NR 534 Week 2 System Structure Analysis Example

System Structure Analysis: Eight Decisions in a Nine-Building Health System Listed Before the Chart Is Drawn, With Who Signs Each One, Who Is Only Consulted, and the Two Local Boards the System Chart Leaves Out

Student Name

College of Nursing, Chamberlain University

NR 534: Healthcare Systems Management

Instructor Name

Month Day, Year

System Structure Analysis: Eight Decisions in a Nine-Building Health System Listed Before the Chart Is Drawn, With Who Signs Each One, Who Is Only Consulted, and the Two Local Boards the System Chart Leaves Out

Why Start With Decisions

The regional health system I work in publishes an organizational chart that looks like most others: a system board, a system chief executive, system chiefs for nursing, medicine, finance and operations, and presidents for each of its nine buildings. The chart shows who reports to whom. It does not show who decides what, and in a multi-hospital system those are different questions. A site president reports to the system chief operating officer, but that does not tell a nurse manager whether the site president or a system committee decides which infusion concentrations her unit uses.

This analysis therefore starts with a list of eight decisions that affect nursing practice and records, for each, who signs, whose views must be sought and who only hears afterward. The structure is then described from that list. The decisions were chosen because each has come up in the system's nursing practice council in the last year. For each, I checked the governing document: system bylaws, the medical staff bylaws of the tertiary center, the pharmacy and therapeutics committee charter, the capital policy and the system nursing practice council charter.

The Decisions

Table 1 lists the eight decisions.

Table 1

Eight Decisions and Who Makes Them

What the List Shows

Read as a whole, the list describes a system that has centralized clinical standards and money while leaving people and staffing at the sites. Every decision about what care looks like, including which drugs, which concentrations and which practice policies, is signed at system level. Every decision about who delivers care and how many of them are on a shift is signed at the site. Capital above a threshold is central; operating budgets are set centrally but spent locally.

This division has a logic. Clinical standards gain value from being the same everywhere, especially when staff and patients move between buildings. Staffing depends on local volume, labor markets and facilities, which a system office cannot see day to day. But the division also creates tension. A system standard can require resources that only the site can provide. When the system pharmacy and therapeutics committee sets a norepinephrine concentration, the critical access hospitals must find a way to prepare it with a pharmacy that is closed at night, yet neither the committee nor the system chief nursing officer controls their pharmacy staffing.

Consulted Is Not the Same as Deciding

The third column of the table matters as much as the second. The system nursing practice council, which includes a nurse from every site, is consulted on practice policies and standard concentrations but signs neither. Its charter describes it as advisory to the system chief nursing officer. Site chief nursing officers are consulted on system policies but can only add site addenda that make a policy stricter, not looser.

For nurses at the smaller sites, this means that decisions affecting their practice are made in rooms where their voice is one of nine, and advisory. That is not unusual in consolidated systems. Research on the effects of hospital acquisitions has found that becoming part of a larger system does not automatically improve quality, and one study of acquired hospitals found patient experience scores slipping modestly after acquisition while readmission and death rates showed no significant difference (Beaulieu et al., 2020). Whether a system improves care at its smallest sites depends partly on whether those sites can shape the standards they are asked to meet.

The Boards the Chart Leaves Out

The published chart shows one board. In fact, both critical access hospitals retain their own local governing boards, because they were acquired under agreements that kept local governance and because each licensed hospital must have a governing body responsible for its operation. The system board delegates many decisions to management, but each local board must formally adopt certain policies for its own hospital, including medical staff bylaws and some patient care policies. The chart does not show these boards at all.

In practice, this means that a system policy is not in force at a critical access hospital until its board has adopted it. The local boards meet quarterly. A system policy approved in January may therefore not take effect at the two smallest sites until April. Anyone planning a system rollout who reads only the chart will miss this step.

What the Structure Costs and Offers

Analysts of health care consolidation have cautioned that the expected benefits of integration, including standardization and coordination, have been slower and smaller than promised, partly because integrating clinical practice is harder than integrating ownership (Burns & Pauly, 2018). Others have argued that size alone does not guarantee quality and that systems must show how scale translates into better care (Tsai & Jha, 2014). Our structure shows both the promise and the difficulty. Central control of clinical standards makes a single norepinephrine concentration possible. Local control of staffing and the local boards mean that the system cannot deliver that standard at every site simply by deciding it.

Implications for Nursing Leaders

Three implications follow. First, a nurse leader proposing a system standard must plan for the site resources it requires and name who will provide them, since the committee that signs the standard does not control them. Second, the system nursing practice council should be given authority to sign at least some practice standards, or its advisory role should be stated plainly so that site nurses understand where decisions are made. Third, every system rollout plan should include the local board calendars for the critical access hospitals. A structure analysis is useful only if it changes how people plan, and these three changes follow directly from reading the decisions rather than the boxes.

References

Beaulieu, N. D., Dafny, L. S., Landon, B. E., Dalton, J. B., Kuye, I., & McWilliams, J. M. (2020). Changes in quality of care after hospital mergers and acquisitions. New England Journal of Medicine, 382(1), 51-59. https://doi.org/10.1056/NEJMsa1901383

Burns, L. R., & Pauly, M. V. (2018). Transformation of the health care industry: Curb your enthusiasm? The Milbank Quarterly, 96(1), 57-109. https://doi.org/10.1111/1468-0009.12312

Tsai, T. C., & Jha, A. K. (2014). Hospital consolidation, competition, and quality: Is bigger necessarily better? JAMA, 312(1), 29-30. https://doi.org/10.1001/jama.2014.4692