Organizational Structure of the Hospital

This teaching hospital in upstate New York has a fairly flat organizational structure, and this is particularly so in the nursing organization.  The Chief  Nursing Officer (CNO) has a set of a dozen Directors and  Associate Directors directly reporting to her from each of the major medical units in the hospital (i.e., critical care nursing, ambulatory care nursing, behavioral health nursing, clinical nursing research, emergency nursing, and so on.)  She also has two more administrative direct reports: the Nursing Support Operations director, and the financial management and reporting director (for nursing practice financial management, not the entire hospital).   The CNO herself reports to the Chief Medical Officer of the hospital who in turn is a direct report to the General Director and CEO of the hospital.  Thus, the CNO has only one management layer between her position and the CEO of the hospital.

How Organizational Structure Influences Operations

Butler & Ewald (2000) point out the vital importance of having an organizational structure that is flexible so the organization can respond appropriately as patient needs change. In this hospital, the organizational structure directly impacts how the hospital functions on a daily basis in a very positive way. One way this happens is due to the flat management structure.  There is a remarkable lack of red tape when it comes to making decisions about patient care which significantly increases flexibility and the ability to respond quickly to emergencies or changing conditions.  A floor nurse, say in the cancer center, can raise an issue with her floor manager, or even directly with the associate director for cancer center nursing.  Administrators and directors at all levels are  encouraged to have an “open door” policy and to spend as much time as possible walking through their areas of responsibility and talking with the staff there.  That flat organizational structure directly contributes to the effectiveness and the communication within the organization.

How Organizational Structure Affects Functionality

Janicijevic (2010) points out the crucial importance of incorporating an understanding of business processes in defining business structure and organization. In the case of this hospital, this is done by organizing the nursing staff in terms of the types of processes they perform—by grouping nurses who perform similar work functions (such as cardio nurses) in a single group.  This organization by functional processes contributes to the efficiency of the organization (Janicijevic, 2010). The organization also affects how the hospital functions on a daily basis.  While some concerns definitely span multiple units within the hospital, those can be processed by the CNO or the Nursing Support Operations Director or (if financial in nature) by the Financial Management & Reporting Director for the nursing organization. Most of the day-to-day functions are handled locally within the individual units.  Only rarely does an issue need to be escalated beyond that level, and even more rarely beyond the CNO herself.

The big advantage of this structure is that nursing functions are managed by those with the technical nursing background to make informed decisions about staff, technology, and other needs.  At the same time, the usual human resources (HR) problems (difficulties and questions with pay checks, benefits, vacation, sick leave, and other standard HR functions are handled by the nursing HR function specialists rather than by nursing managers.

Human Resources Impact on Organization and Function

One way HR departments are organized is by establishing separate operating-unit HR groups (Ulrich, Younger, and Brockbank, 2008).  While this is not optimal when the units are highly similar to each other, in the case of the hospital, the special needs of the nursing organization and the need for constant nurse recruitment, continuing education, and other HR requirements makes this scheme more suitable. Ulrich et al. (2008) defines this HR structure as as a “Shared Services” HR structure. The effect of the separation of HR functions from the technical nursing management is that decisions get made by those best qualified to make them.  That said, it is sometimes difficult to know who to approach when a problem crosses boundaries.  Issues with problems in family leave, tuition reimbursement, and many other cross-function situations may fall under multiple managers if they involve financial resources, general nursing HR concerns, and specific staff or work assignment issues.

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