Clinical Corner

Part 8: Developing New Services

2008-07-08T17:43:00Z

One of the important ways we evaluate ideas for new products or services is through a market and SWOT analysis, something you did last term in your portfolio assignment. Someone suggests something they think would be a great new product or service and then we go out and evaluate it.

In my last executive position the med-surg nurse manager suggested a unit comprised of all private rooms, with custom menus and chef-prepared food, better furniture, cable TV and movies, etc. She wanted to call it the Garden Suites. No one thought it would ever fly as our hospital had a huge percentage of charity cases, Medicaid, etc. However, an analysis was done and we built the unit which remained almost 100% full all the time! People will pay out of pocket (if they have the resources) for more nursing care, a nicer environment, better food, etc. I was amazed!

Does anyone have a story about a similarly surprising venture?

Part 7: Thoughts on Budgeting

2008-06-19T15:40:00Z

The operations budget, while based in part on expenses, is also based on revenue projections. Clearly we would not knowingly budget to spend more than we expect to earn from a product or service and so we budget accordingly. In general, we do not expect to have a great deal of money left over from revenues received after deducting all the operating costs, i.e., the costs of providing services. What we do have left...and it is usually a very small percentage...we do not leave in operations accounts, we move into an account that contains all the positive balances from various operations.

Essentially, capital budget funds come from these assets, ones that are left in the organization after all expenses are deducted. This includes not only operating expenses, but such expenses as depreciation, interest paid, taxes, etc. What is left is usually a pool of money call unrestricted net assets as we can do what we wish with them, up to a point. What is generally done is that the funds are used to replace outdated major equipment, expand existing services, and develop new product lines.

So, we expect operations to pay for themselves through the revenue we generate and we use the resources left to continue to grow our operations. We do this for various reasons. Sometimes we simply do this to remain competitive. In one place I worked, the L&D area was dismal, old and un-renovated, and no one care because most of the mothers were Medicaid recipients. Then another nearby hospital opened a state-of-the-art LDRP center and all the Medicaid moms went there. Despite the fact that the revenue was low on a per-patient basis, losing ALL of it was a blow. My hospital had to create an L&D area that was just as up-to-date in order to regain market share. Similarly, if we want to keep our primary referral sources, usually physicians and payers, we need to have the kind of environment and equipment they expect.

I wish we could allocate those funds back into operations and add to staffing ratios and so on, but you will find other compelling realities exist in the executive offices that require senior administration to make some difficult financial decisions.

Do you feel ready to do this?

Part 6: Management Tip - Staff Buy In

2008-06-05T20:24:00Z

One of the things I had ongoing on all my units was a wish list in the staff lounges on which anyone could put a request for something they wished to have purchased. I always did my best, at every administrative level, to acquire as much as I could of what staff wanted and needed. It is one form of support for their efforts that recognized their value.

One of the most interesting things to me about this strategy is that staff did not ask for raises or longer breaks or fewer patients, which I could not grant. They asked for things like reference books, lockers (that could actually lock), educational classes about clinical topics, a water cooler, and so on. These things required little money and made a huge impact as I was the first director who had every asked what they wanted or needed and then provided them with their requests. If affirmed their value and let them know I was listening and really cared.

Part 5: Creative Accounting

2008-05-13T16:23:00Z

I thought I would confess one of the strategies I employ in dealing with difficult-to-acquire capital items, something I call "creative accounting." As all of my experience has been in behavioral health operations, it was always been clear to me that providing the best equipment for the mentally ill has never been a priority in most hospitals.

In my last administrative position, the unit was old, the furniture was broken down (when the unit first opened the furniture had been acquired from the warehouse of discarded furniture with the belief that there was no point in providing decent furniture to patients who would not appreciate it or who would destroy it), and the floors in terrible disrepair. There were no supplies, no recreational equipment, and the whole environment was pretty sad. The nurses were still using thermometers with probes while every other unit had the ear thermometers. My nurses were still taking manual blood pressures while all the other units had electronic ones that operated automatically. All the other patient care units had a Pyxis machine for medication administration but we still had a rickety cart with wobbly wheels and drawers that wouldn't open or would fall out. The list could go on and on.

I requested capital funds year after year and was turned down. But because I spent just over the limit in every line item-other than salaries-each year I got a little more allocated for that line item in the budget. One of the line items was for repairs to materials and equipment, but this could not be used for replacement as that would be a capital expense with depreciation over several years while repairs were simply expensed out each year. So one year I "repaired" the floor. The whole floor. Three feet at a time. Continuously...until it was all new. If I had been questioned I simply would have said the floor was in such disrepair that I just kept repairing the parts that were dangerous and might trigger patient falls.

