Assignment

Case Study: Organizational Behavior Management

Read the case study, Improving Responses to Medical Errors with Organizational Behavior Management, in Chapter 4 of your course text. In a three-to five-page double-spaced paper (excluding title and reference pages) address the following:

Explain why the increase in the manager’s use of group behavior-based feedback is important.
Propose intervention strategies the group leader can use to enhance the group effectiveness. Justify your proposed strategies with scholarly and/or peer-reviewed sources.
Explain the motivational theory applicable to sustain the four results listed in the case study.

Including an introduction and conclusion paragraph, your paper must be three to five double-spaced pages (excluding title and reference pages) and formatted according to APA style as outlined in the

Ashford Writing Center (Links to an external site.)Links to an external site.

. Including the textbook, utilize a minimum of three (one of which is the case study article used for review) scholarly and/or peer-reviewed sources that were published within the last five years. Document all references in APA style as outlined in the Ashford Writing Center

APA Checklist (Links to an external site.)Links to an external site.

Carefully review the

Grading Rubric (Links to an external site.)Links to an external site.

for the criteria that will be used to evaluate your assignment.

Proofreading Your Draft

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As you wrap up your paper, take a few moments to do the following:

Review the full tutorial: “The Grammarly Guide: How to Set Up & Use Grammarly.” (Links to an external site.)Links to an external site.
Set up a Grammarly account (if you have not already done so).
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Click on “Create Account”
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If you encounter any problems or technical issues, please contact: support@grammarly.com
Use Grammarly to review your rough draft. Remember, your draft is an academic essay.
Carefully read all the issues found by Grammarly and revise your paper.

4 Organizational Behavior—Macro

Learning Objectives

After reading this chapter, you should be able to:

• Identify and define the types of groups found in business organizations.

• Summarize the principal theories of group dynamics.

• Analyze group performance and effectiveness.

• Discuss the role of physicians as stakeholders in health organizations.

• Apply evidence-based management principles to health organizations.

• Compare functional and dysfunctional organizations.

Michael Pole/CORBIS

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Section 4.1Introduction to Organizational Behavior—Macro

Staff and Executive-Level Teams Are Fundamentally Different
A motivational poster frequently found in managers’ offices displays a team of rowers to illustrate the
concept of people working together; a popular offering from the Art of Rowing company is titled Team-
work: Together We Achieve More. When most people on a team are doing similar jobs, the rowing
metaphor is very apt. However, executive-level teams are different:

Executive teams are more like baseball teams. Sure, they are all wearing one uni-
form and following one game plan, but sometimes they work alone (as in the case
of a batter), sometimes they work in pairs (pitcher throws to catcher, or shortstop
and first baseman collaborate in a double play) and only seldom do they all get in
on the action.. . . Don’t expect a team at that level to feel the same way your depart-
ment level team does. You’re not all in the same boat. So figure out the game plan,
play your position, and keep your head up to spot your chances to support your
teammates. (Davey, 2012, p. 1)

When one thinks of the ideal executive-
level team, a better metaphor might be
a company softball team—which can
include both men and women of varying
ages and ethnicities. However, company
softball teams are seldom good at playing
softball; many are formed to encourage
camaraderie among the players and sup-
porters, thereby strengthening working
relationships and organizational com-
mitment. Organizations need and value
talented individuals who can work col-
laboratively with others; being a “team
player” is an important attribute for
success in almost every type of job. Since
much of the clinical and administrative
work in health organizations is done in
groups or teams, it is important for health
care professionals to understand the work-
ings of, participate in, and lead teams.

Critical Thinking and Discussion Questions
1. What have you learned from participating in a department or management team?
2. How important is team camaraderie among executives in health care organizations?

4.1 Introduction to Organizational Behavior—Macro
Chapter 3 focused on the individual behavior in organizations. This chapter focuses
on group behavior and discusses how organizations achieve their goals by coalescing
the skills and efforts of individuals into groups and networks. Organizational behavior
researchers and practitioners study behaviors within and between groups, both formal

Randy Faris/CORBIS

An executive team is similar to a company softball
team.

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Section 4.2Group Dynamics

and informal. Formal groups are officially designated to fulfill certain functions and
accomplish specific tasks. Within the category of formal groups are command groups
and task groups. Command groups are the building blocks of the organization’s struc-
ture. They are specified in the organization chart and include the executives, managers,
supervisors, and the people who report to them. Task forces, also called task groups,
are temporary groups charged with solving a problem or responding to an opportunity.
Stakeholders are groups and organizations that have a vested interest in the organiza-
tion. Informal groups are naturally formed groups of people who work together or who
are drawn together on the basis of friendship or shared interests. Although they are not
officially sanctioned or recognized by the organization, they strongly influence its work-
ings (Ivancevich & Matteson, 2002). Successful health care management requires skill in
managing individuals, groups, and stakeholders.

4.2 Group Dynamics
Cartwright and Zander (1968) define group dynamics as “a field of inquiry dedicated to
achieving knowledge about the nature of groups, the laws of their development, and their
interrelations with individuals, other groups, and larger institutions” (p. 120). They note
that this subunit of organizational behavior became an identifiable field in the United
States in the late 1930s and has four distinguishing characteristics:

1. An emphasis on theoretically significant empirical research, based on effective
experimental design, careful observation, reliable measurement techniques,
and statistical analysis of data performed according to accepted social science
research methods.

2. Interest in the dynamics of group life and observed relationships, in order to
discover general principles concerning what conditions produce what effects and
how certain properties and processes depend on others.

3. Interdisciplinary relevance, incorporating and contributing ideas from and to
sociology, psychology, anthropology, political science, and other social sciences.

4. Potential applicability of findings to professional and business practice, in order
to provide a sounder scientific basis for practitioners in a variety of group set-
tings and organizations.

While groups and teams are terms often used interchangeably in the literature, there are
some important distinctions between them. Groups consist of two or more individuals
who interact with each other and share a common purpose or affiliation. A team is a
type of group; all teams are groups, but not all groups are teams. In business a team is a
group whose members work together on a specific project or are responsible for a specific
organizational function. While there may be a designated team leader, teams collectively
assume responsibility, set goals, develop plans, and divide the work. “In order to be a
team: (1) individuals’ actions must be interdependent and coordinated, (2) each member
must have a specified role, and (3) members must share common task goals or objectives”
(Ivanitskaya, Glazer, & Erofeev, 2009, p. 109).

Group dynamics, as the name implies, deals with changes that occur when people interact.
The following section highlights three important theoretical contributions to the study of

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Section 4.2Group Dynamics

group dynamics in the workplace. The first, roles, places the individual in context among
peers, superiors, and subordinates and also defines his or her function in the organization.
The sections on group process and intergroup behavior deal with group development and
group behavior toward other organizational groups.

Roles

A key construct of psychology is the role an individual plays in a given situation, which
serves a specific purpose and involves a set of shared expectations. For example, nurses
are the primary caregivers of patients in a hospital. In business others in the organization
and the profession establish expectations for a given role. For a nursing supervisor, these
others would include direct reports, the boss, fellow supervisors, patients and their fami-
lies, and the nursing educational, professional, and licensing organizations.

Benne and Sheats (1948) developed functional role theory based on behavioral patterns
they observed among individuals in many different small-group interactions. Some indi-
viduals performed task roles, which involved completing a job and accomplishing an
objective. Others performed maintenance roles, which were social in nature, focusing
on process and relationships. Still others performed individual roles to help the group
accomplish its goals. Whetten and Cameron (2011) noted that two types of roles, task
facilitating and relationship building, were both important contributors to group per-
formance. Most people, whether group members or leaders, tend to emphasize one role
over the other. While at certain times one role may predominate, effective groups need to
strike a balance between task-facilitating and relationship-building roles. Tushman (1977)
described individuals whose roles primarily involve interactions and communications
with external stakeholders as holding boundary-spanning roles, such as compliance or
government-relations officers in a health organization. Another type of role common in
large-scale or high-tech health organizations is that of horizon scanning, which involves
identifying new and evolving interventions or technological advances, as well as ana-
lyzing their potential impact on the health care industry generally and the organization
specifically (Sun & Schoelles, 2013). Whetten and Cameron (2011) categorized a number
of unproductive behaviors that inhibit group work as blocking roles, and emphasized the
importance of managerial proficiency in developing, participating in, and leading groups.

