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A.

History
“A health care system is the totality of services offered by all health disciplines”
(Berman, Snyder, Kozier, & Erb, 2!"# $t incl%des people, or&anizations, facilities and reso%rces
to meet the needs of the pop%lation#
A health care or&anization m%st be concerned 'ith doin& the ri&ht thin&s thro%&h efficacy
and appropriateness and doin& the ri&ht thin&s 'ell thro%&h availability, timeliness,
effectiveness, contin%ity, safety, efficiency and respect and carin& ((e )a%ne & )adner, 2**"
+hro%&ho%t the cent%ries, a lot of chan&es have occ%rred in the field of health care# +he
primitive system of health care years a&o has evolved to today,s advanced and improved health
care#
(%rin& the fifth and si-th cent%ries, .hristianity,s early years, ch%rches and monasteries,
'or/s not only incl%de providin& of food, clothin& shelter and spirit%al s%pport to those in need
b%t also, servin& the sic/# $n the middle a&es, several reli&io%s orders of men provided n%rsin&
care to both 'estern and eastern health instit%tions# Also at this time, instit%tions 'ere
established to ho%se patients 'ith comm%nicable disease li/e leprosy (0all,n#d#"#
$n the ei&hteenth cent%ry, hospitals increased in size and foc%sed more on the medical
aspect than the reli&io%s side# $n America, isolation hospitals and almsho%ses 'ere b%ilt for the
sic/ and for the poor as 'ell# Ben1amin 2ran/lin and (r# +homas Bond spearheaded the
establishment of 3ennsylvania 4ospital in *56* (0all, n#d#"#
$n the nineteenth cent%ry, 7apoleon b%ilt bi& hospitals 'ith more than a tho%sand beds in
2rance to accommodate his 'o%nded troops from the 'ars (0all, n#d#"# $n *!68, 2lorence
7i&htin&ale, the fo%nder of modern n%rsin& created the 7i&htin&ale +rainin& School for 7%rses
at St# +homas 4ospital in )ondon# 7on9profit hospitals s%pported by reli&io%s &ro%ps, p%blic
hospitals and proprietary hospitals 'ere also established d%rin& these times# $n :nited States,
hospitals became more modern and e-pensive d%rin& *!;69*826#$n *!!5, <rs# Bedford
2en'ic/, a 'ell9/no'n leader in En&land campai&ned for n%rse re&istration# After a year, she
fo%nded the British 7%rses, Association 'hich later became the =oyal British 7%rses,
Association# $n *!8>, professionals and artists attended the 0orld,s 2air and .ol%mbian
E-position in America# +he &atherin& of n%rses, mostly directors of n%rsin& paved the 'ay to the
event%al formation of American Society of S%perintendents of +rainin& Schools for 7%rses# +he
standard of n%rsin& ed%cation 'as their foc%s# $n *85, .anadian n%rses also created the
.anadian Society of S%perintendents of +rainin& Schools# +he American or&anization 'as later
renamed to the 7ational )ea&%e for 7%rsin& Ed%cation in *8*2 and event%ally to 7ational
)ea&%e for 7%rsin& in *862 (Ellis & 4artley, 2!"#
$n *8*,s, American hospital became more scientific, emphasized the val%e of antiseptics
and cleanliness and %sed pain medications (3%blic Broadcastin& Service, n#d#"# (%rin& the ?reat
(epression in *8>,s9*8@,s, patients t%rned to p%blic health instit%tions instead of privately9
o'ned hospitals# $n April 5, *8@!, the 0orld 4ealth Ar&anization 'as formed by the :nited
7ations# <edicare and <edicaid 'ere created in *8;6 to provide financial s%pport to the a&ed
and people in need especially those 'ith lo' income (Berman et al#, 2!"# $n *85,s,
comm%nity hospitals offered comple- and advanced services s%ch as open9heart s%r&ery,
radioisotope proced%re and in9ho%se psychiatric facilities#4ospital costs escalated d%e to some
factors s%ch as hi&h <edicare e-penses, rapid inflation of the economy, increase of hospital
e-pendit%res and profits and advancement in technolo&y, medication and treatments (3%blic
Broadcastin& Service, n#d#"# $n *8!,s profit and non9profit health instit%tions started formin&
