400846 Building Organisational Capacity in Health Care School of Nursing and Midwifery | Autumn, 2017 LEARNING MODULE 1 Postgraduate ⦁ This edition: January 2017 Published by: School of Nursing & Midwifery University of Western Sydney Locked Bag 1797 Penrith NSW 2751 tel: (02) 9852 5222 fax: (02) 4570 1565 Current Editor: Robyn Moroney This material has been reproduced for the unit Building Organisational Capacity on behalf of University of Western Sydney pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this compilation may be subject to copyright under the Act. Any further reproduction of this material by you may be the subject of copyright protection under the Act. ⦁ Welcome Welcome to Unit 400846 Building Organisational Capacity in Health Care. This Unit is designed to assist students to develop an understanding of the concept, form and structure of health care organisations and the factors which influence the design, function and effectiveness of those organisations. Organisational theory will be used to analyse the organisational structures which are in common use in the health care setting. Health care is delivered in many different settings including the large, high tech, metropolitan tertiary referral hospitals with many different medical and surgical specialties, urban public and private hospitals and major rural hospitals, through to small multipurpose health centres and isolated single practitioner health clinics in the more remote rural settings. Community health services are also very diverse and include those attached to hospitals delivering post-acute and domiciliary care, family and community services, health promotion, health maintenance and specialist services such as mental health, rehabilitation and palliative care which aim to provide care to people in the community rather than have them admitted to health care institutions. General practice, residential aged care services, ambulance, justice health services and many other types of health care services exist to serve the health care needs of the population. In all of these settings there are internal and external ‘drivers’ putting pressure on health care professionals to deliver high quality care that is safe, evidence-based, effective and efficient. This Unit will explore factors that influence organisational design, function and effectiveness, including organisational behaviour, strategy, culture, power, politics, technology, sustainability and effectiveness. A major focus is the planning for organisational development to meet the challenges of rapid change and the need for performance improvements in patient care. Concepts related to the strategic development of workforce capacity in the health care sector will be considered through the concept of capacity building and the learning organisation. Leadership is examined with an emphasis on managing change and creating flexible workplaces. ⦁ Table of Contents Welcome 3 Table of Contents 4 Table of Essential Readings 6 Table of Activities 7 Module 1. Organisational theory, design and structure in health care 8 1.1. Introduction 8 1.2. Objectives 8 1.3. Organisational Theory 8 Classical Theories of Organisations 9 Neoclassical Organisation Theories 10 Modern Theories of Organisations 11 Summary 12 1.4. Organisational strategy, structure and design 12 Vision, Mission, Values and Strategy 13 Factors impacting on organisational strategy, design and structure 15 Orgasnisational design and structures in health care 17 Types of organisational structures seen in health care 18 Critiques of organisational restructuring and redesign 20 Organisational Behaviour and Motivation 20 Summary 22 1.5. Organisational culture and readiness for change 23 Organisational Culture 23 Subcultures 26 Organisational Culture and Change 27 Summary 28 1.6. Additional Readings for Module 1 29 1.7. References for Module 1 29 ⦁ Table of Essential Readings MODULE 1 Reading 1.1 11 Sullivan, E.J (2013). Effective leadership and management in nursing (8 th ed.) Upper Saddle River, New Jersey: Prentice-Hall. Chapter 2. Reading 1.2 15 Maddern, J., Courtney, M., Montgomery, J., & Nash, R. Strategy and organisational design in health care. In M.G.Harris & Associates (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp. 270-280. 15 Reading 1.3 16 Mickan S.M. & Boyce, R. Organisational change and adaption in health care. In M.G. Harris & Associates (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp 67-78. 16 Reading 1.4 19 Maddern, J., Courtney, M., Montgomery, J., & Nash, R. Strategy and organisational design in health care. In M.G Harris. & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp 281-297. 19 Reading 1.5 20 Marquis, B.L. & Huston, C.J. (2015). Organizational structure. In Leadership roles and management functions in nursing: Theory and application (8th ed.pp.260-283). 20 Reading 1.6 22 Westphal, J.A. ( 2005). Resilient organizations. Matrix model and service line management. Journal of Nursing Administration 35(9), 414-419 Reading 1.7 22 Sullivan, E. & Garland G. (2013). Motivating and developing others. In E. Sullivan & G. Garland Practical leadership and management in nursing (2nd ed.). London: Pearson Education Ltd.pp.135-153 Reading 1.8 Scott, T., Mannion, R., Davis, H. & Marshall, M. (2003). Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care, 15, (2), 111-118 28 ⦁ ⦁ Table of Activities Activity 1.1 11 Activity 1.2 14 Activity 1.3 16 Activity 1.4 20 Activity 1.5 22 Activity 1.6 26 ⦁ Organisational theory, design and structure in health care ⦁ Introduction This module will review organisational theory as basis for understanding organisational design, function and effectiveness in health care. It will also explore issues related to organisational behaviour, strategy, culture, power and politics and how they impact on organisational performance. In an environment where consumers are increasingly well informed about their own health care needs and demand for services is increasing it is important to understand the how organisations can strategically develop the capacity of the organisation. According to Philbin (1996, as cited in Alliance for Non-profit Management n.d.) ‘capacity building is defined as a process of developing and strengthening the skills, instincts, abilities, processes and resources that organizations and communities need to survive, adapt and thrive in the fast-changing world’. Capacity building can take place in one organisation, across a group of organisations, within communities or geographic regions and with teams or groups or individuals. A health-related definition of capacity building is as follows: ‘Capacity building is defined as an approach to ‘the development of sustainable skills, structures, resources and commitment to health improvement in health and other sectors to prolong and multiply health gains many times over’ (Hawe, King, Noort, Jordens & Lloyd, 2000). Understanding of issues related to organisation theory, structure, function and effectiveness can assist health care professionals in their efforts to provide leadership to improve the quality, safety and effectiveness of care for the communities they service. According to Johnson (2009, p.8) ‘a successful manager is a leader who fully understands organization theory, who is a keen observer of organization behaviour, and who facilitates change in ways that foster organization development’. ⦁ Objectives On completion of this module students will be able to: ⦁ Demonstrate an understanding of how organisational theory underpins organisational strategy and the design and structure of health care organisations. ⦁ Identify the factors driving changes in organisational strategy and design within the contemporary health care setting. ⦁ Analyse the impact of organisational culture and professional subcultures, power, politics and technology on readiness for change in health care organisations. ⦁ Organisational Theory According to Mancini (2007) ‘organisations are collections of individuals brought together in a defined environment to achieve a set of predetermined objectives’ (p.110). Health care systems in particular are very complex organisations and they are subject to almost continuous change. In this changing environment there are many factors including technological, scientific, economic, political, social and demographic factors which affect how these complex organisations are structured, their guiding principles and philosophies, their purpose or the services they provide. For health care professionals the challenges of providing quality care to consumers who are increasingly well informed about their health care needs, in an environment of cost constraint and difficulty in recruiting and retaining adequate health care workers is an everyday reality (Daly, Speedy & Jackson, 2014). By increasing our understanding of these complex organisations and by coming to appreciate different organisational theories and perspectives we can improve our ability to deal with change and we can approach the challenges with new ways of thinking. Organisational theory offers a way of thinking about organisations, how they are structured and what impacts on the functions and processes of