NU 651 Unit 1 organizational structure assessment example

How a 300-Bed Community Hospital Is Actually Wired: A Structure Assessment for a Nurse Leader Trying to Improve Patient Flow

Student Name

Department of Nursing, Herzing University

NU 651: Leading and Managing in Complex Organizations

Instructor Name

January 23, 2026

How a 300-Bed Community Hospital Is Actually Wired: A Structure Assessment for a Nurse Leader Trying to Improve Patient Flow

The Organization

The setting is a composite 300-bed community hospital, one of five hospitals in a regional nonprofit health system. It has a 42-bed emergency department, eight medical-surgical units, a 20-bed intensive care unit, and surgical services. I was recently appointed director of patient flow, a new nursing role reporting to the chief nursing officer, with a mandate to reduce emergency department boarding, the time admitted patients wait in the department for an inpatient bed. Boarding has averaged more than six hours per admitted patient for the past year. This assessment maps the structure I have to work through.

Formal Reporting Lines

The hospital president reports to the system's chief operating officer. Reporting to the president are the chief nursing officer, the vice president of quality, the vice president of support services, the chief financial officer, and the chief medical officer. Under the chief nursing officer are the directors of the medical-surgical units, critical care, the emergency department's nursing staff, and now patient flow. Under the vice president of quality are case management and social work. Under the vice president of support services are environmental services, which is run by a contracted vendor with an on-site manager, and patient transport. Pharmacy reports to the chief financial officer.

The structure groups departments by function, which is common in hospitals and efficient for running each function. It makes any process that crosses functions, such as discharging one patient so another can be admitted, dependent on people who report to different executives and are measured on different things.

The Lines Nobody Publishes

Three relationships matter more than the chart suggests. First, the chief nursing officer has a dotted-line relationship to the system chief nursing officer, who sets system-wide nursing policies, including staffing standards, that the hospital cannot change alone. Second, the on-site manager of the environmental services vendor reports formally to the vice president of support services but is measured by the vendor company on cost per cleaned room, which rewards fewer staff on evening shifts, when many discharges happen. Third, the hospitalist group that admits and discharges most medical patients is an independent contracted group. Its physicians answer to their group's medical director and to the hospital's medical staff bylaws, not to any hospital executive.

Where Clinical Authority Stops and Administrative Authority Starts

Physicians belong to a self-governing medical staff with its own bylaws, elected officers, and a medical executive committee that approves clinical policies affecting physician practice. Hospital administrators cannot direct physicians to write discharge orders earlier; they can only negotiate with the hospitalist group's leadership or propose a policy for the medical executive committee to adopt. Nursing, by contrast, sits within the administrative line: the chief nursing officer can change nursing practice directly. This split between professional and administrative authority is characteristic of hospitals, where clinicians, managers, and trustees often work in separate worlds with different logics and loyalties (Glouberman & Mintzberg, 2001). For patient flow, it means that the most important decision in a discharge, the physician's order, sits outside the line of authority I belong to.

Where Decisions About Money Are Made

Operating decisions under $50,000, such as adding hours for a transport aide, are made by the department's vice president within the annual budget. Operating changes above that amount, or any new position, need the chief financial officer and the president. Capital projects over $250,000, such as renovating space, go to the system capital committee, which meets quarterly and compares requests from all five hospitals. Any proposal I make for new space must therefore compete at the system level, not the hospital level.

Informal Influence

The chart also leaves out the people whose opinions carry weight regardless of title. On the medical-surgical units, the night charge nurses decide in practice whether a patient discharged late in the evening leaves that night or the next morning, and their view of any flow initiative spreads quickly to day staff. In case management, one senior case manager with twenty years at the hospital is the person the hospitalists call when a discharge is complicated; her support would do more for a new discharge process than a memo from her vice president. The emergency department's physician medical director, although a contractor, sits on the medical executive committee and has been the loudest voice about boarding, which makes him a natural ally on the medical staff side. And the president's executive assistant controls the executive team's agenda, which affects how quickly any proposal gets a hearing. None of these people appear as decision makers on the chart, and each can speed or stall a change.

What This Structure Means for Patient Flow

A single patient's discharge touches at least five departments under four executives: the nurse and unit manager under the chief nursing officer; the case manager under quality; the hospitalist under an outside group; the pharmacist under finance; and the environmental services worker under support services and a vendor. No one below the president has authority over all of them. Coordination across interdependent units in health care depends heavily on shared goals and communication among the roles involved, not only on formal authority (Gittell et al., 2000). The practical implication is that I will lead mostly through influence and agreements, not through the reporting line.

Three decision points will determine whether flow improves: the hospitalist group's willingness to change rounding and discharge order timing; the vendor manager's evening staffing, which depends on the vendor's cost targets; and the vice president of quality's priorities for case management. None of these three people reports to my boss.

Where to Start

Based on this map, my first conversations will be with the vice president of quality, who controls case management and shares an interest in length of stay, and the hospitalist group's medical director, whose support is needed before any policy reaches the medical executive committee. Hospital managers have been urged to work alongside clinical operations rather than manage them from a distance (Mintzberg, 1997), and in a structure this divided, early conversation is how that happens.

References

Gittell, J. H., Fairfield, K. M., Bierbaum, B., Head, W., Jackson, R., Kelly, M., Laskin, R., Lipson, S., Siliski, J., Thornhill, T., & Zuckerman, J. (2000). Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. Medical Care, 38(8), 807-819. https://doi.org/10.1097/00005650-200008000-00005

Glouberman, S., & Mintzberg, H. (2001). Managing the care of health and the cure of disease: Part I: Differentiation. Health Care Management Review, 26(1), 56-69. https://doi.org/10.1097/00004010-200101000-00006

Mintzberg, H. (1997). Toward healthier hospitals. Health Care Management Review, 22(4), 9-18. https://doi.org/10.1097/00004010-199710000-00005