This document provides an overview of strategies for building a culture of improvement in organizations. It discusses the meaning of organizational culture and how to recognize an organization's culture through various indicators. It then describes common values for organizations like diversity, safety, learning, collaboration and service. The document outlines four types of organizational cultures and strategies for culture change, including top management support, incentives, and considering staffing changes. It emphasizes the importance of cultures that promote safety, learning, and service in health organizations.

1. Chapter 9:
Building a Culture of
Improvement
Objectives
• Understand the meaning of organizational culture
and indicators of organizational culture.
• Be able to describe at least one way of classifying
differences in national cultures.
• Describe common but essential values of
organizations in general and health organizations
in particular: diversity, safety, learning,
collaboration, and service.
• Be able to discuss key strategies for culture
change.
Outline
• Meaning of Organizational Culture
• Indicators of Organizational Culture
• Organizational Cultures in Health

2. • Strategies for Culture Change
Meaning of Organizational Culture
• Culture is “the way we do things around here.”
• Culture can be applied to groups,
communities, and entire societies.
• Culture encompasses the assumptions,
beliefs, values, and norms of an organization.
Components of Culture
• Values are the ideals, customs, and
institutions of an organization that its
members hold in high regard.
• Social norms are expectations about behavior.
• Assumptions and beliefs underlie an
organization’s culture and often include the
conviction that the organization is pursuing
worthwhile ends—what is good for the
organization is good for society
How to Recognize Culture
• Examine a range of activities, artifacts, and

3. behaviors.
• This provides insights into details of its
culture.
• Use multiple measures because culture is
broad and sometime internally inconsistent
within organizations.
Espoused Values
• Espoused values are stated in an organization’s
vision, mission, and value statements.
• Often the organizational values reflect the opinions
of decision-makers at the top of the formal hierarchy.
• Espoused values are often formalized in the ethical
guidelines of professions.
• Many norms are enacted and transmitted informally
through daily behavior.
• Norms about such issues as length of breaks, dress,
and attendance at social functions have to be
learned informally.
Symbols of Culture
• Indirect manifestations of norms, values,
beliefs, and assumptions.

4. • Examples include:
– Specialized language
– Rituals
– Ceremonies
– Physical artifacts such as logos
Stories as a Symbol of Culture
• Stories reflect important values.
• Stories about an organization’s founder or
past leaders are used to transmit important
guidelines for attitudes and behavior.
• Stories about heroic behavior, such as service
during emergencies or difficult times, may
promote the value of service to potential
clients or customers.
Four Types of Culture
• Four groups:
– Networked
– Mercenary
– Fragmented

5. – Communal
Four Types of Culture
• Classification is based on the degree to which
workers share goals (solidarity) and the
degree to which they are friends (sociability).
• Fragmented cultures are lowest on both
criteria.
• Communal cultures are highest on both.
• Managers can help cultures of organizations
change over time based on external
conditions.
Organizational Cultures
in Health
• Some organizational values are particularly
important in health.
• Health organizations are beginning to develop
expertise in cultural transformation.
• They create cultures that emphasize:
– Cultural diversity
– Cross-understanding

6. – Safety
– Learning
Cultural Diversity
• Diversity in the cultures of client or customer
populations, and in an organization’s workforce,
is a reality for most public health organizations.
• Respect for cultural diversity is an imperative for
effective organizational performance.
• Respect for cultural diversity is a moral
imperative for many people.
• Five dimensions of cultures that distinguish
residents of different countries from each other
have been identified.
Power Distance
• Indicates the degree of equality among
individuals.
• High power distance ratings reflect cultures in
which inequalities between people are
accepted and perpetuated.
• Employees are more likely to expect clear
guidance from upper management, and the
relationships between managers and workers

7. are rarely close and personal.
Uncertainty Avoidance
• Encompasses the extent to which people are
comfortable with ambiguity and uncertainty.
• More rule-oriented, with well-established laws,
regulations, and controls.
• Organizational change may be more difficult to
achieve, and proposals for change will be
examined in detail.
• Individuals in countries that exhibit lower levels
of uncertainty avoidance are more willing to take
risks and accept change.
Individualism
• Reflects the importance of individuals versus
collective populations.
• Residents tend to have relationships with many
other people, but the relationships are relatively
weak.
• More likely to express their own personalities at
work, and individual rights such as freedom of
speech are often brought into the workplace.
• In more collectivist societies, ties between

8. individuals are very strong and the family is given
more weight.
Masculinity
• The degree to which a culture emphasizes the
traditional male work role model of ambition
and achievement, versus caring and nurture.
• Males tend to dominate the power structure
more than in less masculine societies.
• Workers are expected to sacrifice personal life
for their jobs.
• Communication style is more direct, concise,
and impersonal.
Long-Term Orientation
• Indicates respect for long-standing traditions
and values.
• Showing respect for traditions, honoring social
obligations, and avoiding loss of face are
important in cultures with high levels of long-
term orientation.
• In cultures with low levels of long-term
orientation, creativity and self-actualization
are valued more.