Theory in Action: Management Behavior and Group Roles

Here are common behaviors of each role type, with examples of statements to illustrate
group leader behaviors or, in the case of blockers, to deal with them effectively (Whetten &
Cameron, 2011).

Task-Facilitating Roles
• Giving directions: “Let’s start by brainstorming ideas.”
• Seeking information: “What do the licensing regulations specify?”
• Giving information: “Here are the regulatory specifications.”

(continued)

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Section 4.2Group Dynamics

Theory in Action: Management Behavior and Group Roles
(continued)

• Elaborating: “To add to Joe’s comments. . .”
• Urging: “We need to win this bid to make our revenue target next year.”
• Monitoring: “Who will be lead staff with accountability for each task we’ve identified?”
• Analyzing process: “Some members seem to have checked out on this project.”
• Reality checking: “Can we really meet this deadline?”
• Enforcing: “We’re getting off track; let’s focus on what we have to decide today.”
• Summarizing: “Here is what I understand are our next steps, and who is lead staff for

each.”

Relationship-Building Roles
• Supporting: “Your root-cause analysis was spot-on!”
• Harmonizing: “Let’s just agree to disagree about this; we don’t need to agree on every

point to move ahead.”
• Relieving tension: “I haven’t had this much fun since my last root canal!”
• Confronting: “Maria, this is your department’s domain, so you need to assign staff to

complete this part of the job.”
• Energizing: “I can’t believe how much we’ve accomplished so far!”
• Developing: “Jerry, I know this is a new area for your department but Ruben will help

you; he’s done a lot of similar projects.”
• Building consensus: “Let’s list the things we have agreed to so far.”
• Empathizing: “I know it’s stressful to have such a lot to do in such a short time.”

Blocker Roles
• Dominating: “Remember, this is a group project; we need everyone’s ideas.”
• Overanalyzing: (a) General: “We need to avoid analysis paralysis”; (b) Specific:

“Hilary, will you please summarize your concerns in no more than 1 page for the next
meeting?”

• Stalling: “Folks, we need to make a decision on this today.”
• Disengaging: “Charlie and Lisa, you haven’t said anything and I know you have

opinions about this.”
• Overgeneralizing: “Is the issue that Oscar raised as much of a problem for other

people?”
• Faultfinding: “Let’s keep an open mind as everyone presents their ideas.”
• Premature decision making: “Are we jumping to a solution here?”
• Presenting opinions as facts: “Do you have any data or facts to support that

statement?”
• Rejecting: Include instructions prior to the meeting: “Please type out on separate sheets

of paper your idea(s) for resolving issues 2 through 5 and bring them to the meeting.”
• Pulling rank: “We need to hear more from the people who will be doing the work.”
• Resisting: “Let’s concentrate on how we can move forward on this project.”
• Deflecting: “We’re getting off track here, let’s focus on the main points.”

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Section 4.2Group Dynamics

Group Process and Phases

Educational and research psycholo-
gist Bruce Tuckman became well
known following the publication of
a short article in 1965 in which he
proposed a four-stage linear process
of group development: Forming,
storming, norming, and perform-
ing. Hare, Borgatta, and Bales (1965)
argued that since group members
will seek a balance between accom-
plishing the task and building rela-
tionships with fellow group mem-
bers, it becomes a repetitive cyclical
process as the group moves from
storming, norming, and performing,
as illustrated in Figure 4.1 (Smith,
2005). Understanding dynamics of the
group developmental process is par-
ticularly important for health profes-
sionals participating in or leading the
multidisciplinary teams so common
in health organizations.

1. In the forming stage, groups organize themselves and test each other to establish
boundaries for both task and relationship behaviors. It is also during this stage
that leadership and dependency roles are established.

2. The storming stage involves some conflict or polarization as members com-
pete for leadership or to control the group’s direction, which disrupts task
requirements.

3. In the norming stage, members develop feelings of identification and cohesive-
ness with the group as they put aside their personal agendas, adopt new roles,
and commit to new behaviors as group members.

4. In the performing stage, the interpersonal structure becomes the vehicle for
accomplishing the task activities as members recognize the importance of group
goals, develop pride in identity, and direct their energies as a group to accom-
plishing the task.

In 1977 Tuckman and Jensen added a fifth stage, adjourning, since not all groups are
ongoing. This stage can be a stressful process because it involves loss and the termina-
tion of roles (Smith, 2005). Coppola (2008) argues that an additional preparation stage is
important, especially in hospitals and other large, complex organizations. The informing

Figure 4.1: Group development phases

Early group dynamics researchers developed a four-phase
developmental model that included the phases of forming,
storming, norming, and performing.

Source: Smith, M. K. (2005). Bruce W. Tuckman—forming, storming, norming
and performing in groups. The Encyclopaedia of Informal Education.
Retrieved August 15, 2013, from infed website: http://infed.org/mobi
/bruce-w-tuckman-forming-storming-norming-and-performing-in-groups

Forming

Storming Norming

Performing

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Bruce W. Tuckman – forming, storming norming and performing in groups

Section 4.2Group Dynamics

stage begins with an initial (written
or verbal) notification of or invita-
tion to membership when a new
team is officially designated or when
new team members join an existing
structural (command) team where
members rotate in and out. During
this stage the member(s) form opin-
ions about both the mission of the
team and its other members. Figure
4.2 displays the team development
phases as a six-stage process that
includes informing and adjourning.

Often, one of a new manager’s first
assignments is to lead a newly formed
or existing group. Understanding
the developmental group processes
will assist managers in maximizing
output; it will also prepare them to
lead more complex interdisciplinary
groups as their careers progress, such
as a hospital committee required by
the Joint Commission or staffing a

board of directors committee. Ledlow and Coppola (2014) suggest strategies for health man-
agers to employ at each of the six stages of group development, as summarized in Table 4.1.

Table 4.1: Group developmental stages and management strategies

Stage Strategy Additional considerations

Informing • Officially notify each member
of appointment to the group

• Formally present group goals,
measurable objectives in a
bounded time frame

• Communicate in person with
group membe

• Allow a reasonable time
period (15 to 30 days)
between notification and
first required meeting

• Known desire of members to
be or not be in the group

• Skill set, track record in prior
groups

• Personality dynamics
between group members

Forming • Hold a “kick-off meeting to:

1. Outline group roles
2. Clarify goals and

objectives
3. Establish time line

with milestones and
deliverables

• Challenge of allowing time
for group development pro-
cess within time constraints
for task completion

Figure 4.2: Tuckman, Jensen, and Coppola’s

group development phases

Groups develop over time in a series of stages that
include preparing to work together and bringing their
work to a close.

Norming

Storming

Adjourning

Forming
Performing

Informing

(continued)

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Section 4.2Group Dynamics
Stage Strategy Additional considerations

Storming • Encourage constructive pro-
fessional discourse

• Resist temptation to intervene
prematurely

• Push to develop a new
collective idea that reflects
input from all group
members

Norming • Recognize that group has
developed a unique per-
spective of the task to be
accomplished

• Work with nonnorming mem-
bers to encourage them to
support group norms

• Better to remove or replace
obstinately noncooperative
members

Performing • Thank group members
• Recognize individual

contributions

• Know contributions of each
member and use this knowl-
edge for staff development
to build on strengths

Adjourning • Document the process and
save the output

• Recap lessons learned

1. Best practices
2. Opportunities for

improvement

• Disseminate knowledge
gained to other segments of
the organization

• Acknowledge that people
will miss some aspects of the
group’s work and time with
each other

• Use learnings to build
knowledge-management
and organizational-learning
systems

Source: Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health care professionals: Theory, skills, and applications (2nd ed.).
Burlington, MA: Jones & Bartlett.

