Elizabeth Layman, PhD, RHIA, CCS, FAHIMA, East Carolina University
Implementation of electronic health records and constant change in the health care delivery system have altered the nature of work in Health Information Services (HIS) Departments. Health information professionals are exhorted to work harder and to work smarter (Cassidya 2011,10; Cassidya 2011, 10).
Working harder, however, is not a long-term solution. Experts state that work overload is the primary cause of stress (Li and Shani 1991, 121). While people can make heroic efforts in unusual or extreme situations, they cannot continue at that level as a daily, work routine (Anderson and Pulich 2001, 3).
Working smarter becomes the reasonable alternative. To assist all departmental members to work smarter, health information managers and directors can redesign work and jobs. However, work and job redesign can be time-consuming tasks. To help these busy health information leaders, this paper integrates concepts from organizational theory, behavior, and context theory in a concise format. Included are indicators that signal the need for work and job redesign, factors to weigh in the redesign, and tools to generate solutions. Finally, to maximize the time of health information managers and directors, the paper concludes with a step by-step approach to work and job redesign.
At the department level, work is the overall effort to produce the desired results. Work reflects all of a department's goals. At the employee level, a job is a set of tasks, duties, assignments, and responsibilities for a class of employees. The sum total of all a department's jobs equals the department's work.
Leaders can examine their departments' alignment to achieve organizational goals at four different levels. In terms of scope, from most extensive to least extensive, these four levels are re-engineering, restructuring, work redesign, and job redesign. Re-engineering is the process of rethinking the business and systems of an organization or department. Therefore, in re-engineering, leaders scrutinize mission, structure, and policies. Restructuring is changing the organizational structure, such as reporting lines or the composition of functional units. The purpose of restructuring is to increase organizational efficiency and cost effectiveness. Work redesign is the rearrangement of the department's efforts to produce its major products and services. In work redesign, health information managers and directors rearrange work through task structure, work processes and procedures, and physical layout. In job redesign, the set of tasks of a job is changed through addition, modification, or deletion. Health information managers and directors may effect change at some or all of these levels, based upon their analysis of the indicators for realignment.
To realize their department's mission, health information managers and directors may reengineer, restructure, or redesign work and jobs. However, the most extensive changes, reengineering and restructuring, are typical the initiatives of upper administration. The likely realignments at the department level are work and job redesign.
Indicators for Realignment
In HIS Departments, work changes over time. Changes in work include its nature of work, its flow and scheduling, relationships among workers, technologies, policies and procedures, volumes of tasks, and types of tasks. Changes in work can result from events or changes in the pace of tasks or services.
Events that change work may be department-specific or industry-wide. For example, creating a mechanism that allows coders to work from home is a department-specific event. On the other hand, identity theft is an industry-wide event. Thus, protecting identity-specific information and the prevention of identity theft is a phenomenon across the nation and all sectors of industry.
The pace of changes affects on the work of HIS Departments. For example, some changes are incremental. A prime example is the slow and gradual increase in the volume of e-mail. Responding to the current volume of e-mails in the morning and throughout the day may not be factored into the task and time allocation of jobs. Yet, responsiveness is a key expectation of the "service-orientation" of many healthcare enterprises. An example of a sudden change was the implementation of the Recovery Audit program under Section 302 of the Tax Relief and Health Care Act of 2006. To HIS Departments came the new tasks of receiving, reviewing, coordinating, and tracking responses and appeals to queries and denials of Recovery Audit Contractors (RACs).
Over time, these changes caused by events and their pace modify a department's work and jobs. In the case of gradual and incremental change, this modification may be almost imperceptible to health information leaders – particularly as they are caught up in immediate and pressing tasks. However, the end result may be an alteration of work and jobs to the point of distortion, fragmentation, and overload. In the face of these misalignments, it is the responsibility of management to reorganize work and restructure jobs to for maximum effectiveness and efficiency.
