almost two decades into the 21st century, the healthcare industry in the United States continues to change dramatically. Given the sizable shifts in regulatory framework, healthcare institutions may need an alternative source of stability, such as Porter’s value-based orientation (Porter, Kaplan, & Frigo, 2017). In essence, this orientation asks healthcare organizations to strategize based on those economic criteria over which they have the most control. With these factors in mind, the purpose of this paper is to evaluate an outpatient surgical clinic, a subunit of a large hospital, in terms of modern theories of organizational culture, complex adaptive systems, good-to-great companies, and disruptive innovation.
Healthcare Organizations as Complex Adaptive Systems
Insofar as they are adaptable rather than inhibited by regulation, healthcare organizations are construable as complex adaptive systems (Nurjono, Yoong, Yap, Wee, & Vrijhoef, 2018). As such, they naturally obey identifiable laws of complexity rather than operating as machines that managers can alter at will. As complex adaptive systems, healthcare organizations consist of self-reinforcing cycles of events, which only partially respond to leaders’ direct dictates. If those dictates contradict the inertia in the system, they will fail. Leaders in healthcare institutions need to understand the natural properties of complex systems and initiate change that aligns with those natural forces rather than operating against them.
Overview of the Organization
The organization under consideration in this paper is Accutrust (pseudonym), which is an outpatient surgical clinic and subsidiary of a larger healthcare system. Accutrust’s mission is to provide a wide range of surgical services to outpatient clients, thereby controlling costs both for the clients and for the institution. Accutrust’s philosophy is to treat patients as clients with their own productive needs, rather than treating them as obedient patients. Showing respect for client time is an important part of how the institution perceives good practice.
Among the full-time staff, Accutrust has three surgical physicians, one advanced-practice nurse (APN), three registered nurses (RNs), two medical technologists (MTs), two laboratory technicians, and three clerical assistants on site. Accutrust contracts with several other specialty physicians, who work in the superordinate hospital or other healthcare institutions in the area to respond to appointments as needed. The most common specialty areas in demand consist of ophthalmologists, endoscopists, pain specialists, podiatrists, orthopedists, gynecologists, and otylarynologists.
The community seems to accept Accutrust as a reliable source of services, but Accutrust has yet to measure customer attitudes directly, aside from the federally mandated survey, which is necessary for keeping federal reimbursements per service from declining. Accutrust places a premium on short cycle times, which shows respect for the customer’s time but may conflict with the implied organizational value of treating customers with care and respect.
Using Schein’s model of organizational culture, a correct analysis of Accutrust addresses artifacts, values, and assumptions (Armenakis & Lang, 2014). The artifacts at Accutrust include cleanliness and orderliness at the clinic and a relatively rigid structure of command and control. The APN often acts as a subordinate to the full-time physicians rather than a peer, despite her doctorate in nursing practice (DNP). Accutrust obeys its espoused values in terms of controlling costs, but the command-oriented behavior of the hierarchy seems to dampen staff enthusiasm to engage deeply and energetically with the work. Thus, the implicit assumptions in the culture reflect distrust in individual employees to make reasonable decisions on their own. The climate emphasizes order and risk-averseness rather than innovativeness.
A learning organization is more than merely a collection of people who learn and study; rather, it is able to react to shifts in the environment smoothly and creatively rather than rigidly (Ortega, Van den Bossche, Sánchez, Rico, & Gil, 2014). For its part, Accutrust may encourage individual study at times, but the hierarchy never rarely provides incentives or time for learning-oriented activities. The APN appears to keep up with research on her own time rather than in the context of her regular duties.
Predominant Leadership Style
The leadership style that predominates at Accutrust is largely transactional rather than transformational, in that the leadership relies on the standard incentive structure to promote individual performance rather than benefiting from the strength of personality of an energetic leader (Rowold, Borgmann, & Diebig, 2015), let alone a Level 5 leader (Poncelet & Lai, 2017). To some degree, the style is also autocratic, but the APN attends organizational meetings, a fact that may suggest some potential for Accutrust to become a learning organization.
Application of the Polarity Thinking Model
In terms of the polarity thinking model, Accutrust is mostly off balance (Wesorick & Shaha, 2015). Areas of concern include the emphasis on stability over change, vertical over horizontal relationships, individual ability over team competencies, and medical care over whole-person care. Other areas of concern include routine tasks over scope-of-practice tasks, standardized care over individualized care, and technology over expertise. The balance between mission and margin seems adequate in terms of the cost-savings emphasis, as does the balance between patient safety and staff safety.
Application of the Collins Model
Accutrust’s leaders seem to operate at Level 3 in the Collins model (Poncelet & Lai, 2017), hence that of the effective manager, using transactional incentives to foster organizational performance. Leaders therefore promote organizational performance through individual rather than team-level talent. The reliance on individuals may be a product of the need to routinize as much as possible, both to save money and to endure wide swings in demand.
Insufficient evidence is present at Accutrust to judge how the leadership responds to the paradox between accepting realism and optimism (Stockdale Paradox), but direct observation of leadership behavior suggests an imbalance, with greater weight placed on realism (Von Bergen & Bressler, 2017). Accutrust has yet to consider the hedgehog concept in its thinking (Johnson, 2014). Nevertheless, on an individual level, the staff often demonstrates considerable passion in the organization’s mission of treating clients quickly and respectfully. The limitation is that the second factor in the hedgehog framework, namely, the best-in-the-world concept, seems missing from the organizational equation. As for what drives the organization’s economic engine, the leadership seems clear on that issue, given its emphasis on cost-savings.
Regarding the culture of discipline, the organization seems to have many staff members in place who could help it move in a positive direction, but the leadership makes no effort to bring about this kind of change. The hierarchical structure contradicts this kind of transformation (Caldwell, Ichiho, & Anderson, 2017). Accutrust seems to be approximately in the middle between being a leader and a laggard in adopting technology, probably because it simply follows the dictates of the superordinate organization.
Accutrust is the product of a kind of disruptive innovation that occurred decades ago, when the first ambulatory surgical unit came into being. However, at present, the organization shows few signs of a readiness to consider disruptive innovation at all (Grady, 2014). A first step toward embracing disruptive innovation could consist of giving the APN more autonomy and a stronger role to play in terms of bringing scholarly material into the organization to share with the RNs and other staff members, while incentivizing brainstorming meetings for improving certain processes. Even if most of this kind of discussion leads only to an expansion of ideas without traction, a continual process of innovative thinking may produce epiphanies from time to time, which could support disruptive innovation in productive ways. The leadership’s risk-averse attitude seems to reduce such a possibility, however.
This paper provided an initial assessment of an outpatient surgical unit, called Accutrust for the purposes of the analysis. It first discussed healthcare organizations as complex adaptive systems and then explored the featured case from the perspective of progressive organizational thinking of recent decades, including organizational culture, leadership styles, polarity thinking, the Collins model, and disruptive innovation. Based on the analysis, a fundamental change in Accutrust’s leadership profile may be in order to ensure adaptiveness to large shifts in the external environment, such as changes in customer behavior or regulatory requirements. While Accutrust benefits financially from operating under the superordinate structure of a successful hospital system, it could pursue stronger innovations and solutions under a more energetic form of leadership. Short of a tumultuous threat to the organization’s continued viability, this kind of change is unlikely to occur at Accutrust.
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