an organisation. Organisational theory also provides a number of different perspectives with which to analyse complicated situations as they arise within organisations. It can help strategists understand how organisations need to be structured in order to achieve their mission and goals; it will help to plan information technology which understands data and communication flows within organisations so that information systems can be designed to facilitate communication and interaction across the organisation; it can help the workforce development people understand the knowledge, skills and attributes that are required in the workforce to deliver the services; it can help stakeholders understand the factors that influence performance in particular organisations; it can help the people who deliver services to understand the organisation and the factors impacting it so they can design systems and process that will improve performance and meet the needs of the organisation and the consumers (Hatch, 1997). In general, leaders and managers who understand organisational theory from a number of different perspectives can use this information in their planning, decision-making and the actions they take to achieve daily goals and objectives as well as longer term strategic directions (Hatch, 1997). Organisational theory arises out of a number of disciplines such as the sciences, humanities and the arts and it brings a variety of perspectives together to help with understanding (Hatch, 1997). Within the health care literature a number of familiar theories and concepts are used to underpin our understanding of health care organisations and how they might need to be restructured or redesigned to improve organisational capacity and performance to meet the needs of the funders (government or private), the organisation itself, the teams and individuals that work in those organisations and of course, the consumers of the services provided (Marquis & Huston, 2015). The next section will provide a short overview of a number of theories which underpin understanding of organisations. The theories will be briefly reviewed under three main headings – the classical theories, neoclassical and modern theories of organisations. The schools of thought and theorists mentioned are but a few of the well-known ones and this is not meant to be a comprehensive coverage of all of the schools of thought or theorists who have written about organisations. ⦁ Classical Theories of Organisations Classical views of managment theory began in the late 19th century and early 20th century (Olden & Diana, 2009) with the industrial revolution. During this time large factories grouped together large numbers of workers in large industrial operations. This led to problems associated with how to structure the organisation, design work processes and supervise large groups of workers in order to increase efficiency and productivity (Olden & Diana, 2009). According to Walonick (n.d.)classical organisation theory evolved from the merging of a number of theories including scientific management, bureaucratic theory and administrative theory. There theories were rigid and mechanistic and looked mainly at structures, rules, standards and management functions. Frederick Taylor (1911) was called ‘the father of scientific management’ and his theory espoused ‘one best way to accomplish a task’ (Daly et al., 2014). The managers’ main tasks were to plan and control the work of the organisation. Standards were set, workers’ skills matched to the work to be done and the managers closely supervised the work undertaken. Rewards and punishment were used by managers to motivate workers to increase productivity. At the time, Taylor’s theory worked well to increase productivity in the simple manufacturing organisations of the day but in the more complex, modern organisations the philosophy of putting the organisation and the production of goods and services first and people second has not worked as well (Walonick, n.d.). Max Weber’s bureaucratic theory is well known in health care where we still see organisations with hierarchical structures along professional lines (known as professional bureaucracies), rules, regulations, operating procedures, work standards and ongoing efforts to improve efficiency and productivity (Daly et al., 2014). Max Weber (1922) expanded on Taylor’s work by espousing the need for internal hierarchical structures with clear lines of power and authority (positional authority), divisions of labour and work design along with rules and regulations to ensure uniform standards of work and the maintenance of stability within the organisation (Daly et al., 2014; Walonick, n.d.). Administrative theory focuses on the organisation as a whole and attempts to develop a universal set of management principles that would help managers to make the organisation more productive and efficient. Writers include Fayol (1925), Gulick (1937), Mooney and Reiley (1939) and again Max Weber. Fayol (1925) is well known for his description of the five main functions of management: ‘planning, organising, command, coordination and control’ (Daly et al., 2014). Gulick (1937) expanded on this work and offered the ‘seven activities of management’. These include those management activities commonly seen in organisations today: ‘planning, organising, staffing, directing, coorcinating, reporting and budgeting’ (Daly et al., 2014). ⦁ Neoclassical Organisation Theories According to Walonick neoclassical organisation theories developed in response to the difficulties inherent in the classical theories of organisations – a major focus on the organisation and a lack of focus on the human aspects. A number of authors argued that organisations have two major objectives – ‘economic effectiveness and employee satisfaction and well-being’ (Stoner, Yetton, Craig & Johnston, 1994, p. 213). In the industrial organisations of the 1920’s where unskilled workers were being pushed to work harder and produce more on the increasingly complex assembly lines, worker unrest began to grow and motivation for work began to decrease, impacting on the productivity of the organisation. Human relation theorists such as Follett (1926) began a dialogue focussing on managers having ‘authority with, rather than over employees’ and the need for managers to involve employees in decision-making (Daly et al., 2014). Other human relations theorists such as Mayo (1953), McGregor (1960), Argyris(1964) and Barnard (1968) all examined aspects of how employees responded to managerial concern and attention to employees in the work environment. Mayo identified the now well known ‘Hawthorne effect’ where there was a positive effect on productivity when the working environment or conditions were manipulated (Daly et al., 2014; Walonick, n.d.). McGregor (1960) developed Theory X and Theory Y which captured what managers thought about the potential of employees in terms of their commitment to the organisation, their motivation and their capacity to have input into processes in the workplace. This affected how these managers subsequently treated the employees and the corresponding effect in terms of employee satisfaction and performance. He found a direct correlation between how managers treated their employees and their satisfaction with work (Daly et al., 2014). The human relations approach focused on the individual as well as on ways to include the individual in aspects of the organisation such as leadership, participatory management and shared decision making, motivation and factors impacting on worker morale (Olden & Diana, 2009). ⦁ Modern Theories of Organisations According to Diana and Olden (2009) most of the organisational theorist reviewed above viewed and studied organisations as ‘closed systems’, meaning that the organisations were closed off and did not consider the environment in which the organisations were operating. From the 1960’s onwards, organisational theorist began to consider how the environment impacted on organisations and developed what are now called ‘open-system models’ (Diana & Olden, 2009). Some of the modern theories of organisations include the follows: ⦁ General Systems Theory ⦁ Contingency theory ⦁ Transaction Cost Economics ⦁ Resource Dependency Theory ⦁ Institutional Theory ⦁ Population Ecology Theory ⦁ Strategic Management theory ⦁ Complex adaptive theory (Diana & Olde, 2009; Daly et al., 2014). Reading 1.1 will take you through a number of these theories from a health care system perspective and it provides some critique of the usefulness of these theories in understanding the current health care environment. Reading 1.1 Sullivan, E.J. (2013). Effective leadership and management in nursing (8th ed.) Upper Saddle River, New Jersey: Prentice-Hall. Chapter 2 Activity 1.1 Consider what you have read in Reading 1.1 and then think about an organisation in which you have worked. ⦁ Do any of these theories or perspectives feel familiar to you? ⦁ Do you see aspects of the bureaucratic theory present in your organisation and if so do those elements: ⦁ facilitate work within the organisation? ⦁ provide barriers to communication and work? ⦁ Can you see that multiple perspectives