Managers and directors of HIS Departments should routinely and periodically assess work and jobs for alignment with current processes. For this periodic assessment, managers and directors may use indicators of changes in work to determine whether a rearrangement is warranted. These indicators fall into three types: sector changes, organizational changes, and employees' perceptions.
At the level of the healthcare sector, changes occur on an ongoing basis because of socioeconomic events, cultural shifts, new technologies, new or revised regulations, and new or revised accreditation or certification standards. One technological change at the sector level is the transition from a paper-based environment in health care to an electronic environment. This change is not only alters the nature of work but also affects the economy, regulations, and accreditation standards.
Managers and directors of HIS Departments have a long history of responding to and preparing their organizations for sector-level changes. For example, in 1979, they implemented the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) and in 1983, the inpatient prospective payment system. Right now, they have already responded and are preparing for the implementation of the International Classification of Diseases, tenth revision, Clinical Modification (ICD-10-CM) and the ICD-10 Procedural Classification System (PCS). Moreover, they are readying their organizations for Accredited Standards Committee (ASC) X12 version 5010. In terms of the federal reimbursement systems, change is constant because of the annual updates to the systems. These sector-level changes alter the operations of HIS Departments. Therefore, in addition to assuring the readiness of their organizations, managers and directors of HIS Departments need to assess the effects of these sector-wide events on the daily routines and workloads of their individual employees.
Indicators of organizational changes include enterprise- wide initiatives and HIS Department initiatives. At the organizational level, changes may occur in goals, in patient or client population, or service mix. For example, an organization may decide to focus on improving the quality of its services, in reducing its costs, or both. The population around a healthcare organization may change. The suburb may gradually age from growing families to empty-nesters and the elderly. These demographic changes affect the case-mix and the HIS Department's work by increasing the number of Medicare cases or by requiring specialized knowledge in coding or registries. Other changes that affect the organization include regional health information exchanges, state registries for various conditions, and relocations of military bases. These events may affect the services and products of the health care organization. As the changes occur, managers and directors may assign tasks to employees. Over time, jobs may be significantly altered.
Of particular importance and at the heart of this technical paper, experts predict many new roles and, correspondingly new functions, for health information professionals. These roles and functions are emerging from the implementation of electronic health records and from future organizational needs. For example, searching between the dates of January 1, 2009 and April 30, 2011 (28 months) on the terms "role" or "roles" in the titles of documents in the Body of Knowledge (BoK) of the American Health Information Management (AHIMA) yielded 20 documents. Authors of these documents described ten different roles for health information professionals. Additionally, three roles for health information professionals emerged from the goals of the Office of the National Coordinator for Health Information Technology (Zeng et al. 2009, 3). Furthermore, the Health Information Technology for Economic and Clinical Health (HITECH) Act depicted 12 roles needed to support electronic health records and their meaningful use. Finally, basing future roles on the field's body of knowledge, analysts projected four more roles in project and financial management, globalization, and clinical terminologies and classification systems (Watzlaf et al. 2009, 5). In sum, a total of 29 new roles are predicted related to the implementation of electronic health records and meaningful use and future organizational information needs.
Initial establishment of these positions has begun. However, typically, the role is added to the set of tasks –the job-of a current employee. This practice is common and familiar to departmental members of HIS Departments. For example, the roles of privacy officer and RAC coordinator were added to the role of director of HIS Services. Thus, one employee wears many hats. This multiplicity of roles may result in fragmentation. Careful assessment of work and job is needed as these roles come on-line.
Employees' perceptions of the work environment and their jobs are another set of indicators that may signal the need for realignment. Typical of these indicators are declines in employees' performance or motivation. Examples related to performance include careless errors, minimal or low productivity, and diminished quality. Declines in motivation may be demonstrated by changes in employees' work habits and personalities, such as absenteeism, tardiness, a lack of collegiality and professionalism, negativity and dissatisfaction, stress, and burnout. At the department level, increased or high turnover may be an indicator.
