Transforming Leadership in Hospitals

by Exploring Leadership Practices for Organizational Success

by

Natasha B.N. Brown

A dissertation submitted in partial fulfillment of

the requirements for the degree of

Doctor of Education

Field of Educational Leadership and Management

at the

DREXEL UNIVERSITY

Spring 2014

Drexel University

May 2014

© Copyright 2014 Natasha B.N. Brown All Rights Reserved

ii

Abstract Transforming Leadership in Hospitals

by Exploring Leadership Practices for Organizational Success Natasha B.N. Brown

Due to the complex and constantly changing environment in hospitals, many attempts in

leadership development and change management fail. The primary purpose of this

qualitative, descriptive case study was to better understand how leadership practices

contribute to organizational success at Lynford Memorial University Hospital’s

Comprehensive Acute Care Rehabilitation Unit (CARU). Organizational success was

defined by meeting the mission and continued financial viability and market

competitiveness. The conceptual stance was critical theory/pragmatism because the

researcher sought to bring about changes in the hospital leadership structure, practices,

and culture by creatively combining a variety of data sources to explore and understand

the research problem. The design included semi-structured, qualitative interviews with

members of the CARU leadership team, a focus group with CARU employees, analysis

of archival records, observation, and memoing. The conceptual framework provided a

systemic approach to explain the importance of integrating leadership practices to

promote organizational success. The researcher analyzed the data through the use of

open coding, axil coding, selective coding, and comparative method to discover themes

and non-supporting trends. The analysis revealed that leadership practices contribute to

organizational success in a hospital by: practicing the SCORE (Service Excellence,

Collaboration, Ownership, Responsibility, and Empowerment) Values with transparency

in leadership; developing rapport with employees and offering them personal and

iii

professional growth opportunities; practicing patient center care; controlling costs and

eliminating waste throughout the system; branding the exceptional care services; and

creating and achieving the desired outcomes environment. Analysis also revealed a non-

supporting trend: a discrepancy with managing large-scale changes better than small-

scale changes. The findings informed the development of a Strategic Leadership

Development Plan for implementation by the CARU leadership team and hospital

employees. Further research is needed to explore the impact of collaborative leadership

and organizational culture on the CARU and the impact of leadership practices on other

units of the hospital as well as on hospitals that are not urban, non-profit, academic

hospitals.

Keywords: employee engagement, financial accountability, leadership, organizational

change, organizational culture, organization development, organizational success, and

patient satisfaction.

v

Dedications

This dissertation is dedicated first to God, the Almighty Father of heaven, earth, and all

creations. The powerful blessings from God has guided me through this journey and provided me

with the knowledge, skills, and faith to trust and believe in all possibilities.

I dedicate this dissertation to my loving parents, Alma and Darnell Brown. They were my

first teachers and mentors in life. They taught me the importance of education, determination, and

respect. They sacrificed so much for me to achieve my personal and educational goals. I will

always love and honor them forever.

I dedicate this dissertation to my loving sisters, Marcella Brown, Shirleen Brown,

La’Tonya Brown and my loving brother, Darnell Brown. Your support and words of

encouragement helped me to complete my dissertation. I admire how you try to protect me from

any obstacles that steer my focus in the wrong path. I will always love and respect you.

I also dedicate my dissertation to my niece, Danielle Brown. I want to set a positive

example for her by being the first doctor in our family. I want her to understand that you can

accomplish all of your dreams by believing in yourself, staying on the path of righteousness, and

never giving up no matter what hardships you may encounter.

I dedicate my dissertation to my host of family, friends, and co-workers who have been my

support system since day one. They have helped me to balance juggling between work, school, and

my personal life so I could still have fun and experience good times during the dissertation process.

Finally, I dedicate this page to my dearest and beloved family members and friends I lost

along the journey. You may be gone, but you are truly remembered. I love you and thank you for

watching over me through the good times and the troubling times.

vi

Acknowledgements

I would like to express my sincere gratitude to my dissertation committee because they were

the key contributors to making sure I succeeded throughout the entire process. First, I would like to

acknowledge Dr. Deanna Hill, my mentor and committee chair for assisting and guiding me

through the dissertation process. I appreciate the time, knowledge, and wisdom you put into

helping me develop a quality dissertation. I also like to express my gratitude to the rest of the

committee members, Dr. Allen Grant and Dr. Jeffrey Branch for their feedback, dedication, and

encouragement both in class and during my dissertation process.

I would like to thank my colleagues from the Drexel University Philadelphia Cohort 2. The

feedback and professional support helped me during the dissertation process.

I would like to thank my employment supervisors Dr. Christine Jerpbak and Dr. William

McNett for allowing me to have a flexible work schedule and time off to complete my course work

and meet my dissertation requirements.

A special note of recognition goes to all of the Comprehensive Acute Rehabilitation Unit

(CARU) employees who participated in my dissertation. The information you provided was

invaluable and I truly respect your time and honesty.

vii

Table of Contents

Abstract ............................................................................................................................................... ii

Dedication Page ................................................................................................................................... v

Acknowledgements ............................................................................................................................ vi

Table of Contents .............................................................................................................................. vii

List of Tables ..................................................................................................................................... xii

List of Figures .................................................................................................................................. xiii

List of Appendices ............................................................................................................................ xiv

Chapter 1 – Introduction to the Research ............................................................................................ 1

Introduction to the Problem ............................................................................................................. 1

Statement of the Problem to be Researched .................................................................................... 4

Purpose and Significance of the Problem ........................................................................................ 5

Purpose Statement ....................................................................................................................... 5

Significance of the Problem ........................................................................................................ 6

Research Questions Focused on Solution Finding .......................................................................... 7

Conceptual Framework ................................................................................................................... 8

Researcher’s Stances ................................................................................................................... 8

Conceptual Framework of Three Research Streams ................................................................... 8

viii

Definition of Terms ....................................................................................................................... 11

Assumptions, Limitations, and Delimitations ............................................................................... 13

Assumptions .............................................................................................................................. 13

Limitations ................................................................................................................................. 14

Delimitation ............................................................................................................................... 14

Organization of the Study .............................................................................................................. 15

Summary ....................................................................................................................................... 15

Chapter 2 – Literature Review .......................................................................................................... 17

Introduction of the Statement of the Problem ............................................................................... 17

Conceptual Framework ................................................................................................................. 22

Definition of Terms ....................................................................................................................... 26

Critical Review of the Literature ................................................................................................... 28

Leadership practices (Organization development principles, employee engagement, and patient

satisfaction) ............................................................................................................................... 28

Organizational change (traditional hierarchy structure, collaborative leadership, and cultural

change) ...................................................................................................................................... 47

Introduction ................................................................................................................................... 60

Site and Population ........................................................................................................................ 61

ix

Population Description .............................................................................................................. 61

Site Description ......................................................................................................................... 62

Site Access ................................................................................................................................ 66

Research Design and Rationale ..................................................................................................... 67

Introduction of Design ............................................................................................................... 67

Rationale .................................................................................................................................... 68

Research Methods ......................................................................................................................... 70

Description of Methods Used .................................................................................................... 70

Interviews .................................................................................................................................. 71

Focus Group .............................................................................................................................. 73

Archival Data ............................................................................................................................ 74

Observations .............................................................................................................................. 75

Memoing ................................................................................................................................... 75

Stages of Data Collection .......................................................................................................... 76

Data Analysis Procedures .......................................................................................................... 77

Ethical Considerations ................................................................................................................... 78

Introduction ............................................................................................................................... 78

x

IRB Approval ............................................................................................................................ 78

Known or Anticipated Ethical Considerations Surrounding the Research ............................... 80

Summary ....................................................................................................................................... 82

Chapter 5 – Conclusions and Recommendations ............................................................................ 129

Introduction ................................................................................................................................. 129

Conclusions ................................................................................................................................. 130

Recommendations ....................................................................................................................... 135

For Actionable Solutions for the Research Problem ............................................................... 135

For Further Research ............................................................................................................... 137

References ....................................................................................................................................... 140

Appendix A ..................................................................................................................................... 144

Appendix B ...................................................................................................................................... 145

Appendix C ...................................................................................................................................... 146

Appendix D ..................................................................................................................................... 147

Appendix E ...................................................................................................................................... 148

Appendix F ...................................................................................................................................... 149

Appendix G ..................................................................................................................................... 151

xi

Appendix H ..................................................................................................................................... 153

Appendix I ....................................................................................................................................... 155

Appendix J ....................................................................................................................................... 156

Appendix K ..................................................................................................................................... 164

xii

List of Tables

Table 3.1 Research Data Collection Timeline ...................................................................... 76

Table 4.1 Focus Group Questions ....................................................................................... 92

xiii

List of Figures

Figure 1.1. Organizational Change and Success Theory .................................................................. 10

Figure 1.2. Organizational Success Theory ....................................................................................... 25

Figure 1.3. Center for Creative Leadership. ..................................................................................... 49

Figure 3.1. Lynford Memorial Rehab Department Organizational Chart ........................................ 65

Figure 4.1. Themes of the Research Data ........................................................................................ 86

Figure 4.2. Developing Talent .......................................................................................................... 96

Figure 4.3. Rewards for Successful Performances ......................................................................... 100

Figure 4.4. CARU Overall Mean Score Trend ............................................................................... 102

Figure 4.5. Rehabilitation Department Organizational Chart ......................................................... 110

Figure 4.6. Techniques for Effective Change Management. .......................................................... 113

Figure 4.7. Research Patterns .......................................................................................................... 119

xiv

List of Appendices

Appendix A: Introduction Letter ……………………………………………………. 163

Appendix B: IRB Approval Letter…………………………………………………… 164

Appendix C: Invitation Email for CARU Leadership Team………………………… 165

Appendix D: Invitation Email for CARU Financial Leader………………………… 166

Appendix E: Invitation Email for CARU Employees………………………………. 167

Appendix F: Leadership Team Interview Protocol…………………………………. 168

Appendix G: Financial Accountability Interview Protocol…………………………. 170

Appendix H: Employee Focus Group Interview Protocol…………………………… 172

Appendix I: Strategic Leadership Development Plan for CARU……………………. 175

Appendix J: Executive Summary…………………………………………………….. 176

Appendix K: Strategic Leadership Development Plan for CARU ………………..… 182

1

Chapter 1 – Introduction to the Research

Introduction to the Problem

Hospitals experienced an unprecedented amount of changes and resource dependence

(Bates, 2000; Gary, 1995; Goetz, Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Jungyoon,

2011; Kaufman & Goldstein, 2008; Levin & Gottlieb, 2009; Merry, 1994; Meyer Silow-Carroll,

Kutyla, Stepnick, & Rybowski 2004; Roberson, 2008; Rondeau & Wagar, 1998; Tsai, 2011).

Previous research indicated that there was a need to understand what it took to apply leadership

practices into hospital settings and how the process actually took place (Katz, 2007; Kim,

Thompson, & Herbeck, 2012; McAlearney, Scheck & Butler, 2008; Wolf, Hanson, & Moir, 2011).

However, an unprecedented amount of internal and external change was impacting organizational

success in hospitals (Farell, 2003; Katz, 2007; Mayfield, 2006; Wolf, Hanson, & Moir, 2011).

Hospital executives faced major challenges dealing with increasing shifts in the culture

demographics, the growing elderly population, and 60% of baby-boomers retiring within three- to-

five years (Berger & Berger 2011; Cummings & Worley, 2009, Farrell, 2003). Although personnel

shortages continued to increase, hospitals were struggling to develop experienced, competent

clinical staff and supervisors, excellent alignment of physician and hospital relationships, and

stakeholder relationships to ensure cooperation across the hospital functions (Browning, Toain, &

Patterson, 2011; Farrell, 2003). Meanwhile, for the last two decades leaders have been battling

declines in staff morale, and 44% of the United States population reported having low employee

engagement (Berger & Berger 2011; Farrell, 2003).

Complexity in changes also derived from technological advances and implementation of

new systems while trying to deliver quality health care, patient safety, and patient satisfaction

(Browning, Toain, & Patterson, 2011; Farrell, 2003). Hospitals were having difficulties trying to

2

attract higher levels of premium reimbursement while making complicated decisions on how to

successfully implement health care reform, manage budgetary restraints, and governmental

mandates (Browning, Toain, & Patterson, 2011; Farrell, 2003). Competition with other hospitals

and specialized treatment centers continued to impact profits and change the way health care was

managed and delivered (Carey, Burgess, & Young, 2011). According to the American Hospital

Association, 60% of the hospitals in the United States lost money in providing health care services

and $60 billion a year was lost due to patient registration errors (Legislative Advisory, 2010).

With the rate of chronic disease predicted to outgrow the general population, health care

executives needed well targeted leadership development initiatives to succeed in operational and

financial performances (Evashwick & Ory, 2003; Goetz, Janney, & Ramsey, 2011; Kim,

Thompson, & Herbek, 2012; McAlearney, Scheck, & Butler, 2008; Sears 2009). In today’s

economic and health care environment, hospital executives faced unprecedented challenges in their

systems; however, leadership practices that focused on enhancing organization development,

employee engagement, and patient satisfaction brought benefits to the workplace (Katz, 2007;

Kaufman & Goldstein, 2008). Successful hospitals developed from exceptional leadership

embedded in delivering high-quality outcomes in a cost effective manner (Goetz, Janney, &

Ramsey, 2011; Hughes-Cromwick, 2007; Kaufman & Goldstein, 2008; Meyer Silow-Carroll,

Kutyla, Stepnick, & Rybowski, 2004; Roberson, 2008). Hospital leaders needed to understand the

organizational themes that guided future growth. Hospital leaders also needed to examine how

successful hospitals harnessed financial forces. Key capabilities for emerging opportunities in

long-term economic and societal trends reshaped health care economies (Ovanessoff & Purdy,

2011).

3

The leadership roles of the hospital management teams fashioned the culture, formulated the

strategy, and directed the business operations to secure success (Ballein, 1997). Nurturing the

appropriate organization culture was vital to achieving a successful philosophy for maintaining

good hospital outcomes, effective quality improvement, establishing leadership, and establishing

ethical practices throughout the organizational channels (Meyer, Silow-Carroll, Jutyla, Stepnick, &

Rybowski, 2004). According to Katz (2007), various studies explained the importance of practicing

the organization development principles to “increase employee satisfaction, improve team

functioning, improve processes and increase efficiencies all contributing factors of improved

financial outcomes” (p. 121). Kaufman and Goldstein (2008) explained how excellence in health

care leadership practices among high performing organizations understand the big picture, practice

effective communication, lead through innovation, manage change, and built trust. In addition,

leadership development among the organizational cultural consisted of educational initiatives,

mentoring sessions, 360-degree feedback, skill-based trainings, continuing educational learning

programs, and leadership development programs (Kaufman & Goldstein, 2008; Kim, Thompson, &

Herbek, 2012; McAlearney, Scheck, & Butler, 2008). As a result, the present qualitative,

descriptive case study explored leadership practices that contributed to organizational

transformation and success as defined by organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change in Lynford Memorial University

Hospital’s Comprehensive Acute Care Rehabilitation Unit (CARU) located in the northeast region

of the United Sates (the researcher used a pseudonym for the hospital to protect the hospital and the

confidentiality of the participants in the study).

4

Statement of the Problem to be Researched

Due to the constantly changing and complex environment in hospitals, many attempts in

leadership development and change management fail (Kim, Thompson, & Herbeck, 2012;

McAlearney, Scheck & Butler, 2008; Wolf, Hanson, & Moir, 2011). As a result, the traditional,

vertical, hierarchal leadership structure prevented hospitals from reaching their peak performances

and competitive advantages (Evashwick & Ory, 2003; Gary, 1995; Jungyoon, 2011; Kaufman &

Goldstein, 2008; Merry, 1994; Ovanessoff and Purdy, 2011). Extensive research has been

conducted on leadership, organizational structure, change management, employee engagement,

patient satisfaction, financial performance, and organizational culture in hospitals (Berger &

Berger, 2011; Browning, Toain, & Patterson, 2011; Cummings & Worley, 2009; Evashwick & Ory,

2003; Gary, 1995; Jungyoon, 2011; Katz, 2007; Kaufman & Goldstein, 2008; Kim, Thompson, &

Herbeck, 2012; McAlearney, Scheck & Butler, 2008; Merry, 1994; Ovanessoff and Purdy, 2011;

Swanson & Holton, 2009; Wolf, Hanson, & Moir, 2011). However, little or no research explored

the phenomena of combining all of these elements to understand their impact on organizational

transformation and success in hospitals. Exploring the impact of organization development,

employee engagement, patient satisfaction, financial accountability, and organizational change in

hospitals may provide invaluable information to the health care industry, health care executives,

employees, patients, and health care educators.

The existence of hospitals depended on transforming the leadership structure and

responding to organizational changes through the use of leadership principles and financial

accountability initiatives (Bates, 2000; Gary, 1995; Jungyoon, 2011; Merry, 1994; Rondeau &

Wagar, 1998; Thompson, 2011; Trinh & Connor, 2006; Tsai, 2011). The transformation process of

an organization began with strategic positioning and organization of the processes, designs, and

5

environment to achieve specific results (Berger & Berger, 2011; Cummings & Worley, 2009; Daft,

2010; Swanson & Holton, 2009). At the organizational level, it was imperative for hospital leaders

to understand how they influenced organizational responses to internal and external forces

(Kaufman & Goldstein, 2008; Merry, 1994; Rondeau & Wagar, 1998). A systemic, collaborative

leadership approach was needed to strategically align the organizational goals to achieving high

performances (Berger & Berger, 2011; Browning, Toain, & Patterson, 2011; Cummings & Worley,

2009; Daft, 2010; Gary, 1995; Merry, 1994; Swanson & Holton, 2009). Therefore, this study was

designed to create a shared understanding of leadership practices for creating organizational

transformation and success as defined by organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change. This study focused on Lynford

Memorial’s Comprehensive Rehabilitation Unit (CARU) located in the northeast region of the

United States.

Purpose and Significance of the Problem

Purpose Statement

The purpose of this research was to create a strategic leadership development plan that

assisted hospital leaders in improving their organizations through transformative leadership

practices and financial accountability. The new millennium has drawn us into an era of

transformation as health care leaders manage the changes and challenges in the system (Bate, 2000;

Browning, Toain, & Patterson, 2011; Gary, 1995; Junyoon, 2011; Katz, 2007; Levin & Gottlieb,

2009; Merry, 1994; Rondeau & Wagnar, 1998; Sears, 2009; Thompson, 2011; Trinh & Connor

2002; Tsai, 2011; Wolf, Hanson, & Moir, 2011). The changes and challenges in our society

affected socioeconomics, cultural, political, environmental, academic, and financial arenas (Levin

and Gottlieb, 2009). The data collected from the qualitative, descriptive case study provided

6

evidence of the best leadership practices for promoting organizational transformation and success as

defined by organization development, employee engagement, patient satisfaction, financial

accountability, and organizational change in Lynford Memorial’s CARU.

Significance of the Problem

The significance of this study was paramount as it contributed invaluable insight and theory

into understanding organizational success and transformative leadership in hospitals defined by

organization development, employee engagement, patient satisfaction, financial accountability, and

organizational change. The changes and challenges in the hospital system impacted increasing

costs, competition, quality improvement, safety issues, and employee and patient satisfaction in

hospitals (Kaufman & Goldstein, 2008; Ovanessoff & Purdy, 2011; Carey, Burgess, & Young,

2011; Goetz, Janney, & Ramsey, 2011; Roberson, 2008; Hughes-Cromwick, Root, & Roehrig,

2007; Evashwick & Ory, 2003). Currently, some hospitals lacked the understanding about the

potential benefits of organization development principles, and the need to provide evidence and

data to support the value of organization development principles was essential (Katz, 2007).

Therefore, hospital leaders needed extended knowledge on how to use organization development

principles to reform their current leadership models for addressing issues in management, employee

engagement, patient satisfaction, finance, and change (Farrell, 2003; Shuck & Herd, 2012;

Cummings & Worley, 2009; Swanson & Holton, 2009; Berger & Berger, 2011; Katz, 2007;

Kaufman and Goldstein, 2008; Kim, Thompson, Herbek, 2012; McAlearney, Scheck, & Butler,

2008; Katz, 2007; Mayfield, 2008; Wolf, Hanson, & Moir, 2011).

According to Maxwell (2005), the research topic had to have meaning and a clear purpose

that changed a situation. From an organizational cultural perspective, the researcher explored the

impact of changing the traditional hierarchy level of hospital leadership to a horizontal level of

7

collaborative hospital leadership to succeed in today’s economy. This allowed Lynford Memorial

CARU to function in a systemic environment that promoted participative management and shared

leadership. Knowledge about organizational management, finance, and change from the research

results were utilized to create a strategic leadership development plan for helping the hospital

leaders in Lynford Memorial CARU build and sustain their organizational success by improving

their organization development, employee engagement, patient satisfaction, financial

accountability, and organizational change (Kaufman & Goldstein, 2008).

Research Questions Focused on Solution Finding

The research questions aimed at identifying the evidence:

Primary Research Question: How do leadership practices contribute to organizational success?

Qualitative Research Questions:

1. How do organization development principles contribute to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

2. How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness?

3. How does patient satisfaction contribute to organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness?

4. How does Lynford Memorial’s CARU’s preferred theory of organizational change align

with their preferred leadership practices?

8

Conceptual Framework

Researcher’s Stances

The researcher’s conceptual stance was critical theory/pragmatism because the research

sought radical changes in the hospital leadership structure, practices, and culture that enhanced the

lives of the employees through meaningful development and the patient lives with better health care

delivery services and outcomes. In addition, a variety of methods were creatively combined to

explore and understand the research problem (Bloomberg & Volpe, 2012).

Conceptual Framework of Three Research Streams

The research topic was trying to find patterns of success in the leadership practices for

building capacity to transform organizational structure and manage change for achieving greater

effectiveness in organization development, employee engagement, patient satisfaction, and financial

accountability. The three streams of research for the study were (1) leadership practices:

organization development, employee engagement, and patient satisfaction, (2) financial

accountability: financial performance and competitive advantage, and (3) organizational change:

traditional hierarchy structure, collaborative leadership, and cultural change.

The researcher studied leadership practices in hospitals to explore the various strategies

hospitals used to manage employees and the daily operations of running a hospital and the

processes hospitals used to implement change. In addition, the researcher studied leadership

practices to learn how to improve employee morale and engagement, and how to build patient-

centered organizations for improving patient satisfaction. Moreover, the researcher studied

financial accountability to investigate the economical practices that harnessed and harmed

profitability and impacted competitive advantage. The entire conceptual framework was a

transformational change to the hospital system. Therefore, the researcher studied organizational

9

change to examine the continuity of organizational culture during the stages of strategic change

from a traditional hierarchy leadership to collaborative, interdependent leadership.

The conceptual framework for the present study derived from the various concepts

composed by the theorists. The conceptual framework was designed to understand the process for

transforming the hospital structure by using the leadership practices and financial accountability to

position the current culture to a preferred future culture for ensuring organizational success,

efficiency, quality, and growth. Katz (2007) explained how to develop talent, engage employees,

and build patient satisfaction by focusing on the elements of organization development, which were

vision, mission alignment, communication, leadership and people development, team and

relationship building, change and transition management, and service quality. Kaufman and

Goldstein (2008) identified five accountability characteristics contributing to an ideal, financially

successful organization (1) visioning in partnership with the board, (2) building and sustaining a

strong and accountable executive team, (3) developing a high-quality, integrated plan, (4) skillfully

executing the plan and managing the fundamentals, (5) and building and maintaining credibility.

Levin and Gottlieb (2009) developed the instrumental levers for changing the context of an

organization with (1) organization structure, (2) business process design, (3) human resources

practices, and (4) leadership management practices. Rondeau and Wagar (1998) and Tsai (2011)

explained how health care leadership behaviors and practices impacted organizational change and

culture. The following conceptual framework provided a systemic approach to explain the

importance of integrating leadership practices, financial accountability, and organizational change

to promote organizational success in Lynford Memorial CARU.

10

Conceptual Map

Leadership Practices + Financial Accountability = Organizational Change and Success

Figure 1.1. Organizational Change and Success Theory (on the basis of Bate, 2000; Browning,

Toain, & Patterson, 2011; Gary, 1995; Junyoon, 2011; Levin & Gottlieb, 2009; Merry, 1994;

Rondeau & Wagnar, 1998; Thompson, 2011; Trinh & Connor 2002; Tsai, 2011).

11

Definition of Terms

Change Management: Tools, techniques, and strategies that guide activities and manage

resources to implement a change (Cummings & Worley, 2009).

Collaborative Leadership: Flat, matrix-structured organization achieving successful

outcomes through participatory management, networking, influencing, and relationship building.

Knowledge is shared throughout the organization, feedback is provided, problem solving and

decision-making are encouraged throughout all organizational levels (Berger & Berger, 2011).

Competitive Advantage: Companies analyze their set of capabilities to see what they do best

to win in the market that is differentiated and distinctive compared to anyone else (Ovanessoff &

Purdy, 2011).

Customer Driven Health Care (CDHC): Incentives for consumers to become more

concerned about the cost of their health care and more knowledgeable about their own health and

array of providers (Hughes-Cromwick, Root, & Roehrig, 2007).

Employee Engagement: Organizations showing an interest in employee well-being and

providing opportunities to develop competencies and skills. Supervisors building rapport with

employees, providing challenging work assignments to broaden their skills, supporting education

and career advancements, and encouraging innovative thinking and decision-making (Shuck &

Herd, 2012).

Financial Accountability: Establishes a structure for creating policies that produce effective

financial processes. It also includes taking responsibility for positive and negative financial

decisions and outcomes (Easton, Wild, Halsey, & McAnally, 2008).

12

Instrumental Levers: Used for realigning the organizational cultural for effective change by

focusing directly on modifying the work context and how work is performed (Levin & Gottlieb,

2009).

Leadership practices: Observable behaviors, skills, and competencies that develop

individuals to produce positive and effective outcomes in the workplace and society (Gallos, 2008).

Operational Excellence: Companies striving to make intelligent decisions about their

operating models and asset footprints through careful observation in the decision-making process,

selecting the right performers, and determining efficient locations for their operations (Ovanessoff

& Purdy, 2011).

Organizational Success: For profit: businesses that achieve strong financial results year in

and year out (Kaufman and Goldstein, 2008) or non-profit: businesses that accomplish their mission

and meet the needs of the population they serve by producing beneficial, desirable outcomes

(Blazek, 2008).

Organization Development: Designing strategies to align with the mission and manage

change to increase effectiveness and behavioral science knowledge throughout the organization by

(1) establishing relationships, (2) researching and evaluating dysfunctions and goals, (3) identifying

interventions to improve effectiveness, (4) applying approaches to improve effectiveness, and (5)

evaluating the ongoing process of change (McNamara, 2011).

