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FOURTH EDITION Organizational Behavior in HEALTH CARE Nancy Borkowski, DBA, FACHE, FHFMA Professor Department of Health Services Administration School of Health Professions University of Alabama at Birmingham Birmingham, AL Katherine A. Meese, PhD Assistant Professor Department of Health Services Administration School of Health Professions University of Alabama at Birmingham Birmingham, AL World Headquarters Jones #038; Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] .com www .jblearning .com Jones #038; Bartlett Learning books and products are available through most bookstores and online booksellers . To contact Jones #038; Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www .jblearning .com . Substantial discounts on bulk quantities of Jones #038; Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations . 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Parker Senior Media Development Editor: Troy Liston Rights Specialist: Maria Leon Maimone Cover Image (Title Page, Part Opener, Chapter Opener): © Valex/Shutterstock Printing and Binding: Sheridan Books Brief Contents Preface xii About the Authors PART I PART II Introduction xiii 1 CHAPTER 1 Overview and History of Organizational Behavior . . . . . . . . . . . . . . . . . . . . . . .3 CHAPTER 2 Diversity, Equity, and Inclusion in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CHAPTER 3 Diversity Management and Cultural Competency in Health Care . . . . . . . . . . . . . . . . . 27 CHAPTER 4 Attitudes and Perceptions . . . . . . . . . . . . . . . . . . 45 CHAPTER 5 Workplace Communication . . . . . . . . . . . . . . . . . . 71 Understanding Individual Behaviors 103 CHAPTER 6 Content Theories of Motivation . . . . . . . . . . . . 105 CHAPTER 7 Process Theories of Motivation . . . . . . . . . . . . .127 CHAPTER 8 Attribution Theory and Motivation . . . . . . . . 145 PART III Leadership CHAPTER 9 161 Power, Politics, and Influence . . . . . . . . . . . . . . .163 CHAPTER 10 Trait and Behavioral Theories of Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 © Valex/Shutterstock iii iv Brief Contents CHAPTER 11 Contingency Theories and Situational Models of Leadership . . . . . . . . . . 187 CHAPTER 12 Contemporary Leadership Theories . . . . . . . 205 PART IV Intrapersonal and Interpersonal Issues 227 CHAPTER 13 Stress in the Workplace and Stress Management. . . . . . . . . . . . . . . . . . . . . . . . . 229 CHAPTER 14 Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261 CHAPTER 15 Conflict Management and Negotiation Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 PART V Groups and Teams 297 CHAPTER 16 Overview of Group Dynamics . . . . . . . . . . . . . . 299 CHAPTER 17 Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315 CHAPTER 18 Work Teams and Team Building . . . . . . . . . . . 327 PART VI Managing Organizational Change 341 CHAPTER 19 Organization Development. . . . . . . . . . . . . . . . . 343 CHAPTER 20 Managing Resistance to Change . . . . . . . . . . . .361 Index 379 Contents Preface . . . . . . . . . . . . . . . . . . . . . . xii About the Authors . . . . . . . . . . . xiii PART I Introduction 1 CHAPTER 1 Overview and History of Organizational Behavior . . . . . . . . . . . . . . . . . . . . . . 3 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Why Study Organizational Behavior in Health Care? . . . . . . . . . . . . . . . . . . . 4 The Health Care Industry . . . . . . . . . . . . 4 History of Organizational Behavior . . . . . 6 The Hawthorne Studies . . . . . . . . . . . . . . 7 Theories X and Y . . . . . . . . . . . . . . . . . . . . 8 Related Disciplines . . . . . . . . . . . . . . . . . 9 Discussion Questions . . . . . . . . . . . . . . 10 What Do You Know About Organizational Behavior? . . . . . . . . . . 10 Scoring . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Interpretation . . . . . . . . . . . . . . . . . . . . . 11 References . . . . . . . . . . . . . . . . . . . . . . . 11 CHAPTER 2 Diversity, Equity, and Inclusion in Health Care . . . 13 Overview . . . . . . . . . . . . . . . . . . . . . . . . . 13 Diversity, Equity, and Inclusion Defined . . . . . . . . . . . . . . . . . . . . . . . . 14 Changing U .S . Population . . . . . . . . . . . 16 Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . 17 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 © Valex/Shutterstock Sexual Orientation, Gender Identity, and Gender Expression . . . . . . . . . . . . . 19 Implications for the Health Care Industry . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 2-1 . . . . . . . . . . . . . . . . . . . . . . Exercise 2-2 . . . . . . . . . . . . . . . . . . . . . . Exercise 2-3 . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings . . . . . . . . . . 21 23 23 23 23 23 24 25 CHAPTER 3 Diversity Management and Cultural Competency in Health Care . . . . 27 Diversity Management . . . . . . . . . . . . . . The Future Workforce . . . . . . . . . . . . . . Diversity in Health Care Leadership . . . Cultural Competency . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 3-1 . . . . . . . . . . . . . . . . . . . . . . Exercise 3-2 . . . . . . . . . . . . . . . . . . . . . . Exercise 3-3 . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . 28 29 30 33 41 42 42 42 42 42 CHAPTER 4 Attitudes and Perceptions . . . . . . . . . . . . . . . . . . 45 Overview . . . . . . . . . . . . . . . . . . . . . . . . . Attitudes . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Dissonance . . . . . . . . . . . . . . Formation of Attitudes . . . . . . . . . . . . . . 45 46 47 48 v vi Contents Measurement of Attitudes. . . . . . . . . . . . . . 49 Changing Attitudes. . . . . . . . . . . . . . . . . . . 50 Perception . . . . . . . . . . . . . . . . . . . . . . . . 55 Attribution Theory . . . . . . . . . . . . . . . . . . 56 Social Perception. . . . . . . . . . . . . . . . . . . 58 Halo Effect. . . . . . . . . . . . . . . . . . . . . . . . . Contrast Effects. . . . . . . . . . . . . . . . . . . . . Projection. . . . . . . . . . . . . . . . . . . . . . . . . . Stereotyping. . . . . . . . . . . . . . . . . . . . . . . . Pygmalion Effect. . . . . . . . . . . . . . . . . . . . . 58 59 60 60 62 Impression Management . . . . . . . . . . . . Employee Selection. . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . . Case Study and Exercises. . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . . 63 64 66 66 66 68 70 CHAPTER 5 Workplace Communication. . . . . . . . . . . . . . . . 71 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . 71 Communication Process. . . . . . . . . . . . . 72 Feedback . . . . . . . . . . . . . . . . . . . . . . . . . 73 The Johari Window . . . . . . . . . . . . . . . . . . 75 Communication Channels. . . . . . . . . . . . 76 Verbal Communication. . . . . . . . . . . . . . . . 76 Electronic Communication. . . . . . . . . . . . . . 78 Nonverbal Communication . . . . . . . . . . . . 80 Barriers to Communication . . . . . . . . . . 81 Environmental Barriers. . . . . . . . . . . . . . . . 81 Personal Barriers. . . . . . . . . . . . . . . . . . . . . 83 Overcoming Barriers to Improve Communication . . . . . . . . . . . . . . . . . . 84 Effective Communication for Knowledge Management. . . . . . . . . . . 85 Strategic Communication. . . . . . . . . . . . . . 87 Flows of Intraorganizational Communication . . . . . . . . . . . . . . . . . . 87 Upward Flow. . . . . . . . . . . . . . . . . . . . . . . 88 Downward Flow. . . . . . . . . . . . . . . . . . . . . 89 Horizontal Flow. . . . . . . . . . . . . . . . . . . . . 89 Diagonal Flow . . . . . . . . . . . . . . . . . . . . . . 89 Communication Networks . . . . . . . . . . . 89 Informal Communication . . . . . . . . . . . . 93 Cross-Cultural Communication. . . . . . . 94 Communicating with External Stakeholders. . . . . . . . . . . . . . . . . . . . . 96 Summary . . . . . . . . . . . . . . . . . . . . . . . . . 98 Discussion Questions . . . . . . . . . . . . . . . 99 Case Studies. . . . . . . . . . . . . . . . . . . . . 100 References. . . . . . . . . . . . . . . . . . . . . . . 101 PART II Understanding Individual Behaviors 103 CHAPTER 6 Content Theories of Motivation. . . . . . . . . . . . . . . . . 105 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Maslow’s Hierarchy of Needs Theory. . . . . . . . . . . . . . . . . . . Alderfer’s ERG Theory. . . . . . . . . . . . . . Herzberg’s Two-Factor Theory. . . . . . . Job Design. . . . . . . . . . . . . . . . . . . . . . . McClelland’s Three-Needs Theory. . . . 105 106 110 112 115 118 Achievement. . . . . . . . . . . . . . . . . . . . . . . 119 Power. . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Affiliation. . . . . . . . . . . . . . . . . . . . . . . . . 120 Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Studies and Exercises . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . 121 121 122 126 126 CHAPTER 7 Process Theories of Motivation. . . . . . . . . . . . . . . . . 127 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Expectancy Theory. . . . . . . . . . . . . . . . . Equity Theory. . . . . . . . . . . . . . . . . . . . . Satisfaction–Performance Theory . . . . 127 127 130 133 Contents Goal-Setting Theory. . . . . . . . . . . . . . . . Reinforcement Theory. . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Studies. . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . 135 137 139 139 140 144 CHAPTER 8 Attribution Theory and Motivation . . . . . . . . 145 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Attribution Theory . . . . . . . . . . . . . . . . . Attribution Style. . . . . . . . . . . . . . . . . . . Attributions and Motivational States . . . . . . . . . . . . . . . . . . . . . . . . . 145 145 147 Learned Helplessness . . . . . . . . . . . . . . . . Aggression . . . . . . . . . . . . . . . . . . . . . . . . Empowerment . . . . . . . . . . . . . . . . . . . . . Resilience. . . . . . . . . . . . . . . . . . . . . . . . . 148 149 150 151 148 Promoting Motivational Attribution Processes. . . . . . . . . . . . . . . . . . . . . . 152 Screening for Resilience . . . . . . . . . . . . . . Attributional Training. . . . . . . . . . . . . . . . Immunization. . . . . . . . . . . . . . . . . . . . . . Increasing Psychological Closeness. . . . . . Multiple Raters of Performance. . . . . . . . . 152 153 153 153 154 Conclusion . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Studies and Exercise . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Reading. . . . . . . . . . . 154 155 155 158 159 PART III Leadership 161 CHAPTER 9 Power, Politics, and Influence. . . . . . . . . . . . . . . . . 163 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 163 Sources of Power . . . . . . . . . . . . . . . . . . . 164 Other Sources of Power in an Organization. . . . . . . . . . . . . . . 165 Uses of Power . . . . . . . . . . . . . . . . . . . . 167 Developing a Power Base. . . . . . . . . . . Organizational Politics. . . . . . . . . . . . . . Upward Influence. . . . . . . . . . . . . . . . . . Conclusion. . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Studies. . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . vii 167 168 169 170 170 170 172 CHAPTER 10 Trait and Behavioral Theories of Leadership. . . . . . . . . . . . . . . . . 173 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Trait Theory . . . . . . . . . . . . . . . . . . . . . . Lewin’s Behavioral Study . . . . . . . . . . . Ohio State Leadership Studies. . . . . . . University of Michigan Studies. . . . . . . 173 174 176 177 178 Blake and Mouton’s Leadership Grid. . . . . 178 Conclusion. . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Study and Exercises. . . . . . . . . . . Exercise 10-1. . . . . . . . . . . . . . . . . . . . . Exercise 10-2. . . . . . . . . . . . . . . . . . . . . Exercise 10-3. . . . . . . . . . . . . . . . . . . . . Exercise 10-4. . . . . . . . . . . . . . . . . . . . . Exercise 10-5 Leadership Questionnaire. . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . 180 181 181 182 182 182 182 182 185 CHAPTER 11 Contingency Theories and Situational Models of Leadership. . . . . . . . . . 187 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Fiedler’s Contingency Theory. . . . . . . . House’s Path–Goal Leadership Theory. . . . . . . . . . . . . . . . . . . . . . . . . Tannenbaum and Schmidt’s Continuum of Leadership Behavior . . . . . . . . . . . . . . . . . . . . . . . Hersey and Blanchard’s Situational Leadership Model. . . . . . 187 188 190 193 194 viii Contents Leader–Member Exchange Theory. . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 11-1 . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . 196 198 199 199 203 CHAPTER 12 Contemporary Leadership Theories. . . . . . . . . . 205 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 206 Transformational Versus Transactional Leadership . . . . . . . . . 206 Transactional Leadership . . . . . . . . . . . . . 207 Transformational Leadership. . . . . . . . . . . 207 Transformational Leadership: A Contradictory View . . . . . . . . . . . . . 208 The Implications of Transformational Leadership for the Health Care Industry. . . . . . . . . . . . . . . . . . . . . . . . 209 Other Contemporary Leadership Approaches. . . . . . . . . . . . . . . . . . . . . 210 The Charismatic Leader . . . . . . . . . . . . . . 211 Servant Leadership. . . . . . . . . . . . . . . . . . 213 Collaborative Leadership . . . . . . . . . . . . . 214 Another Look at Traits and Behavior . . . . . . . . . . . . . . . . . . . . . . . 215 Big Five Personality Factors . . . . . . . . . . . 215 Emotional Intelligence . . . . . . . . . . . . . . . 216 Behavioral Competencies . . . . . . . . . . . . . 218 Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 12-1 . . . . . . . . . . . . . . . . . . . . . Exercise 12-2 Are You a Charismatic Leader?. . . . . . . . . . . . . Exercise 12-3 What Is Your EQ?. . . . . . Exercise 12-4 . . . . . . . . . . . . . . . . . . . . . Appendix 12-A Traits and Skills of Collaborative Leaders. . . . . . . . . . 219 220 220 Appendix 12-B Six Key Practices and Necessary Steps for Leaders to Guide Successful Collaborations . . . . . . . . . . . . . . . . . . 222 References. . . . . . . . . . . . . . . . . . . . . . . 223 Other Suggested Readings. . . . . . . . . . 225 PART IV Intrapersonal and Interpersonal Issues 227 CHAPTER 13 Stress in the Workplace and Stress Management. . . . . . . . . . . . . . . . 229 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 229 Work-Related Stress. . . . . . . . . . . . . . . 233 Workplace Violence . . . . . . . . . . . . . . . . . Stressors. . . . . . . . . . . . . . . . . . . . . . . . . . Positive and Negative Stressors . . . . . . . . . Internal or External Stressors/Acute or Chronic. . . . . . . . . . . . . . . . . . . . . . . Individuals and Stress. . . . . . . . . . . . . . . . Personalities. . . . . . . . . . . . . . . . . . . . . . . Underrepresented Populations. . . . . . . . . Gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . Beliefs About Stress. . . . . . . . . . . . . . . . . . Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . Presenteeism. . . . . . . . . . . . . . . . . . . . . . . 233 234 234 235 236 236 238 239 239 240 241 Causes of Workplace Stress. . . . . . . . . 243 Coping with Stress. . . . . . . . . . . . . . . . . 245 Organizational Coping Strategies . . . . . . . 246 Joy in Work. . . . . . . . . . . . . . . . . . . . . . . 247 220 221 221 222 Job Design . . . . . . . . . . . . . . . . . . . . . . . . 248 Individual Coping Strategies. . . . . . . . . 249 Learned Optimism. . . . . . . . . . . . . . . . . . 250 Stress Management Programs. . . . . . . 252 Summary . . . . . . . . . . . . . . . . . . . . . . . . 254 ix Contents Discussion Questions . . . . . . . . . . . . . . 254 References. . . . . . . . . . . . . . . . . . . . . . . 256 Other Suggested Readings. . . . . . . . . . 258 CHAPTER 14 Decision Making. . . . . . . . . . . . . . . . . . . . . . . 261 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 261 Rational Approach . . . . . . . . . . . . . . . . . . Bounded Rationality Model . . . . . . . . . . . Intuition. . . . . . . . . . . . . . . . . . . . . . . . . . Heuristics or Biases Approach. . . . . . . . . . Escalation of Commitment and Framing Heuristics. . . . . . . . . . . . . Decision-Style Model . . . . . . . . . . . . . . . . Vroom-Yetton Decision-Making Model. . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 14-1. . . . . . . . . . . . . . . . . . . . . Exercise 14-2. . . . . . . . . . . . . . . . . . . . . Exercise 14-3. . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . 262 262 264 264 266 268 269 272 272 272 272 272 272 273 CHAPTER 15 Conflict Management and Negotiation Skills . . . . . . . . . . . . 275 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 275 Types of Conflict. . . . . . . . . . . . . . . . . . . 276 Levels of Conflict. . . . . . . . . . . . . . . . . . 277 Intrapersonal Conflict. . . . . . . . . . . . . . . . Interpersonal Conflict. . . . . . . . . . . . . . . . Intragroup Conflict. . . . . . . . . . . . . . . . . . Intergroup Conflict. . . . . . . . . . . . . . . . . . Interorganizational Conflict . . . . . . . . . . . 278 279 279 280 281 Conflict Management . . . . . . . . . . . . . . 282 Conflict Negotiation Models. . . . . . . . . . . 284 Distributive Model. . . . . . . . . . . . . . . . . . . 284 Integrative Model. . . . . . . . . . . . . . . . . . . . 285 Interactive Model. . . . . . . . . . . . . . . . . . . . 287 Benefits of Skilled Conflict Resolution and Negotiation. . . . . . . . Conclusion. . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Studies. . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . PART V Groups and Teams 288 288 289 289 294 296 297 CHAPTER 16 Overview of Group Dynamics. . . . . . . . . . . 299 Overview. . . . . . . . . . . . . . . . . . . . . . . . . What Is a Group?. . . . . . . . . . . . . . . . . . Group Interaction. . . . . . . . . . . . . . . . . . Why Do People Join Groups? . . . . . . . . Roles of Group Members. . . . . . . . . . . . Group Norms. . . . . . . . . . . . . . . . . . . . . Cohesiveness. . . . . . . . . . . . . . . . . . . . . 299 300 300 301 302 304 307 Size of the Group. . . . . . . . . . . . . . . . . . . Social Loafing. . . . . . . . . . . . . . . . . . . . . . Experience of Success. . . . . . . . . . . . . . . . Group Status. . . . . . . . . . . . . . . . . . . . . . Outside Threats to the Group. . . . . . . . . . 307 307 308 308 308 Conformity . . . . . . . . . . . . . . . . . . . . . . . Groupthink. . . . . . . . . . . . . . . . . . . . . . . Conclusion. . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 16-1. . . . . . . . . . . . . . . . . . . . . Exercise 16-2. . . . . . . . . . . . . . . . . . . . . 309 309 311 312 313 313 Be the Best We Can Be Team Norms . . . . . . . . . . . . . . . . . . . . . . . . . 313 Exercise 16-3. . . . . . . . . . . . . . . . . . . . . 313 References. . . . . . . . . . . . . . . . . . . . . . . 313 x Contents CHAPTER 17 Groups . . . . . . . . . . . 315 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 315 Types of Groups . . . . . . . . . . . . . . . . . . . 315 Primary Groups . . . . . . . . . . . . . . . . . . . . 316 Secondary Groups . . . . . . . . . . . . . . . . . . 316 Reference Groups. . . . . . . . . . . . . . . . . . . 316 Informal or Formal Group Structure. . . . . . . . . . . . . . . . . . . . . . . 317 Informal Groups. . . . . . . . . . . . . . . . . . . . 317 Formal Groups. . . . . . . . . . . . . . . . . . . . . 318 Group Development. . . . . . . . . . . . . . . . 320 Group Decision Making. . . . . . . . . . . . . 320 Rational Decision-Making Processes. . . . . . . . . . . . . . . . . . . . . . 321 Brainstorming. . . . . . . . . . . . . . . . . . . . . . 322 Nominal Group Technique. . . . . . . . . . . . 323 The Delphi Technique . . . . . . . . . . . . . . . 323 Irrational Decision-Making Processes. . . . . . . . . . . . . . . . . . . . . . 323 The “Garbage Can” Decision-Making Process. . . . . . . . . . . . . . . . . . . . . . . . . 323 Conclusion . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Exercise 17-1 . . . . . . . . . . . . . . . . . . . . . Exercise 17-2 . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . 325 325 325 325 325 CHAPTER 18 Work Teams and Team Building . . . . . . . . . . . 327 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Teams and Teaming. . . . . . . . . . . . . . . . Types of Teams. . . . . . . . . . . . . . . . . . . . Virtual Teams. . . . . . . . . . . . . . . . . . . . . Building Team Performance. . . . . . . . . Common Characteristics of Successful Teams . . . . . . . . . . . . . Barriers to Effective Teamwork . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . 327 328 330 331 331 335 337 338 339 Exercise 18-1. . . . . . . . . . . . . . . . . . . . . Exercise 18-2. . . . . . . . . . . . . . . . . . . . . Exercise 18-3. . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . 339 339 339 340 340 PART VI Managing Organizational Change 341 CHAPTER 19 Organization Development. . . . . . . . . . . . . . . . 343 Overview. . . . . . . . . . . . . . . . . . . . . . . . . Organization Development . . . . . . . . . . The Organization Development Professional . . . . . . . . . . . . . . . . . . . . Action Research. . . . . . . . . . . . . . . . . . . Steps in the Organization Development Process . . . . . . . . . . . . 343 344 Entering and Contracting. . . . . . . . . . . . . Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . Planning and Implementing Change. . . . . Evaluating and Institutionalizing Change. . . . . . . . . . . . . . . . . . . . . . . . . 349 350 351 Organization Development Interventions. . . . . . . . . . . . . . . . . . . . Appreciative Inquiry. . . . . . . . . . . . . . . . Conclusion. . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . 346 348 348 352 353 354 355 355 359 CHAPTER 20 Managing Resistance to Change . . . . . . . . . 