9. Cross-Understanding
• Provides a way for organizations to develop an
appreciation for all types of employee differences,
including cultural diversity.
• The extent to which group members have an
accurate understanding of one another’s mental
models.
• Group members are better able to anticipate the
behavior of their colleagues and then adjust their
own behavior.
• Can be developed through self-awareness, shifting of
perspective, and adaptation of new behavior.
Culture of Safety
• Health organization work includes interaction
with clients in situations that can result in
injury or death if safety is not a value.
• Excellent guidelines for promoting cultures of
safety are emerging in organizations that are
committed to safe practices.
• These include applying labels such as “cultures
of safety” and “fair and just culture.”

10. Fair and Just Culture
• One that learns and improves by openly identifying
and examining its own weaknesses.
• Employees feel they are supported and safe when
voicing concerns.
• Employees speak safely on issues regarding their
own actions and the actions of others.
• Employees seek help when concerned that the
quality of the services being delivered are
threatened.
• Employees are comfortable monitoring others,
detecting excessive workloads, and redistributing
work.
Culture of Safety
• Continuously seeks to minimize harm to
customers or clients that may result from the
processes used to deliver goods, programs, or
services.
• Not acting when conditions are unsafe or safety
protocols have been breached is unacceptable.
• Teamwork and openness to innovation should be
prominent values in the pursuit of organizational
safety.

11. High-Reliability Organizations
• Strive to maximize reliability of organizational
operations and services when the
consequences of error can be disastrous.
• Establishing and maintaining an underlying
high reliability structure constitutes an
organizational commitment to values and
behaviors that increase reliability, improve
responses to surprises, and reduce the
probability of errors.
High-Reliability Organizations
(continued)
• Creating a culture of mindfulness requires
organizational commitment and infrastructure in
at least four areas.
– Commitment to mindfulness in their beliefs,
values, and actions.
– Commitment must be perceived by workers as
being consistent rather than hypocritical.
– Rewards flow toward those who act mindfully and
away from those who do not.
– Emphasize the need to “walk the talk.”

12. Learning
• When learning is valued in an organization, workers
improve processes and structures in the fields for
which they have been trained.
• Learning organizations create and capture knowledge,
disseminate it to all employees, and apply it in their
products and services
• The value of learning through scientific research and
evidence is central to the mission of many health
organizations.
• Evidence-based management is a movement that
attempts to promote the better use of scientific
evidence in strategic and operational decision-making.
Collaboration and Service
• Teamwork and collaboration are synergistic when
both occur simultaneously.
– Teamwork is sharing duties and responsibilities.
– Collaboration is sharing knowledge and
information.
• Promoting service as a cultural value requires
managers that model, recognize, and reward workers
who deliver high quality service.
• These organizational leaders must convey passion and
inspiration through stories, presentations from
consumers, and publicly recognizing consumer service

13. heroes and heroines.
Strategies for Culture Change
• Implementing new cultures requires both a
commitment to goals and hard work.
• Three strategies to change culture:
– Enthusiastic support of top management
– Use rewards, incentives, and public
recognition
– Consideration of terminating or moving
those who are uncomfortable with the new
culture
Chapter 8:
Organizing Human Resources
Objectives
• Understand the recruitment process.
• Know key issues of compensation and
benefits.
• Be better able to retain valued employees.

