Stewardship as a Shared Mental Model for Health Care Management and Delivery, Part 2

By Kimberly S. Anderson-Drevs, RN, MSN, CPPS, and Ronald Wyatt, MD, MHA

S

tewardship theory emerged in the early 1990s to provide a different perspective of work relationships. The theory addressed

the relationship between leaders and workers while providing an alternative description for how and why people are motivated to work with regard to their alignment with the employing entity.1 This is the final installment of a two-part series on applying stewardship theory to health care organization management and patient safety systems.

Relationship Based on Trust

Developing relationships is a critical task for leaders. Research demonstrates that leaders who have developed relationships that foster shared commitment and ownership by subordinates had a

great propensity to develop long term trust.2 Effective stewardship of health care resources benefits the entire

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community.

Stewardship as a Shared Mental Model

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The cornerstone of stewardship theory is that a worker can be trusted with something of value that he or she does not own, but will work toward improving. In such relationships, two key characteristics can be seen: humility and benevolence. leader’s exhibition of personal humility (while praising the success of others) contributes to a culture in which people feel successful in their work.3 Benevolence is the extent to which staff believe the leader is trustworthy with the goal to do well by staff in deference to any self-gain.4

In this management philosophy, leaders partner with employees and consider employees the organization’s most valuable resource. To be successful, leaders must be committed to this model in the long term. Short-lived stewardship erodes trust, and once destroyed, it can take years for that trust to be regained.

Achieving a Shared Mental Model

The establishment of trust contributes to the development of a shared mental model in an organization, in which behaviors of the manager align with the interests of the principal. All parties involved place great value on goal convergence.5 Thus, a shared mental model emerges among leaders and employees that includes the organization’s goals and vision.

In stewardship theory, leaders place greater value on collective (rather than individual) goals, with the steward understanding that the organization’s successes are achieved through collaboration among leaders and employees. Stewards are motivated by intrinsic rewards such as reciprocity and mission alignment rather than

extrinsic rewards. The steward understands he or she has a responsibility toward the long term welfare of others and the greater good.6

To develop stewardship as a shared mental model, critical components must be in place. For instance, management must believe in the abilities of employees. Leaders also must be comfortable relinquishing control so that self-direction and autonomy can flourish among staff. Leaders and employees must be able to demonstrate their commitment to a greater good, which becomes integral

to the organization’s culture. All of the work and energy performed by leadership, physicians, and staff reflect that shared mental alignment.

Health Care Managers as Stewards

The for-profit sector of health care has undergone a growth explosion. As the health care community continues to evolve, it is critical for health care stakeholders to maintain their focus on the common good and the well-being of patients. This can be a complicated proposition. Health

care leaders struggle to balance the needs of patients with shareholder expectations. The consolidation of hospitals into large national conglomerates has also blurred the lines between hospital and community. It is hard to fathom a relationship with the community when the health care system spans multiple geographical locations.

Health care disciplines are founded on public service, and decisions should be made with regard to what is best for the common good of patients and not solely on technology or economic criteria.7 The health care steward works toward promoting and engaging actions that improve the patient’s situation.8 “Stewardship is a metaphor or expression . . .

to describe the ethical responsibilities and obligations of a discipline” to the body that it serves.7(p. 108)

The health care industry often sees hospital executives paid millions of dollars each year in compensation based on expectations that are unrelated to the well-being of patients. The efforts of some leaders may be solely focused on increasing services and technology to grow the health care system, rather than improve patient outcomes.9 The consumer may rightly question whether a not-for-profit hospital should lose related tax benefits when it focuses more on self-interest and profits in deference to the pursuit of what would benefit the community it is supposed to serve.10

Physicians as Stewards

Much of the discussion of stewardship in health care is focused on organization leaders. However, physicians are also important stewards. Faced with continually increasing health care costs and stagnating hospital financials, physicians

must remain conscious of the cost of care, treatment, and services. The physician must offer options that are expected to positively impact patient outcomes while using resources appropriately.