361 Overview. . . . . . . . . . . . . . . . . . . . . . . . . 361 Drivers of Change . . . . . . . . . . . . . . . . . 362 Resistance to Change. . . . . . . . . . . . . . 363 Individuals’ Barriers to Change. . . . . . . . . 363 Discomfort with Uncertainty . . . . . . . . . . 364 Perceived Negative Effects on Interests. . . . 365 Contents Perceived Breach of Psychological Contract. . . . . . . . . . . . . . . . . . . . . . . . 365 Lack of Clarity as to What Is Expected. . . . . . . . . . . . . . . . . 365 Excessive Change. . . . . . . . . . . . . . . . . . . 365 Lewin’s Change Model. . . . . . . . . . . . . . 366 Transformation of Health Care Organizations. . . . . . . . . . . . . . . . . . . 369 Summary . . . . . . . . . . . . . . . . . . . . . . . . Discussion Questions . . . . . . . . . . . . . . Case Study. . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . Other Suggested Readings. . . . . . . . . . xi 370 371 371 378 378 Index . . . . . . . . . . . . . . . . . . . . . . . 379 Preface In the first edition of this book, Chapter 1 stated that “the U .S . health care industry has grown and changed dramatically over the past twenty-five years .” That was an understatement! Since that time, the industry has experienced some of the most dynamic changes that health care managers have seen . In the coming years, more system-wide changes will occur as we continue our push forward to achieve patient-centered, value-based health care . Health care managers are quickly learning that what worked in the past might not work in the future . This was the compelling reason to write an organizational behavior book specifically for health care managers who are on the front lines every day, motivating and leading others in a constantly changing, complex environment . This is not an easy task, as we know firsthand! The purpose of this book is to provide health care managers and other professionals with an in-depth analysis of the theories and concepts of organizational behavior while embracing the uniqueness and complexity of the industry . Although health care is similar to other industries, it is also very different . As the nation’s largest industry, health care employs more than 16 million people in numerous interrelated and interdependent segments . Using an applied focus, this book provides a clear and concise overview of the essential topics in organizational behavior from the health care manager’s perspective . It is our goal to give you a greater understanding of why and how people and groups behave as they do in the workplace . With this knowledge, you will be able to predict and effectively influence the behavior of the people you lead . Please let me know if we accomplish our goal! You can reach us at [email protected] .edu or [email protected] .edu . We have tried to ensure that we referenced all the individuals whose work contributed to the development of this book . However, if by chance we failed to give credit to someone along the way, please contact us so that we can make the necessary correction . At this time, we wish to thank our families for their patience, understanding, and support over the years . Finally, we wish to thank the many wonderful and caring people employed throughout the health care industry with whom we have had and will continue to have the opportunity to work with . Our lives continue to be blessed by these dedicated individuals! Thank you for purchasing (and reading) our book . We welcome your comments and suggestions, and we wish you the best on your health care management and leadership journey . With personal regards, Nancy Borkowski, DBA, FACHE, FHFMA Katherine A . Meese, PhD xii © Valex/Shutterstock About the Authors Nancy Borkowski, DBA, FACHE, FHFMA, is Professor in the Department of Health Services Administration at the University of Alabama at Birmingham . She received her DBA with specializations in health services administration and accounting from Nova Southeastern University . Dr . Borkowski has over 25 years’ experience in the health care industry and is a two-time past recipient of the American College of Healthcare Executives’ (ACHE) Southern Florida Senior Career Healthcare Executive Award, which recognizes individuals who have made significant contributions to the advancement of health management excellence . A nationally recognized author, Dr . Borkowski is also board certified in health management and is a Fellow of both the American College of Healthcare Executives and the Healthcare Financial Management Association . The first edition of her book, Organizational Behavior in Health Care, referred to as “one of the most significant advances in the field of health services administration,” was honored with the American Journal of Nursing’s 2005 Book of the Year Award for nursing leadership and management . Dr . Borkowski is the author of three textbooks that are widely used in graduate and undergraduate health administration and nursing programs both nationally and internationally . Dr . Borkowski’s work has been published in the Journal of Ambulatory Care Management, Leadership in Health Services, Group #038; Organization Management, Organizational Behavior and Human Decision Processes, Health Care Management Review, Journal of Health Administration Education, Journal of Health and Human Services Administration, International Journal of Public Administration, and various other journals . Her teaching interests are leadership, organizational behavior, and strategic management . Dr . Borkowski is a past recipient of the ACHE’s Excellence in Teaching Award, which is given to faculty who engage in furthering academic excellence and the professional development of health management students . Over the past three decades, Dr . Borkowski has served in various leadership roles for the Association of University Programs in Health Administration, Academy of Management’s Health Care Management Division, the American College of Healthcare Executives’ Southern Florida Regent’s Advisory Council, the South Florida Healthcare Executive Forum, the Alabama Healthcare Executive Forum, and various other health-related organizations . In 2013, Dr . Borkowski received the Jessie Trice Hero Award for her leadership and commitment to improving the lives of underserved and minority populations . She has also been honored with the Exemplary Service Award from the American College of Healthcare Executives (2012) and the Frederick T . Muncie Gold Award from the Healthcare Financial Management Association (2017) . Katherine A. Meese, PhD, is an Assistant Professor in the Department of Health Services Administration at the University of Alabama at Birmingham . She earned her PhD in Health © Valex/Shutterstock xiii xiv About the Authors Services Administration with a specialization in strategic management from the University of Alabama at Birmingham in 2019. Dr. Meese has seven years of industry experience, encompassing work in ten countries on four continents, including management positions for a large academic medical center. Her work has been published in Anesthesia #038; Analgesia, Health Services Management Research, Journal of Health Administration Education, and various other journals. Her research interests are in wellness, burnout, quality and safety, and delivery models that enhance organizational learning. PART I Introduction Part I includes four different but related topics. In Chapter 1, the history of organizational behavior and its importance to today’s health care managers are discussed. Chapter 2 describes the changing environment in which health care managers find themselves. The chapter examines the numerous issues that have emerged within the health care industry because of the nation’s changing demographics. Chapter 3 focuses specifically on cultural competency and the skills that managers need to adapt to the changing environment explored in Chapter 2. Chapter 4 deals with attitudes and perceptions, which are the foundation for understanding organizational behavior. You will find the terms “attitude” and “perception” frequently referred to in the various organizational behavior theories. Finally, Chapter 5 discusses the importance of communication. Recent surveys have revealed that 70% of small- to medium-sized businesses claim that ineffective communication is their primary problem. Sentinel event data from The Joint Commission estimated that communication failure was the root cause for patient harm 70% of the time in 2400 reported negative outcomes studied. No wonder the ability to communicate effectively is considered an essential job skill for today’s health care managers and leaders. © Valex/Shutterstock 1 C HAPT E R 1 Overview and History of Organizational Behavior LEARNING OUTCOMES After completing this chapter, the student should understand: definition of organizational behavior. • The major challenges facing today’s and tomorrow’s health care organizations and health care • The managers. importance of the Hawthorne Studies to the study of organizational behavior. • The importance of McGregor’s Theory X and Theory Y to the study of organizational behavior. • The differences between organizational behavior, organization theory, organizational development, • The and human resources management. ▸ Overview Organizational behavior (OB) is an applied behavioral science that emerged from the disciplines of psychology, sociology, anthropology, political science, and economics. OB is the study of individual and group dynamics in an organizational setting. Whenever people work together, numerous and complex factors interact. The discipline of OB attempts to understand these interactions so that managers can predict behavioral responses and, as a result, manage the resulting outcomes. According to Ott (1996, p. 1), OB asks the following questions: 1. Why do people behave the way they do when they are in organizations? 2. Under what circumstances will people’s behavior in organizations change? 3. What impacts do organizations have on the behavior of individuals, formal groups (such as departments), and informal groups (such as people from several departments who have lunch together regularly)? 