Stewardship as a Shared Mental Model for Health Care Management and Delivery, Part 1

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

This is the first part of a two-part series on applying stewardship theory to health care organization management and patient safety systems. The second part of this series will appear in the December 2015 issue of this newsletter.

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

addresses the relationship between the leaders and workers while providing an alternative description for how and why people are motivated to work. Although this is only one approach to viewing work relationships, this theory identifies elements in work relationships that differ greatly from the older agency theory.1 (See page 8 for a detailed comparison of

the two theories) Stewardship theory is described as a more In the stewardship model, leadership moves away from a strict

(continued on page 8)

top-down approach toward a sense of shared ownership and collaboration.

Stewardship as a Shared Mental Model

“applied and discussed within

(continued from page 1) Servant leadership has been

enlightened approach to motivate workers, and stewardship is promoted as an essential management strategy in the relationship between the hospital and the community, staff, leaders, care team, and patients.

Stewardship, as it relates to health care, is a relatively new term. In current literature, stewardship as a concept is most associated with management of antibiotic use. As early as the 1990s the judicious use of antibiotics was promoted to address the development of drug-resistant organisms due to overuse. To address overuse, the medical community in

conjunction with pharmacies developed the idea of antibiotic stewardship to promote appropriate use to decrease the development of drug-resistant organisms.

Servant leadership has been applied and discussed within the health care environment. There are similarities between servant leadership and the stewardship model, but the two approaches are synonymous. Although both models endorse trust, commitment, and core ethical/moral beliefs, servant leadership is a leadership style, whereas stewardship is a management strategy.

In 1993 Peter Block published Stewardship: Choosing Service over Self Interest which took Donaldson and Davis’ stewardship management theory straight into the health care organization.2 Accurately characterizing health care culture as historically paternalistic—Block challenged the industry to create a culture in which autonomy and trust permeate the fiber of the health care organization. He used a broad brush to provide concrete examples of how stewardship as a management model could be used to foster a shared mental model. Trust and respecting staff promotes teamwork and commitment to safe, high-quality care. Staff feel trusted by leadership to perform their work. The process and system controls built into the system are not to monitor staff productivity but are provided by leadership to assist staff in providing safe and high-quality care.

The respect, trust, and shared mental model that are so important in the stewardship model are also elements

considered essential for a culture of safety. The US Agency for Healthcare Research and Quality (AHRQ) defines a culture of safety as having a foundation of mutual trust, a shared belief in the importance of patient safety, and confidencethat preventive measures are effective.3 It is an accepted perspective that in order to create a safe and high-quality health care system, staff must be willing to report deviations that affect the quality of care. That willingness can be fostered through the creation of a culture of safety. Staff feel respected as part of the team and are willing to work toward higher levels of patient safety. A rich culture of safety is essential if health care is to reach high reliability status.

the health care environment. There are similarities between servant leadership and the stewardship model, but the two approaches are

synonymous. ”

The Joint Commission’s Leadership (LD) Standard LD.03.01.01 requires accredited organizations to create and maintain a culture of safety and quality throughout the hospital. (See “Related Requirements” on page 9 for the complete standard.)

Understanding Agency Theory

Before delving into stewardship as a management methodology, understanding the older agency theory approach is helpful. Developed in the mid-1970s, agency theory is baded on the concept that different entities operating within an organization may possess different goals, visions, and strategies.1 However, due to the nature of work requirements entities must work in concert.4 In the agency theory model, no distribution of power is in place,

and leadership exerts power over the workers through control mechanisms and delegation. A foundational belief in the theory is that the agent (worker) focuses on self-interest,

with an aversion toward self-risk. The motivational forces for the agent come from extrinsic sources.5 The agent will not pursue the goals of the company unless a promotion or a paid bonus is presented as a motivator. The agent focuses on enhancement of personal gains in deference to what might benefit the principal or the organization.6

Trust between the principal and agent does not exist, and hence the leader will establish process and system controls so agent work can be verified.7 Controls are applied in an attempt to ensure that the agent is creating adequate output. The relationship between principal and agent lacks components of collaboration in which trust can be fostered.

We can all identify characters that demonstrate this type of work relationship. (Cartoon character Fred Flintstone’s relationship with his boss, Mr. Slate, comes to mind.) Nevertheless, agency theory doesn’t explain the worker who is a loyal operative for the company when no promotion or monetary bonus is held in the balance. This theory does not account for workers who are fully engaged in striving toward the company’s success and striving to have a positive impact

Related Requirements

Standard LD.03.01.01

Leaders create and maintain a culture of safety and quality throughout the hospital.

Elements of Performance for LD.03.01.01

1. Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.

2. Leaders prioritize and implement changes identified by

the evaluation.

3. Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives.

4. Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety.