Patient Satisfaction: Patient perceptions and outcome measures based on quality of health

care services and delivery (Mayfield, 2006).

Patient Throughput: Interconnected processes that focus on the patient rather than the

individual department to streamline patient flow (Roberson, 2008).

13

Transformational Change: Is disruptive to the status quo. It moves one or more elements of

a system in a new direction for developing, refining, and implementing new protocols and standards

(Wolf, Hanson, & Moir, 2011).

Assumptions, Limitations, and Delimitations

Assumptions

Various assumptions impacted the development process of the present study. One

assumption was that hospitals placed a high value on interdepartmental team building and

communication. The present study planned to discover what procedures Lynford Memorial’s

CARU used to create open lines of communication for transferring information throughout the

hospital system while delivering care to patients and interacting with each other. Another

assumption was valuing your employees. The present research was interesting in seeing how

Lynford Memorial’s CARU treatment of employees impacted the work they produced. The

researcher wanted to see what systems Lynford Memorial’s CARU had in place for treating their

employees with kindness, dignity, and respect. Another assumption was the concept of the patient

always being right. The present researcher wanted to reveal feedback procedures the hospital had

in line for organizational improvements in the patient satisfaction. Another assumption was

whenever there were issues in the system, follow the money to solve problems or create desired

results. The main goal of a hospital was to stay open and increase their finances to better serve the

patient population. The present research was interesting in seeing what financial strategies were

helping or hindering Lynford Memorial’s CARU. The final assumption was the organizational

culture impacted employee performance in the workplace. Since work environments impact

employee morale, the researcher was interesting in seeing how supportive and interactive vs. non-

supportive and non-interactive work environments impacted performance outcomes.

14

Limitations

The study had several limitations. Cultural changes were difficult to implement. Trying to

transform a hospital system into a business model aspect was a major challenge since any

hospital’s primary focus is to care for patients and not function as corporate entities. Most

clinicians had difficulty looking at the hospital structure with organization development eyes.

Getting clarity on whether the professional backgrounds of hospital leaders influenced their

decisions or policies was another challenge. The gender imbalance within the hospital system

produced biases in the collective data because there were all female participants from leadership

team at Lynford Memorial’s CARU. In addition, the race imbalance of high-level leadership

positions in the hospital system produced biases in the collective data because all of the participants

in the study were Caucasian except for one African-American at Lynford Memorial’s CARU.

Lynford Memorial was a teaching health care hospital; therefore, the information from the study

may vary from a standard health care hospital that is not affiliated with a medical university.

Delimitation

There were numerous hospitals throughout the city and in the rural areas surrounding the

city as well. However, to narrow the scope, the present study focused on one urban hospital.

Lynford Memorial had 21 clinical departments and 18 clinical medical departments. However, the

Department of Rehabilitation Medicine was selected as the research site because (1) it was a clinical

medical department, (2) it contained an adequate number of employees for the selected samples,

and (3) their employees showed a great amount of interest and commitment of time to provide

relevant information that answered the research questions. The Department of Rehabilitation

Medicine used the Comprehensive Acute Rehabilitation Unit (CARU) to provide rehabilitation

services to in-patients. The following study focused on interviewing only the leadership team and

15

employees who provide direct care to patients in CARU at Lynford Memorial. The roles of the

leadership team and employees who provide direct care to patients aligned with the leadership

principles and financial accountability. The leadership team and employees who provided direct

care to patients were interviewed with interview protocols for qualitative data collection to develop

a detailed understanding of the research problem.

Organization of the Study

The research study was presented in five chapters. Chapter 1 contained the introduction of

the study, statement problem, purpose and significance of the study, research questions, conceptual

framework, definition of terms, assumptions, limitations, and delimitations, and the summary.

Chapter 2 contained a review of the literature, which included leadership practices, financial

accountability, and organizational change. Chapter 3 described the methodology section used for

this research study, and it contained the selection of participants, instrumentation, data collection,

and data analysis procedures. Chapter 4 presented the study’s findings, results, and interpretations.

Chapter 5 provided a summary of the entire study, implications, and recommendations for

actionable solutions of the research problem and recommendations for future research study.

Summary

Rapid changes continued to occur in our hospital systems. Systemic changes in

socioeconomics, cultural, political, environmental, academic, and financial reforms affected the

hospital systems (Wolf, Hanson, & Mori, 2011). Change was opportunity, and hospital leaders of

the Comprehensive Acute Care Unit (CARU) at the Lynford Memorial identified the change

process, managed the change, and used the experience to create new learning opportunities for their

organization. Hospital leaders were trampling with strategies to improve health care quality,

eliminate health care disparities, build employee engagement and patient satisfaction, maintain

16

costs, and balance competition while trying to master leadership practices for effective management

and world-class performance from their workforce. To conclude, leadership had value in

organizations that explains why people perform well. Hospitals continued to need highly qualified,

competent leaders to create paths of excellence in leadership development, change management,

and financial accountability in the present and for the future.

17

Chapter 2 – Literature Review

Introduction of the Statement of the Problem

The hospital environment faced internal and external challenges (Bates, 2000; Gary, 1995;

Goetz, Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Jungyoon, 2011; Kaufman &

Goldstein, 2008; Levin & Gottlieb, 2009; Merry, 1994; Meyer Silow-Carroll, Kutyla, Stepnick, &

Rybowski 2004; Roberson, 2008; Rondeau & Wagar, 1998; Tsai, 2011). Hospital leaders faced

major challenges dealing with increasing demographic shifts in the culture, the elderly population

growth, and 60% of baby-boomers retiring within three-to-five years (Berger & Berger, 2011;

Cummings & Worley, 2009; Farrell, 2003). Meanwhile, for the last two decades leaders battled

declines in staff morale, and 44% of the United States population reported having low employee

engagement (Berger & Berger, 2011; Farrell, 2003). As a result, hospital leaders were left

struggling to develop the best practices for effective management and the creation of a world-class

workforce (Katz, 2007; Kim, Thompson, & Herbeck, 2012; McAlearney, Scheck, & Butler, 2008;

Wolf, Hanson, & Moir, 2011). Organizations needed to reanalyze the way they recruited and

developed their talent pool to create a workforce of eclectic, diversified individuals who had various

learning styles and skills in order to improve performance (Berger & Bereger, 2011; Rothwell,

Jackson, Knight, & Lindholm, 2005).

According to the American Hospital Association, 60% of the hospitals in the United States

lost money providing health care services, and $60 billion a year was lost due to patient registration

errors (Legislative Advisory, 2010). Hospital leaders were struggling to find strategies and ideas on

how to improve health care quality, maintain costs, and balance competition (Goetz, Janney, &

Ramsey, 2011; Hughes-Cromwick, 2007; Kaufman & Goldstein, 2008; Meyer Silow-Carroll,

Kutyla, Stepnick, & Rybowski 2004; Roberson, 2008). Changes in any organization transpired

18

opportunities (Trinh & Connor, 2002). Organizational transformation was time consuming and

demanding from all participants of the organization (Trinh & Connor, 2002). However, Katz

(2007) argued to manifest a hospital environment with high value and quality work, a universal

level of organization development knowledge was needed to be shared throughout the hospital

system, the principles explained, and the benefits highlighted to connect to financial performances.

McNamara (2011) explained the definition of organization development as:

“Designing strategies to manage change and meet the changing needs of organizations to increase effectiveness and behavioral science knowledge throughout the organization by (1) establishing relationships, (2) researching and evaluating dysfunctions and goals, (3) identifying interventions to improve effectiveness, (4) applying approaches to improve effectiveness and (5) evaluating the ongoing process of change” (Retrieved from http://managementhelp.org/organizationdevelopment/od-defined.htm.)

The value of using organization development principles in a hospital was expressed in the

organizational outcomes, employee performance, and cost reductions (Swanson & Holton, 2009).

Value increased from enhancing organizational performance and cutting costs (Kaufman &

Goldstein, 2008). Dr. David Miller, the chief executive officer of Lynford Memorial Family

Medical Center, stated in an interview, “While hospital leaders make adequate productivity

improvements, improve patient care delivery, and incorporate the new mandated health care laws

into the practice, they will need to incorporate a strategic plan for utilizing organization

development, employee engagement, and patient satisfaction to increase their performance and

elevate their training and development learning outcomes for all employees” (David Miller,

personal communication, April 16, 2012). Hospital leaders focused on patient satisfaction by

working on launching some new initiatives to improve their quality and delivery of health care

services (Mayfield, 2008). The medical hospital workers needed specific training sessions to help

improve their overall job functions and responsibilities, customer service skills, and motivation

19

(Kim, Thompson, & Herbeck, 2012; McAlearney, Scheck, & Butler, 2008). The front-line

supervisors needed leadership development to improve in their communication skills and learn to

incorporate employees into the decision-making process (Katz, 2007; Kim, Thompson, & Herbeck,

2012; McAlearney, Scheck, & Butler, 2008).

The financial performance of hospitals was a major concern for leaders. Accountability and

ownership for acquiring monetary outcomes initiated with the financial analyst. The financial

analyst focused on productivity improvement, cost reduction strategies, and bottom-line

performance (Goetz, Janney, & Ramsey, 2011). Carey, Burgess, & Young (2011) discovered that

“over the past three decades, the U.S. hospital industry has been experiencing growing competitive

challenges in an environment of wide-ranging health care organizational change” (p. 571). The

2010 American College of Health Care Executives annual survey ranked financial challenges as the

number one top issue confronting hospital leaders (Goetz, et al., 2011). Hospital systems suffered

from scarce resources, but understanding the importance of sustaining organizational success

focused on human, physical, and financial resources for making effective changes. A study by

Evashwick and Ory (2003) listed shared organizational vision, institutional strength, project

effectiveness, community marketing techniques, behavior change principles, and involving key

stakeholders as financial lessons for learning to overcome challenges in health care. Moreover,

Kaufman and Goldstein (2008) described five characteristics to enhance and extend financial

performance: (1) visioning in partnership with the board, (2) building and sustaining a strong and

accountable executive team, (3) developing a high-quality, integrated plan, (4) skillfully executing

the plan and managing the fundamentals, (5) and building and maintaining credibility.

Previous studies focused on using positive competition in the hospital industry to promote

efficiency in hospital services, success in controlling costs, and maintaining margin profitability

20

(Goetz, Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Kaufman & Goldstein, 2008;

Ovanessoff & Purdy, 2011; Roberson, 2008). Revenue and cost changes impacted profits in return.

Hospitals had to develop strategic tactics to maintain profits, such as increasing revenue through

other channels, changing service mix, offsetting revenue declines with cost reductions, and limiting

expenses through staff adjustments and reducing uncompensated care (Carey et al., 2011). Bottom

lines were affected by patient throughput. Hospitals focused on putting their patients first by

increasing patient throughput, increasing financial performance, and preventing the loss of $1

million in revenue from improper medical screening, denial management, and slow patient entry

processing (Roberson, 2008). While the quality of health care sometimes faced criticism, the

current trend of consumer driven health care (CDHC) was on the rise to revolutionize information,

increase provider competition, and expand market orientation in health care expenditures by

providing patient autonomy in considering their health care costs and the quality of the health care

they demanded (Hughes-Cromwick, Root, & Roehrig, 2007). Hospitals succeeded in organization

development and financial accountability by concentrating on connecting the competitive advantage

to operational excellence, developing deeper customer connections with information technology,

creating new approaches for recruiting talent, extending their innovation process, and balancing

their local relevance on a global scale (Ovanessoff & Purdy, 2011).

Cultural realignment was an essential long-term process that developed and evolved over

time in any organization. The hospital culture was complex in experiencing massive cultural

changes among employees with various backgrounds and beliefs. Many of the changes

concentrated on roles and power structure. Jungyoon (2011) and Thompson (2011) suggested that

health care leaders promote multidisciplinary teams and collaboration to ensure that the roles and

responsibilities of the various health care disciplines were respected and understood by all the

21

employees. Most importantly, Levin and Gottlieb (2009) proposed organization structure, business

process design, human resources practices, and leadership management practices as instrumental

levers for supporting and changing the organizational context to achieve the desired results.

At the organizational level, it was imperative for hospital leaders to understand how they

influenced organizational responses to internal and external forces. A systemic, collaborative

leadership approach was needed to strategically align the organizational goals to achieving high

performances. One aim of the study was to create a shared understanding of the best leadership

practices used for creating organizational transformation and success in organization development,

employee engagement, patient satisfaction, financial accountability, and organizational change for

the CARU at Lynford Memorial.

The research topic of the present study explored the process of a hospital’s leadership

practices for promoting organizational transformation and success as defined by organization

development, employee engagement, patient satisfaction, financial accountability, and

organizational change. The three streams of research for the study were (1) leadership practices—

organization development principles, employee engagement, and patient satisfaction, (2) financial

accountability—financial performance and competitive advantage, (3) organizational change—

traditional hierarchy structure, collaborative leadership, and cultural change. The researcher studied

leadership practices in hospitals to explore the various strategies hospitals used to manage

employees and the daily operations of running a hospital, and the processes hospitals used to

implement change. The researcher studied financial accountability to investigate the economical

practices that harnessed and harmed profitability and competition. In addition, the researcher

studied organizational change to examine the continuity of organizational life during the stages of

strategic change and the impact on the organizational culture. The research questions for the

22

present study were: How do leadership practices contribute to organizational success? How do

organization development principles contribute to the organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability and market

competitiveness? How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU as defined by meeting the mission and continued financial viability and market

competitiveness? How does patient satisfaction contribute to organizational success of Lynford

Memorial’s CARU as defined by meeting the mission and continued financial viability and market

competitiveness? How does Lynford Memorial CARU’s preferred theory of organizational change

align with their preferred leadership practices?

The researcher completed an extensive literature review on the three streams of research

with a systemic search in the following databases: EBSCO, ProQuest, and ProQuest Nursing and

Allied Health Source. The search allowed access to Medline, PubMed, PsychINFO, and Goggle

Scholar. The researcher used a variety of key words and combinations from the three research

steams to narrow the search selection for references. The reference list was comprised of peer

reviewed journal articles and books identified as relevant to the research questions. As a result, the

present study explored the process of a hospital’s leadership practices for promoting organizational

transformation and success as defined by organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change.

Conceptual Framework

The research topic found patterns of success in the leadership practices for building capacity

to transform organizational structure and manage change for achieving greater effectiveness in

organization development, employee engagement, patient satisfaction, and financial accountability.

The three streams of research for the study were (1) leadership practices—organization

23

development, employee engagement, and patient satisfaction, (2) financial accountability—

financial performance and competitive advantage, (3) organizational change—traditional hierarchy

structure, collaborative leadership, and cultural change.

The researcher studied leadership practices in hospitals to explore the various strategies

hospitals used to manage employees and the daily operations of running a hospital and the

processes hospitals used to implement change. In addition, the researcher studied leadership

practices to learn how to improve employee morale and engagement and how to build patient-

centered organizations for improving patient satisfaction. Moreover, the researcher studied

financial accountability to investigate the economical practices that harness and harm profitability

and impact competitive advantage. The entire conceptual framework was a transformational

change to the hospital system. Therefore, the researcher studied organizational change to examine

the continuity of organizational culture during the stages of strategic change from a traditional,

hierarchy leadership to collaborative, interdependent leadership.

The conceptual framework for the present study derived from the various concepts

composed by the theorists. The conceptual framework was designed to understand the process for

transforming the hospital structure by using the leadership practices and financial accountability to

position the current culture to a preferred future culture for ensuring organizational success,

efficiency, quality, and growth. Katz (2007) explained how to develop talent, engage employees,

and build patient satisfaction by focusing on the elements of organization development, which were

vision, mission alignment, communication, leadership and people development, team and

relationship building, change and transition management, and service quality. Kaufman and

Goldstein (2008) identified five accountability characteristics contributing to an ideal financially

performing organization: (1) visioning in partnership with the board, (2) building and sustaining a

24

strong and accountable executive team, (3) developing a high-quality, integrated plan, (4) skillfully

executing the plan and managing the fundamentals, (5) and building and maintaining credibility.

Levin and Gottlieb (2009) developed the instrumental levers for changing the context of an

organization with (1) organization structure, (2) business process design, (3) human resources

practices, and (4) leadership management practices. Rondeau and Wagar (1998) and Tsai (2011)

explained how the behaviors and practices of health care leadership impacted organizational change

and culture. The following conceptual framework provided a systemic approach to explain the

importance of integrating leadership practices, financial accountability, and organizational change

to promote organizational transformation and success in Lynford Memorial.

25

Conceptual Map

Leadership Practices + Financial Accountability = Organizational Change and Success

Figure 1.2. Organizational Success Theory (Bate, 2000; Browning, Toain, & Patterson, 2011; Gary,

1995; Junyoon, 2011; Levin & Gottlieb, 2009; Merry, 1994; Rondeau & Wagnar, 1998; Thompson,

2011; Trinh & Connor 2002; Tsai, 2011).

26

Definition of Terms

Change Management: Tools, techniques, and strategies that guide activities and manage

resources to implement a change (Cummings & Worley, 2009).

Collaborative Leadership: Flat, matrix-structured organization achieving successful

outcomes through participatory management, networking, influencing, and relationship building.

Knowledge is shared throughout the organization, feedback is provided, problem solving and

decision-making are encouraged throughout all organizational levels (Berger & Berger, 2011).

Competitive Advantage: Companies analyze their set of capabilities to see what they do best

to win in the market that is differentiated and distinctive compared to anyone else (Ovanessoff &

Purdy, 2011).

Customer Driven Health Care (CDHC): Incentives for consumers to become more

concerned about the cost of their health care and more knowledgeable about their own health and

array of providers (Hughes-Cromwick, Root, & Roehrig, 2007).

Employee Engagement: Organizations showing an interest in employees’ well being and

providing opportunities to develop competencies and skills. Supervisors building rapport with

employees, providing challenging work assignments to broaden their skills, supporting education

and career advancements, and encouraging innovative thinking and decision-making (Shuck &

Herd, 2012).

Financial Accountability: Establishes a structure for creating policies that produce effective

financial processes. It also includes taking responsibility for positive and negative financial

decisions and outcomes (Easton, Wild, Halsey, & McAnally, 2008).

27

Instrumental Levers: Used for realigning the organizational cultural for effective change by

focusing directly on modifying the work context and how work is performed (Levin & Gottlieb,

2009).

Leadership practices: Observable behaviors, skills, and competencies that develop

individuals to produce positive and effective outcomes in the workplace and society (Gallos, 2008).

Operational Excellence: Companies striving to make smart decisions about their operating

models and asset footprints through careful observation in the decision-making process, selecting

the right performers, and determining efficient locations for their operations (Ovanessoff & Purdy,

2011).

Organizational Success: For profit: businesses that achieve strong financial results year in

and year out (Kaufman and Goldstein, 2008) or non-profit: businesses that accomplish their mission

and meet the needs of the population they serve by producing beneficial, desirable outcomes

(Blazek, 2008).

Organization Development: Designing strategies to align with the mission and manage

change to increase effectiveness and behavioral science knowledge throughout the organization by

(1) establishing relationships, (2) researching and evaluating dysfunctions and goals, (3) identifying

interventions to improve effectiveness, (4) applying approaches to improve effectiveness, and (5)

evaluating the ongoing process of change (McNamara, 2011).

Patient Satisfaction: Patient perceptions and outcome measures based on quality of health

care services and delivery (Mayfield, 2006).

Patient Throughput: Interconnected processes that focus on the patient rather than the

individual department to streamline patient flow (Roberson, 2008).

28

Transformational Change: Is disruptive to the status quo. It moves one or more elements of

a system in a new direction for developing, refining, and implementing new protocols and standards

(Wolf, Hanson, & Moir, 2011).

Critical Review of the Literature

Key motivators to improve performance and foster excellence in hospital leadership began

with vision, mission, and innovation (Katz, 2007). The new millennium called for a hospital

transformation in leadership that was patient centered, accessible, and coordinated (Davis, 2009).

Incorporating elements of leadership practices, financial accountability, and organizational change

into hospital leadership provided a strategy for creating a collaborative hospital system to address

issues in management, finance, quality care delivery, employee engagement, and patient

satisfaction. The hospital leadership responsibilities governed principles to promote a safe,

productive workplace environment and ensure accountability and value for resources. Every

successful hospital system needed to combine the three components of leadership practices,

financial accountability, and organizational change to achieve significant gains in quality and

safety, high employee performance improvement, rapid organizational learning, transparency in

patient care, and improvement of the bottom-line results (Sears, 2009). The following literature

review provided a systemic approach to explain the importance of integrating leadership practices,

financial accountability, and organizational change to promote success in the Comprehensive Acute

Care Rehabilitation Unit (CARU) in Lynford Memorial:

Leadership practices (Organization development principles, employee engagement, and

patient satisfaction)

Transforming the hospital leadership practices required vision and innovation through

learning, development, diligence, commitment, perseverance, and motivation. Improving the

29

hospital leadership practices created innovative ideas and new methods for producing highly

qualified work that led to sustainability, clinical improvement processes, and positive satisfaction

results from employees and patients. One of the biggest lessons learned in the hospitals was that

learning comes from doing. Learning derived from building knowledge, doing the work, and taking

the job execution to the next level (Gallos, 2008).

Previous researchers agreed that leadership development plans, succession talent

management plans, career development, and competency building were critical elements for

developing employees and building organizational performance (Berger & Berger, 2011;

Cummings & Worley, 2009; Kim, Thompson, & Herbeck, 2012; McAlearney, Scheck & Butler,

2008). On the contrary, small hospitals, for-profit hospitals, and rural hospitals really did not

support leadership development plans due to budgeting constraints (Kim et al., 2012). In addition,

the lack of support for leadership development plans in these types of hospitals ignored competency

development and career advancement opportunities for women and minorities (Kim et al., 2012).

McAlearney et al., (2008) suggested hospital leaders invest in education and development

initiatives for health care employees to build quality and safety improvements, retention, and

financial growth. Although leadership development plans and talent management strategies were

successful tactics for building organizational performance, differences in location, size, and the

financial identity of a hospital being non-profit or for-profit influenced the decision of hospital

leaders creating and using leadership development plans. As a result, this produced detrimental

effects on organizational effectiveness by not investing in the development of hospital employees

and organizational performance (Kim et al., 2012). In this dissertation, the researcher explored the

missing connection of leadership practices to the improvement of quality and efficiency in a

hospital environment.

30

Many scholars insisted that the use of organization development strategies improved system

thinking, performance on multiple levels (individual, group, and organization), profits, employee

and patient satisfaction, and the organizational culture (Berger & Berger, 2011; Cummings &

Worley, 2009; Farell, 2003; Katz, 2007; Mayfield, 2006; Shuck & Herd, 2012; Swanson & Holton,

2009; Wolf, Hanson, & Moir; 2011). Wolf, Hanson, and Moir (2011) documented that researched-

based, practical processes and methods on health care organizations around the world were

significantly impacted with increases in quality care delivery, employee performance, and financial

profits from organization development practices. Conversely, Katz (2007) asserted there is a lack

of detailed research linking the evidence of organization development principles to improve

financial performance and increase organizational success. This dissertation explored the

importance of utilizing organization development principles to impact the hospital’s organizational

performance and financial growth. If the hospitals chose not to utilize these principles, they faced a

continuing struggle of trying to provide quality services, developing competent, engaged

employees, and meeting patient satisfaction standards.

This stream was organized by identifying patterns to support the body of evidence. This

process built a claim for telling how the evidence fit together (Machi & McEvoy, 2012). The

evidence was combining themes to support the core idea of leadership practices and the sub-ideas of

organization development principles, employee engagement, and patient satisfaction. The

researcher used universal language when summarizing the research studies to make the concepts

familiar to a general audience (Booth, Colomb, & Williams, 2008).

The researcher organized this section by explaining the roles and importance of using the

departmental leaders and financial analyst of the hospital environment. They started the foundation

of transforming the leadership structure and financial accountability to create a preferred

31

organizational culture based on collaborative leadership. Then, the researcher described in detail

how building a well-developed workforce starts with innovative methods of talent management for

selecting, hiring, recruiting, and retaining the right employees for the right job. Once the hospitals

had the right employees in place, the researcher explained how one must continue to develop the

employees through competency building, leadership development plans, and succession talent

management plans. This was important because highly skilled, educated employees helped

hospitals provide quality services and innovate new ideas for producing high performances

beneficial on the individual, group, and organizational levels. Hospitals were experiencing internal

and external changes while trying to complete their daily functions. Therefore, the researcher

elaborated how organization development principles developed and collaborated employees to

improve organizational performances, effectively manage change processes, and create evaluation

measures to ensure successful outcomes. The next section stated how it was important to build

engagement so employees had a continuous drive for producing high-end results and remaining

loyal to the hospital and the patients. Lastly, the researcher focused on the patients receiving the

services the hospital employees provided. The researcher ended this section by explaining how

patient satisfaction increased from practicing patient-centered care and by working diligently to

improve clinical outcomes, patient safety, and loyalty. As a result, talent management, organization

development principles, employee engagement, and patient satisfaction were key factors of the

leadership practices in this section of the conceptual framework for identifying, developing, and

aligning employees to achieve the organizational mission, goals, and strategies.

The roles and responsibilities of the hospital departmental leaders supported a generative

process in a learning organization that enhanced creativity and extends accountability. The hospital

departmental leaders operated in complex environments that exposed them to personal and

32

organizational risks. The hospital departmental leaders in hospital settings were responsible for

implementing polices, governing finances, and overseeing clinical performance throughout the

organization. In addition, the hospital departmental leaders worked with the chairs of their boards,

built relationships within the organization and created partnerships with local agencies, managed

change initiative programs, enacted national priorities for health care, and ensured public

confidence with governmental imperatives (Blacker and Kennedy, 2004).

The financial analysts in hospital settings controlled all the monetary aspects throughout all

the hospital systems by conducting financial planning, managing financial risks, data analysis, and

record keeping. The financial analyst offered meaningful advice for decision-making, building

relationships and partnerships within and outside the organization, built trust, confidence, and

accountability throughout the system, and provided continual communication for transparency

(Ballein, 1997). Previous research studies indicated that development of leadership programs to

deal with everyday complexities, problems, and dilemmas throughout the hospital organization

allowed financial analysts to fully practice their work responsibilities without any difficulties

(Farrell, 2003; Goetz, Janney, & Ramsey, 2011; Kaufman & Goldstein, 2008; Kim, Thompson, &

Herbek , 2012; McAlearney, Scheck, and Butler, 2008).

