The Regulation and Accreditation of Organizations and Organizational Theories In Healthcare. Healthcare organization accreditation serves to assess and recognize organizations that meet certain quality standards and promote organizational change and improvement.
What are Regulation and Accreditation of Organizations and Organizational Theories In Healthcare
Organizational theories, such as institutional theory and contingency theory, provide a framework for understanding the functioning of healthcare organizations and their potential for improvement. These theories guide accreditation processes and improve the overall quality and effectiveness of healthcare.
Regulation And Accreditation
Nurses at all levels must understand the complex health-care system and the impact of policy, regulations, and accreditation on these systems (AACN, 2008). Nurse leaders and managers are responsible for educating staff on legislative and regulatory processes and interpret the impact on nursing and health-care organizations (AONE, 2011).
Regulation
Health care is a highly regulated industry. Health-care regulatory policies directly and indirectly influence nursing practice and the nature and functioning of the health-care system (AACN, 2008). Regulations are developed and implemented by federal, state, and local governments, as well as private organizations, and can be very complex and difficult to understand (Mensik, 2014).
Regulations and policies can affect the quality of patient care, the workplace environment, the availability of resources, and finances. Nurse leaders and managers need to stay current regarding federal and state laws and regulations that can affect patient care (AONE, 2011).
Accreditation
Nurses must have a basic understanding of not only the legislative and regulatory processes but also the accreditation process. Accreditation ensures that health-care organizations meet certain national quality standards. When health-care organizations are accredited, it means the accrediting agency has conferred deeming status on the organization and the organization has met Medicare and Medicaid certification standards (Shi & Singh, 2008).
Although accreditation is voluntary, Medicare, Medicaid, and most insurance companies require accreditation by The Joint Commission or the DNV GL through state regulatory agencies to provide funds to an organization. State governments also oversee the licensure and certification of health-care organizations. State standards address the “physical plant’s compliance with building codes, fire safety, climate, control, space allocations, and sanitation” (Shi & Singh, 2008, p. 320). State departments of health certify health-care organizations through periodic inspections. Certification entitles health-care organizations to receive Medicare and Medicaid funding.
The Joint Commission
The mission of The Joint Commission (TJC) is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (TJC, 2015, para. 2).
TJC accredits more than 20,000 health-care organizations in the United States, and the international arm of TJC accredits health-care agencies in more than 90 countries. TJC accreditation can be earned by many types of health-care organizations, including hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services (TJC, 2015).
DNV GL
DNV GL was created in 2013 in a merger between Det Norske Veritas (Norway) and Germanischer Lloyd (Germany). The international organization partners with National Integrated Accreditation for Healthcare Organizations (NIAHO) to provide accreditation for health-care agencies. The NIAHO standards are based on Medicare Conditions of Participation standards and the International Organization for Standardization (ISO) 9001 quality management standards. The ISO 9001 standards provide a framework for organizations to implement quality management systems that will streamline processes, maintain efficiency, and increase productivity (ACS Registrars, 2014, para. 1). More than 500 hospitals now have accreditation through DNV GL (DNV GL, 2015).
Magnet Recognition Program
In 1983, the American Academy of nursing task force on nursing practice in hospitals conducted a study to determine what attracted nurses to hospitals (American Nurses Credentialing Center [ANCC], 2016e). The study determined that 41 of 163 hospitals could be considered Magnet hospitals—in other words, they possessed qualities that attracted and retained nurses (ANCC, 2016e).
A total of 14 qualities were identified that distinguished these hospitals from others, and these qualities became known as the “Forces of Magnetism” .Building on this study, the Magnet Hospital Recognition Program for Excellence in Nursing was approved by the American Nurses Association in December 1990 (ANCC, 2016e). The University of Washington Medical Center in Seattle, Washington, became the first ANCC Magnet-designated organization, in 1994.
