Governance Structures & Corporate Culture Introduction This paper explores a few elements found In any healthcare organization or business organization in general, in particular, certain organizational structures and hypothetical constructs. First, consideration is given to some of the provisions of governance found in healthcare organizations. Consideration is also given to some of the possible antecedents and organizational outcomes of responsible leadership and on ethical decision making that account for the interests and objectives of organizational stakeholders along with their Importance.Lastly, an attempt Is also dad to Identify several key philosophical Ideas and historical events that appear to largely shape many of the decisions that organizations make when they choose or do not choose to define their organizational culture. Governance Formal definitions of governance structures today, and their application, are pervasive features of many organizations. The lists of functions assigned to the notion vary widely, depending upon the space in which it is envisioned.For example, we have global governance, corporate governance, Internet governance, regulatory governance, project governance, and clinical governance, etc.
But for as much as one may hear about governance, there seems to be dearth of commentary or general discussion on the most ubiquitous, naturally-derived, easily-identifiable, accessible form of them all?self-governance.A number of corporate governance studies have attempted to link various governance factors, such as board structure and composition, shareholder engagement, and executive incentives, directly with an organization’s financial performance rather than managerial strategic decisions (Affiliation and Wright, 2005), as If financial performance Is tied to any factors like these directly. More attention has been paid to the role of corporate governance that concerns laws and regulations, and internal organizational structures than to the life of the organization ?its people.For instance, the passage of the Serbians Solely Act of 2002 put legislative pressure on biblically traded companies, including biblically traded healthcare organizations, to institute a defined corporate governance structure, based on certain principles recommended in the Catbird and COED reports, which Similarly, non-profit healthcare organizations operate under pressure from their respective states to describe certain governance structures and describe and comment them in their articles of incorporation. Moreover, the IRS “encourages” non-profit entities to “establish and review regularly the organization’s mission.A clearly articulated mission, adopted by the board of directors, serves to explain [the organization’s] purpose and guide its work” (IRS, 2008). While often related to certain legal requirements that arise when an organization is first created, mission statements elaborate on reasons behind an organization’s existence and can serve as a vehicle to continually remind it of its purpose, which is a fundamental reason why they are important. In patient-care delivery, clinicians and others’ purpose is to serve or treat the patient, directly or indirectly, and that is there mission.
But a mission statement and similar legislatively enforced or encouraged governance structures are not simply some pro format agreement made with a government agency around the time it was formed. They are more. Or they should be. Yet, inside some healthcare organizations this might not always seem to be the case.
The reasons that contribute to this perception, and indeed this reality, are many. This all goes toward saying that sometimes there is a disconnection between an organization’s stated mission and their actual or realized mission.It is conceivable that there is not a single healthcare organization in the U. S. Whose mission statement declare that the accumulation of money is driving their mission, yet there is probably a good number that demonstrate Just the opposite to the observer. The governance frameworks established in various laws and regulatory provisions are no doubt important to comply with, and are often benign; however, they are there, presumably, because many organizations lack the capacity to effectively self- regulate.Achieving organizational self-regulation without encouraging individual self-regulation is a difficult thing to conceive.
The key to the former is contained in the primacy of the latter. Linking governance factors with managerial strategy, as noted above, seems a step in the right direction, but the path forward is still unclear if that is all that is said on the matter. As Deltas and Toffee (2008) suggest, organizational authority moderates perceptions of institutional pressures and thus the managerial practices that are adopted.Self-governance is not as easy, if it is not impossible, to codify as are other governance structures, such as those that might be found in an organization’s corporate charter company handbook. Moreover, integrity, a term often used in formal governance documents, is a fine word, and the notion that people should employ it in their daily work is good, but the issue of how to get it to come when it is needed is unresolved (Strives, 2014).At stake here is the pursuit of a fuller understanding of one’s relationship to the broader context by reconciling scientific knowledge with the more natural forms of existential knowledge. Societies have employed various forms of governance in one form or another throughout history precisely because it can afford a certain degree of power to those governance” is by Richard Eels (1960, pig. 108) to denote “the structure and functioning of the corporate polity”.
