Politics and Medical Organizations
No, this is not a discussion of payment reform or any of the other discussions in our national life. Michael Jarrett has recently set out four types of organizational politics and limned the pros and cons of each. Most physicians would react in horror at the notion of “playing politics.” To us, medicine is about what is the right course of action. Our need for plausible certainty, based on medical “facts,” drives a lot of our behaviors. And, of course, organizational politics can be self-serving and destruction.
This aversion to “politics” is not confined to physicians, of course. But Jarrett has a specific definition in mind in which organizational politics is both inevitable and possibly productive.
“Organizational politics refers to a variety of activities associated with the use of influence tactics to improve personal or organizational interests. Studies show that individuals with political skills tend to do better in gaining more personal power as well as managing stress and job demands, than their politically naïve counterparts. They also have a greater impact on organizational outcomes.”
He maps organizational politics along two dimensions. The first is the source of power—informal or formal. The second is the level where the political activity takes place—personal or organizational. This leads to a 2 x 2 square. Jarrett calls it “the weeds” when the power is informal and operates at a personal level. He calls it “the woods” when power is informal, but operates at the organizational level. He terms power that is formal, but operating at the personal level “the rocks.” But when the power is formal and operates at the organizational level, politics is the “high ground.”
In the weeds, personal influence and informal networks rule. This is an organic development and characterizes most physician groups and the way doctors characteristically operate in hospitals and other medical organizations. These systems can help keep an organization true to its mission even when the leadership is distracted or dysfunctional.
“But the weeds, if left unchecked, can also form a dense mat through which nothing else can grow. In these circumstances informal networks can be a countervailing force to legitimate power and the long-term interests of the organization.”
I suspect many hospital administrators would see their medical staff as the dense mat blocking necessary changes to cope with the changing reimbursement environment. Of course, the truth is that constructive dialog, rather than brute force, is more likely to help medical organizations maintain their inherently dual focus—patient care and financial survival.
Jarrett calls the mix of individual interactions and formal power “the rocks” because is can be a “stabilizing foundation that keeps an organization steady in times of crisis. But conversely, the sharp edges of hard power can wreck a plan.”
He characterizes the “high ground” as the combination of formal authority and organizational system. A pejorative term for this, though is bureaucracy. In an overly bureaucratic organization, “rules are used as a political device to challenge interests not aligned with the bureaucrats, or to prevent innovation and change.”
Certainly all medical organizations, confronted with the highly regulated nature of the business, have the challenge of having enough bureaucracy to keep the organization operating “inside the lines.” But, at the same time, it is the responsibility of senior leadership to make sure these same structures do not prevent adaptation to changing clinical and financial imperatives. In my opinion, this is where a combination of physicians and administrators who work together well can be most powerful. The physicians (and nurses) can make sure the patient does not get lost in the bureaucracy, but the administrators can make sure the clinicians operate within the constraints of regulatory authorities. Of course, creating and maintaining this sort of dynamic equilibrium is difficult and, if my experience is representative, uncommon.
“In addition to their formal processes and guidelines, organizations also have implicit norms, hidden assumptions, and unspoken routines—and that’s where we get into the woods.” Jarrett notes strong implicit norms can define what is even discussable. I was appointed to a board committee at my hospital more than a dozen years ago. In addition to two board members, the meeting was attended by the senior leadership team and a mix of formal and informal physician leaders. The implicit protocol was NEVER to admit there was a problem or a challenge nor that the solution was not already in progress. I like to think my incessant challenges to this set of implicit norms helped lead the committee to where it is now—discussing problems and outlining various to mitigate the problem. Of course, it also helped that the previous approach was not working anymore so there was real interest in changing the rules.
The takeaway, of course, it that all four types of politics are operating in every organization, but given the dual responsibility of medical organizations to both deliver care and stay financially solvent, the challenges are even more severe. I think it is appropriate for physicians to recognize and use all four sorts of influence to further the care of patients. What I don’t think is appropriate, though, is to mix patient care with economic concerns in a coercive manner. For the physician, this has usually been “If you don’t give me what I want, I will admit my patients to Elsewhere General.” And for the administrator it is “If you don’t give me what I want, you will lose your staff privileges.” Unfortunately, both still occur with the end result that no one wins.
12 May 2017
 Jarrett, M. The 4 Types of Organizational Politics. Harvard Business Review, 24 April 2017. Accessed 24 April 2017 at https://hbr.org/2017/04/the-4-types-of-organizational-politics.htm.
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