Management by missions in the healthcare sector

Abstract

This article discusses the importance of the mission statement in the healthcare sector. It's also argued that only formal declaration of the mission it's insufficient to the appropriate professional coordination of doctors, nurses and managers. It's proposed a systematic approach to facilitate the introduction of the mission within the systems of the organization, what is called “Management by missions.” It promotes horizontal and vertical integration between doctors, nurses and managers. Criteria that ensure this integration are specified.

Resumen

En este artículo se aborda la importancia de la declaración de la misión en instituciones del sector sanitario; también se constata la insuficiencia de esta declaración formal para la adecuada coordinación profesional de médicos, enfermeros y gestores. Se propone un abordaje sistemático que facilite la introducción de la misión en los sistemas de la organización, lo que se denomina “Dirección por misiones”. Se explicita como esto promueve la integración horizontal y vertical entre médicos, enfermeros y gestores. Se especifican los criterios que garantizan esa integración.

Introduction

As in other industries, the mission of a hospital is its reason for being; it defines its role and associated responsibilities in the community, namely, the service it should provide to society.¹

On the other hand, when seen alongside companies of the same size in other industries, the complexity and scope of the mission of hospitals are comparatively greater. The purpose of a hospital comprises and underscores variables such as clinical care, community service, health promotion, training and research (for and by doctors, nurses, pharmacists and other participants in the sector), financial results and, in some cases, religious factors, etc.²

Taking into account the scope and importance of the studies on mission in leadership and the management of organizations in general, it is clear that the hospital industry lags far behind other sectors with respect to the design, development and use of the mission statement,³ and there is a surprisingly meager amount of research that has applied it to the healthcare sector as a whole and to the mission statement in hospitals in particular.

Desirability of health institutions having a mission

Crafting a mission statement with the proper direction is one of the most critical strategic tools for a healthcare organization to succeed,⁴ as it is an important management tool in healthcare sector organizations⁵ and guarantees the foundations for the future success of a hospital. On one hand because it sets out organizational guidelines⁶ and on the other, because it can be one of the most powerful methods for assessing the success of the hospital.⁷

In addition, it is crucial for both executives and employees in the healthcare sector that there should be a robust mission statement that they can turn to in times of uncertainty, and this because the healthcare sector is the target of a rapidly changing situation (financing, legislation, technology, etc.) which may lead the members of healthcare organizations to lose sight of the institution's reason for being. Besides, given the scope and complexity of the interprofessional relations established among doctors, nurses, managers and other healthcare professionals, employees need to have the support of the organization as a whole, to know they are supported and included in the joint efforts involved in fulfilling the mission.⁸

This is also upheld by Bart,⁹ who sustains that given the progressive complexity and dynamics of change in the healthcare sector, the mission statement has gained increasing importance in modern healthcare organizations because

• (a)

  it helps identify and focus on its critical core capabilities in order to better cope in times of change;

• (b)

  it addresses the allocation of scarce resources, simultaneously promoting operational effectiveness and efficiency, especially important during periods of budget constraints;

• (c)

  it helps react when faced with new strategies, turning the organization's focus back to its intended purpose;

• (d)

  it can compensate the breakdown in employee morale, creating an inspiring, motivating movement around the high aspirations of the organization.⁴

In another study made of the healthcare sector¹⁰ the reasons put forward to justify the mission statement were summarized as follows: focus resource allocation; motivate and inspire employees to reach a common purpose or aim; balance competing interests among the different stakeholders; ensure the alignment of the organization during a crisis; create standards of behavior; provide direction and common goals; define the challenge for the company's activities; maintain control over the organization; develop a common culture and values.

The mission in hospitals and cooperation among professionals

A well-known phenomenon that is widely recognized in the literature is that professionals in the healthcare sector – doctors, nurses, managers and others, form different groups with specific activities, organizational arrangements and ways of relating with each other.¹¹

The healthcare sector is therefore multidisciplinary, insofar as it contains several professional groups. The dynamics of interprofessional interaction by far exceeds this complexity: the organizational subcultures that coexist in the healthcare sector – doctors, nurses, managers and others, are heterogeneous, have multiple levels of identity and arrange themselves in various professional communities.¹² The way these professionals experience the sector and their responsibilities often leads them to confinement in self-contained professional silos,^13,14 which reveals certain growing complications.

In an organization as complex as a hospital, a collaborative stance with views to fulfilling the mission may help overcome organizational obstacles. In a hospital setting, collaboration presupposes a shared mission.¹⁵ Having a common culture is beneficial to professionals in that it leads them to identify with the institution and its operating model, share with others and remain motivated with altruistic aspects that benefit patients.¹⁶

So, the success factors for this collaboration may include clearly defining the mission, having a robust implementation strategy¹⁷ and striving for consistency between what is expressed in the mission and the day-to-day reality of the institution¹⁸ what it's called “managing by missions”.