Intergroup Behavior

Industrial psychologists Blake, Shepard, and Mouton (1964) found in their studies of group
dynamics that members of a group who strongly identify with the group will feel obli-
gated to conform to its norms and positions and to uphold their group’s positions against
other groups. Acting in ways contrary to their own group position would be regarded
as disloyal to the group, whereas holding fast to it would be considered highly effective
behavior as a member or leader. Each group within an organization has its own goals, yet
these groups are interdependent with each other. When organizations encourage groups to
compete with each other and reward them on a relative basis with group incentive plans,
the groups perceive defeat of the other groups as necessary to achieve their objectives, and
a power struggle ensues. The researchers proposed three sets of assumptions about inter-
group disagreement and identified mechanisms of intergroup conflict resolution for each.

Table 4.1: Group developmental stages and management strategies (continued)

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Section 4.2Group Dynamics

1. If intergroup disagreement is considered inevitable and permanent, the operating
assumption is that it must be resolved in favor of one or the other group, either
by a power struggle or by a third party arbiter—or left to resolve itself.

2. If intergroup disagreement is not considered inevitable but agreement is not possi-
ble, conflict can be resolved by reducing the interdependence between groups and
allowing or encouraging the groups to act more independently from each other.

3. If achieving agreement and maintaining interdependence are both considered
possible and necessary to organizational functioning, conflict may be resolved
by group actions to (a) maintain surface harmony, (b) bargain or compromise, or
(c) make a genuine effort to address fundamental points of difference between
groups (Blake et al., 1964).

Alderfer (1987) notes the importance of intergroup relationships to explain group behav-
iors in larger organizations. He distinguished between identity groups and organizational
groups, which are comparable to informal and formal groups. Identity group members
share some common characteristic (e.g., age, ethnicity, gender) and have shared experi-
ences (e.g., alumni, professional degree), and as a result they have similar perspectives
on life and work. Members are assigned to organizational groups based on the organiza-
tion’s division of labor and authority structure. Identity group and organizational group
membership is frequently related. For example, a majority of executives in health orga-
nizations are older white males who often share prior work or educational experiences
and similar hobbies such as golf; clinicians who trained in the same institution often work
together in other organizations during their careers. Intergroup theory proposes that both
organization and identity groups affect members’ intergroup relations and thus shape
beliefs and behaviors.

Teams

Teams are widespread in health organizations because the clinical and administrative staff
need to work together closely to meet the needs of their patients, customers, or members.
There are teams based on discipline (such as those composed exclusively of physicians or
nurses) or hierarchical position (such as the governing body/board of directors, executive
team/chief team, directors/unit leaders council, etc.). Multidisciplinary teams are used
extensively for quality-improvement initiatives.

Permanent and Temporary Teams
Interdisciplinary teams are organized to perform a particular function involving the
work of several operational units; if the functions are ongoing, the teams are designated
as committees. Committees have permanent standing, elected or appointed member-
ship, and provisions for alternate representatives. In some committees members have
time-limited terms of office. In other committees membership is automatically assigned
to the position; for example, the quality-improvement committee of a hospital typically
includes the chief of the medical staff and the director of nursing or their delegated

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Section 4.2Group Dynamics

physician or nurse representatives. Staffing committees is a key health administration
role and helps support clinicians or senior executives.

Theory in Action: Typical Health Organization and
Hospital/Health-System Board Committees

Some typical health organization committees with ongoing responsibilities and a brief
description of their function are:

• Utilization Review—patient-care management case reviews, medical-management
process analysis

• Clinical Documentation Review—monitoring of documentation adequacy
• Risk Management—liability exposure and overall safety assessment
• Infection Control—physical facility and patient-care process monitoring to prevent and

deal with infection
• Patient Safety—adverse event case analysis, care-process improvement to prevent

adverse events
• Quality Improvement—proactive patient-care and business-process improvement
• Professional Development—individual and group skill enhancement and training
• Credentials—clinical credential assessment, verification and monitoring
• Patient/Health Plan Member Grievance Review—complaint assessment and

adjudication

At the governing body level, hospital and health-system boards commonly do much of their work
through committees. A 2013 survey by the American Hospital Association’s Center for Healthcare
Governance found that over half had committees for finance (83%), quality (75%), executive (68%),
governance and nominating (61%), and audit and compliance (51%) (Gamble, 2013).

Task forces are temporary teams organized as needed to solve a particular problem or
complete a specific project. These teams are time limited, have specific and strategic objec-
tives, and disband when the problem is resolved or the project is finished. Often there
is a work product such as an accreditation self-study or a revised policy and procedure
manual. Examples of health organization task force functions and work products include:

• Accreditation or licensing application or renewal
• Policies and procedures—development or update
• Event planning: Holiday party, charitable activity, organizational anniversary

celebration
• Space planning (for a move or facility renovation)
• Technology transitions—planning and implementation (e.g., electronic medical

records)
• Customer service initiatives involving significant business-process changes
• Feasibility studies for new business ventures or programs
• Pursuing an award such as the Baldrige prize for quality, magnet hospital designa-

tion, or five-star Medicare health plan rating

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Section 4.2Group Dynamics

Cross-Functional Teams
Many organizations create customer teams in response to increased market competition
and customer demands for better service coordination. Managed health care systems have
resulted in the creation of ever-larger economic bargaining units among both payer and
care delivery organizations as evidenced by health plan mergers and acquisitions and
hospital system affiliations. These large customers (mega health plans and multihospital
systems) expect not only lower prices but also knowledge of their business and rapid
responsiveness to their needs; they often demand a single point of contact for inquiries
and service. In such an environment, a coordinated approach to business development
and customer relations is essential and typically involves people from marketing, finance,
information systems, and operations on the team. The cross-functional team members
possess the competencies needed to achieve an optimal outcome, such as winning a new
contract or improving customer satisfaction and regulatory or accrediting agency ratings.

Theory in Action: Ten Tips for What Not to Do as a
Team Manager

Parker (1994) offers a David Letterman–style “Top 10 List” of practices to avoid when managing
cross-functional teams.

10. Don’t listen to any new idea or recognition from a team. It’s probably not a good idea
since it’s new and comes from a team.

9. Don’t give teams any additional resources to help solve problems in their area. Teams
are supposed to save money and make do with less. Besides, they will probably just
waste more time and money.

8. Treat all problems as signs of failure and all failures as a reason to disband teams and
downgrade team members. Teams are supposed to make things better, not cause you
more problems.

7. Create a system that requires lots of reviews and signatures to get approvals for all
changes, purchases and new procedures. You cannot be too careful these days.

6. Get the security department involved to make it difficult for teams to get information
about the business. Don’t let those team members near any computers. You don’t want
them finding out how the business is run.

5. Assign a manager to keep an eye on teams in your area. Tell the teams that he or she is
there to help facilitate (teams like that word)—but what you really want these managers
to do is control the direction of the teams and report back to you on any deviations
from your plan.

4. When you reorganize or change policies and procedures, do not involve team members
in the decision or give them any advance warning. This will just slow things down and
make it difficult to implement the changes.

3. Cut out all training of team members. Problem solving is just common sense
anyway, and besides, all that training really accomplishes is to make a few
consultants really rich.

2. Express your criticisms freely and withhold your praise and recognition. Teams need
to know where they have screwed up so that they can change. If you give out praise,
people will expect a raise or reward, and you don’t want that.

