Whose Side Are You On? Interdependence and its Consequences in Management
of Healthcare Delivery, Kent D. Fairfield
employees who are committed to the organization and go the extra mile
are especially needed today. An empirical study of visiting nurse agency
employees showed that a sense of being "in the same boat" with
management, or perceiving outcome interdependence, contributed to positive
behaviors. Supervisors were generally more inclined than were their subordinates
to perceive this interdependence, to be committed, and to exhibit good
citizenship behavior. Unexpectedly, physical therapists who worked as
hourly part-time contractors reported even stronger feelings of being
in the same boat with management and being more committed than the supervisors.
Such a sense of partnership could have been a result of the therapists'
long-term relationship with the agency over an indefinite time. They might
have also felt that they worked voluntarily and autonomously, rather than
under close supervision.
These findings point to various management actions that can engender a
feeling of interdependence, pride in the organization, and fairness of
treatment. One step is to involve employees in joint goal-setting, organized
around "our problems" not just the person's own concerns. Authentic
downward communication and the sharing of operating results can convey
to employees the major issues that challenge the organization. Such information
makes it possible for employees to provide vital input, if not actually
take on more decisions themselves. Executives can expect less commitment
and less inclination from employees to go above and beyond what is expected
if they fail to acknowledge good performance and if they accentuate differences
between the most-senior leaders and lower-level employees.
A Strategic Response to the Challenges Presented by Older Patients with
Alzheimer's Disease and Other Types of Dementia, Brian Kaskie and Sarah
dementia has become one of the most serious and persistent health problems
affecting persons over the age of 65. Efforts to find a cure for Alzheimer's
disease and other causes of dementia are ongoing, while healthcare executives
continue to face a number of challenges. Access to targeted programs and
services for persons with dementia is lacking. The costs of program development
and service delivery are substantial. Persons with dementia who do use
services often do not receive the most effective and efficient care, and
their providers often do not receive sufficient payment. Because few examples
exist of how healthcare executives can appropriately respond to these
challenges, we created an operational planning strategy. This strategy
defines the challenges presented by persons with dementia, identifies
four viable responses, and describes two factors that will contribute
to successful implementation of these responses. If healthcare executives
begin planning now, then the challenges presented by one of the more serious
health problems of the next 20 years can be mitigated.
The Role of Leadership in Instilling a Culture of Safety: Lessons from
the Literature, Hirsch S. Ruchlin, Nicole L. Dubbs, and Mark A. Callahan
of To Err Is Human has highlighted concern for patient safety.
Attention to date has focused primarily on micro issues such as minimizing
medication errors and adverse drug reactions, improving select aspects
of care, and reducing diagnostic and treatment errors. However, attention
is also required to a macro issue-an organization's culture and the level
of leadership required to create a culture.
This article discusses the concepts of culture and leadership and summarizes
two paradigms that are useful in understanding the precursors of medical
errors and developing interventions to prevent them: normal accident theory
and high-reliability organization theory. It also delineates approaches
to instilling a safety culture. Normal accident theory asserts that errors
result from system failures. An important element of this perspective
is the need for a system that collects, analyzes, and disseminates information
from incidents and near misses as well as regular proactive checks on
the system's vital signs. Four subcultures are necessary to support such
an environment: a reporting culture, a just culture, a flexible culture,
and a learning culture.
High-reliability organization theory posits that accidents occur because
individuals who operate and manage complex systems are themselves not
sufficiently complex to sense and anticipate the problems generated by
the system. Lessons learned from high-reliability organizations indicate
that a safety culture is supported by migrated distributed decision making,
management by exception or negotiation, and fostering a sense of the "big
picture." Lessons from other industries are also shared.