To maximize physicians’ potential as stewards, they need evidence-based policies that guide practice and treatment decisions. Stewardship is a multilevel prospect, with the national and state level at the top, followed by payers and government payer entities, and finally the practice level.11 At all levels, actions must be centered on improving the health of the population.

A national- or state-level entity would engage health care institutions as primary stakeholders, acting as a “steward for stewards.”11 It would perform the following functions12:

• Formulate strategic policy

• Ensure that policy objectives and organizational structures and cultures are copacetic

• Ensure the availability of tools for implementation

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  Stewardship as a Shared Mental Model

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• Build coalitions and partnerships

• Generate intelligence

• Ensure accountability

Such a framework would inform actions taken at the payer level and the practice level. Physicians are principally

involved at the practice level, and their role as stewards is twofold13:

1. The judicious offering of cost effect health care services and products.

2. Providing beneficent care to their patients

   
   

   Consider this example: When recommending courses of treatment to a patient identifies two optimal approaches

   
   

   

   Stewardship and the Health Care Commons

   
   

   Stewardship occurs not only within a single organization, but across entire systems. For example, the collaboration and integration among health care systems that is currently under way in the United States is a form of local and regional stewardship. This is referred to as stewardship of the health care commons. The commons is a shared resource to which any member has access.1 If the commons is not governed, the result is destruction of the commons. The steward must have the authority to manage the commons.

   Stewardship of a health care commons demands local action, single organizations and systems of care, and a set of governing principles. Elinor Ostrom, who won the Nobel Prize for economic sciences is 2009, described eight design principles of stable local common pool resources2:

   1. Boundaries are clearly defi

1. Congruence between appropriation and provision rules

2. Collective choice processes that enable the most affected individuals to participate in rule making

3. Monitors that are accountable to appropriators

4. Graduated sanctions are applied if rules are violated.

5. Participants are involved in accessible, low-cost

   confl resolution.

6. Appropriators have rights to self-organize and devise their own institutions that are recognized by authorities.

7. Nested enterprises for appropriation, provision rule- making, monitoring, enforcement, confl resolution, fi coordination, and evaluation

   Ostrom’s principles might hold solutions on how to better steward community health, better quality of health, and lower cost of care in a sustainable way.3 Although a comprehensive discussion of concepts of governing the commons is beyond the scope of this article, they are

   important to understand when considering the design of health care as micro-commons.4 The health care micro- commons is the fi physical, human, and social resources that are used in the health care delivery system and made available to communities. A program that effectively manages the health care commons could save money, improve health, and increase health care worker satisfaction. Such a program would be very diffi to implement, due to obstacles such as the following4:

   • Ambiguous boundaries

   • Diverse stakeholders

   • Lack of mutual understanding of how systems respond to combinations of new systems

   • Competition

   • Lack of data sharing, suspicion from regulators and consumers

Obstacles such as these can be countered or mitigated by the setting of a national agenda to promote stewardship, evaluation of current medical practice, and a renewed focus on social determinants of health, particularly disease prevention and health promotion.5 Stewardship

of the health care commons will require clinicians to form stronger links with patients. More activated clinicians

in the health care commons will result in appropriate allocation and utilization of the common pool of health care resources and measurable improvements in patient safety and health care outcomes.

References

1. Hardin, G. (1968). The tragedy of the commons. Science. 1968 Dec 13;162(3859):1243–1248.

2. Ostrom E. Governing the Commons: The Evolution of Institutions for Collection Action. Cambridge, UK: Cambridge University Press, 1990.

3. Berwick DM. The moral test. Keynote address of 23rd Annual National Forum on Quality Improvement in Health Care, Orlando, FL, Dec 7, 2011.

4. McGinnis, MD. Caring for the health commons: What it is and who’s responsible for it. Working paper W13-5. Presented at the Vincent and Elinor Ostrom Workshop in Political and Policy Analysis, Indiana University, Bloomington, IN, Feb 20, 2013.