4. Why do different groups in the same organization develop different behavior norms? From Ott. Classic Readings in Organizational Behavior, 2E. © 1996 South-Western, a part of Cengage Learning, Inc. © Valex/Shutterstock 3 4 Chapter 1 Overview and History of Organizational Behavior OB has three goals. First, OB attempts to explain why individuals and groups behave the way they do in organizational settings. Second, OB tries to predict how individuals and groups will behave on the basis of internal and external factors. Third, OB provides managers with tools to assist in the management of individuals’ and groups’ behaviors so that they willingly put forth their best effort to accomplish organizational goals. In the health care industry, OB has become more important because people with diverse backgrounds and cultural values have to work together effectively and efficiently. ▸▸ Why Study Organizational Behavior in Health Care? The largest U.S. industry is health care, which currently employs over 20 million individuals. The industry will account for almost a third of the nation’s projected job growth through 2026, adding over 2 million jobs. The projected 1.9% per year growth rate is the fastest among all industry sectors (Bureau of Labor Statistics, 2019). Each segment of the health care industry (e.g., hospitals, home health, rehabilitation facilities) comprises a different mix of health-related occupations, ranging from highly skilled licensed professionals, such as physicians and nurses, to those with on-the-job training. Furthermore, each segment of the industry has various economic structures (e.g., for-profit, not-for-profit, governmental). Therefore, today’s health care managers need to have the skills to communicate effectively with, motivate, and lead diverse groups of people within a large, dynamic, and complex industry. Communication, motivation, and leadership are all concepts in the discipline of OB. Furthermore, managers need to understand the causes of workplace problems, such as low performance, turnover, conflict, and stress, so that they may be proactive and minimize these unnecessary negative outcomes. With a greater understanding of OB, managers are better able to predict and therefore influence the behavior of employees to achieve organizational goals. Given the service-related intensity of the health care industry, understanding individuals’ behavior and group dynamics within health service organizations is critical to a health care manager’s success. Research indicates that the primary reasons why managers fail stem from difficulty in handling change, not being able to work well in teams, and having poor interpersonal relations. There is a saying that employees don’t leave organizations, they leave managers! ▸▸ The Health Care Industry Changes within the health care industry over the past 30 years have been powerful, far reaching, and continuous. Because readers are probably familiar with most of these changes either from their own experiences or from a previous health care delivery system course, the discussion will address some of the trends or future concerns that will affect tomorrow’s health care industry. Past changes and future trends are interrelated forces that have shaped or will shape tomorrow’s health care organizations at both the system level and the organizational level. Declining reimbursement and changes in payment schemes for services have had, and will continue to have, two of the deepest impacts on the industry. Technology has also caused significant changes within the industry. Biomedical and genetic research, advances in information technology, and use of “big data” are producing rapid changes in clinical treatments. In addition, the industry has experienced The Health Care Industry 5 more government mandates and substantial legislative changes, such as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003; the American Recovery and Reinvestment Act of 2009; the Patient Protection and Affordable Care Act of 2010 (ACA) and subsequent legislation to repeal portions of the act; and the Medicare Access #038; Chip Reauthorization Act of 2015 (MACRA). With an increased focus on chronic disease management, patients are living longer, and requiring more long-term and home health care services now and in the future. Patients’ and health care workers’ characteristics are also changing. Both populations are becoming older and more diverse. Patients are better informed and have increasingly high expectations of health care professionals. This trend has changed the way in which health care services are delivered, with a focus on patient satisfaction and safety as well as on the quality and value of services provided. Physician–patient relationships have changed because patients are beginning to understand that much of the responsibility for wellness lies with them and have easy access to health-related information. A growth in high-deductible insurance plans places a larger financial responsibility on patients to manage their own health and reduce unnecessary health spending. The economics of health care are in a state of flux. For exle, reimbursements are moving toward value-based payments; therefore, we see an increase in the use of evidence-based medicine. There are continuing shortages of staff, especially in the areas of primary care physicians, nurses, imaging technicians, and pharmacists, leading to competition for well-qualified people. Changes are also taking place in the disease environment. Many factors of modern life are contributing to the emergence of new diseases, reemergence of old ones, and evolution of pathogens that are immune to many of today’s medications. In addition, because of potential terrorism attacks, health care providers are concerned with biodisaster preparedness. Finally, even with some states’ Medicaid expansion programs and the ACA, there continues to be the issue of caring for the uninsured which can contribute to the overuse and misuse of hospital emergency departments. To deal with these changes, a number of health care organizations have adapted their organizational forms by restructuring themselves into integrated delivery networks, which may be part of a local, regional, or national system. We have seen increased vertical, horizontal, and virtual integration. Vertical integration focuses on the development of a continuum of care services to meet the patient’s full range of health care needs. This integration model, in which a single entity owns and operates all the segments providing care, may include preventive services, s­ pecialized and primary ambulatory care, acute care, subacute care, long-term care, and home health care, as well as a health plan. Recently, we have seen the creation of accountable care organizations (ACOs), in which groups of doctors, hospitals, and other health care providers have joined together to provide coordinated care to predetermined patient populations. Horizontal integration usually occurs through mergers, acquisitions, and/or consolidation within one segment of the industry. For exle, during the 1990s, numerous hospitals were acquired by the large, forprofit, publicly held hospital chains of Hospital Corporation of America (HCA), Tenet Healthcare, and Health Management Associates (now part of Community Health Systems), and these acquisitions continue today. Consolidation in health care began to rise rapidly in 2009 and doubled between 2011 and 2015 (Health Care Financial Management Association, 2017). In addition, not-for-profit hospitals have merged with for-profit health systems as a result of competition and the need to reduce cost through economies of scale. Virtual integration, which emphasizes coordination of health care services through patient-management agreements, provider incentives, and/ or information systems, has increased. This virtual integration has evolved to meet the need for better technology and information infrastructures that allow for information sharing, patient care management, and cost control. 6 Chapter 1 Overview and History of Organizational Behavior Because of the dramatic changes and the future trends in the health care industry, most managers have had to change the ways in which they and other employees carry out their job responsibilities. These changes have been forced on the industry by the need to increase productivity, due to decreasing reimbursement and increasing competition. At the same time, health care providers must deliver patient-centered, value-based care. These are not easy tasks to balance. As a result, many health care providers are breaking down their traditional hierarchical structures and moving toward multidisciplinary team-managed environments. Employees are finding themselves in new roles with new responsibilities. All of these changes cause disruptions in the workplace. The study of OB will assist health care managers to minimize the negative effects (such as stress and conflict) related to this “new” environment and to maximize their ability to motivate staff and lead their organizations effectively. ▸▸ History of Organizational Behavior The beginnings of OB can be found in the human relations/behavioral management movement, which emerged during the 1920s as a response to the traditional or classic management approach. Beginning in the late 1700s, the Industrial Revolution was the driving force for the development of large factories employing many workers. Managers at that time were concerned “about how to design and manage work in order to increase productivity and help organizations attain maximum efficiency” (Daft, 2004, p. 24). This traditional approach included Frederick Taylor’s (1911) wellknown framework of scientific management, or “Taylorism,” as it is now labeled. Taylor believed that efficiency was achieved by creating jobs that economized time, human energy, and other productive resources. Through his time-and-motion studies, Taylor scientifically divided manufacturing processes into small, efficient units of work. Through Taylor’s work, productivity greatly increased. For exle, Henry Ford developed his assembly line according to the principles of Taylorism and was able to churn out Model Ts at a remarkable and economical pace (Benjamin, 2003). Although the classic approach to management focused on efficiency within organizations, Taylor did attempt to address a human relations aspect in the workplace. In his book The Principles of Scientific Management, Taylor stated that: in order to have any hope of obtaining the initiative (i.e., best endeavors, hard work, skills and knowledge, ingenuity, and good-will) of his workmen, the manager must give some special incentive to his men beyond that which is given to the average of the trade. This incentive can be given in several different ways, as, for exle, the hope of rapid promotion or advancement; higher wages, either in the form of generous piecework prices or of a premium or bonus of some kind for good and rapid work; shorter hours of labor; better surroundings and working conditions than are ordinarily given, etc., and, above all, this special incentive should be accompanied by that personal consideration for, and friendly contact with, his workmen which comes only from a genuine and kindly interest in the welfare of those under him. It is only by giving a special inducement or incentive of this kind that the employer can hope even approximately to get the initiative of his workmen. Although Taylor included a concern for workers in the scientific management approach, the human relations or behavioral movement of management did not begin until after the landmark Hawthorne Studies. The Hawthorne Studies 7 ▸▸ The Hawthorne Studies Elton Mayo, Frederick Roethlisberger, and their colleagues from Harvard Business School ­conducted a number of experiments