1. Above all, remember you know best. That’s why they pay you the big bucks. Never
forget that (pp. 210–211).

Source: From Parker, G.M., Cross-functional teams: Working with allies, enemies & other strangers. © 1994 John Wiley
and Sons Inc. Reprinted by permission.

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Section 4.3Group Performance and Effectiveness

Virtual Teams
Advances in electronic communication technology have encouraged the formation of vir-
tual teams in many organizations and some entirely virtual organizations as well. As the
use of virtual work teams grew, both organizations and workers realized that virtualiza-
tion had both benefits and drawbacks. At International Business Machines (IBM), an early
adopter, more than 45% of its 400,000+ employees and independent contractors work
remotely; however, employees joke that the company’s initials stand for “I’m by myself”
(Johns & Gratton, 2013). Marissa Mayer made headlines when she was named CEO of
Yahoo! in July 2012 at age 37, when she was 6 months pregnant with her first child; she
sparked a firestorm of controversy 7 months later by eliminating the company’s long-
standing telecommuting programs. Mayer argued that employees needed to be physically
present to create a unified organization. Yahoo!’s share price increased by more than 70%
in Mayer’s first year in office, although the company’s revenue rose at a much slower rate
than its competitors in the digital advertising industry (Efrati & Silverman, 2013).

As in other businesses, a growing
number of administrative profession-
als in health organizations are telecom-
muting. Managers in these organiza-
tions recognize that new work models
bring new challenges, and it is not
easy to achieve a balance between the
independence and freedom of vir-
tualization and the camaraderie and
opportunities for collaboration in a
traditional office setting. Finding or
creating new ways to provide a sense
of community can mitigate worker
isolation, avoid alienation, and foster
team collaboration (Johns & Gratton,
2013).

4.3 Group Performance and Effectiveness
Teams are an integral element of health organizations’ administrative infrastructure. Effec-
tive teams are like flocks of geese: Both have interdependent members who care for and
support each other and are more efficient working together than alone. Members rotate as
leaders and help each other when one falters or is distressed.

Benefits and Costs of Teams

Considerable research has demonstrated the benefits of teams for both the organization
and the individual: Enhanced communication, higher productivity and satisfaction, and
decreased turnover (Buchbinder & Thompson, 2012).

Blend Images/John Fedele/Getty Images

A virtual team meeting via video chat saves time
and money.

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Section 4.3Group Performance and Effectiveness

Teams maximize the organization’s human resources, for in teams, each
member learns to be more effective through the coaching, help and leader-
ship of all the other members. All members, not just the individuals, feel
success and failures alike. Because failures are not blamed on individual
members, they have the courage to take more risks in a team setting and
more ideas are forthcoming. The greatest lesson learned by team members
is: Teams consistently outperform individuals. And the second greatest is:
Individuals may be considered for career advancement as a result of broad-
ening their knowledge of the organization and acquiring teamwork skills.
(Costa, 2009, p. 315)

Katzenbach and Smith (1993), in their best-selling business book, The Wisdom of Teams,
present the following findings to support their fundamental premise that teams and orga-
nizational performance are inextricably connected.

• “Real teams” are jointly responsible for specific results that the company perfor-
mance ethic demands. They emerge and operate best when management makes
clear and strong performance demands and holds them accountable for results.

• High-performing teams are rare, mainly because few teams elicit the high degree
of personal commitment that distinguishes members of high-performing teams
from people on other teams.

• Teams integrate, rather than replace, formal hierarchical structures and processes.
• Teams integrate performance and learning by defining performance goals and

developing the skills needed to achieve them.
• Teams are increasingly the primary unit of performance for organizations, essen-

tial for the speed and quality that customers in all types of industries expect.

There are, however, significant costs of teamwork. The greatest cost is the staff time spent
in meetings and the associated opportunity costs (how that time might be better spent).
Other costs include time spent in arranging, scheduling, and recording meetings; travel or
communication expenses for in-person or virtual meetings; and expenses for food, travel,
and accommodations. There are also psychic costs associated with having to work with
other people, such as delayed decisions, loss of autonomy, and pressure to compromise
(Buchbinder & Thompson, 2012).

Health administrators therefore need to weigh the costs and benefits of forming teams
under varying circumstances, since whether a team or individual approach is most appro-
priate depends on the nature of the problem, the goal to be achieved, and the skill of the
team leader (Maier, 1967). Generally, teams are most useful in situations requiring mul-
tiple skills, a variety of perspectives, broad experience, and a free flow of communication
(Whetten & Cameron, 2011).

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Section 4.3Group Performance and Effectiveness

Dysfunctional Teams

Not all teams function successfully. Patrick Lencioni (2002) has identified five dysfunc-
tions of teams that prevent them from performing effectively. Table 4.2 compares the prin-
cipal characteristics of dysfunctional and well-functioning teams.

Table 4.2: Functional and dysfunctional teams

Attribute Dysfunctional teams Functional teams

Trust In the absence of trust, team
members are unable to be
genuinely open with each
other about their mistakes and
weaknesses.

Team members feel free to ask
for or offer help.

Conflict Failure to establish a founda-
tion of trust creates fear of
conflict, so that team members
cannot frankly and passionately
debate ideas, and fail to resolve
the issues about which they
disagree.

Productive conflict enables a
team to produce the best pos-
sible solution in the shortest
amount of time, then move on
to the next important issue.

Commitment Lack of healthy conflict results
in lack of commitment, since
team members have not openly
expressed their opinions. The
quest for certainty about the
correctness of a decision can
paralyze a team and undermine
members’ confidence in their
ability to make any decisions.

Seeking consensus is not
necessary; reasonable people
can support a decision they do
not agree with as long as they
perceive that their opinions
have been heard and seriously
considered.

Accountability Lacking commitment to a clear
plan of action, team mem-
bers avoid accountability and
hesitate to confront their peers
regarding counterproductive
actions and behaviors.

Members of great teams dem-
onstrate their respect for each
other by holding them account-
able for performing at a high
level.

Results Failure to hold each other
accountable leads to inattention
to results when team members
put their individual needs or
the needs of their work unit
above the collective goals of the
team.

Great teams want to achieve the
goals they set and the results to
which they commit.

Source: Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass.

Teamwork in health organizations is often very challenging, especially in large, complex
organizations with members from different professional groups. Forming and leading a
great team is hard work, but the results are worth the effort.

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Section 4.3Group Performance and Effectiveness

Web Field Trip: Mind Tools Team Effectiveness Assessment

Go to http://www.mindtools.com/pages/article/newTMM_84.htm. Answer the 15-question
assessment for a team in which you are a leader or participant.

1. Analyze your responses and identify your areas of strength and weakness.
2. How will you use what you learned from this assessment to become a more effective

group leader?

Groupthink

Yale University research psycholo-
gist Irving Janis (1971) developed this
concept from research on the actions
of President John F. Kennedy’s cabi-
net toward Cuba. After concluding
that Cuban president Fidel Castro
was working on behalf of the Soviet
Union, in late 1961 Kennedy autho-
rized a clandestine brigade of Cuban
exiles to invade the island. The Bay of
Pigs fiasco, as it became known, failed
within days and was an embarrass-
ing defeat for the Kennedy adminis-
tration. A few months later, the same
team handled the Cuban missile cri-
sis brilliantly. After aerial reconnais-
sance photographs revealed Soviet
missiles under construction in Cuba, the administration boldly confronted Soviet premier
Nikita Khrushchev while avoiding armed conflict (U.S. Department of State, n.d.).