Together, these three types of indicators signal managers and directors of HIS Departments that realignment is necessary. Absorbing 29 new roles will almost certainly require some level of work and job redesign. The scope of the project may be any or all of re-engineering, restructuring, work redesign, or job redesign, dependent on the extent of the misalignment
Prior to beginning the project of realignment, managers and directors should obtain the approval of their superiors, the support of the department of human resources (HR), and the buy-in of the departmental employees. The superior's approval is important because the project may result in a long-term plan to change the department's composition in terms of credentials, educational levels, or both. A change in composition may affect the department's overall budget for salaries. This compositional change also affects the department of human resources. HR Departments oversee the compensation scales, job grades, and employee recruitment. Moreover, changes in the HIS Department should be consistent with organization-wide structures. Buy-in of departmental employees is important in any change initiative. The factors to weigh, described in the next section, provide the evidence to obtain approval, support, and buy-in.
FACTORS TO WEIGH
An effective realignment balances three sets of factors. These factors include the "hard" factors of organizational structure and theory and the "soft" human factors of organizational behavior and motivation. Occasionally, these two sets of factors are contradictory – they move in opposing directions. Moreover, an effective realignment takes into account a third factor. This overarching factor is organizational context. The next section describes all three sets of factors and synthesizes the totality of their effects through comparison and contrast.
Principles of Organizational Structure and Features of Bureaucracies
The principles of organizational structure include specialization, departmentalization, unity of command, and span of control.
- Specialization – focus on a single task increases proficiency, productivity, efficiency, and cost effectiveness
- Departmentalization- grouping similar jobs into logical units increases efficiency and opportunities for economies of scale
- Unity of command-an employee having only one boss promotes clarity
- Span of control – limits, based on the complexity and diversity of tasks and the expertise of the superior, exist to the number of employees that a superior can effectively supervise
Standardization and uniform application of rules are features of bureaucracies. Standardization and uniform application of rules promote utility and fairness.
However, the positive aspects of these principles and features are balanced by their equally negative aspects. Specialization and standardization may result in tedious, repetitive tasks. This monotony may result in boredom, inattention, fatigue and stress. Offsetting the ease of administration fostered by departmentalization, unity of command, and span of control are obstacles to innovation and formulation of multidisciplinary solutions.
Structure of the Job and Motivational Actions
The structure of a job includes:
- Types of tasks that the job encompasses (unit/custom, mass/batch, process/routine; Woodward 1965, 69)
- Nature of the job (serial, parallel, unit assembly)
- Characteristics (control or autonomy, task identity, cognitive demand, responsibility, social interaction, variety, feedback) (Wall et al. 1990, 208; Boonzaier et al 2001, 13, 17)
- Demands of the job and role (quantitative work overload, qualitative work overload, role ambiguity, role conflict) (Anderson and Pulich 2001, 3, 6)
Inherent conflicts occur between aspects of the structure of jobs. For example, responsibility and control are related to worker satisfaction. However, by their very nature, some jobs are sequential and, thus, the timing of these jobs is out of the workers' control and is dependent upon the timing and achievement of others. Jobs on the "boundaries" that interact with other departments and units are prone to role ambiguity. Where does one worker's job stop and the other worker's job begin? Yet, in the complex environment of health care organizations, these cross- boundary activities are common.
Many are familiar with three commonly considered motivational actions:
- Job enlargement-addition of new tasks at the same level of skill and responsibility
- Job enrichment-addition of new tasks at higher levels of skill, responsibility, and accountability
- Job rotation-rotation of employees through jobs at the same level
The purpose of these actions is to offset the monotony of routine tasks in bureaucratic or batch environments. Offsetting monotony is often thought to motivate employees. However, rather than monotony, employees most often mention work overload as a stressor. Job enlargement and enrichment both add tasks. Employees may view these actions as adding to their stress rather than reducing it. Thus, the purpose of these actions may not match the situations in today's work environments.