14. • Understand the importance of training and
developing employees.
• Have knowledge about identifying problem
employees.
Outline
• Ongoing Responsibilities of Human Resources
• Legal Considerations and Responsibilities
• Recruitment
• Compensation and Benefits
• Retaining Valued Employees
• Training and Developing Employees
• Problem Employees
Ongoing Responsibilities of Human
Resources
• Creating and maintaining position descriptions
• Recruiting
• Union activities

15. • Employee training
• Employee problems
• Documentation
Important Federal Statutes
• Social Security Act (1935)
• Fair Labor Standards Act (1938)
• Equal Pay Act (1963)
• Civil Rights Act (1964)
• Age Discrimination in Employment Act (1967)
Important Federal Statutes (continued)
• Employee Retirement Income Security Act
(1974)
• Consolidated Omnibus Budget Reconciliation
Act (1986)
• Americans with Disabilities Act (1990)
• Family and Medical Leave Act (1993)
• Health Insurance Portability and
Accountability Act (1996)

16. Recruitment Within an Organization
• Word of mouth is generally quite informal and unscientific,
but may be efficient for small organizations.
• Many employers advertise positions through job postings.
• Employers generally post positions internally for 5 to 7
working days before initiating external recruitment.
• Current employees may be a good source of referrals for
new workers.
• Some employers offer bonuses for successful employee
referrals.
Recruitment Outside an Organization
• Two types of employment agencies:
– State employment agencies and union
referral halls (free)
– Private employment agencies (agency fee)
• Private employment agencies will screen and
interview candidates prior to referring them to
an organization.
• Employment agency’s fee is generally paid by
the new employer.

17. Ways to Recruitment On Your Own
• Organizations such as professional societies or
special interest groups provide referrals.
• Use the internet.
– Open to a wide range of applicants
– Continuously available
– Less expensive
• Contact local colleges and universities for
internship programs
Screening Candidates
• Determine the key qualifications for the
position.
• Keep detailed records about the process,
make notes about people who are retained in
the pool as well as those who are rejected
during the initial screening.
• Reasons for inclusion or exclusion from an
initial pool should be noted.

18. Preparing for the Interview
• The purpose of an interview is to determine
the suitability and fit of an applicant for the
open position.
• Review the current position description.
• Prepare a list of basic questions to ask all
applicants.
• Read each applicant’s resume.
Interviewing a Candidate
• Ways to conduct an interview:
– Unstructured
– Semi-structured
– Group interviews
• Set the interviewee at ease.
• Ask innocent but open-ended questions to
encourage interviewees to talk.
• Honestly describe the position and the organization.
• Ask if the interviewee has any questions about the
potential job or organization.
Selecting Candidates
• Once a candidate has been selected, agree on pay,

19. complete paperwork, and set a start date.
• Employment is usually contingent upon several points:
– Legal age to work?
– Does the person have permission to work in the
United States?
– Can the applicant pass minimum physical
requirements for the job?
– Is the candidate able to pass a medical examination
including drug and alcohol screening tests if these
are used?
What Are Compensation and Benefits?
• While money provides considerable motivation,
other factors provide more motivation.
• Direct compensation refers to salaries, bonuses,
and other forms of incentive pay.
• Indirect compensation refers to employee
benefits and perquisites, items that employees
typically receive in forms other than cash
payments.
• Health workers typically are motivated to serve
the public as well.
Direct Compensation

20. • Develop a base-salary compensation program.
• General increases reflect satisfactory completion of work
responsibilities.
• Incentive plans are intended to reward outstanding
performance.
• External equity means that rates of pay in an organization
are reasonable compared with other similar positions in a
given area for people performing the same or similar job
duties.
• Internal equity means that all employees think that their
pay is fair when compared to others with the same job title
in the same organization.
Benefits
• Benefits fall into two categories:
– Benefits required by statutes.
– Benefits to attract and retain the best employees.
• Two approaches to benefits:
– Defined benefit plans provide the same package of
benefits to all employees.
– Defined contribution plans allocate a fixed amount
of money for benefits and provide a list of benefit
options.

21. Required Benefits
• Social Security has expanded from a form of basic
pension coverage for about 50 percent of the
workforce to a full-scale social insurance program
available to more than 90 percent of the population.
• Unemployment compensation insurance is
administered by individual states.
• Workers’ compensation insurance is intended to
provide health care, income maintenance, and
survivor protection for employees who become
disabled or killed due to an occupational injury or
illness.
Optional Benefits
• Health insurance plans provide various forms of health
coverage.
• Paid Time Off (PTO) plans where employees accumulate an
allotted number of days and then use them in a more
discretionary manner.
• Long-term disability insurance is a benefit designed to
protect employees from the devastation of serious illness
or accident.
• Life insurance provides employees with a level of coverage
equal to some multiple of their annual compensation.

