Transcript Organizational Analysis PPT

Organizational
Analysis Module:
Developing an
Organizational Profile
Roberta Fruth, RN, MS, PhD, FAAN
Senior Consultant
Joint Commission Resources
1
Faculty Introduction(s)
Roberta Fruth, RN, MS, PhD, FAAN
Senior Consultant
Joint Commission Resources
2
Welcome and Introduction
 This module is 1 out of 9 available to help prepare
candidates towards the JCCAP exam. Additional
webinar modules include:
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–
–
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Understanding the Joint Commission’s Accreditation Process
Environment of Care
Leadership
Standards
Patient Safety
Performance Improvement
How to Engage Your Medical Staff into The Joint Commission
Accreditation Process
– Understanding the CMS Regulatory and Survey Process for Hospitals
3
Welcome and Introduction
 Please note that all modules and Exam
Questions related to the JCCAP product line
are specifically related to The Comprehensive
Accreditation Manual for Hospitals, in
addition to CMS related materials
 JCCAP Questions
– Please visit www.jcrinc.com/jccap
– Email questions to: [email protected]
4
JCCAP Module 2: Organizational Analysis
Disclosure Statement
The following staff and speakers have disclosed that they do not have any
financial arrangements or affiliations with corporate organizations
that either provide educational grants to this program or may be
referenced in this activity:
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–
–
–
Speaker
Program Manager
Nurse Planner
Other planning team member
The following staff and speakers have verbally disclosed their
arrangements and affiliations: Not Applicable to this presentation
Furthermore, each of the previously named speakers has also attested
that their discussions will not include any unapproved or off-label use
of products.
5
Publications and Record Restrictions
• The program may be electronically recorded by JCR
and is subject to the protection of the copyright laws
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electronically record any portion of these programs
for any purpose without the written permission of
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Tips for Using Module
 Optimize your experience
– Viewers are encouraged to pause your screen at
any time to bring other staff and faculty in to
segments that you find appropriate for team
building and/or communication
– Take advantage of printing out the slides (pdf
available on the left side bar) for easy note taking
– Make sure to review attached links, documents
and references mentioned throughout this
module (available on the left side bar)
7
Objectives
 Identify the organizational elements of a
healthcare organization
 Describe methods to develop the
organizational profile
 Describe the impact of the organizational
profile on the functions of the accreditation
manager
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Accreditation Manager
Communicates across the organization
Develops teams
Manages change
Accesses resources
Interprets standards
Directs improvements in quality and patient safety
9
Accreditation Manager
Who will provide support?
Who are the stakeholders?
What are the priorities?
How does the work get done?
10
In the beginning
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
11
Organizational Design
What is inside
the organization
Boundaries
What is outside
the organization
Permeability
12
Organizational Characteristics
Health Care
Systems
Health Care
Structures
Independent
Sponsorship
Multihospital System
Centralized or
Decentralized
Joint Ventures
For Profit or Not-forProfit
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Organizational Characteristics
Affiliations
• University, community, government, faith-based
Location
• Urban, suburban, rural, critical access
Focus
• Full general, limited general, specialty
Region
• East, West, North, South, Northeast, Southeast, etc.
Market
• Stable, dynamic, hostile, competitive
Regulation and Accreditation
• Local, state, federal
• Academic, professional, financial
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Changing Ownership
Creates turmoil
Always say “nothing will change”
Change always occurs and usually significant changes
Leadership changes
Lack of clarity of goals
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Changing Ownership
Mergers and Acquisitions
50% do not succeed
Communications are critical
Working relationships change
Employee productivity decreases
Friendly vs. hostile
Policies, procedures, practices change
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Changes and
Accreditation Managers
Research the new owners/sponsors
Identify current practices in known organizations
Review current reporting structures
Consider how accreditation fits in the new system
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Organizational History
Stable or Dynamic
• Original sponsors/owners
• Ongoing changes
Innovative
• Innovators
• Early adopters
• Early majority
• Late majority
• Laggards
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Organizational History
History of Change
• Accurate timelines
• Successes and failures
Players
• Support
• Resistance
• Team approaches
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Stakeholders
A person, group, or organization
that has a direct or indirect stake
in an organization because it can
affect or be affected by the
organization’s actions,
objectives, work or policies
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Stakeholders
Board members
Physicians
Staff
Vendors
Community
Colleges, universities
Unions
Affiliates
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Stakeholders
If you view yourself as a stakeholder, you are a stakeholder.