Organizational leaders were responsible for growing and developing employee talent to

align with strategic business goals. Berger and Berger (2011) published a book focusing on

leadership skills to build competitive workforces through creative selecting, hiring, recruiting, and

retaining techniques. Employee development needs were identified in competency models, and

leaders assessed employee talent through their development needs. Competency models were

attributes that guided employee behavior while they worked on achieving organizational goals

(Berger & Berger, 2011). Organizational leaders needed to develop well crafted competency

33

models, leadership development plans, succession talent management plans, and career

development plans. Most importantly, these leadership practices had to match job positions and

reflect updates when organizations shifted strategies due to economic, political, social, and external

market changes. Comparable to Cummings and Worley (2009) and Daft (2010), this book

explained how leadership was about interactions and relationships. Therefore, organizations were

starting to shift from the traditional hierarchy system of leadership to a matrix, flat-level,

collaborative leadership (Berger & Berger, 2011). On the contrary, leaders had to be prepared to

handle resistance from employees fighting to maintain the status quo while trying to incorporate the

leadership practices Berger and Berger (2011) suggested for transforming organizations and

improving employee performance. Meanwhile, this book supported the present research problem

by stating that organizational leaders had to adapt their leadership structure and skills to remain

current during times of change while continuing to invest in employee development and drive

business value results.

Employees were hospitals’ primary asset. Therefore, Kim, Thompson, and Herbek (2012)

corroborated with Berger and Berger (2011) on the idea of investing in employees through

leadership and training development. Kim et al., (2012) understood the importance of building

leadership competencies to improve organizational performance in the hospital sector. The

researchers used information reported in the American Hospital Association (AHA) from 3,000

acute care hospitals across the U.S. The researchers created a conceptual framework to conduct a

national study on leadership development programs and organizational and market factors. The

market characteristics were identified as environmental munificence, uncertainty, and complexity

while the organizational factors were identified as ownership, size, and system. The results from

the study showed a positive association between leadership development programs and the

34

organizational and market factors. The findings from the study indicated for-profit hospitals, small,

rural hospitals, and women and minorities in health care really did not have opportunities to engage

in leadership development program activities. It was unfair for organizations to ignore

opportunities to invest in developing all of their employees. These results were shocking because

Berger and Berger (2011) indicated improving leadership competencies was known to enhance

skills that increased organizational profits. Information from Kim et al., (2012) study assisted the

present researcher in understanding if developing leadership skills for hospital leaders impacted

performance in nonprofit hospitals over for-profit hospitals and the impact leadership development

skills had on urban hospitals.

Leadership development programs improved employee competency for achieving the

organizational business strategies. McAlearney, Scheck, and Butler (2008) explored the impact of

leadership development programs improving quality and efficiency in health care. McAlearney et

al., (2008) analyzed interview data from three qualitative studies on leadership development from

200 hospital executives, managers, academic experts, and consultants during September 2003-

December 2007. The results of the research revealed leadership development programs improved

quality and efficiency in health care by increasing the number of high-quality health care

employees, providing education and development initiatives, decreasing turnover and wasted

resources, and creating target-specific strategies for the overall hospital improvements. This study

corroborated with Kim, Thompson, and Herbek (2012) supporting the use of leadership

development programs to enhance leadership skills, knowledge, and strategies that increased

effectiveness, staffing stability, talent management, and succession management planning. This

study supported the significance of the present research by explaining the benefits of leadership

development plans. Leadership development programs were great for developing talented

35

employees, but they sometimes they were costly on hospital budgets. However, further research

was still needed on this topic to understand the connection of leadership development programs

improving quality and efficiency in health care.

A universal level of organizational development and leadership knowledge needed to be

shared throughout the hospital system. Organization development principles succeeded in

manifesting a hospital environment with high-value, quality work when the principles were

explained and the benefits were highlighted in connection to financial performances (Wolf, Hanson,

& Moir, 2011). Organization and development principles established a framework for managing

change. Farrell (2003) interviewed network and hospital administrators of Victoria, Australia to

understand the benefits of leadership principles during turmoil and change. The author described

the structural frame, human resource frame, political frame, and the symbolic frame as the

leadership themes for the network and hospital administrators. Farrell argued that leadership and

the process of leading significantly impacted the success of a hospital during times of uncertainty

and change. A qualitative method was used for obtaining information from semi-structured

interviews with the CEOs, Board of Directors, and the Nurse Directors. The findings revealed cost

constraints, technology, consumer expectations, corporatization, restricting and the aging

population as the external and internal changes that significantly impacted the delivery of quality

services to the patient population. Farrell (2003) corroborated with Mayfield (2008) on the

concepts examining multi-organizational levels to understand performance and improve

organizational culture. Transforming the organizational culture sometimes took years to

successfully implement. Therefore, organizations needed to find innovative methods to speed up

the implementation process. This study helped the research by addressing all the underlying factors

that encompassed a hospital system while trying to practice effective leadership on

36

multidimensional levels. This study related to the research from observing the organizational

cultural and the roles and responsibilities of the people in the system while studying change

management.

Looking at the organizational system with a holistic approach allowed leaders to use

systems thinking to see internal and external connections, patterns, and obstacles that enhanced or

hindered organizational growth and sustainability during times of change (Senge, Smith,

Kruschwitz, & Laur, 2008). Swanson and Holton (2009) explained the impact human resource

models, processes, interventions, learning and performance paradigms, organization development,

and training and development practices had on the individual, group, and organizational levels.

Leadership and employee engagement were parallel when trying to execute organizational changes.

Organizational leaders had to set the stage and the conditions for employees to engage and thrive in

the organizational change process. Designing organizational support systems, engaging employees,

and increasing job enrichment paved the way for employees to build excitement and a sense of

urgency to participate in organizational changes. It was positive that leaders wanted to move their

employees beyond the status quo, but leaders also had to be prepared to handle nonconforming

employees who did not want to adapt to organizational changes. This book corroborated with

Cummings and Worley (2009) and Berger and Berger (2011) on the leadership concepts that

improved organizational growth, fulfillment, and performance. This book supported the research

study on the concept of increasing organizational effectiveness by using a systems approach to

identify and manage change throughout the various hospital levels.

Hospitals used organization development principles to develop employees, improve profits,

and manage the change process in complex environments. Katz (2007) described the importance of

adding organization development strategies to Aramark Health Care. She emphasized the lack of

37

organization development strategies in health care and highlighted the benefits of organization

development and leadership strategies. She argued the connection of organization development

principles for increasing financial return on investment, improving employee morale, employee

satisfaction, patient satisfaction, teamwork, and reducing turnover. A community of organization

development professionals around the country who received support from the Aramark Health Care

created the “Six Organizational Development Program Absolutes: communication, change and

transition management, leadership/people development, team and relationship building, vision,

mission alignment, and service quality” through emails, phone conferences, and annual meetings

(Katz, 2007, p.122). Comparable to Cummings & Worley (2009) and Swanson and Holton (2009)

this study emphasized the need to use organization development principles for systemic change and

high-quality, performances and outcomes. There still was a lack of research studies proving

organization development improved financial performance, and some people did not believe this

connection was possible. This study paralleled with the research topic by addressing the need for

hospital leaders to learn the importance of organization development principles to promote

successful financial performances.

Employee engagement needed to be a leadership priority. Shuck and Herd (2012) designed

a conceptual framework that examined the relationship between leadership behavior and the

development of employee engagement. The study had a unique definition of employee engagement

as a cognitive, emotional and behavioral connection of energies used by employees to achieve

organizational goals. The study supported the notion of how engaged employees improved a

company’s competitive advantage because they were more efficient, innovative, loyal, quality

focused and customer focused. Shuck and Herd (2012) agreed with Berger and Berger (2011),

Cummings and Worley (2009), and Swanson and Holton (2009) that the dynamics of work had

38

changed and the traditional, hierarchy structure of leadership was no longer efficient to motivate the

new generation of employees. In the evolving new workplace, employees were looking to be

involved in the decision-making process, expand their organizational responsibilities, and be treated

with kindness, dignity, and respect. Leaders adept with exceptional competencies were in great

demand to lead the engaging new workforce through this transformational leadership process.

Some researchers had different definitions for employee engagement and also a different process

for implementing it. The study was connected to the research problem because it identified a need

for changing the organizational culture through leadership transformations and employee

engagement to enhance organizational performance. However, future research for understanding

the connection of leadership and employee engagement to promote organizational performance was

still needed.

Employee engagement was a critical element for building organizational effectiveness.

Cummings and Worley (2009) wrote a book on how organizations modified their work designs and

organizational environments to improve organizational performance and effectiveness. Leaders

improved organizational performance and employee engagement through coaching, mentoring,

open communication, team building, group decision-making, information sharing and 360-degrees

feedback, removing roadblocks, reducing job stress, providing sufficient resources and materials,

celebrating milestones, benchmarks, and personal accomplishments, financial rewards, bonuses,

flexible schedules, and retreats (Berger & Berger, 2011; Shuck & Herd 2012). In agreement with

Berger and Berger (2011), Cummings and Worley (2009) supported the concept of leaders

increasing organizational performance and employee engagement through leadership development

programs, talent management and succession planning, education and training programs, human

capital management, knowledge management, and intellectual capital management. This book

39

supported the significance of the present research study by identifying the need to increase

employee performance and engagement through innovative leadership practices.

Hospitals were trying to find innovative methods for improving the quality and compassion

in patient-centered care and patient satisfaction. Mayfield (2006) created a quality update report to

assist hospitals in improving their quality and safety processes, organizational performance

outcomes, and patient satisfaction. He explained how external pressures were impacting the

internal environments of hospitals while they tried to satisfy patient needs and remain relevant in a

competitive health care market. He identified leadership, business case for quality, physician and

workforce engagement, performance measurement and reporting, information technology, culture

and communication, and patient focus as the eight quality dimensions for improving organizational

performance. The researcher encouraged hospitals to practice patient/family-centered care by

building partnerships, respecting patients’ wants and needs, providing education and support on

health decisions. The researcher predicted practicing patient/family-centered care would result in

improving the quality in clinical outcomes, patient loyalty, patient safety, market share, increased

patient satisfaction, and employee satisfaction. Practicing patient-centered care was time-

consuming and required workers with skills in compassion and empathy. However, this was a

challenge for high-impact, fast-paced hospital environments. This study corroborated with

McAlearney et al., (2008), Katz (2007), and Shuck & Herd (2012) with the concept of using

leadership strategies to improve performance, engage employees, and increase patient satisfaction.

This present study assisted in supporting the dissertation by the various dimensions of leadership

strategies that improved organizational performance and cultures.

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Financial accountability (financial performance and competitive advantage)

Financial accountability focused on holding leaders and employees accountable to examine

factors and create strategies for increasing quality performance in patient-centered care while

reducing hospital costs. In addition, financial competition promoted marketing the hospital’s

services and brand to outweigh competitors. Traditional revenue cycle management was not

working for hospitals during recent societal and economic changes in the United States. These

societal and economic changes caused key capabilities to develop for emerging opportunities in

health care. Hospital leaders had to evaluate their organizations to identify actions that contributed

to organizational excellence and financial success. While the fundamental changes of society

transformed the economy, hospital leaders improved outcomes and satisfaction in the health care

system by reducing errors and waste. Hospital costs decreased without diminishing quality.

Coordinated care throughout the hospital system improved financial performance by linking

accountability to the patient-centered care approach.

Previous research studies indicated that managing daily hospital activities through the use of

effective leadership strategies and team approach methods improved performance, profits, patient

safety, and employee engagement (Goetz, Janney, & Ramsey, 2011; Hughes-Cromwick, 2007;

Roberson, 2008). Moreover, researchers indicated that organization development principles

improved financial performance, employee performance, and patient satisfaction (Berger & Berger,

2011; Cummings & Worley, 2009; Evashwick & Ory, 2003; Katz, 2007; Kaufman & Goldstein,

2008; Swanson & Holton, 2009).

Hospitals needed to focus on leadership strategies to improve financial accountability.

However, Carey, Burgess, and Young (2011) argued the location of hospital facilities and the types

of services hospitals provided impact competition and profits. On the contrary, Ovanessoff and

41

Purdy (2011) declared hospital leaders needed to focus on marketing themselves, their resources,

and location differentiation to outweigh their competitors, expand their brand, and expose their best

services during times of change in the society and economy.

Although there was some research in the field of financial accountability in hospitals,

research was still needed to understand exactly what environmental factors affected urban hospital

competition and profits. This dissertation discovered the best leadership strategies for controlling

internal and external environmental factors that impacted financial success and the competition

advantages in hospitals. If hospitals did not focus on building their financial accountability and

competitive advantage, they continued to waste valuable resources, decrease their profits, and loose

patients to competitor hospitals and specialized treatment centers.

The researcher organized the financial accountability (financial performance and

competitive advantage) stream by identifying patterns to support the body of evidence. This

process built a claim for telling how the evidence fit together (Machi & McEvoy, 2012). The

evidence was combining themes to support the core idea of financial accountability and the sub-

ideas of financial performance and competitive advantage. The researcher used universal language

when summarizing the research studies to make the concepts familiar to a general audience (Booth,

Colomb, & Williams, 2008).

The researcher organized this section by stating how it was important to focus on strategies

that put patients’ needs first because patient satisfaction increased profits for the hospitals. Then

the researcher described how revenue, costs, profit margins, and patient margins were affected from

hospital competition and location of specialized treatment centers. To overcome loss in profits and

competition, the researcher explained how hospital leaders and employees needed to collaborate on

creating strategies that improved the delivery of quality services, held themselves and employees

42

accountable for their performances, and eliminated wasting resources. The next section described

how internal and external forces drove or harmed future growth and sustainability for hospitals

unless they worked on how they marketed their services and utilized their resources to outweigh the

competition. As a result, financial leadership strategies focused on managing daily operational

functions, performance, accountability, and the competitive advantage were key factors in this

section of the conceptual framework for ensuring that hospitals were prepared to meet society’s

health care demands, and sustain profits, growth, and productivity.

Hospitals were incorporating the use of interdepartmental methods to save money and

reduce admission errors and patient stay delays. Roberson (2008) explained a program designed to

improve the admission process of patients to increase financial performance and patient satisfaction.

Roberson (2008) reported using a team approach method involving the steering commitment, the

emergency department, and the inpatient team of Lowell General Hospital in Lowell,

Massachusetts. Metric tools for processes, patient outcomes, and service quality were set in place

to monitor progress throughout the program. The findings of the study created considerations for

reducing patient throughput delays and methods for ensuring the effectiveness of a

multidisciplinary patient throughput team generating $1.5 million in additional net revenue for the

hospital. This study was similar to Hughes-Cromwick (2007) by examining leadership approaches

that improved financial performance and patient satisfaction. However, employees needed to

receive training on systems-based thinking that transformed their independent mind frames and

traditional hierarchy departments to prevent them from acting alone to solve hospital problems and

inspired them to work with boundary-spanning capabilities involving multiple perspectives and

stakeholders to solve hospital problems. Roberson (2008) made a great resource for the dissertation

43

by understanding the issues that prohibited financial growth and built an infrastructure to promote

organizational strategies for successful management of daily hospital activities.

Although hospitals were learning how to work interdepartmentally, competition was on the

rise among hospitals competing to provide various care services and specialty treatment centers.

Carey, Burgess, and Young (2011) examined the effect of growing competition among ambulatory

surgical centers in Arizona, California, and Texas in comparison to general hospital services.

Revenues, costs, and patient margins were the dependent variables while the number of ambulatory

surgical centers in operation for two or more years was the independent variable in a regression

analysis. Carey et al. (2011) provided evidence of a competitive effect with the ambulatory surgical

centers negatively impacting the profit levels for general hospitals. This study corroborated with

Goetz et al. (2011) by indicating financial variables effected profitability in the financial

performances of hospitals. Carey et al. (2011) related to the present research by providing

information about competition between hospital environments. Due to the increasing amount of

uninsured citizens and the rise of health care costs, patients were being conscientious about picking

their health care facilities based on costs, quality of services, and locations. However, further

research examining a broader societal influence and location comparisons to general hospitals were

recommended.

Collaboration among hospital leaders was vital for creating an atmosphere capable of

producing financial changes while holding employees accountable. Goetz, Janney, and Ramsey

(2011) analyzed the structure, processes, and tools that led to effective leadership in the

Northwestern Memorial Hospital of Chicago, Illinois. They explained how the accountability

model assessed the actions and thought processes of the organizational culture. The chief nurse

executive and the chief financial officer worked collaboratively to create an accountability model

44

for all the nursing employees to use as quality indicators and collective accountability to improve

performance, communication, direct care, and profits. As a result, productivity improved since

patients fall rates declined, infection rates declined, engagement rates increased, certified nurse

rates increased, and the turnover rates decreased. The nursing leadership team reduced hospital

costs by $10 million over four years and exceeded achievement levels indicated in the national

benchmark for quality nursing outcomes. This study was similar to Roberson (2008) because they

both used leadership principles to improve financial performance, patient safety, and employee

engagement. This was an excellent example of improving financial performance in the hospital

system, but it needed to include other hospital employees in addition to nurses to make it a systemic

approach for all hospital employees to follow and improve productivity. Goetz, Janney, and

Ramsey (2011) related to the study by providing ideas on how to study leadership, strategy,

execution, financial improvement, advancement in patient care, and development of a world-class

workforce during economic hardships and reform.

New health care expenditures were forcing hospitals to become transparent in their services

and prices while patients increased their rights to choose services. Hughes-Cromwick, Root, and

Roehrig (2007) explained the growth of consumer-driven health care in the twenty-first century.

They articulated the importance of consumer-driven health care to provide information to patients,

eliminate health care barriers, compare rates, and introduce new products in the markets. They

revealed a new health care framework, Altarum Health Sector Model, as the method to investigate

the potential impact of national health care expenditures for making health care accessible to

customers and controlling costs. This study was similar to Roberson (2008) because it explained

how financial performance was affected by the way patients made decisions based on the

information they received, the quality of service, provider costs, and the predicted outcomes. The

45

consumer-driven health care services benefited some patients because they had a choice in their

health care selection, but sometimes it was a disadvantage to some hospitals that had employees

seek other health care plans. Hughes-Cromwick et al. (2007) related to the research by emphasizing

the importance of how hospital systems provided data to educate and satisfy their patients, and the

impact customer-driven health care had on financial outcomes.

Health care leaders were discovering the importance of achieving exceptional financial

performance through leadership, strategy, and execution. Kaufman and Goldstein (2008) described

five key factors of leadership that incurred in organizational success for hospitals and health care

systems. The key factors contributing to organizational success in hospitals were “visioning in

partnership with the board, building and sustaining a strong and accountable executive team,

developing a high-quality, integrated plan, skillfully executing the plan and managing the

fundamentals, and building and maintaining credibility” (p. 8). A qualitative method was used to

interview the chief executive officers and the chief financial officers of the top ten nonprofit

hospitals and health care systems throughout the United States. The findings revealed a positive

correlation between excellence in leadership and financial performance. This research provided a

framework on how to develop strategies for discovering effective health care leadership to promote

financial accountability and growth. Some of the suggested strategies were executive team

building, coaching, mentoring, leadership development plans, talent management, succession

planning, 360-degree feedback, skilled-based training, job empowerment, participative decision-

making, and incentive programs. Kaufman and Goldstein (2008) concepts of developing leadership

skills to build employee engagement, patient satisfaction, and financial performance outcomes

corroborated with Evashwick and Ory (2003); Goetz et al. (2011); Hughes-Cromwick et al. (2007);

and Roberson (2008). Kaufman and Goldstein (2008) supported the research topic by

46

understanding a systematic approach for including all key stakeholders in the change process and

observing the operating ingredients that go into developing an organizational culture capable of

excellence and fiscal responsibility. This was a great study, but the researcher wondered if the

framework in this study produced a positive correlation between excellence in leadership and

financial performance in for-profit hospitals since their study only focused on nonprofit hospitals.

Internal and external factors were impacting hospital expenses and revenue. Ovanessoff and

Purdy (2011) examined the forces that drove future growth for businesses on a global level. They

focused on how the population growth was changing due to decreasing birth rates and the growing

aging population. As a result, the economy was building sustainability from a new market. In

addition, the researchers explored how health care and pharmaceuticals were increasing from the

changing demographics, rapid urbanization and migration, new information, and energy

technologies. They acknowledged that increasing incomes in the emerging markets were causing a

demand for green energy developments, innovations, and technologies. Ovanessoff and Purdy

(2011) predicted the median age will increase from 29 to 38 by the year 2050, and health care

spending continued to increase the gross domestic product. While society and the economy went

through transformations, hospitals had to focus their efforts on competitive excellence. They

defined competitive excellence by paying attention to what one organization did better than anyone

else, how to market an organization, resources, and the differentiation in the locations between

competitors. This study was similar to the concepts in Carey et al. (2011) of internal and external

organizational changes affecting financial performances. Most importantly, Ovanessoff and Purdy

(2011) provided a resource for the present study by showing the importance of understanding how

internal and external factors impacted hospital profits, revenues, and competitive advantage while

attempting to deliver quality services during times of unprecedented changes.

47

Hospitals leaders built long-term sustainability and improved financial hardship by creating

innovative methods to enhance their organizational characteristics. Evashwick and Ory (2003)

identified leadership and financial practices to sustain health care programs for older adults. They

reported strategies for overcoming financial challenges in the health care field. A structured

questionnaire was the method used to obtain information from the health care administrators. As a

result, they provided a list of advice on how to succeed in the complex U.S. health care system in

the twenty-first century and how to develop funds for health care programs. They listed

“collaboration, relationship building, dedication, establishing community ties, starting small and

moving slow, getting buy-in from the right stakeholders, shared visions, shared leadership,

patience, networking, a mix of experts on the team, clear deadlines, clear definitions of success,

recruiting the right people, and risk takers” as some aspects for succeeding in the health care

industry (Evashwick & Ory, 2003, p.188 ). This study related to Kaufman and Goldstein (2008) by

providing insight into organizational processes that were effective in fostering longevity for

productive medical systems. However, hospitals trying to model this study had to create their own

metric according to their hospital environment for evaluating the impact of the strategies.

Evashwick and Ory (2003) helped focus the research on human, physical, and financial resources

for creating innovative approaches for leadership.

Organizational change (traditional hierarchy structure, collaborative leadership, and cultural

change)

Transformational change in the health care sector required the removal of the traditional,

vertical, hierarchical authority-driven structure. Transforming the traditional hierarchy structure in

hospitals to a collaborative leadership meant allowing employees opportunities to contribute in

meaningful ways for articulating knowledge, developing shared goals and purposes, improving

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project management, operations, and conflict resolution. Clinical and non-clinical leaders from

various cross-boundary groups, teams, disciplines, and professional levels were needed for creating

innovative strategies for organizational success (Browning, Toain, & Patterson, 2011).

Researchers agreed that transforming the traditional, vertical, hierarchy leadership systems

into lean, interactive, collaborative leadership systems improved organizational success by building

employee engagement, patient satisfaction, and financial accountability in hospitals (Bates, 2000;

Gary, 1995; Jungyoon, 2011; Merry, 1994; Thompson, 2011). A consensus existed for hospital

leaders to develop strategic skills for realigning the organizational culture to the hospital’s mission

and vision to achieve an engaged workforce capable of optimal performance and effectiveness

(Levin & Gottlieb, 2009; Rondeau & Wagar, 1998; Tsai, 2011). Several scholars reported a

collaborative leadership environment in hospitals was critical for managing strategic change,

improving decision-making, problem solving, communications, engagement and well being, and

enhancing the delivery of quality services (Gray, 1995; Jungyoon, 2011; Trinh & Connor, 2006).

49

Figure 1.3. Center for Creative Leadership. Retrieved November 7, 2012 from

http://www.ccl.org/leadership/pdf/research/CollaborativeHealth care Leadership.pdf.

Despite evidence, such alignment was beneficial because changing the organizational

culture was complicated (Tsai, 2011). All change was not beneficial to the entire organization;

sometimes it positively impacted one dimension and caused havoc in another (Trinh & Connor,

2006). Gray (1995) argued reducing the number of executive job positions, duplicate job positions,

and middle-man positions (such as coordinators) to create lean management structures with ratio

balances between employees and supervisors.

Changing the hospital structure, culture, and change management strategies improved

overall performance in a number of ways. However, there was still a gap on how to balance the

impact of change to produce positive results and not harm employees and the system. This

50

dissertation explored the process of transforming hospital leadership while controlling the effects of

change on the system.

The researcher organized this stream by identifying patterns to support the body of

evidence. This process built a claim for telling how the evidence fit together (Machi & McEvoy,

2012). The evidence was combining themes to support the core idea of organizational change and

the sub-ideas of structure transformation, collaborative leadership, and cultural change. The

researcher used universal language when summarizing the research studies to make the concepts

familiar to a general audience (Booth, Colomb, & Williams, 2008).

The researcher organized this section by explaining the importance of removing the

traditional hierarchy leadership structure because it was no longer effective in producing quality

work in an ever-changing society. Then the researcher explained the importance of transforming

the leadership structure into a collaborative leadership structure capable of building employee

engagement and value-added organizational performance by using a multidisciplinary team

approach. Since hospitals working together were potentially smarter, the researcher described how

quality circles and shared leadership brought all of the hospitals’ employees together to share

knowledge and skills for solving organizational problems and improving the organizational culture,

profits, and service delivery. Then the researcher elaborated on the importance of understanding

how the environmental context and culture of hospitals influenced how they handled change and the

impact change processes had on organizational characteristics. As a result, structural

transformation, collaborative leadership, and cultural change were key elements in the

organizational change section of the conceptual framework for aligning an engaged workforce and

organizational environment capable of optimal performance and effectiveness.

51

Thompson (2011) published an article summarizing how cooperative leadership and

quality circles provided opportunities for employees to unite together in self-managing teams for

developing talents, contributions, and improving organizational processes and products. A new

model of leadership revolutionized the organizational cultural by using a horizontal and collegial

interaction of cooperative leadership and quality circles. The cooperative leadership and quality

circles transformed the current culture into a preferred culture with exquisite knowledge, skills,

competence, elective interdependence, empowerment, motivation, critical thinkers, and action-

takers (Thompson, 2011). The cooperative leadership and quality circles eliminated barriers to

producing quality work by uniting integrated patterns of human behavior that included language,

thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, political and religious

groups of employees. This article was similar to Bates (2000); Gary (1995); and Jungyoon (2011)

because cooperative leadership and quality circles benefited organizations by creating open,

respectful, clear lines of communication, personal and social development, a sense of belonging,

trust, and accountability. This article supported the research because employees of the hospital

setting were encouraged to engage in quality circles for practicing leadership skills in their daily

tasks that resulted in transformational structural and behavioral changes. On the contrary, fast-

paced hospital settings were complicated environments for trying to implement quality circles.

An interdependent culture of hospital employees with various disciplines and job levels was

needed for providing efficient, high-quality, compassionate patient-centered care and leadership.