22. • Employee retirement plans include benefit and contribution
plans.
Retaining Valued Employees
• Valued employees can be given special assignments
that provide variety as well as allowing them to
demonstrate their readiness for promotion.
• Valued employees can serve as mentors, allowing
them to learn or practice supervisory skills.
• Organizations that ignore their valued employees run
a risk of losing them due to boredom, stagnation, or
loss of morale.
• All managers have a responsibility to identify and
develop new managers, which helps retain valuable
employees by giving them opportunities to grow as
leaders.
Training and Developing Employees
• Managers eliminate training and development when
budgets become tight.
• Have a new employee orientation plan.
• When performance does not meet expectations,
supervisors may consider additional training.
• Cross training is defined as learning how to do one or

23. more jobs normally performed by other persons.
• On-the-job training is occasionally appropriate.
• Inappropriate training is to give employees files or
folders to review, or to direct them to a website.
Problem Employees
• Mental problems can interfere with work and
job duties.
• Three relatively common mental health
problems include chemical dependency,
depression, and abuse.
• Physical and sexual abuse are common in the
United States.
• Managers are reminded not to attempt
providing therapy.
Identifying Personality Disorders
• Four common personality disorders:
– Narcissistic
– Borderline
– Histrionic

24. – Paranoid
Identifying Personality Disorders
• Common characteristics to all four include:
– Difficulties with relationships and lack empathy
– Very rigid and cannot easily accept ideas of others
– Boundary problems cause them to disregard
procedures, protocols, and organizational chains
of command
Narcissistic Personality Disorder
• Tend to think very highly of themselves, often
exaggerating their achievements and talents beyond
their actual real abilities.
• They love to be in the limelight and may steal ideas and
take credit for the accomplishments of others.
• They often demonstrate excessive self-promotion and
attention-seeking behavior.
• Difficulty accepting other points of view.
• Feel little loyalty to either supervisors or employers.
• Strategies include giving employees credit for their
accomplishments, avoiding challenges, and not taking
their criticism personally.

25. Borderline Personality Disorder
• Most common personality problem in the workplace.
• Very intense and tend to have frequent outbursts of
temper.
• They can become physically abusive.
• Their relationships tend to be dramatic and turbulent.
• These employees are prone to extreme mood swings
ranging from cheerful and cooperative to angry and
abusive.
• Difficulty distinguishing between personal and professional
relationships.
• Useful strategies include not getting caught up in their
personal problems and minimizing interactions.
Histrionic Personality Disorder
• Appear to be in a constant state of crisis.
• Their personal lives often overflow into the workplace.
• Tend to be overly dramatic and pull anyone willing to listen
or be used by them into their world.
• They are usually very engaging and seductive.
• Upon first meeting them, most people like them.
• Take days off on a whim.
• See themselves as victims.

26. • Expect special treatment for missing work.
• Useful strategies include staying calm and not giving in to
their demands.
Paranoid Personality Disorder
• They are suspicious of others.
• Combative in their interactions with others, rigid, and
critical of coworkers but unable to accept criticism.
• Harmless remarks can cause them to threaten legal action.
• Useful strategies include not giving constructive feedback
since it will be perceived as criticism, not teasing them, and
not assigning them to positions or projects that require
collaborative work relationships. Instead, they should be
placed in positions where they can work independently.
Progressive Discipline Model
Chapter 7:
Managing Organizational
Dynamics

27. Objectives
• Understand the strength of informal groups.
• Appreciate the nature and structure of
informal channels of communication.
• Know how to work with informal groups in
occupational settings.
• Apply organizational theory to resolving
conflict.
• Apply organizational politics to increase
organizational effectiveness.
Outline
• Informal Groups
• Conflict
• Power and Politics
• Other Ways to Influence Organizational
Dynamics
What Is an Informal Group?
• Informal groups are often peer groups that
exist within most formal organizations.

28. • They have their own norms for status and
prestige.
• Peer groups provide four benefits:
1. Satisfy complex needs
2. Offer emotional support
3. Help shape personal identities
4. Assist in meeting personal goals
How Informal Groups Are Formed
• Physical closeness and a chance to
communicate must exist before people can
form mutually satisfying groups.
• Groups begin with friendships based on
contacts at work, equipment used, or
common interests.
• Once these groups are established, they
develop lives of their own.
• The process is dynamic and self-generating.
Group Identification
• Members of professional groups differentiate
themselves with signs of group membership.

29. – Physicians display stethoscopes around
their necks.
– Nurses wear nursing school pins.
– Members use professional jargon.
Status in Groups
• Two classes of factors are relevant to status:
• External: attributes brought from the outside
– Age, gender, race, education, and seniority
• Internal: created when senior management
establishes and defines an organization
– Titles, job descriptions, perquisites, work
schedules, and offices
Managing Informal Groups
• Managers experience difficulties when the
goals or structures of the formal organization
conflict with those of informal groups.
– Occurs when management’s evaluation of
positions does not correspond with group
member opinions.
• Managers must select between two positions.