Not all stakeholders are equal.
Vary on involvement, impact, and influence.
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Stakeholders and
Accreditation Managers
Identify the stakeholders
Identify why they are considered stakeholders
Develop a strategy to include stakeholders
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In the beginning
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
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Let’s Define These Elements
Executive Leadership
• Individuals charged with overall
responsibility for the organization
Organizational Work
• The basic work of the organization
• The individuals who do the work
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Let’s Define These Elements
Technology
• Methods to support the work of the
organization
• The individuals who provide the support
Support Services
• Individuals who provide support to the
organization outside the work flow
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Let’s Define These Elements
Operational Management
• Individuals with formal authority
who connect the executive
leadership with the
organizational work
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• Form follows
function
• Members of
the group
• History of the
group
• Priorities
• Use of data
• Preferred
method
• Decision
processes
Executive Leadership
• Structure
Executive Leadership
Executive Leadership
And Now Some Details
• Organizational
Culture
• Established or
in transition
• Just or Punitive
• Culture of
Safety
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Culture Definition
 Pattern of shared basic assumptions
– Learned by group
– Taught to or assimilated by new members
• As correct way to perceive, think about, feel and act in
all aspects of daily work life
• In order to solve problems
Edgar Schein, Organizational Culture and Leadership
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Culture of Safety Definition
 An integrated pattern of individual and
organizational behavior, based upon shared
beliefs and values, that continuously seeks to
minimize patient harm that may result from
the processes of care delivery.
Kizer, K.W. 1999. Large system change and a culture of safety.
In: Enhancing Patient Safety and Reducing Errors in Health Care.
Chicago, IL. National Patient Safety Foundation.
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Elements of a Culture of Safety
 Shared beliefs and values about the health care
delivery system
 Recruitment and training with patient safety in mind
 Organizational commitment to detecting and
analyzing patient injuries and near misses
 Open communications regarding patient injuries
 Establishment of a just culture
Kizer, K.W. 1999. Large system change and a culture of safety. In: Enhancing
Patient Safety and Reducing Errors in Health Care. Chicago, IL. National
Patient Safety Foundation.
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Purposes of a Culture of Safety
ENSURE
SAFETY
ISSUES
RECEIVE THE
ATTENTION
WARRANTED
BY THEIR
SIGNIFICANCE
ENSURE THAT
REDUCE
ORGANIZATIONAL
MEMBERS SHARE
SIMILAR
IDEAS/BELIEFS
ABOUT RISKS
ADVERSE
EVENTS
CREATE
INCREASE
BEHAVIORAL
NORMS
AROUND
SAFETY
INDIVIDUAL
COMMITMENT
TO PATIENT
SAFETY
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Culture and
Accreditation Managers
Define “how we do things here”
What are the symbols of the culture?
Identify the leaders beliefs about culture
Identify what elements of a culture of safety exist
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Communication Patterns
Miscommunications are one of the root causes of most
sentinel events.
Is the Chain of Command a rigid structure for all
communications?
What are the preferred methods of communications in your
system?
How many levels of filters exist for information to reach the
right person?
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Physicians, Key Players
MS Structure
Private
Employed
Mixed
CMO
No CMO
Academic
Community
Age
Distribution
35
Nurses, Valuable Players
Role on the
Executive
Team
Nursing
Structure
Advanced
Practice
Practitioners
Staffing Mix
The Magnet
Journey
36
Professionals and
Accreditation Managers
What are the structures?
Who are the leaders?
Have they been introduced to accreditation activities?
What areas are a good fit for physician and nurse
involvement?
Develop a strategy to include physicians and nurses.
37
More to come …
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
38
References
– Mintzberg, H.(1979).The Structuring of
Organizations. Prentice-Hall. New Jersey
– Weisbord, M. (1978) Organizational Diagnosis: A
Workbook of Theory and Practice. Basic Books.
New York.
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Organizational Analysis:
Organizational Work and
Technology
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Objectives
 Identify the work and technology elements of
a healthcare organization
 Describe methods to develop the
organizational profile
 Describe the impact of the organizational
profile on the functions of the accreditation
manager
41
In the beginning
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
42
Organizational Work
What do we do here?
