Most nurses work as employees, so it is important to look at the types of healthcare organizations that exist and how individual nurses practice.
So, today we are hoping to do the following: [Read slide]
Organizational characteristics have an impact on the day-to-day functioning of the organization and how nurses interact with patients and other healthcare providers.
Important characteristics include:
Types of services provided by the organization– Is this a full-service hospital, a psychiatric facility, a pediatric referral hospital?
Length of direct care services – Is this an ambulatory care center, an acute care hospital, or a long-term care facility?
Teaching status – Does the mission of the organization include the education and preparation of healthcare providers?
Accreditation – Is the organization accredited by a nationally recognized body and thus committed to meeting standards of care established by that body?
Ownership – Is the organization established as a not-for-profit or for-profit entity?
How might the characteristic of ownership impact the functioning of the organization and the care delivered?
A not-for profit healthcare organization is typically controlled by a voluntary board or trustees, who are responsible for ensuring the mission of the organization is maintained.
These organizations provide care to a mix of paying and nonpaying patients.
Excess revenue over expenses is redirected into the organization for maintenance and growth.
Although a for-profit healthcare organization usually has a mission to provide high-quality healthcare, it is typically controlled by appointed boards and operated with the specific intent of earning a profit by providing healthcare services to individuals who can afford to pay.
Healthcare facilities can organize themselves in a number of different ways.
In a desire to improve efficiency and effectiveness, many are organizing to become accountable care organizations or consolidated systems and networks.
In these formats, organizations agree to provide a constellation of care to individuals and communities with careful attention to epidemiology, evidence-based care, and best practices that have been shown to result in high-quality outcomes.
All healthcare is not provided in large, urban, integrated health systems. Healthcare services are also delivered through:
Community services
Subacute facilities
Home health
Long-term care and residential facilities
Hospice
Nurse-owned and nurse-organized services
Self-help voluntary organizations
Supportive and ancillary organizations that impact care include:
Regulatory agencies
Accrediting bodies
Third-party financing organizations
Pharmaceutical and medical equipment
Professional, educational, and training
Organizational relationships are rarely static. They are frequently changing through:
Integration
Acquisitions and mergers
With regard to economics, we read in the papers and in online news that the percentage of the gross domestic product devoted to health care continues to rise. We also see a growing population of people needing healthcare services, whether through survival of people who a century ago would have died, through increased population numbers, or through changes in employment benefits that limit the amount of coverage or direct the conditions under which a health benefit can be used. General factors such as inflation also make wages and products more expensive in health care and thus may influence people in their choices about spending. Finally, a direct reduction in governmental payments influences how organizations can operate.
Social is the next area. As the baby boomer generation retires, they are likely to become activists about the conditions and quality of services in healthcare. Patients in general are becoming more proactive and often come with a predetermined diagnosis and treatment plan. The issue of whether healthcare is a privilege or a right has not been resolved and will continue as a social issue.
Geographic distribution of the population and of services has long been an issue. The struggle of rural hospitals to survive and the intensity with which rural communities recruit a primary care provider are two examples of how geographic distribution is a force in healthcare delivery. Disparity of care based on income is well documented. The numbers of immigrants in the United States also poses challenges, especially in terms of providing culturally competent care. Increasing numbers of uninsured populations are clustered around particular healthcare provider organizations. Also, we already are aware of the influence of older adults, both from the numbers who will expect services and from their activism.
If you think of a local healthcare organization, you may be able to see how these forces play out directly in shaping the services provided, the hours of access, the costs and availability of products, and so forth.
To understand how organizations work and how nurses can best work within them, it is critical to understand two basic theories: Systems Theory and Chaos Theory.
Systems Theory
Systems theory attempts to explain productivity in terms of a unifying whole as opposed to a series of unrelated parts. Systems can be either closed (self-contained) or open (interacting with both internal and external forces). In systems theory, a system is described as comprising four elements: structure, technology, people, and their environment. Systems theorists focus on the interplay among these elements in a framework of (1) inputs—resources such as people, money, or materials; (2) throughputs—the processes that produce a product from the inputs; and (3) outputs—the product of inputs and throughputs.
The theoretical concepts of systems theory have been applied to nursing and to organizations. Systems theory presents an explanation of organizational evolution that is similar to biological evolution. The survival of an organization depends on its evolutionary response to changing environmental forces; it is seen as an open system. The response to environmental changes brings about internal changes, which produce changes that alter environmental conditions. The changes in the environment, in turn, act to bring about changes in the internal operating conditions of the organization.
This open systems approach to organizational development and effectiveness emphasizes a continual process of adaptation of healthcare organizations to external driving forces and a response to the adaptations by the external environment, which generates continuing inputs for further healthcare organization development. This open system is in contrast to a closed system approach, which views a system as being sufficient unto itself and thus is untouched by that which happens around it.
Nurses need to aware of how they interact with their organization as an open system and what components of that system they can influence to achieve the best patient outcomes.