could be helpful in broadening your understanding of organisations? ⦁ Supplementary readings Mick, S.S. & Mack, B.A. (2005). The contribution of organization theory to nursing health services research. Nursing Outlook, 53, 6, 317-323 This reading focusses on nursing and health services research, and demonstrates how organisational theory underpins knowledge about how health care organisations function and respond to change and therefore they can provide a basis for developing research into health care organisations. ⦁ Summary Health care organisations are extremely complex and subject to ongoing pressures and continuous change. The human element of these organisations is also extremely complex and dynamic. Developing a basic understanding of organisation theory can help health care professionals better understand the modern health care organisation and its ongoing efforts to reorganise and restructure in order to deal with environmental challenges and stakeholder needs and demands. If you analyse any particular health care organisation you will generally see that because the complexity of the services provided a number of theories or perspectives will underpin management practice and the structure and delivery of those services. ⦁ Organisational strategy, structure and design Many health professionals will be familiar with their organisation’s vision and mission and will have been part of the strategic planning process for their organisation as a whole or at departmental level or even at ward level. You may have recognised elements of your own organisation in some of the organisation theories reviewed in the previous section of this module. With the ever changing health care environment clinical leaders and managers appear to be continuously engaged in trying to envision what the future will hold for the organisation and planning or redesigning the services in order to meet the needs of the stakeholders. Many of you will have been part of an organisational restructure in recent times and have views about whether that change in organisational structure was effective or not in achieving the stated objectives. But how do organisation theory, strategy, design, vision, mission, goals or objectives and action plans fit together and what does it have to do with capacity building? Work is carried out by teams or groups within the structure of the health care organisation. To keep pace with change managers and leaders engage in designing or restructuring organisations and the way that work is carried out in those organisations so that employees are satisfied with the conditions, work is interesting and challenging, resources are used in an efficient manner and the consumers are satisfied with the level and quality of the services they receive. ⦁ Vision, Mission, Values and Strategy According to Maddern, Courtney, Montgomery and Nash (2006) ‘Organisational strategy defines what an organisation seeks to do and how it plans to do it’ and that strategy is ‘influenced heavily by the organisation’s mission, vision and goals’ (p.272). Factors in the external environment such as government policy, economic circumstances, demographic changes and workforce availability will impact on an organisation’s future directions and opportunities for growth or the need for restructure and change. The strategy that is adopted by an organisation will impact on the type of organisational structure adopted, how the groups and teams work to deliver the services, levels of management required to support the work, how information and communication flows, where the power and authority lies within that structure and the decision making processes (Maddern et al. 2006). Many organisations adopt a strategic framework for their planning and that framework may include some or all of the following elements: ⦁ a vision ⦁ a mission (or purpose) ⦁ values ⦁ strategy, and ⦁ goals (or objectives) and action plans (Heathfield, 2016) Not all strategic planning documents will include all of these elements. Definitions It is appropriate at this stage to review some definitions related to this strategic planning framework. A vision is a statement about what an organisation wants to become and it is generally future oriented. It is usually short and designed to motivate staff (Maddern et al., 2006). According to Heathfield (2016) a vision statement should resonate with the employees and make them feel proud and excited to be part of the organisation. A good example from Hatfield (2000) is the one from Westin Hotels. Their vision is as follows: ‘Year after year, Westin and its people will be regarded as the best and most sought after hotel and resort management group in North America.’ This example makes it clear to employees and to customers what the organisation wants to become in the future. It considers the people who work at Westin Hotels part of the vision. Of course, it would be interesting to ask the people who work in Westin hotels and resorts what that vision means to them and how it impacts on their motivation and loyalty to the organisation. A mission statement or the purpose of an organisation is generally a concise description of why an organisation exists and what it does (Maddern et al., 2006). The mission of an organisations is usually on display in a prominent positions like the main entrance to the organisation, on publications and on job descriptions and employees are generally expects to be able verbally express the mission statement (Heathfield, 2016). The core values of an organisation are also often stated along with the vision and mission. The values are the core priorities and beliefs of the people within the organisation and are said to underpin decision making (Maddern et al., 2006). Values often represent the foundation for the organisation’s culture and how employees act within the organistion (MacNamara, 2008). Core values usualy relate to the principles underpinning the services provides (e.g. leadership, teamwork, collaboration, person-centred care) or they may be guiding prinicples for behaviour within the organisation (e.g. treat each other with respect; compassion, ethics, integrity; life-long learning, etc). Sometimes organisations will use either a vision or mission statement, or both and sometimes the terms are used interchangeably. For example NSW Health publishes a vision, goals and seven broad strategic direction statements that underpin Area Health Service (AHS) strategic planning (Sydney West AHS, 2007). In a number of examples, particularly in religious health care organisations, it could be said that the vision, mission and values are all rolled up into one. One such mission statement is from St Joseph’s Hospital in Sydney. It states: The mission of St. Joseph's Hospital is to extend Christ's healing love by providing excellent health care in the areas of: ⦁ rehabilitation, ⦁ psychiatry for the aged, ⦁ palliative care, ⦁ outpatient services, and to work with unity of purpose, respect for the human dignity of all, and to treat all with compassion and justice. Activity 1.2 Consider the mission statement from St Joseph’s Hospital above. ⦁ Does it express the purpose of the organisation? (Yes/No) ⦁ Does it define the scope of the ‘business’? (Yes/No) ⦁ Does it indicate what the organisation is intending to be in the future? (Yes/No) ⦁ Does it contain the core values that underpin organisational behaviour and culture? (Yes/No) (Complied from Swords & Turner, 1997). Access your own organisation’s vision and mission statement and ask the same questions. Remember the vision, mission and values may be stated separately (see the definitions above) or contained in one statement as with St Joseph’s Hospital. Organisational strategy lays out what an organisation seeks to achieve and how it will do it. The strategic planning document usually defines a number of priorites and approaches that will be used to accomplish the mission of the organisation and to move it towards its future state as set out in the vision statement (Heathfield, 2016). A health service may have a strategy that drives continuous improvement in the quality and safety of care. For organisations having difficulty in recruiting and retaining staff, they may have strategies that are aimed at making them an ‘employer of choice’. These strategies may include actions related to developing simplified on-line application processes, providing subsidised housing (especially in rural areas), training and education, mentoring and support and incentives to stay where that is possible. The goals or objectives and the action plans flow from the strategy. These provide the specifics direction on what needs to be done, the targets that have been set, timeframes for achievement and how the success of the strategy will be measured (Maddern et al., 2006). The goals and objectives help leaders and staff focus on what needs to be done to achieve the organisation’s mission (Drucker, 1992 as cited in Maddern et al., 2006). ⦁ Factors impacting on organisational strategy, design and structure The organisation’s vision, mission and strategy will heavily influence the way that the organisation is structured and work is organised so that it can