Introduction
Oak Clinic (OC) is an inner city healthcare medical center founded in 1970. The clinic's foundation has been an outcome of concerted efforts of grass roots organizations, healthcare activists and, not least, neighborhood and surrounding areas' residents. OC is located in an area made up mainly of African-Americas and Latinos. Lacking a proper healthcare facility for years, OC has come as a landmark in area's history. The initial staffing vision, if any, had affordable healthcare as a primary concern. That is, providing general practice healthcare services, particularly to families and elderly, was initially motivated by affordable healthcare costs for minority groups in a much underserved area of almost about every public service. Consequently, GP resident physicians –fresh from college – were invited and hired.
The primary and GP healthcare services were initially delivered to neighborhood and surrounding area's residents with few complaints. Over years, however, more ambitious resident physicians declined offers to join in due to dwindling resources but also to increasing safety risk in surrounding area. OC's situation was made worse by recent budget cuts due to national and state economic downturns. Notably, in a recent state congress a bill has been passed stipulating stricter medical practices state-wide and, moreover, tying up state funding to new specific medical standards and regulations which, if not followed, would subject violating medical institutions to disciplinary actions and budgetary cuts.
Predictably, OC has been subject to numerous state funding cuts and, as a result, a further decline in overall performance and morale. Moreover, milder organizational and physician-patient conflicts have been exacerbated for different reasons (discussed later in detail). Currently, OC has 100 staff members made up of physicians, nurses and supporting personnel. Permanent physicians are residents of surrounding areas. Resident physicians usually request residence switch. Turnover among nurses is among highest in nation. Consequently, overall organizational performance has experienced a series of setbacks, all impacting negatively on healthcare service provided for patients.
This background has initiated paper's author hiring as an external consultant to identify fault lines in OC's organizational structure, major problematic areas, propose remedial measures for improved organizational performance and more effective healthcare service delivery options for local (i.e. staff) and external (i.e. patient) customers. This background paper covers, hence, four major problematic areas in OC namely, (1) role conflicts within groups, (2) communication problems among group members, (3) lack of cohesiveness in groups with diverse members and (4) excessive intergroup conflict.
Each problematic area is discussed in detail supported by appropriate literature and/or similar case studies, followed by suggestions and possible recommendations as remedial measures.
In-group Role Conflict
One major area of concern is role conflict between and across care proving groups at OC. Given unsystematic staffing policies, high turnovers, increasing pressure on existing staff role conflict emerges as a serious area of particular concern. At OC, role conflicts assume different forms falling into two main categories namely, role-specific conflicts and role-overlap conflicts.
The second category of role conflicts, i.e. role-overlap conflicts, can be defined as a conflict arising from performing duties by one role clearly falling into another's. Given growing complexity of organizations and expansion in defining roles not only across but also within departments, possibility of role-overlap conflict has increased considerably. In OC's case, numerous cases have been identified as sources of existing or potential role overlap. For current purposes, however, one major source of conflict comes from an overlap between managerial and financial roles. More specifically, senior staff is usually required to make decisions which involve financial decisions as well. This covers a broad range of decision-making options including, for example, medical equipment procurement and residency compensation. The question of a possible overlap between professional and financial roles is discussed from an organizational perspective (Comerford & Abernethy, 1999) and is of particular interest in OC's case.
The limited potential for professional growth – let alone compensation packages – has made hiring competent financial controllers and accountants of broad experiences across industries at OC increasingly difficult. Consequently, more senior medical staff – of far more professional experiences but who may not be of a comparable financial knowledge competencies – has chosen to make financial decisions based on own understanding of medical, not financial, expertise. For current research purposes, an investigation has been performed in order to verify economic feasibility of procured equipment and residence compensation packages. Findings show notable discrepancies in costs based on independent decisions made by senior medical staff compared to decisions made after collaborative consultation with financial department.
The role-overlap conflict can be resolved by developing financial skills of managerial staff as well as developing medical management practices of financial staff. This can be achieved by participating in selected executive-style seminars and/or arranging for regular meetings addressing issues arising from making financial decisions and broader implications for OC. (A suggested list of course offerings and venues are offered separately for reference.)
Group Communication
OC has a communication problem. This has been reported and documented in initial data gathering phase and later in analysis phase (reported: "OC Communication Styles – Physician-to-Physician" and "OC Communication Styles – Physician-to-Patient"). The problem involves physician-to-physician and physician-to-patient communication. Namely, given how diverse OC's work force as well as patient pool (mostly from neighborhood and surrounding areas) is, miscommunication conflicts have arisen based not only on cultural differences but also on professional practices.
For instance, OC has been shown to exhibit a high turnover in nurse and resident physician staff for reasons noted above. This organizational inequilibrium has resulted in mishandling patient handoffs from one physician to another, which has been further complicated by cultural and linguistic barriers between physicians and confirmed to impact negatively on patient's satisfaction (Solet, Norvell, Rutan & Frankel, 2005). Initial research shows end-of-employment process for physicians – or, for that matter, nurses – does not include a formalized reference for patient handoff. In phasing out of a medical intervention, OC leaving physicians do not handoff patients as proper, if at all, an indicator of malpractice which might bode ill for OC. Solet et al. identify four barriers to effective handoffs: (1) physical setting, (2) social Setting, (3) language barriers, and 4) communication barriers. To help remediate handoff's communication problem, Solet et al. recommend standardization of handoff process and face-to-face communication as best way to ensure effective handoffs of hospitalized patients. Clearly, in performing remediation acts as just mentioned (re)orientations should incorporate protocols and formalities necessary not only for placement and regular appraisals but also for end customer's, i.e. patient's, best interest.
