Coordinating

Coordinating is by definition the act of assembling and synchronizing people and activities so that they
function harmoniously in the attainment of organizational objectives. In essence, coordination is a
preventive managerial function concerned with heading off conflict and misunderstanding.

Think about the situations in your own life when you have had to coordinate the multiple activities for an
important event. A school or community event involves the process of coordi- nating just as completely as
formal managerial situations. The manager is aware of who is doing what and what the outcome should
be and has the responsibility to make sure that the specific and interrelated tasks are accomplished. This
is not the easiest activity to achieve, but by having a thorough knowledge of the staff ’s responsibilities,
the manager is in a good position to meet the appropriate goals.

● Coordinating—clarifies the relationships among the various ideas and attempts to pull
things together.

Coordinating is the management activity that assembles and synchronizes people and activi- ties so that
they function harmoniously in the attainment of organizational objectives.

REWARDS

Rewards in nursing have become an issue in recent years and a concern of management. Recall the
reorganization of patient care standards discussed in Chapter 1 and the different expectations among
nurses—because of their different orientations to the profession— discussed in the chapter on motivation
(Chapter 10). Satisfying expectations of staff nurses and meeting the needs of higher-acuity-level
patients, as a result of DRGs, forced manage- ment to reconsider the traditional single-track reward
system for nurses. For decades, the only way a staff nurse could advance was vertically into an entirely
different role. Staff nurses, proficient at the bedside, were “promoted” to a management or teaching
position. Few management and teaching positions were available, however, and most nurses remained in
staff-nurse positions throughout their careers, with the concomitant salary compression and shift-change
schedules.

Attempts on the part of nurse managers to satisfy the different needs of individuals included
experimenting with variable scheduling to replace the traditional 8-hour shifts 5 days a week. Several
alternatives have emerged that provide attractive incentives for some nurses to remain in nursing. Various
patterns provide for:

• Four 10-hour shifts a week.

• Three 12-hour shifts a week.

• Two 12-hour weekend shifts every week.

In some acute care settings, the latter provides a salary greater than that of a 40-hour-a-week schedule.
The “menu” of schedules has been met with varying degrees of enthusiasm and success. The hours can
be ideal for students who need to be free during the week to attend classes. Parents of young children
might find the hours attractive in that they can avoid costly child care expenses. Variable scheduling has
the potential to reduce the dissatisfaction of nurses in patient care settings and to improve staff-nurse
satisfaction because it fits their lifestyles.

However, there are also problems with variable scheduling. Coordinating the schedule when nurses work
different time patterns can be difficult. Confusion about patient care responsibilities during overlap hours
can cause conflicts. Finally, there has been no systematic evaluation of the effect of long working hours
on the ability to perform quality patient care.

Another strategy for improving rewards for nurses has been the introduction of clinical ladders (see
Figure 11.2). The concept of a clinical ladder permits horizontal advancement, keeping excellent clinicians
in their chosen roles. Nurses advance through a determined number of levels within a position category
(e.g., staff nurse), based on predetermined criteria. At each level, there are additional advantages for the
nurse (e.g., fewer rotating shifts, higher salary, or fewer weekends on duty). Once the highest level in the
category has been reached, advancement requires additional education—usually a master’s degree in
nursing.

TIME MANAGEMENT

Time impacts individuals in complex ways. Coordinating activities with others may cause psy- chological
distress for some people. Individuals tend to be more effective at different times of the day. The ability to
manage and lead people with different concepts of time involves patience and knowledge of time
management. Effective nurse leaders evaluate the constraints on time, as well as develop and
implement methods that conserve and use time effectively. Time management is intended to foster good
work habits that use time productively. The activities for organizing time should take into account a variety
of principles, including:

• Communicating • Planning

• Delegating

• Prioritizing goals1

Functional Method

The functional method evolved as a way to deal with multiple levels of caregivers. Assignment of tasks
rather than patients was the way in which care was provided. Each caregiver performed one certain task
or function in keeping with the employee’s education and experience. Nurse aides gave baths, fed
patients, and took vital signs. Professional nurses were responsible for medications, treatments, and
procedures. The head nurse was responsible for overall direction, supervision, and education of the
nursing staff. The obvious problem with this system was the fragmentation of care. It complicated the
process of coordination, leading to reduction in the quality of care and a high level of dissatisfaction
among the staff.
Introduction
Unit III provided a background in planning, the first phase of the management process. Organizing follows
planning as the second phase of the management process and is explored in this unit. In the organizing
phase, relationships are defined, procedures are outlined, equipment is readied, and tasks are assigned.
Organizing also involves establishing a formal structure that provides the best possible coordination or
use of resources to accomplish unit objectives. This chapter looks at how the structure of an organization
facilitates or impedes communication, flexibility, productivity, and job satisfaction. Chapter 13 examines
the role of authority and power in organizations and how power may be used to meet individual, unit, and
organizational goals. Chapter 14 looks at how human resources can be organized to accomplish patient
care.