manufacture goods or provide services in the most efficient manner. Of course as pointed out by Maddern et al. (2006) ‘strategy development is a continous process, enabling the organisation to respond to changes in the environment’ (p.272). In many instances when change occurs in the internal or external environment or within the organisation, the strategy and how the ‘business’ is structured or organised will need to be reviewed. Hence the terms ‘redesign’ or ‘restructure’ have come into common parlance in today’s business and service sectors. The strategic planning process will usualy involve an in-depth analysis of the environment in which the business or the service is operating and an attempt to forecast future shifts and trends in service need and delivery (Maddern et al., 2006). In recent years in health care there has been a dramatic increase in survival in people with chronic and complex conditions. New models of care promote interdisciplinary teams to work in partnership with primary and community care providers to help these people learn to manage their own conditions, improve their quality of life and stay out of hospital. Successful organisations are those that are able to able to forecast or predict these trends and adapt their organisations, or partner with others, to meet those challenges. The SWOT analysis (strengths, weaknesses, opportunities and threats) will be familiar to many people and it is commonly used to analyse the environment in which an organisation operates. An analysis of the external environment aims to assess the opportunity and threats to the organisation that arise from changes in the social, technological, economic circumstances and political factors that can impact on an organisation (Maddern et al., 2006). These external factors may be in the community where the service is provided, the state, the nation or in fact, they may be global like a global economic recession. An analysis of the internal environment of an organisation will help the stakeholders understand the organisation’s strengths and weaknesses, its capacity and resources and what is required to meet the challenges. Reading 1.2 Maddern, J., Courtney, M., Montgomery, J., & Nash, R. Strategy and organisational design in health care. In M.G.Harris & Associates (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp. 270-280. The following diagram, which has been adapted from Daft (2010) summarises the complex web of issues for consideration by management in setting direction and restructuring or redesigning health care organisations for effective and efficient care delivery. ⦁ Management Role in Organisational Direction, Design and Effectiveness. (Adapted from: Daft, R. (2010) Organisational theory and design. Mason, Ohio: South-Western Cengage Learning, Chapter 2, page 59) Activity 1.3 Think about your own health care environment. ⦁ What factors in the external environment are impacting on how your organisation is functioning and its ability to deliver services into the future? ⦁ What factors in the internal environment are impacting on your organisation and the services it is able to provide? Make a list of these factors and compare them with those referred to in Reading 1.3. Reading 1.3 Mickan S.M. & Boyce, R. Organisational change and adaption in health care. In M.G.Harris & Associates (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp 67-78. This reading provides an overview of the forces driving change in the Australian health care system. Similar driving forces for change in health care systems will be found in the majority of developed and developing countries. With these increasing concerns about meeting consumer needs, about the cost of technology and treatments and concerns with quality of care and difficulties in recruiting health care professionals there is ever increasing pressure to restructure organisations and to improve the management of resources and services. The next section of this module will look at organisational design and structures in health care. ⦁ Organisational design and structures in health care In an ideal world, organisational ‘structure follows the strategy’ (Chandler 1966 cites in Maddern et al., 2006). That means that the structure of an organisation should be designed to support management in their efforts to coordinate and organise the workforce and resources to achieve the agreed mission, vision and strategy of the organisation. The structure needs to be a good fit with the tasks that are to be performed. Health care organisations have traditionally been organised around the professionals who were responsible for delivering care, but now many organisations have been restructured to focus on the needs of the recipients of care – rather than the providers of care. This means that different organisational structures and designs are being adopted to assist in reorganising services and personnel to meet the new imperatives of patient focus and efficient use of human and other resources. According to Glickman, Baggett, Krubert, Peterson and Schulman (2007) as the quality and safety agenda becomes more prominent, health care organisations will need to develop organisational and management structures that create mechanisms for accountability for improving quality and safety of care at all levels. Organisational design is the ‘process by which managers select and manage aspects of the organisational structure and culture’ (Jones, 2007, p.9) to control activities, manage resources, increase effectiveness and achieve the organisational goals. Structural redesign and change management go hand-in-hand when there is what Daft (2007) calls ‘symptoms of structural deficiency’ (p.123). These symptoms could include one or more of the following: ⦁ Decision-making is delayed or lacking in quality due to the hierarchy being overloaded or information not reaching the right people ⦁ The organisation does not respond innovatively to a changing environment ⦁ Employee performance declines and goals are not being met ⦁ Too much conflict is evidence. In response to these symptoms managers generally make changes to the structure and the design of work to find a better balance between the vertical lines of authority and control and the horizontal linkages that are necessary to improve communication, collaboration and achieve coordination of services (Daft, 2007). Of course any change in organisational design or structure will have implications for the power structures and internal politics within the organisation. Some groups and individuals thrive on change while others will be more hesitant, will not see the need and may in fact be resistant or obstructive. This quote from Peter Drucker (as cited in Marquis & Huston, 2015, p. 264) sums up the difficulties of, and the need for, change: ...society, community, family are all conserving institutions. They try to maintain stability, and to prevent, or at least to slow down, change. But the organization of the post-capitalist society of organizations is a destabilizer. Because it functions to put knowledge to work – on tools, processes, and products; on work; on knowledge itself – it must be organized for constant change. Power and politics will inevitably be a part of any change. External factors such as government policies, budgets and influence will bring both politics and power to bear on health care organisations. Internally leaders will use formal power and authority structures and as well personal power to influence health care professionals to think about change and adopt change. According to Maddern et al. (2006) power is necessary within organisations in order to influence people to work toward the goals and objectives of that organisation. Politics, on the other hand is the ‘way in which power is exerted’ (p. 282). Politics can also be seen as ‘the art of using power wisely’ (Marquis & Huston, 2015, p.295). Everyone has some type of power – very few people are completely powerless. Clinicians have expert power related to their knowledge and skills; specialists and managers have position power; many people have power because of the information they hold; charismatic leaders have personal power and as individuals we all have a level of power arising from our maturity, sense of self-worth and confidence. As Marquis and Huston say ‘Power, therefore, is not good or evil; how it is used and for what purpose it is used determine if it is good or evil’ (2015, p.296). Organisational structure is defined by Jones (2007) as the ‘formal system of tasks and authority relationships that control how people coordinate their actions and use resources to achieve organizational goals’ (p. 7). According to Jones (2007) structures evolve to increase the ability of the organisation to control the activities it undertakes to achieve its goals. The form of an organisation will influence levels of management, lines of authority, how groups of people interact and communicate and how efficiently services are provided (Maddern et al., 2006). It may also shape relationships and the behaviour of people in the organisation and affect the ‘sentiment’ with which individuals engage and how they perform their work. Many studies