- Organisation
A group of individuals who interact with each other to achieve a common goal
Researchers have identified many different types of organisations (McKenna, 1998). The term organisation includes a hunting tribe in Papua New Guinea, a primary healthcare unit somewhere in the Northern Territory, a university in New Zealand, a sophisticated cancer research institute in France and the World Health Organization itself. What do these organisations have in common? First, they have one or more objectives. This means that their activity has a direction and purpose. The French institute tries to better understand cancer and its treatment. The tribe has a mission to hunt for food and to survive. The university exists to train new specialists and health professionals. Second, all of these organisations have two or more members within them. Third, all of these members are organised. The primary healthcare centre has a doctor (or several doctors), a nurse (or several nurses), a receptionist and a practice manager. All these people have different responsibilities, but all these activities are targeted at achieving a common goal. The World Health Organization has a more sophisticated organisational structure, with different specialists and functions. Therefore, an organisation could be described as a group of individuals who interact with each other in an interdependent relationship towards achieving a common goal or goals.
Organisations are platforms for management. For a better understanding of this, we need to discuss the structure of organisations. All organisations (from primeval tribes to international corporations) have certain similar structures, presented in Figure 1.1. All organisations are targeted to achieve a series of agreed goals. This means that all organisations produce results, or outcomes. For example, results for a tribe will be hunted game; for a hospital, healthy patients; for a pharmaceutical company, a new drug against hypertension. However, we cannot expect these desired results to occur without doing something. Therefore, we always have to develop some process before seeing results. Processes for a hospital may be the examination, treatment and rehabilitation of patients; for a university, the teaching of students; and for a non-governmental organisation, running a project against smoking.
Figure 1.1 Structure of an organisation
These processes (a core of any organisation) are possible if we have objects, people and tools. A hospital will stop functioning if it does not have patients admitted with health issues. We can define these patients as objects. Little will happen to these patients if there are no health specialists, which we define as the workforce. The workforce ensures a process within the organisation. In this case, doctors, nurses and other allied health specialists take care of the patients. However, for most of the processes we need tools, or instruments. Doctors and nurses would not be able to do much without facilities, technologies and drugs. All these instruments help the workforce in the process towards achieving the common goals or outcomes.
A disorganised group of people will not be able to achieve their organisation’s goals. If we want a group to work effectively and in one direction, we need to have adequate management.
Management
As we have already seen, there are many definitions of management. Literally every author provides their own definition; however, the main principle is the same in all definitions and lies in the classic works of French mining engineer Henri Fayol, known for his theory on the fundamental functions of management. According to Fayol (1917), every manager plans, organises, commands (or leads), coordinates and controls. This definition of management is generic: it should be suitable for all industry sectors. Can it be applied to the healthcare sector?
- Management
Planning, organising, leading and controlling resources in order to achieve an organisation’s goals
Management happens in organisations, so health management happens in health organisations. According to the World Health Organization (2000), all the organisations, institutions and resources that are devoted to producing health actions are components of a health system. Based on this, we can define health management as planning, organising, leading and controlling resources in order to promote, restore or maintain health. It is noteworthy that some authors use the terms healthcare management and health services management; these emphasise the focus on the organisation and delivery of services (Fulop, Allen, Clarke & Black, 2001). Health management covers management and organisation of the health system and its various subsystems and components (Hunter & Brown, 2007).
- Health management
Planning, organising, leading and controlling resources in order to promote, restore or maintain health
- Health system
Combined activities whose primary purpose is to promote, restore or maintain health
However, health management has an unfortunate reputation. It is often regarded as an unnecessary activity that at best diverts resources from the real frontline activities of providing healthcare or preventing ill health (Green, Collins & Mirzoev, 2012). Nevertheless, scientific data oppose this. A recent systemic review has proven clear positive correlation between the performance of healthcare systems and their organisation and management practices, leadership and manager characteristics (Lega, Prenestini & Spurgeon, 2013).
Health management is a social process and reflects national social, political and cultural values. It cannot be transferred easily from one country to another. Most likely, successful health management practices in New Zealand will not work in Tajikistan. This is not because of any ineffectiveness in New Zealand’s principles; simply, these two countries have different histories of development.
The World Health Organization’s (1999) regional office for Europe has identified the most crucial functions for public health managers. Although these principles are targeted at the European region, they are relevant in the Australasian context.
Essentially what is needed are public health managers, with the skills to manage partnerships and coordinated multisectoral action within alliances. They must … be trained in population-based analysis of health problems, be grounded in the approaches to deal with problems of lifestyles, the environment and health care, and be capable of the advocacy and networking needed to bring many partners together. They must also be skilled in creating excellent public health information for the general public, professionals and politicians.
Within the health service itself they must be trained in policy and programme planning, including target-setting, outcome measurement and evaluation, and instrumental in shaping the pattern of services provided. They must be able to help plan, monitor and evaluate broad health development programmes, defined by disease category or client group, making scientifically informed judgements about the balance to be struck … between health promotion, disease prevention, therapy and rehabilitation.