5. Block DJ. Healthcare Stewardship. Bloomington, IN: iUniverse, 2009.

   that differ greatly in cost, the anticipated patient outcomes must be very similar. The physician has a moral obligation to discuss both treatments, but may recommend the lesser- costing treatment.13 The physician would be failing the patient ethically if he or she promotes or offers only the most expensive treatment. If offering only the most expensive treatment, the care could still be considered beneficent— however, the physician would have made a wasteful decision.

   

   trusting relationships with staff. Trust allows the employee to be comfortable managing his or her own work flow, leading to a sense of ownership and accountability. The employee who trusts leaders and the system will be more comfortable alerting leaders of safety issues, process deviations, or system failures, thus improving the quality of care. TS

   Neither of these aspects of physician stewardship is

   currently covered in any depth in medical education.14 Medical education should address both stewardship roles as part of a curriculum that emphasizes patient-centered care and transparency. Berwick and Finkelstein identified stewardship as one of the following critical curriculum components that is needed for the next generation of providers14:

   • Patient-centered care

   • Awareness of economics

   • Social stewardship

   • Reduction of waste while pursuing patient safety

   • Making health care available to all

   • Honest disclosure and transparency

   • Teamwork with embedded accountability between team members

   • Eliminations of unprofessional behavior

The Path Forward

First and foremost, health care professionals are all stewards to the patient. We do this by guiding and facilitating care, treatment, and services with the goal of safe and high- quality care. Safe and high-quality care is the shared mental model that should be universal in the health care industry. This shared mental model ultimately will promote better patient outcomes without drastically increasing health care costs.

All health care professionals need to realize their role as a steward to the patient. Physician and management leaders must embrace stewardship and encourage adoption of its principles throughout their organizations. Leaders who adopt the stewardship management model lay the foundation for

References

1. Chemers MM. An Integrative Theory of Leadership. Mahwah, NJ: Lawrence Erlbaum Associates, 1997.

   

2. Maslyn JM, Uhl-Bien M. Leader–member exchange and its dimensions: Effects of self-effort and other’s effort on relationship quality. J Appl Psych. 2001 Aug;86(4):697–708.

   

3. Collins J, Powell S. Spotlight: The characteristics of level 5 leadership.

   Management Decision. 2004;42(5–6):709–716.

4. Mayer RC, Davis JH, Schoorman FD. An integrative model of organizational trust. Acad Manage Rev. 1995 Jul;20(3):709–716.

   

5. Van Slyke D. Agents or stewards: Using theory to understand the government-nonprofit social service contracting relationship. J Public Adm Res Theory. 2006;17(2):157–187.

6. Hernandez M. Toward an understanding of the psychology of stewardship. Acad Manage Rev. 2012 Apr;37(2):172–193

7. Milton CL. Stewardship and leadership in nursing. Nurs Sci Q. 2014 Apr;27(2):108–110.

8. Haase-Herrick KS. The opportunities of stewardship. Nurs Adm Q.

   2005 Apr–Jun;29(2):115–118.

9. NJBIZ. Medical millionaires: The compensation packages of hospital heads are drawing attention. Fitzgerald B. Mar 5, 2014. Accessed Nov 10, 2015. http://www.njbiz.com/article/20140305/NJBIZ01

   

   /140309913/medical-millionaires-the-compensation-packages-of

   

   -hospital-heads-are-drawing-attention.

10. Maynard GF, Rice JA. Governing Healthcare Foundations at the Dawn of the 21st Century. Falls Church, VA: Association for Healthcare Philanthrophy, 1998.

11. Reuben DB, Cassel CK. Physician stewardship in health care in an era of finite resources. JAMA. 2011 Jul 27;306(4):430–431.

12. Travis P, et al. Towards better stewardship: Concepts and critical issues. In Murray CJL, Evans DB, editors: Health Systems Performance Assessment: Debates, Methods and Empiricism. Geneva: World Health Organization, 2003, 289–300.

13. Jansen LA. Between beneficence and justice: The ethics of stewardship in medicine. J Med Philos. 2013 Feb;38(1):50–63.

14. Berwick DM, Finkelstein JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new “public interest.” Acad Med. 2010 Sep;85(9 Suppl):S56–65.