What business are we in?
What business do we want to be in?
What work do we have to do?
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Organizational Work: Populations
Ages
Special
Needs
Cultural
• Infants
• Children
• Adults
• Elderly
• Behavioral Health
• Trauma
• Burns
• Chronic illnesses
• Non English speaking
• Immigrant groups
• Religious affiliations
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Organizational Work: Services
Acute
•
•
•
•
Continuum of services
Trauma level
Neonatal level
Behavior Health
Ambulatory
or Out Patient
•
•
•
•
On site or distant
Growth area
Acute, preventative
Physician practices
Specialty
•
•
•
•
Women’s and Children
Surgical (transplant)
Behavioral Health
Research Programs
45
Organization Work and
Accreditation Managers
Create an inventory of populations served.
Create an inventory of services offered
Create an index of locations of all services
Visit all service locations
Develop a system to maintain this information
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Complexity of the Work
Healthcare organizations are complex.
1. Many goals throughout the organization.
2. Various levels of workers.
3. Variability in the trajectory of services.
4. Variation in the number and ranges of activities
involved.
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Complexity of the Work:
Pain Management
Type
Age
Treatment
• Acute
• Chronic
• Scale to use
• Communication
• Family involvement
• Goal
• Non medication
• Medication options
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Complexity of the Work:
Equipment
Purchase
Introduce
Maintain
Repair
• Purpose
• Vendor
• User
• Contracts
• Policies
• Procedures
• Inventory
• Training
• Competencies for
clinical and
medical
equipment staff
• Train
• Monitor
• PM
• Clean
• Store
• Train
• Monitor
• Verify repair
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Work and Accreditation Managers
Define the work of the organization
What work is core, what is growing, what is
declining
Identify content experts
Recruit content experts
Develop a strategy to include content experts
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Predictability
To know in advance
What work will be required?
What is the sequence of the work?
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Stability
Steadfastness
Consistently unmoved
Not changing
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Stability
Healthcare is experiencing constant whitewater.
New technologies are driving change.
Changing reimbursement is driving change
Increasing prevalence of chronic illness is driving change.
Demographics are driving change.
None of these factors will change anytime soon.
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Work and Accreditation Managers
Re examine the work of the organization.
What work is predictable and what is not?
What work is the most and least complex?
What work is stable and what is changing?
How does the profile of various work processes impact
accreditation readiness?
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Technology
Methods to support the work of the organization
Methods that help co-ordinate the work of the
organization
Methods to standardize the work
Individuals who provide the methods of support
The support individuals do not supply direct care to
patients.
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Methods to Support Work
Medical equipment
Electronic health record
Medications
New and modified procedures
Standardization processes
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Technology
Technology can make the work more standardized
Goal of standardization is to reduce variation
Many forms of technology
Most individuals think of equipment as the first example of
technology
The activities that support standardization are part of
technology
Not just equipment but other methods as well
57
Technology and
Accreditation Managers
Stay aware of potential changes in technology
Listen to your sources
Think about the implications to accreditation readiness
Identify content experts related to various technologies
Keep notes to help you track activity
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Organizational Issues
with Technology
Introduction of technology changes workflow
New or additional skills are needed by many
There are always unintended consequences
Different stakeholders have different levels of commitment
Changes impact productivity and standardized practices
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Electronic Health Care Records
Resource intensive
Long term project and it never ends
Just because it is electronic does not mean you can count
it
Every level of adopters will be involved
Workflow is sequential and concurrent
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Medications
Requires partnerships with pharmacy, MDs, nurses
Constantly changing: new drugs, unavailable drugs, use changed
Involves patients and families
Competencies of pharmacists and nurses
Medication changes lead to changes in workflow
61
Research
Unique impact on workflow
May have implications on other technologies
May introduce other new technologies
62
Technology and
Accreditation Managers
Learn as much as you can about the emr in your
organization .
Connect with the individuals on the emr work teams
Connect with the staff in biomedical equipment
Connect with key pharmacy leaders
Identify research areas and content experts
63
Accreditation Managers
Know the work of the organization
Establish connections everywhere
Develop tracking systems
Never assume you know what is going on
A kind word opens many doors.