Janis (1971) reviewed hundreds of documents on the Bay of Pigs invasion attempt and
other unsuccessful government and military leadership team decisions and made a sur-
prising discovery: Each group of high-level leaders and officials displayed the same
type of social conformity that psychologists had routinely observed in studies of groups
composed of students and the general population. Janis called this phenomenon
groupthink, defined as

remaining loyal to the group by sticking with the policies to which the
group has already committed itself, even when these policies are working
out badly and have unintended consequences that disturb the conscience
of each member . . . when concurrence-seeking becomes so dominant in a
cohesive ingroup that it tends to override realistic appraisal of alternative
courses of action. (p. 157)

Henry Burroughs/AP

The Kennedy administration’s 1961 Bay of Pigs
fiasco is a prominent example of groupthink.

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http://www.mindtools.com/pages/article/newTMM_84.htm

Section 4.3Group Performance and Effectiveness

Groupthink Signs and Signals
Behavioral symptoms of groupthink typically arise during the norming stage of the group
developmental process, but they can develop at any time. Signs and signals of groupthink
include:

1. Illusion of invulnerability: Members feel their group or organization is too smart,
powerful, or rich to be wrong or to experience defeat.

2. Rationalization: Members discount warnings and other signals that their think-
ing is incorrect.

3. Morality: Members’ belief in the inherent morality of their group and the right-
ness of their position leads them to ignore the ethical consequences of their
decision.

4. Stereotypes: Members consider opponents too weak, stupid, or corrupt to deal
effectively with whatever the in-group decides to do and dismiss disconfirming
information by discrediting its source.

5. Pressure: Group leaders and members apply direct pressure to any member
who expresses doubts about the proposed course of action or who questions the
assumptions on which it is based.

6. Self-censorship: Members suppress misgivings and doubts, deciding that they
are not relevant and should be set aside.

7. Illusion of unanimity: Members assume that not speaking in opposition indicates
agreement with the group’s position.

8. Mind guarding: Members protect the group leader and fellow members from
adverse information that would disrupt the consensus, such as objections or
questions from “outsiders”— even highly respected experts.

The author’s experience during the 1980s in a nonprofit hospital system executive team
meeting illustrates groupthink in health care organizations. The corporate director of
marketing and planning presented her plan for an integrated marketing approach by the
system’s member hospitals as a cost-effective way to promote the hospitals in their respec-
tive communities and compete with the erosion of market share and doctor defections to
for-profit hospitals chains in the region. The CEO of the flagship hospital stated, “I refuse
to engage in any form of advertising; it’s not dignified, and it’s unethical for a nonprofit
religious hospital to use its funds in this manner. Besides, everyone knows we provide the
best quality care and have the best physicians. They lure patients with false advertising
and doctors with kickbacks. If we adopt their tactics, we stoop to their level.” The senior-
level leadership team ignored the marketing director’s rejoinder that advertising was just
one small part of the overall plan and that the physician relations program did not and
would never involve payment for admissions. After some murmuring, discussion of the
plan was tabled; it did not appear on the executive council agenda again until the flagship
hospital CEO was on vacation.

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Section 4.4Stakeholder Dynamics

Groupthink Remedies
To counteract groupthink, Janis (1971) offers the following suggestions based on the suc-
cessful actions taken by the Truman administration’s Marshall Plan team for post–World
War II European economic recovery as well as the actions of the Kennedy cabinet in peace-
fully resolving the Cuban missile crisis:

• Assign the role of critical evaluator to at least one team member, who will encour-
age the group to consider both pros and cons of any proposed course of action.

• Leaders should refrain from expressing their opinions or expectations at the
beginning of a group discussion.

• Set up subgroups of team members or outsiders to develop and debate indepen-
dent proposals.

• Require each team member to seek input from members of their organizational
units and report back to the group.

• Invite one or more outside experts to each meeting to hear and critique core
members’ views.

• Assign at least one team member to play devil’s advocate whenever the agenda
calls for an evaluation of policy alternatives. In contrast to the critical evaluator’s
neutral stance, this member’s role is to make opposing arguments.

• Hold a “second-chance” meeting at least 1 day after the group reaches a pre-
liminary consensus, where all members are encouraged to express their second
thoughts about the decision.

Taking these actions will help ensure that team decisions in health organizations are well
formed, carefully considered, vigorously debated, and thoughtfully adopted.

An illustration of groupthink often used in management classes is the Abilene Paradox
(http://www.crmlearning.com/abilene-paradox), which recounts the story of a Texas family
that made a long, hot, and unpleasant drive to Abilene for dinner. They all would have pre-
ferred to stay home, but each agreed because they felt the others wanted to go (Harvey, 1988).

4.4 Stakeholder Dynamics
Health care organizational stakeholders and their relationships are especially complex
and involve many players and forces. These individuals, groups, and organizations are
linked together by cooperative economic exchanges as well as legal and regulatory rela-
tionships. Table 4.3 lists the major types of health organization stakeholders and briefly
describes their primary characteristics (White & Griffith, 2010).

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http://www.crmlearning.com/abilene-paradox

Section 4.4Stakeholder Dynamics

Table 4.3: Principal attributes of health organization stakeholders

Stakeholder Principal attributes

Owners Vary according to whether the organization
is a not-for-profit or for-profit corporation, or
a federal, state, or local government agency

Customers, buyers, and payers Patients and families, differentiated by age,
gender, clinical need, and language prefer-
ence; employers, health insurance and other
types of payers differentiated by company
and type of coverage

Suppliers and workers Direct patient-care providers differentiated
by professional credentials; many other
types of employees; contract providers; sup-
pliers of goods and services; and volunteers
who support and supplement the efforts of
workers in myriad ways

Regulators and advocates Government agencies (federal, state, and
local); accrediting bodies; trade and profes-
sional associations; lobbying groups; unions;
consumer associations; community groups;
competitors; and other organizations influ-
encing health organization transactions and
operations

Source: White, K. R., & Griffith, J. R. (2010). The well-managed healthcare organization (7th ed.). Chicago: Health Administration Press.

Health organization stakeholders include individuals and groups within and exter-
nal to the organization. Employees, including managers and executives, are internal
stakeholders. There are also interface stakeholders, which function both externally
and internally; for health care organizations these groups would include the medi-
cal staff, the governing body, and stockholders in the case of for-profit organizations.
External stakeholders for health care organizations include patients, community orga-
nizations, insurers, vendors, competitors, employers, labor unions, and regulatory and
accrediting bodies (Ledlow & Coppola, 2014). Sometimes stakeholders are individu-
als; more often they are groups. Figure 4.3 illustrates a generic model of stakeholder-
organizational relationships.

Stakeholder Management

Health organization leaders must thoroughly understand the function and role of stake-
holders to determine which are relevant to their organizations and then assess which are
potential partners or allies and which are potential threats. Stakeholders have their own

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Section 4.4Stakeholder Dynamics

interests and agendas, which may
align or conflict with that of the health
organization, and they all make
demands on the organization to some
degree. Balancing the demands of
multiple stakeholders pursuing dif-
ferent interests and seeking to influ-
ence the organization to act in ways
that further their agendas is a major
challenge for health organization
leaders—especially when conflicting
responsibilities to patients, governing
bodies, professional staff, employees,
and community pose ethical dilem-
mas (Levey & Hill, 1986). Achiev-
ing this balance is part of the larger
challenge of delivering high-quality
care while simultaneously increas-
ing access to health care services
and reducing costs; to achieve one
objective often involves a trade-off in
another area. Thus, health organiza-
tion leaders are hard-pressed to sat-
isfy their various stakeholder groups
in terms of what these stakeholders
most value in terms of access, cost,
and quality (Coppola, Erckenbrack,
& Ledlow, 2009).

Stakeholder analysis is a widely used method in health organizations to understand how
different stakeholders influence the organizational decision-making process. As part of
the strategic planning process, it is especially useful in generating knowledge of relevant
individuals, groups, and organizations in order to understand their interests, agendas,
interrelationships, resources, and vulnerabilities (Brugha & Varvasovszky, 2000). When
stakeholder representatives are willing to forthrightly state the positions of their organiza-
tions and share these with other relevant stakeholders, organizational leaders can engage
in a more transparent and productive relationship with stakeholders. Unfortunately, this
situation rarely occurs, so it is often necessary to conduct interviews, focus groups, or sur-
veys to discern stakeholders’ true intentions or to accurately predict their actions.

