Reengineering the Corporate Culture of Hospitals
Johnson, Joyce, Billingsley, Molly, Nursing and Health Care Perspectives
How nursing leadership can prevent the hospital bus from going to Abilene.
As we move closer to the turn of the century, the American health care system continues to provide management experts with a wealth of case studies describing the winners and losers in today's business environment. Winners in this cost-conscious era of institutional reengineering, said Senge in his best-selling book The Fifth Discipline (1990), are those organizations that bind together around a common identity, a sense of destiny, and a shared commitment to reconciling the existing threats to their survival. Senge suggests that the organizations that are able to tap people's commitment and capacity to learn at all levels of the structure will overcome the type of maladaptation to business threats so commonly seen in corporate failures today.
Such maladaptation in the business environment and its consequences in terms of economic and psychic losses was popularized by Harvey (1988) in his now classic work The Abilene Paradox and Other Meditations on Management. The Abilene paradox is a real-life story of Harvey and three other family members who agree to take a car trip across the desert. They suffer through a very unpleasant trip, with heat, dust, unpalatable food, and fatigue, only to discover after returning home that no one really wanted to take the trip in the first place.
Harvey, a psychologist and management science professor at George Washington University in Washington, D.C., uses this scenario to represent what he considers to be the major source of organizational dysfunction in the business environment today, i.e., the inability to manage agreement. Although individual members might privately agree about the nature of the dilemmas facing their organization, they more often fail to communicate their beliefs to one another. Collective decisions within the organization, based on incomplete and often faulty information, then lead to actions that are counterproductive to the organization's purposes, and sometimes its viability. Employees then experience growing frustration and dissatisfaction as the cycle repeats itself with even greater intensity.
Although it may be difficult to admit, hospital managers and their employees have undoubtedly taken more than a few trips to Abilene in the last decade. Prior to direct reimbursement groups and health care reform, hospital culture--the norms, values, and beliefs pervasive within the organization--could be characterized as typically dysfunctional. Although they should have been, many hospitals were not organized to accommodate patients. Patient satisfaction was often not a high priority, and employee satisfaction was of even less importance. Cost and quality determinations were not conducted. Staff were unaware of or uninterested in the cost of supplies, and there was often a lack of teamwork and a high degree of internecine warfare within health care institutions.
Prior to health care reform efforts in the early 1990s, the prevailing characteristic in health care institutions was the absence of a service orientation for patients, hospital colleagues, and other departments within the institution. Employees who were concerned about these trends often didn't speak up because of the apparent hopelessness of the task or their anxiety about losing their positions in increasingly cost-conscious times. These employees, as well as other members of the staff, then suffered the consequences when their institution floundered economically. As Harvey would say, they took the bus to Abilene.
Hospitals no longer have the number of patients we are organized to treat, those patients don't stay as long as we think they should, and payors won't reimburse whatever we charge. Adapting to these realities has required systemic and personal change, and leadership that can engineer a major shift in the corporate culture of hospitals.
According to Schein (1985), corporate culture is a pattern of basic assumptions that has worked well enough to be considered valid, and to be taught to new members as the correct way to perceive, think and feel. …