedside.  Care can be delegated to appropriate staff members. Copyright © 2017, Elsevier Inc. All rights reserved.16

Primary Nursing (Cont.)  Advantages  Improved quality and continuity of care  Simplified communication  Increased nurse satisfaction  Patients perceive their care as more personalized  Disadvantages  Increased number of RNs are needed  Inconclusive data on patient satisfaction  Difficult to implement if patient has multiple unit transfers Copyright © 2017, Elsevier Inc. All rights reserved.17

Case Management  Collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs  Assigned case manager works with assigned nursing staff to coordinate patient progress  Case manager follows patient for entire hospital stay and performs all post-hospital care coordination Copyright © 2017, Elsevier Inc. All rights reserved.18

Case Management (Cont.)  Advantages:  Provides professional practice model for nurses  Cost-effective  Disadvantages:  May lead to fragmented communication  Needs to be integrated into the care delivery model  Nurses caring for patients may become more skills focused if case manager makes all decisions Copyright © 2017, Elsevier Inc. All rights reserved.19