Manager Span of Control
Organizations identified a number of strategies that are being implemented that may assist in alleviating the negative impact of a wide manager’s span of control. However, many of the strategies reported were not isolated to addressing the impact of large span of control and the impetus for implementing the strategies were a result of a number of factors.
A thematic analysis was conducted of the strategies and tools reported by each senior nursing leader and only the strategies that have a frequency of three or greater are presented in detail in this report.
The key informant interviews were conducted with senior nursing leaders/executives. These nursing leaders provided a different perspective on the type of strategies to manage span of control than those provided by managers in the survey. Their perspective provides a broader scope focused on organizational strategies and included:
• Redesign of the patient/client services organization structure
• Changes to the model of care
• Redesign of the manager role
The strategies are further described below by health sector and by hospital type where applicable.
As well sample documents from organizations can be found in Appendix E and include the following:
• Role Profile, Patient Care Manager, Sunnybrook Health Sciences Centre
• Model of Care - Coordinated Care Team, Toronto East General Hospital
• Model of Care – Coordinated Care Team evaluation results, Toronto East General Hospital
• Model of Care – Potential Core Team Compositions, Toronto East General Hospital
• Role Description, Manager, Windsor Regional Hospital
• Organization Chart, Vice President Acute Care & Chief Nursing Executive portfolio, Windsor Regional Hospital
5.2.1
Structure Redesign
The most frequent strategy implemented was the redesign of the patient/client services portfolio structure. This strategy was inherent in both the long-term care and hospital sectors and again their strategy was implemented as a result of a number of factors within organizations with span of control being cited as one of the factors.
Six hospitals, four community hospitals and two academic health science centres reported a change in structure in the patient/client services portfolio to include the addition of new manager roles. These new roles were either a result of the addition of a new manager position where a position did not originally exist or additional manager roles where organizations have added different levels to their current manager role.
Three hospitals, two community hospitals and one academic health science centre have also introduced additional manager levels to their current manager role.
For example at the Windsor Regional Hospital, structure was redesigned to include three different leadership roles with in each clinical program; director, operational manager and clinical practice leader. The operational manager(s) and the clinical practice leader(s) are peers and report to the director and have specific and distinct responsibilities and accountabilities. The operational manager is responsible for the overall management of the programs and the patient care services provided within their unit(s). Key responsibilities include budgeting, program planning, performance management, quality of care and safety. The clinical practice leader acts as a resource to staff and assists staff with learning plans. As well, the clinical practice leader plays a key role in patient safety and infection control initiatives. A sample manager role description, organization chart and a depiction of the structure has been made available by Windsor Regional Hospital and can be found in Appendix E.
Another community hospital introduced a new manager role (supervisor, patient care manager) which has primary responsibility for the day-to-day operations of the clinical unit, as well as patient flow, staff support and service recovery. These roles may or may not have responsibility for fiscal or performance management and these roles generally report to a manager however may report to a director level.
Sunnybrook Health Sciences Centre has developed three levels for their patient care manager role (PCM I, II, II). The responsibilities for PCM I, II and III are similar, however the breadth of the role varies for example in the number of direct staff reports and/or the size of the budget. PCM experience will facilitate a higher level of functioning of PCM. Like the community hospitals, these roles may report to a manager of a different level or to the director level.
The PCMs are responsible and accountable for the patient care provided on their unit and provide leadership in the management of human and financial resources. As well, the PCMs are responsible for unit planning, implementing
their unit’s quality improvement plan and supporting coordinated interprofessional practice within the context of a competent care delivery model. For further details see the sample PCM role profile from Sunnybrook Health Sciences Centre located in Appendix E.
A LTC home introduced a new manager role to provide leadership to resident care, by redistributing the workload of resident care in a multi-site organization to a more manageable size. Two new manager positions were created and implemented. Each manager is responsible for resident care on their respective site and report to the director of resident care. The role is non union, and oversees clinical issues, family concerns, supports the direct care coordinator (RN), leads patient care projects e.g. falls, restraints. The managers do not have budget or performance appraisal responsibility, however, contribute to both.
A community hospital introduced a new supervisor role in one particular clinical area which required additional leadership support.
The news roles and additional manager levels have assisted with decreasing manager span of control and enabling the majority of the managers to have responsibility for a single patient/client care unit in hospitals and long-term care. It was noted that clarifying the different manager roles and levels is essential to ensure the roles are distinct with minimal overlap/duplication and are aligned with the portfolio.
The redesign of structure was also cited in the literature as a strategy for addressing span of control. In particular, Fairview Health Services in Minneapolis studied the span of control and identified a strong relationship between manager span of control and employee engagement. As a result, they added four additional nurse managers to their structure.