Merry (1994) published an article depicting the traditional hospital leadership structure by calling

for a shared, collaborative leadership structure in hospitals to improve organizational culture,

quality, cost, and service delivery. Merry’s model of shared leadership brought clinical and non-

clinical leaders together for managing hospitals and change. In addition to a new leadership model,

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hospital leadership needed to create a genuine shared vision for employees to embrace while

enhancing the organizational culture. Eliminating conflict between physicians and non-clinical

managers helped hospitals move beyond the individual, traditional structure and the presumptive

mentality that “doctors know best” by having Hospitals boards and executive positions made up

exclusively of physicians. The researcher believed current hospital leadership battled with the idea

of expanding leadership and collaborative decision-making opportunities to non- clinical leaders.

The article supported Thompson (2011) and Jungyoon (2011) on the idea of collaborative

leadership improving organizational culture, performance, and employee engagement. The article

paralleled with the present research study by incorporating a shared vision and a mix of innovative

leadership backgrounds and styles that were needed to encourage participatory management to

create well established hospital environments.

Changing the hospital structure to lean management required dramatic shifts throughout the

organization and the process of operations. Gray (1995) published an article calling on health care

leaders to transform their leadership organizations into learner management structures. The health

care industry adapted to change less rapidly than other business industries. The traditional model of

leadership had increased costs, wasted resources, and lacked efficient leadership development

plans, competencies, and talent management succession planning. He suggested hospitals

functioned in an integrated leadership system with a maximum of five official titles and decision-

making levels, monitor the span of manager-to-employee ratio, eliminate unneeded positions, and

provide management skills training. The health care industry benefited from flatting their

organizational structure with outcomes such as improving the speed of their decision-making

processes, developing multidisciplinary care teams to deliver quality services, enhancing employee

lines of communication, and managers analyzing and improving operations using quality

53

management approaches and problem-solving skills. Gray’s concepts of collaborative leadership

structures to improve team management, empower employees, and increase value-added

performances were in accordance with Berger and Berger (2011); Daft (2010); Kim, Thompson,

and Herbek (2012); and McAlearney et al. (2008). Gray (1995) was significant to the present

research study with the idea of improving organizational structures and management so they

function more efficiently and eliminate waste. However, the researcher disagreed with eliminating

positions and dismissing competent employees in the interest of creating lean management

structures because the value and organizational knowledge invested in these employees were lost

and no longer valuable to the organization.

The organizational culture of hospitals impacted employee behavior and job satisfaction.

Tsai (2011) conducted a cross-sectional study on two hospitals in Central Taiwan with a

quantitative survey to explore the relationship between job satisfaction, organizational culture, and

leadership behaviors. The researcher was able to retrieve relevant data from 200 nurses and

health care leaders. The results of the study produced a positive correlation between leadership

behaviors impacting the organizational culture and job satisfaction among the hospital nurses. The

study supported health care leaders improving their leadership skills and behaviors to align with the

organizational mission for improving employee job satisfaction. Leaders were responsible for

maintaining the organizational culture. Therefore, exceptional leadership skills and styles

established the foundation of how employees interacted and reacted to their work environment. Tsai

(2011) was similar to Shuck & Herd (2012) suggesting organizational leaders reevaluate their

behaviors and actions to improve employee engagement and increase organizational performance

and the organizational environment. Due to the large number of unengaged employees in the United

States, it was difficult for the health care industry to improve employee satisfaction and well-being,

54

especially using traditional methods. Tsai (2011) was a helpful resource to the dissertation by

proving that there was a need to satisfy and engage the health care workforce by focusing on

transforming leadership and behaviors, improving communications between employees and

supervisors, establishing a shared vision, and promoting organizational collaboration.

The organizational culture of hospitals impacted how employees performed and perceived

the organization. Rondeau and Wagar (1998) conducted a study to examine the relationship

between organizational culture and performance. They used a questionnaire to collect data from

441 Canadian hospitals’ chief executive officers. The study measured organizational culture in the

categories of group, entrepreneurial, hierarchical, and rationale. The study measured performance in

the categories of customer measures, employee measures, operational measures, organizational

cultures, organizational learning, and organizational characteristics. The results indicated that small

hospitals function in-group cultures, have high employee morale, organizational commitment to

employee training and development, and great reputations. The researchers found that larger

hospitals functioning in entrepreneurial cultures (risk-takers, innovative services), have high

organizational flexibility, adaptability, high employee morale, and less resistance to change. The

results also indicated that hierarchical organizations had low patient and employee satisfaction rates,

less commitment to education and training, more resistance to change, and more lawsuits, and

rationale cultures had high scores in organizational operating efficiency and financial performance.

Although the larger hospitals acting in the entrepreneurial culture had better results, they did not

have “good reputation” listed as a characteristic. Rondeau and Wagar (1998) corroborated with Tsai

(2011) on the concepts of improving the relationships between organizational culture, performance,

and leadership behavior. Rondeau and Wagar (1998) supported the present research by proving that

the organizational culture impacted performance, employee engagement, and patient satisfaction.

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Sometimes hospitals had to realign their organizational culture to make changes and

improvements for optimal performance outcomes. Levin and Gottlieb (2009) reported information

on the strategic process of realigning an organizational cultural. Executive leadership was critical

to promoting culture change throughout organizations. They discussed the following six principles

for framing the conduct of cultural realignment: “understanding the required scope of change,

model, teach and embed, use multiple levers, create board involvement of key organization

constituencies, manage with rigor and disciple, and integrate into daily work life” (pp. 33-35).

They listed the following eight practices as the roadmap for executing organizational change in a

clear and precise format: “establish infrastructure and oversight, define the preferred culture,

conduct culture gap audit, ensure leadership modeling, manage priority culture realignment levers,

promote grassroot learning, integrate into priority strategic initiatives, and assess progress” (pp. 36-

44). Adapting the six principles and eight practices to meet your organization realigned the culture

to improve performance, but every organization had to adapt the context, needs, and challenges to

their unique processes and culture. Levin and Gottlieb (2009) process of organizational change,

performance improvement, and collaborative leadership related to Bates (2000); Rondeau and

Wagar (1998); Thompson (2011); and Tsai (2011). Levin and Gottlieb (2009) helped the research

study by understanding how critical a structured, multifaceted approach was needed for

organizational alignment of the mission and goals to achieve financial success, a competitive

advantage, and optimal performances for creating a world-class workforce.

After you changed the leadership structure, you had to change the organizational culture.

Bate (2000) conducted a case study on an organizational culture change program at NHS, a hospital

in the West of England. The hospital was rebuilding a new site and wanted to transform the

organizational culture for the relocation. He used ethnographic and qualitative techniques such as

56

interviews, focus groups, observations of meeting, and interactive contexts to collect data from the

hospital’s consultants, managers, nurses, and ancillary staff over a two-year period. He also used

the hospital’s library and its redevelopment documents as secondary sources of data collection. The

data collection process covered topics on organizational structure, change, culture, patient-focused

care, and leadership. The results of the study indicated that changing organizational cultures were

complicated and effective change efforts were needed to change employees’ mindsets, behaviors,

and actions to produce expected outcomes. The study proved that network organizations were more

acceptable to change, and the hospital improved in areas of trust, culture, process, structure,

systems, and behavioral changes. Comparable to Berger and Berger (2012) and Thompson (2011),

the results suggested hospitals function in network/collaborative communities because they

performed better than traditional hierarchy leadership styles. Transformational change of hospital

leadership sometimes took several years to successfully implement and complete. Bate (2000)

supported the dissertation on the concepts of improving performance and effectiveness by

transforming hospitals’ organizational structure into flat, collaborative leadership structures to

improve the organizational culture.

Strategic change sometimes produced positive and negative effects in performance

outcomes. Trinh and O’Connor (2002) conducted a two-year longitudinal study using a panel

design on nonprofit and for-profit acute care urban hospitals. They used the American Hospital

Association Annual Survey, Medicare Cost Reports, Medicare HMO Files, U.S. Bureau Census

Files, and Area Resources Files for the data sources. The sample consisted of 2,423 urban hospitals

throughout the United States. The study focused on variables of urban hospital performance,

strategic change, environmental characteristics, and organizational characteristics. The results

indicated that environmental contexts influenced urban hospitals’ HMO business enhancement

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strategies, and organizational characteristics impacted cost-saving strategies. In contrast to the

researchers mentioned in the present study, Trinh and Connor (2002) found that strategic change

can positively impact one dimension of hospital performance and negatively impact another

dimension of hospital performance. Trinh and Connor (2002) collaborated with Bate (2002)

suggesting that organizational leaders engage in collaboration while working on strategic change

projects to achieve better performance outcomes. Since change sometimes had detrimental

outcomes, leaders had to be efficient in how they identified the change process and strategically

implement standards appropriate to the change process. Trinh and Connor (2002) related to the

dissertation by observing helpful and harmful variables that impacted strategic change in urban

hospitals.

The leadership designs of organizations impacted how well they practiced change

management. Jungyoon (2011) examined the organizational structure and change management

process of long-term care organizations. She used a cross-sectional survey as the data source. The

sample contained100 acute care organizations that participated in a workforce development and

culture change project. She observed six structural indicators: centralization, formalization, degree

of job related training, vertical communication, horizontal communication, and supervisory span of

control. The results from the study indicated a positive correlation with the organic class

(professional) and readiness for change and commitment to change, and a negative correlation with

the minimalist class (low training and low communication) and readiness for change and

commitment to change. In collaboration with Tsai (2011), Jungyoon (2011) suggested hospital

leaders and policy makers reevaluate their budgets and training plans to include continuing

education, career development, and training opportunities to improve employee engagement,

development, and organizational change. Sometimes employees did not agree with organizational

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changes and developments. Therefore, this study needed to include training in preventing

resistance to change and communication to help employees who are noncompliant to organizational

changes. This study helped the researcher understand various strategies needed to implement

successful structural changes, and the impact it had on the organizational design, context, and

culture.

Convergence and Conclusion

Rapid changes occurred in hospital systems for the past couple of years. Systemic changes in

socioeconomics, cultural, political, environmental, academic, and financial reforms affected

hospital systems (Wolf, Hanson, Mori, 2011). Change was associated with opportunities. While

America was struggling with health care changes, the following paper identified organization

development, employee engagement, and patient satisfaction as leadership practices, and financial

accountability, and organizational change as the key elements for success, and performance

improvement to close operational and financial gaps to improve employee and patient satisfaction

in hospitals. There was a mandate to change the traditional, hierarchical hospital culture to a

culture of collaborative leadership for delivering high-quality, efficient care in a safe, affordable,

and effective manner.

The hospital leaders had to be able to identify the change process, manage the change, and

use the experience to create new learning opportunities for themselves and for their organizations.

New leadership development incentives and talent management alignment demanded a need to sync

establishing the right culture, leadership, strategies, and tools for moving the organization profits to

a path of success. Leadership, employee engagement, and guidance were needed to transform the

United States hospital system into a “mission-driven, patient-centered, value-enhancing system of

care” while making health care leaders accountable to patients, consumers, and their employees

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(Davis, 2009, p. 1). In summation, a collaborative leadership strategy was needed to create

cooperative, interdependent hospitals resulting in high-quality, high-value care at low costs, and

more efficient use of resources for the present and future.

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Chapter 3 – Research Methodology

Introduction

Hospital leaders in high-level positions played a vital role in creating and maintaining

stability in the performance and survival of their organizations (Ballein, 1997). Current issues such

as health care reform, ongoing economic issues, demographic shifts, physician shortages, mergers,

downsizing, cutting employee wages and shifts, low employee morale, and employee turnover

continued to add to the challenges in the health care sector (Berger & Berger 2011; Browning,

Toain, & Patterson, 2011; Cummings & Worley, 2009). To cope with the growing constraints,

hospital leaders in high-level positions had to create powerful tools to leverage these challenges

through the way they accessed, provided, and funded health care in the United States (Goetz,

Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Kaufman & Goldstein, 2008; Meyer Silow-

Carroll, Kutyla, Stepnick, & Rybowski 2004; Roberson, 2008). David Nivet (2011), the Chief

Diversity Officer from the American Association of Medical Colleges (AAMC), suggested health

care leaders “build capacity for innovation by engaging people with different perspectives, skills

sets, and experiences to create strategies, and solve problems” (p. 1487). The primary purpose of

this qualitative, descriptive case study was to explore the process of leadership practices for

promoting organizational transformation and success as defined by organization development,

employee engagement, patient satisfaction, financial accountability, and organizational change in

Lynford Memorial’s Comprehensive Acute Care Rehabilitation Unit (CARU).

Hospital leaders valued the importance of utilizing leadership practices to enhance their

organizational culture, foster change, embrace communication, build relationships, resolve conflict,

and align their organizational processes to sustain profitability (Kaufman & Goldstein, 2008; Kim,

Thompson, & Herbek, 2012; McAlearney, Scheck, & Butler, 2008). The researcher sought to

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better understand this phenomenon by focusing on specific research questions, the primary one

being “How do leadership practices contribute to organizational success?” The secondary questions

were as follows:

1. How do organization development principles contribute to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

2. How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness?

3. How does patient satisfaction contribute to organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness?

4. How does Lynford Memorial’s CARU’s preferred theory of organizational change align

with their preferred leadership practices?

The methodology section defined how the research was conducted (Bloomberg & Volpe,

2012). This section included the rationale for the research design, as well as description of the site

and population, selection of participants, instrumentation, data collection, data analysis procedures,

and ethical considerations.

Site and Population

Population Description

The researcher selected Lynford Memorial as the primary site for the qualitative, descriptive

case study. Lynford Memorial was the place of the researcher’s employment. Glesne (2005)

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supported the notion of “backyard research in the hope that the whole organization will gain viable

knowledge, establish new tendencies, and engage in the change-oriented process” (p. 33).

The selection strategy for the sample population was purposive, so the researcher

deliberately selected individuals who could provide a great deal of information for the research

study and answer the research questions (Maxwell, 2005). In addition, purposeful sampling

allowed the researcher to discover, understand, and interpret relevant information from the

appropriate parties (Merriam, 2009).

The first sample consisted of nine participants in a clinical medical department leadership

team from the CARU for the interviews. The second sample consisted of five hospital employees

(occupational therapists and physical therapists) from the CARU for the focus group. The goal of

the second sample was to use multiple groups of hospital employees until a level of saturation was

met. However, only one group of five employees agreed to participate in the study, and the level of

saturation in the information was met by the five employees who agreed to participate in the focus

group.

Site Description

Lynford Memorial (Lynford) is located in a large metropolitan area and was founded in

1825 by a group of physicians. The hospital was ranked by 2011 U.S. World News & Report as

among the nation’s top medical centers in 11 specialties: Orthopedics, Rehabilitation, Pulmonology,

Urology, Neurology and Neurosurgery, Geriatrics, Gastroenterology, Gynecology, Diabetes,

Endocrinology, and Ear, Nose, and Throat. In addition, Lynford Memorial made the honor roll as

the best hospital in the 2013-2014 U.S. World News & Report. The hospital was also one of the

first hospitals in the nation to be affiliated with a medical school, Lynford Medical College,

established in 1824 (http://www.lynfordhospital.org/About-Us.aspx.).

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Lynford Memorial was prestigious for teaching students and residents excellent clinical care

setting techniques and learning experiences from being an academic medical center. The hospital

defined the future of clinical care and quality by teaching students and residents mastery skills in

their professions while learning how to work in a multidisciplinary environment.

Lynford Memorial was committed in providing excellence in patient care, patient safety,

and high-quality health care experiences. These services were delivered in four locations. In

addition, the hospital had several radiation therapy satellite locations set up throughout the region.

The hospital had 969 licensed acute care beds with 46,386 admissions and 475,031 annual

outpatient visits in a year. The hospital had 7,200 full-time employees, 977 house staff, 1,176

medical staff, and 1,848 full-time registered nurses. Lynford Memorial performance ratings were

73% in overall satisfaction, 72% in inpatient pain management, and 77% in recommending

inpatient stay (Retrieved from http://www.lynfordhospital.org/About-Us.aspx.).

The researcher selected the Department of Rehabilitation Medicine at Lynford Memorial as the

research site for the present study. The Department of Rehabilitation Medicine at Lynford

Memorial was created about 50 years ago (Anita Chambers, personal communication, May 7,

2013). For the past 30 years, the Department of Rehabilitation Medicine physicians and therapists

have been leading our nation as the best practice in rehabilitation medicine. In 2012-2013, U.S.

News & World Report ranked the Department of Rehabilitation Medicine among the nation’s top

medical centers for rehabilitation medicine (Retrieved from

https://pulse.lynford.edu/webapps/portal/frameset.jsp?tab_id=_1_1).

The Department of Rehabilitation Medicine had 23-bed Comprehensive Acute

Rehabilitation Unit (CARU) that specialized in evaluating and taking care of patients throughout

the Delaware Valley with diseases, disorders, or injuries such as stroke, amputation, heart

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transplant, spinal cord injury, traumatic injury, and neurological disease that impairs normal

functions, daily living functions, and mental capabilities. The unit population consisted of adults

who stayed 16-18 days. The unit served an average of 360 inpatients per year. The department

contained a full-time team of 47 employees in the disciplines of medicine, nursing, occupational

therapy, physical therapy, speech language pathology, psychology, recreational therapy, case

management, social work, pharmacy, nutrition, admissions, administrative support, and pastoral

care (Anita Chambers, personal communication, May 7, 2013).

The CARU functioned as an interdisciplinary program within the overall hospital

organizational structure (Figure 1.3). The Rehabilitation Operations Group (ROG) provided

executive leadership for the CARU program. Component services of the CARU were organized

under the Department of Nursing, Rehabilitation Medicine, and Social Work/Case Management.

The daily operational leadership of CARU was managed by the Administrator of Rehabilitation

Services and the Nursing Unit Management. They were known as the Unit Management

Committee which was the focus of the leadership team for the present research study. The Unit

Management Committee consisted of an administrator of rehabilitation services, the medical

director, the rehabilitation unit nurse manager, rehabilitation unit nursing clinical specialists, the

rehabilitation program manager, the social worker, the case manager, the admissions and outcome

coordinator, the clinical liaison, and the occupational therapy, physical therapy, speech language

pathology advanced clinicians (Anita Chambers, personal communication, May 7, 2013).

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Figure 3.1. Lynford Memorial Rehab Department Organizational Chart

The current organizational context of the CARU dealt with internal and external changes.

The department experienced an organizational restructure in the leadership in 1997 (Anita

Chambers, personal communication, May 7, 2013). The individual positions of occupational

therapy, physical therapy, and speech chiefs were eliminated to prevent overlapping in roles and

responsibilities, low performance issues, lack of information sharing, and ineffective

communication and staff interaction. Anita Chambers was appointed administrator of rehabilitation

services in 1999. She managed the professional and support personnel, maintained and enforced

appropriate administrative and personnel policies, ensured that they met the CARU objectives, built

interdepartmental relationships, interactions, and communications, maintained budget and fiscal

President

Sr. Vice President

Chief Medical Officer

Chief Operating Officer Dean

Lynford Medical College

Vice President

Clinical Resource

Sr. Vice President for Patient

Services & Chief Nursing Officer

Administrator of Rehab

Services

Vice President

Nursing Services

CARU

Nurse Manager

Rehab Program Manager

Case Management Manager

Therapy Staff

Support Staff

Chairman, Dept. of Rehab

Medicine

Medical Director CARU

Nursing Staff

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operations control, and resolved departmental operating issues (Anita Chambers, personal

communication, May 7, 2013).

The CARU was continuing to work on effective measures to build quality and patient

satisfaction. Currently, these areas scored the lowest on a recent patient satisfaction report. As a

result, Anita Chambers supervised the case management manager instead of the vice president of

Clinical Resource Management and a social worker was hired, as well. The unit had team

conferences, team reviews, and team huddles to discuss patient progress and discharge plans on a

regular bases. These changes were made to help the unit improve informing patients of treatment

and the discharge planning process (Anita Chambers, personal communication, May 7, 2013).

Due to the nature of health care changes in access to physician care and reimbursement, the

CARU continued to struggle to keep beds filled. The CARU was trying to work on effective,

creative techniques to advertise and market their services to recruit more patients and expand the

availability of the rehabilitation physician under these extraneous circumstances. In addition, they

were trying to deal with understanding and educating their staff on the new health care laws for

uninsured patients (Anita Chambers, personal communication, May 7, 2013).

Site Access

To implement the research designs for collecting the data, the researcher gained access to

the research site. Initiating access and consent to the site and participants were processes to fulfill

research goals (Glesne, 2005). The researcher located a gatekeeper to gain access to a Lynford

Memorial department. The gatekeeper provided consent for the researcher to conduct the study and

provided access to participants (Glesne, 2005). In this case, the gatekeepers were department chairs

listed on the hospital website for the initial contact of a research site confirmation. The researcher

proceeded through the proper channels of contacting the appropriate gatekeepers. The researcher

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contacted the gatekeepers for site access, the researcher prepared an introduction email that

introduced the researcher, described the research, and asked for permission to use the medical

department as a research site (Appendix A). In addition, the researcher prepared a lay summary as

an attachment to the introduction email that explained the research expectations by outlining who

the researcher was, what the researcher planned to do, how long it would take, participants

involved, benefits, confidentiality, and record keeping methods (Glesne, 2005).

The researcher emailed 18 Lynford Memorial clinical medical department chairs requesting

permission to use their department as the research site. Lynford Medical College and Lynford

Memorial share the same department chairs (http://www.lynfordhospital.org/). Once permission

was confirmed with a department chair, a contact person was assigned to assist the researcher with

future activities. The researcher set up informal meetings with the department chairs who agreed to

grant the researcher access the medical department as the research site. The researcher and the

department chairs discussed the research project and expectations so the researcher could decide

which department best matched the research project and expectations for the dissertation study.

The Department of Rehabilitation Medicine’s Comprehensive Acute Rehabilitation Unit (CARU)

was selected as the research site because the researcher developed a good rapport with the

department chair, the administrator, and the leadership team during their informational meeting.

Research Design and Rationale

Introduction of Design

The qualitative, descriptive case study method was an effective approach for the purpose

of this study. Creswell (2012) defined qualitative research as an inquiring approach used to explore

and understand a central phenomenon by gathering information through general questions and

analyzing the information for descriptions and themes. The research design in the study consisted

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of a qualitative approach within and across the stages of the research. The qualitative method

design for conducting the study had research phases in a sequential time order with a dominate

status of qualitative data collection (Johnson and Onwuegbuzi, 2004).

A descriptive case study was an in-depth analysis that investigated the core essence of

human experience of phenomenon by exploring the meaning of lived experiences, perceptions, and

interpretations in a real life, bounded context through multiple sources of information (Bloomberg

& Vault, 2012; Creswell, 2012; Merriam, 2009; Tellis, 1997). The researcher used the descriptive

case study approach to explore real-world situations through the participants’ personal values and

experiences (Bloomberg & Vault, 2012; Creswell, 2012; Merriam, 2009; Tellis, 1997). Research

conducted in the present case study was descriptive because the approach produced an end product

that was substantive, rich, holistic descriptive data for understanding the research problem. The

hospital environment was complex and dynamic (Browning, Toain, & Patterson, 2011). Bloomberg

and Vault (2012) suggested using the descriptive case study approach to understand complex,

bounded systems in social contexts. The information gathered using the descriptive case study

approach allowed the researcher to discover patterns and themes of leadership practices that

contribute to the hospital’s optimal performance.

Rationale

The purpose of this qualitative, descriptive case study was to explore the process of

leadership practices for promoting organizational transformation and success as defined by

organization development, employee engagement, patient satisfaction, financial accountability, and

organizational change. The researcher was intrinsically interested in exploring the leadership

practices mentioned throughout the study by using a qualitative, descriptive case study for the

following reasons: (1) the phenomenon was unique, (2) statistical approaches missed the rare

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human experiences, and (3) the multiple data collection techniques captured a variety of human

experiences (Merriam, 2009). The researcher chose a qualitative, descriptive case study because

sometimes participants felt powerless, isolated, and ignored in some research studies, and the

researcher wanted the participants to feel valued and understood throughout the study. According

to Tellis (1997), the case study approach provided multiple-perspective analyses by providing a

voice to the powerless and voiceless and exposing counterproductive group interactions.

The multiple sources of data collection methods in the qualitative, descriptive case study

helped to provide in-depth meaning (Bloomberg & Vault, 2012; Creswell, 2012; Merriam,

2009;Tellis, 1997). The qualitative method in this study used multiple sources of data collection:

informational, in-depth, face-to-face interviews, a focus group, archival records, observations, and

memoing. The researcher selected the leadership team and employees of a clinical medical

department, the Department of Rehabilitation Medicine’s Comprehensive Acute Care

Rehabilitation Unit in Lynford Memorial, as the participants for the research study to understand

the background and impact of leadership practices in the hospital. The researcher selected the

qualitative approach to explain what leadership practices enhance the organizational cultural to

achieve significant gains in organization development, employee engagement, patient satisfaction,

and financial accountability. The researcher understood the phenomenon of how leadership

practices contribute to organizational success, primarily by (1) creating organizational learning

environments, (2) enhancing the organizational cultural to achieve significant gains in quality and

safety, (3) improving employee performance and engagement, (4) establishing transparency in

patient care and patient satisfaction, and (5) improving financial accountability and the bottom-line

results (Sears, 2009).

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Research Methods

Description of Methods Used

The researcher generated information from the hospital leaders and employees to understand

the impact of leadership practices as measured by organization development, employee

engagement, patient satisfaction, financial accountability, and organizational change. The

researcher designed a study that allowed the hospital leaders of the Department of Rehabilitation

Medicine’s Comprehensive Acute Care Rehabilitation Unit in Lynford Memorial to deeply examine

their perceptions about what leadership was and how it was impacting their organization in a

productive and profitable manner. The essence of leadership is to influence what happened

anywhere and at any time in a system (Wolf, Hanson, & Moir, 2011). Leadership rested in the

process of building a dynamic group of individuals to interact through their relationships, ideas,

actions, and technologies (Wolf, Hanson, & Moir, 2011). The researcher’s goal was to help the

participants reframe the way they saw people, problems, or things in their organizations with the

hope of discovering something new, positive, useful, and beneficial to the organizational system

and financial accountability. In addition, the researcher’s goal was to help the participants begin to

think about how to connect the reframing of positive ideas to developing and achieving attainable

goals for the entire hospital system.