Another example I will share was cited in a book published by Sigma Theta Tau called "Ordinary People, Extraordinary Lives." It is a book about inspirational nurses whose personal stories were written by someone whose life the nurse impacted. I am honored to be one of the nurses included in this book and I will post to document sharing the story that was written about me by one of my graduates. That story, too, describes an example of creative accounting and how I used it for the benefit of the patients for whom I was responsible.

One of the most valuable things nurse managers and administrators can learn is how to find "workarounds" to solve problems that are caused by the often-rigid structures and policies within our organizations.

Both stories illustrate one of my mottos: "I would rather ask forgiveness than permission." I did what I needed to do for the patients and did so creatively. Does anyone have a similar story?

When I reflect further on "creative accounting" and tried to think of more examples, I first thought I would share my personal accounting activities in which I rely on the famous "float" so I use more of my money than the bank does, but then I realized the IRS might read the post and notice and I would have to finish my postings from a Federal prison...

Seriously, part of the strategy has to do with willingness to engage in risk-taking behavior. As you become more experienced, you begin to develop a sense, quite frankly, of what you can get away with in the system and which activities are too far below the radar to get anyone's attention.

Part 4: Reimbursement of Costs…ALL Costs!

2008-04-29T17:21:00Z

When nurses begin to learn about the difference between cost for an item and the total cost for everything involved in supplying the item they are often upset to learn that there indeed may be a charge of $12 for a simple aspirin. Most see it as health care facilities having "marked up prices" when there are, in fact, the only way we can cover other costs associated with providing care for which we cannot be reimbursed.

What we do when we develop charges is try to determine all the costs associated with the service or item, and there are many. We then develop a charge consistent with the total amount. Thus, these are not inflated charges, but rather a reasonably accurate determination of all associated costs.

We are often reimbursed an amount less than what we charge and there are Generally Accepted Accounting Principles (GAAP) that determine how we handle the difference. Typically this is done through including a contractual allowance that is a deduction from the gross revenue we "book" or enter into the ledger. If we enter only the amount we receive, we will not capture the actual charges and not accurately reflect the discount we gave to the payer.

The only way we collect money in our facilities is to charge insurers for the actual care we provide to the patients who are their members. This includes tests, treatments, etc. But far more is included in the costs of running the facility than just those elements that are part of the direct care of patients.

For example, how do you think we are paid for the laundry we use in patient care and other activities? How do we get paid for the security guard who ensures staff and visitor safety? What about the people in payroll who process our paychecks? And the medical records people who maintain patient records even after they are discharged? Do you think we bill the insurer for these services? Do you think they would pay? Do we just absorb all these costs?

When considering accruals for all costs, we must also add to the cost of supplies a portion of the salary for the person who orders them, the individual who unloads them from the truck and places them in storage, and the person who delivers them to the unit. Then there is the cost of maintaining the inventory so the hospital never runs out of them and the cost of the people who review the bills for them, process the account payable, input the payment information into the general ledger, and someone to actually cut the check and put it into an envelope and mail it! Oh yes, and the postage...

While we add up the costs of doing business, we also have significant economies of scale that allow these costs to be spread over many items and payers so that, if we run our operations efficiently, the average of what we are paid covers our actual costs...and a little more. For example, if we are paid $25 for a bag of IV fluid, that may actually include $5 for the cost of the nurse who hangs it. But she is also hanging several other IV bags for several other patients whose payers are also paying $5 for it. In the end, we make enough from the volume of payers to cover the cost of both the IV fluid as well as the nurse. If you add to that the payers who pay, say $55, there is additional revenue to cover the cost of the nurse.

Ultimately, payers must reimburse us for the cost of all supplies and operational costs. This can be done as when we charge for each item as it is used, when we bundle charges and include it in the cost of a procedure, or it may be included in a per diem charge for a day's care (or another unit of service). Inevitably, everything we use for patient care must somehow be reimbursed to us or we are giving it away and, even for an item as inexpensive as a needle lock syringe, it would undermine our success as a business.

We are often using supplies that, individually, cost very little. But multiply cost by volume and a $1 item becomes $1000 a month, conservatively. We are constantly looking for ways to maximize our reimbursement while cutting costs. It is clear we do not even get reimbursed for all the actual costs of the care we provide, let alone achieve the surplus of funds that might be called a profit. What happens is that those patients with better insurance, for whom we get better reimbursement, carry the burden of the patients for whom we are paid less than the cost of their care.