30. – Rearrange the formal organization to
accommodate the desires of an informal group.
– Change the composition of the informal group.
Types of Conflict
• Three distinct types of conflict are of interest
to professional managers:
– Interpersonal
– Intergroup
– Specialist versus generalist
• Conflict can be constructive
Interpersonal Conflict
• Interpersonal conflict is the least important but
most exaggerated type of friction.
• Managers often blame organizational problems
on individual personalities or general worker
incompetence.
• Poorly structured formal channels of
communication frequently contribute to
interpersonal conflict.

31. • Individuals resent communications that flow in
only one direction.
Intergroup Conflict
• Intergroup conflict develops when clusters of
employees belonging to different informal groups
must interact with each other.
• Apathetic groups are least likely to exert
concentrated pressure on management.
• Erratic groups display inconsistent behavior
towards management.
• Strategic groups tend to be shrewd and
calculating when applying pressure.
• Conservative groups are composed of elite
members who are secure and powerful.
Pressure on Groups
• When organizations exert pressure on
employees, lateral communication among peers
tends to increase.
• Concurrently, vertical communications between
different levels of management tend to decrease.
• Personal differences among group members are
minimized when presented with the threat of a

32. common danger such as a tough supervisor.
• Strong management policies toward workers may
encourage the formation of strong informal
groups to resist the pressure.
Specialist Versus Generalist
• Specialist: advanced skills and specific knowledge
• Generalist: knows something about many
positions but not enough to displace a specialist
– Uses means other than technical knowledge to
succeed, which results in relying on subordinates
– Subordinates are unable to go to their supervisor
for assistance with technical problems, which
leads to resentment and feelings that the boss is
incompetent.
Constructive Conflict
• Conflict can be a constructive force in
organizational life.
• Suppressing conflict can create a significant
barrier to improvement.
• If employees (and managers) fear retribution
for delivering bad news or correcting their
superiors, opportunities will be missed.

33. 5 Methods of Conflict Management
• Compromise requires each side to give up
something for a solution that is not ideal for
either party but is best for the organization.
• Collaboration is ideas that appeal to both
parties.
• Competition is letting both sides battle to resolve
a disagreement, with the most powerful winning.
• Accommodation is when one side surrenders.
• Avoidance is when both sides let conflict fester.
Power and Politics
• Organizational politics involves the use of
power to get things done.
• Power derives from formal authority, control
over resources, expertise, and certain
personal characteristics and social networks of
individuals.
Power from Formal Authority
• Authority is a system in which a small number of

34. individuals make decisions for many people.
• Authority is deep seated, and often thought to be
innate to individuals and organizations.
• Decisions are made using two guidelines:
– Standing policies: long-lived and may affect many
people
– Ad hoc rules: either an interpretation of existing
(standing) policies or is made because no explicit
guidelines exist.
Power from Informal Authority
• Individuals emerge as informal leaders because
group members accept their suggestions.
• Leaders may be accepted due to their charisma
or their relationships with powerful others.
• Leaders can be accepted through wisdom or
judgment acquired from previous successful
decisions or leadership experiences (expertise).
Reward and Punishment
• Managers control rewards and punishments
that can be dispensed to influence employees’
behavior in a positive manner.

35. • Positive rewards make individuals feel good
• Negative rewards (sanctions) tend to be given
along a continuum of increasing degrees of
coercion with repeated applications.
Constructive Politics
• Constructive politics can be used in organizations
to move controversial issues to decision points
and to advance the agenda of the organization.
• Constructive politics means using power in ways
that are moral, open, and caring.
• Managers can use politics to help achieve
organizational goals by setting agendas,
anticipating resistance, networking and building
coalitions, and bargaining and negotiating.
Other Ways to Influence
Organizational Dynamics
• Behavioral changes can be achieved by taking
direct action or working with political
channels.
• Effective managers motivate employees to
think about problems before they occur.
• Managers understand the dynamics of groups
and their rules of behavior.

36. • Change may also involve altering the existing
formal structure of an organization.
Other Ways to Influence
Organizational Dynamics (continued)
• Effective managers spend a significant amount
of time responding to subordinates.
• Planning and modifying the structure and flow
of work to minimize stress or factors that
deter effective performance is important.
• Managers do not to routinely expect levels of
production they would be unwilling or unable
to produce themselves.