The “corporate government” concept itself is older and was already used in finance textbooks at the beginning of the 20th century (Beech, Bolton, and Rowel 2004).Corporate governance consists of the set of processes, customs, policies, laws and institutions affecting the way people direct, administer, or control a corporation. Corporate governance also includes the relationships among the many players involved (the stakeholders) and the corporate goals. The principal players include the shareholders, management, and the board of directors. Other stakeholders include employees, suppliers, customers, banks and other lenders, regulators, the environment and the community at large.
The concept of governance, as it has been used throughout history, has been notably represented by various power structures. In The Republic, Plato provides readers with a few distinct types, categorized from the “worst” to the most “ideal” forms. Principally, Plat’s discussion concerns the type of governance commonly associated with the role of the state government; such as the type that Thomas Hobbes wrote of in Leviathan, wherein, he advocates for the necessity of a strong central authority as a means to promote civil order.Prior to the rise of Western thought and its impact on the development modern social structures found today, governance may likely have been viewed by the majority simply as a collection of rules promulgated by various forms of state power. Alternatively, while there is likely some measure of truth in the case Just ascribed, because of the socio-economic organization of societies throughout most of human history?toward agrarianism, in particular, it is also conceivable, and quite likely, that other forms of governance, perhaps Just as many as today, have always existed.However, because of spatial and temporal differences of populations at large, among others, the more homogeneous cultural groups found in the modern social institutions and socio-economic structures (I. E.
Business network, healthcare networks, professional communities, etc. ) did not exist as they do today. Indeed, this seems to be the case, since governance, whether this term is out rightly used to convey the meaning, is a fundamental, existential component to human nature, this author would argue, which spans the arc of human history.Perhaps the ubiquitous application of governance within many different functional areas? regardless of scope, content, or context?has given rise to an unequal notion of what it actually is or what its purpose is from one environment to the next. Take the following characterization of governance, for example: Governance refers to “all recesses of governing, whether undertaken by a government, market or network, whether over a family, tribe, formal or informal organization or territory and whether through laws, norms, power or language” (Alder, 2009).While this definition of governance almost does a good Job of capturing the arc of governance in that it confers wide latitude on ability of certain human constructs to regulate affairs of human activity, it is inattentive to the prime originators of governance?people, and Governance always emanates from people, whether as individuals or as a collective, such as an organization. It is possible, and indeed may often be practical, to separate the notion of governance into two distinct forms, which are manifestly different in their approach to affect a desired behavior.The first form may be viewed as consisting of internal and external regulatory process, which can be envisioned through the apparatus of governments or organizations.
Here, organizations create internal regulatory processes and structures that aim to affect processes and behavior of its resources?people, in particular. Also, it is in this setting that invariably, or so it seems, there is an external regulatory governance structure, most often represented by the government or the state.Now, what differentiates this form from the other form, that is, individual, self-directed governance, which emanates from within an individual, whose edict and regulatory processes are an expression of an emergent, highly individualized and organically driven will of an engaged practitioner. The first form, however cleverly crafted or well-intended, can never affect the same end as well as the self-directed will of the individual. To clarify this proposition, first consider that the best leaders, and even the best followers in an organization are, in large part, self-governing.Next, consider that the worst employees within an organization are self-governing too, albeit they do a poor job. But, because even the best leaders within an organization will benefit from structure of governance at times, how much more will who perform to a lesser degree? The main point is this: Everyone governs his or her own behavior, for better or worse. When an individual is on his own, however, so long as he obeys societal laws, there is generally no public issue concerning governance and the individual’s mission, vision, and goals are his own to pursue, whether they serve a noble or base cause.