from 1924 to 1933 at the Hawthorne Plant of the Western Electric Company in Cicero, Illinois. The Hawthorne Studies were significant to the development of OB because the researchers demonstrated the important influence of human ­factors on worker productivity. It was through these experiments that the Hawthorne Effect was ­identified. The Hawthorne Effect is the bias that occurs when people know that they are being studied. Roethlisberger and Dickson (1939), in their book Management and the Worker, and Homans (1950), in his book The Human Group, provided a comprehensive account of the Hawthorne Studies. The Hawthorne Studies had four phases: the illumination experiments, the relay-­assembly group experiments, the bank-wiring observation-room group studies, and the interviewing program. The intent of these studies was to determine the effect of working conditions on productivity. The illumination experiments were conducted to determine whether increasing or decreasing lighting would lead to changes in productivity. The researchers were surprised to learn that productivity increased in both the control group (no change in lighting) and the experimental group (lighting alternated upward and downward). The researchers determined that it was not the lighting that caused the increased productivity; rather, the improvement resulted from the attention received by the group. In the relay-assembly group experiments, productivity of a segregated group of workers was studied as they were subjected to different working conditions. The researchers and management observed the group closely for 5 years. During the first part of the experiment, the employees’ working conditions were improved by extending their rest periods, decreasing the length of their workday, and providing them a free day and lunches. In addition, the workers were consulted before any changes were made, because their agreement had to be obtained before the change would be implemented. The workers of the group were given the freedom to interact with one another during the workday. Furthermore, one researcher also served as their supervisor, who, during the experiment, expressed concern about the workers’ physical health and well-being. The researchers eagerly sought the employees’ opinions, hopes, and fears during the experiment. During the improved-conditions period, the workers’ productivity increased. In part two of the experiment, the original working conditions were restored. Surprisingly, the researchers found that the employees’ productivity remained at the high level that had occurred under the improved working conditions. This result was attributed to group dynamics because the group was allowed to develop socially with a common purpose. The bank-wiring observation-room experiment was similar to the relay-assembly experiment. A group of workers were segregated so that their productivity and group dynamics could be studied. The workers were paid at a piecework rate that reflected both group and individual efforts. The researchers found that the wage incentive did not work. The group had developed its own standard as to what constituted a “proper day’s work.” As a result, the group’s level of productivity remained constant because they did not want management to know that they could produce at a higher level. If a member of the group produced more than the agreed-upon level, the other members influenced the “rate buster” to return their productivity level to the group’s norm. In addition, if a member of the group failed to produce the required level of output, the other members traded jobs to ensure that the group’s output level remained constant. The results of the bank-wiring experiment mirrored the relay-assembly experiment results. The researchers concluded that there 8 Chapter 1 Overview and History of Organizational Behavior was no cause-and-effect relationship between working conditions and productivity and that any increase or decrease in productivity was attributed to group dynamics. As a result of the bank-wiring experiment, researchers became very interested in exploring informal employee groups and the social functions that occur within the group and influence the behavior of the individual group members. As part of the Hawthorne Studies, the researchers conducted extensive interviews with the employees. Over 21,000 interviews were conducted to determine the employees’ attitudes toward the company and their jobs. A major outcome of these interviews was that the researchers discovered that workers were not isolated, unrelated individuals; they were social beings and their attitudes toward change in the workplace were based on (1) the personal social conditioning (values, hopes, fears, expectations, etc.) that they brought to the workplace, formed from their previous family or group associations, and (2) the human satisfaction that the employees derived from their social participation with coworkers and supervisors. What the researchers learned was that an employee’s expression of dissatisfaction may be a symptom of an underlying problem in the workplace, at home, or in the person’s past. ▸▸ Theories X and Y Another significant impact in the development of OB came from Douglas McGregor (1957, 1960) when he proposed two theories by which managers view their employees: Theory X (negative/ pessimistic) and Theory Y (positive/optimistic). Theories X and Y reflect polar positions and are ways of seeing and thinking about people, which, in turn, affect their behavior. Theory X states that employees are unintelligent and lazy. They dislike work, avoiding it whenever possible. Employees should be closely controlled because they have little desire for responsibility, have little aptitude for creativity in solving organizational problems, and will resist change. In contrast, Theory Y states that employees are creative and competent; they want ­meaningful work; they want to contribute; and they want to participate in decision-making and leadership functions. Borrowing from Maslow’s Hierarchy of Needs, McGregor stated that the autocratic (Theory X) managers were no longer effective in the workplace because they relied on an employee’s lower needs for motivation (physiological concerns and safety), which, in modern society, were mostly satisfied and therefore no longer acted as motivators for the employee. For exle, managers would ask, “Why aren’t people more productive? We pay good wages, provide good working conditions, have excellent fringe benefits, and provide steady employment. Yet people do not seem to be willing to put forth more than minimum efforts.” The answers to these questions were embedded in Theory X’s managerial assumptions about people. If managers believed that their employees had an inherent dislike for work and must be coerced, controlled, and directed to achieve organizational goals, the resulting employee behavior was nothing more than a self-fulfilling prophesy. The manager’s assumptions caused the staff’s “unmotivated” behavior. At the opposite end of the spectrum from Theory X, McGregor proposed Theory Y, which suggested productivity increased when managers created opportunities, removed obstacles and encouraged growth and learning for their employees. McGregor stated that participative ­(Theory Y) managers supported decentralization and delegation of decision making, job enlargement, and participative management because these allowed employees some freedom to direct their own activities and to assume responsibility, thereby satisfying their higher-level needs (see Figure 1-1). Related Disciplines 9 Manager’s Beliefs Theory X (negative/pessimistic) Theory Y (positive/optimistic) • People are lazy and managers need to provide money and other rewards to motivate workers to produce outcomes. • People are motivated by the satisfaction and self-esteem achieved from the work they do. • People avoid responsibilities and will do the minimum to get by so managers need to use authoritarian and coercion behaviors to force workers to comply. • People are ambitious and capable of directing their own behaviors. • People are self-centered and have no interest in the organization so managers need to control and direct all activities. • People are committed to achieving organizational goals through creativity and shared decision making. Figure 1-1 McGregor X–Y Theory Diagram ▸▸ Related Disciplines Before we conclude this chapter, we would like to explain the differences between OB and three other related fields: organization theory (OT), organizational development (OD), and human resources management (HRM). As was noted at the beginning of the chapter, OB is the study of individual and group dynamics within an organization setting and therefore is a micro approach. OT analyzes the entire organization and is a macro perspective, since the organization is the unit examined. The field of OD describes a planned process of change that is used throughout the organization with the goal of improving the effectiveness of the organization. Since, like OT, OD involves the entire organization, it is a macro examination. Finally, HRM can be viewed as a micro approach to managing people. The difference between HRM and OB is that the latter studies human behavior in various settings with an emphasis on explaining, predicting, and understanding behavior in organizations, whereas HRM emphasizes systems, processes, procedures, and the like for personnel management and is usually housed in a functional unit within an organization. Since 1960, a wealth of information has emerged within the study of OB, which will be addressed in this textbook. In Part I, the issues of diversity, perceptions, attitudes, and communication are discussed. Part II addresses motivation and individual behaviors. Part III examines the subject of leadership from four approaches—power and influence, behavioral, contingency, and transformational. Part IV emphasizes the importance of intrapersonal and interpersonal issues within the context of stress and conflict management. Part V examines group dynamics, working in groups, and teams and team-building. Part VI provides an overview of managing organizational change within the context of organizational development. 10 Chapter 1 Overview and History of Organizational Behavior Discussion Questions 1. 2. 3. 4. 