1. Health Care Organizations from the Inside-Out EPI 247: Week 2 Power and Control Laura Schmidt, PhD, MSW,MPH Associate Professor

2. KEY PARTS OF AN ORGANIZATION 1. Structure 2. Culture 3. Governance/Power Structure 4. Organizational Environment

3. Discussion Questions: Organizational Anatomy Does the organizational culture keep people on task? Clearly define the mission? Is the structure optimal for the mission and technical aspects of the work? Are the powerful people in the organization critical to its survival and performance? Are people attentive to the most important stakeholders in the environment?

4. STRUCTURE: Discussion Questions STRUCTURE: Discussion Questions What is the size, hierarchy, degree of complexity and interdependency in the organization? What is the optimal structure for the goals and tasks it wishes to pursue?

5. CULTURE: Discussion Questions CULTURE: Discussion Questions What is the professed goal of the organization? Does the organization spend most of its energy pursuing that goal? If not, what was the main goal people pursue?

6. GOVERNANCE/POWER: Discussion Questions GOVERNANCE/POWER: Discussion Questions To whom does power flow in the organization? To what extent should decision-making be routinized? To what extent do informal rules (off-the-books practices) govern decision-making?

7. ENVIRONMENT: Discussion Questions ENVIRONMENT: Discussion Questions What players in the environment are critical to the organization’s survival? How does the organization stay legitimate? How much influence does the organization have over key parts of its environment?

8. WEEK 3 INTRODUCTION The Central Problem for Managing Healthcare Systems: Autonomy and Control Autonomy and Control

9. The Bureaucracy Modernity’s answer to the problems of controlling subordinates. Max Weber 1864-1920

10. POWER, AUTHORITY AND CONTROL POWER, AUTHORITY AND CONTROL POWER= The ability to impose one’s will on someone else. AUTHORITY=The routinization of power based on an assumption of legitimacy. CONTROL= Fixed, built-in systems that maintain constrain subordinates automatically and invisibly.

11. Features of the Classical Bureaucracy Equal treatment for all employees Reliance on expertise, skills, experience Position belongs to the organization Specific standards of work and output Extensive record-keeping Rules and regulations serve the organization’s interests People are bound to the organization by formal contract

13. The Central Problem for Managing Healthcare Organizations AUTONOMY versus CONTROL How does the system control professionals who require autonomy and decision-making power?

14. Solutions to the Problem Classic dual hierarchy hospital Newer managed care systems: –Integrated Delivery Systems –Network Model Health Plans

15. The Classic Form: Dual Hierarchy Medical Staff Chief of Medicine Doctors Hospital Administration Hospital Administrator Hospital Staff

16. Newer Forms: Integrated Delivery Systems Kaiser- Permanente Permante Medical Group Kaiser Hospitals Kaiser Clinics Kaiser Health Plan

17. Newer Forms: Network Models SUTTER HEALTH PLAN Sutter Medical Group Participating Doctors Participating Clinics Sutter Hospitals Participating Labs, Pharmacies

18. Week 3 Exercise How bureaucratic is the organization? How much professional autonomy is required? How does management balance autonomy and control? Is it working?