bi&&er hospital systems# “A system 'as a corporate entity that o'ned or operated more than one
hospital” (0all, n#d#"# .ost control 'as the foc%s of hospitals in the *88,s# <edicare and
<edicaid contin%ed to be infl%ential and ins%rance companies became more active in mana&in&
hospital costs#
$n the 3hilippines, 2ray B%an .lemente, a 2ranciscan friar established a dispensary in
<anila in *655# $t later became the San B%an de (ios 4ospital in *;68 ((epartment of 4ealth,
2**"#Aside from San B%an de (ios 4ospital, the San )azaro 4ospital is also one of the old
hospitals in the co%ntry# An September 2, *822, Anastacia?iron9+%pas fo%nded the 2ilipino
7%rses Association 'hich became the 3hilippine 7%rses Association in *8;;# +he (epartment of
4ealth 'as separated from the (epartment of 3%blic 4ealth and 0elfare as an individ%al entity
in *8@*# 2rom the *86s on'ards, there 'as a steady improvement in patient care, medical
ed%cation, and p%blic health comparable to other developin& co%ntries(=om%aldez, et al#, 2**"#
$n *8;8, the 3hilippine <edical .are Act approved hospitalization, medical and s%r&ical e-pense
benefits for 2ilipinos# 4ealth care services 'ere classified into primary, secondary and tertiary
levels in *85# 3rivate sector health services, free9standin& hospitals, physician9r%n individ%al
clinics, and mid'ifery clinics, have mainly follo'ed the 7orth American models of independent
instit%tions 'hich 'ere based on fee9for9service payments# 2rom *88,s on'ards, health pro1ects
s%ch as 7%trition 3ro1ect, +raditional <edicine and (octors to the Barrio 'ere p%shed f%rther
((epartment of 4ealth, 2**"# $n *886, the 3hil4ealth 'as established as the national health
ins%rance corporation (=om%aldez, et al#, 2**"#
B. Structure and Organization of Health Care
1. Primary, Secondary and Tertiary
$nnovations in biomedical science have almost eradicated sco%r&es s%ch as polio and
measles and have allo'ed s%ch marvels as or&an transplantation, “/nifeless” &amma ray s%r&ery
for brain t%mor, and intensive care technolo&y that saves the lives of children 'ith asthma
complicated by pne%monia# $n cases s%ch as the fail%re to prevent severe asthma flare9%p is not
related to financial barriers, b%t rather reflects or&anizational problems, partic%larly in the
delivery of primary care and preventive services (Bodenheimer & ?r%mbach, 28"#
+he or&anizational tas/ facin& all health care systems is one of “ass%rin& that the ri&ht
patient receives the ri&ht service at the ri&ht time and in the ri&ht place” (=od'in, *8!@"# An
additional criterion co%ld be “# # # and by the ri&ht care&iver” (Bodenheimer & ?r%mbach, 28"#
0ho is responsible for plannin& and ens%rin& that every child receives the ri&ht service at the
ri&ht timeC .an an %r&ent care center or an in9store clinic at 0atson,s desi&ned for episodic
needs be held acco%ntable for providin& comprehensive care to all patients passin& thro%&h its
doorsC Sho%ld parents be e-pected to ma/e appointments for ro%tine visits at medical offices and
clinics, or sho%ld p%blic health n%rses travel to homes and day9care centers to provide preventive
services o%t in the comm%nityC 0hat is the proper balance bet'een intensive care %nits that
provide life9savin& services to critically ill patients and primary care services &eared to'ard less
dramatic medical and preventive needsC
Primary Health Care
+he first level of contact bet'een individ%als and families 'ith the health system refers
to the 3rimary 4ealth .are (Kareem, *88;"# Accordin& to the Alma Atta (eclaration of *85!,
3rimary health care is essential health care based on practical, scientifically so%nd and socially
acceptable methods and technolo&y made %niversally accessible to individ%als and families in
the comm%nity thro%&h their f%ll participation and at a cost that the comm%nity and co%ntry can