The organizational context is the overarching structural and cultural patterns of an organization. Structural patterns include the industry, its typical operations, organizational size, and resources. Cultural patterns include beliefs and assumptions of all organizational members. Organizational context frames the zone of acceptable, possible solutions. Organizational members take for granted that managerial actions will occur within this set of norms and expectations. For example, if the industrial norm is centralized decision making, managers are unlikely to persuade superiors to approve job redesigns that allow line employees great latitude in autonomous decision making. Organizational context is powerful because it is imperceptible, ubiquitous, presumed, and pervasive.
Managers and directors of HIS Departments can use concepts from the hard factors of organizational structure and features of bureaucracies, the soft human factors of organizational behavior and motivation, and organizational context as they re-engineer, restructure, and redesign work and jobs in their departments. Dependent upon the perceived problem, managers and directors may take actions that strike a balance among the concepts. The following section demonstrates syntheses of the hard, soft, and context factors in response to common problems.
Boredom, careless errors, tardiness, absenteeism, low moral
Proposed solution: Introduce variety (decrease specialization)
Potential actions: Job enlargement, job enrichment, job rotation
Risks to balance: Fragmentation, quantitative overload, qualitative overload, role ambiguity, role conflict, questionable acceptance in highly centralized organization, HR concerns about pay grade, risk management concerns about licensure and credentialing
Proposed solution: Increase task identity
Potential action: Redistribute tasks so work is concurrent or unit rather than serial
Risks to balance: Qualitative overload, role ambiguity
Proposed solution: Increase control
Potential action: Allow workers freedom to schedule tasks or self-inspect quality
Risk to balance: Questionable acceptance in highly regulated industry or in environment with high accountability demands, inadequate supervision for new employees or employees lacking confidence
Logjams, gridlock, production delays due to illness or vacations
Proposed solution: Increase capacity and coverage
Potential action: Job rotation
Risks to balance: Qualitative overload, role ambiguity, potential violations of unity of command
Boredom, mediocrity, skill leveling
Proposed solution: Develop employee
Potential action: Job enrichment
Risks to balance: Fragmentation, qualitative overload, role ambiguity, role conflict, questionable acceptance in highly centralized organization, HR concerns about pay grade, risk management concerns about licensure and credentialing
Low morale, low accountability
Proposed solution: Increase autonomy
Potential action(s): Job enrichment
Risks to balance: Fragmentation, qualitative overload, role ambiguity, questionable acceptance in highly centralized organization, HR concerns about pay grade, risk management concerns about licensure and credentialing
Proposed solution: Increase responsibility
Potential action(s): Reorganize work processes so employees reap rewards of excellence or bear consequences of poor quality or services
Risks to balance: Qualitative overload, role ambiguity, inadequate supervision for new employees or employees lacking confidence, HR concerns about pay grade, risk management concerns about licensure and credentialing
Proposed solution: Increase feedback
Potential action: Reorganize work processes so employees reap rewards of excellence or bear consequences of poor quality or services
Risks to balance: Quantitative overload for supervisor, qualitative overload for peers or co-workers
Proposed solutions: Increase task identity, decrease specialization
Potential action: Redistribute tasks among the work group so employees have better cohesion among tasks and can see end product
Risks to balance: Qualitative overload, role ambiguity
Delays in decision making
Proposed solution: Reduce supervisory load
Potential action(s): Job enrichment for subordinates
Risks to balance: Qualitative overload, role ambiguity, questionable acceptance in highly centralized organization, HR concerns about pay grade, risk management concerns about licensure and credentialing
Proposed solution: Equalize supervisory load
Potential action(s): Redistribute work among supervisors
Risks to balance: Qualitative overload, role ambiguity, role conflict
Turfism, lack of team spirit
Proposed solutions: Increase task identity, increase social interaction
Potential action: Reorganize work processes so employees see product of collaborative efforts and/or must communicate with one another in process
Risks to balance: Role ambiguity, increased interpersonal conflict
Proposed solutions: Decrease routine tasks, decrease variety
Potential actions: Specialization, departmentalization, redistribution of tasks among the work group so employees have better cohesion among tasks and can see end product
Risks to balance: Qualitative overload, monotony, mediocrity
Proposed solutions: Increase task identity
Potential actions: Redistribute tasks among the work group so employees have better cohesion among tasks and can see end product
Risks to balance: Qualitative overload, role ambiguity
Tools exist to detect, identify, and analyze problems and to generate solutions. These tools use data collected by employees, supervisors, managers and directors, and external consultants. Generally, these tools show the frequency, timing, and flow of tasks in the context of applicable performance standards.
