The Role of Organizational Culture in Healthcare
The Role of Organizational Culture in Healthcare
American Public University
The assumptions, values and artifacts that comprise organizational culture can have a significant impact on patient outcomes in a healthcare setting. Healthcare institutions seeking to change their organization should aim to change not only external presentation but the organizational culture of assumptions, values and artifacts through S.M.A.R.T. goals.
The Role of Organizational Culture in Healthcare
Leadership and management and management do not exist in a vacuum. Each organization has its own set of unique attributes that influence how it is run and what goals it has. Understanding organizational culture, its artifacts and S.M.A.R.T. goals are crucial for effective leadership and management in field of health care.
Organizational culture is defined as the “deepest level of basic assumptions and beliefs that are shared by members of an organization” (Burns, Bradley and Weiner, 2013). This set of assumptions and beliefs affects everything within the organization. In health care settings organizational culture can influence the quality of care that a patient receives. D’Eugenio (2017) reported that cohesion among teams in the emergency room led to better outcomes for heart attack victims, as did hospital follow-up with heart attack patients about adherence to medication. The effects of organizational culture are by no means confined to a particular outcome or nation. The 2017 analysis by Braithwaite, Herkes, Ludlow, et. al. found a consistent correlation between patient outcomes and positive organizational culture in health care settings across North America, Europe and Australasia.
Artifacts are the signs of the physical, psychological or social environment including the physical space of a facility, written and verbal communication, signage and other behaviors (Burns, Bradley and Weiner, 2013). There are three levels of organizational culture: assumptions (at the core), values (in the middle) and artifacts (the outermost layer) (University of Minnesota, 2015).
Artifacts can be either positive or negative. A positive artifact for a children’s specialty hospital might be toys in the waiting rooms and stickers at each appointment, as is the case with Shriner’s Hospital for children. The underlying assumption is that appointments with doctors and specialists can be frightening or tedious for children. The value associated with this artifact are that appointments should be child-centered. A negative artifact in a neonatal intensive care unit might be a lack of lactation support for mothers. The underlying assumption might be that breastfeeding has minimal benefits for a premature infant and the values reflected might be that formula feeding is normal and that parents play a minor role in infants’ care.
When an organization attempts to make changes and move in a different direction, it is tempting to focus on external superficial changes rather than changing the underlying assumptions, values and artifacts of the organizational culture. S.M.A.R.T. goals can help the leadership and management accomplish an effective change of direction. “S.M.A.R.T.” is an acronym for specific, measurable, achievable, realistic, and time bound. These goals cause direct action and change rather than vague aspirations.
S.M.A.R.T. goals could have helped Brookwood Medical Center with creating a niche in the Birmingham, Alabama market for birth care. Brookwood Medical Center is one of multiple hospitals in the Birmingham area that delivers babies. To differentiate themselves and gain an edge in the market, Brookwood began an advertising campaign that stated that Brookwood Medical Center would support mobility in labor, personalized birth plans, wireless fetal monitoring and offer "specifically trained" nurses. Based on these advertisements, Caroline Malatesta chose Brookwood Medical Center for the birth of her fourth child. However, when she was denied access to any of the advertised options. The nurses said they would not abide by Ms. Malatesta’s birth plan she had crafted with her doctor. The nurses required her to be attached to a fetal monitor.
As Ms. Malatesta’s son was crowning, Ms. Malatesta attempted to move to a hands and knees position and one nurse twisted Ms. Malatesta’s wrist and rotated Ms. Malatesta’s forearm above her head to force her into a supine position while another nurse held the baby’s head in Ms. Malatesta’s vagina for six minutes to delay the birth. Ms. Malatesta sustained permanent nerve damage to her pelvic region that causes her chronic pain and requires ongoing medical management. Her injuries also prevent her from having normal sexual relations or giving birth again. Brookwood Medical Center was found guilty of fraud and negligence in a lawsuit brought by Mr. and Ms. Malatesta, who were awarded $16 million in damages (Pastucci and Adams, 2017).