Organisations, then, need management. Therefore, all organisations have formal managerial positions – for example, chief executive officer, director, president, vice-chancellor and director of nursing. A 2011 survey found that 22 400 managers were employed in all health services in Australia (Martins & Isouard, 2014), and this number had increased by 15.6 per cent since 2006.
For many years, there was a common understanding that all management functions should be delegated to formal managers with the power to manage organisations, and their departments and units. However, new approaches suggest that these responsibilities should not be concentrated in formal positions but shared within the organisation (for example, see Czabanowska, Smith, Stankunas, Avery & Otok, 2013). This means that more people in organisations should have a chance to participate in decision-making in and the running of organisations.
Leadership
This has inspired a discussion on the importance of leadership. According to the classic work of Abraham Zaleznik (1977), managers are reactive, and while they are willing to work with people to solve problems, they do so with minimal emotional involvement. On the other hand, leaders are emotionally involved and seek to shape ideas instead of reacting to others’ ideas.
Moreover, leadership is not locked to formal positions in organisations. This means that everybody can be a leader, and there can be more than one leader in an organisation. Many academics and managers emphasise the growing importance of leadership in the healthcare sector (Beaglehole, Bonita, Horton, Adams & McKee, 2004; Simpson & Calman, 2000). According to the literature, every public health and healthcare organisation should be engaged in developing leaders at every level and creating collaborative organisational cultures (Czabanowska et al., 2013).
What it is leadership? Researchers mostly define it according to their individual perspectives and the aspects of the phenomenon of most interest to them (Yukl, 2013), leading to many and varied views. Ralph Stogdill (1974, p. 7) reviewed over 3000 studies directly related to leadership and suggests that there are almost as ‘many different definitions of leadership as there are persons who have attempted to define the concept’. In this text, we use the definition of leadership devised by Peter Northouse (2007, p. 3): ‘a process whereby an individual influences a group of individuals to achieve a common goal’. This definition emphasises the main elements of leadership: it is a process, it entails influence, it occurs within a group setting or context, and it involves achieving goals that reflect a common vision.
- Leadership
‘A process whereby an individual influences a group of individuals to achieve a common goal’ (Northouse, 2013, p. 5)
According to Rowitz (2003, as cited in Stankunas et al., 2012, p. 582), health leadership ‘includes commitment to the community and the values it stands for’. Grainger and Griffiths (1998, as cited in Stankunas et al., 2012, p. 582) argue that ‘health leaders differ from leaders in other sectors, as they are required to balance corporate legitimacy, while also existing outside the corporate environment’. Kimberly (2011, as cited in Stankunas et al., 2012, p. 582) suggests that a flatter, ‘more distributed and collaborative world will require a new generation of leaders in public health with new mind sets, an appetite for innovation and interdisciplinary collaboration and a strong dose of political savvy’. Koh (2009, as cited in Stankunas et al., 2012, p. 582) believes that a health leader ‘must be the transcendent, collaborative “servant leader” who knits and aligns disparate voices together behind a common mission, pinpoints passion and compassion, promotes servant leadership, acknowledges the unfamiliarity, ambiguity, and paradox, communicates succinctly to reframe, and help understand the “public” part of public health leadership’. Another study emphasises that health leaders must be ‘exceptional “networker–connectors” capable of “putting the pieces of the jigsaw together”; they combine administrative excellence with a strong sense of professional welfare and actively develop the profession, articulate its shared values and build for the future’ (Day et al., as cited in Stankunas et al., 2012, p. 582).
This short discussion of health leadership reveals that most authors agree on the presence of Northouse’s (2007, p. 3) leadership elements in health leadership. However, they also emphasise health leadership’s specific characteristics, such as a servant leader approach with community and specific orientation to public health values, which make it unique and important in the health sector (Stankunas et al., 2012, p. 582).
Challenges
The specificity of the health sector creates many challenges for leadership. According to McAlearney (2006), there are two main challenges to developing leadership in healthcare settings: environment and organisation. Environmental challenges arise because healthcare organisations are faced with a myriad of regulatory influences, some largely out of their control. Therefore, provider organisations rarely have much power or influence over some areas – for example, reimbursement for hospital and doctor services.
McAlearney (2006, p. 968) suggests that ‘multiple hierarchies of professionals, on both the clinical and administrative sides of the organization, generate special challenges for directing the organization and coordination of work in healthcare. Often noted is the cultural chasm between administrators and clinicians’. McAlearney also says that the healthcare industry is behind other sectors in implementing new leadership and management methods. This suggests a need for competent managers and leaders in healthcare organisations.
Power and skills
Both leadership and management are about influencing people in order to achieve organisational goals. The outcome (effectiveness) of the influence process depends largely on the power of the leader or manager over their followers or staff. Two major types of power have been identified: positional and personal (Rahim, 1988). Positional power is based on legitimate authority, control over resources, rewards, punishments, information and the physical work environment. Personal power comes from task expertise, friendship and loyalty. Gary Yukl (2010) claims that personal and position power have different subpowers, brief descriptions of which are presented in Table 1.1.
- Power
An agent’s ability to influence the target
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