Leaders create and implement a process for managing behaviors that undermine a culture of safety.
Leaders provide education that focuses on safety and quality for all individuals.
Leaders establish a team approach among all staff at all levels.
All individuals who work in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and quality. (See also LD.04.04.05, EP 6)
Literature and advisories relevant to patient safety are available to all individuals who work in the hospital.

10. Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital.

Standard LD.03.06.01

Those who work in the hospital are focused on improving safety and quality.

Elements of Performance for LD.03.06.01

1. Leaders design work processes to focus individuals on safety and quality issues.

3. Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment, and services. (See also IC.01.01.01, EP 3)

Note: The number and mix of individuals is appropriate to the scope and complexity of the services offered.

Those who work in the hospital are competent to complete their assigned responsibilities.
Those who work in the hospital adapt to changes in the environment.
Leaders evaluate the effectiveness of those who work in the hospital to promote safety and quality.

on company performance and financial success. So why would a worker who has no financial stake in the company hold a work philosophy that is focused on company growth and success? From the disciplines of psychology and sociology, a newer theory emerged to address these questions and explain this complex relationship between the principal and the agent.

Stewardship Theory
The word steward is derived from the eleventh-century word stigwaerd, which translates into “warden of a house.”8 The steward was expected to cultivate and improve the owner’s possessions devoid of any thoughts of self-interest or self-gain.9 In medieval times, the steward acted as the landowner’s servant, responsible for all aspects of running the home and land. Given great responsibilities, the steward was dedicated to the goals of the landowner. The steward
was expected to maintain and improve whatever he had been given charge of by the owner and with total dedication to the owner’s goals and visions.
Stewardship, simply put, is a willingness to be responsible for something you do not own. In this model,
while under your watch, you do whatever is possible to improve an organization’s present state.2 Decisions are made with concern for the greater good rather than any benefits to the individual. Thus, the opportunistic self-serving agent is replaced with a steward who displays pro-organizational behaviors and one that works for the common good above self-interest.10
This dynamic is essential to designing an effective patient safety system. For example, Joint Commission Standard LD.03.06.01 requires those who work in the hospital to be focused on improving safety and quality. (See “Related Requirements” above for complete standard.) A shared mental model built on trust helps supply a foundation for this kind of mind-set.
The steward is driven by intrinsic motivation. This is key in the stewardship model.7 Trust is established between workers and managers, allowing for the development of a shared mental model.6 A shared mental model is a mental representation of knowledge regarding key components of a group.11
(continued on page 10)
Stewardship as a Shared Mental Model
(continued from page 9)

Within a group of workers, a shared mental model is essential for trust to exist. The system and process controls seen in agency theory are no longer required, because leadership trusts that the worker will complete the tasks. Leadership adopts a perspective of personal humility creating interactions in which worker successes receive praise. This
in turn contributes to the creation of a culture in which workers feel successful.12 The following four criteria are hallmarks of the stewardship management model:
1. Focus on the greater good
2. Distribution of power
3. Loss of control systems
4. Sense of autonomy

Focus on the Greater Good

The steward achieves personal satisfaction from a sense of accountability. The individual is willing to protect the

long term welfare of others with less for personal interests.13 Within the stewardship model, people feel a moral obligation to act in ways that are consistent with the mission and goals of the company.14 The steward will have a commitment

to not only present but future stakeholders.6 The ethical steward honors obligations toward all stakeholders’ welfare, growth, and wholeness.15

Literature frequently paints the picture of stewardship as something intermittently practiced by leadership. If

not a critical component in the organization, stewardship may occur in specific situations consistent with individual motivations and perceptions.10,16 But the concept of the stewardship organization should not be abandoned, because it has been hardwired into very rigid institutional environments with great success.7

Distribution of Power

Stewardship means that management has made a deliberate choice to distribute power in an orderly fashion.2 Because of

“

Within a group of workers, a shared mental model is essential for trust to exist. The system and process controls seen in agency theory are no longer required,

as leadership trusts that the worker will complete the tasks. Leadership adopts a perspective of personal humility creating interactions in which worker

successes receive praise. ”

this distribution of power, stewardship is not confined to the leader-worker relationship; this can be practiced at any level of the organization.

Ethical stewardship holds firm commitments to all stakeholders through a shared governance approach while holding on to institutional mission and purpose.17 The steward regards the autonomy within the relationship with great respect and care.

Loss of Control Systems

In the stewardship theory model, the emphasis is not on development of controls to validate worker productivity. The trust between worker and leader discourages the need for controls to validate or refute worker accountability.

The focus is on service rather than control, because there is a shared vision for success. Hernandez conceptualizes stewardship as follows6, p. 122 :

“. . . not created through formal rules but rather is facilitated through organizational structures that help leaders to generate interpersonal and

institutional trust, clarity regarding organizational

strategy, and intrinsic motivation in followers, which, in turn, encourages followers to act with moral courage in service to the organization. . . .”