On the other hand, the situation is markedly changed when someone Joins an organization, prompting them to align their mission, vision, and values?with those of the organization. Therefore, if we generally assume (as Moscow did) that motivation is based on people seeking fulfillment and personal growth, and too that this process is a protean as human behavior itself, how important is it then that organizations work to foster an environment where people can find meaning and purpose in their work? ?And that they hire the right people, who support the organization’s mission, ideally tit passion, or who are at least amenable to the organization’s cause? Rarely is it enough for an organization leadership to simply articulate policy, no matter how well defined. Leaders, that is, managers, senior directors, Coos, project managers, and the like should see to it that the members of the organization or project team have the understanding, motivation, and means to implement them.An appropriate model of governance included process flows, procedures, and reporting mechanisms, and is supported by fundamental organizational components such as structure, oversight, and values and culture, and the sub-components that give meaning to and support them. Speaking on several of the constraints that are hampering the healthcare delivery in the U. S.
, the former Administrator for the Centers for Medicare and Medicaid Services, Donald Berwick, suggested that one of major barriers to quality improvement is due to the highly fragmented system, which has not built coordination into health care.Indeed, coordinated care is touted as one of the keys to better and more cost- effective care, and is being encouraged with financial rewards and penalties under the 2010 federal health care overhaul, as well as by private insurers. Government regulatory agencies are stepping up pressure and wielding their governance over a variety of players in the healthcare industry in an effort to stimulate solutions to the problem of poor healthcare delivery.This pressure is no less present in the field of health information technology (HIT) than in other areas of the healthcare industry. HIT solutions, such as ERR implementation, prompts fundamental changes not only to an organization’s technology infrastructure, but to its cost structure and behaviors as well. And because nothing in health care operates in a vacuum, effective ERR implementation requires precise coordination of HIT activities across the entire organization.Depending on the configuration that the organization chosen for its various structures and other frames, a behemoth project like this one can be easier and more effective in terms of the intended outcomes than it could otherwise have been.
Culture “Where there is No vision, the people perish. ” -Proverbs 29:18 Research suggests there are three factors that affect what an organization can and cannot do: its resources, processes, and its values (Here, value refers less to corporate values”, and more to the procrastination of business decisions) (Christensen and Overlord, 2000).Understanding how these elements are related to each other and how they comport with the organization is an important component to successful change management. Christensen and Overlord (2000) explain how theses three factors are relate to an organization’s culture. In the start-up stages of an organization, they explain, much of what gets accomplished is done through its resources, people, in particular, which in part define the initial culture.
The organizational structure in this stage often, but not necessarily, consists of a simple Truckee (Imitating, 1981).As the organization matures and its locus of capabilities shifts toward processes and values, those elements, which are typically less amenable to change, often become the dominant forces that influence the organization’s capabilities. Being familiar with and understanding how an organization’s business model affects its environment, culture, in particular, will better inform leaders and other decision makers when driving transformation is their goal. An organization’s culture can be used as a powerful management tool if it has been maintained properly.But, as Christensen processes and values, and those elements have become embedded in the culture, change can be very difficult.
Sorer Aggregated, generally considered the first existential philosopher (Cromwell, 2010), proposed that each individual, not society or religion, is responsible for giving meaning to life and for living it “authentically. ” The opposite of living authentically is considered in existentialism to be “bad faith” (Gloom, 1995).Aggregated believed that for an individual to find authenticity, it was first necessary for him to find authentic faith and become true to oneself. Moreover, he developed the idea that the news media of his day and the bourgeois church presented challenges for an individual in society trying to live authentically, as intervening agencies, impeding an individual’s capacity to have true experiences.
Consequently, many individuals suffer from loss of individual significance (Holt, 2012), which he refers to as “leveling. In order to counter this leveling and achieve authenticity, Aggregated believed it was necessary for individuals to “[face] reality, making a choice and then passionately sticking with it (Holt, 2012). Aggregated was not alone in his views. While many existential thinkers held strongly conflicting doctrinal beliefs, they expressed a similar regard for traditional systematic of academic philosophies, in both style and content, as being too abstract and remote from concrete human experience (Kaufmann, 1956).Central to the existentialist’s view of man’s place in the natural world is the idea posited by Sartre, which states that “all existentialists have in common is the fundamental doctrine that existence precedes essence (Cobblestone, 2009).
