chapter 5 | Organizations, Power, and Empowerment 59organizations. These organizations can be classi-
fied into three types on the basis of their sponsor-
ship and financing:
1.Private not-for-profit.Many health-care
organizations were founded by civic, charitable,
or religious groups. Some have been in exis-
tence for generations. Many hospitals, long-
term care facilities, home-care services, and
community agencies began this way. Although
they need money to pay their staff and expenses,
they do not have to generate a profit.
2.Publicly supported.Government-operated
service organizations range from county public
health departments to complex medical centers,
such as those operated by the Veterans
Administration, a federal agency.
3.Private for-profit.Increasing numbers of health-
care organizations are operated for profit like
any other business. These include large hospital
and nursing home chains, health maintenance
organizations, and many freestanding centers
that provide special services, such as surgical
and diagnostic centers.
The differences between these categories have
become blurred for several reasons:
■All compete for patients, especially for patients
with health-care insurance or the ability to pay
their own health-care bills.
■All experience the effects of cost constraints.
■All may provide services that are eligible for
government reimbursement, particularly
Medicaid and Medicare funding, if they meet
government standards.
Organizational Characteristics
The size and complexity of many health-care organ-
izations make them difficult to understand. One way
to begin is to find a metaphor or image that describes
their characteristics. Morgan (1997) suggested using
animals or other familiar images to describe an organ-
ization. For example, an aggressive organization that
crushes its competitors is like a bull elephant, where-
as a timid organization in danger of being crushed by
that bull elephant is like a mouse. Using images, an
organization adrift without a clear idea of its future in
a time of crisis could be described as a rudderless boat
on a stormy sea, whereas an organization with its
sights set clearly on exterminating its competition
could be described as a guided missile.
Organizational Culture
People seek stability, consistency, and meaning in
their work. To achieve this, some type of culture
will develop within an organization (Schein, 2004).
An organizational culture is an enduring set of
shared values, beliefs, and assumptions (Cameron
& Quinn, 2006). It is taught (often indirectly or
unconsciously) to new employees as the “right way”
or “our way” to assess patient needs, provide care,
and relate to fellow caregivers. As with the cultures
of societies and communities, it is easy to observe
the superficial aspects of an organization’s culture,
but much of it remains hidden from the casual
observer. Edgar Schein, a well-known scholar of
organizational culture, divided the various aspects
of organizational culture into three levels:
1.Artifact level:visible characteristics such as
patient room layout, patient record forms, etc.
2.Espoused beliefs:stated, often written, goals;
philosophy of the organization
3.Underlying assumptions:unconscious but
powerful beliefs and feelings, such as a commit-
ment to cure every patient, no matter the cost
(Schein, 2004)
Organizational cultures differ a great deal. Some are
very traditional, preserving their customary ways of
doing things even when these processes no longer
work well. Others, in an attempt to be progressive,
chase the newest management fad or buy the latest
high-technology equipment. Some are warm, friendly,
and open to new people and new ideas. Others are
cold, defensive, and indifferent or even hostile to the
outside world (Tappen, 2001). These very different
organizational cultures have a powerful effect on the
employees and the people served by the organization.
Organizational culture shapes people’s behavior,
especially their responses to each other, which is a
particularly important factor in health care.
Culture of Safety
The way in which a health-care organization’s oper-
ation affects patient safety has been a subject of much
discussion. The shared values, attitudes, and behav-
iors that are directed to preventing or minimizing
patient harm have been called the culture of safety
(Vogus & Sutcliffe, 2007). The following are impor-
tant aspects of an organization’s culture of safety:
■Willingness to acknowledge mistakes
■Vigilance in detecting and eliminating error-
prone situations