Part 3: Fiscal reality and length of stay

2008-04-18T16:07:00Z

As I reflect upon the massive changes in health care in the last couple of decades, one of the most profound relates to our focus on length of stay and the ever-present need to reduce hospitals stays until they are so short I wonder sometimes how patients can be adequately treated in such short time frames. If we examine readmission rates, we find they have gone up and I wonder if they are proportional to the decreases in length of stay so we could assume an inverse relationship. Inevitably, this emphasis has found its way into long term care as fewer and fewer days are provided to residents, most of whom cannot fund their care out-of-pocket.

In some ways I wish we could return to an earlier model in which patients were kept in the facility until they were truly better. In other ways, I know this is not only impossible, it is undesirable. And, as the cost of care continues to escalate due to costs of medication, expensive technology, increasing salaries, etc., it would be impossible. In actuality, I think the quality of care has improved significantly as we are now required to be very attentive to how we use increasingly scarce resources. That has resulted in the need to provide patients with what they need when they need it and to reduce waste in terms of time and activities that do not make a difference.

Case management has allowed us to do this and to focus far more closely on the real needs of the patient. To this we have added our awareness and understanding that complete healing does not need to occur in acute care facilities; this has allowed the development of skilled nursing and rehab facilities, LTACHs, and other creative care environments, as well as an enhanced role for families in the care of their ill or injured member.

I remember years ago when my father had gall bladder surgery and was in the hospital for three weeks! Did he really need to be there all that time? No, of course not! And let us not forget the untoward consequences of overlong hospital stays...

Part 2: Prospective Payment Systems: An Historical View

2008-04-14T16:58:00Z

What happens with Prospective Payment Systems (PPS) is that we are paid a flat rate for each Diagnostic Related Group (DRG), rates that were determined after extensive research into the cost of treatment for specific diagnoses. What the PPS system did was identify a huge number of diagnostic categories based on research that determined the average cost required for hospitals to treat patients with various diagnoses. The individual diagnoses were grouped into related categories for which reimbursement was standardized. A length of stay was identified for each diagnosis and daily activities identified during the stay that were required to provide care for individuals with that diagnosis. Average cost of providing the treatment was identified per day and a total amount specified, one that is now what hospitals are paid. For example, a total hip replacement is worth $XXX per day and allocated a length of stay of X.x days. All costs related to the care of that patient are included. The same is true for the diagnosis of pneumonia, but the cost was determined to be less so the DRG payment is less.

As a consequence, we know in advance exactly how much we will be paid for each patient when he or she is admitted, based on his or her diagnosis. Comorbid conditions that carry additional diagnoses provide increased payments as do complications that occur while the patient is in the hospital. If we are able to discharge the patient in fewer than the number of days for which we are paid, we get to keep the extra money. However, if the patient exceeds the predetermined length of stay, we must absorb the cost...and the loss. That is why you notice such scrutiny on length of stay and so many initiatives aimed at reducing averages even by a tenth of a day!

Therefore, if the patient's care costs less than the amount we are paid, we keep the difference and the money is used to fund the cost of improvements, repairs, patients who have no insurance, etc. If the costs exceed the payment, we absorb the difference. As the greatest correlation exists between length of stay and cost of care, our efforts have focused on reducing length of stay as well as on the most appropriate use of resources. Furthermore, patients often do better at home, as some research has demonstrated. Beyond that, when a patient who develops complications we are going to be paid more as we are able to request money for secondary diagnoses and other ancillary conditions.

Currently, the other key issue is quality. The days of cutting costs at the price of quality are long gone as payers and other stakeholders are far too aware of the importance of quality. We are constantly required to demonstrate higher levels of quality while conserving valuable resources. It is honestly my opinion that the managed care initiatives of the last 20 years have required us to improve quality vastly over what existed under the old fee-for-service model. Case management allows us to provide patients with the right care, at the right time, in the right setting and mandates that we do so with our eyes constantly on the patient and patient-related outcomes.

Part 1: Sharing Financial Information with Staff

2008-04-14T16:53:00Z

One of my pet issues relates to the level of knowledge of nurse managers and administrators about financial operations. I even believe strongly in the importance of beginning to educate staff nurses in the fiscal realities of health care operations! I think nurse managers must be clinically competent as they must supervise direct care staff, but it is equally important that they possess strong managerial skills, particularly related to financial and human resource management. I published an article in JONA a few years ago titled something like "How Prepared are our Nurse Managers?" that addresses this reality.

