A crucial component of value-based health care concerns the redesign of organizational structures. In theory, hospital structures should follow value creation: addressing medical conditions for specific groups of patients over full cycles of care. In practice, however, it remains unclear how hospitals can reorganize themselves into value-based structures. The purpose of this study is to explore the ways in which Dutch hospitals are currently implementing and pursuing value-based redesign.
The organizational structures of hospitals have repeatedly been criticized for impeding coordination, hampering efficiency, and delivering suboptimal patient care [1,2,3]. Moreover, much of this critique is supported empirically [2, 4,5,6]. In this regard, the recent and widespread uptake of value-based health care (VBHC) is of particular interest since a key component of VBHC concerns the redesign of organizational structures [3, 7, 8].
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While the pioneering work on VBHC has informed a range of health policies across the globe [9,10,11,12], the actual reorganization into value-based hospital structures remains unclear and understudied [10, 13, 14]. This study aims to provide a deeper understanding of how hospitals realign their organizational structure with the creation of value for patients. Our research zooms in on the Netherlands, a country in which VBHC is high on the national health policy agenda and where multiple hospitals have started implementing VBHC principles [15, 16]. Therefore, we examine how Dutch hospitals are currently working toward value-based redesign: structural coordination around medical conditions over full cycles of care. Accordingly, we offer insight into the various ways in which value-based redesign is established in practice.
In practice, however, profound structural changes such as these are highly challenging, particularly in organizations such as hospitals, where a highly professionalized workforce operates within firmly established traditional structures [1, 19]. Additionally, most of the changes professed by hardline VBHC proponents are primarily described conceptually, and several scholars have expressed the need for a deeper connection with real-life organizational complexities, including more explicit guidance that can aid providers in their internal reorganization process [10, 20].
To explore the ways in which Dutch hospitals are working toward more value-based structures, this qualitative study made use of semi-structured interviews and a focus group for data collection. Throughout the research, we have built on our synthesis of organizational design parameters [17] and VBHC [7].
I think you have two possible change strategies. One is that you have an idea, top-down, and you force it upon the organization, based on some kind of blueprint. [O]r, you let it arise organically from practice, bottom up, because the demand for a new organizational structure comes up. And that is the choice [our hospital] made (2).
Multidisciplinary, around a medical condition, we have now four [teams]. [E]ach of those [multidisciplinary teams] has a daily leadership board. [A]s the daily management of the team, the leadership board is responsible for the quality of care within such a team. [N]ow, we are mainly concerned with really working from within those multidisciplinary teams, that people know each other, know the process that a patient goes through, and know what the most important objectives are and shape that into a whole. [W]hat we are working toward is that these teams will be incorporated into the organizational structure (3).
Organizational structure affects organizational action and provides the foundation on which standard operating procedures and routines rest. It determines which individuals get to participate in which decision-making processes, and thus to what extent their views shape the organization's actions.[2] Organizational structure can also be considered as the viewing glass or perspective through which individuals see their organization and its environment.[2]
Bureaucratic have many levels of management ranging from senior executives to regional managers, all the way to department store managers. Since there are many levels, decision-making authority has to pass through more layers than flatter organizations. A bureaucratic organization has rigid and tight procedures, policies and constraints. This kind of structure is reluctant to adapt or change what they have been doing since the company started. Organizational charts exist for every department, and everyone understands who is in charge and what their responsibilities are for every situation. Decisions are made through an organized bureaucratic structures, the authority is at the top and information is then flowed from top to bottom. This causes for more rules and standards for the company which operational process is watched with close supervision. Some advantages for bureaucratic structures for top-level managers are they have a tremendous control over organizational structure decisions. This works best for managers who have a command and control style of managing. Strategic decision-making is also faster because there are fewer people it has to go through to approve.[citation needed] A disadvantage in bureaucratic structures is that it can discourage creativity and innovation in the organization. This can make it hard for a company to adapt to changing conditions in the marketplace.
The term of post bureaucratic is used in two senses in the organizational literature: one generic and one much more specific.[9] In the generic sense the term post bureaucratic is often used to describe a range of ideas developed since the 1980s that specifically contrast themselves with Weber's ideal type bureaucracy. This may include total quality management, culture management and matrix management, amongst others. None of these however has left behind the core tenets of Bureaucracy. Hierarchies still exist, authority is still Weber's rational, legal type, and the organization is still rule bound. Heckscher, arguing along these lines, describes them as cleaned up bureaucracies,[10] rather than a fundamental shift away from bureaucracy. Gideon Kunda, in his classic study of culture management at 'Tech' argued that 'the essence of bureaucratic control - the formalization, codification and enforcement of rules and regulations - does not change in principle.....it shifts focus from organizational structure to the organization's culture'.
Still other theorists are developing a resurgence of interest in complexity theory and organizations, and have focused on how simple structures can be used to engender organizational adaptations. For instance, Miner et al. (2000) studied how simple structures could be used to generate improvisational outcomes in product development. Their study makes links to simple structures and improviser learning. Other scholars such as Jan Rivkin and Sigglekow,[11] and Nelson Repenning[12] revive an older interest in how structure and strategy relate in dynamic environments.
A functional organizational structure is a structure that consists of activities such as coordination, supervision and task allocation. The organizational structure determines how the organization performs or operates. The term "organizational structure" refers to how the people in an organization are grouped and to whom they report. One traditional way of organizing people is by function. Some common functions within an organization include production, marketing, human resources, and accounting.
This organizing of specialization leads to operational efficiency, where employees become specialists within their own realm of expertise. On the other hand, the most typical problem with a functional organizational structure is that communication within the company can be rather rigid, making the organization slow and inflexible. Therefore, lateral communication between functions becomes very important, so that information is disseminated not only vertically, but also horizontally within the organization. Communication in organizations with functional organizational structures can be rigid because of the standardized ways of operation and the high degree of formalization.
The disadvantages of the divisional structure is that it can support unhealthy rivalries among divisions. This type of structure may increase costs by requiring more qualified managers for each division. Also, there is usually an over-emphasis on divisional more than organizational goals which results in duplication of resources and efforts like staff services, facilities, and personnel.
One of the newest organizational structures developed in the 20th century is team and the related concept of team development or team building. In small businesses, the team structure can define the entire organization.[16] Teams can be both horizontal and vertical.[20] While an organization is constituted as a set of people who synergize individual competencies to achieve newer dimensions, the quality of organizational structure revolves around the competencies of teams in totality.[21] The team could classified into functional team structure, lightweight team structure, heavyweight team structure and autonomous team structure.[22] For example, every one of the Whole Foods Market stores, the largest natural-foods grocer in the US developing a focused strategy, is an autonomous profit centre composed of an average of 10 self-managed teams, while team leaders in each store and each region are also a team.[23] Larger bureaucratic organizations can benefit from the flexibility of teams as well. Xerox, Motorola, and DaimlerChrysler are all among the companies that actively use teams to perform tasks.
As pointed out by Lawrence B. Mohr,[34] the early theorists of organizational structure, Taylor, Fayol, and Weber "saw the importance of structure for effectiveness and efficiency and assumed without the slightest question that whatever structure was needed, people could fashion accordingly. Organizational structure was considered a matter of choice... When in the 1930s, the rebellion began that came to be known as human relations theory, there was still not a denial of the idea of structure as an artifact, but rather an advocacy of the creation of a different sort of structure, one in which the needs, knowledge, and opinions of employees might be given greater recognition." However, a different view arose in the 1960s, suggesting that the organizational structure is "an externally caused phenomenon, an outcome rather than an artifact."[35] 2ff7e9595c
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