The research design in the study consisted of qualitative approaches within and across the

stages of the research. According to Johnson and Onwuegbuzie (2004), corroborated findings

across different approaches increased the level of information and knowledge found in the study

while expanding the researcher’s understanding of the research problem. The qualitative design for

conducting the study had research phases in a sequential time order with a dominate status of

qualitative data collection (Johnson and Onwuegbuzi, 2004). The researcher used various research

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data sources to collect information for the research. The qualitative design consisted of

informational, in-depth, face-to- face interviews, a focus group, open-ended questions, archival

records, observations, and memoing. The researcher used the informational, in-depth, face-to-face

interviews with open-ended questions to collect the information from the CARU leadership team

concerning leadership practices of organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change. The researcher used a focus group

to collect information from the employees concerning employee engagement and the organizational

culture. The researcher used archival data of patient satisfaction records and the hospital website

for cross-reference documents throughout the research study. The researcher used observations to

gather real-time behaviors and interactions when the participants experienced the phenomenon.

The researcher collected field notes such as the memoing data source to record perceptions,

thoughts, and experiences throughout the various phases of the data collection process. The

following sections described how the data sources were used to collect the data for the present

study.

Interviews

The researcher selected the leadership team of a clinical medical department from the

CARU in Lynford Memorial for semi-structured qualitative interviews. The researcher conducted

the interviews with the participants either at their place of employment or in the researcher’s office.

This selection achieved relevant information from the appropriate participants who had an extensive

amount of knowledge and experience in the subject. In addition, concentrating only on one inner-

city hospital and one department had an achievable timeframe with cost and travel considerations in

mind. The face-to-face interview style allowed the researcher and the participants to build a

productive, trustworthy partnership for sharing confidential information (Glesne, 2005). The

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researcher used open-ended, semi-structured questions for the interview. The semi-structured

interview approach allowed flexibility and opportunities to probe for meaningful, information

(Bloomberg & Vault, 2012; Creswell, 2012; Moustakas, 1994). The researcher interviewed the

nine members of the leadership team by using the Leadership Interview Protocol (Appendix F).

The researcher interviewed the financial analyst of the leadership team by using the Financial

Accountability Interview Protocol (Appendix G). The time allotted for the interviews was 20-25

minutes. The researcher emailed the participants a consent form and electronic invitation to read

and reply if they decided to participate in the research study (Appendix C, Appendix D, and

Appendix E). With each participant’s verbal permission, the researcher recorded the interview for

note-taking purposes only. The researcher transcribed each audio recording to produce a written

record of the interview for the data analysis process. The information from the participants was

confidential and anonymous. The researcher assigned each participant a pseudonym. The

researcher did not record or report identifiers or identifying information. Only the researcher had

access to the data. The researcher will destroy the data three years after the completion of the

study.

The researcher created 12 open-ended questions to ask the eight members of the leadership

team about leadership practices and organizational change. The researcher designed the Leadership

Interview Protocol for the data collection process (Appendix F). The researcher conducted

interviews with the leadership team of the CARU with open-ended questions from the Leadership

Interview Protocol. Open-ended questions allowed the participants to provide in-depth information

about the organizational leadership strategies and organizational change. The purpose of the

interview protocol was to retrieve information on leadership and the development of high-

performance work practices, organizational strategies, and organizational change.

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The researcher created open-ended questions for interviewing the financial analyst of the

CARU in Lynford Memorial (Appendix G). The Financial Accountability Interview Protocol

contained eight open-ended questions to assess organizational financial accountability through the

dimensions of financial performance and competitive advantage. The purpose of the interview

protocol was to retrieve information on how the hospital leverages its financial infrastructure,

design, and collaboration to match organizational needs and strategies.

Focus Group

The researcher collected data from hospital employees by conducting a focus group. The

focus group comprised of five occupational therapists and physical therapists from the CARU who

had direct contact with patients. The researcher chose this type of focus group because the

participants interacted with the patients on daily bases, they had a working relationship with their

supervisor, and the leadership practices impacted how they engaged in the organizational

environment. Creswell (2012) advised keeping focus groups small and intimate while selecting

participants who provided vital information related to solving the research problem. The researcher

conducted a focus group based on these criteria, and the level of saturation in the information was

met by the five participants. The researcher worked with the department chair’s contact person, the

department administrator, invited clinical staff employees to participant in the focus group. Focus

group participants agreed to attend on their own free will by responding to an invitation their

supervisor emailed to them (Appendix E). The focus group was a useful method for allowing the

researcher to engage into the world of the participants. It also provided an opportunity for the

hospital employees to function as co-researchers (Bloomberg & Vault, 2012; Creswell, 2012;

Moustakas, 1994). The goal of the focus group was to gather information regarding hospital

employee perceptions on employee engagement and the organizational culture. The Employee

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Focus Group Interview Protocol contained six open-ended, semi-structured questions (Appendix E).

The focus group met for half an hour took place in a private location in the hospital. With each

participant’s verbal permission, the researcher recorded the focus group for note-taking purposes

only. The researcher transcribed each audio recording to produce a written record of the focus

group for the data analysis process. The information from the participants was confidential and

anonymous. The researcher assigned each participant a pseudonym. The researcher did not record

or report identifiers or identifying information. All data was stored on the researcher’s personal

password-protected computer. Only the researcher had access to the data. The researcher will

destroy the data three years after the completion of the study.

Archival Data

From the beginning stages of the research project to the concluding stages of the research

study, archival records and documents were used as data sources. The archival records and

documents provided references and background information to support the information provided by

the leadership team and the hospital employees throughout the study. The archival data sources

consisted of patient satisfaction records and the hospital website. The researcher reviewed

documents on the patient satisfaction rating to understand how the patients approved of the

leadership practices and quality of services provided. The hospital website provided background

information for the site descriptions, leadership principles, strategies, quality and safety measures,

and general employee information. The aggregated data on patient satisfaction in the CARU was

analyzed. The data did not include identifiers or identifying information. The data did not include

private health information. According to Russ-Eft and Preskill (2009), archival data was useful

because it was easy to access, free, answered research questions, provided chronological timing of

events, and credible.

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Observations

The researcher conducted observations to supplement the information gathered during the

interviews (Merriam, 2009). The purpose of the direct observations helped the researcher gather

data in real-time situations (Tellis, 1997). The information from the observations helped the

researcher to understand the research problem and gain insight into the participants’ interactions

and behaviors in a real-world context. In addition, the direct observations supported information

about what the researcher observed in the field to assist with the writing of the field notes in the

memoing process of the data collection. The researcher conducted four informal, non-participative

observations. The researcher arrived 10-15 minutes early for the scheduled interviews and focus

group to observe behaviors, communication, and interactions to understand any connections to the

information obtained. The researcher also observed the participants’ verbal and non-verbal

behavior when responding to the investigative questions during the leadership interview, the

financial accountability interview, and the focus group. The researcher assigned pseudonyms to

individuals. The researcher did not record or report identifiers or identifying information.

Memoing

The researcher collected field notes as the memoing data source to record perceptions,

thoughts, and experiences throughout the various phases of the data collection process. Memoing

provided detailed information of the researcher’s reflection process of what was happening

(Groenewald, 2004). The information was nonjudgmental and descriptive, and it was used as a

reference to relate to the data. The researcher summarized the interview experience after each

interview during the collection phase to produce accurate field notes. The memoing data source

was a very useful tool for the data analysis process.

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Stages of Data Collection

The researcher approached the data collection process through the use of multiple data

sources. Once permission to use the department as the research site was granted from the clinical

medicine department’s chair in February 2013, the researcher was in contact with the department

administrator for further research preparation activities. The researcher met the CARU leadership

team and presented a formal presentation of the study to them in March 2013. The researcher

passed the proposal defense in April 2013. The researcher completed the proposal defense

revisions in May-June 2013. The Institutional Review Board of Drexel University and Lynford

Memorial approved the researcher’s proposal defense in July 2013. After the interviews were

confirmed and permission from the participants was obtained, the researcher prepared to organize

and make copies of the documents and the instruments for the research collection process in July

2013. First, the researcher conducted face-to-face interviews with the each of the CARU leadership

team members in August-October 2013. Second, the researcher conducted a face- to-face

interview with the financial analyst/senior administrator in October 2013. Third, the researcher

conducted a focus group with the CARU occupational and physical therapists in October 2013. The

researcher conducted observations and memoing in August-October 2013. The researcher

transcribed the interview and focus group data and analyzed the archival records in October-

December 2013. The researcher analyzed the data information in January-February 2014. The

researcher completed writing the results and findings chapter in March 2014. The timeframe for the

study is described in Table 3.1.

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Table 3.1. Research Data Collection Timeline

February 2013 Contact research site March 2013 Meet the CARU Leadership Team April 2013 Proposal hearing May-June 2013 Proposal hearing revisions July 2013 Complete IRB process

Final approval from Lynford and Drexel Invite interview participants

August-September 2013 Conduct leadership interviews Memoing Observations

October 2013 Conduct financial interview Conduct focus group Memoing Observations Transcribe interviews

November-December 2013 Transcribe interviews Analysis of archival records

January-February 2014 Data analysis March 2014 Complete Chapter Four – Findings and Results

Data Analysis Procedures

This study employed a qualitative methodology of data collection and data analysis. The

qualitative analysis of data contained similarities and differences, coding and categorizing, and the

constant comparison method (Creswell, 2007). The researcher transcribed each audio recording to

produce a written record of the interviews and focus group for the data analysis process. Each

interview was about 20-25 minutes and the focus group was 30 minutes. The researcher entered the

data into a Microsoft Word document and analyzed the data by hand to generate open codes and

create memo notes for personal self-reflection.

The analysis and interpretation of the data collected was based on a thorough examination of

the research data. The researcher compared the interviews of the leadership team to observe

similarities and differences using the comparative method (Creswell, 2007). The researcher

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analyzed the focus group interview to discover categories of patterns and themes (Creswell, 2007).

Categories were developed from the comparative method and analyzed, coded, and triangulated to

generate themes for the research questions (Creswell, 2007). The researcher used open coding to

identify words, phases, or sentences into systematic patterns and categories (Creswell, 2007). The

researcher used axial coding to resemble the data in order to create new codes (Creswell, 2007).

The researcher used selective coding to integrate the relationship process of the codes (Creswell,

2007). Finally, the researcher compared and contrasted the open codes to create a clear

understanding of their meaning until no further coding descriptions were created (Creswell, 2007).

The researcher designed a code book table to display data codes, abbreviations, and definitions.

Ethical Considerations

Introduction

Ethics was a consideration from the beginning stages of research until the final stages of

research. The researcher behaved ethically to ensure protection of the research study participants

and the environment at Lynford Memorial. The researcher collaborated with the participants

throughout the qualitative research process. Creswell (2012) suggested researchers establish a

caring relationship with research partners and honor social justice by exhibiting “open and

transparent participation, respect for people’s knowledge, democratic and nonhierarchical practices,

and positive and sustainable social change among the action research community” (p. 588).

IRB Approval

First, the researcher completed the Social, Behavioral and Educational Research

Investigators Curriculum by the CITI Collaborative Institutional Training Initiative. This certified

the researcher to conduct research in a social or educational context with human subjects. Then, the

researcher submitted the consent forms—Invitation Email, the Leadership Interview Protocol,

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Financial Accountability Interview Protocol, and the Employee Focus Group Interview Protocol—

to the Institutional Review Board of Drexel University and Lynford Memorial for approval before

the researcher administered the data collection process. The researcher had to obtain approval from

the Institutional Review Boards and consent from the participants before proceeding with the data

collection process. The approval letter for the dissertation is in Appendix B. The researcher

conducted the data collection process for the dissertation only after receiving approval from the

Institutional Review Boards and consent from the participants.

When conducting the research and writing the dissertation proposal, the researcher followed

the ethical principles and guidelines for the Protection of Human Subjects of Research in the

Belmont Report. The basic ethical principles guiding research were respect for persons,

beneficence, and justice. To ensure respect for persons, the researcher was sensitive and respectful

of the participants and the research environment at all times. The researcher protected the patients’

rights by granting them autonomy to participant and make decisions. The researcher used consent

forms via electronic invitation emails to ensure their full participation and explain privacy rights

and protection. In addition, the consent forms provided a brief description of the research project,

highlighted the importance of the study, and encouraged participants to share their thoughts, beliefs,

actions, and experiences (Creswell, 2012). The researcher informed the participants that their

participation was voluntary and they could withdraw from the study at any time without

consequence. During the introduction of each interview and the focus group, the researcher

explained to the participants that the research was part of the processes and practices of the

organizations and not their personal leadership actions and decisions.

To practice beneficence, the researcher protected the participants from risks and harm and

maximized their well-being throughout the research process. The researcher refrained from

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withholding information that could hinder their thoughts and actions. The information from the

participants was confidential and anonymous. Each participant was assigned a pseudonym. The

researcher did not record or report identifiers or identifying information. All data was stored on the

researcher’s personal password-protected computer. Only the researcher had access to the data.

The researcher will destroy the data three years after the completion of the study.

To ensure justice, the researcher treated the participants equally with fair benefits and

without burdens to them and society (Belmont Report, 1979). The researcher extended the

invitation to participate in the study to the entire CARU staff. The researcher also planned to

present the completed dissertation to the CARU staff members who participated in the study.

The researcher planned to submit the dissertation for publication in a health and

organizational journal. Furthermore, stakeholders such as professional colleagues, universities, and

other hospitals will benefit from the dissertation process and results that will be summarized in a

publication journal. Publishing the dissertation project in a research journal will allow for the

opportunity to share the information with all health care leaders and providers, enabling them to

approve their leadership practices and create a high-impact organizational environment.

Known or Anticipated Ethical Considerations Surrounding the Research

The researcher managed known or anticipated ethical considerations surrounding the

research. In the field of health care, change was constant and effective change management

produced systemic improvements throughout the hospitals and the communities. The systemic

improvements enhanced or hindered many facets that were scientific, political, economic, cultural,

and professional—all contributing to change in the health care system and communities (Wolf,

Hanson, & Moir, 2011). This qualitative, descriptive case study was designed to help hospitals

benefit from using the best leadership principles to increase financial accountability in various areas

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such as improving quality and safety, reducing turnover and absenteeism, identifying cost-saving

opportunities, strengthening supervision, assessing training needs, eliminating communication

barriers between staff and supervisors, improving team building and alignment of employee job

responsibilities to the mission, and benchmarking organizational success to match the health care

industry progress (Powell, 2001). This qualitative, descriptive case study was designed to improve

the overall well-being of all hospital employees, patients, business partners, vendors, and the

surrounding communities through the concept of treating human beings with kindness, dignity, and

respect in daily encounters, and valuing ideas and input to make the health care system highly

efficient and functional on a globally competitive level (Wolf, Hanson, & Moir, 2011).

The researcher believed it was very easy to navigate the combined roles of manager-

researcher. The researcher remained disciplined and opened to new ideas and perspectives

throughout the research process. The researcher bracketed personal experiences by removing biases

and emotions from the research and preparing to deal with unanticipated results (Moustakas, 1994).

The researcher’s life revolved around organization development and leadership. The researcher

faithfully practiced these principles in personal, social, and organizational aspects of daily life. It

was difficult for the researcher to accept that some of these leadership principles were not fully

enhancing the organizational performance of the hospital. However, the researcher appreciated and

respected the fact that personal, valid evidence-based data supported it. The researcher was also

able to put personal skills to the test to further investigate the meaning and find innovating methods

to improve the organizational performance. Creswell (2012) mentioned that researchers had to be

reflexive when drawing on conclusions in their research study; one had to be able to accept the fact

that the research data might lead to new discoveries, ideas, and conclusions that were very different

from what was anticipated.

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The researcher implemented several additional measures into the research process to ensure

high ethical standards. To ensure that the findings of the research study were related to truly

understanding the research problem, the researcher refrained from using biases during the data

collection process and during the analyzing process. The researcher practiced the concept of

epoche and bracketing by not letting personal ideas, perceptions, feelings, or beliefs distort the

resultant information (Moustakas, 1994). Lastly, the researcher collected the data by using the

same procedures for conducting interviews and the focus group to ensure consistency.

Summary

This descriptive case study was accomplished through a qualitative methodology research

using a sequential exploratory approach. The primary purpose of this qualitative, descriptive case

study was to explore the process of leadership practices for promoting organizational

transformation and success as defined by organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change. The researcher collected the data

through the use of multiple data sources: informational, in-depth, face-to-face interviews, a focus

group, open-ended questions, archival records, observations, and memoing. Open coding, axial

coding, selecting coding, and compared method were used to analyze and interpret the collected

data into themes for answering the research questions. The researcher followed and upheld ethical

considerations to protect the participants, the data, and their environment throughout the research

process.

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Chapter 4: Findings, Results, and Interpretations

Introduction

In recalling the statement of the problem, leadership development and change management

failed due to the constant pressures of internal and external changes impacting organizational

success in hospitals. The purpose of this qualitative, descriptive case study was to explore the

process of leadership practices for promoting organizational transformation and success as defined

by organization development, employee engagement, patient satisfaction, financial accountability,

and organizational change in a hospital environment. The researcher collected the data from the

leadership team and employees of the CARU through the use of informational, in-depth, face-to-

face interviews, a focus group, archival records, observations, and memoing. All of the interviews

and the focus group were audio-recorded and transcribed word for word for data analysis. Open

coding, axial coding, selecting coding, and compared method were used to analyze and interpret the

collected data into themes for answering the following research questions:

Primary Research Question: How do leadership practices contribute to organizational success?

Qualitative Research Questions:

1. How do organization development principles contribute to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

2. How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness?

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3. How does patient satisfaction contribute to organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness?

4. How does Lynford Memorial’s CARU’s preferred theory of organizational change align

with their preferred leadership practices?

This chapter contained several sections. First, the data demographics section explained the

background of the participants in the study. Second, the findings section provided a meaningful,

rich description of what the study revealed. Third, the results section gave a synopsis of the

patterns and the non-supporting trends from the findings. Fourth, the interpretations section

provided an understanding of the results. Lastly, the summary explained a comprehensive

overview of the key points from the findings, results, and interpretations.

Data Demographics

The first sample consisted of nine leadership team members from the CARU. The

leadership team contained a senior administrator, a program manager, nurse managers, a speech

therapist, a physical therapist, a recreational therapist, a social worker, and a clinical liaison. All of

the leadership team members were females ages 27-52. The leadership team consisted of eight

Caucasian participants and one African American. The leadership team’s highest levels of

education were one Bachelor of Science Degree, one Bachelor of Science Degree in Nursing, one

Occupational Therapy Registered License, five Masters Degrees, and one Doctorate of Physical

Therapy. Participant employment with the organization ranged from three months to 14 years.

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The second sample consisted of five focus group employees from the CARU. The employee focus

group specialties were four physical therapists and one occupational therapist. The gender for the

focus group was two males and three females. All of the focus group participants were Caucasian.

Findings

The findings were related to the participants’ responses to questions about organization

development, employee engagement, patient satisfaction, financial accountability, and

organizational change in order to determine leadership practices for organizational success in

hospitals. Several themes emerged from the data collected through informational, in-depth, face-to-

face interviews, a focus group, archival records, observations, and memoing (Figure 4.1).

Organization development themes focused more narrowly on strategic goals and objectives,

organizational performance, competencies, and communication to manage a high-performing

workplace. Employee engagement themes revealed the importance of managing employees,

providing a supportive environment, measuring work duties, and ensuring successful performance

rewards as key contributors to developing a highly competent workforce. Patient satisfaction

themes pertained to utilizing patient satisfaction scores and surveys, leadership perspectives of

patient satisfaction, and employee perspectives of patient satisfaction to improve how patients

perceived and experienced the delivery of health care services. Financial accountability themes

focused on assessing the financial performance, controlling costs and eliminating waste, internal

environment vs. external environment, and financial transitions and ideas to increase profits and

marketing. Organizational change themes revealed how the organizational structure, collaboration,

change management, and organizational culture impacted how an organization operates and

functions during uncertainty.

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Figure 4.1. Themes of the Research Data

Leadership Practices for Organizational Success

The Leadership Interview Protocol (Appendix F) retrieved information on leadership and

the development of high-performance work practices, organizational strategies, and organizational

change. The researcher scheduled the interviews through emails and phone calls. The interviews

were conducted in the participants’ place of work or in the researcher’s office on campus. The

participants responded to 12 questions related to the impact of leadership practices on (1)

organizational structure, (2) organizational performance, (3) strategic goals and objectives, (4)

competencies, (5) management, (6) effective communication, (7) collaboration, (8) employee

engagement, (9) patient satisfaction, (10) organizational culture, (11) change management, and (12)

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strategic change. The following section provides a thorough description of leadership practices that

impact organizational success in the CARU. The researcher organized this section under the

following three leadership practices: organization development, employee engagement, and patient

satisfaction. Organizational structure, organizational culture, change management, and strategic

change are described in the organizational change section of the chapter to prevent redundancy.

Organization Development

Theme One: Strategic Goals and Objectives

The findings pertaining to aligning leadership practices to meet the organization’s strategic

goals and objectives concentrated on clear and defined goals, accountability, and evaluations and

accreditations. The CARU is “structured under a large umbrella model for the entire hospital so

smaller departments can follow the same structure as a whole” (Leadership Team Participant,

Interview). Clear and defined goals guide the hospital employees’ daily job responsibilities to

achieve desired outcomes for the unit. The Leadership Team Participant stated “establishing

strategic goals, values, and plans allow everyone to work on the same goals together so we can

actually move forward and seek improvement and achieve the results” (Leadership Team

Participant, Interview).

Accountability was an important aspect for leaders and employees to uphold when carrying

out the organizational goals and objectives. The leadership team members were attending more

training and leadership classes offered by the Human Resource Department. “We are given the

tools now to perform better, and we are being held accountable, and we are holding our staff

accountable, so that way we are all working together for the same common goals” (Leadership

Team Participant, Interview).

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Evaluations and accreditations helped employees organize and share information for

improving employee performances and providing high-quality health care service delivery. The

Leadership Team Participant stated “our evaluations define how we achieve our successes”

(Leadership Team Participant, Interview). Employees received annual performance evaluations.

The performance evaluations measured how employees achieved the organizational goals and

objectives through the SCORE Values (Service Excellence, Collaboration, Ownership,

Responsibility, and Empowerment). “All of the employees have to work toward achieving the

SCORE Values. Our managers have a managing system that if you want to do something good

then you are recognized for it, so this makes you want to achieve the goals of the organization”

(Leadership Team Participant, Interview). In terms of accreditations:

The CARU has accreditations such as JCAHO (Joint Commission on Accreditation of Health care Organizations), CARF (Commission on Accreditation of Rehabilitation Facilities), and Magnet ANCC (American Nursing Credentialing Center) Visits that we must pass so much of what we do is based on the goals that are coming down from management. (Leadership Team Participant, Interview)

Theme Two: Organizational Performance

The findings pertaining to leadership practices that were most important for achieving

optimal organizational performance pertained to developing action plans with employees and

creating a supportive environment. The leadership team responses revealed that allowing

employees opportunities to engage in developing action plans improved work productivity. Getting

feedback from all employees and using consensus to make decisions were helpful techniques that

enabled the CARU to achieve optimal work performances. The Leadership Team Participant

explained the importance of group feedback and consensus to make decisions:

First, you always want to get feedback from everybody. You do not want the leadership to be like a dictatorship; you will want to have a consensus. You want the leadership to make everyone happy. For example, I always say a productive staff is a happy staff and vice

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versa a happy staff is productive. Basically, you want input from everyone to gather information and to see where things can be better because you may feel that something is good, but someone else may not feel that something is good and someone else can give you a viewpoint that can better the whole situation. I think that, for the staff, you never want to assign people different patients. You want to get viewpoints from everybody because some people may be better at dealing with different acuity patients and some people may not be, so if you get everyone’s input that’s how it makes the assignments flow and that’s how the patients care is delivered better. (Leadership Team Participant, Interview) A well established, supportive environment set the foundation for employees to achieve

high levels of excellence in their job responsibilities. All of the members of the leadership team

emphasized the importance of leaders being approachable and “present on a day-to-day basis”

(Leadership Team Participant, Interview). Leaders should have “diverse backgrounds and unique

approaches for interacting and managing employees” because employees should feel comfortable

approaching their leaders with ideas or problems without the fear of consequences (Leadership

Team Participant, Interview). The Leadership Team Participant explained that employees

performed their best when their leaders were knowledgeable, dedicated, team players, did not

micromanage, delegated work assignments, and monitored and assisted employees when they

needed help. Lastly, participants from the leadership team revealed that leaders needed to ensure

that employees have the adequate tools, resources, and training to fulfill their work duties.

Theme Three: Competencies

The findings pertaining to how the leadership team planned to adapt their leadership

competencies as the health care system continues to evolve concentrated on knowledge

management and skill development. Knowledge management was the process of gathering and

sharing data from various forms of information to improve the understanding of a topic.

Knowledge management was vital in assisting the leadership team to build their skills and

professional development to remain competent and competitive in the health care environment.

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“Employees must be adaptive and flexible because you cannot function the same way as you did in

the past” (Leadership Team Participant, Interview). The Leadership Team Participant explained

that she planned to be a leader on health care changes and reform, so she can gather updated

information on the rules, regulations, insurances, and reimbursements to share with the staff to learn

how it impacts the department (Leadership Team Participant, Interview). The Leadership Team

Participant supported the idea of training, continuing education courses, and advanced degrees to

help employees stay updated in their fields (Leadership Team Participant, Interview). The

leadership team revealed that reading articles, journals, and literature in one’s particular field and

other disciplines increased knowledge management. The Leadership Team Participant suggested

staying involved in the various committees throughout the departments, and attending the huddles,

in-services, and conferences to stay abreast about what was going in the various fields and changes

and updates on the units (Leadership Team Participant, Interview).

The CARU needed to continue building skill development with the leadership team and

employees so they could successfully adapt to the evolving health care system. “Practicing

coaching and mentoring allows you opportunities to improve yourself and others” (Leadership

Team Participant, Interview). Attending the Human Resources Leadership classes and 360-Degrees

Feedback Classes assisted leaders with developing management skills to lead an effective

workforce. Lastly, the Recreational Therapist recommended:

Trying to practice good listening skills, research skills, and feedback to whatever the systems are that might be and help by doing something in a positive way that can be beneficial to all of us and hopefully help us reach our bottom-line results. (Leadership Team Participant, Interview)

Theme Four: Communication

The findings pertaining to effective communication processes that the CARU practiced

focused on communicating with employees and disseminating information throughout the system.

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The leadership team responses revealed that communicating with employees on a daily basis

impacted organizational performance. Communication needed to be transparent and delivered in a

timely manner to the appropriate parties. “Employees want their leaders to listen to them, share the

voice of the employee, and have an open-door policy” (Leadership Team Participant, Interview).