5. Define organizational behavior. What are some of the major challenges facing today’s and tomorrow’s health care organizations and health care managers? Why? Why did the Hawthorne Studies have an impact on the study of organizational behavior? Why did McGregor’s Theory X and Theory Y have an impact on the study of organizational behavior? Discuss the difference between organizational behavior, organization theory, organizational development, and human resources management. What Do You Know About Organizational Behavior? Questions True/False 1 OB is the study of individuals, groups, and organizations. ___________ 2 Under Theory Y, managers create opportunities, remove obstacles, and encourage growth and learning for their employees. ___________ 3 Attitudes are very individual and subjective; therefore, we do not currently have ways to measure employees’ attitudes about their jobs. ___________ 4 Extroverts do best in quiet, nonsocial jobs such as computer work, while introverts show the best job performance when they must work and present in front of large groups of people. ___________ 5 Motivation is described as the conscious or unconscious stimulus, incentive, or motives for action toward a goal resulting from psychological or social factors, the factors giving the purpose or direction to behavior. ___________ 6 Employee motivation has a direct impact on a health services organization’s performance. ___________ 7 Process theories of motivation assist managers in predicting employees’ behavior so that the behavior may be influenced if necessary. ___________ 8 An employee’s degree of job satisfaction is proportional to the actual amount of rewards the employee is receiving. ___________ 9 Power may be defined as the influence over the beliefs, emotions, and behaviors of people. ___________ 10 A leader is a person who directs the work of employees and is responsible for results. ___________ 11 Management and leadership are both necessary for an organization to achieve its goals. ___________ 12 The leader who is able to respond to ever-increasing levels of environmental uncertainty through the utilization of more than one style of leadership will be most likely to increase motivation, satisfaction, and productivity of employees. 13 Transactional leadership is all about change, innovation, improvement, and entrepreneurship through vision and inspiration. ___________ ___________ References 11 14 Transactional and transformational leader approaches are clearly in opposition. 15 Because stress is a complex and highly personalized process, some individuals see a specific situation as a threat, whereas others see the same situation as a challenge or opportunity. 16 Managers are under the constraints of limited time and resources, personal bias, and other factors, which make rational decision making unrealistic. ___________ 17 Conflict is inevitable and unavoidable. ___________ 18 Individuals join groups to satisfy their need for safety and social interaction. ___________ 19 Barriers to effective teamwork fall within four categories: (1) lack of management support, (2) lack of resources, (3) lack of leadership, and (4) lack of training. ___________ The two primary forces influencing an individual’s perception, attitude, and response toward change are cumulative life experiences and social (informal group) forces. ___________ 20 ___________ ___________ Scoring The correct answers to the above 20 questions are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. False True False False True True False False True False 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. True True False True True True True True True True Interpretation How much do you know about organizational behavior? If you scored well—good for you! However, the above questions represent only a very small part of organizational behavior. If you didn’t score high, don’t be concerned. You will learn the many theories and concepts of organizational behavior that will provide you with the necessary skill set to successfully manage and lead others. References Benjamin, M. (2003, February 24). Fads for any and all eras. U.S. News #038; World Report, 134, 74–75. Bureau of Labor Statistics, U.S. Department of Labor. (2019). Employment projections to 2016–2026. Available from https://www.bls.gov/emp/ Daft, R. L. (2004). Organization theory and design (8th ed.). Mason, OH: Thomson South-Western. Health Care Financial Management Association. (2017, March 8). Mergers and acquisitions: Strategy takes precedence over scale. HFMA Buyer’s Resource Guide. Available from www.hfma.org 12 Chapter 1 Overview and History of Organizational Behavior Homans, G. C. (1950). The human group. New York, NY: Harcourt, Brace and Company. McGregor, D. M. (1957). The human side of enterprise. Management Review, 46, 22–28. McGregor, D. M. (1960). The human side of enterprise. New York, NY: McGraw-Hill Book Company. Ott, J. S. (1996). Classic readings in organizational behavior (2nd ed.). Albany, NY: Wadsworth Publishing Company. Roethlisberger, F. J., #038; Dickson, W. J. (1939). Management and the worker. Cambridge, MA: Harvard University Press. Taylor, F. W. (1911). The principles of scientific management. New York, NY: Harper and Brothers. C HAPT E R 2 Diversity, Equity, and Inclusion in Health Care* LEARNING OUTCOMES After completing this chapter, the student should be able to: ne diversity, equity, and inclusion. • Defi major trends in U.S demographics. • Understand why changes in U.S. demographics affect the health care industry. • Understand Understand the unique challenges facing different groups of people. • ▸ Overview Demographics of the U.S. population have changed dramatically in the past three decades. These changes directly affect the health care industry in regard to the patients we serve and our workforce. Over the next 40 years, there is expected to be a fundamental shift in which demographic groups represent majority and minority percentages of the U.S. population. According to the U.S. Census Bureau, by midcentury the White, non-Hispanic population will make up less than 50% of the nation’s population. The health care industry needs to change and adopt new ways to meet the diverse needs of our current and future patients and employees.* This chapter is presented in three parts. First, we define the terms “diversity,” “equity,” and “inclusion.” Second, we discuss the changing demographics of the nation’s population. Last, we examine how these changes are affecting the delivery of health services from both the patient’s and the employee’s perspectives. Because diversity challenges faced by the health care industry are not limited to quality-of-care and access-to-care issues, in part three of our discussions we explore * We would like to thank Dr. Justin Lord for his contribution to this chapter. We wish to acknowledge and thank Dr. Jean Gordon, who was the contributing author of an earlier version of this chapter, which appeared in Organizational Behavior in Health Care (2014), Jones #038; Bartlett Learning. © Valex/Shutterstock 13 14 Chapter 2 Diversity, Equity, and Inclusion in Health Care how these changes will affect the health services workforce and, more specifically, the current and future leadership within the industry. ▸▸ Diversity, Equity, and Inclusion Defined The American Heritage Dictionary of the English Language (4th ed.) defines diversity as “(1) the fact or quality of being diverse; difference, and (2) a point in which things differ.” Dreachslin (1998) provides a more specific definition of diversity as “the full range of human similarities and differences in group affiliation including gender, race/ethnicity, social class, role within an organization, age, religion, sexual orientation, physical ability, and other group identities” (p. 813). Therefore, diversity can mean a great many things, from differences in education, language, and background to race and gender identity. For our discussions, we will focus on the following characteristics: (1) race/ethnicity, (2) age, (3) biological sex at birth, and (4) sexual orientation, gender identity, and gender expression. Equity is providing fair treatment, access, opportunity, and advancement for all people while at the same time striving to identify and eliminate barriers that have prevented the full participation of some groups. Improving equity involves increasing fairness of the procedures and processes within the organization as well as in their distribution of resources. Tackling equity issues requires an understanding of the root causes of outcome disparities within our society and organizations (Kapila, Hines, #038; Searby, 2016). Inclusion refers to the act of creating environments in which any individual or group can feel welcomed, respected, and supported and can fully participate. An inclusive and welcoming climate embraces differences and offers respect in words and actions to all people (Kapila et al., 2016). Inclusion allows people to have a sense of belonging. A diverse environment with many different types of people might not be equitable or inclusive. Therefore, just increasing diversity is not enough. For exle, if a manager does not offer the same mentorship and coaching to employees from underrepresented populations and therefore these employees do not get the same opportunities for promotion as nonminority employees do, that is not an equitable environment. An environment can be diverse and equitable but not inclusive. For exle, maybe all employees have access to the same coaching and career development opportunities, but the manager plans a celebratory lunch during an important Jewish religious holiday. This lunch would not be inclusive because Jewish employees could not attend as a result of their religious obligations. One way to remember the differences between diversity, equity, and inclusion is by thinking about going to a dance. Diversity means that everyone is invited to the dance. Equity means that each person gets to contribute to the playlist. Inclusion means everyone gets asked to dance (Meyers, 2017; University of Michigan, 2018; see Case 2-1). Unfortunately, we all have implicit or unconscious biases that can affect how we treat people of certain genders, gender identities, sexual orientations, races, ethnicities, and ages. Despite our best intentions, these implicit biases are often unknown even to ourselves, and they can lead us to create or accept environments in which certain people are treated poorly or are discriminated against. “Think of implicit bias as the thumbprint of the culture on our brain,” says Harvard University social psychologist Mahzarin Banaji (Joplin #038; Kunitz, 2018). Harvard University’s Project Implicit provides a series of free online implicit association tests to help people determine what implicit biases they hold. An analysis of almost 8000 participants found that people tend to demonstrate a moderate implicit preference for Whites over Blacks and for heterosexuals over homosexuals and Diversity, Equity, and Inclusion Defined 15 a strong implicit preference for young over old people. People also have a stronger implicit association with men and science than with women and science (Project Implicit, 2019; see Case 2-2). It is only by recognizing our unconscious and implicit biases that we can hope to change them. Instead of denying their existence—we all have them—we must actively work to eliminate our own blind spots that might be leading us to treat certain types of people differently. CASE 2-1 Diverse but Not Inclusive Jill, a young White female, was hired to work at a health care consulting firm. The team was very diverse, with people