afford to maintain at every sta&e of the development in the spirit of self9reliance and self9
determination# $t incl%ded care for mother and child 'hich incl%ded family plannin&,
imm%nization, prevention of locally endemic diseases, treatment of common diseases or in1%ries,
provision of essential facilities, health ed%cation, provision of food and n%trition and adeD%ate
s%pply of safe drin/in& 'ater ((epartment of 4ealth, 2**"#
$n the 3hilippines, the &oal of 3rimary 4ealth .are is “4ealth for All 2ilipinos by the
year 2 and 4ealth in the 4ands of the 3eople by the year 22”# +here are t'o levels of
3rimary 4ealth .are 'or/ers, the Baran&ay 4ealth 0or/ers, 'ho are trained comm%nity health
'or/ers r health a%-iliary vol%nteers or traditional birth attendants or healers, and the
$ntermediate )evel 4ealth 0or/ers, incl%des the 3%blic 4ealth 7%rse, =%ral Sanitary $nspector
and mid'ives (3rimary 4ealth .are (34.""#
Elements of Primary Health Care
Education for Health
$t is one of the potent methodolo&ies for information dissemination# +his helps promote the
partnership of both the family members and health 'or/ers in the promotion of health as 'ell as
prevention of illness (3rimary 4ealth .are (34.""#
Locally Endemic Disease Control
+his foc%ses on the prevention of occ%rrence of endemic disease to prevent morbidity rate
(3rimary 4ealth .are (34.""#
Expanded Program on Immunization
+his pro&ram controls the occ%rrence of preventable illnesses especially of children belo' ;
years old# $mm%nizations on poliomyelitis, measles, tetan%s, diphtheria and other preventable
disease are &iven by the &overnment and on&oin& pro&rams of the (A4 for free#
Maternal and Child Health and Family Planning
As the name implies, this pro&ram foc%ses on the most delicate members of the comm%nity, the
mother and child# +he &oal of 2amily 3lannin& incl%des spacin& of children and responsible
parenthood (3rimary 4ealth .are (34.""#
Environmental anitation and Promotion of afe !ater upply
Environmental Sanitation is the st%dy of all factors in the man,s environment, 'hich e-ercise or
may e-ercise deleterio%s effect on his 'ell9bein& and s%rvival# As a basic need for life, 'ater is
necessary for the maintenance of healthy lifestyle# +his pro&ram is necessary for basic promotion
of health (3rimary 4ealth .are (34.""#
"utrition and Promotion of #de$uate Food upply
+here are many food reso%rces fo%nd in the comm%nities b%t beca%se of fa%lty preparation and
the lac/ of /no'led&e re&ardin& proper food plannin&, maln%trition is one of the problems that
'e have in the co%ntry (3rimary 4ealth .are (34.""#
%reatment of Communica&le Diseases and Common Illness
<ost comm%nicable diseases are preventable# +he ?overnment foc%ses on the prevention,
control and treatment of these illnesses (3rimary 4ealth .are (34.""#
upply of Essential Drugs
+his foc%ses on the information campai&n on the %tilization and acD%isition of dr%&s# $n response
to this campai&n, the ?E7E=$. A.+ of the 3hilippines is enacted (3rimary 4ealth .are (34.""#
Secondary Health Care
$f a person has been referred to a specialist by the primary care provider, then heEshe has
been referred to secondary care# Secondary care simply means bein& ta/en care of by someone
'ho has more specific e-pertise in 'hatever problem a person is havin& (+orrey, 2**"#
Secondary 4ealth .are incl%des smaller, non9departmentalized hospitals incl%din& district
hospitals and r%ral hospitals# Services offered to patients 'ith symptomatic sta&es of disease,
'hich reD%ire moderately specialized /no'led&e and technical reso%rces for adeD%ate treatment
(3rimary 4ealth .are (34.""# Secondary care is 'here most of %s end %p 'hen 'e have a
medical condition to deal 'ith that canFt be handled by primary care# Sometimes, problems 'ith
specialty care develop beca%se 'e have been referred to the 'ron& /ind of specialist (+orrey,
2**"#
Tertiary Health Care