The Leadership Team Participant declared that the CARU practiced various forms of verbal

feedback, visual feedback, and tactual feedback to share information (Leadership Team Participant,

Interview). For example, the Employee Engagement Survey that was distributed to unit employees

was an excellent feedback assessment that allowed the leaders to learn what the employees needed

to do to improve their work productivity and their professional development. In addition, the

leadership team members revealed that open forums such as Breakfast with the President, Grand

Rounds with Senior Leaders, leadership focus groups, daily conferences, and weekly meetings

between supervisors and employees provided opportunities for employee voices to be heard

(Leadership Interview Protocol). Most importantly, the Leadership Team Participant suggested

using face-to-face communication to handle personal, challenging, or difficult issues. This

eliminated misunderstandings and provided opportunities for employees to ask questions and gain

clarification (Leadership Team Participant, Interview).

Effective communication exchange strategies such as the internet, intranet, voice mails,

emails, text messages, daily memos, notes in charts, interdisciplinary staff meetings and

communication boards in patient rooms were necessary to successfully disseminate information

throughout the system so employees understood what was going on in the hospital and on their unit

in order to know how to best address the patient needs (Leadership Interview Protocol). The

Leadership Team Participant described the importance of communication exchange to achieve

strategic goals and objectives:

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Writing notes to either family or staff to disseminate information, I think it is an ongoing process because it is something that has to happen every day. We have to write documentation so that the professional people that help with the patient know what the issues are. The patients have a communication board in their rooms that gives them a quick update of who their therapists are and their status on getting up and out of bed and do they have to wear a splint. You know that kind of thing. There is quick stuff, there is in-depth stuff, and hopefully you feel that you have that ongoing process of communication exchange. (Leadership Team Participant, Interview)

Employee Engagement

The Employee Engagement Focus Group Interview Protocol retrieved information

regarding the hospital employee perceptions on employee engagement and the organizational

culture. The Employee Engagement Focus Group Interview Protocol contained six open-ended,

semi-structured questions (Table 4.1). The researcher scheduled the focus group through emails

and phone calls with the Program Manager who then recruited the employees. The focus group was

conducted in the participants’ place of work.

Table 4.1. Focus Group Questions

1. Describe what the term employee engagement means to you? 2. Describe some of the measures the hospital utilizes to ensure their employees are treated with

kindness, dignity, and respect? 3. How can your supervisor provide a supportive environment for you to produce your best

work? 4. How can your supervisor involve you in the decision-making process when it comes to

improving work productivity? 5. What measures should the hospital take to ensure that your work duties are?

a. distributed equally b. challenging c. motivating

6. How are you rewarded for successful performances? Comments

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The researcher received information from the leadership team by asking the following

questions with Leadership Interview Protocol:

Investigative Question 1: In managing the people process to improve organizational performance

and effectiveness, how do you?

a. assess talent

b. develop talent

c. retain talent

Investigative Question 2: How can leaders build employee engagement?

The following paragraphs explain how employee engagement impacts organizational

success in the CARU. These phrases described the definition of employee engagement from the

Employee Focus Group Members perspectives:

Focus Group Participant One stated, “It determines that employees participate and function

outside of their normal work duties something like collaboration with other departments”.

Focus Group Participant Two stated, “We also do fundraisers and participate in different

charity walks to do things outside of the Lynford Memorial community but as a Lynford Memorial

community”.

Focus Group Participant Three stated, “I think like engagement means feeling like a fully

utilized employee other than just your remote responsibilities. It means feeling really valued and

having people actively listen to the feedback we provide and then do something in regards with the

feedback we provide. It really comes down through the SCORE Values”.

Focus Group Participant Four stated, “When it comes to making decisions that have to do

with our department then leadership can bring it to us so it’s like a democratic decision”.

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Focus Group Participant Five stated, “It makes you feel useful, needed, and like we are

participating as a full body”.

Theme One: Managing Employees

The CARU has measures in place for managing employees to ensure they are treated with

kindness, dignity, and respect. As mentioned previously in the Organization Development section

of the chapter, the Employee Engagement Survey was an anonymous survey given every 1-2 years

as means for employees to provide feedback about supervision, job responsibilities, professional

development, communication, and the work environment. Applying SCORE Values to all

employees ensured that everyone displayed communications and interactions of Service Excellence,

Collaboration, Ownership, Responsibility, and Empowerment. A focus group participant

explained:

It’s a number of Feedback Committees that have been established to take the feedback they get through feedback forms and the general yearly six months’ assessments, both formal and informal, so they can respond to it. Then there are several other committees where the information goes up and down the chain so they can find what will be the best course of action to address the issues that are raised by employees in both formal and informal settings. (Participant, Focus Group)

The Leadership Interview Protocol revealed that managers needed to have a clear

understanding of the employee talents, attributes, skills, and contributions on the CARU. The main

tool to assess talent on the CARU was the annual performance evaluation that each employee

received as previously mentioned in the Organization Development section. In addition, the Patient

Satisfaction Survey was used to understand what aspects of health care services on the unit are

working well and what aspects of the health care services need improvement (Leadership Interview

Protocol). The Leadership Team Participant stated that Competency Tests are distributed to

employees to assess their health care knowledge (Leadership Team Participant, Interview). The

Leadership Team Participant described how new employees go through a 90-day probationary

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period process that requires weekly check-ins with their supervisors to review their job

responsibilities and skill development (Leadership Team Participant, Interview).

To assess talent on an everyday basis, the Leadership Team Participant declared that leaders

need to be present on the unit to observe their employees in real time. “This gives them the

opportunities to see their bedside manners, how they handle challenges, ask questions, and find

solutions” (Leadership Team Participant, Interview). Likewise, the Leadership Team Participant

explained, “It’s important to assess clinical expertise but leaders have to assess employees’

adaptability, flexibility, communication skills with patients and families, people skills, emotional

intelligence, maturity, creativity, and confidence” (Leadership Team Participant, Interview).

Ideas to develop talent on the CARU are illustrated in Figure 4.2. Based on the Leadership

Interview Protocol, goal setting and reviewing achievements were great tactics for developing talent

in the CARU. Employees wanted to be empowered, so giving them autonomy and opportunities to

experience different situations built their skills (Leadership Team Participant, Interview). Leaders

needed to make sure their employees felt comfortable to make decisions without their involvement

all the time, but employees needed to have the reassurance that leaders were available to assist them

with troubleshooting (Leadership Team Participant, Interview). Leaders needed to have regular

communication with their employees through weekly meetings to review clinical experiences and

the creation of development plans for professional growth and improving patient care services

(Leadership Team Participant, Interview). Lastly, the Leadership Team Protocol revealed that

orientations, education, training, coaching, mentoring, peer teaching, support, feedback, listening,

role modeling, meeting, committees, and career growth opportunities were great methods for

developing talent on the CARU.

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Figure 4.2. Developing Talent

With the high turnover of health care workers, the large number of baby boomers getting

ready to retire, and the high cost of recruiting health care workers, the CARU was continuing to

develop creative methods to retain their health care talent pool. Employees wanted to work in a

pleasant, safe and supportive work environment (Leadership Team Participant, Interview).

Employees wanted to have their needs met in terms of good benefits and compensation, rewards for

success (bonuses, incentives, awards, public recognition, etc.) and work/life balance (Leadership

Team Participant, Interview). The Leadership Team Participant recommended “building employee

ownership by helping meeting their goals and tapping into their talents” (Leadership Team

Participant, Interview).

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The Leadership Team Protocol revealed that employees wanted to feel appreciated, valued,

and happy. The Career Ladder System provided career mobility opportunities within the unit or

throughout the organization that built retention and enhanced recruitment for the hospital.

Leadership’s support of employees seeking training, wanting to attend conferences, continue their

education or take advantage of development opportunities helped retain talent and kept the talent

pool fresh and competitive. Leaders needed to have conversations with their employees to find out

if their jobs were fulfilling and challenging, and make adjustments to meet their needs. Coaching,

mentoring and peer teaching opportunities were great techniques to allow all of the employees to

participate in assisting in each other’s development and provide a learning environment that

attracted employees. The Leadership Team Participant summarized how to retain talent:

You have to create a nice work environment that will make someone want to stay there. This can come in good benefits and rewards. It is not so much monetary, but it can be intrinsic rewards. If you feel valued as a worker, you will want to stay on. And if you feel that the organization values you then you will value the organization. (Leadership Team Participant, Interview)

Theme Two: Supportive Environment

The Employee Focus Group revealed some suggestions for supervisors to provide a

supportive environment to enhance employee work productivity. Leaders need to have an open-

door policy, so the employees can approach them. They suggested having a lateral platform to feel

like they are all on the same level. They wanted their leaders to follow up with concerns to make

sure their solutions work. A Focus Group Participant stated, “Leaders need to understand your

personality to understand how you best digest feedback, and learn and support you in that kind of

respect” (Participant, Focus Group).

Most importantly, employees wanted a supportive work environment that allowed them to

be involved in decision-making. The Employee Focus Group provided the following responses

when asked: How can your supervisor involve you in the decision-making process when it comes to

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improving work productivity? Focus Group Participant One stated, “Good feedback about what’s

difficult about achieving certain responsibilities.” Focus Group Participant Two stated, “Let us

know what is working and what is not working so they understand what things we run into when we

are on the floor and what obstacles occur so we can solve them.” Focus Group Participant Three

stated, “Help you to analyze your monthly productivity sheets. This shows what you did and they

can help you find ways to do it better.” Focus Group Participant Four stated, “Open

communication so when anything occurs in the hospital, we are aware of what we are going

through and what the issues are so we have a clear understanding of why things might go better or

worse depending upon the circumstances.”

Theme Three: Measuring Work Duties

It was imperative for the leaders of the CARU to ensure that they measured the

Employee work duties by distributing work evenly, providing challenging work tasks, and

motivating employees to do their best. The Focus Group revealed that the hospital ensured their

work duties were distributed equally by (1) “defined roles, (2) consistent communication, (3)

understanding the learning curve (know why things are the way they are and understand that there

is a progression to an ultimate goal and people are ok with that), (4) charts are used to define what

you should accomplish each week, and (5) ask questions” (Participants, Focus Group).

The Focus Group revealed that the hospital ensured their work duties were challenging by

(1) “rotations, (2) growth besides patient care, (3) constantly learning, (4) in-services, continuing

education, financial support, committees (take on various responsibilities), (5) invest in employees

career interests, and (6) think outside the box” (Participants, Focus Group).

The Focus Group revealed that the hospital ensured their work duties were motivating by (1)

“competitive salaries and Incentives, (2) satisfaction surveys, (3) supportive environment, (4)

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educational opportunities (inside the hospital and at conferences) and (5) communication and

follow-up to make sure we are satisfied or not” (Participants, Focus Group). To build employee

morale, the CARU hosted Rehab Week consisting of providing coffee and donuts, pizza parties,

dress-down days, and funny shirt days. A focus group participant summarized the importance of

supervisors meeting their needs to build motivation:

They can try to learn what our needs are and meet our needs within the budget. They let us know they have a capital budget and a discretionary budget, but they can ask us what our wish lists are to help with patients and we submit them to them so they know what we are open for. They can try to get it if they can and explain if they cannot. (Participant, Focus Group)

Theme Four: Successful Performance Rewards

The Employee Focus Group listed some methods the CARU employed to reward their

successful performance (Figure 4.3). The employees received annual raises and High Fives—

acknowledgements at departmental meetings. “The employees were given STAR awards when

they had done exceptionally well with a patient, family member, or within the department”

(Participant, Focus Group). The Oscars was a peer-recognition ceremony among staff members.

Lastly, employees were promoted to new positions on the unit for exceptional job performance over

an extended period of time. However, they mentioned that there are “not too many levels on the

career ladder” (Participant, Focus Group).

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Figure 4.3. Rewards for Successful Performances

Patient Satisfaction

The researcher reviewed archival data on patient satisfaction to understand how the

patients approved of the leadership practices and quality of services provided on the CARU (Patient

Satisfaction Quarterly Report, 2013). The Senior Administrator provided Patient Satisfaction

Quarterly Reports for the researcher to review how the CARU met the inpatient rehabilitation

facility metrics. The information from the Patient Satisfaction Quarterly Reports came from the

results of the Press Ganey Surveys. The Leadership Interview Protocol contained a question asking

the leadership team how to enhance patient satisfaction. In addition, the Financial Accountability

Interview Protocol provided detailed information for increasing patient satisfaction to build

financial performance and competitive advantage.

Theme One: Patient Satisfaction Scores and Surveys

Patient satisfaction scores and surveys were a major theme describing how patients

experienced their stay on the CARU. The CARU distributed the Press Ganey Survey to patients to

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measure inpatient rehabilitation facility benchmarking. The Press Ganey Survey asked former

patients to rank their level of satisfaction with hospital services such as rehabilitation physician

care, nursing care, physical therapy, occupational therapy, discharge, and personal issues. The

Press Ganey Survey used a Likert Scale of 1 (very poor rating) to 5 (very good rating). The

numbers on the scale had their own points from 0 to 100 which were compiled on quarterly bases.

“All ‘5’ ratings were given a score of 100, all ‘4’ ratings were given a score of 75, all ‘3’ ratings

were given a score of 50, all ‘2’ ratings were given a score of 25, and all ‘1’ ratings were given a

score of 0” (Patient Satisfaction Quarterly Report, 2013, p 6). The mean score for each question

came from averaging the scores of each question. The hospital overall mean score came from

averaging all the questions. The point scores were compared to other hospitals on a scale of 0-

100% (Patient Satisfaction Quarterly Report, 2013).

The Patient Satisfaction Quarterly Report included responses from 16 discharge rehab

patients. The surveys were received between Janaury 1 and March 31, 2013. The response rate

was 29%. The Overall Mean Score for standard questions was 86.3%. The goal was to be in

highest percentile of the Peer Group Database—PD Database (90th – 95th percentile). The CARU

excelled in the highest percentile most of the time except in the end of 2010 and the beginning of

2011. As of completion of this dissertation, the CARU was very close to making the benchmark at

86.3% (Figure 4.4).

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Figure 4.4. CARU Overall Mean Score Trend

Theme Two: Leaders’ Perspective of Patient Satisfaction

The second patient satisfaction theme focused on how leadership improved patient

satisfaction. The Program Manager articulated how leaders enhanced the patient experience on the

CARU:

We can make sure employees are satisfied and engaged because happy employees produce

better outcomes for our patients. If your employees are not engaged and feeling dissatisfied

with their jobs then they cannot make our patients feel satisfied. So this is kind of a dual. I

also feel like it is important for leaders to have an interest in talking with patients to

understand how we can better engage our patients to be heard better. One of the things I try

to do is make sure I leave my business card with patients and families. I tell staff, if the

patients have any sort of comments or complaints, whether it’s positive or constructive, to

ask them, “Would you like my manager to come and talk to you?” Because sometimes they

want to make a comment about the staff or see if I can do something while they are here. I

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always tell patients that they will get a survey when they leave here because we have Press

Ganey, and let them know that we want to make a difference while they are here and not

wait until they get a survey two weeks from now and say, “You know, I wish I had done X,

Y, and Z.” The sooner I can find out something and do something about it while they are

here—that makes a whole lot of a difference. I think that patient satisfaction on their level,

even if it’s just that they know I might not be able to do something about it, they just want

somebody to talk to. Then I can help because it won’t take up a therapist’s time from

making the most productive time for our department. (Leadership Team Participant,

Interview)

Theme Three: Employees’ Perspective of Patient Satisfaction

Another major theme focused on how employees tried to improve the patient experience

on the CARU. The Leadership Development Interview Protocol revealed that therapy and support

staff of the CARU practiced patient advocacy to improve patient satisfaction. They were the voice

of the patient. They functioned as the vehicle for making sure the CARU met the patients’ needs

during their stay on the unit. Their daily job responsibilities focused on providing exceptional care

services to assist patients with rehabilitating from their illnesses and surgeries, so they could be

prepared to enter back into the community. Most importantly, “employees must display positive

attitudes toward the patients because happy employees trickle down to make happy patients”

(Leadership Team Participant, Interview). “Effective communication is very important at a large

organization because patients have several health care employees working for them at the same

time. Therefore, we must provide clear communications and follow up on requests to eliminate

confusion” (Leadership Team Participant, Interview).

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The employees represented the mission and values of the hospital, as a result, the

employees’ interactions and communications with the patients on the CARU had an impact on how

patients perceived and experienced their delivery of health care services. The Leadership Team

Participant articulated how the employees tried to “put the patients’ needs first by getting families

cab vouchers, parking tickets, or lunch passes because this helps make patients and their families

feel that we are providing quality services and trying to give them a comfortable stay (Leadership

Team Participant, Interview).

Financial Accountability

The Financial Accountability Interview Protocol (Appendix C) obtained information on

how the hospital leverages their financial infrastructure, design, and collaboration to match the

organizational needs and strategies. The researcher scheduled the interview through emails and

phone calls with the Senior Administrator. The interview was conducted in the participant’s place

of work. The Senior Administrator responded to eight questions about assessing organizational

financial accountability through the dimensions of financial performance and the competitive

advantage. The following sections explain how these categories impact financial accountability and

organizational success in the Comprehensive Acute Rehabilitation Unit.

Theme One: Financial Performance

The first theme of financial accountability focused on financial performance. To

understand the financial performance of the CARU, the researcher assessed its current state of

financial performance. The Financial Accountability Interview Protocol with the Financial Analyst

revealed the following:

We look at in terms of (1) the contribution margin of the Rehab Unit and we review that on a monthly basis with the management team and the Vice President of the Rehab Unit, (2) the length of stay (3) outcome data (short and long term) that is directly tied into performance, length of stay, and efficiency (4) falls/injuries that tie back into efficiency with

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the hospital for unanticipated care (6) time of discharge, (7) patient satisfaction, (8) hospital pressure ulcers, (9) benchmarking in terms of billable units versus hours worked. None of our reimbursement at this time is tied into our outcomes or financial performance, but at some point down the road our patient satisfaction could be tied into it. (Financial Analyst, Interview)

The financial performance of the CARU was impacted by the treatment of the

stakeholders. The Financial Analyst described “the hospital stakeholders as anyone who has

an interest in what goes on.” The patients and the family members were the key stakeholders. As

part of the mission, the CARU worked very diligently to meet their needs “to give them information

on the length of stay and the outcomes in terms of how many patients we plan to discharge into the

community” (Financial Analyst, Interview). The Financial Analyst explained that they were

required to provide information to patients and family members due to the Commission on

Accreditation of Rehabilitation Facilities (CARF). They also kept information updated on their

website and available on the units about patient satisfaction and primary insurers. To hold the

stakeholders accountable, the patients also received the Press Ganey Survey that gave them an

opportunity to provide feedback about the services they received on the unit. The referral sources

had access to this information as well. The Financial Analyst clarified that, “the Rehab Unit sends

out—on an annual basis every October or November—a Stakeholder Survey to our referring

physicians and referring case managers so they give us feedback, too, on how well we are doing.

Not necessarily in terms of financial performance, but overall peer perception and satisfaction of

our work” (Financial Analyst, Interview).

Theme Two: Controlling Costs and Eliminating Waste

Controlling Costs and Eliminating Waste was the second theme of financial accountability.

The Financial Accountability Interview Protocol revealed several tactics that have been

implemented to control costs on the unit. The Clinical Liaison prepared a discharge plan before the

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patient arrived on the unit to eliminate delay in services and extended stays, and assisted the family

with discharge preparations. Since controlling the length of stay decreased from three to four

weeks to 13 days, the employees had to work together and efficiently to build patients’ strength and

independence to care for themselves so they could meet their discharge deadlines. The Financial

Analyst noted, “We have to be realistic about what a patient needs to go to home because they do

not need all the bells and whistles” (Financial Analyst, Interview).

The Financial Analyst described valuable resources as labor and medical supplies. The

Financial Analyst described the importance of building retention, training staff, and mentoring to

make them feel valued, engaged, and happy to work on the unit. The cost to recruit and train

therapists was time consuming and expensive. Therefore, she tried to work on creative ways to

maintain the turnover rates. “Our assets are our employees and happy employees make happy

patients. (Financial Analyst, Interview). Leadership had to know what was happening on the unit.

As a result, monitoring the therapists’ downtown was important because leaders wanted to keep

them engaged to build employee satisfaction.

The CARU really tried to control their costs in supplies for the unit. “We purchase

supplies in terms of the hospital since we are a part of a larger system. We try to get the best bang

for our buck in terms of medical supplies and wheel chairs” (Financial Analyst, Interview). The

Financial Analyst mentioned, “Everything has a cost to it” (Financial Analyst, Interview). The

Financial Analyst used checks and balances within the department to makes sure the employees

were not underutilizing and overutilizing office supplies, and the Financial Analyst had to review

and approve all orders, correspondences, and invoices.

Theme Three: Internal Environment vs. External Environment

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A major theme of financial accountability pertained to the impact of changes on the internal

and external environments. Based on information from the Financial Accountability Interview

Protocol, the CARU was continuing to make progress on how its internal culture was adapting to

the external competitive environment. The CARU had a large network system throughout the

Delaware Valley such as Bryn Mawr Rehab, Moss Rehab, Magee Rehab, and rehabilitation

competitors in New Jersey. As a result, to outweigh the competition, the Clinical Liaison’s main

responsibility was to get patients to their unit in a timely manner after receiving referrals. The

Financial Analyst stated:

So when we get a referral in, the Clinical Liaison needs to go out on the floor and see that patient and get the information she needs then have the patient see the Medical Doctor. So we cannot have any barriers to getting the patient in the door. (Financial Analyst, Interview) The Financial Analyst explained that the physical barrier of being in an older building did

not allow the unit the luxury of having every patient in a private patient room. The CARU did not

have marketing advertisements such a commercials or billboards like their network competitors.

She stated, “We have to think and act like we are a freestanding unit” (Financial Analyst,

Interview). Therefore, they had to “market their services through word of mouth by emphasizing

their exceptional clinical care, good patient outcomes, highly trained clinical staff, and good patient

satisfaction ratings” (Financial Analyst, Interview).

Theme Four: Financial Transitions and Ideas

The final financial accountability theme focused on future financial transitions and ideas to

improve the CARU’s effectiveness. Based on information from the Financial Accountability

Interview Protocol, the Financial Analyst would like to see the hospital implement the following

changes to build a sustainable competitive advantage over other hospitals: (1) “more alignment of

the hospital and rehab unit to manage the Affordable Care Act, (2) keeping the Rehab Unit in the

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loop of organizational changes and the 30-day admission patients, (3) fighting to sustain the Rehab

Unit, (4) shorten the length of stay needed for patient care by admitting sicker patients faster to the

Rehab Unit” (Financial Analyst, Interview).

Based on information from the Financial Accountability Interview Protocol, the Financial

Analyst planned to manage the financial organizational forecast for the next three years by fine

tuning the following:

1) Continue to focus on our length of stay and improving the discharge process

2) Utilize our resources appropriately

3) Balancing the length of stay with the outcomes. When we are getting the change we

need, one of the things we look at is length-of-stay efficiency—so how affective are you

in improving the patients’ functional levels during their time of stay?

4) Keeping staff involved and having staff know what we are focusing on

5) Bumping up our education to help us improve outcomes

6) Keeping patients and families happy (Financial Analyst, Interview)

Organizational Change

Studying organizational change in a hospital environment was complicated. Many hospitals

today are trying to transition from the traditional hierarchy form of leadership to a collaborative

leadership model. Consequently, this is impacting the organizational culture and the environment

employees are exposed to. As a result, the researcher combined data from the Leadership

Interview, the Financial Accountability Interview and the Focus Group to understand how the

Comprehensive Acute Rehabilitation Unit implements effective change management during

organizational transitioning and the impact organizational change has on the organizational culture.

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Theme One: Organizational Structure

The first theme of organizational change focused on how the organizational structure set the

stage of leadership. “A good foundation of leadership begins with the essential building block of

organizational structure” (Leadership Team Participant, Interview). According to the data from the

Leadership Interview Protocol, the CARU organizational structure followed the traditional, vertical,

hierarchy leadership model. “The organizational structure started with strategic goals, values, and

plans” (Leadership Team Participant, Interview). Figure 1.3 illustrates the organizational structure

of the CARU. First, the Hospital President created the organizational goals and objectives and

transmitted the information to the Senior Vice President for Patient Services and Chief Nursing

Officer. Second, the Senior Vice President for Patient Services and Chief Nursing Officer

communicated the information to the Administrator of Rehab Services. Third, the Administrator of

Rehab Services disseminated the organizational goals, objectives, and plans to the CARU’s

Program Manager, therapy staff, and support staff (Leadership Team Participant, Interview).

The Leadership Interview Protocol revealed that the organizational structure is designed to

create an environment that works to achieve positive outcomes and exceptional service delivery.

The Leadership Team Participant believed “the strong leadership hierarchy trickles down to impact

lower levels to create accountability” (Leadership Team Participant, Interview). The identification

of leaders and clearly defined roles eliminate role confusion (Social Worker, Interview). Although

the organizational structure of the CARU followed the top-down approach, the Leadership Team

Participant stated that “the set-up on the employee level is a multidisciplinary team approach”

(Leadership Team Participant, Interview).

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Comprehensive Acute Rehabilitation Unit Organizational Structure

Figure 4.5. Rehabilitation Department Organizational Chart

Theme Two: Collaboration

The second theme of organizational change pertained to collaboration between employees to

accomplish tasks and implement change activities. The leadership team members agreed that

building collaboration initiates with having a supportive supervisor who is visible, available, and

approachable (Leadership Interview Protocol). The supervisor set the stage for how employees

should engage and interact with each other. The Leadership Team Participant explained how to

build collaboration with employees:

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Leaders can take more time to get to know their employees better not just as an employee but who they really are. One thing that our staff does is when someone new is hired; we ask them for a photo. We have them lists their interests, what they like to do in their spare time, anything about their family, just so that we can get to know somebody—not just who they are as an employee but who they are as a person. This helps to engage leadership with the employees and they feel more of a connection and comfort level with the employees, even if it was “I used to live in that neighborhood” or something. (Leadership Team Participant, Interview) As mentioned previously in the organizational structure section of the chapter, the therapy

staff and support staff level of the CARU functioned with a multidisciplinary approach. They

constantly communicated information throughout the system and supported each other in their daily

responsibilities to accomplish mutual goals in their patient care delivery services. They “work

together on action plans to help build quality outcomes and improve service delivery” (Leadership

Team Participant 1, Interview). The Leadership Interview Protocol revealed that leadership builds

collaboration through coaching and mentoring throughout the department and the various levels,

and provides employees with tools to perfect their daily practices.