have now documented the relationship between variables of organisational structure and job satisfaction (Marquis & Huston, 2015). Organisational structures are often shown on an organisational chart which provides a ‘picture’ of an organisation. The organisational chart provides a schema of the formal relationships within an organisation, the ‘chain of command’ or lines of authority, span of control, management levels, the location of positions in the organisation and the communication and information flows (Marquis & Huston, 2015). The difficulty with an organisational chart is that it cannot depict the complexity what goes on within an organisation. ⦁ Types of organisational structures seen in health care A simple bureaucratic organisational structure is often depicted as a functional structure or a line structure (Marquis & Huston, 2015) (See Figure 1.1). You can clearly see who reports to whom, who is responsible for work and where the power and authority lies. Of course there are many disadvantages of this type of organisational structure, with decision-making being centralised at the top and communication usually flowing one way - from top to bottom. Upward communication or feedback is often inhibited by the layers of the bureaucracy or dependent upon the middle manager. There is also poor communication between the different lines (nurses, doctors and corporate services) which can result in a lack of coordination of patient care and result in quality and safety issues within the health care environment. Of course the ‘informal’ organisational structure often circumvents the strict lines of authority and informal, horizontal communication flows between the different lines in order to ‘get the job done’. Figure 1.1 Line Structure As health care has become more complex and organisations have become much larger the structures have evolved to flatter structures with more horizontal linkages to facilitate communication and coordination between teams. The types of structures commonly seen in health care organisations include the functional design (see above), the divisional or product/market design, the matrix design and mixed structures. Go to reading 1.4 for details of the different structure types. Reading 1.4 Maddern, J., Courtney, M., Montgomery, J., & Nash, R. Strategy and organisational design in health care. In M.G Harris. & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. pp 281-297. This reading briefly discusses organisational culture, politics and power before describing and critiquing a number of different types of organisational structures that are found in health care today or are emerging due to environmental pressure to improve coordination of care and the performance of the organisations. As you can see from this reading, the structures that are most commonly described in health care are the functional, divisional or product-line structures, matrix structures or hybrids of different models (Maddern et al., 2006). Of course the traditional organisational structures that are defined in the literature are not always present in the same form in health care organisations. They are often an amalgam of features from different types of structures. There may be features of a functional model with the different professional groups having professional reporting line to Directors of Nursing Services, Medical Services, and Allied Health Services for professional issues, and operational reporting lines to a clinical stream, directorate or network head that has responsibility for service delivery in a specialty or geographical area. Sometimes the lines of communication and authority in these hybrid structures can be confusing for health care professionals at the front line. In an effort to coordinate services across organisations and different groups of service providers a number of different models or structures for integrating services have also arisen. Many private or non-government health care providers use contractual arrangements, alliances and networks to try to achieve integration of services for the client base as well as economies of scale for services such as pathology services, catering, linen supplies to name a few (Stoelwinder, Blandford & Perkins, 2006). Reading 1.5 Marquis, B.L. & Huston, C.J. (2015). Organizational structure. In Leadership roles and management functions in nursing: Theory and application (8th ed.pp.260-283). Philadelphia, PA: Wolters Kluwer Health. Activity 1.4 Access the organisational chart from your own organisation. ⦁ What type of organisational structure is in place? ⦁ Is it a traditional form as discussed in the literature or is it an amalgam of a number of different structure types? ⦁ Are the lines of authority and communication clear? ⦁ Are there any features of the structure that create a problem for those delivering services at the front line? ⦁ How might this structural problem be overcome? ⦁ Critiques of organisational restructuring and redesign Of course the constant restructuring of health care organisations or the redesign of clinical services is often politically driven and can be subject to a great deal of criticism. A number of researchers have studied the aims and the outcomes of a number of organisational efforts to restructure and in the readings below they provide a critique of the process. ⦁ Organisational Behaviour and Motivation Hospitals and other health care settings have missions which are about providing ‘caring’ services and so, as organisations, they have what Johnson (2009) calls quite ‘unique behavioural qualities’ (p. xv). These organisations are made up of many highly educated and credentialed professionals who work within strictly regulated and controlled environments and this often presents many challenges for the leaders and managers within the organisation (Johnson, 2009). Leaders and managers need to understand organisational behaviour and the dynamics within the organisation in order to be able to facilitate and manage change while motivating and retaining highly qualified staff. According to Johnson (2009) it is important to understand motivation in order to deal with these different and sometimes unique behaviours, particularly if they want to motivate people to learn and develop their skills and change or improve service provision. Some people are very motivated and will often initiate change, while other people lack motivation, are comfortable in what they are doing and want things to stay as they are. Even those who are usually motivated, may experience periods of low motivation, so how do managers deal with these different behaviours? People will take action to achieve their needs and motivation is the key to their willingness and the level of effort they put into achieving the desired goals or rewards that relate to satisfying those needs (Marquis & Huston, 2015). Intrinsic motivation is generally regarded as coming from within the person themselves and may be shaped by factors such their upbringing or culture. Extrinsic motivation is related to rewards and recognition and can be shaped by the environment, particularly the work environment. Having an understanding of motivational theories will help but as Johnson (2009) says – no one theory will be effective in explaining all behaviours and the different contexts within the work settings. Mazlow’s hierarchy of needs theory is familiar to many health care professionals. The different levels of need are psychological, safety, social, esteem and self-actualisation. Hertzberg reclassified Maslow’s hierarchy of need into the Two-Factor Theory with what he called as hygiene (or maintenance) factors and motivator factors. Motivators or job satisfiers are related to the motivation to do well in the work itself and are factors such as achievement, recognition, work, responsibility, advancement, possibility for growth and development (Marquis & Huston, 2015). The hygiene or maintenance factors are those that keep the people in the work and include salary, supervision, job security, positive work environment, interpersonal relationships and peers, personal life, company policy and status (Marquis & Huston, 2015). Reading 1.6 Westphal, J.A. ( 2005). Resilient organizations. Matrix model and service line management. Journal of Nursing Administration 35(9), 414-419 People are motivated to follow certain paths to reach goals to satisfy these different levels of need. There are also quite a few other theories that contribute to our understanding of what factors motivate people. These factors are generally ‘need, intrinsic motivation, expectancy, goal setting, equity and reinforcement’ (Johnson, 2009, p. 98). According to Johnson (2009) need and intrinsic motivational theories suggest that people are internally motivated, generally behave in ways that are positive and happy and that can be controlled by other people. The expectancy and goal-setting theories are based on the understanding that people are rational and behave in ways that will help them achieve their desired outcomes. In relation to the equity and reinforcement theories it is asserted that external factors are what motivate people. The following reading critically discusses the