from all over the world who had a variety of educations and backgrounds. Jill’s coworkers had different religious and cultural beliefs, races, languages, and countries of origin. Jill felt that she connected well with all of her colleagues and really appreciated the unique perspectives they all brought to the team. However, she started to notice that the senior vice president, Mark, had a small group of favorites. The only people whom he would invite to lunch or have coaching sessions with were the younger White employees. In fact, as individuals started to get promoted, the White employees were promoted much higher and more quickly than anyone else. Although these employees’ promotions were usually deserved, other employees seemed to have a harder time gaining promotion even if they had performed equally well. When Jill had been at the company for almost a year, Mark scheduled a team lunch at an expensive restaurant to thank the entire team for surpassing productivity targets. The lunch was scheduled during Ramadan, which is an important religious time for Muslims, and involves fasting during the day. Jill overhead one of her Muslim coworkers whispering to another coworker, “Doesn’t he know how insulting it is to invite us knowing that we can’t eat anything? I mean if he had just waited one more week to schedule the lunch, we could all enjoy it.” Jill thought that Mark might have been unaware of the poor timing, so she brought it to his attention at their next one-on-one meeting. When Jill raised the issue, Mark replied, “Well, I’ve got to keep the numbers down somehow if I want us to go somewhere expensive. They are invited. It’s not my problem if they choose not to eat.” Was this environment diverse, equitable, and inclusive? Why or why not? CASE 2-2 You Don’t Look Like a Doctor Tamika Cross, a young African American physician who worked in Houston, was flying home from a wedding in Detroit. When the flight attendants asked for any physicians on board to help a passenger who had become unresponsive, Dr. Cross raised her hand and offered to help. The flight attendant responded, “Sweetie, put [your] hand down. We are looking for actual physicians or nurses or some type of medical personnel, we don’t have time to talk to you.” When Dr. Cross tried to inform the flight attendant that she was a physician, she was repeatedly dismissed and asked to show credentials. When she insisted that she was a doctor, the flight attendants responded with surprise and disbelief. The crew continued to ask any physicians on board to press their call buttons. A few moments later, a white male physician told the flight attendant that he was a physician, and Dr. Cross was sent back to her seat. Dr. Cross posted the account to her Facebook page, which then went viral on a number of social media sites and news outlets, sparking the #WhataDoctorLooksLike movement. What implicit biases do you think the flight attendant held about what a physician should look like? Reproduced from https://twitter.com/hashtag/TamikaCross and https://twitter.com/hashtag/whatadoctorlookslike accessed September 2, 2019. 16 Chapter 2 Diversity, Equity, and Inclusion in Health Care ▸▸ Changing U.S. Population To better appreciate the need for more diverse, equitable, and inclusive environments, it is important to understand how our population is changing. The demographic profile of the U.S. population is projected to undergo significant alterations over the next 40 years in age, gender, and ethnicity (see Table 2-1). In 2016, 323.1 million people resided in the United States, an increase of 41.7 million ­people, or 14.8%, between 2000 and 2016. The 2016 census data showed a decline in the White, non-Hispanic population for the first time in history since the first census in 1790. This decline was almost a decade ahead of earlier projections. Additionally, there are currently more non-White Table 2-1 Projected Population of the United States by Age, Gender, and Race/Ethnicitya (in Millions) 2016 Total population Under age 18 2060 2016–2060 Change Number Percent Number Percent 323.1 100 403.7 100 Number Percent 80.6 24.9 73.6 22.8 79.8 19.8 6.2 8.4 200.2 62.0 229.7 56.9 29.4 14.7 49.2 15.2 94.7 23.5 45.4 92.3 Males 159.1 49.2 200.9 49.8 41.8 26.3 Females 164.0 50.8 203.6 50.4 39.6 24.1 One race 314.6 97.4 379.2 93.9 64.6 20.5 White 248.5 76.9 275.0 68.1 26.5 10.7 Non-Hispanic White 198.0 61.3 179.2 44.4 −18.8 −9.5 43.0 13.3 60.7 15.0 17.7 41.1 4.1 1.3 5.6 1.4 1.5 37.7 18.3 5.7 36.8 9.1 18.5 101.0 Native Hawaiian and Other Pacific Islander 0.8 0.2 1.1 0.3 0.4 45.9 Two or more races 8.5 2.6 25.3 6.3 16.8 197.8 Hispanic or Latino 57.5 17.8 111.2 27.5 53.7 93.5 Ages 18–64 Ages 65 and over Black or African American American Indian and Alaska Native Asian Data from U.S. Census Bureau. (2108) 2017 National Population Projections Tables. Available at: https://www.census.gov/data/tables/2017/demo/popproj /2017-summary-tables.html Vespa, J., Armstrong, D. M., #038; Medina, L. (2018). Demographic turning points for the United States: Population projections for 2020 to 2060. US Department of Commerce, Economics and Statistics Administration, US Census Bureau. a Changing U.S. Population 17 children than White children under 10 years old for those born after 2007 (Frey, 2018). This means that as the youngest generation ages, we are on the verge of a fundamental shift in the diversity of both patients and workers in the United States. In addition to the changing ethnic and racial composition of America, another trend is the aging population. The percentage of the population over age 65 is projected to increase from 15% to 23% by the year 2060, an increase of 45.5 million people (see Table 2-1). Finally, by the year 2030, international migration is projected to outpace the natural increase (excess of births over deaths) as the main cause of population growth (Vespa, Armstrong, #038; Medina, 2018). Males and females are almost evenly divided in the total population, representing 49.2% and 50.8%, respectively (see Table 2-1); however, in the population under age 25 years, males outnumber females. Among older adults, the male–female ratio reverses, with women outnumbering men, typically due to longer life spans (Vespa, Armstrong, #038; Medina, 2018). This imbalance is expected to persist through 2060 and beyond. However, the gap between males and females over age 65 is narrowing as men are living longer than men in previous generations. Race/Ethnicity The U.S. population continues to diversify racially as minority populations continue to increase at a faster rate than the White population. Although the non-Hispanic White population still represents the largest group (61.3%) of the U.S. population, this number is expected to decrease by almost 10% by 2060 (see Table 2-1). In 2016, the Hispanic or Latino population represented the largest minority in the United States, at almost 18% of the population. By 2060, Hispanics are expected to make up over a quarter of the U.S. population (27.5%), almost doubling in number. The remaining population is composed of 13% Black or African American, 6% Asian and Pacific Islanders, 1% American Indians and Alaska Natives, and 3% people who identify themselves as belonging to another or more than one race (see Table 2-1). The Asian population in the United States is increasing rapidly as a percentage of the total population. From 2000 to 2010, the population of people who identified themselves as being Asian (either alone or in combination with another race) grew 43.3%, while the total population grew only 9.7% (U.S. Census Bureau, 2010). After people identifying as more than one race, the Asian population is expected to be the fastest-growing segment, doubling in size by 2060 (see Table 2-1). In addition to the resident population in the United States, health care organizations may encounter an even more diverse patient population, due to the strong reputation of U.S. health care and its popularity as a destination for medical travel and medical tourism. The United States is a highly desirable destination for health care for people around the world who might not be able to access various types of procedures or treatments in their home countries. Hundreds of thousands of visits from international patients from almost every country occur at U.S. hospitals every year (Johnson #038; Garman, 2010). As the middle class expands in countries such as China and India, this trend is expected to continue as more patients around the world are able to afford to travel for treatment. This means that health care workers will need additional skills and tools for dealing with a vastly more diverse population of patients coming from other countries in addition to the growing diversity in the domestic population. Unfortunately, people from underrepresented racial and ethnic groups often face additional challenges when they interact with the U.S. health care system. A survey by the Commonwealth Fund (2002) found that Black non-Hispanics, Asian Americans, and Hispanics are more likely 18 Chapter 2 Diversity, Equity, and Inclusion in Health Care than White non-Hispanics to experience difficulty communicating with their physician, to feel that they are treated with disrespect when receiving health care, to experience barriers to access to care such as lack of insurance or not having a regular physician, and to feel that they would receive better care if they were of a different race or ethnicity. In addition, the survey found that Hispanics were more than twice as likely as White non-Hispanics (33% versus 16%) to cite one or more communication problems, such as not understanding the physician, not being listened to by the physician, or not asking questions they needed to ask. Twenty-seven percent of Asian Americans and 23% of Black non-Hispanics experience similar communication difficulties. Age The world’s population is aging at unprecedented rates. Slow population growth brought about by reductions in fertility leads to population aging; that is, it produces populations in which the proportion of older persons increases while that of younger persons decreases. For the first time in history, in 2018 the number of people over age 65 in the world outnumbered the number of children under age 5. By 2050, the number of people over age 65 is projected to be double the number of people under age 5 (United Nations, 2019). The United States is experiencing the same trend. Between 2016 and 2060, the U.S. population under age 18 is expected to grow by 8%, and the population aged 45–64 is expected to grow by almost 15%. In stark contrast, the country is experiencing substantially faster growth rates for older ages. For exle, the population over age 65 is expected to almost double (U.S. Census Bureau, 2018, see Table 2-1). The large growth in this age group is primarily attributable to the aging of the Baby Boom population and longer life spans due to disease control and advances in medical technology. One of the