+ertiary health care lies at the ape- of the or&anizational pyramid 'hich involves the
mana&ement of rare and comple- disorders (Bodenheimer & ?r%mbach, 28"# Specialized
cons%ltative care is provided %s%ally on referral from primary and secondary medical care
(Kareem, *88;"# +ertiary healthcare services are specialised and are a hi&hly technical level of
healthcare, 'hich involves dia&nosis and treatment of disease and disability# +hese services
involve the specialised intensive care %nit, hi&hly trained doctors and health 'or/ers, 'hose
main role is to offer healthcare (Bodenheimer & ?r%mbach, 28"#
2. Profit !on"Profit
+he health care system is composed of different health care providers, cons%mers and
settin&s# A health care or&anization can either be a profit or non9profit or&anization# “7o sin&le
a&ency or &ro%p controls the entire health care system”((e )a%ne & )adner, 2**"#
Profit Health Care Organization
+hro%&ho%t the history of the health care ind%stry, a lot of non9profit or&anizations have
been created, providin& services to those in need of medical attention# 4o'ever in the last 2
years, several for9profit or&anizations s%ch as hospitals and dialysis centers have also been
established (Andre & GasD%ez, 2*"#
3rofit or&anizations are said to provide D%ality service and benefits at affordable costs beca%se of
their efficiency, cost9c%ttin& and innovations# “+his cost9c%ttin& trend 'as attrib%ted to mana&ed
care, 'ith the percenta&e of hospitals participatin& in mana&ed care pro&rams almost do%blin&
bet'een *88> and *88@” (Sac/man, n#d#"# <ost non9profit or&anizations 'or/ independently# An
the other hand, for9profit or&anizations are %s%ally connected to each other, allo'in& for
economies in financin& and mana&ement, centralized services and shared eD%ipment, thereby
leadin& to lo'er costs (Andre & GasD%ez, 2*"# +hey also have easy access to capital 'hich is
necessary to replace o%tdated materials and machine 'ith ne' and improved ones, %nli/e non9
profit health care or&anizations# 2or9profit instit%tions pay ta-es and by doin& so, they believe
that they can contrib%te to society,s 'elfare thro%&h these remittances#
4o'ever, there are also disapprovals thro'n to profit or&anizations# +hey are said to
serve only those 'ho are rich and avoid receivin& %nins%red patients# $n addition, they co%ld
promote hi&hly9l%crative dr%&s, tests and treatments instead of the cheaper and traditional ones#
!on"Profit Health Care Organization
7on9profit or&anizations are important part of the p%blic health sector# +hese are
vol%ntary a&encies that are f%nded thro%&h different 'ays s%ch as individ%al contrib%tions,
corporate philanthropy and membership d%es((e )a%ne & )adner, 2**"#As a non9profit health
care or&anization, they aim to provide care and services 'itho%t re&ard of the patient,s capacity
to pay ()ayne, n#d#"# +hese or&anizations are responsible to the comm%nities and pop%lations
they serve# +he earnin&s of non9profit health care or&anizations are reinvested to benefit the
comm%nity (Alliance for Advancin& 7onprofit 4ealth .are, n#d#"#+heyr%n health care
instit%tions 'hich are %s%ally operated by reli&io%s or&anizations or other comm%nity
&ro%ps(?overnment of Sas/atche'en, 2*2"#
.onsideration of 1%stice is the concern of non9profit or&anization# “All persons have a
ri&ht to live their lives 'ith di&nity” (Andre & GasD%ez, 2*"# +hey believe that every member
sho%ld be &iven the ri&ht to health care access, 'hether they are rich or poor, partic%larly in
'ealthy co%ntries s%ch as America#
.ontrary to for9profit or&anizations 'hich have ample so%rce of capital, non9profit
or&anizationshave diffic%lty attractin& f%nds beca%se they depend on donations and s%pport#
Some people don,t consider &oin& to them beca%se of the sti&ma that these are “p%blic
instit%tions” and that some of their facilities are a&in& and o%tdated (Andre & GasD%ez, 2*"#