Formal and Informal Organizational Structure

Fayol (1949) suggested that an organization is formed when the number of workers is large enough to
require a supervisor. Organizations are necessary because they accomplish more work than can be done
by individual effort. Because people spend most of their lives in social, personal, and professional
organizations, they need to understand how organizations are structured—their formation, methods of
communication, channels of authority, and decision-making processes.

Each organization has a formal and an informal organizational structure. “Essentially, in the formal
organization, the emphasis is on organizational positions and formal power, whereas in the informal
organization, the focus is on the employees, their relationships, and the informal power that is inherent
within those relationships” (Hartzell, 2003–2016, para. 3). In addition, the formal structure is generally
highly planned and visible, whereas the informal structure is unplanned and often hidden.

Formal structure, through departmentalization and work division, provides a framework for defining
managerial authority, responsibility, and accountability. In a well-defined formal structure, roles and
functions are defined and systematically arranged, different people have differing roles, and rank and
hierarchy are evident.

Informal structure is generally a naturally forming social network of employees. Hartzell (2003–2016)
suggests that it is the informal structure that fills in the gaps with connections and relationships that
illustrate how employees network with one another to get work done. Because informal structures are
typically based on camaraderie, they often result in a more immediate response from individuals, saving
people’s time and effort (Schatz, 2016). People also rely on informal structure if the formal structure has
stopped being effective, which often happens as an organization grows or changes but does not
reevaluate its hierarchy or work groups (Schatz, 2016).

The informal structure even has its own communication network, known as the grapevine. Hartzell (2003–

2016) suggests that grapevine communication is at the heart of the informal organization; it is the
conversations that occur in the break room, down the halls, during the carpool, and in between work that
allows the relationships of informal groups to develop. In addition, social media sites (Facebook,
Instagram, Snapchat, Twitter, etc.) and electronic communication such as e-mail and text messages are
also used to facilitate communication among informal group members.
Although grapevine communication is fast and can facilitate information upward, downward, and
horizontally, it is difficult to control or to stop. With little accountability for the message, grapevine
communication often becomes a source for rumor or gossip.

Using a diffusion of innovation framework, Baker completed a literature review and interviews with rural
primary care providers. Her study findings yielded seven domains for care management for the RN
primary care coordinator. She then wrote a job description for RN primary care coordinators that
encompassed these seven domains. The seven domains required for primary care coordination included
the following:

1. Population health management: A change from a focus on a single provider caring for the
health and well-being of an individual patient to a focus on a health-care team managing
the health of a panel of patients
2. Comprehensive assessment and care planning: A thorough knowledge of chronic disease
management and evidence-based guidelines and protocols, especially for chronic heart
failure (CHF), chronic obstructive pulmonary disorder (COPD), diabetes, and depression
3. Interpersonal communication: Includes the ability to use different communication styles,
including active listening, to counsel, interview, resolve conflict, build relationships, and
develop effective interdisciplinary teams
4. Education/coaching: A working knowledge of adult education principles and learning
techniques, readiness to change, and identification of necessary person-centered
components for a self-management plan
5. Health insurance and benefits: Current knowledge of health insurance, managed care, and
other payer sources and benefits.
6. Community resources: A thorough familiarity of public and private community-based
providers, services, and support available in the local geographical area
7. Research and evaluation: A basic understanding of research and evaluation techniques to
assist in quality improvement of care and interpretation of program outcomes.

Coordination
Nurses coordinate patient care through planning and implementing care, and they have been involved in
the development of care coordination throughout its evolution (Lamb, 2013). “Care coordination involves
deliberately organizing patient care activities and sharing information among all of the participants
concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s
needs and preferences are known ahead of time and communicated at the right time to the right people,
and that this information is used to provide safe, appropriate, and effective care to the patient” (HHS,
AHRQ, 2014b). Effective coordination needs to be interprofessional. Coordination and collaboration
should be interconnected. Care is complex, and patients require healthcare providers with different
expertise to meet these needs. With this type of situation, the different providers need to collaborate to
reach a plan and then implement care in a manner that makes sense— meeting the timeline required,
with minimal conflict and confusion.
Although the need for care coordination is clear, there are obstacles within the U.S. healthcare system
that must be overcome to provide this type of care. Redesigning a healthcare system in order to better
coordinate patients’ care is important for the following reasons (HHS, AHRQ, 2014b):

Current healthcare systems are often disjointed, and processes vary among and between primary care
sites and specialty sites.