Because of intrinsic motivation, controls are unnecessary and possibly counterproductive.13 Block states, “Stewardship as a governance strategy forces attention on distribution of power, purpose and rewards.”2(p. 23) Stewardship governance can use reward systems that foster employee desire to do the work, however the employee believes in his or her ability

and work product.18 This belief in contribution is the true motivator for why they work so hard for the organization. Intrinsic motivation is key to stewardship, and over- monitoring of employees drastically destroys their trust and autonomy.7

Sense of Autonomy

Organizations that are wedded to the top-down mentality are not candidates for adoption of the stewardship model of management. As leadership fosters employee autonomy, employee motivation to perform is accentuated. Shared influence fosters an inclusive culture in which workers feel a sense of autonomy and have collective responsibilities for work products.19 However stewardship leadership is not paternalistic, and this is very apparent in how leadership communicates with staff.

Instill and foster employees’ belief that they are self- directed in the work they do so that theyare committed to the high-quality work product are important components of the stewardship model of management. It should be evident to employees that they are valued by their leadership and empowered to make changes to improve systems and processes. Ultimately it is leadership that supports the actions of their employees, ensuring that the employee feels he or she is an important part of the organization. TS

References

Jensen MC, Meckling WH. Theory of the firm: Managerial behavior, agency costs and ownership structure. J Financ Econ . 1976 Oct;3(4):305–360.
Block P. Stewardship: Choosing Service over Self-Interest. San Francisco: Berrett-Koehler Publishers, 1993.
Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. AHRQ Publication No. 04-0041. Rockville, MD: US Agency for Healthcare Research and Quality, 2004. Accessed Oct 8, 2015. http://www.ahrq
.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety

/patientsafetyculture/hospital/resources/hospcult.pdf.
Eisenhardt KM. Agency theory: An assessment and review. Acad Manage Rev. 1989 Jan;14(1):57–74.
Wasserman N. Stewards, agents, and the founder discount: Executive
compensation in new ventures. Acad Manage J. 2006 Oct;49(5):960–976.
Hernandez M. Promoting stewardship behavior in organizations: A leadership model. J Bus Ethics. 2008 Jun;80(1):121–128.
Segal L, Lehrer M. The institutionalization of stewardship: Theory, propositions, and insights from change in the Edmonton Public Schools. Organization Studies. 2012 Feb;33(2):169–201.
Paterson J. Conceptualizing stewardship in agriculture within the Christian tradition. Environ Ethics. 2003; 25(1):43–58.
Welchman J. The virtues of stewardship. Environ Ethics.
1999;21(4):411–423.
Davis JH, Schoorman FD, Donaldson L. Toward a stewardship theory of management. Acad Manage Rev. 1997 Jan;22(1):20–47.
Mohammed S, Klimoski R, Rentsch JR. The measurement of team mental models: We have no shared schema. Organ Res Methods. 2000 Apr;3(2):123–165.
Collins J, Powell S. Spotlight: The characteristics of level 5 leadership.
Management Decision. 2004;42(5–6):709–716.
Hernandez M. Toward an understanding of the psychology of stewardship. Acad Manage Rev. 2012 Apr;37(2):172–193.
Caldwell C, et al. Ethical stewardship—The role of leadership behavior and perceived trustworthiness. J Bus Ethics. 2008 Mar;78(1–2):153– 164.
Caldwell C, Bischoff SJ, Karri R. The four umpires: A paradigm for ethical leadership. J Bus E thics. 2002 Mar;36(1–2):153–163.
Donaldson L, Davis JH. Stewardship theory or agency theory: CEO governance and shareholder returns. Australian Journal of Management. 1991 Jan;16(1):49–65.
Caldwell C, Hayes LA, Long DT. Leadership, trustworthiness, and ethical stewardship. J Bus Ethics. 2010 Nov;96(4):497–512.
Sundaramurthy C, Lewis M. Control and collaboration: Paradoxes of governance. Acad Manage Rev. 2003 Jul;28(3):397–415.
About the Authors

Ronald M. Wyatt, MD, MPH, is the medical director in the Division of Healthcare Improvement at The Joint Commission. Wyatt promotes quality improvement and patient safety to internal and external audiences, works to influence public policy and legislation for patient safety improvements, and serves as the lead patient safety information and education resource within The Joint Commission.

Kimberly S. Anderson-Drevs, RN, MSN, CPPS, is a patient safety specialist and TeamSTEPPS master trainer in The Joint Commission’s Office of Quality and Patient Safety. Anderson-Drevs assists health care organizations that have experienced a sentinel event in identifying root causes and identifying actions to prevent recurrence.
Donaldson L. Ethics problems and problems with ethics: Toward a pro-management theory. J Bus Ethics. 2008 Mar;78(3):299–311.