Theme Three: Change Management

Another major theme was change management pertaining the utilization of systemic

methods to improve operations and functionality of the change process. “Change is inevitable”

(Leadership Team Participant, Interview). The Leadership Interview Protocol revealed that the

CARU continued to work on improving change management. “Implementing effective change

management at an institution with about 15,000 employees is difficult, but we still have to work on

making it better” (Leadership Team Participant, Interview). As a result, the Human Resource

Department hired new employees to find creative and effective measures to disseminate

information throughout the organization on new projects, so everyone receives the same

information at the same time. “Communication is the key” (Leadership Team Participant,

Interview). Most importantly, the Leadership Team Participant stated that gathering various

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feedback viewpoints and committees helped the CARU come up with different solutions to see

what was important for implementing action plans to improve the situation (Leadership Team

Participant, Interview). The following paragraph describes an employee’s experience with change

on the CARU:

The theory of change is effective but the practice of change is tough. I think that some of us try to embrace forward thinking. I think that some of us [who have] been working for a long time have trouble with change or things that are very different from what we did in the past. For example, before the advent of technology, we were writing all of our notes by hand. Now that we know that electronic medical records (EMR) are available, [yet] we are still writing notes by hand. A lot of us are frustrated by that, but I am not a tech-savvy person so I am okay with it. I think that it will probably eventually help me but it has given me odds, and I am thinking, “Oh God when it is going to happen?” Because I am going to be freaking out knowing that it is going to happen and feel like your trained well because one-day training is not necessarily always good for everybody. And trying to schedule everybody around that takes away from patient time. I understand that it has to happen, but I feel bad because I am here for the patient. I understand that it is important but I miss my patient time. (Leadership Team Participant, Interview) The CARU understood the trials and tribulations when it came to implementing effective

change management. Also, they were aware that employees needed time to embrace change and

adequate support systems and training. Therefore, the Leadership Team Participant mentioned

some key points to implement effective change management (Figure 4.5).

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Figure 4.6. Techniques for Effective Change Management. Retrieved from Nurse Manager 1,

Interview

Theme Four: Organizational Culture

The last theme of organizational change concentrated on creating a high-functioning

organizational culture capable of producing desired results. According to the Leadership Interview

Protocol, the organizational culture was established through the values, goals, and behaviors that

were displayed in the CARU environment. The Leadership Interview Protocol revealed that the

organizational culture set the guidelines for creating a top-performing hospital. The following

statement explained how the Leadership Team Participant believed leadership practices impacted

the organizational culture:

I feel that the leadership practices set the tone for what is done within the organizational

culture. For example, if you walk by and see the President of the organization picking up

trash on the ground, then that really set the tone for other people/employees within the

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organization, That is a huge component. I remember a clinical instructor who was in the

military once tell me that if you expect your employees to take out the trash or clean up

something really gross, then if you have a few extra minutes…you better put your back into

it and do it as well. I feel like that type of attitude really teaches the employees. Although I

am sitting here and managing you and telling you what to do, when I have some free time I

will sure help you out with whatever you need to do. (Leadership Team Participant,

Interview).

“Enhancing employee engagement, treating staff equally, and developing a diverse

workforce to treat a diverse patient population with high-quality service delivery are some of the

leadership practices we incorporate to develop our organizational culture” (Leadership Team

Participant, Interview). The Financial Accountability Interview Protocol revealed that creating an

organizational environment that valued and strived to achieve high outcomes in patient satisfaction

and employee satisfaction resulted in profitable financial performance and a competitive advantage.

The employees in the CARU supported each other and functioned as a multidisciplinary

team (Leadership Team Participant, Interview). The employees in the CARU built mutual respect

by complimenting each other and communicating their qualities to each other to increase their

motivation for providing exceptional patient care (Leadership Team Participant, Interview). For

example, the various Resource Groups allowed the employees to come together to share ideas and

information to grow and develop in their personal and professional aspects (Leadership Team

Participant, Interview). The Leadership Team Participant stated, “Leadership cares how the

employees are doing, and they help us to be successful” (Leadership Team Participant, Interview).

In addition, the Employee Focus Group Interview revealed leadership provides a supportive

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environment and an open-door policy that allows them not to fear asking questions and seeking

guidance.

The changes the hospital initiated impacted the CARU organizational culture. The

organization as a whole was trying to work on improving change management because it had some

detrimental effects on employee feelings toward leadership. The hospital was aware of this, and

leadership was working to improve the organizational culture. The following statement explains

the Leadership Team Participant’s reaction on the organizational culture during their time of

transitioning:

The last few years we have been in a change mode around here with the leadership practices and whole culture. The culture before is different than the culture now. I think the staff is more engaged here now, and they understand the “why” behind things. I think the communication in the last few years has been better and that has been impacting the culture in the right way, too. I think there was some distrust towards leadership and the organization a few years ago, but we are getting past that…The changes with HR and the leadership there is making it more open, honest, and advanced. I think in the past leadership didn’t understand the impact some of their changes had on the organization, but they are really trying to work on making effective improvements. Admitting the mistakes in the new Employee Time-Off Policy—ETO and letting the employees know that they are going to make changes and move forward can reduce distrust. I think the culture is moving in a new direction. Employees are starting to trust again and believe that the leaders care and their voices are being heard, and they are able to move past prior incidents. (Leadership Team Participant, Interview)

Findings from Observations

The researcher conducted informal observations to gather real-time behaviors and

interactions of the participants in their work environments (Merriam, 2009; Tellis, 1997). The

researcher conducted seven out of nine interviews and the focus group in the participants’ work

environment. The researcher arrived early for the interview appointments and had to wait about 10-

15 minutes for the interview participants to finish their tasks before beginning the interviews. This

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provided an ample amount of the time for the researcher to observe behaviors, communications, and

interactions to better understand any connections to the information obtained from interviews.

During the time of the data collection process, the CARU was undergoing construction, so

there were construction workers and equipment throughout the hallways. The lighting was usually

bright and the temperature was moderate. Some of the work areas had temporary stations set-up

which were unusual. Nevertheless, employees still displayed pleasant demeanors while completing

their work assignments. While waiting for the interviewees, someone always asked if the

researcher was being helped, needed assistance, or would like something to drink. The staff

members spoke to each other with respect and supported each other by lifting and preparing

patients for therapy sessions. No matter what time the researcher arrived, all of the employees

seemed to be very busy providing patient care or completing paperwork.

The summary of the observations related to the research findings. The employees knew

how to adapt to their environment because the construction did not interrupt their workflow. The

employees incorporated the mission into their interactions with other employees and with patients

by (1) effectively communicating to each other and patients with kindness, dignity, and respect, (2)

collaborating to complete work assignments and provide therapy and nursing services, (3) using

consensus to make decisions on how to care for the patients, and (4) making preparations to ensure

that the therapy area was clean and safe for rehabilitation services. The employees and the

supervisors engaged each other and displayed well established interpersonal relationships by

seeking advice from each other, asking questions, and engaging in friendly chitchat. Lastly, by

observing their interactions, the researcher clearly understood that the CARU employees enjoyed

working together and took pride in collaborating to provide exceptional patient care.

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Findings from Memoing

The researcher conducted memoing throughout the data collection process to assist with the

data analyzing process. After each interview, the researcher recorded a summary of the interview

experience with each leadership team member, the focus group, and the senior administrator. This

was a great opportunity for the researcher to reflect on what was happening (Groenewald, 2004).

The memoing revealed information about communications and interactions between the

participants, the development of rapport and trust, and how the participants responded to the

research questions.

The researcher also wrote summaries of personal perceptions, thoughts, and feelings

throughout the data collection and exploration process. One tends to go through a host of emotional

highs and lows during the data collection and exploration process. It is helpful to express how one

felt through writing and reflecting on ways to calm down while trying to complete the data

collection phase. By putting these emotions in writing and reviewing them, the researcher learned

how to continue to master what was working at the time, and created a plan to overcome what was

not working.

The memoing related to the findings because the researcher was exposed to the participants’

personalities, values, and behaviors through the interviews and focus group. The researcher was

able to see a connection between the investigative questions and the provided information. The

memoing allowed the researcher to see how the employees tried diligently to achieve the mission at

hand by incorporating the SCORE Values into their everyday job activities. From the memoing,

the researcher learned (1) employees were compassionate about effective communication between

supervisors and employees, (2) open-door policy was a must-have for all employees, (3) meeting

the patients’ needs was a top priority, (4) employees wanted to learn, grow, and develop in their

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fields, and (5) employees valued the CARU by marketing their services to their stakeholders and

allocating their resources to save costs and eliminate waste. Finally, the memoing revealed how the

CARU used leadership practices to achieve organizational success and transformation through

organization development, employee engagement, patient satisfaction, financial accountability, and

organizational change.

Results

Several patterns or trends emerged from the research findings while the researcher was

analyzing the data (Figure 4.7). The data derived from the interviews and the focus group coincide

with the concepts in the three streams from the literature review in Chapter 2. To eliminate

duplication and confusion, the researcher organized the patterns under the following: Organization

Development—(1) SCORE Values as Best Practices, and (2) Transparency with Leadership,

Employee Engagement—(1), Developing Rapport with Employees (2), Personal and Professional

Growth Opportunities, Patient Satisfaction—(1) Patient Center Care: Putting the Patient First,

Financial Accountability—(1) Controlling Costs and Eliminating Waste, (2) Branding the CARU,

and Organizational Change—(1) Creating an Achieving Desired Outcomes Environment.

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Figure 4.7. Research Patterns

Organization Development

Pattern 1: SCORE Values as Best Practices

The goals and objectives of an organization are guided by the mission and vision. The

mission of Lynford Memorial University Hospital was implemented by employees incorporating

the SCORE Values into their daily work assignments. The SCORE Values concepts of service

excellence, collaboration, ownership, responsibility, and empowerment helped the CARU achieve

their mission of providing high-quality rehabilitation services. The hospital guaranteed that the

employees incorporated the mission into their everyday work assignments by measuring their

performance of the SCORE Values in the yearly performance appraisal reviews. This leadership

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practice of implementing the mission into everyday work assignments to achieve desired outcomes

concurred with Berger and Berger (2011), Cummings and Worley (2009), and Swanson and Holton

(2009).

Pattern 2: Transparency with Leadership

The data from the interviews and focus group revealed that the employees of the CARU

wanted honesty in their leadership and in-depth information on assignments and changes. Clear

communication was repeated throughout all of the interviews and mentioned in several responses to

the questions. The employees wanted to be in the loop of what was happening throughout the

hospital and, most importantly, what was happening on their unit. The employees also wanted to

know why the change was needed and how the change will impact the system. In the literature,

Cummings and Worley (2009), Swanson and Holton (2009), and Wolf et al. (2011) explained the

process of implementing change in large-scale systems by providing employees with detailed

information using various forms to communicate the information, explaining the importance of

change, and indicating how the change will impact the system, as well as identifying how to

measure the success of the change. The hospital and the CARU used several channels to

communicate information to employees such as weekly and monthly meetings, conferences,

huddles, internet, intranet, phone, email, texts, memos, and charts. However, the hospital must still

continue to make sure all 15,000 employees received the same information.

Employee Engagement

Pattern 1: Developing Rapport with Employees

The concept of developing rapport with employees appeared in responses from the

leadership team and the focus group. The CARU leaders wanted to develop interpersonal

relationships with their employees because they wanted them to feel comfortable in their work

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environment and confident in decision-making and to seek help when needed. The CARU’s

employees wanted their leaders to make an extra effort to familiarize themselves with employee

personalities, skills and talents. The photos of the employees with their background, skills, talents,

and hobbies was a great method that the CARU practiced to build rapport with employee, especially

new employees. The study of Shuck and Herd (2012) supported building rapport with employees to

increase opportunities to meet their needs, build self-efficacy and self-esteem, and improve

employee loyalty to the organization.

Pattern 2: Personal and Professional Growth Opportunities

In the literature, McAlerney, et al. (2008), Kim et al. (2012), and Farrell (2003) linked

successful performances in hospitals to leadership practices and leadership competencies. The

Leadership Interview, the Financial Accountability Interview, and the Focus Group provided data

showing that employees enjoyed engaging in personal and professional growth opportunities. The

CARU’s employees were exposed to a variety of personal and professional growth opportunities

such as coaching, mentoring, job shadowing, job rotations, career system ladder, role modeling,

observations, continuing education, training, workshops, and conferences. According to Shuck and

Herd (2012) and Berger and Berger (2011), these were effective great methods for developing and

retaining a highly qualified, competitive workforce. In addition, McAlerney, et al. (2008), Kim et

al. (2012), and Farrell (2003) agreed that these practices improved operational, clinical, and

financial performance.

Patient Satisfaction

Pattern 1: Patient-Center Care: Putting the Patient First

The Lynford Memorial University Hospital was trying to function more like a patient-center

care facility. This meant designing all of the clinical operations to align with meeting the patient

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needs. Mayfield (2006) designed a study using the patient-center care model to improve

performances in hospitals. The employees of the CARU revealed how the concept of putting the

patient first was truly important to them, and they tenaciously strived to meet their needs through

nursing, speech therapy, physical therapy, occupational therapy, recreational therapy, and social

work/case managing. In their responses, the employees provided several examples of how they

endeavored to rise above required work performance to satisfy patients. In the literature, Mayfield

(2006) reported that putting the patient first built patient satisfaction, partnerships, and patient

loyalty and it improved quality in clinical outcomes, patient safety, and market share.

Financial Accountability

Pattern 1: Controlling Costs and Eliminating Waste

The Senior Administrator explained that the primary goal of the CARU was to provide

exceptional clinical care to rehabilitation patients. However, they had to work together as a team to

be conscience of controlling costs and eliminating wasting resources and labor. According to

Goetz, Janney and Ramsey (2011), Hughes-Cromwick (2007) and Roberson (2008), emphasizing

team-approach methods in governing everyday hospital activities improved performance, and

profits. All of the responses to the Financial Accountability Interview kept referring back to saving

costs and careful resource distribution without diminishing providing quality patient care. There

were several strategies in place to assist the Senior Administrator and the employees with

monitoring spending for equipment, medical and office supplies. They also worked together as a

team to fully utilize and monitor their resources while taking care of patients.

Pattern 2: Branding the CARU

The Senior Administrator acknowledged that the CARU, located in the center of a

metropolis, needed to improve its marketing strategies to remain relevant in the ever-changing

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health care sector. Its location gave it the advantage of being accessible to the surrounding

neighborhoods and to the Delaware Valley. Most importantly, the Lynford Memorial University

Hospital had been providing health care services for 200 years. The CARU’s location and

longevity are beneficial to branding. In the literature, Carey, Burgess, and Young (2011) argued

how the location of hospitals and the services they provided impacted competition and profits.

Marketing the CARU by word of mouth will no longer suffice in our rapid information-requesting

world. The Senior Administrator understood this and is working diligently to create new marketing

strategies to share the CARU’s clinical services and successes on a global level. In the literature,

Ovanessoff and Purdy (2011) supported leaders focusing on marketing their exceptional services,

resources, and location differentiation to edge out the competition and create brand exposure during

times of economic and societal uncertainty.

Organizational Change

Pattern 1: Creating an Achieving Desired Outcomes Environment

The CARU was diligently trying to create an achievement outcome environment. Trinh and

Connor’s (2002) study proved that the rate of exponentially accelerating change was impacting the

health care environment. The CARU was no exception to this dilemma. Information from the data

revealed that leadership and employees of CARU were aware that they could not expect to survive

in the health care sector doing the same things they had done in the past. Using the traditional top-

down leadership model to manage employees and organizational changes would no longer suffice

in the rapidly growing health care environment with employees who seek transparency leadership,

independence, accountability, decision-making, and collaboration (Browing, et al., 2011). The

CARU tried to organize an adaptive culture that was prepared to handle medical, economic,

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cultural, political, global, and technological changes that can help or hinder their organizational

performance and success (Tsai, 2011).

The CARU had to build a frame of mind similar to a free-standing structure in order to

achieve success during times of transitioning. This was congruent with Wolf, Hansen and Moir’s

(2011) and Cummings and Worley’s (2009) books on developing frameworks and action plans to

manage planned change initiatives, solve problems, improve organizational performance, increase

efficacy, effectiveness, productivity, and profits. Lastly, the process of effective change

management was key to creating a culture that was constantly learning and working to achieve

growth and sustainability (Jungyoon, 2001).

Non-supporting Trends

The researcher discovered one non-supporting trend while analyzing the data: all seven of

the leadership team members were in accordance agreeing that change management was effective

on the CARU but improvements can be beneficial to help them achieve their organizational goals

and provide exceptional rehabilitation services to the patients (Leadership Interview Protocol).

However, one Leadership Team Participant disagreed with change management being effective

throughout the unit and the hospital. The Leadership Team Participant believed that large-scale

change management was successfully implemented, but small-scale change management was not.

The Leadership Team Participant recommended support systems and clear communications to help

improve implementing incremental changes (Leadership Team Participant, Interview). The

following statement was the Leadership Team Participant’s response describing how effective

change management activities were during organizational transition:

I think it is great our department does a much better job managing big changes as they do sometimes the typical day to day; that kind of change gets lost in the shuffle. I think when there is a big change, we are automatically given extra support and better communication

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that we can anticipate big changes. I think it is the smaller, everyday change practices that does not get involved or address. (Leadership Team Participant, Interview)

Interpretations of Findings and Results

Creating a qualified health care employee environment began with aligning the

organizational goals and the employees to achieve the mission. A competent leadership structure

organized the operational functions to meet the desired outcomes. Clear and defined goals and

roles helped employees understand their responsibilities for incorporating the SCORE Values into

their work practices of providing rehabilitation services to the patients. Building employee

engagements through understanding their personalities, skills, and talents, providing them with

knowledge management, personal and professional development, and creating a well established,

trusting, supportive environment helped the CARU develop a highly competent, competitive

workforce capable of meeting patient needs. Likewise, satisfied employees increased patient

satisfaction because they were eager to go the extra mile to provide outstanding care to patients and

their families. As a result, the organization of daily work activities, the outcomes of employee

productivity, and patient interaction impacted how the CARU met its bottom line, built a

competitive advantage against other hospitals, and marketed their brand of services.

The Lynford Memorial University Hospital was undergoing transitions in how they

organized and implemented change. They were learning from their mistakes with change

management, and the Human Resource Department was endeavoring to improve communication,

include employees in change, and provide them with support systems while implementing changes

throughout the hospital. However, the CARU needed to continue to work on improving how it

handled small-scale changes impacting everyday work assignments. The lack of successfully

managing small-scale changes was beginning to frustrate employees, which could impact morale

and productivity if not addressed.

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The CARU therapy employees and support staff functioned as a multidisciplinary team, but

the leadership practices the top-down approach. The entire Lynford Memorial University Hospital

and the CARU leadership need to transition to collaborative, lean, interactive leadership to manage

their everyday work tasks to provide patient care services, handle strategic change, improve

decision-making, problem solving, and communications. The transition from traditional hierarchy

leadership to collaborative leadership will help the Lynford Memorial University Hospital and the

CARU remain relevant and achieve organizational success (Gray, 1995; Jungyoon, 2011; Trinh &

Connor, 2006).

Summary

This chapter presents a comprehensive analysis of the data obtained from interviews, a

focus group, archival records, observations, and memoing. This qualitative, descriptive case study

explores the process of leadership practices for promoting organizational transformation and

success as defined by organization development, employee engagement, patient satisfaction,

financial accountability, and organizational change in a hospital environment. The researcher

analyzed the data manually using open coding, axil coding, selective coding, and comparative

method to discover themes.

Chapter 4 provided six demographic representations of the leadership team participants.

The demographics for the first sample included (a) position/specialty, (b) gender, (c) race, (d) age,

(e) highest level of education, (f) duration of years employed in the position. Chapter 4 also

provided three demographic representations of the employee focus participants. The demographics

for the second sample included (a) position/specialty, (b) gender, and (c) race.

The findings from the data revealed several themes that the researcher organized under their

own topics. Organization development themes focused more narrowly on strategic goals and

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objectives, organizational performance, competencies, and communication to manage a high-

performing workplace. Employee engagement themes revealed the importance of managing

employees, providing a supportive environment, measuring work duties, and ensuring rewards for

successful performance as key contributors to developing a highly competent workforce. Patient

satisfaction themes pertained to utilizing patient satisfaction scores and surveys, leadership

perspective of patient satisfaction, and employee perspective of patient satisfaction to improve how

patients perceived and experienced the delivery of health care services. Financial accountability

themes focused on assessing the financial performance, controlling costs and eliminating waste,

internal environment vs. external environment, and financial transitions and ideas to increase profits

and improve marketing. Organizational change themes revealed how the organizational structure,

collaboration, change management, and organizational culture impacted how an organization

operated and functioned during times of uncertainty.

The results revealed the following patterns or trends that the CARU needed to continue

implementing for improving organizational success in their leadership practices, financial

accountability, and organizational change: Organization Development—(1) SCORE Values as Best

Practices, and (2) Transparency with Leadership; Employee Engagement—(1), Developing Rapport

with Employees (2), Personal and Professional Growth Opportunities; Patient Satisfaction—(1)

Patient Center Care: Putting the Patient First; Financial Accountability—(1) Controlling Costs and

Eliminating Waste, (2) Branding the CARU; and Organizational Change—(1) Creating an

Achieving Desired Outcomes Environment. The research study had one non-supporting trend

revealing a discrepancy with managing larger-scale changes better than small-scale changes.

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Chapter 5 provides conclusions, implications, and recommendations for actionable solutions

of the research problem and recommendations for future research study. Chapter 5 also provides a

strategic development plan for the Comprehensive Acute Rehabilitation Unit.

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Chapter 5 – Conclusions and Recommendations

Introduction

This qualitative, descriptive case study focused on leadership practices that contributed to

organizational success in Lynford Memorial University Hospital’s Comprehensive Acute Care

Rehabilitation Unit (CARU) located in the northeast region of the United Sates. The purpose of

this study was to explore the process of hospital leadership practices for promoting organizational

transformation and success as defined by organization development, employee engagement, patient

satisfaction, financial accountability, and organizational change. This study addressed the existing

problems of leadership development and change management failing due to a constantly changing

and complex hospital environment (Kim, Thompson, & Herbeck, 2012; McAlearney, Scheck &

Butler, 2008; Wolf, Hanson, & Moir, 2011).

The research questions for the present study were:

1. How do organization development principles contribute to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

2. How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness?

3. How does patient satisfaction contribute to organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness?

4. How does Lynford Memorial’s CARU’s preferred theory of organizational change align

with their preferred leadership practices?

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The researcher conducted an extensive literature review to provide a systemic approach to

explain the importance of integrating leadership practices, financial accountability, and

organizational change to promote success in the Comprehensive Acute Care Rehabilitation Unit

(CARU) in Lynford Memorial. The researcher accomplished this descriptive case study through a

qualitative methodology research using a sequential exploratory approach. The researcher collected

the data using multiple data sources: informational, in-depth, face-to-face interviews, a focus group,

open-ended questions, archival records, observations, and memoing from the leadership team and

employees of the CARU to understand the background and impact of leadership practices in the

hospital. The researcher analyzed the data by hand through the use of open coding, axil coding,

selective coding, and comparative method to discover themes of organization development,

employee engagement, patient satisfaction, financial accountability, and organizational change and

non-supporting trends. Five major sections organize this chapter of the study: (a) introduction, (b)

conclusion, (c) recommendations for actionable solutions, (d) suggestions for future research study,

and (e) summary.

Conclusions

The following paragraphs provide responses to the primary research question and the

investigative research questions of the qualitative, descriptive case study.

Primary research question: How do leadership practices contribute to organizational success?

Leadership began with a strong foundation of organizational structure that was followed

by strategic goals and objectives geared to achieve the hospital’s mission and vision. Adapting the

leadership structure to incorporate a collaborative approach of leadership was necessary to remain

relevant in the every-changing hospital environment and today’s society. First, leadership

development began with hospital leaders participating in leadership development programs,

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continuing educational learning activities, coaching and mentoring classes, 360-degree feedback

sessions, and competency and skill development training. Then leaders practiced transparency in

their actions and communications to build trust and interpersonal relationships.

Leaders used innovative methods to recruit, hire, and train the best employees in order to

provide high, exceptional health care services to the patients in the CARU. Leaders used

organization development principles such as collaboration, relationship building, identifying

problems, developing action plans, evaluating the change, celebrating success to manage daily

functions impacted by internal and external changes. Leaders had to find creative measures to

motivate and build employee engagement to foster retention, patient satisfaction, productivity, and

profits. Leaders promoted activities that focused on patient-center care because putting the patient

first increased the likelihood of positive clinical outcomes and improved patient safety and

retention. The results of practicing organization development, employee engagement, and patient

satisfaction improved the hospital’s overall financial performance. As a result, the hospital held the

CARU’s leadership and employees accountable for implementing strategies to increase quality

performance in patient-centered care while reducing hospital costs and eliminating waste of hospital

resources. Most importantly, the employees of the CARU had to market their health care services

to build their brand and outweigh the competition. Lastly, transforming the traditionally vertical

hierarchical leadership systems into lean, interactive, collaborative leadership systems improved

organizational success by building employee engagement, patient satisfaction, and financial

accountability in hospitals (Bates, 2000; Gary, 1995; Jungyoon, 2011; Merry, 1994; Thompson,

2011). Lynford Memorial University Hospital underwent a transformational change that was

creating a results-oriented cultural environment capable of meeting the mission and vision and

improving optimal performance and effectiveness.

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Research question # 1. How do organization development principles contribute to the

organizational success of Lynford Memorial’s CARU, as defined by meeting the mission and

continued financial viability and market competitiveness?

The organization development principles of strategic goals and objectives, organizational

performance, competencies, and communication contributed to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness. Clearly defined goals and objectives and the SCORE Values of

Service Excellence, Collaboration, Ownership, Responsibility, and Empowerment guided the

CARU employees’ everyday work activities to ensure success in the organizational outcomes,

evaluations, and accreditations. Organizational performance was enhanced through implementing

employee accountability, involving them in decision-making and action plans, practicing effective

feedback, and providing a supportive, interactive, well-equipped work environment. Building

competency involved focusing on enhancing knowledge management and skill development to

create competent employees who could adapt to a competitive and ever-changing health care

environment. Lastly, communication that was transparent and thoroughly disseminated throughout

the system has a positive impact on organizational performance. These findings concurred with the

literature review indicating that managing daily hospital activities through the use of effective

leadership strategies and team-approach methods improved performance, profits, patient safety, and

employee engagement (Goetz, Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Roberson,

2008).