Patients are often unclear about why they are being referred from primary care to a specialist, how to
make appointments, and what to do after seeing a specialist.

Specialists do not consistently receive clear reasons for the referral or adequate information on tests that
have already been done. Primary care physicians do not often receive information about what happened
in a referral visit.

Referral staff deal with many different processes and lost information, which means that care is less
efficient.

Coordination through team effort—working to see that the pieces and activities fit together and flow as
they should—can help to meet patient outcomes. “Conscious patient-centered coordination of care not
only improves the patient experience, it also leads to better long-term health outcomes, as demonstrated
by fewer unnecessary trips to the hospital, fewer repeated tests, fewer conflicting prescriptions, and
clearer advice about the best course of treatment” (HHS, 2013).

Patients often complain about the number of care providers that interact with them. They may not know
who is responsible for which aspects of their care, and they receive confusing and often conflicting
communication and information. The patient needs to have an anchor—a healthcare provider to whom
the patient can turn for support and knowledge of the plan. Basically, patients are saying that they are not
the center of care and their care is fragmented. This leads to an increased risk of errors and decreases
the quality of care. Care is coordinated through the implementation of the care plan, documentation of
care, and teamwork. Healthcare teams that recognize these concerns can help patients more, engaging
patients in the care and as a member of the care team. All of this increases opportunities to improve care
and reach outcomes.

Barriers and Competencies Related to Coordination

Coordination is not easy to achieve even when team members want to achieve it. Some of the barriers to
effective coordination are listed here:

Failure of team members to understand the roles and responsibilities of other team members, particularly
members from different healthcare professions

Lack of a clear interprofessional plan of care

Limited leadership

Overwork and excessive burden of team member responsibilities Ineffective communication, both oral
and written

Lack of inclusion of the patient and family/significant others in the care process
Competition among team members to control decisions

Despite these barriers, coordination can be achieved through use of effective interventions. First, the
team must recognize that coordination is critical and strive to ensure that it is used. The team needs to
understand the purpose and goals of coordination and work to achieve them. To do so, the team must
evaluate its work and be willing to identify weaknesses and figure out methods to improve coordination.
Team members need to communicate openly and in a timely manner. Teams that effectively solve
problems together will improve their coordination. Delegation, discussed elsewhere in this chapter, is an
important part of coordination. One person cannot do everything (and that one person may not even be
the best person for the task or activity). Coordination requires team members who understand the
different roles and expertise of the members, determine the best member to deliver care to meet the
timeline, and then evaluate the outcomes.

Tools to Improve Coordination

Health care has developed a variety of tools and methods to increase coordination. From a chronic illness
perspective, disease management is a process used to improve coordination and collaboration, typically
using practice guidelines and clinical protocols or pathways. A clinical protocol or pathway is a written
guide to provide direction for specific clinical problems. The pathway content includes interventions,
timeline, and resources needed; identifies expected outcomes; and provides a sequencing of
interventions to

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reach the outcomes. Figure 10-5 provides examples of information categories that might be found in a
clinical pathway.
Figure 10-5 Categories of Information Found in Clinical Pathways

Pathways are developed in a number of ways. In some situations, healthcare organizations may create
them by identifying focus areas based on needs commonly found in their patients—for example,
pathways that focus on the care of a diabetic patient who has been hospitalized, a patient who needs a
hip replacement and then rehabilitation, or a patient who is severely depressed and suicidal. An
interprofessional team of experts then develops the pathway describing expected care and outcomes.
Current literature and evidence from research should be used when developing pathways, and examples
from other hospitals or examples found in professional literature may be used. In other situations, the
healthcare organization may decide to use a published clinical pathway rather than develop one for the
organization. After the clinical pathway is developed or selected, staff members need training about the
pathway and its use. Pathways can be used to evaluate care and outcomes by collecting data about their
use and the patients’ outcomes. The question to be addressed during evaluation is simple: Does the
pathway, or specific interventions within a pathway, make a difference? Are expected outcomes met?

There are a number of advantages to using clinical protocols or pathways. First, this type of tool improves
team coordination and increases the likelihood of meeting outcomes. Because clinical protocols or
pathways are written and based on evidence, there is a care standard and greater consistency in care
provided, which should enhance quality of care and facilitate evidence-based practice. However,
whenever a pathway is used, the team must review the standard pathway to ensure that it meets the
individual needs of the patient and then adapt it accordingly. Other advantages of using clinical protocols
or pathways include more effective use of expertise and resources, better management of healthcare
costs, improved collaboration and communication, decreased errors, improved patient satisfaction
(because patients feel that their care is organized and they are more informed), improved care
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documentation (because it follows a consistent plan), improved identification of responsibilities, and a

clear statement of interventions.