7on9profit hospitals are either operated as a charitable or ed%cational instit%tion or both#
Some charitable hospitals incl%de faith9based hospitals and comm%nity hospitals# +here are also
other non9reli&io%s affiliations that offer help# Ed%cational hospitals are also prevalent# +hey are
%s%ally %niversity9affiliated and foc%s on st%dent ed%cation and research# +hese hospitals %s%ally
%se ne' technolo&y and e-perimental techniD%es# +here are also research instit%tions 'hich
cond%ct research b%t are not %niversity9affiliated# E-amples of these research instit%tions are the
<ayo .linic, Scripps $nstit%te and .ity of 4ope in (%arte, .alifornia# Apart from hospitals, there
are also other non9profit health care a&encies (2ei&enba%m, 2*>"#
<ost p%blic health pro&rams are considered non9profit or&anizations# =ecipients of these
pro&rams %s%ally pay a little amo%nt or none at all# 2ree clinics, imm%nization clinics, hospice
care for the indi&ent and A$(S prevention pro&ram are some of the services they provide
(2ei&enba%m, 2*>"#
E-amples of not9for9profit or&anizations in :#S# are the American 7%rses Association and
the American <edical Association# +here are also or&anizations 'hich provide ed%cational
reso%rces to health care providers and &eneral p%blic# +hese incl%de :#S# a&encies li/e the
American .ancer Society and the American 4eart Association((e )a%ne & )adner, 2**"#
Aside from the aforementioned &ro%ps, there are more p%blic health service
or&anizations# +he 4ealth =eso%rces and Services Administration (4=SA" provide the p%blic
'ith health9related information and spearhead pro&rams abo%t health care to the homeless, or&an
transplant, 4$G9infected and A$(S patients, and impart /no'led&e abo%t r%ral health care and
employee occ%pation health# +he 2ood and (r%& Administration (2(A" protects the p%blic from
the %se of %nsafe dr%&s, food and cosmetics# +he .enter for (isease .ontrol and 3revention
(.(." assists in preventin& the transmission of comm%nicable diseases# +he 7ational $nstit%tes
of 4ealth (7$4" cond%cts research and ed%cation abo%t specific diseases# )astly, the Alcohol,
(r%& Ab%se and <ental 4ealth Administration (A(A<4A" tac/les on information abo%t
s%bstance ab%se and other mental health iss%es# +hese instit%tions are some of the or&anizations
s%pported by the :#S# 3%blic 4ealth Service((e )a%ne & )adner, 2**"#
+here has been a &reat iss%e bet'een non9profit and for9profit or&anizations, on 'hether
'hich type benefits the society more or 'hich a&ency delivers the better health care service than
the other# $n the end, these or&anizations are all %nder the health care system# +hey o%&ht to
provide care to those in need to elevate the standard of health in any society# +r%ly, as previo%sly
mentioned, neither of them controls the entire health care system#
C. CHA!#$!# %&'O#(APH$CS A!% H&A)TH CA(&
+he variation of different demo&raphics has constantly affected health care 'orld'ide#
$ncreased n%mber of elderly, &eo&raphical location and economics are 1%st some of the factors
involved#
#ging Population
By 22, it is estimated that people over the a&e of ;6 years old in America 'ill be more
than 6> million H * million more than the c%rrent pop%lation (;6 years old and above"# +his
statistics is alarmin& considerin& that the elderly reD%ire close attention# +hey are %s%ally
affected by lon&9term illnesses and reD%ire special ho%sin&, treatment services and financial
s%pport# Since only 6I of the elderly are instit%tionalized, home mana&ement and n%rsin&
s%pport services 'ill be essential for these patients# $n addition, health care or&anizations sho%ld
not only foc%s on the elderly,s health b%t consider their 'orth and prod%ctivity as 'ell, thro%&h
special pro&rams (Berman, et al#, 2!"#
“$f health care cons%mption patterns and physician prod%ctivity remained constant over