Research question # 2. How does employee engagement contribute to organizational success

of Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

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Employee engagement contributed to the organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness by concentrating on managing employees, providing a supportive environment,

measuring work duties, and ensuring successful performance rewards to develop a highly

competitive workforce. The CARU followed the mission of Lynford Memorial by treating their

employees with kindness, dignity, respect. The CARU’s leadership knew the employees’ talents,

attributes, and skills, so they could successfully match them to job responsibilities that would

contribute the most successful results for the unit. The leaders had to accurately assess, develop,

and retain the CARU’s talent. Providing a supportive environment improved productivity because

employees were able to asked questions without being ridiculed, involved in decision-making, and

received feedback from their supervisors to confirm issues were resolved. Measuring work duties

was a process the CARU leaders implemented to ensure even distribution of employee work

(challenging but accomplishable) and as motivation for success. Once these measures were met the

CARU leadership rewarded successful performance through annual raises, acknowledgements,

awards, ceremonies, and promotions. The results of employee engagement from the study agreed

with Shuck and Herd (2012), Berger and Berger (2011), Cummings and Worley (2009), and

Swanson and Holton (2009) because engaged employees improved a company’s competitive

advantage; they were more efficient, innovative, loyal, and focused on quality and customer

focused.

Research question # 3. How does patient satisfaction contribute to organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

134

The leaders of the CARU utilized patient satisfaction scores and surveys, leadership

perspectives of patient satisfaction, and employee perspectives of patient satisfaction to improve

how patients perceived and experienced the delivery of health care services that contributed to the

organizational success of Lynford Memorial’s CARU, as defined by meeting the mission and

continued financial viability and market competitiveness. The CARU excelled in its patient

satisfaction ratings (see Figure 4.4), but they continued to use the information from those to make

more improvements on the units. The leadership and employees practiced patient-center care that

focused on putting the patient’s needs first by providing outstanding health care services and

bedside manners, a safe hospital environment, and effective communication channels for the

patients and their families. The CARU’s leadership and employees advocated for the patients by

making sure their voices were heard and their needs were met. These findings corroborated to

Mayfield (2006) with the concept of practicing patient-centered care to improve the quality in

clinical outcomes, patient loyalty, patient safety, market share, and increased patient and employee

satisfaction.

Research question # 4. How does Lynford Memorial’s CARU’s preferred theory of

organizational change align with their preferred leadership practices?

The organizational change themes revealed how the organizational structure, collaboration,

change management, and organizational culture impacted the CARU‘s operations and functions

during times of change. During the final stages of the study, Lynford Memorial University Hospital

hired a new President who brought a vision of collaborative, participative, and lean leadership to

change the nature of health care service delivery and medical education. The previous traditionally

hierarchical form of top-down leadership would no longer suffice under the new President or in the

transforming health care sector. The CARU unit might have an advantage over other hospital

135

departments adapting to the new form of collaborative leadership because the employees revealed

that they already function as a multidisciplinary team. However, the executive leaders in their

department follow the top-down approach. The CARU’s employees collaborated on tasks and

action plans to achieve change initiatives. They practiced effective communication and supported

each other with their work. However, implementing successfully change management in a large-

scale institution was complicated, but the Human Resources Department and the CARU’s

leadership were continuing to provide supportive measures to make sure information was shared

throughout the system (see Figure 4.5). The organizational culture of the CARU was continuing to

improve in their trust, transparency, communication, engagement, patient services, and productivity

to achieve a desired-outcome environment. As a result, this study supported the idea of Thompson

(2011) and Jungyoon (2011) that collaborative leadership improves hospitals’ organizational

culture, performance, and employee engagement.

Recommendations

For Actionable Solutions for the Research Problem

The researcher designed the following strategic development plan to address several issues

in the CARU’s work environment. The hospital was undergoing changes in population

demographics, shortage of competent health care workers, low employee morale, reimbursement

and budgetary issues, health care reform, new technologies, and competition (Browning, Toain, &

Patterson, 2011; Carey, Burgess, & Young, 2011; Farrell, 2003; Legislative Advisory, 2010).

Based on information from the interviews, the focus group, archival records, observations, and

memoing, the researcher created an outline of topics the leaders and employees of the CARU

should continue to focus on and improve in order to produce a high-quality health care workforce

and environment capable of organizational success. The researcher organized an outline of topics

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into a Strategic Development Plan for the CARU (Appendix I). The researcher planned to present

the findings, results, and the strategic development plan to the participants of the research study

from the CARU. In addition, the researcher created an executive summary to share with the

participants of the CARU (Appendix J).

Strategic Development Plan for CARU

Organization Development: Continue to work on improving everyday tasks to provide

better patient care services on the unit so the employees are prepared for visits from JCAHO—Joint

Commission on Accreditation of Health care Organizations, CARF—Commission on Accreditation

of Rehabilitation Facilities, and Magnet ANCC Visits—American Nursing Credentialing Center.

Update paperwork to accommodate changes in health care. Add more objective information to

patient charts. Continue to provide electronic medical records (EMR) training. Continue to

improve the process through the role of the social worker/case manager. Have the social

worker/case manager lead conference meetings on patient discharge plans, and make sure the

medical director and all the staff are present so everyone receives the same information at the same

time.

Employee Engagement: Continue to develop a highly qualified, diverse talent pool.

Empower employees by continuing to provide staff opportunities to earn advanced degrees, engage

in research opportunities, and attend training, workshops, and conferences. Have contingency plans

in place to make staff adjustments and provide opportunities for promotions. Provide the tools the

employees needed to complete all job responsibilities. Encourage open communication and an

open-door policy for all employees of the CARU.

Patient Satisfaction: Continue to improve the Press Ganey Scores and stay above the

benchmarks by making adjustments to better serve the patient population. Also, improve the

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patient experience by providing high-quality beside manners. Incorporate safety measures to

provide a safe patient environment, eliminate patient falls and ulcers, and increase staff

handwashing to eliminate the spread of disease.

Financial Accountability: To adapt to future financial changes, to create a plan to connect

reimbursement to outcomes since the current financial assessment does not incorporate this

strategy. Teach the staff the new health care reform laws and changes and they are aware of how it

impacts unit productivity. Let the staff know about available resources and implement guidelines to

ensure they are using the resources appropriately. Improve marketing strategy beyond word of

mouth to include billboards, commercials, and radio advertisements.

Organizational Change: Eliminate the top-down leadership approach. Build a

collaborative organizational culture by involving employees in decision-making and action

planning on the individual, group, and organizational levels. This horizontal, collaborative,

participative, lean leadership approach will help the CARU remain relevant during the

organizational transformation.

For Further Research

Although this study provided an abundant amount of literature on leadership practices that

contributed to organizational success in a hospital environment, further research is highly

recommended to explore other concepts. Since the hospital is in the beginning stages of

transforming to collaborative leadership from traditionally hierarchical leadership, the researcher

recommends that this study be implemented in the CARU after five years to observe the impact of

collaborative leadership practices. The researcher also recommends conducting a study on the

impact of the organizational culture in the hospital as it changes from traditionally hierarchical

leadership to collaborative leadership. Another recommendation would be to utilize this study in

138

other units in the hospital to see if the resultant leadership practices are similar or different. This

would help the hospital to make sure they practice consistency and transparency in their leadership

practices. The researcher also recommends utilizing this study in a nonacademic hospital to see

how leadership practices compare to a regular hospital. It would be useful to see if teaching

hospitals implement better leadership practices, possibly, because students are observing and

learning from staff actions a majority of the time. Lastly, another recommendation would be to

utilize this study in a rural, for-profit hospital to see how the resultant leadership practices compare.

It would be helpful to know if location and a mission to profit impact leadership practices and

performances.

Summary

The hospitals in the United States were failing in their leadership practices as the health care

system and society underwent changes. The executive leaders of the hospitals, the hospital

stakeholders, health care insurance companies and business partners, health care employees,

patients, academic medical colleges and universities were seeking to find the best leadership

practices to ensure organizational success during times of change. The problem statement of the

present research indicated that leadership development and change management failed due to

internal and external changes impacting the hospital environment. As a result, this qualitative,

descriptive case study focused on leadership practices that contributed to organizational success in

Lynford Memorial University Hospital’s Comprehensive Acute Care Rehabilitation Unit (CARU)

located in the northeast region of the United Sates. The purpose of this study was to explore the

process of a hospital’s leadership practices for promoting organizational transformation and success

as defined by organization development, employee engagement, patient satisfaction, financial

accountability, and organizational change.

139

The use of multiple data sources in the qualitative method consisted of semi-structured,

qualitative interviews from the CARU’s leadership team, a focus group from the CARU’s

employees, archival records of patient satisfaction scores, observations, and memoing. The

qualitative, descriptive case study was designed to answer the primary research question: How do

leadership practices contribute to organizational success? The results revealed that leadership

practices contribute to organizational success in the hospital by practicing the SCORE (Service

Excellence, Collaboration, Ownership, Responsibility, and Empowerment) Values with

transparency in leadership, developing rapport with employees by offering personal and

professional growth opportunities, practicing patient-center care, controlling costs and eliminating

waste throughout the system, branding care services, and achieving a desired-outcomes

environment. The research study had one non-supporting trend revealing a discrepancy with

managing large-scale change better than small-scale changes. Future recommendations suggest

implementing the Strategic Development Plan on the CARU’s leadership team and hospital

employees. Further research is needed to explore the impact of collaborative leadership on the

CARU after five years and the impact of the organizational culture. Further research is needed to

explore the impact of collaborative leadership and organizational culture on the CARU and the

impact of leadership practices on other units of the hospital as well as on hospitals that are not

urban, non-profit, academic hospitals.

To conclude, anticipating the future changes in health care will always continue to challenge

health care leaders and stakeholders. However, they must continue to collaborate on innovative

methods of leadership practices that will produce high-value health care employees and services in

order to achieve a sustainable future with positive outcomes.

140

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Qualitative Report [On-line serial], 3(3), Available: http://www.nove.edu/sss/QR/QR3-3tellis2.html.

Thompson, T.A. (2011, Fall). Circles of change. Standard Social Innovation Review. 1-6. Trinh, H. Q. & O’Connor, S. J. (2002). Helpful or harmful? The impact of strategic change

on the performance of U.S. urban hospitals. HSR: Health Services Research, 37(1), 143-169.

Tsai, Y. (2011). Relationship between organizational culture, leadership behavior and job

satisfaction. Biomed Central Health Services Research, 11(98), 1-9. Wolf, J.A., Hanson, H., & Moir, M.J. (2011). Organization development in health care : High

impact practices for a complex and changing environment. Charlotte, NC: Information Age Publishing.

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Appendix A

Introduction Letter

Hello Dr. X, My name is Natasha Brown. I work here at Lynford Memorial Medical College as the Education Coordinator for the Introduction to Clinical Medicine Course- ICM 1. I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. I am currently working on my dissertation, which focuses on leadership practices that contribute to organizational success, as defined by organization development, employee engagement, patient satisfaction, and financial accountability. I really hope I can be able to conduct my research at Lynford since our hospital has a remarkable reputation and is known for providing exceptional health care services throughout the Delaware Valley. Thus, the purpose of my letter is to request a confirmation to use your department to conduct the data collecting phase of my dissertation. I can assure you that their participation in the study would be completely confidential, and the identity and privacy of the hospital would be protected through the use of a pseudonym in my report. All activities would occur during the months of June and July and would be scheduled at your convenience. Activities would include interviews with your leadership management team, focus groups with employees, and the analysis of existing publicly-available data (e.g., patient satisfaction ratings). Individual participation in the study would be voluntary, and any participant in the study could choose not to participate or withdraw from the study at any time without consequence. I have conducted an exhaustive review of the literature on leadership practices and organizational success, which I will be happy to share with you. Additionally, my findings and results will be included in my dissertation report, which will document successful leadership practices in your organization and provide a roadmap for continued success. If the department have additional goals, my research design could be adjusted to better meet their needs. I have attached a brief summary of my study, as well as the contact information for my dissertation chair. I look forward to hearing from you, so we can discuss the possibilities. Best regards, Natasha Brown, MS

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Appendix B

IRB Approval Letter

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Appendix C

Invitation Email for CARU Leadership Team

My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial performance. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As a member of the CARU team, you are eligible to participate in the study. As a member of the CARU leadership team, I am inviting you to participate in the study by completing a brief interview. The interview will take no longer than 34-45 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain completely confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. If you will voluntarily participate in the study, please email me at nbb@drexel.edu so we can schedule a mutually-agreeable date and time to meet. Thank you for your consideration. Sincerely, Natasha Brown, MS

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Appendix D

Invitation Email for CARU Financial Leader

My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial performance. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As the finance person for CARU, you are eligible to participate in the study. I am inviting you to participate in the study by completing a brief interview. The interview will take no longer than 34-45 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain completely confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. If you will voluntarily participate in the study, please email me at nbb@drexel.edu so we can schedule a mutually-agreeable date and time to meet. Thank you for your consideration. Sincerely, Natasha Brown, MS

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Appendix E

Invitation Email for CARU Employees

My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial performance. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As a member of the CARU team, you are eligible to participate in the study. I am inviting you to participate in the study by participating in a focus group with approximately 5 other employees. The focus group will take no longer than 34-45 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. If you will voluntarily participate in the study, please email me at nbb@drexel.edu so we can schedule a mutually-agreeable date and time to meet. Thank you for your consideration. Sincerely, Natasha Brown, MS

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Appendix F

Leadership Team Interview Protocol Purpose and Ethical Considerations: My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial accountability. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As a member of the CARU team, you are eligible to participate in the study. As a member of the CARU leadership team, I am inviting you to participate in the study by completing the Leadership Team Interview Protocol. The interview will take no longer than 20-25 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. Recording: Do I have your permission to audio record our conversation? Instructions: I will read each statement to you and allow you to respond to the statement. Part 1: Read the definition of Organization Development and Successful Organizations as it pertains to the study. Organization Development: Designing strategies to align with the mission and manage change to increase effectiveness and behavioral science knowledge throughout the organization by (1) establishing relationships, (2) researching and evaluating dysfunctions and goals, (3) identifying interventions to improve effectiveness, (4) applying approaches to improve effectiveness and (5) evaluating the ongoing process of change (McNamara, 2011). Successful Organizations: For profit: businesses that achieve strong financial results year-in and year-out (Kaufman and Goldstein, 2008) or nonprofit: businesses that accomplish their mission and meet the needs of the population they serve by producing beneficial, desirable outcomes (Blazek, 2008).

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Part 2: Ask the participant to please respond briefly to the following questions.

1. Explain how the organizational structure of leadership impacts the organizational performance?

2. Explain the leadership practices that are most important for achieving optimal organizational performance?

3. How do you align the leadership practices to meet the organization’s strategic goals and objectives?

4. How do you plan to adapt your leadership competencies as the health care system continues to evolve?

5. In managing the people process to improve organizational performance and effectiveness, how do you? a. assess talent b. develop talent c. retain talent

6. What effective communication processes are practiced throughout the organization? 7. How can leaders collaborate more effectively with their employees? 8. How can leaders build employee engagement? 9. How can leaders enhance patient satisfaction? 10. Explain the impact the leadership practices currently have on the organizational culture. 11. How effective is change management activity during organizational transition? 12. Describe the future strategic plans you have in place to meet the changing needs of your

organization? Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Demographics Gender:_____________ Age:_______________ Race/Ethnicity: _______________ Highest Level of Education:____________ Number of years employed in position:__________

Thank you for your valuable participation!

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Appendix G

Finance Accountability Interview Protocol Purpose and Ethical Considerations: My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial accountability. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As a member of the CARU team, you are eligible to participate in the study. As a member of the CARU leadership team, I am inviting you to participate in the study by the Financial Accountability Interview Protocol. The interview will take no longer than 20-25 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. Recording: Do I have your permission to audio record our conversation? Instructions: I will read each statement to you and allow you to respond to the statement. Part 1: Read the definition of Financial Accountability and Competitive Advantage as it pertains to the study. Financial Accountability: Establishes a structure for creating policies that produce effective financial processes. It also includes taking responsibility for positive and negative financial decisions and outcomes (Easton, Wild, Halsey, & McAnally, 2008). Competitive Advantage: Companies analyze their set of capabilities to see what they do best to win in the market that is differentiated and distinctive compared to anyone else (Ovanessoff & Purdy, 2011). Part 2: Ask the participant to please respond briefly to the following questions.

1. How do you assess the CARU’s current state of financial performance?

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2. How are the CARU stakeholders’ held accountable for financial management? 3. Describe some of the greatest strategic challenges that impact the financial performance? 4. During organizational transitions, how do you control costs throughout the system? 5. How do you eliminate wasting valuable resources throughout the system? 6. How is the CARU’s internal culture adapting to the external competitive environment? 7. Describe the future changes you believe the CARU should create in order to build a

sustainable competitive advantage over other rehabilitating facilities? 8. What ideas do you have for managing the financial organizational forecast for the next 3

years? Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Demographics Gender:_____________ Age:_______________ Race/Ethnicity: _______________ Highest Level of Education:____________ Number of years employed in position:__________

Thank you for your valuable participation!

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Appendix H

Employee Focus Group Interview Protocol Purpose and Ethical Considerations: My name is Natasha Brown, and I am a doctoral student in Educational Leadership and Management with a concentration in Human Resource Development at Drexel University. For my dissertation research, I am studying leadership practices that contribute to organizational transformation and success, as defined by organization development, employee engagement, patient satisfaction, and financial accountability. Lynford Memorial has given me permission to conduct my dissertation research in the Comprehensive Acute Rehabilitation Unit. As a staff employee of the CARU, you are eligible to participate in the study. As a staff employee of the CARU, I am inviting you to participate in the study by participating in a focus group with approximately 5 other employees. The focus group will take no longer than 20-30 minutes to complete. Please note that your participation in the study is completely voluntary and you may decline to participate without consequence. If you do choose to participate, you may decline to answer any question or withdraw from the study without consequence. There is no compensation for participating, nor is there any known risk in participating. There is no right or wrong answer to the questions I will be asking. Additionally, your responses will remain confidential. I will not collect or report any identifiers or information that will identify you as an individual. I would like to record the session for note-taking purposes only. I will not record your name or information that will identify you individually. When I transcribe the audio, I will assign you a pseudonym. Once I transcribe the audio, I will destroy the audio. All data will be stored on my personal, password-protected computer and shared with my supervising professor via encrypted email. All data will be destroyed three years after the study is completed. Recording: Do I have your permission to audio record our conversation? Instructions: I will read each statement to you and allow you to respond to the statement. Questions: Ask the participants to please respond briefly to the following questions.

7. Describe what the term employee engagement means to you? 8. Describe some of the measures the CARU utilizes to ensure their employees are treated with

kindness, dignity, and respect? 9. How can your supervisor provide a supportive environment for you to produce your best

work? 10. How can your supervisor involve you in the decision-making process when it comes to

improving work productivity? 11. What measures should the CARU take to ensure that your work duties are?

d. distributed equally e. challenging

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f. motivating 12. How are you rewarded for successful performances?

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your valuable participation!

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Appendix I

Strategic Leadership Development Plan for CARU

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Appendix J

Executive Summary

Hospital leaders in high-level positions played a vital role in creating and maintaining

stability in the performance and survival of their organizations (Ballein, 1997). Current issues such

as health care reform, ongoing economic issues, demographic shifts, physician shortages, mergers,

downsizing, cutting employee wages and shifts, low employee morale, and employee turnover

continued to add to the challenges in the health care sector (Berger & Berger 2011; Browning,

Toain, & Patterson, 2011; Cummings & Worley, 2009). To cope with the growing constraints,

hospital leaders in high-level positions had to create powerful tools to leverage these challenges

through the way they accessed, provided, and funded health care in the United States (Goetz,

Janney, & Ramsey, 2011; Hughes-Cromwick, 2007; Kaufman & Goldstein, 2008; Meyer Silow-

Carroll, Kutyla, Stepnick, & Rybowski 2004; Roberson, 2008). The Chief Diversity Officer from

the American Association of Medical Colleges (AAMC), David Nivet (2011) suggested health care

leaders “build capacity for innovation by engaging people with different perspectives, skill sets, and

experiences to create strategies, and solve problems” (p. 1487). The primary purpose of this

qualitative, descriptive case study was to explore the process of leadership practices for promoting

organizational transformation and success as defined by organization development, employee

engagement, patient satisfaction, financial accountability, and organizational change in Lynford

Memorial University Hospital’s Comprehensive Acute Care Rehabilitation Unit (CARU).

Hospital leaders valued the importance of utilizing leadership practices to enhance their

organizational culture, foster change, embrace communication, build relationships, resolve conflict,

and align their organizational processes to sustain profitability (Kaufman & Goldstein, 2008; Kim,

Thompson, & Herbek, 2012; McAlearney, Scheck, & Butler, 2008). The researcher sought to

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better understand this phenomenon by focusing on the following research questions. The central

question of the research was “How do leadership practices contribute to organizational success?”

The subquestions were as follow:

1 How do organization development principles contribute to the organizational success of

Lynford Memorial’s CARU, as defined by meeting the mission and continued financial

viability and market competitiveness?

2 How does employee engagement contribute to organizational success of Lynford

Memorial’s CARU, as defined by meeting the mission and continued financial viability

and market competitiveness?

3 How does patient satisfaction contribute to organizational success of Lynford Memorial’s

CARU, as defined by meeting the mission and continued financial viability and market

competitiveness?

4 How does Lynford Memorial’s CARU’s preferred theory of organizational change align

with their preferred leadership practices?

The methodology section defined how the research was conducted (Bloomberg & Volpe,

2012). This section included the rationale for the research design, as well as a description of the

site and population, selection of participants, instrumentation, data collection, data analysis

procedures, and ethical considerations. The researcher gathered information from the hospital

leaders and employees to understand the impact of leadership practices as measured by organization

development, employee engagement, patient satisfaction, financial accountability, and

organizational change. The researcher designed a study that allowed the hospital leaders of the

Department of Rehabilitation Medicine’s Comprehensive Acute Care Rehabilitation Unit in

Lynford Memorial to closely examine their perceptions about what leadership was and how it was

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impacting their organization in a productive and profitable manner. The essence of leadership is to

influence what happened anywhere and at any time in a system (Wolf, Hanson, & Moir, 2011).

Leadership rests in the process of building a dynamic group of individuals to interact through their

relationships, ideas, actions, and technologies (Wolf, Hanson, & Moir, 2011). The researcher’s

goal was to help the participants reframe the way they saw people, problems, or things in their

organizations with the hope of discovering something new, positive, useful, and beneficial to the

organizational system and financial accountability. In addition, the researcher’s goal was to help

the participants begin to think about how to connect the reframing of the positive ideas to

developing and achieving attainable goals for the hospital system.

The study’s research design consisted of qualitative approaches within and across the stages

of the research. The researcher used various research data sources to collect information for the

research. The qualitative design consisted of informational, in-depth, face-to- face interviews, a

focus group, open-ended questions, archival records, observations, and memoing. The researcher

used the informational, in-depth, face-to-face interviews with open-ended questions to collect the

information from the CARU’s leadership team concerning leadership practices of organization

development, employee engagement, patient satisfaction, financial accountability, and

organizational change. The researcher used a focus group to collect information from employees

concerning employee engagement and the organizational culture. The researcher used archival data

of patient satisfaction records and the hospital website to cross-reference documents throughout the

research study. The researcher used observations to gather real-time behaviors and interactions

when the participants experienced the phenomenon. The researcher collected field notes as the

memoing data source to record perceptions, thoughts, and experiences throughout the various

phases of the data collection process.

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All of the interviews and the focus group were audio-recorded and transcribed verbatim for

data analysis. The researcher analyzed the data by hand. Open coding, axial coding, selecting

coding, and compared method were used to analyze and interpret the collected data into themes for

answering the research questions.

This qualitative, descriptive case study answered the research question about how leadership

practices contribute to organizational success. Leadership began with a strong foundation of

organizational structure that was followed by strategic goals and objectives geared to achieve the

mission and vision of the hospital. Adapting the leadership structure to incorporate a collaborative

approach of leaderhip was necessary to remain relevant in the every-changing hospital environment

and today’s society. First, leadership development began with hospital leaders participating in

leadership development programs, continuing educational learning activities, coaching and

mentoring classes, 360-degree feedback sessions, and competency and skill development trainings.

Then, leaders practiced transparency in their actions and communications to build trust and

interpersonal relationships.

Leaders used innovative methods to recruit, hire, and train the best employees to provide

high, exceptional health care services to patients in the CARU. Leaders used organization

development principles such as collaboration, relationship building, identifying problems,

developing action plans, evaluating the change, celebrating success to manage daily functions

impacted by internal and external changes. Leaders had to find creative measures to motivate and

build employee engagement to foster retention, patient satisfaction, productivity, and profits.

Leaders promoted activities that focused on patient-centered care because putting the patient first

increased the likelihood of positive clinical outcomes and improved patient safety and retention.

The results of practicing organization development, employee engagement, and patient satisfaction

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improved the overall financial performance of the hospital. As a result, leaders and employees of

the CARU were held accountable for implementing strategies to increase quality performance in

patient-centered care while reducing hospital costs and eliminating waste of hospital resources.

Most importantly, the employees of the CARU had to market their health care services to build

their brand and outweigh their competitors. Lastly, transforming the traditionally vertical,

hierarchical leadership systems to lean, interactive, collaborative leadership systems improved

organizational success by building employee engagement, patient satisfaction, and financial

accountability in hospitals (Bates, 2000; Gary, 1995; Jungyoon, 2011; Merry, 1994; Thompson,

2011). Lynford Memorial University Hospital underwent a transformational change that was

achieving results and creating a cultural environment capable of meeting the mission and vision and

improving optimal performance and effectiveness.

Based on information from the interviews, the focus group, archival records, observations,

and memoing, the researcher created an outline of topics the leaders and employees of the CARU

should continue to focus on and improve in order to produce a high-quality health care workforce

and environment capable of organizational success. The outline of topics was organized into a

Strategic Development Plan for the CARU (Appendix I).

The results revealed that leadership practices contribute to organizational success in the hospital by

practicing the SCORE Values with transparency in leadership, developing rapport with employees

and offering personal and professional growth opportunities, practicing patient-center care,

controlling costs and eliminating waste throughout the system, branding the exceptional care

services, and achieving a desired-outcome environment. The research study had one non-

supporting trend revealing a discrepancy with managing large-scale change better than small-scale

changes.

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Future recommendations suggest implementing the Strategic Development Plan on the

CARU’s leadership team and hospital employees. Further research is needed to explore the impact

of collaborative leadership on the CARU after five years and the impact of the organizational

culture. Further research is needed to explore the impact of collaborative leadership and

organizational culture on the CARU and the impact of leadership practices on other units of the

hospital as well as on hospitals that are not urban, non-profit, academic hospitals.

To conclude, anticipating the future changes in health care will always continue to challenge

health care leaders and stakeholders. However, they must continue to collaborate on innovative

methods of leadership practices that will produce high-value health care employees and services in

order to achieve a sustainable future with positive outcomes.

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Appendix K

Strategic Leadership Development Plan for CARU