Coordinating and integrating missions

If we could speak of an “implicit” connection between the corporate mission and the personal mission, many would argue that the healthcare institutions have been managing by missions for a long time. And they would have a point. Chances are, as a philosophy of action, management by missions has been in the mindset of directors and collaborators in many healthcare organizations. But speaking of “implicit” management by missions can lead to confusion rather than understanding of what we are discussing here, since we are talking about something more than a philosophy of action of “some managers” or a cultural phenomenon (in which missions are transmitted tacitly through socialization processes).

Management by missions is a systemic transformation of management, where missions are defined and, more importantly, explicitly evaluated by all members of an organization. Although management by missions starts when a company, a team or an individual defines a mission, it is not executed until the company, team or individual conducts continuous and periodic monitoring of the degree of fulfillment of these missions.^19–21

As management by missions becomes standard practice in business organizations, several forms of developing the connection between the institutional mission and the role mission of their members have emerged in the literature. Some of these are, for example, the “nested missions”,²² “shared missions”,²⁰ the “matrix of interdependencies”,¹⁸ the “leadership philosophy”,¹⁹ the “letter of understanding”,²³ or the “mission impact plan”.²⁴ These solutions seek vertical coordination of the missions (by deploying the corporate mission in cascade throughout the divisions, departments and people) and horizontal coordination (by establishing negotiation and support processes among people who have interconnected missions). In turn, they propose the integration of missions in management systems (objectives, processes, competencies, compensation, etc.).

Applying these ideas in the healthcare sector involves tackling a fundamental issue which is not always well resolved, namely, clarifying the shared mission of the 3 main groups in the healthcare sector: doctors, nurses and managers/administrators.¹¹ This should result in a vertical as well as horizontal coordination of the missions. The aim of vertical coordination is that everyone knows how they contribute to the organization's mission from their own job. As suggested by some authors,^18,21 this would be achieved through a knock-on effect of the institution's mission, beginning with each of the 3 groups, continuing down to the level of each collaborator.

In turn, horizontal coordination of the missions should seek to clarify the relations of mutual interdependence that exist among the 3 groups since, while it is important that each group understands its role mission, it is also fundamental that each group understands the mission of the other roles. In this way, doctors should fully understand the role of nurses as well as of managers (Fig. 1). And the same can be said about nurses and managers; ensuring that each collaborator understands the mission of the institution, their own, and that of the other groups with which they interact.

Figure 1.

Shared missions: deployment of the corporate mission.

According to Cardona and Rey,¹⁸ mission integration should follow 3 fundamental criteria:

Criterion of inclusion

Inclusion means that each shared mission must contribute to the accomplishment of the next higher-level mission and, ultimately, the corporate mission. In the healthcare sector, this would entail asking each of the 3 groups the following question: How does my area (doctors, nurses or managers) help to achieve the institutional mission?

For example, if we want to derive a definition of the shared missions directly from the Hospital mission and the Hospital mission is oriented toward patient satisfaction, employee development and quality of care, then each area will have to ask itself: How does our area contribute to patient satisfaction? How does it contribute to employee development? How does it contribute to providing high-quality care?

Criterion of complementariness

Complementariness ensures that there is a horizontal or logic process among the various shared missions. It is important to ensure that the shared missions adopted by the different areas or functions do not collide with one another. On the contrary, the shared missions at any given level should be complementary in every respect. Taking patient satisfaction as an example common to most hospitals’ missions,^{1,3,9,25–28} management must ensure that each area defines its contribution to patient satisfaction in a way that is complementary and no against to the way other areas define theirs. The same applies to other mission contributions, such as the contribution to employee development and quality of care.

Criterion of coherence

Coherence contemplates that all missions have common content that guarantees unity among them; in other words, that the issues of shared responsibility in the institutional mission are accurately reflected in all the next higher missions. For example, if quality of care provided to patients is included in the institutional mission, this does not only apply to doctors and nurses, but must also be included in the administrators’ missions (for example, ensuring that reports are delivered in a timely and complete fashion). Likewise, if the hospital's financial survival is included in the mission, this concern should not only be contemplated in the managers’ mission, but in the doctors’ and nurses’ missions as well. In fact, we believe that a good criterion of coherence for missions in the healthcare sector is that they all include at least 3 focal points: patient satisfaction, employee development and the sustainability of the institution.

Conclusion

Through management by missions, healthcare organizations have the opportunity to attain a greater level of identification among their members and better coordination of groups. This new form of management will offer healthcare institutions a huge potential for motivation and performance, we think of equal magnitude as the transformation that meant moving from management by tasks to management by objectives. This becomes especially evident in the matter of coordination, where the missions and other elements of an organization (structures, processes and systems) form a whole that cannot be coordinated properly if it is not considered as such.^18,29,30 Thus, further research on organizational theory based on missions is required; one that contemplates individuals from a transcendent perspective, capable of acting for reasons other than the mere satisfaction of their own needs, and considers something that is especially relevant in the healthcare sector: above all other things, the first motivation of human beings is to find a mission in their daily activities.³¹

Conflict of interest

The authors declare that there is no conflict of interest.