The hospital record, the nurses’ testimony under oath and Brookwood Medical Center’s response to the verdict are all very indicative of the organizational culture of the hospital that led to the outcome of injuring Ms. Malatesta and a successful multi-million dollar suit against the hospital. The hospital record stated that Ms. Malatesta was “instructed to lie on her back....encouraged not to push." No mention was made of any emergency that would have required a change of position. Ms. Malatesta’s doctor stated in testimony that, “The doctor is the one who ultimately has the choice of how things are going to happen”.
The nurses claimed they had no memory of the incident. The nurses did, however, indicate in their testimonies that they believed the baby would be born before the doctor arrived if they did not intervene and that women who plan unmedicated births “typically don't follow instructions as well" and are "not as cooperative" as women receive epidurals (Pastucci and Adams, 2017). In response to the verdict, Brookwood Medical Center issued a press release stating, “We are disappointed in the outcome of the case. Brookwood Baptist Medical Center strives for excellence in patient care and satisfaction, and we respectfully disagree with the jury's verdict.” (Hu, 2016).
Despite their advertising campaign that claimed women could have autonomy and flexibility in labor and birth, Brookwood Medical Center’s organizational culture does not support such claims. The staff’s statements reflected an assumption that the doctors and nurses were not likely to cause serious damage to the patient, that the doctor’s role in the birth was more important than the mother’s and that Brookwood Medical Center was not capable of committing fraud or negligence. The values attached to these assumptions were that the doctors and nurses should have ultimate say over the patient’s care, that providing the promised services was not important and that laboring women did not need to be treated with respect. Artifacts that resulted from this organizational culture included denial of requested services, the use of physical force for compliance from the mother and a denial of any responsibility for harmful outcomes.
Brookwood’s strategy of attracting mothers desiring natural births to stand out in the local health care market was potentially viable. The problem is that they did not have a sound way to implement that strategy. Their hospital and staff were not trained to accommodate natural birth. Using S.M.A.R.T. goals they could have achieved this. A S.M.A.R.T goal would have been “Change our staff and facility to be natural birth supportive over the course of the next twelve months by carrying out trainings and education sessions, acquiring necessary equipment, and by instituting and enforcing natural birth friendly practices.”
Such a goal would have been specific enough to implement changes, measurable to track progress, achievable with follow through, realistic with good management, and time-bound over the next twelve months. The strategies in a goal like this and the efforts to achieve it would have changed the organizational culture of Brookwood Medical Center and actually offered the options and services their advertising claimed. Brookwood Medical Center’s organizational culture and accompanying artifacts would have changed from being physician centered to being patient centered. Artifacts from such goal setting would include free access to natural birthing aids, availability of doulas, and nurses who are supportive of maternal autonomy in labor.
The assumptions, values and artifacts that comprise organizational culture are critical to how an organization works and what it achieves. Institutions wishing to change how they operate or embrace different values can not focus on external presentation. S.M.A.R.T. goals (specific, measurable, achievable, realistic, and time-bound) when implemented can help to change an organization for the better by influencing its organizational culture.
Braithwaite, Jeffrey, Herkes, Jessica, Ludlow, Kristiana Testa, Luke and Lamprell, Gina (2017).Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open; 7(11). DOI: 10.1136/bmjopen-2017-017708
Burns, Lawton, Bradley, Elizabeth, Weiner, Bryan J. (2012). Shortell and Kaluzny's Healthcare Management: Organization Design and Behavior, 6th Edition. Cengage Learning, 20110121. VitalBook file.
D’Eugenio, Rosalind (2017 November 6). Hospital organization culture impacts patient care. Yale School of Public Health News. Retrieved from https://publichealth.yale.edu/article.aspx?id=16094
Hu, Lydia (2016 August 7). Couple awarded $16 million against Brookwood Medical Center. WBRC Fox News. Retrieved from http://m.wbrc.com/story/32704927/couple-awarded-16-million-against-brookwood-medical-center
Pastucci, Cristen and Adams, Ellise (2017). Workplace aggression in the perinatal setting. Journal of Perinatal and Neonatal Nursing; 31(1). Retrieved from https://www.nursingcenter.com/journalarticle?Article_ID=3965848&Journal_ID=54008&Issue_ID=3965842
University of Minnesota (2015). Understanding organizational culture in Principles of Management. University of Minnesota Libraries. Retrieved from http://open.lib.umn.edu/principlesmanagement/chapter/8-3-understanding-organizational-culture/