importance of actively managing employee motivation if organisational change is to be successful. It discusses the use of the Herzberg et al. ‘‘motivation-hygiene’’ theory of motivation and the ‘motivator’ and ‘hygiene’ factors that can impact on motivation, job satisfaction and performance in the health care sector. Examples are given in relation to the structural reform of the Irish Health Sector. Reading 1.7 Sullivan, E.J. & Garland, G. (2013) Motivating and developing others. In Practical leadership and management in healthcare (2nd ed.) (pp.134-153). Harlow. U.K: Pearson Education. This reading provides an overview of the issues motivating individuals and groups in the workplace. You are asked to consider the role of the leader in facilitating this and the importance of the organisational structure in providing support for communication capacity that provides the support for the workforceWhile understanding motivation is important for leaders, it is not a simple concept. Cherry (Laschinger, Duffield, & Read, 2014) warns that motivation is complicated and involves intrinsic and extrinsic rewards, such as job satisfaction and is created maintained by good leadership. According to Kimball and Nick (2006 cited in Johnson 2009) a critical factor in job satisfaction, commitment to the organisation, retention in the workplace and levels of productivity was the relationships between the manager and the employee. By engaging with employees, leaders and managers can discover what people need in their work and what motivates them and then work with them to redesign work roles, set achievable but challenging goals and provide the support they need to develop and flourish (Johnson 2009). Wolf (1970 cited in Johnson, 2009) found that job satisfaction was linked to job motivation. He found that elements related to the job such as security, supervision and relationships were not related to motivation because in most instances the person couldn’t change those factors. According to Marquis and Huston (2015) these are the maintenance factors that keep employees from being dissatisfied or demotivated but they do not act specifically as motivators. However what Wolf calls job ‘content elements’ such achievement, recognition and reward were related to job satisfaction because the person was able to increase job satisfaction by increasing the amount and standard of work and gain more recognition. Activity 1.5 Reflect on your own personal situation and: ⦁ Identify the greatest motivator in your life ⦁ Has this motivator always been so strong? ⦁ If not – what happened to increase your motivation? ⦁ What can you learn from this reflection? According to Marquis and Huston (2015) because the organisations in which we work have such an impact on our extrinsic motivation, as leaders and managers it is important for us to think about the environment, the culture and the attitudes that directly impact on the motivation and morale of the staff and indirectly on the customers and clients accessing services. While leaders and managers cannot directly motivate people, they need to have the knowledge, skills and resources to create a climate where employees feel valued, where they are challenged and positively rewarded for their efforts and when change needs to occur, they are given support and encouragement to contribute to the new directions (Marquis & Huston, 2015). Feedback and using positive reinforcement are both powerful motivators and yet managers frequently overlook or underutilise these leadership tools (Marquis & Huston, 2015). Remember also that you, as a clinical leader or manager, are a powerful role model and your attitudes and motivation will have a direct impact on the people that you work with and according to Marquis and Huston (2015) may directly impact on the ‘staff’s commitment to duties and morale’. ⦁ Summary This section has covered issues and concepts related to organisational strategy, structure and design, as well as a brief overview of power, politics and organisational behaviour. For clinical leaders and managers it is important to understand the relationship among organisational theory, structure, design and change and organisational culture in order to effectively initiate and manage change and improve organisational performance. The next section of this module will provide an overview of organisational culture and how it impacts on an organisation’s readiness for change. ⦁ Organisational culture and readiness for change ⦁ Organisational Culture Organisational culture is described in many ways in the literature. According to Jones (2007) it ‘is the set of shared values, and norms that control organizational members’ interactions with each other and with suppliers, customers, and other people outside of the organization’ (p. 8). Brown (1995, cited in Willcoxon & Millett, 2000, p. 93) describes organisational culture ‘as a set of norms, beliefs, principles and ways of behaving that together give each organisation a distinctive character’. As we saw above the culture of an organisation is often reflected in its mission, vision and values statements about how people will treat each other and those who access the services offered by the organisation. In older, well established organisations the culture may be ‘taken for granted’ and people often do not think about it until something happens to betray what they believed were the cultural norms or values of the organisation. According to Willcoxon and Millett (2000) workplace culture develops over time, is part of the history of the organisation and can be seen as the established patterns of behaviour and beliefs of those working within the organisation. The culture relates to groups of people, their sense of belonging to an organisation and the perception as to whether these groupings ‘share similar ways of seeing and interacting with the world’ (Willcoxon & Millett, 2000, p. 92). Of course different groups in one organisation may share slightly different beliefs and values. An example of this could be where clinician groups believe that management could not possible share the values, beliefs and concerns for standards of patient care when they keep cutting the budget! The workplace culture should support and reinforce the strategy and structure that an organisation needs to be effective within a certain environment. Johnson (2009, p. 367) contends that culture can be assessed along a number of dimensions including: ⦁ The extent to which people and departments collaborate or work in isolation ⦁ The importance and extent of control and where it is concentrated ⦁ Whether the organisation has a short term or long term strategic focus ⦁ The extent to which the external environment requires flexibility or stability, and ⦁ The extent to which the organisation’s strategic focus and strengths are internal or external. From this assessment, Johnson (2009) identifies four categories of culture which arise out of the congruence between the organisation’s stated values, its strategy, structure and the environment in which it operates. The 4 types of culture are summarised as follows: ⦁ The ‘adaptability culture’ where the organisation has a strategic focus on the external environment and it is able to be flexible and change to meet the needs of its stakeholders and customers. This is not a reactive culture, but one which actively seeks to create change. According to Johnson (2009) in this culture ‘innovation, creativity and risk taking are valued and rewarded’ (p. 368). ⦁ The ‘mission culture’ is one which is driven by its mission and vision and focuses on a serving specific target group. This culture is often found in a stable environment where rapid change is not required and so it is well suited to organisations that are in a competitive environment and are profit oriented. ⦁ The ‘clan culture’ focuses on the needs of employees as a way of bringing about change and improving performance. The external environment is rapidly changing and the focus of the organisation is to motivate and empower employees to use their knowledge and skills along with their initiative and creativity to satisfy customer needs. ⦁ The ‘bureaucratic culture’ is one that has an internal focus, values stability and consistency and has a focus on following policies, procedures and established practices to achieve goals. The organisation can be successful because of the consistency of business processes, integration and collaboration but it has difficulty in being flexible and able to change in response to the external environment. Health care delivery requires strong cultures that have an external focus and an ability to adapt and change to meet the needs of consumers and the political imperatives of the government and health authorities. According to Johnson (2009, p. 371) this type of culture ‘enhances performance by energising and motivating employees, unifying people around shared goals and a higher mission, and shaping and guiding employee behaviour so that everyone’s actions are aligned with strategic priorities’. Adaptive organisations often have values related seeing the importance of the organisation as a whole and how people fit into it and contribute