Similarly, I think senior administrators need an understanding of the current processes that occur at the point of care...which is one reason nurses often do far better at executive levels than non-nurse administrators. However, at that level of administration business knowledge and skill often assumes greater importance than maintaining clinical skills.

So, what is the relative importance of clinical versus business skill and knowledge as one moves up the management and administrative ladder? Are nurse managers prepared for the business-related aspects of the role? Are senior nurse executives even fully prepared?

It has become crucial for staff members at all levels and in all positions understand the realities of financial decision-making and the issues related to expenses that confront us all. One of the things I did as a new nurse manager a long time ago was include financial results in monthly staff meetings for all staff. I took the monthly operating budget reports and simplified them, extracting key information, and used overheads (in the old days before PowerPoint) to show staff where we were related to projected budget numbers. I explained the concept of variances to them, showed them how I was required to justify variances, and demonstrated the way in which current results had implications for future management decisions I had to make.

I know it was eye-opening for them as no one had ever actually explained the "why" of financially-based decisions, no one had ever provided an understandable rationale for making some of the difficult choices managers often have to make. The information ranged from basic, such as the incredible amount of coffee and orange juice we used and were charged for (the stuff that seemed to grow little feet and walk out of the hospital), to complex, such as the aggregate of individual incremental overtime which could amount to an actual full-time salary at the end of a month!

This effort had many positive results as staff became educated about the cost of things they were using as well as the relationship between patient volume and expenses. They felt their intelligence was being respected as it was clear I believed they could understand complex financial operations and appreciated the increased level of open communication. They also felt they were more active participants in controlling costs and in ensuring the unit's financial success.

However, what do we do with staff who are often resistant and glassy-eyed when financial information is presented in meetings? I found dealing with this situation was actually pretty simple. I took my various financial reports---monthly operating statements, biweekly staffing reports, admission and length of stay data---and extracted selected information which I put on flip chart paper. Then I used them for mini-lectures first to educate staff about what these were and then to identify the figures I wanted to discuss. For example, I found the nourishment budget was completely out of control and I assumed the orange juice, coffee, and sugar were growing little feet and walking out of the hospital by themselves as there could be no other explanation for the incredible volume the units were using. When I presented this to the staff, all of them, on all shifts, the changes were dramatic.

I had a situation once, in the same hospital, when I had to reduce staff by two FTEs. In the days before my arrival the last two nurses to be hired would simply have been laid off. Instead, I met with all the staff on each unit, all three shifts, and laid out the financial reality, along with the need to reduce total hours by the equivalent of two FTEs. In each meeting I also asked the person with the least seniority to raise his or her hand. This made it real to them as we would not lose an FTE...we would lose Sarah or John or Yvonne. Eventually the staff themselves all decided to reduce their paid hours by two hours per pay period and the cost savings I needed were realized without anyone losing their job.

A Primer on Finance

2008-03-20T17:22:00Z

Nursing leadership skills have changed dramatically in a health care environment so different from years past. Nursing management skills are required at all levels…even at the bedside…as nurses have become coordinators of care. Financial issues have come to the forefront for health care organizations and nurses must be ever-conscious of fiscal realities. Additional skills are needed to justify staffing, ensure adequacy of supplies, and maintain quality in a time of fiscal restraint. Unfortunately, most nurses—even many nurse managers and directors—have had little formal preparation for the financial aspects of the managerial role.

The budgeting process in a health care organization is not unlike a personal budget. Budgets help us to manage ongoing expenses, allow us to plan for what we can purchase, and provide a mechanism for saving. Much in the same way our personal budgets allow us to implement a personal or family strategy, a departmental or organizational budget is consistent with the organization’s mission and allows it to achieve short and long term goals that are part of a strategic plan. By evaluating what we spend on a monthly basis, we and our families are able to evaluate our expenses and control excess spending. In exactly the same way, nurses who develop awareness of and insight into unit and department expenses can facilitate cost-consciousness throughout the organization.

I am constantly amazed at how little nurses know about how we get paid for what we do and how we run our organizations! In my opinion, it reveals a deficiency in our basic education.

The next several blogs will present a series on the financial aspects of care management. I hope they will provide an introduction to financial concepts and a basic understanding of how financial realities impact all of us.