most striking characteristics of the older population is the change in the ratio of men to women as people age. As Howden and Meyer (2011, p. 3) point out, this is a result of differences in mortality rates for men and women, in that women tend to live longer than men. For exle, life expectancy for men in the United States is 76.1 years, whereas women’s life expectancy is 81.1 years. While the elderly population is not as racially and ethnically diverse as younger generations, its racial and ethnical makeup is projected to diversify over the next four decades. As in the past, the largest proportion of the U.S. population age 65 and over is White. However, the racial composition of the older population is changing; the percentage of Whites is projected to decrease by 2060, and the percentages of all other race groups will increase (Vespa et al., 2018). Technology and other medical advances have given us the ability to increase longevity. As our citizens grow older, more services are required for the treatment and management of both acute and chronic health conditions. Health care professionals must devise strategies to care for the growing elderly patient population. America’s older citizens are often living on fixed incomes and have small or nonexistent support groups. Although this may be considered an infrastructure dilemma, the reality is that medical professionals must be able to understand and empathize with poor, sick, elderly people of all races, sexes, and creeds. The term “ageism” was coined in 1968 by Robert N. Butler, MD, a pioneer in geriatric medicine and a founding director of the National Institute on Aging (NIA). Butler (1969) was among the first to identify the phenomenon of age prejudice, initially describing it as “a systematic stereotyping of and discrimination against people because they are old” (p. 12). Ageism can be defined as “any attitude, action, or institutional structure, which subordinates a person or group because of age or any assignment of roles in society purely on the basis of age” Changing U.S. Population 19 (Traxler, 1980, p. 4). Health care professionals often make assumptions about their older patients on the basis of age rather than functional status (Bowling, 2007). This may be due to the limited training physicians receive in the care and management of geriatric patients. For exle, Warshaw and colleagues (2002, 2006) related that medical residents have only limited training in geriatric medicine. Findings from Warshaw et al.’s 2006 study were compared with those from a similar 2002 survey to determine whether any changes had occurred. Of the participating 3-year residency training programs, only 9% required 6 weeks or more of training. As in 2002, the residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for the medical residents’ geriatrics training. A report from the Alliance for Aging Research (2003) related that there continues to be shortcomings in medical training, prevention, screening, and treatment patterns that disadvantage older patients. The report outlined five domains of ageism in health care: 1. Health care professionals do not receive enough training in geriatrics to properly care for many older patients. 2. Older patients are less likely than younger people to receive preventive care. 3. Older patients are less likely to be tested or screened for diseases and other health problems. 4. Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatment. 5. Older people are consistently excluded from clinical trials, even though they are the largest users of approved drugs. On a positive note, Perry (2012) relates that progress against systematic ageism in health care has begun, in part, as a result of the passing of the 2010 Affordable Care Act (ACA). He notes that the law’s various provisions, such as Medicare’s increased focus on chronic disease prevention, new models of care for reducing rehospitalizations, and improved care coordination, as well as annual screening for cognitive impairment, will assist in changing attitudes toward elderly patients. Gender As was previously noted, according to the U.S. Census Bureau, in 2016, 50.8% of the U.S. population was female and 49.2% was male—almost identical to percentages in the 2000 Census. That translates to 96 men for every 100 women. However, the ratio of men to women varies significantly by age group. There were about 105 males for every 100 females under age 25 in 2010 (U.S. Census Bureau, 2010), reflecting the fact that more boys than girls are born every year and that boys continue to outnumber girls through early childhood and young adulthood. However, the male–female ratio declines as people age. Among older adults, the male–female ratio falls as women increasingly outnumber and outlive men. When we look at education, it appears that females and males are somewhat equal. Among the population age 25 and older, 90% of both men and women were high school graduates, with 34% of men and 35% of women graduating from college (U.S. Census Bureau, 2017). Sexual Orientation, Gender Identity, and Gender Expression Another important aspect of diversity to consider in health care is sexual orientation, gender identity, and gender expression. The last decade has led to an increased focus on disparities that 20 Chapter 2 Diversity, Equity, and Inclusion in Health Care exist in the lesbian, gay, bisexual, transgender, and questioning community (LGBTQ). Various surveys estimate that people over age 18 who identify as LGBT make up 2.8%–4.1% of the total population, or 5–10 million individuals in the United States, according to a Kaiser Family Foundation Report (Kates, Ranji, Beamesderfer, Salganicoff, #038; Dawson, 2018). The term “LGBTQ” may encompass elements of sexual orientation, gender identity, and gender expression. Sexual orientation is defined by the Institute of Medicine report as “an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one’s same sex, the other sex, or both sexes” (Graham et al., 2011, p. 27). For many people, sexual orientation does not fall neatly into any specific category and may be better described as belonging somewhere along a spectrum. Gender identity refers to one’s internal sense of being male, female, or something else (Kates et al., 2018). Because gender identity is internal, it is not necessarily visible to others. Gender expression refers to the outward and external portrayal of gender. Gender expression may include clothing, hairstyles, mannerisms, and taking on gender roles that are defined by one’s culture. Both gender identity and gender expression may be different from one’s biological sex at birth. These aspects of identity and orientation can span all ages, races, and biological genders. According to the Kaiser Family Foundation report, “while sexual orientation and gender identity are important aspects of an individual’s identity, they interact with many other factors, including sex, race/ethnicity, and class. The intersection of these characteristics helps to shape an individual’s health, access to care, and experience with the health care system” (Kates et al., 2018, p. 2). Individuals who identify as LGBTQ may experience unique health challenges that cannot be explained by differences in race/ethnicity, age, or gender alone. Because of discrimination and a variety of other factors, research has shown that self-identified lesbian, gay, and bisexual individuals are more likely to rate their health as poor and have higher prevalence of many chronic diseases such as cancer and cardiovascular disease, as well as asthma, allergies, headaches, and disabilities. In addition to concerns about physical health, studies have found that people who identify as LGBT are at a higher risk for mental health conditions, often as a result of prejudice, discrimination, and stigma. Various studies show that LBGT individuals are 2.5 times more likely to suffer anxiety, depression, and substance misuse; are more likely to have experienced both sexual and physical violence; and have a substantially higher rate of suicidal ideation or attempts. In addition to stigma and discrimination, LGBTQ individuals may face additional health disparities resulting from practices that pose barriers to accessing health services. For exle, some insurance companies will not pay for mental health services for transgender individuals. Additionally, between 6% and 15% of employers reported not offering same-sex spousal benefits to workers. Although these numbers are improving, there is still a substantial disparity in this area (Kates et al., 2018). However, there has been some progress in this area. Since 2007, the Healthcare Equality Index (HEI) of the Human Rights Caign (HRC) Foundation has been available for use by hospitals and other organizations. This survey is a resource for health care organizations that are seeking to provide equitable, inclusive care to LGBTQ Americans and for LGBTQ Americans who are seeking health care organizations that have a demonstrated commitment to their care (HRC, 2019). In 2018, 680 facilities across the country participated in the HEI survey, with 60% designated as leaders and 22% as top performers demonstrating that they have varying inclusive LGBT patient and employment policies. These nondiscrimination policies are required for Joint Commission accreditation. In addition, both The Joint Commission and the Centers for Medicare and Medicaid Services require that facilities allow visitation without regard to sexual orientation or Implications for the Health Care Industry 21 Table 2-2 Healthcare Equality Index’s Core Four Leader Criteria Criteria Non-discrimination and staff training Patient non-discrimination Equal visitation Employment non-discrimination Staff training Patient services and support LGBTQ patient services #038; support Transgender services and support Patient self-identification Medical decision making Employee benefits and policies Equal benefits Additional support for LGBTQ employees Healthcare benefits impacting transgender employees Patient and community engagement LGBTQ community engagement and marketing Understand the needs of LGBTQ patients and community © 2019 by the Human Rights Caign Foundation. gender identity. The HEI has two sections: (1) the core four leader criteria and (2) the additional best practices checklist. The core four leader criteria are reflected in Table 2-2. Additionally, patient forms should reflect diverse gender identities, allowing patients to identify both their biological sex at birth and their gender identity. The additional best practices checklist is designed to familiarize HEI participants with other expert recommendations for LGBT patient-centered care, to help identify and remedy gaps. ▸▸ Implications for the Health Care Industry The changing demographics of the U.S. population affect the healthcare industry significantly. Health care organizations need to work to reduce disparities in care and trea…

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