to that whole, engendering equity and trust as guiding principles for building relationships and improving performance and encouraging questioning, risk taking, change and improvement at all levels. Creating and enhancing this type of adaptive culture requires great skill and engagement by clinical leaders and managers at all levels. Change management processes in organisations often begin with a leadership development program which will help equip leaders and managers with the competencies and strategies to work with people to bring about change in a positive way. Organisational cultures in some health services can be quite non-adaptive, negative and resilient and provide a robust challenge to anyone trying to bring about change and reform. In 2005 when Queensland Health undertook a review of the health system they were inundated with reports of a very negative organisational culture that was having a direct impact on performance of the system. The traditional types of organisational structures and pressures from the changing environment were resulting in strained relationships, conflict and frustration and having a negative impacting on service delivery. The final report contains a very forthright description of the existing organisational culture (both positive and negative aspects) and the real need for change. The following is a quote: It was reported during district visits, that bullying, and intimidation on the one hand, and blaming and avoiding responsibility on the other typify part of Queensland Health’s culture. Descriptions such as “tribalism”, “tokenistic consultation”, “no culture of teamwork” and a “culture of power and control” were repeated themes throughout the consultation. This should not distract from other very positive aspects such as a culture of dedication towards patient care and wellbeing which was also very strongly evident during district visits. Staff were described as being “helpful and supportive”, “committed to a standard of care for patients” and “having pride” in the services they provide (Queensland Health, 2005, p.56). The report (Queensland Health, 2005) acknowledges that this culture has built up over time and reflects the manner in which staff have had learnt to deal with the different layers of the bureaucracy and management that was mechanistic, authoritarian and very much about control rather than participation and innovation. Any change to this culture will need to be very well planned and focused and show clear benefits for all stakeholders. The report admits that: A paradigm shift in the pattern of behaviours, attitudes, values and beliefs is required if Queensland Health is to be able to address these issues. (Queensland Health, 2005, p.61). A change management strategy has been designed by Queensland Health to enable the development of a more adaptive culture. The strategies include aspects of organisational structure, design, culture and leadership. The final report can be found at: http://www.parliament.qld.gov.au/documents/tableoffice/tabledpapers/2005/5105t4447.pdf The follow up review can be found at: https://www.oic.qld.gov.au/__data/assets/pdf_file/0006/7791/report-qld-health-2010-11-review-report.pdf A major review of a health system is one way of finding out about the organisational culture however this is often done in reaction to major complaints or reviews, issues about service delivery or disasters. Another way is to regularly survey the workforce to ascertain the ‘health’ of the organisation or the organisational climate. ‘A healthy’ organisation is one that has a ‘climate, culture, values and practices that facilitate good employee health and well-being and improved organisational productivity and performance’ (Queensland State Government, 2006, p. 1). The ‘organisational climate’ is the shared perceptions of employees about what an organisation is like at a given period in time. An organisation climate survey is used to measure how employees are feeling about ...leadership practices, decision-making processes, working relationships with management and co-workers, appraisal and recognition systems, employee development, work demands, workgroup distress, clarity of roles and goal alignment (Queensland State Government, 2006, p.1). This type of survey is about perceptions of what is going on in the organisation, complaints and suggestions for addressing issues of concern at the time of the survey and to generally assess the impact of major change on the workforce. This type of survey does not try to measure the more deeply embedded beliefs, values, assumptions and behaviour that make up the more lasting workplace cultures – it is really looking at workplace satisfaction, motivation and commitment (Queensland State Government, 2006). The perceptions of the people about the climate in which they work may have a direct impact on how individuals behave in the workplace. The workplace climate is about the working environment and individuals’ perceptions which are much more amenable to management intervention and influence than workplace culture which has developed over many years. Low levels of satisfaction with the workplace climate can manifest in many ways including employee absence and turnover rates, the of incidence workplace stress and harassment claims, the incidence of unethical behaviour, poor individual and team performance, the quality of service delivery and levels of customer satisfaction and customer complaints. (Queensland State Government, 2006, p. 2) Workplace culture surveys can also be carried out regularly and they often use data from the climate surveys. The issue for the workforce is not that a particular survey was carried out, but what was done about the results. Activity 1.6 If you were asked to take part in or review a workplace climate or a workplace culture survey, reflect on the following: ⦁ What was the reason given for undertaking the survey? ⦁ How were the results communicated back to the workforce? ⦁ Was the organisation benchmarked against other similar organisations so that you could get an idea of how the workplace climate or culture compared with similar organisations? ⦁ Are there strategies in place to address the main issues raised? If you haven’t had the opportunity to complete a workplace culture survey and are interested in the types of questions asked you can go to the following website for an example. The Patient Safety Group. AHRQ Culture Survey. Retrieved on 24/01/17 from https://www.patientsafetygroup.org/survey/index.cfm?sample=1 Workplace culture surveys are seen by the Patient Safely Group as crucial to being able to identify and remedy patient safety issues. Certainly the culture (or ‘the way things are done around here’) underpins individual and team attitudes to risk taking and safety issues as medication administration, how routines such as checking operative sites are implemented and the acceptance of new risk management initiatives to reduce error and improve patient safety. When employees feel good about their workplace, when there is a culture of trust and respect, there is good communication, they feel involved and valued for their efforts then they are more likely to be motivated, committed, creative and productive. These are the attributes of a healthy organisation (Jones, 2005). ⦁ Subcultures Of course organisations may not just have one ‘culture’. According to the NHS (2000 cited in Scott, Mannion, Davies & Marshall, 2003, p.115) subcultures ‘may be structured by occupation, department, specialty, ethnic or religious group, social class or other affiliations’. There are also professional sub-cultures in health care – the ‘nursing culture’, the ‘medical culture’ and other professional groups – all of whom may see the world in different ways and have different values and beliefs about issues like standards of patient care, leadership and teamwork, ethics and many other aspect of organisational life. These values and beliefs often operate at a subconscious level. They make up the assumptions that guide people in their work and interactions with others and because they are shared across the groups and the organisation, they are difficult to change (Willcoxon & Millett 2000). Fitzgerald and Teal (2004) in a study of health reform, professional identity and occupational subcultures found that not only were there cultural differences between doctors, nurses and other health care professionals they also saw cultural differentiation within the medical profession. Subcultures were becoming evident in groups of doctors from different generations, with different types of qualifications, working in different medical specialties. ⦁ Organisational Culture and Change In health care the organisational culture is often expressed as ‘the way we do things around here’ and people who do things differently or behave differently are generally seen as outsiders and may be ostracised. This may happen at the ward level when a newly employed clinician challenges ‘routine practice’ and seeks to change the old routine to a more evidence-based model of practice. Often when a new Chief Executive Officer is appointed to a health care organisation or in the private sector when a