Finance and Nursing - The Business of Caring

http://www.hfma.org/hfm/2006archives/month01/CoverStory0106.htm

Long-term care, anyone?

http://findarticles.com/p/articles/mi_m3257/is_n9_v43/ai_7894365

Noncompliance

2008-03-07T20:09:00Z

Few situations challenge and frustrate us as the need to deal with residents who are noncompliant with treatment protocols. In a world in which health care dollars are increasingly scarce, we must carefully allocate the resources we have to those who will benefit most. These decisions become far more complicated when patients and residents refuse the care that is recommended.

The consequences of noncompliance with treatment are profound. Estimates of the total annual healthcare costs in the US resulting from patient noncompliance vary from $100 billion to $170 billion to $300 billion. These costs include relapse, readmission, repeated tests and treatments, additional medications required, recurrent infections, drug resistance, and more.

Many reasons have been proposed as explanations for this seemingly self-destructive patient behavior. Lack of understanding of drug or treatment regimen, previous experiences with treatment, fear and anxiety, side effects of medication or treatment, pain and discomfort, cost of copayments or coinsurance, presence of psychological symptoms, cultural bias, and others have been identified.

To a physician it makes perfect sense to say, “I recommend this medication regimen because, left untreated, your hypertension could increase your risk of renal failure, myocardial infarction, and cerebral hemorrhage.” However, it would make absolutely no sense at all to many residents, leaving them more confused than motivated to be compliant.

Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way. One of the most effective ways to enhance compliance is to simplify the instructions or treatment regimen as much as possible. Residents should always get the sense that the members of the health team care about them and their health and respect their concerns. Finding out residents’ attitudes and past experiences can deeply affect compliance and save time and problems later.

Noncompliance with treatment has been a quality issue with which I have long been interested. I was asked to consult a few years ago with a wound care clinic in a hospital that tracked its patients and found almost 30 percent in varying degrees of noncompliance. After working with them for a while, I implemented a simple depression screening evaluation with all patients and discovered that a large percent of the patient population in the clinic suffered from some degree of undiagnosed depression. Implementing treatment for the depression reduced the noncompliance rate significantly.

There are no simple answers to this problem. It is imperative to try and determine the reasons behind the behavior. Solutions, for the most part, lie in quality education and communication between the resident and his or her caregivers.

For more information, see the Massachusetts Medical Asscoation's site: http://www.massmed.org/Content/NavigationMenu2/DifficultPatients/TheNoncompliantPatient/default.htm

Change, Part 5

2008-02-28T17:34:00Z

Parable:

Millions of years ago people lived in extended families—often with their farm animals—in houses made of wood and thatch. One day, one of these houses caught fire and burned down. A pig was inside and burned along with the house, which was reduced to ashes giving off a smell of fire and of burnt pig. The farmer returned to his house and found the pig. He touched it and burned his fingers, which promptly he put in his mouth to cool them off. In tasting the wonderful taste of roasted pig, cooking was discovered.

Thereafter, when anyone in the village wanted to celebrate, they picked a house, put a pig inside of it, and burned it down.

Moral of the story: If you don’t understand why the pig gets cooked, you are going to waste a lot of houses.

For me, this story truly reflects some of the underlying issues related to change in organizations. It seems so often that we implement changes without a thorough understanding of the issues or the need for change.

What do you think when you reflect on changes you have experienced in your own professional roles?

Change, Part 4

2008-02-19T19:25:00Z

I thought I would share an online article by Rosabeth Kanter called "The Enduring Skills of Change Leaders." The abstract in the Harvard Business Review states, “Leaders use seven leadership skills in conceiving and managing change projects, whether innovations in established organizations, culture and process changes, or entrepreneurial ventures for industry or social change. The skills leaders need are different at various phases of change projects. Offers details and also discusses the rhythm of change and resistance to change.”

Ms. Kanter says that leaders can order change, but the kind of change that is long lasting is built slowly throughout the organization with input from many people. People cannot be forced to change. Change comes from people using their imaginations and working together. People from many levels need share goals. She outlines seven classic skills useful for leaders.