Interface stakeholders present the biggest challenge in stakeholder management, since
they interact with the organization across boundaries. With the increase in integrated
delivery systems and new organizational structures, the number and types of these stake-
holders are increasing. Managers need to identify the key stakeholders and understand
their interests and agendas in order to develop and sustain successful relationships with
them (Dansky & Gamm, 2004).

Figure 4.3: Stakeholder-organizational

relationships

An understanding of stakeholder-organizational
relationships is essential to stakeholder management.

O
w

n
er

s/
G

er
nin

g B
ody

R
e

g
u

lators/Advocates Custo
me

rs
/B

uy
er

s/
P

a
y
e

Suppliers/W
orkers

Organization

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Section 4.4Stakeholder Dynamics

Physician Relations

Physicians are key interface stakeholders who can interact across organizational bound-
aries to manage a variety of internal and external stakeholders. In addition to practic-
ing medicine, physicians may serve on hospital, medical group, and health plan commit-
tees; on medical school faculties; on governmental planning or advisory committees or
review boards; as consultants to pharmaceutical, medical device, and other health care
organizations; and as expert witnesses in legal actions. In these various roles they can
be valuable sources of organizational business intelligence. Physicians also represent the
organization to the external environment and thereby contribute positively or negatively
to the organization’s reputation and image, particularly with respect to clinical outcomes
and quality-performance indicators reported to and reviewed by insurers and regulatory
and accrediting agencies. Most importantly, physicians represent their organizations to
patients; as patient care managers, they are the principal source of both the medical care
and the information about the care that patients receive.

Since stakeholder relationships directly impact an organization’s financial performance,
an important function for health organization executives is to help physicians, as interface
stakeholders, develop and maintain strong positive connections with their mutual key stake-
holders of patients, insurers, and regulatory and accrediting agencies. To do this involves
assessing specific physician behaviors about patient communications, adherence to insur-
ance clinical and administrative protocols, and compliance with regulatory and accrediting
agency data collection and reporting requirements (Malvey, Fottler & Slovensky, 2002).

Theory in Action: Training Physicians as Group Leaders

An example of how health organizations might help physicians with patient communications
is to offer them training in group facilitation and education skills. Group patient visits are an
emerging trend in a growing number of medical practices today and have been proposed as one
way to deal with anticipated increases in demand for medical care by newly insured patients
under the ACA.

The percentage of practices offering group visits grew from 6% to 13% between 2005 and 2010
and includes some of the nation’s leading medical groups such as the Cleveland Clinic and
Harvard Vanguard Medical Associates (Park, 2013). Cleveland Clinic nurses note that shared
medical appointments have improved patient access, outcomes, and patient satisfaction. For
chronic conditions, patient education is repetitive and time-consuming yet necessary; group
visits are a much more efficient way to provide this education. They allow providers to devote
more time to patients and encourage patients to learn from each other how to manage their
conditions. Additionally, the group visit model allows nurse practitioners to serve as primary
care providers by leading patients in group discussions and evaluating their current health
status (Bartley & Haney, 2010). Physicians who move into management positions will benefit by
acquiring skills in group leadership.

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Section 4.4Stakeholder Dynamics

Strong positive relationships with physicians are essential to health organizations in
almost every sector of the industry. Pressures to do more with fewer resources make it
more difficult to maintain the trust and respect that are essential building blocks of posi-
tive relationships. As a result, relationships with physicians are becoming more adver-
sarial than collaborative. This situation often negatively impacts workplace morale and
patient care and increases the risk of litigation and its associated costs (Yamada, 2009).

Under conditions of steadily increasing economic pressures to deliver high-quality care at
affordable costs, physicians and administrators today must (a) document in increasingly
precise and standardized ways how they are meeting quality standards and (b) break down
and justify their service charges to increasingly demanding and sophisticated purchasers
of care. These pressures drive efforts for health organization alignments with physician
groups. However, achieving successful alignment is difficult for administrators and physi-
cians alike, since their training and professional orientation predispose them to different
ways of working. Physicians and nurses operate from a clinical framework, advocating
at the individual level for patients and families, while managers are trained to look at
population-level health status and organization-wide issues. Health administration edu-
cation emphasizes working collaboratively with employees and colleagues, while clinical
care education focuses on development of individual skills and competencies (Buchbinder
& Shanks, 2012). Research on hospital-medical staff collaborations and the effectiveness of
interdisciplinary teams shows that conflicts between physicians and hospital staff (includ-
ing nurses) are often due to physicians’ refusal to embrace teamwork (Weber, 2004).

The ACA has strong financial incentives designed to encourage closer physician-
organization alignment through formation of clinically and administratively integrated
delivery systems called accountable care organizations (ACOs), as discussed in Chapter 2.
Integration offers physicians opportunities to access greater financial resources and focus
on practicing medicine while remaining independent members of their medical group or
independent practice association. To succeed, integrated arrangements require structures
and processes for administrators and physicians to jointly set goals, develop strategies,
make decisions, and resolve conflicts. Studies of successful physician-integration efforts
found that trust was considered the critical success factor in establishing the cooperative
relationship necessary to make these processes work, and identified these indicators of
trust-based relationships (Zuckerman et al., 1998):

• frequent, open, and candid communication, both formal and informal;
• willingness to share and explain relevant clinical, financial, and performance data;
• demonstrated management competence—responsiveness, following through on

actions, and delivering on promises; and
• placement of physicians in management and governance positions.

There are varying degrees of physician alignment, ranging from loosely structured con-
tractual agreements to those in which the physicians become salaried employees of either
the hospital/health system or a separate integrated services–delivery organization. Hos-
pitals and health systems were eager to acquire and manage physician practices during
the 1990s, but many of these acquisitions turned out to be expensive mistakes: Hospitals
did not know how to manage medical practices, and many physicians were less hardwork-
ing and productive as employees than they had been as independent practitioners. Today
hospitals recognize the need to carefully evaluate physician practices before acquiring

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Section 4.5Organizational Misbehavior and Dysfunction

them and to employ experienced medical group administrators to manage them (Aston,
2013). Professional services agreements in which the physician remains employed by the
practice allow physicians to more closely align with a health system without becoming an
employee. Various practice services agreement models enable hospitals and health sys-
tems to realize financial benefits without incurring the legal obligations and financial risks
of an employer (Reiboldt & Greeter, 2013).

4.5 Organizational Misbehavior and Dysfunction
Organizations, like individuals, can behave in ways that are counterproductive, self-
defeating, and even pathological. Researchers have found that organizational dysfunc-
tion reflects problems with the leadership of the organization and, to a lesser extent, with
managers at lower levels. This chapter concludes by discussing the diagnosis, prognosis,
and treatment of organizational dysfunction.

Theory in Action: Crime Does Not Pay

Some cases of organizational misbehavior are so flagrant that they make front page headlines,
such as the saga of Richard Scrushy. Trained as a respiratory therapist, Scrushy quickly rose
to top management and in his early 30s founded the HealthSouth Corporation to deliver a
wide range of outpatient rehabilitation services. The company soon went public and rapidly
expanded into sports medicine and workers’ compensation, despite repeated lawsuits and
settlements with Medicare and private insurers claiming fraudulent billing practices. Scrushy
enjoyed and flaunted the company’s success, earning millions of dollars and traveling and
living in high style. He was widely admired as a brilliant businessman—until he was indicted
for securities fraud.

Although all five of the HealthSouth chief financial officers who worked for him were found
guilty and sentenced to prison terms, Scrushy was acquitted. However, a few months later
Scrushy was convicted on unrelated charges and spent about 5 years in prison. Once revered as
a Wall Street wonder, today Scrushy is a poster boy for greed who was profiled in a 2009 episode
of the CNBC series American Greed.