Since then, the Magnet Recognition Program has expanded to include long-term care facilities and health-care organizations internationally (ANCC, 2016e). As of 2015, about 7% of all hospitals in the United States had achieved Magnet recognition (ANCC, 2016d). Magnet recognition is a credential that organizations earn in recognition for quality patient care, nursing excellence, and innovations in professional nursing practice (ANCC, 2016f). Organizations recognized as Magnet organizations must meet three goals (para. 8):
- Promote quality in a setting that supports professional practice.
- Identify excellence in the delivery of nursing services to patients or residents.
- Disseminate best practices in nursing services.
The ANCC integrated the 14 Forces of Magnetism into the following five model components, which form a framework of excellence in nursing practice and make up the Magnet Model (ANCC, 2016a):
- Transformational leadership: Nursing leaders at all levels of a Magnet-recognized organization must use futures thinking and demonstrate advocacy and support on behalf of staff and patients to transform values, beliefs, and behaviors. Nurse leaders and managers must be transformational and lead staff “where they need to be in order to meet the demands of the future” (para. 6). The Forces of Magnetism represented in this element are Quality of Nursing Leadership and Management Style.
- Structural empowerment: Nurse Leaders and managers at all levels of a Magnet organization are influential and participate in an innovative environment where professional practice flourishes. Nurse leaders and managers must develop, direct, and empower staff to participate in achieving organizational goals and desired outcomes. The Forces of Magnetism represented in this element are Organizational Structure; Personnel Policies and Programs; Community and the Health-Care Organization; Image of Nursing; and Professional Development (para. 8).
- Exemplary professional practice: Exemplary professional practice in Magnet recognized organizations is evidenced by a comprehensive understanding of the role of nursing, strong intra-professional and inter-professional teamwork, and ongoing application of new knowledge evidence in practice. Nurse leaders and managers must promote interprofessional collaboration and teamwork. The Forces of Magnetism represented include Professional Models of Care, Consultation and Resources, Autonomy, Nurses as Teachers, and Interdisciplinary Relationships (para. 9).
- New knowledge, innovations, and improvements: Magnet-recognized organizations embrace transformational leadership and foster professional empowerment. Nurse leaders and managers must focus on redesigning and redefining practice to be successful in the future. The Force of Magnetism represented is Quality Improvement (para. 10).
- Empirical quality results: The empirical measurement of quality outcomes related to nursing leadership and clinical practice in Magnet-recognized organizations is imperative. Currently, organizations have some structure and processes in place. However, the focus in the future must shift from “What do you do?” or “How do you do it?” to “What difference have you made?” Nurse leaders and managers must participate in establishing quantitative bench marks for measuring outcomes related to nursing, the workforce, patients, consumers, and the organization. The Force of Magnetism represented is Quality of Care (paras. 12 to 14).
Achieving Magnet status benefits the organization and all stakeholders. Further, Magnet-recognized organizations are able to recruit and retain top-notch nursing talent; improve patient care, patient safety, and staff safety; increase patient satisfaction; foster a collaborative culture; advance nursing standards and professional practice; and improve business stability and financial success (ANCC, 2016f). Magnet designation is associated with many positive outcomes for patients and nurses (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2007).
Higher overall patient satisfaction, lower morbidity and mortality rates, decreased numbers of pressure ulcers, patient safety, and higher-quality care are evident in Magnet hospitals (ANCC, 2016b). Nurses report job satisfaction, autonomy and control over nursing practice, fewer injuries, and less burnout than do nurses working in non-Magnet organizations (Ulrich et al., 2007).
Health-care consumers are becoming more aware of the Magnet designation and recognize a Magnet hospital as one with high quality nursing care. The US News & World Report uses the Magnet designation as a primary competence indicator to rank the best medical centers in 16 specialties. In fact, in 2013, 15 of the 18 medical centers on the US News Best Hospitals in America Honor Roll were Magnet organizations (ANCC, 2016f).
Organizational Theories
Health-care organizations are called to deliver safe, timely, effective, equitable, evidence-based, patient-centered care. To understand how health-care organizations function in today’s complicated health-care landscape, nurse leaders and managers need to be knowledgeable about some theoretical elements that shape organizations and explain organizational behavior. In general, organizations are complex, unpredictable, ambiguous, and, at times, deceptive. As a result, they can be difficult to manage (Bolman & Deal, 2008).