Chaos Theory
Unfortunately, health care as an industry is not always as predictable and orderly as systems theorists would have us believe. In contrast to the somewhat orderly universe described in systems theory, in which an organization can be viewed in terms of a linear, cause-and-effect model, chaos theory sees the universe as filled with unpredictable and random events. According to the proponents of chaos theory, organizations must be self-organizing and adapt readily to change in order to survive. Organizations, therefore, must accept that change is inevitable and unrelenting. When one embraces the tenets of chaos theory, one gives up on any attempt to create a permanent organizational structure. Using creativity and flexibility, successful managers will be those who can tolerate ambiguity, take risks, and experiment with new ideas that respond to each day’s unique situation or environment. They will not rest upon a successful transition or organizational model because they know the environment within which it flourished is fleeting. The successful nurse leaders will be those individuals who are committed to lifelong learning and problem solving.
Economic, social, and demographic factors provide the input for future development and act as major forces driving the evolution of healthcare organizations.
Economic Factors
Overall economic conditions, as well as decisions surrounding the financing of health care, have shaped the supply, configuration, and distribution of healthcare organizations and substantially changed the provision of health care in the United States. The radical restructuring of the healthcare system that is required to reduce the continuing escalation of economic resources into the system and to make health care accessible to all citizens will necessitate ongoing changes in healthcare organizations. As the impact of healthcare reform legislation unfolds, more people will be covered by insurance, and more services will be needed.
In addition to struggling to respond to the increasing numbers of uninsured patients and the concomitant increase in the amounts of uncompensated care, healthcare organizations are being confronted daily with the financial pressures associated with rapidly escalating drug costs, expensive new technology, and spiraling personnel costs.
Increasing consumer attention to disease prevention and promotion of healthful lifestyles is redefining relationships of healthcare organizations and their patients. Patients are becoming increasingly active in care planning, implementation, and evaluations and are seeking increased participation with their providers. Demands will be made of healthcare organizations for more personal, responsive, and coordinated care. As such, development of strategies that allow patients to become empowered controllers of their own health status is essential.
Geographic dispersion, regional access to care, incomes of the population, aging of the population, and immigration trends are among the demographic factors influencing the design of healthcare organizations. Changing economic and demographic characteristics of many communities are resulting in a larger number of uninsured and underinsured individuals. Geographic isolation often limits access to necessary health services and impedes recruitment of healthcare personnel. Community-based rural health networks that provide primary care links to urban health centers for teaching, consultation, personnel sharing, and the provision of high-tech services are one solution for meeting needs in rural areas. Federal and state funding, which includes incentives for healthcare personnel to work in rural areas, is another approach. Strategic planning by nursing is critical to address community needs.
A major influence exerted on healthcare organizations comes from the aging of the population. By the year 2025, more than 18% of the population is expected to be older than 65 years. The number of “the old-old,” those older than 80 years, is increasing dramatically. To meet the emerging needs of older adults, new healthcare organizations will continue to evolve, be evaluated, and be restructured based on findings. New roles for nurses as leaders and managers of the care of older adults are evolving, such as the role of advanced nurse practitioners to direct the care of patients who have become members of geriatric care organizations such as retirement centers.
Another demographic factory that is impacting health care is the increasing number of individuals and families who cannot afford care to meet even their most basic needs. These individuals may be truly indigent or may be the working poor who are but one paycheck or illness from being hungry or homeless. Without a broad array of basic healthcare services affordable and available to these individuals, failure to treat a minor problem such as high blood pressure can result in a high-cost illness such as a cerebrovascular accident. This lack of healthcare provision is compounded by the number of people excluded from coverage because of preexisting health conditions, job loss, or immigration status.
The U. S. Department of Health and Human Services has described the spectrum of health care as having six levels –
Primary care, secondary, care, tertiary care, respite care, restorative care, and continuing care.
Each of these levels of care has a purpose and a number of healthcare organizations designed to achieve that purpose. We will take a look at each level.
In Primary Care, the purpose is threefold.
Early detection and prevention of disease,
Maintenance of health and wellness
Management of common health problems and chronic illnesses
Examples of Organizations where primary care is delivered includes:
Healthcare provider practices
Community and neighborhood clinics
School and occupational health offices
Secondary or Acute Care is the next level of care. The purpose of secondary care is the diagnosis and treatment of disease and injury.
Examples of organizations where this level of health service is provided includes acute care hospitals and long-term care facilities.
The purpose of tertiary care is the diagnosis and treatment of complex disease and injuries. Examples of organizations that provide this level of care are acute care hospitals with specialty units such as coronary care or transplant units as well as specialty hospitals such as psychiatric facilities.
The purpose of respite care is to provide caregivers of chronic care patients a short-term period of relief. This care may be provided in the home or at a short-stay facility.
The purpose of restorative care is to provide routine follow-up for acute conditions (e.g. nursing home care), or for conditions such as drug rehabilitation (e.g. half-way house)
Continuing care provides ongoing care for those who need assistance with activities of daily living (e.g. geriatric care centers).
Understanding the type of healthcare organization in which you practice helps you understand the populations served, the availabilities of healthcare providers, the concerns of owners or taxpayers, and how forces are likely to change the organization in the future.