Quite conceivably, this proposition conveys the notion that the most important inconsideration for individuals is that they are essentially Just as described? individuals?rather than labels or roles assigned to then by an arbitrary governing body, societal institution, or any other individual for the purpose of being bandied about to suite the purpose of another.Moreover, human beings, through their own consciousness, create their own values and assign meaning to their life, of which they are often disenfranchised of throughout their lifetime by external agents and agencies indifferent to them and seeking to compel them into conformance with an agenda that is either unforgiving or indifferent to them, however profound?or slight ?are the offenses.So, what does existential philosophy have to do with anything that goes on in healthcare delivery? Often in healthcare there is an inclination to develop mechanized solutions that suite the machine organization, and through centralized controls performance output is measured; well-intentioned, but misaligned and compulsory incentives spate the clinician form a cold regulatory apparatus, which pushes and pulls “solutions” at will in favor of something that..
. Might work, inconceivably.Evans (2008) remarks that “the real offence is one of hijacking values and visions, an offence committed by outsiders who do not hold those values and visions authentically, brandishing them against those practitioners who, left to their own two prevailing business models in healthcare, the “professional organization” versus the “machine organization”, ” … A very different model, that can be called a “professional organization”, is more common in health care: expert driven, skills oriented, and highly oriented to pigeonholing, which means getting the client into the eight box (mania, hernia, etc. ..
[s]such pigeonholing describes the great strength of the professional organization as well as its debilitating weakness… Unfortunately as humans patients we are sometimes square pegs forced into these round holes. ” Building organizational communities that engage people rather than conventional hierarchies, as Imitating (2011) points out, is more effective if decision makers (I.
E. , leaders, managers, administrators, etc. ) realize that healthcare is at best a calling, not a business.Consider the drive and determination required to get clinicians where hey are in the first place. Furthermore, considering the orientation of the healthcare delivery, so long as it is patient-centric, its environment, and indeed the very nature, should be a source of moral and ethical influence upon the daily application of patient care.
But when machine-type healthcare organizations turn to mechanized, top-down, centrally controlled solutions, such as Imitating described, they can overshadow the will of the clinician.He also explains that these controls do not work well with independent professional, and that such professional organizations would deter serve and do more to foster a collaborative, patient-focused culture by drawing on the healthcare sense of calling, and enhancing their organization as a community of service: “…
When people are committed to their organization, and not just to their own profession, they are more likely to collaborate (Imitating, 2010).Values both define and contribute greatly to an organization’s culture, while the combination of values and ethics results in a variety of human behaviors. If an organization is having behavioral management issue, it might want examine its culture to see what sort of values are being encouraged. Often organizational values are informally maintained by the status quo. Consequently, they are often out of line with the organizational values.
Bringing them back in line with their original intent is like exercising; in fact, creating a consistent values-driven culture is as well.The reason is simple and goes something like this: “Use it or lose it. ” For example, consider that body builders go to the gym and lift weights to build muscle. They work out, and the harder and more they work out, the stronger they become. It is a process of nurturing and cultivation, and it takes action. Unlike working out or alluding muscles, however, values are hypothetical constructs; but Just as the individual who eats healthy and exercises, the person who actively seeks and maintains their values, will see the results.One way to maintain or exercise you values is through social interaction and self-examination. To carry the analogy one step further, work could be seen as going to the gym.
There are many worldviews that co-exists on the social stage?the complex socio- technical stage of healthcare being Just one. The existentialists give us a picture of human beings as not merely the thinking subject, but the acting, feeling, living hurry, and Taylor (1915) started the scientific management movement, each depicting man’s view of himself at odds with his environment.Descartes’ worldview entails each individual separated from the world and from every other individual, and so on, and so on. All of these ontological views of human nature?often profoundly conflicting?make it nearly impossible for many to conceptualize how collaboration is actually accomplished.