- Periodic review of work process and products: supervisory and managerial review of current work processes and products against the department's purpose and organizational mission with special attention to changes in technology, policies, standards, and regulations
- Satisfaction survey: survey of administrators, clients, and workers on their satisfaction with products, services, work environment, and organizational context
- Job Diagnostic Survey: a publicly available survey that both assesses current jobs for potential redesign to improve employee satisfaction and evaluates the effects of redesign (Hackman and Oldham 1975, 159,168)
- Performance reports: results of studies on productivity and quality
- Personnel reports: reports on tardiness, absenteeism, and turnover
- Job description review: supervisor and employee review, for accuracy and currency, content of job description
- Job procedure review: supervisor and employee review, for accuracy and currency, documentation of procedural steps
- Work distribution chart: overall view of division of work and work processes within a department by aggregating data from each job in department (time and motion studies, work sampling, logs) in terms of content, frequency, and time spent
- Flow charts: records steps of processes and procedures including time, distance, and sequence
- Time and motion study: recording and analysis of tasks within a job using stopwatches to find the most efficient methods in terms of time and effort
- Work sampling: randomized observations of employees as they perform their jobs that result in data on frequency of and time spent on the jobs' tasks
- Log: daily record of employee's activities, work-related and non-work-related, during a period. Period may be day, week, or month and time increments may be 15, 30, or 60 minutes depending upon the job's periodicity and fragmentation
Generally, the managers and directors can use these tools to identify and analyze problems. To suggest or generate solutions, managers and directors may use the periodic review of work processes, the Job Diagnostic Survey, and the work distribution chart. No simple, magic tool or procedure exists; instead, realignment requires the collaborative, creative efforts of employees and management.
Many new roles and, correspondingly, functions, are coming into HIS Departments. Managers and directors need to integrate these roles and functions into the work of their departments. The step-by-step approach summarizes the key points in realigning work and integrating these new roles to meet departmental goals.
- Detect, monitor, and collect data related to indictors of change that have the potential to affect the sector, organization, or department.
- Enlist superiors, human resource staff, and employees on the potential for redesign.
- Secure additional data, decide the extent of the realignment, determine the objective measures of achievement, and initiate plans for redesign.
- Identify potential barriers to redesign, devise solutions and contingency plans, and obtain clearance for issues related to human resources.
- Get feedback from superiors, human resource staff, and employees. If positive, implement realignment.
- Note effect of redesign and notice contributors to success and celebrate both with public recognition
The mnemonic, "DESIGN," assists managers and directors in following the step-by-step approach.
For managers and directors of HIS Departments, change is constant. In health care, change is occurring at the levels of the sector, organization, and employee. Change affects the nature, volume, and type of work in HIS departments. Change may be imperceptible or seemingly small; however, over time, even small changes can create misalignments and distortions in departmental operations. Of special note to health information professionals are the many roles and functions emerging from the transition to an electronic environment from a paper-based environment. Managers and directors may use the indicators of change to monitor environment. Environmental monitoring may provide the evidence to support re-engineering, restructuring, work redesign, job redesign, or some combination. Should these reorganizations of work be warranted, managers and directors may then systematically weigh the factors to determine their actions. Successful actions in work redesign and job redesign are a balance of the hard factors organizational theory, the soft factors of organizational behavior, and the context factors. Tools exist to identify, analyze, and solve problems in the work environment. Finally, DESIGN is a step-by-step approach to increase the likelihood of a successful redesign.
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