Nurse leaders and managers who are able to see beyond the complexity and apply appropriate organizational theories can influence organizational effectiveness. Organizational theory can provide a framework to bring people together to accomplish work (Roussel, 2013). An organizational theory is not one size fits all. In fact, organizational administrators, leaders, and managers may vacillate among various theoretical concepts based on organizational behavior. Various schools of thought about leadership, management, and human behavior make up the various organizational theories (Mensik, 2014).
Classical Organization Theories
Organizational theories became prevalent during the industrial age, when large organizations were first developed; before this period in history, most businesses were family owned and run. Max Weber, a German sociologist, believed that a more formal approach was needed to foster success in the new organizations of the late 1800s and early 1900s.
In turn, he developed the first organizational theory, the bureaucratic management theory, which focused on the structure of formal organizations, the authority of management, and rules and regulations to improve the success of an organization. He believed that a bureaucratic structure would protect employees from arbitrary decisions from supervisors and promote opportunities for employees to become specialists in their work area (Max Weber’s theory of bureaucracy, 2009).
A subsequent theory was the principles of management theory, developed by the engineer Henri Fayol, who is best known for identifying management functions of planning, organization, command, coordination, and control—all of which are still used today (Krenn, 2011). The scientific management theory was developed by another engineer, Frederick Taylor, who used scientific knowledge and mathematical formulas to manage the amount of work that could be accomplished in a specific time period and improve productivity.
Taylor introduced the concept of using financial rewards to increase productivity (Dininni, 2011). In the early 20th century, organizational theories began to explore the underlying differences in human behavior, characteristics, and roles of the work group. Mary Parker Follett was a theorist who embraced human relations theory and developed basic principles of participatory and humanistic management.
She advocated for the principles of negotiation, conflict resolution, and power sharing (Dininni, 2010). All the classical theories were developed in an effort to improve overall organizational management and productivity, as well as define the functions of the manager and create a formal structure for solving problems in the organization.
Contemporary Organizational Theories
Contemporary organizational theories were built on the classical theories, and, in fact, elements of classical theories are present in many organizations today. However, modern organizations demand new organizational structures to survive as they discover that the linear theories of the past are not effective. Contemporary organizational theories need to reflect patterns, purposes, and processes and require a continuum-based, person- and outcome-driven system design (Porter-O’Grady & Malloch, 2013).
Emerging theories are cyclical rather than linear and require organizations to react with speed and flexibility. Contemporary organizational theories that can be used to understand the complexity of health-care organizations include the general systems theory, complexity theory, and learning organization theory.
General Systems Theory
The primary premise of the general systems theory is that “the whole is greater than the sum of its parts” (Mensik, 2014, p. 38). The theory is based on two types of systems: an open system, which interacts with systems inside and outside; and a closed system, which has little or no interaction outside. Health-care organizations are seen as complex open systems in a dynamic state of flux. Open systems are com posed of interrelated elements including inputs, throughputs, and outputs.
The inputs are resources such as staff, patients, equipment, and supplies. The work of the organization is the throughput. The outcome of the work is the output. In the nursing environment, input is nursing personnel and their knowledge, skills, beliefs, and education; throughput involves the management of patient care by nurses; and output consists of patient care outcomes (Roussel, 2013). The system is a constant cycle of input, throughput, and output. For example, a hospital is an open system, and within the hospital are departments or units, the subsystems (the laboratory, pharmacy, radiology, various nursing units, and so on).
The overall effectiveness of the organization relies on the interdependent functioning of the subsystems. Open subsystems have permeable boundaries and are in constant interaction with other subsystems. In contrast, closed subsystems do not interact with other subsystems. Nurse leaders and managers need to be flexible and open to new ideas to maintain the nursing unit as part of the open system.
A nurse leader or manager who works in a closed-system unit is overly focused on internal functions and does not recognize that the unit is part of the larger system. This thinking can negatively impact the overall functioning of the organization. By being open to the system, nurse leaders and managers can maximize the functioning of the unit and enhance patient outcomes (Mensik, 2014).