Ultimately, and fortunately for us all, ontology is something to articulate, not something to prove. The better organizations are at owing this, the better of they will be. The following few paragraphs offer a glimpse of what this might look like in a healthcare organization.
An Exemplary Healthcare Organization Increasing the level of quality while constraining cost in healthcare requires modifying or replacing some of the traditional frameworks within the industry. New methods for achieving quality must be incorporated into every level of the system, including the patient level, the clinical level, the healthcare organizational level and the governance level. (Berwick, 2002). However, this is not an easy goal due to certain arises to innovation posed by the traditional framework, as many organizations within the industry have experienced.Still, where some organizations have failed, similar organizations have made major strides toward this goal.
These atypical but exemplary organizations have insights to offer others that chose the same path. A report published by the Cleveland Clinic in 2013, highlights some of the measures that the clinic has taken to improve on an already exceptional record of patient care. Following hospital stays and outpatients procedures, patients’ perspectives were measured using surveys.Questions on the surveys were related to appointment scheduling, waiting time, communications, courtesy, care, and overall assessment and willingness to recommend. According to the report, the feedback gathered from these surveys is made available to executive leadership, front-line managers, and caregivers throughout the organization though an online dashboard. Also, physician pay is not linked to activity. Their physicians are salaried employees, with no financial incentives of bonus schemes. There is no tenured staff and each physician is on a one-year contract, which is based on an annual performance view.
Furthermore, everyone at the clinic including leadership is required to go through a training program that focuses on the patient experience. Leadership development and accountability are a foundational component of their initiatives to improve quality patient-centered care. It is also interesting to note that the clinic leadership expressly sought to instill a culture of service among the entire organization through policy and training measures, while patient and caregiver feedback was administered through a formal monthly rounding program on inpatient and outpatient units throughout the organization.The purposes of these rounds are to give patients and caregivers the opportunity to talk with leaders and voice any concerns ideas for improvement that they may have. The issues and concerns that were collected and the appropriate person provided timely follow-up.
That all of their members of the organization regardless of whether they provide direct or indirect patient care understand, they contribute to the patient experience.The “Cleveland Clinic Experience” is an initiative that includes an interactive learning session that brings all caregivers in the organization together to discuss the organization’s mission, vision and values, as well as the service behaviors expected of them. It is not enough to have clearly defined governance, though.
Just because an organization has a defined governance structure in place, does not mean that is can check that item off of the list, thinking that all is well in the organization.Organizations may find come to find one day that they are profoundly limited in their collective organizational effectiveness to weather change. One of the more salient features of the Cleveland Clinic is its governance. In 2007, the organization implemented drastic change when they reorganized its major medical departments. What emerged were newly formed “institutes”, in which physicians and others belonged to divisions that were not comparable to departments at other academic medical centers.Even though, this created concerns with some of the physicians regarding the perception of their professional affiliation or identity within the larger medical community, those concerns were addressed and subsided. The Cleveland Clinic’s vision of transformation began to take shape, and while this transformation enfolded, the clinic continued to live up to its already outstanding reputation for quality coordination of care, and in 2011 was ranked fourth in the nation in terms of overall care delivery, and fourteen of its institutes were awarded spots in the top ten performers within their respective classes.Concepts like collaboration or integrity are commonly incorporated or referred to in governance documents, yet they may only be related to a particular business function that is ultimately tied to the organization’s bottom line.
By relegating these values to business processes, without incorporating them into the social contract impotent of the organization’s governance, company leaders do little to help positively shape the overall culture of the organization. In doing so, organizations undervalue such ideals by simply employing them as some type of heuristic device with which to generate more money.If only things like trust and collaboration could be mandated..
. But since they cannot, the issue is how to get them show up when they are needed, but nowhere in sight. The value of the story of the Cleveland Clinic, and similar stories, is that its resource?people, in particular?are still in control of its recess and its culture. Katie et al. Have noted that few healthcare organizations have built both HARM and HIT capabilities while realizing their complementary nature.Those that have, however, have improved their clinical outcomes significantly.
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