time, the a&in& pop%lation 'o%ld increase the demand for physicians per tho%sand pop%lation
from 2#! in 2 to >#* in 22# (emand for f%ll9time9eD%ivalent (2+E" re&istered n%rses per
tho%sand pop%lation 'o%ld increase from 5 to 5#6 d%rin& this same period” (.han&in&
(emo&raphicsJ $mplications for3hysicians, 7%rses, and Ather 4ealth 0or/ers, 2>"#
'neven Distri&ution of ervices
:rban and r%ral areas have different health care opport%nities# =%ral areas &enerally have
shorta&e of health care services compare to %rban areas 'ith adeD%ate health instit%tions,
personnel and services# 3atients in r%ral areas often travel lon& distance in order to access health
care services# “Efforts to increase the s%pply of health professionals in these areas m%st deal 'ith
economic, c%lt%ral and lan&%a&e considerations (.han&in& (emo&raphicsJ $mplications
for3hysicians, 7%rses, and Ather 4ealth 0or/ers, 2>"#
An increasin& n%mber of health care 'or/ers provide specialized services# +his
specialization can ca%se fra&mentation of services and increased e-penses#
'r&anization ( #dvances in %echnology
(%e to the modernization, health care delivery has constantly improved# 4i&h9end and
sophisticated dia&nostic proced%res have helped in early detection of diseases# <ore medicines
have also been prod%ced to treat different diseases and even the more complicated ones# Also, a
lot of s%r&ical proced%res, 'hich 'ere non9e-istent 2 years a&o have already been performed#
(%e to the modernization of technolo&y, the p%blic are becomin& a'are of their health sit%ation
thro%&h the %se of comp%ters and internet# 4o'ever, beca%se of the escalation of health care
standards, these treatment and proced%res entail hi&her costs for the people#
Economics
3ayin& for health care services is becomin& a &reat concern# A co%ntry,s economic stat%s
affects the delivery of health care# Berman et al# (2!" indicated the ma1or reasons for the
escalation of costs# 4ealth care instit%tions contin%e to improve their facilities and eD%ipment in
order to /eep %p 'ith the pace of modern health# +he increase in pop%lation, especially the
elderly and %nins%red has also ca%sed the increase of costs# (%e to improved technolo&y, more
people are becomin& a'are ca%sin& them to see/ for health assistance# +here is also an increase
in the n%mber of health care providers# And lastly, medicines are also becomin& more costly#
Poverty
+he health problems of homeless and poor are %s%ally e-acerbated d%e to their inability
to avail of health care services# 3hysical, mental, social, and emotional factors create health care
challen&es for them (Berman et al#, 2!"#
!omen)s Health
0omen,s movement has ca%sed health care or&anizations to &ive attention to 'omen,s
needs# .hildbirth services have been improved# 0omen,s health iss%es s%ch as osteoporosis and
heart disease are addressed# +here is also an increased emphasis on the psychosocial aspects of
'omen,s health#
Family Fragmentation
Sin&le9parent families and alternative family str%ct%res have been prevalent# 0omen are
%s%ally the head of these sin&le parent families# +hey often are 'or/in& individ%als and need
s%pport in providin& care for their children, especially 'hen they are sic/#
Cultural and Ethnic Diversity
4ealth care or&anizations &ive emphasis on patients, differences in c%lt%re# +o address
this problem, instit%tions employ personnel 'ho can comm%nicate in En&lish#
%. TH& C*)T*(& O+ H&A)THCA(& O(#A!$,AT$O!S
.%lt%re is the characteristics of a partic%lar &ro%p of people, defined by everythin& from
lan&%a&e, reli&ion, c%isine, social habits, m%sic and arts (Kimmermann, 2*2"# $t is “ho' and
'hy yo% do 'hat yo% do” (0iseman & Kaprielian, 26"# Accordin& to 0iseman and Kaprielian
(26", “c%lt%re is made %p of the overarchin& themes 'ithin an or&anization %s%ally made %p of