1. Tuning in to the environment.

2. Challenging the prevailing organizational wisdom.

3. Communicating a compelling aspiration.

4. Building coalitions.

5. Transferring ownership to a working team.

6. Learning to persevere.

7. Making everyone a hero.

Change, Part 3

2008-02-08T15:32:00Z

Change is ever-present in our lives, both personal and professional. There are many theories of change and in an earlier posting I suggested a website that presents many such theories. One that I like very much was developed by Rosabeth Kanter, called the Big Three Model of Change. I will very briefly summarize the model as I think it may be interesting for you to consider:

The Big Three Theory of Change

•Three kinds of movement

•Three forms of change

•Three action roles in the change process

Kinds of Movement

• Macroevolutionary – historical, related to whole industries, the movement of an organization as it relates to motion in its environment; the environment is always shifting due to geographical, political, economic, demographic, and social realties

• Microevolutionary – developmental, related to the movement of parts of the organization as it grows, ages, and progresses through its life cycle; momentum is created in organization as they increase in size and its members, values, and practices change

• Revolutionary – the manipulation and struggle for power and control to make decisions or attain benefits from the organization; over time different stakeholders advance their own interests and make claims on the organization’s resources

Forms of Change

• Identity – changes in the relationships between the organization and its environment; its assets and market, its relationships to customers and other organizations

• Coordination – changes which involve the internal parts or configuration of an organization; the problems of shape and structure as it grows and ages

• Control – changes that stress the political dimension; which coalition is dominant in the organization, which set of interests predominate, who governs and sets strategy; ownership

Action Roles

• Change strategists – concerned with the organization’s direction and the connection between the organization and its environment; usually found in top leaders at the beginning of a change sequence

• Change implementers – responsible for the change effort itself, concerned with internal organizational structure and coordination; usually the mid-level managers in the middle of the change sequence

• Change recipients – those most strongly affected by the change and its implementation but without the opportunity to influence those effects; organizational staff at the end of the change sequence

Kanter, R. (1992). The Challenge of Organizational Change: How Companies Experience it and Leaders Guide it. Free Press: New York.

Change, Part 2

2008-01-29T21:10:00Z

The nature of organizations is that success in one area inevitably produces problems in another. Organizations, whatever their specific purpose, facilitate the production of problems and dilemmas; therefore there is always a need for change and change management.

However, organizations change as little as they must, rather than as much as they should.

In reality, organizations are always in motion and change is always occurring, whether guided by the leaders or not. However, change is not always planned nor desired. Those involved in controlling events or guiding change must always be aware of the forces within and around organizations. Forces that prompt change include the relationship of the organization to its environment, growth during its life cycle, and its internal and external struggle for power

So, the question is, is planned change in complex organizations possible? Or do enormous internal and external forces overcome any attempt to control them? There are limits to the potential for change as not everyone has the power to effect change and change cannot be ordered to happen. In addition, conflicts of interests may resist change. Can you relate to these ideas?

Ponder this thought: The change problem may lie within current new models of organizations and systems which are required to be focused, flexible, and innovative. However, the need for change may actually make it harder to change.

Adversity produces a necessity for change that may promote innovation. At the same time, however, scarcity of resources creates a climate less likely to embrace innovation as the organization wishes to maintain its status quo. Therefore, the ability of an organization to change significantly may be greatest when inclination to change is least. In times of plenty there are increased resources for change but less necessity.

Can any of you see this at work in your own organizations?

Change, Part 1

2008-01-22T15:38:00Z

In adopting change, often the primary goal is increased revenue or significant cost savings, a first order effect. Revenue generated or savings realized create resources that can be used in other areas, a second order effect that also influences the decision to introduce change. Third order effects, however, are often missed and represent opportunities to develop new structures or systems for organizing work.

An organization may be seen as a living system, much like a coral reef in which various elements struggle for supremacy…and even for survival. In organizations we are all in competition for increasingly scarce resources and this often shapes the decisions that are made. This reality, of course, is related to the struggle for power.

Power has been defined as the ability to influence others. The outcome of that influence is the ability to achieve our initiatives over those of others who possess less power and results in our success at the expense of another. A tough concept? To be sure, but an organizational and system reality, one well known to effective administrators.

Nonetheless, the activities of management in an attempt to solidify a power base, frequently serves only to alienate staff at all levels, disenfranchise those who have the least formal power within the organization, and reduce morale among all.

We could all probably come up with many examples of change that have NOT been planned, at least not sufficiently. The reality is that change must be approached carefully, with thought and planning, with investigation of the impact on stakeholders, and with the involvement of those who will be most affected by the change.

While a success in one area may mean the demise of another, this can be anticipated in order to minimize chaos. Change is always difficult, but chaos need not always be the result. While changes may be needed, too often the approach used is heavy-handed and brutal.