Diagnosing Organizational Misbehavior and Dysfunction

Seldom is organizational misbehavior by health organization executives so clearly patholog-
ical. More often organizational dysfunction reflects egotism and groupthink, when highly
intelligent people display poor judgment. It can also result when leaders are unable to

• clearly articulate the organization’s vision, values, goals, and culture;
• engage and motivate employees;
• develop meaningful reward systems; and
• effect needed changes (Graber, 2009).

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Section 4.5Organizational Misbehavior and Dysfunction

Manfred Kets de Vries (2003) of the international INSEAD business school faculty developed
a typology of five types of neurotic organizations based on the typical and repetitive behav-
ior patterns of their leaders and managers and the effects of these behaviors on the organiza-
tion’s employees. Each style has its strengths and weaknesses, as displayed in Table 4.4.

Table 4.4: Neurotic organization leadership style summary

Style Description Illustrative
example

Strengths Weaknesses

Dramatic Driven by the
need to impress
and gain atten-
tion. Leaders are
highly charis-
matic, act boldly,
are undeterred
by risk, and take
controversial
stands.

Richard Branson,
Virgin Airlines

Strong entrepre-
neurial spirit

Decisions may
become too
centralized;
leader may
micromanage.

Suspicious General atmo-
sphere of distrust
and paranoia;
hyperalertness
for problems and
enemies.

J. Edgar Hoover,
Federal Bureau of
Investigation

Knowledge
and aware-
ness of external
threats and
opportunities

Punitive poli-
cies; encourages
subterfuge and
information
hoarding.

Compulsive Preoccupied with
rules; exhaustive
evaluation proce-
dures. Relation-
ships defined
by control and
acquiescence.

John Akers, IBM Efficient opera-
tions, strong ana-
lytics, thorough
problem-solving
approach

Risk of analysis
paralysis.

Detached Cold, unemo-
tional; lack of
involvement;
indifference to
praise or criti-
cism; intolerance
of dependency.

Howard
Hughes, Hughes
Corporation

Open to ideas
and influence
from people at
all levels and
outside the
organization

Leadership
vacuum induces
managers to
create individual
fiefdoms.

Depressive Inactivity, pas-
sivity, powerless-
ness, insularity;
lack of confi-
dence in ability
to effect changes.

Many government-
sector organizations

Consistent inter-
nal processes

Focus on mainte-
nance of internal
processes; can
become detached
from the
marketplace.

Source: Kets de Vries, M. (2003). Organizations on the couch: A clinical perspective on organizational dynamics. Retrieved August 19,
2013, from INSEAD Faculty & Research website: http://www.insead.edu/facultyresearch/research/doc.cfm?did=1321

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http://www.insead.edu/facultyresearch/research/doc.cfm?did=1321

Section 4.5Organizational Misbehavior and Dysfunction

Organizational Dysfunction Prognosis

Leaders in dysfunctional organizations often struggle to understand why people in the orga-
nization continue to behave in counterproductive ways that result in poor strategic deci-
sions, ineffective execution of strategy, factionalized management teams and business units,
hiring mistakes, inadequate succession planning, and low productivity. Too often, however,
they blame others for their own lack of communication and problem-solving skills.

Organizations that are in a state of decline or experiencing rapid and unsettling change
display a variety of similar dysfunctional characteristics when they lose resources (rev-
enue or market share) and employees, which Cameron (1994) identified as the “dirty
dozen” (p. 183):

1. Decision making is centralized, as employee empowerment is constrained.
2. Long-range planning is neglected in favor of focusing on short-term survival and

crisis management.
3. Tolerance for risk taking and learning from mistakes decreases.
4. Employees become more resistant to change in order to protect themselves from

loss of jobs, benefits, and perks.
5. Morale drops as employees become suspicious and angry.
6. Special interest groups become more visible and outspoken.
7. Across-the-board cutbacks are used to minimize organizational resistance.
8. Organizational leaders lose credibility with subordinates.
9. Organizational competition for shrinking resources leads to conflict and

infighting.
10. Information, especially bad news, is suppressed rather than passed up the

hierarchy.
11. Teamwork declines as employees focus on individual performance and rewards.
12. Leaders are blamed for organizational uncertainty and decline.

Astute professionals will be aware of and alert to these warning signs of organizational
dysfunction and take steps to address them promptly to prevent further deterioration and
improve organizational functioning.

Organizational Dysfunction Treatment

The remedy for organizational dysfunction is evidence-based management, which involves
using leadership practices supported by solid research. Walshe and Rundall (2001) observed
that just as clinicians have been slow to adopt an evidence-based approach to their own
practices, so have health care managers: They also tend to overuse ineffective interventions
and underuse effective ones. Shortell (2006) named ineffective health managerial decision
making as a significant contributor to the quality deficiencies, excessive costs, and overall
underperformance of the U.S. health care system. A later study by Kovner and Rundall
(2006) found that improving the quality of management decision making received little
attention, even when a management mistake results in significant harm to patients or
financial loss, such as the failed merger of Stanford University and University of California
hospitals that cost $176 million over a 29-month period. Health-system leaders believed
that their organizational cultures promoted the use of evidence-based decision making—
but their definition of evidence consisted mostly of personal and anecdotal experience,

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Section 4.5Organizational Misbehavior and Dysfunction

information from Internet sites, and advice from consultants or services such as the advi-
sory board. None reported any oversight or regular review of the decision-making pro-
cesses in their organizations.

Health organization executives and managers have been reluctant to acknowledge their
mistakes for the same basic reasons that prevent clinicians from doing so: They are embar-
rassed and do not want to lose face with colleagues. They may also lack financial or staff
resources or time to adequately research, analyze, or monitor the effects of a decision, or
they may be under pressure from superiors, medical staff or regulatory agencies. Some
executive decisions seem reasonable at the time they are made but turn out badly. Further-
more, it often takes a long time before it is clear that a specific decision is not working out
as planned. Hoffman (2002) urges health organizations to encourage managers to disclose
and learn from their mistakes by taking the following actions:

• Establish and obtain governing board approval for a managerial disclosure policy
based on criteria such as legal risk, regulatory agency requirements, board man-
dates, and ethical considerations.

• Analyze the root causes of the problem, the decision-making process, and its
consequences.

• Discuss the analysis with the management team to determine how best to avoid
repetition of a similar error, such as:
1. articulating lessons learned,
2. developing new or modifying existing policy,
3. changing the decision-making process, and/or
4. developing new or modifying training activities.

• Learn more about how to handle management mistakes from case studies of
other health organizations and national professional development organizations’
educational programs.

• Incorporate questions or discussions of mistakes and lessons learned into execu-
tive, managerial, and supervisory performance reviews.

Cohen (2011) makes a business case for use of evidence-based human-capital manage-
ment practices in health care organizations where at least 60% of budgets are allocated to
labor costs and notes the financial benefits of such practices for staff recruitment, selec-
tion, development, and retention. For example, a poor executive hire could cost the orga-
nization 6 to 10 times that individual’s annual earnings. Pfeffer and Sutton (2006) recom-
mend that managers relentlessly seek new knowledge from both inside and outside their
companies and industries so that they can keep updating their skills and knowledge, just
as medical professionals must do.

Because clinicians and health administrators have different professional cultures,
research orientations, and decision-making styles, evidence-based practice concepts
need to be translated from the clinical to the management arena (Walshe & Rundall,
2001). “Until both components are in place—identifying the best content (i.e., EBM [or
evidence-based medicine]) and applying it within effective organizational contexts
(i.e., EBMgt [or evidence-based management])—consistent, sustainable improvement
in the quality of care received by US residents is unlikely to occur” (Shortell, Rundall, &
Hsu, 2007, p. 673). The following case study describes the use of evidence-based medi-
cine and management to improve patient safety.