new owner takes over a group of hospitals, they will attempt to engender a culture change by asserting their own values and beliefs in a new vision or mission statement or a new organisational structure. According to Willcoxon and Millett (2000) it usually takes a long time and may require rewards and /or sanctions to get people to change their behaviour and start acting in the manner advocated by the new leader. The success of such change is dependent upon leadership and the change management process used. Organisational change is defined by Jones (2007, p. 9) as ‘the process by which organizations move from their current state to some desired future state to increase their effectiveness. The goal of organizational change is to find new or improved ways of using resources and capabilities to increase an organization’s ability to create value and, hence, its performance’. Organisational structures and cultures combine to shape and control behaviour within an organisation and so the change management process is very important if one or both of those factors are going to change. According to Jones and Redman (2000) ‘One of the most decisive functions of leadership may be the creation, the management, and when necessary, the destruction of a culture’ (p.604). According to these authors strategic goals and initiatives may fail if the leaders do not pay attention to the organisational culture when undertaking organisational restructure or work redesign. Interwoven into the organisational culture is of course organisational power structures and politics. When change is contemplated Maddern et al. (2006, p. 282) believe it is important to ask: ⦁ How is power exercised within the organisation? ⦁ Which individuals or groups have power in which circumstances? ⦁ Who is lobbying for what and why? ⦁ Who benefits and who loses from the proposed changes? It is important to consider how these stakeholders will react to the proposed change and to plan to involve them in the change management process. Reading 1.8 Scott, T., Mannion, R., Davis, H. & Marshall, M. (2003). Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care, 15, (2), 111-118 This reading provides an overview of the issues related to managing organisational culture to improve performance in health care systems that are undergoing change and reform. It discusses what is meant by ‘organisational culture’, the different types of subcultures seen in health care, strategies for changing and managing cultures, and the possible barriers to culture change in health care organisations (including a lack of ownership, complexity, external influences and forces, cultural diversity and a lack of appropriate leadership). A number of figures are provided to summarise the important points. ⦁ Summary For leaders and managers contemplating change, it is important to understand that there are many different theories underpinning change, different models and ways of thinking about change and different ways for leaders to approach the change management process. It is important not just to consider the organisation and its mission and vision and the strategy that is driving change, but to consider the individuals and groups within the organisation and why there might be resistance to change. It is good to remember as Nadler and Nadler state (1998, cited in Johnstone, Dwyer & Lloyd, 2006, p. 163) ‘Real change... is intensely personal and enormously political’. The next Module will cover aspects of organisational capacity building, workforce development, leadership and change management. ⦁ Additional Readings for Module 1 Braithwaite, J. & Westbrook, J. (2004). A survey of staff attitudes and comparative managerial and non-managerial views in a clinical directorate. Health Services Management Research, 17, (3), 141-157 Braithwaite J, & Westbrook M. (2005). Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. Journal of Health Services Research & Policy, 10, (1), 10-7 Braithwaite, J., Westbrook, M., Hindle, D., Iedema, R.A. & Black, D. (2006). Does restructuring hospitals result in greater efficiency? An empirical test using diachronic data. Health Services Management Research, 19, (1), 1-12. Duffield, C., Kearin, M. & Leonard, J. (2007). The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing, 24, (3), 42-46 Johnson, J.A. (Ed.) (2009). Health Organisations: Theory, Behaviour and Development. Boston: Jones and Bartlett Publishers. MacNamara, C. (2008). Basics of Developing Mission, Vision and Values Statements. Free Management Library. Retrieved 29/01/17 from: http://managementhelp.org/plan_dec/str_plan/stmnts.htm ⦁ References for Module 1 Australian commission on safety and quality in health care. Developing a safety and quality framework for Australia. Retrieved on 24/01/17 from https://www.safetyandquality.gov.au/wp-content/uploads/2009/01/Developing-a-Safety-and-Quality-Framework-for-Australia.pdf Backer, T.E. Strengthening non profits: Capacity building and philanthropy. Retrieved January 23, 2017 from: http://www.csun.edu/sites/default/files/hiri_capacity.pdf Daft, R. (2010). Organization theory and design. Mason, Ohio: South-Western Cengage Learning Daly, J., Speedy, S & Jackson, D Leading and Managing in Nursing Practice. In J. Daly, M.N. Hill & D. Jackson (Eds.). (2014). Leadership & nursing (2nd ed.). Sydney: Elsevier Diana, M.L. & Olden, P.C. Modern Theories of Organisations. In J.A. Johnson (Ed.) (2009). Health organisations: Theory, behaviour and development. Boston: Jones and Bartlett Publishers. Fitzgerald, A. & Teal, G. Health Reform, Professional Identity and Occupational Sub-Cultures: The changing inter-professional relations between doctors and nurses. Contemporary Nurse, 16, (1-2), 9-19 Gauld, R. & Gould, D. (2002). The Hong Kong health sector: Development and change. Hong Kong: Chinese University Press Glickman, S.W., Baggett, K.A., Krubert, C.G., Peterson, E.D. & Schulman K.A. (2007). Promoting quality: The health-care organization from a management perspective. International Journal for Quality in Health Care, 19, (6), 341-348 Hatch, M. (1997). Organization theory: Modern symbolic and postmodern perspectives. New York: Oxford University Press. Hawe, P., King, L., Noort, M., Jordens, C. & Lloyd, B. (2000) Indicators to Help with Capacity Building in Health Promotion. Sydney: NSW Health Department. Heathfield, S.M. (2016). Build a Strategic Framework: mission statement, vision, values. Retrieved January23, 2017 from: http://humanresources.about.com/cs/strategicplanning1/a/strategicplan.htm Johnson, J.A. (2009). Health Organisations: Theory, Behaviour and Development. Boston: Jones and Bartlett Publishers. Jones, G.R. (2007). Organizational theory, design and change. Upper Saddle River New Jersey: Pearson Prentice Hall Jones, K.R. & Redman, R.W. (2000). Organizational culture and work redesign: Experiences in three organizations. Journal of Nursing Administration, 30, (12), 604-610 Kotter, J.P. & Schlesinger, L.A. (2008). Choosing strategies for change. Harvard Business Review, July-Aug 2008, 130-139 Laschinger, H., Duffield, C. & Read, E. (2014). Empowerment, leadership, nursing work environment. In J. Daly, M.N. Hill & D. Jackson (Eds.) (2014). Leadership & nursing (2nd ed.). Sydney: Elsevier Maddern, J., Courtney, M., Montgomery, J., & Nash, R. Strategy and organisational design in health care. In M.G. Harris & Associates. (2006). Managing health services: Concepts and practices. Sydney: Mosby Elsevier. Mancini, M.E. Health Care Organizations. In Yoder-Wise, P.S. (Ed). (2007). Leading and managing in nursing (4th ed.). Lubbock, Texas: Mosby Elsevier. Marquis, B.J., & Huston, C. J. (2015). Leadership roles and functions in nursing: Theory and application (8th ed.). Philadelphia: Wolters Kluwer Lippincott Williams and Wilkins. Olden, P.C. & Diana, M.L. Classic Theories of Organisations. In Johnson, J.A. (Ed.) (2009). Health Organisations: Theory, Behaviour and Development. Boston: Jones and Bartlett Publishers. Queensland Health Systems Review – Final Report. (2005) Retrieved on 27/01/17 from: http://www.parliament.qld.gov.au/documents/tableoffice/tabledpapers/2005/5105t4447.pdf Scott, T., Mannion, R. Davies, Huo, T.O., & Marshall, M.N. (2003). Implementing culture change in health care: Theory and practice. International Journal for Quality in Health Care, 15, (2), 111-118 St Joseph’s Hospital Mission Statement. Retrieved January 24, 2017 from: https://svhs.org.au/home/about-us/mission-vision-creed-and-values Stoner, J. A., Yetton, P.W., Craig, J.F & Johnston, K.D. (1994). Management (2nd ed.). Sydney: Prentice Hall Australia. Swords, D. & Turner, I. (1997). Strategy from the inside out. London : International Thomson Business Press Sydney West Area Health Service. (2007). A new direction for Sydney west. Health Services strategic plan towards 2010. Kingswood: Sydney West Area Health Service. Walonick, D.S. (n.d.). Organizational theory and behavior. Retrieved January 27, 2017 from: http://www.unc.edu/courses/2006fall/sowo/804/957/Readings/orgtheoryandbehavior.htm Willcoxon, L. & Millett, B. (2000). The management of organisational culture. Australian Journal of Management and Organisational Culture, 3, (2), 91-99