stories and %n'ritten r%les &overnin& behavior 'hich mi&ht be clearly stated or merely implied,
intentional or %nintentional”#
.%lt%re is not necessarily %niform 'ithin a sin&le or&anization# 2or e-ample, in a
hospital, each healthcare 'or/er may have a different c%lt%re# +hese differences may either
benefit or impede the patient care# +he latter is more li/ely, as c%lt%ral differences freD%ently
res%lt in comm%nication differences (0iseman & Kaprielian, 26"#
$n the healthcare environment, the c%lt%re of an or&anization has many competin&
variables# +he conflictin& needs of patients, families, providers, instit%tions, re&%lators and
others create many discrepancies and mi-ed messa&es (0iseman & Kaprielian, 26"# <any
have said that a c%lt%re of blame has been pervasive in healthcare# Beca%se medicine 'as often
vie'ed as the 'or/ of a sole physician (or other professional" 'or/in& 'ith an individ%al patient,
'hen somethin& did not &o 'ell the a%tomatic reaction 'as to try to determine 'ho 'as at fa%lt
and, often, to discipline them# +his “shame and blame” approach leads to hidin& rather than
reportin& of errors, and th%s is the antithesis of a c%lt%re of safety# =ecent efforts have tried to
chan&e thisLto enco%ra&e people to report problems rather than hide them, so they can be
addressed# 2or'ard9thin/in& healthcare or&anizations remember that their primary reason for
e-istence is to ta/e care of patients, and they 'ant to /eep them as safe and healthy as possible#
+here are formal and informal c%lt%res in an or&anization# (ifference bet'een the formal
operational style stim%lated by the mana&ement and the style demonstrated and felt by staff
members may be evident# +his can res%lt in an incompetent or&anization# +herefore, the c%lt%re
of an or&anization definitely affects D%ality of care# A positive c%lt%re prod%ces tr%st, information
sharin&, collaboration and ris/ ta/in&# An the other hand, a ne&ative c%lt%re promotes
divisiveness, resistance and a desire to maintain the stat%s D%o leadin& to employees lac/in&
creativity and self9direction ((e )a%ne &)a%dner, 2**"#
4ere is an e-ample of t'o different c%lt%res in a health care or&anizationJ
+im reco&nized the %niD%e 'ay the teams at 4ospital A 'or/ed 'hen d%rin& a fairly
serio%s proced%re a n%rse spo/e %p and as/ed for a proced%ral stop# +he physician had &iven a
verbal order for an antibiotic in con1%nction 'ith the proced%re# She D%estioned this beca%se of a
recollection that the patient had several dr%& aller&ies# +he team held the proced%re %ntil the
record 'as revie'ed, and it 'as confirmed that the patient 'as indeed aller&ic to the medication
that 'as ordered# +he physician &ladly chan&ed the order, an alternative medication 'as
administered, and the proced%re 'as then performed# After'ards, the doctor act%ally than/ed the
n%rse for her 'illin&ness to as/ the D%estion#
+im realized this 'as tr%ly a different 'orld than he had lived in at 4ospital B# 4e
recalled n%rses avoidin& raisin& D%estions abo%t doctors, orders beca%se of the conseD%ences# 4e
specifically remembered one physician “dressin& do'n” a n%rse ri&ht o%tside the e-am room,
f%lly 'ithin earshot of the patient and a n%mber of other 'or/ers# +here had been some
mana&ement intervention and a 'or/shop on team'or/ as a res%lt, b%t it 'as common
/no'led&e that the n%rse received a 'ritten 'arnin& 'hile the doctor &ot only a mild verbal
reprimand#
$n the above e-ample, 4ospital A e-emplified a positive or&anizational c%lt%re as
evidenced by open comm%nication bet'een the members of the health care team# +he n%rse 'as
not afraid to spea/ %p 'hile the physician 'as open to corrections# $n the end, they 'ere able to
identify and correct the error and promote the 'elfare of the patient# An the other hand, n%rses in
4ospital B 'ere afraid of raisin& D%estions beca%se of fear of &ettin& reprimanded by the
physician#