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Many doors to be opened …
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References
– Mintzberg, H.(1979).The Structuring of
Organizations. Prentice-Hall. New Jersey
– Strauss, A., Fagerhaugh, S., Suczek, B., Wiener, C.
(1985) Social Organization of Medical Work.
University of Chicago Press.
– Weisbord, M. (1978) Organizational Diagnosis: A
Workbook of Theory and Practice. Basic Books.
New York.
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Organizational Analysis:
Support and Management
Activities
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Objectives
 Identify the support and management
elements of a healthcare organization
 Describe methods to develop the
organizational profile
 Describe the impact of the organizational
profile on the functions of the accreditation
manager
68
In the beginning
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
69
Developing the
Organizational Profile
Discussed
•
•
•
•
Boundaries
Executive leadership
Organizational work
Technology
Current Discussion
• Support Services
• Operational Management
Accreditation Manager
• Roles
• Responsibilities and activities
70
Support Services
Individuals who
provide support to the
organization outside
the work flow.
Risk Management,
Process Improvement,
Legal Affairs, Billing,
Cafeteria, Human
Resources
71
Support Services
Critical to the work of the organization
Important to accreditation readiness
Not always aware of their role in
accreditation readiness
72
Support Services
Process Improvement
May or may not be directly connected
Own data that is important to accreditation readiness
Stakeholder in establishing priorities for improvements
A critical partner
73
Process Improvement and
Accreditation Managers
Identify and understand the organizational relationship between PI
and Accreditation
Create connections between the PI staff and Accreditation Readiness
Identify ownership and availability of data
Understand the priority setting process of PI
Develop strategies for partnerships and shared work
74
Non-clinical Support Services
Risk Management
Legal Services
Security Services
Employee Health Services
Facilities
75
Clinical Support Services
Educators
Environmental Services
Medical Records
76
Support Services and
Accreditation Managers
Identify available support services and their reporting relationships
Understand the relationship between the service and accreditation readiness
Identify the contact for accreditation readiness issues and activities
Consider how accreditation connects with these services
Develop a strategy to establish and strengthen the relationship with these areas
77
Operational Management
Individuals with formal
authority who connect
the executive
leadership with the
organizational work.
Clinical managers,
clinical supervisors,
directors and
individuals with other
titles unique to each
organization
78
Operational Management
Includes all departments
Structures may vary by department
Reporting structures are important
79
Operational Managers
Tenure in a line position varies
Management styles vary
Clinical experiences vary
Understanding of accreditation varies
Structures in the department or division vary
Leadership in the department/division varies
80
Operational Managers
Lots of variations in their responsibilities based on the organization:
Scope of services they manage
Number of clinical areas and direct reports
Responsibilities in their roles
• Budget responsibilities
• Staffing
• Staff education
• PI data collection
• Active role in accreditation readiness
81
Operational Managers and
Accreditation Managers
Have a current copy of the organizational chart that includes all areas
Keep the organizational chart updated to the front line levels
Meet the operational managers
Assess the operational managers understanding of accreditation readiness
Develop materials to share with operational managers about accreditation
readiness
Develop strategies to develop partnerships with operational managers
82
Connections … Network
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
83
Times change …
Organizational Boundaries
Technology
Organizational
Work
Executive Leadership
Support
Services
Accreditation
Operational
Management
84
During Mergers and Acquisitions
Organizational Boundaries
Technology
Organizational
Work
Executive
Leadership
Support
Services
Accreditation
Operational
Management
85
Times change …
Organizational Boundaries
Technology
Support
Services
Organizational Work
Executive
Leadership
Accreditation
Operational
Management
86
Accreditation Managers
Challenging work
Dynamic environment
Necessary communication skills
Understanding change processes and tools
Acute situation awareness
Flexibility
Team Player
87
References
– Katzenbach, J., Smith, D., (1993) The Wisdom of
Teams. Collins Business. New York.
– Mintzberg, H.(1979).The Structuring of
Organizations. Prentice-Hall. New Jersey
– Patterson, K., Grenny, J., Maxfield, D., McMillan,
R., Switzler,A.(2008) Influencer The Power to
Change Anything. McGraw-Hill. New York.
– Weisbord, M. (1978) Organizational Diagnosis: A
Workbook of Theory and Practice. Basic Books.
New York.
88
Closing Comments About JCCAP
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Thank you!!!
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