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Section 4.5Organizational Misbehavior and Dysfunction

Case Study: Improving Responses to Medical Errors With
Organizational Behavior Management

A 146-bed general acute care community hospital in southwest Virginia conducted an assessment
of patient safety needs and the various organizational behavioral management techniques
used by hospital managers in response to the nine most frequently reported patient safety
events. The most frequently reported category of patient safety events (errors) was procedure/
treatment variance, and the least effective management responses were to witnessed falls. The
organizational behavioral management intervention therefore selected managers’ follow-up
responses to procedure/treatment variance and witnessed falls as targets.

Managers first received the results of the needs assessment, then were instructed to (a) respond
to the two targeted event types with corrective-action communication combined with individual
and group behavior-based feedback and (b) use positive recognition to support behavior that
prevented harm, including reporting events. For the 3-month intervention period, researchers
Cunningham and Geller (2011) reviewed 361 patient safety event follow-up descriptions, with a
total of 527 interventions that achieved the following results:

1. Reports of targeted event types increased in the first month of intervention, then
decreased in subsequent months, indicating that the intervention increased employees’
sensitivity to the need to report close calls and learn from them.

2. The two targeted events displayed opposite trends in impact scores associated with
managers’ follow-up actions during the intervention phase. The impact scores for
follow-up behaviors for procedure/treatment variance increased sharply in the first
month, then gradually declined in the next 2 months. In contrast, impact scores for
follow-up behaviors for witnessed falls increased slightly in month one, then sharply in
subsequent months.

3. Managers significantly increased use of individual and group feedback during the
intervention phase and decreased use of no intervention, a significant improvement in
the management of patient safety errors. Especially significant was the increased use of
group feedback.

4. Participating managers and health care workers expressed positive perceptions of the
intervention techniques used and related outcomes. Managers received summaries of
the monthly events and intervention follow-up reports at monthly managers’ meetings
and were encouraged to share them with their employees. Intervention perception
survey results found that both managers and workers perceived an increase in managers
delivering praise for behaviors to prevent harm than delivering reprimands for errors.

This study demonstrates the benefits of applying an evidence-based intervention strategy by
teaching health care managers to (a) communicate more effectively in follow-up responses
to patient safety events, (b) more carefully document their follow-up actions to learn what
intervention behaviors do most to promote patient safety, and (c) provide group rather than
individual feedback when appropriate. This intervention demonstrably improved patient safety
and offers a model for managers in other organizations to follow.

Reflection Questions:
1. How does the trend in impact scores for managers’ follow-up actions reflect the Haw-

thorne effect?
2. Why was the increase in managers’ use of group behavior-based feedback important?
3. What would you recommend to sustain the use of the intervention strategy?

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Section 4.6Summary and Resources

4.6 Summary and Resources

Chapter Summary
Much of the work in organizations is done by teams of people rather than individuals.
Organizations need talented individuals who can work collaboratively with others. Being
a team player is an important attribute for success in most jobs, and being able to lead a
team effectively is a critical success factor for managers and leaders.

There are many different types of groups—formal and informal, permanent and tempo-
rary, structural and functional. An understanding of group dynamics and processes helps
managers effectively channel and coalesce the skills and efforts of their subordinates for
maximum productivity and performance. Not all employees are natural team players, so
managers also need to know how to deal with negative individual and group behaviors.

High-performing teams are results oriented, with managers who set clear performance
expectations and hold them accountable. Effective team managers establish a climate of
trust, so that team members can be open with each other when asking for or offering help.
They also encourage and manage constructive conflict, so that members of the group can
frankly debate their ideas and consider a wide range of solutions. Without a free exchange
of ideas, team members will lack commitment to the plan of action or fall victim to group-
think, a condition that occurs when group loyalty prevents members from expressing
their doubts about or opposition to an apparent consensus decision.

Health organizations have many different stakeholder groups with which they interact
and which have a vested interest in the organization. Stakeholders’ interests may align or
conflict with those of the organization, so balancing their demands is a major challenge
and responsibility for organizational leaders. Developing and maintaining positive rela-
tionships with physician stakeholders is a critical success factor for leaders of most health
organizations, as is attention to the experience of patient stakeholders.

Just as physicians are increasingly expected to make deliberate and thoughtful use of the
current best clinical evidence when making treatment decisions, so should health admin-
istrators use management practices that are supported by solid research. In addition,
health organizations should create conditions that encourage leaders and managers to
acknowledge and learn from their own and others’ mistakes.

Critical Thinking and Discussion Questions
1. What are examples of task and maintenance roles for health organization group

leaders, and why are both roles important?
2. Can a group leader streamline the group development process?
3. How can managers help a task force end on a positive note?
4. How can managers hold teams accountable for results?
5. Why is lack of conflict a sign of a dysfunctional team?
6. Identify the key internal, interface, and external stakeholders for a general acute

care hospital.
7. Give an example of evidence-based management.

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Section 4.6Summary and Resources

Key Terms

Abilene Paradox (Harvey) An agreement
to a group decision that none of the group
members desires, but each member thinks
the other members of the group prefer the
decision.

adjourning The final stage of group
development process, when the group
disbands after task completion.

blocking roles Behaviors that hinder a
group from accomplishing its goals.

command groups Groups specified in the
organization chart; members are respon-
sible for a specific function.

committees Formal groups that have per-
manent standing within the organization’s
administrative structure, regular meetings,
and elected or appointed members, often
with specific terms.

evidence-based management Manage-
ment practices based on effectiveness sup-
ported by research.

evidence-based medicine Clinical care
practices based on effectiveness supported
by research.

external stakeholders Members of groups
outside the organization, such as custom-
ers, suppliers, and regulators.

formal groups Groups officially desig-
nated by the organization to fulfill certain
functions and accomplish specific tasks.

forming The first stage in group devel-
opment process, when groups organize
themselves and establish boundaries for
task and relationship behaviors.

functional role theory (Benne and Sheats)
The observation that individuals in small
groups played task roles, maintenance
roles, or individual (blocking) roles.

groupthink (Janis) Remaining loyal to
a group position even when the policies
are not working out or the members have
misgivings about the position.

identity group A group in which mem-
bers share a common biological character-
istic or experiences.

independent practice association A
medical group formed as an economic
bargaining unit in a managed care delivery
system.

individual roles Behaviors that help a
group accomplish its goals.

informal groups Naturally formed groups
of people who work together or who are
drawn together on the basis of friendship
or shared interests.

informing A group process preparation
stage that involves an invitation to mem-
bership and prospective group members
forming opinions about the purpose of the
group and its members.

interface stakeholders Stakeholders that
function both internally and externally,
such as the medical staff, governing body,
and stockholders of for-profit corporations.

internal stakeholders Employees, includ-
ing executives and managers.

maintenance roles Roles that are social
in nature, focusing on process and
relationships.

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Section 4.6Summary and Resources

neurotic organizations Organizations
that are characterized by counterproduc-
tive behaviors that impede achievement of
organizational goals.

norming The third stage of group devel-
opment process, when members develop
feelings of cohesion and adopt new roles
as group members.

organizational behavior management
Intervention techniques designed to
improve managerial effectiveness.

organizational groups Groups to which
members are assigned based on the organi-
zation’s division of labor and its authority
structure.

performing The fourth stage of group
development process, when members
focus their energies on accomplishing the
task for which they are responsible.

role A key construct of psychology; the
shared social expectations of how an indi-
vidual behaves in a given situation.

stakeholders Individuals, groups, and
organizations that have a vested interest in
the organization.

storming The second stage of group
development, when members compete
for leadership or to control the group’s
direction.

task force A temporary group charged
with solving a problem or responding to
an opportunity.

task roles Roles that are involved with
completing a job and accomplishing an
objective.

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