A second communication concern OC should consider is clinic's approach to patients. Indeed, central to a professional and effective healthcare service delivery should be patient-oriented as opposed to physician-oriented. That is, instead of a closed-loop communication cycle in which physicians exchange limited repertoires of patient interviewing strategies – which can actually block open patient disclosures –patient-oriented interviews enhance physician-patient communication (Barrier, Li & Jensen, 2003). Apparently out of scope, physician-patient communication is, in fact, integral to best industry practices, particularly since communication process is not only an organizational issue but a 360-degree feedback cycle which is never complete without patient's input.
Qualified as such, communication practices at OC – whether physician-physician or physician-patient communication – should factor in cultural differences. Typically, communication between minority patients and physicians exhibits features as biased expectations (by physicians), discrimination practices (perceived by patients) and linguistic asymmetry (Perloff et al., 2006). In remediating communication imbalances in physician-patient communication, Tucker at al. (2003) propose as indicators of culturally sensitive healthcare: "people skills, individualized treatment, effective communication, and technical competence" as well as "physical environment characteristics (e.g. culturally sensitive art, pictures, music, and reading materials) and office staff behaviors".
Lack of Cohesiveness
Throughout, OC's fragmented workforce has been referred to as a chronic organizational issue. This fragmentation is manifest in different forms. Yet, most significant forms – as has been shown in research – include lack of proper communication channels between senior management and lower ranks; notable discord in emergency room group members, professionally and culturally; interpersonal conflicts arising from role overlaps or character differences. To remediate, regular (re)orientations – again – come as a particularly effective strategy. Proven across different organizational makeups, regular (re)orientations (re)introduce and refresh an organization's staff into underlying values and missions – and, most significantly, raison d'être – to which everyone should subscribe in order to perform as required on a daily basis. If anything, organizational learning is a process which, in order for workgroups to properly cohere, should be brought home not once but repeatedly. Further, in order to consolidate workgroup cohesiveness from a cultural sensitivity perspective a diversity program should be developed in order to raise staff awareness and enhance intercultural competencies.
Excessive Intergroup Conflict
Conflict is, unfortunately, a recurring watchword at OC. Given current practice, OC experiences high levels of conflict in and across different units. This conflict is attributed to cultural and professional reasons as noted but also speaks of deeper organizational ailments. That is, given OC's history and her surrounding area's community culture part of why OC staff retention rates are very low is attributed to an unhealthy organizational culture which is informed by – instead of shaping – surrounding area's culture. More specifically, if resident physicians and nurses show high levels of excessive intergroup conflict – due to career-based reasons – OC staff exhibit a remarkable lack of a culture of inclusion. Handling mostly minority, low income patients, career-driven healthcare providers at OC consistently violate one basic value of healthcare: compassion. Thus, in communicating with peers or patients conflict stands out as a defining feature of OC's organizational culture. To remediate, OC needs to lobby and campaign aggressively for more state funding which should secure more qualified resident physicians and nurses. Further, by tying up compensation to patient feedback service delivery should be improved and be patient-oriented.
References
Barrier, A. P., Li, T-C J., Jensen, M. N. (2003). Two Words to Improve Physician-Patient Communication: What Else? Mayo Clinic Proceedings, 78(2), 211–214. doi: 10.4065/78.2.211
Comerford, E. S., & Abernethy, A. M. (1999). Budgeting and the management of role conflict in hospitals. Behavioral Research in Accounting, 11, 93-110. ProQuest. Retrieved from http://search.proquest.com/openview/a1131aa583cdd73aad1357067dc65ae5/1?pq-origsite=gscholar
Perloff, M. R., Bonder, B., Ray, B. G., Ray, B. E., & Siminoff, A. L. (2006). Doctor-Patient Communication, Cultural Competence, and Minority Health: Theoretical and Empirical Perspectives. American Behavioral Scientist, 49(6), 835-852. Sage Journals. doi: 10.1177/0002764205283804
Piko, F. B. (2006). Burnout, role conflict, job satisfaction and psychosocial health among Hungarian health care staff: A questionnaire survey. International Journal of Nursing Studies, 43(3), 311–318. doi: 10.1016/j.ijnurstu.2005.05.003
Solet, J. D., Norvell, J. M., Rutan, H. G., & Frankel, M. R. (2005). Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs. Academic Medicine, 80(12), 1094-1099. Retrieved from http://journals.lww.com/academicmedicine/Abstract/2005/12000/Lost_in_Translation__Challenges_and_Opportunities.5.aspx
Tucker, M. C., Herman, C. K., Pedersen, R. T., Higley, B., Montrichard, M., & Ivery, P. (2003). Cultural Sensitivity in Physician-Patient Relationships Perspectives of an Ethnically Diverse Sample of Low-income Primary Care Patients. Medical Care, 41(7), 859–870. Retrieved from http://journals.lww.com/lww-medicalcare/Abstract/2003/07000/Cultural_Sensitivity_in_Physician_Patient.10.aspx