Complexity Theory
Complexity theory is derived from the general systems theory, as well as physics, and it suggests that relationships are the key to everything (Mensik, 2014). Some key concepts of complexity theory are attractors, patterns, nonlinearity, self-organization, and emergence. Attractors are points of attraction that describe behavior in a complex system in which patterns of energy attract more energy (Crowell, 2011, p. 20). As attractors interrelate in many different nonlinear ways, self-organization occurs, and unexpected new ideas or structures emerge. Hierarchical structures with top-down management approaches are no longer effective in the complexity of health care today.
Patient care involves numerous processes with multiple factors that influence outcomes in various ways. At any given time, it is impossible to predict patient outcomes with 100% accuracy because many of the factors that influence patients’ responses are unknown. Nurse leaders and managers need to abandon linear, controlling, orderly, and predictable approaches to management. Instead, they must embrace the complexity of health care, patients, staff, and the work environment to promote a relationship oriented structure that is adaptable, self-organizing, and self-renewing. Nurse leaders and managers face situations daily in which stability and instability are present at the same time (Crowell, 2011).
In this paradox, nurse leaders and managers must balance three areas of tension in their roles. First, the nurse leader and manager must be efficient and effective, which involves managing the relationship between resource inputs and clinical outputs. Nurse leaders and managers are called to do more with less and manage staffing, skill mix, and patient care process while ensuring that safe, effective, evidence-based nursing care is delivered, all in compliance with regulations and professional standards.
Second, nurse leaders and managers are ultimately accountable for the knowledge and competency of nursing staff and for the relational aspects of nursing care. Finally, nurse leaders and managers are responsible for stability and change, by balancing the need to ensure that patient care activities are on track and predictable with the drive for innovation and change needed for safe nursing practice (Crowell, 2011, p. 64).
Nurse leaders and managers must constantly monitor the balance between stability and complete chaos to maximize variety and creativity within the system (Porter-O’Grady & Malloch, 2010). Further, nurse leaders and managers must focus on outcomes, develop fluid roles, and be able to act with speed and adaptability through chaos.
Learning Organization Theory
The learning organization theory was first described by Peter Senge (1990), who suggested that to excel, future organizations will need to “discover how to tap people’s commitment and capacity to learn at all levels in an organization” (p. 4). He called on leaders to move away from traditional authoritarian “controlling organizations” and instead create learning organizations.
Senge (1990) defined a learning organization as an “organization where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together” (p. 3). Senge (1990) identified five disciplines that organizations need to adopt and practice to become learning organizations:
- Systems thinking: The understanding that everything is connected and interdependent
- Personal mastery: The development of high-level personal proficiency, involving “the discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively” (p. 7)
- Mental models: Deeply ingrained assumptions that influence how a person understands and reacts to the world; understanding current mental models through reflection and inquiry, resulting in awareness of one’s attitudes and perceptions and helping avoid jumping to conclusions and assumptions
- Building shared vision: The establishment of a “mutual purpose” (p. 32) that fosters genuine commitment to the vision and organizational goals, rather than compliance
- Team learning: Involving dismissal of assumptions, free-flowing exchange of meaning that allows group members to discover insights they would not attain individually, and a focus on working toward common goals Members of a learning organization are continually practicing the five disciplines and are continually learning.
Nurse leaders and managers can support a learning organization by involving staff in problem solving and decision making, promoting inter-professional and intra-professional teamwork, improving communication, and empowering staff. In the quest to deliver safe and quality patient care, health-care organizations must seek continuous learning and quality. A learning organization is no longer an ideal but an imperative (Glaser & Overhage, 2013).
Conclusion
Health-care organizations are complex systems that are constantly changing and that are moving away from being disease focused to patient centered. Nurses at all levels must understand the basic makeup of these systems as well as the role that organizational structure and culture, regulation and accreditation, and organizational theories play in the delivery of safe and quality evidence-based care.
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