Fir Creek Pediatrics 1
Running head: FIR CREEK PEDIATRICS
An Organizational Analysis of Fir Creek Pediatrics
Elizabeth Hopewell, Julia Delcour, Brita Hanson, Kristi Eilers, Susie Clabots
Pacific Lutheran University
Fir Creek Pediatrics 2
In a health care industry increasingly dominated by corporate interests, Fir Creek
Pediatrics offers a refreshing alternative. As the founder, owner, and solo practitioner, Michelle
(“Miki”) Hayes has emerged as a successful nurse entrepreneur, establishing the only private
practice pediatric clinic run by a Nurse Practitioner in Pierce County, WA. Located in
University Place, the organization is described on their web site (www.fircreekpediatrics.com) as
“a full service pediatric medical clinic owned and operated by a Pediatric Nurse Practitioner
(PNP)”. The unique status and structure of Fir Creek Pediatrics lends itself to accordingly
unique successes, as well as obstacles, as discussed within this paper.
In a business world overflowing with complex organizational hierarchies and seemingly
endless confusion, sometimes a simplistic organizational structure is just what the proverbial
nurse practitioner (NP) ordered. As a uniquely organized, privately-owned and operated
business, Fir Creek Pediatrics offers many of the desired organizational simplicities seen in
traditional, small, family-run business models.
Miki, who founded the clinic in 2000, is the sole proprietor, clinician, and self-appointed
“Mother Hen” of the business and its employees. In addition to Miki, the remainder of the tight-
knit group that comprises this office includes her daughter, Theresa (office manager), Peaches
(medical assistant), Alicia (receptionist), and Miki‟s husband Dale (a NICU-trained LPN and
certified lactation consultant), who assists when needed. Each employee has his or her own role
within the organization. There is minimal overlap, and a great deal of independence within each
Fir Creek Pediatrics 3
As a health care provider, Miki performs all physical assessments, screening exams, and
provides individualized parenting advice. For children with more complex health issues, she
initiates referrals and serves as coordinator of multi-disciplinary care. She has developed an
extensive network of specialists in the Tacoma/Seattle area with whom she works to ensure that
her patients are receiving the most appropriate care. In addition, she has established herself in a
niche market by providing home visits for newborns under two weeks old, as well as offering her
personal cell phone number to her patients and their families for 24/7 reassurance. This
component of her business has been in existence since the clinic‟s inception, and she feels
strongly that it is the reason why many clients are drawn to her practice.
In addition to Miki, Peaches, as the medical assistant, and Dale, as the LPN/lactation
consultant, have direct patient contact. Peaches, in some ways, acts as the “gatekeeper” of
patient care, and implements protocols set forth by Miki. For example, she makes sure that
children whose parents want immunizations have them at the appropriate times, performs initial
vital sign readings during appointments, etc. Dale, in his role as consultant, is available upon
request for mothers experiencing nursing difficulties, and often accompanies Miki to the initial
home visits. In the past Miki has utilized other NPs as consultants, hiring them on a part-time
basis. For example, an additional NP conducted screening for developmental abnormalities,
referring those families identified as needing additional developmental support to appropriate
providers and/or resources in the community. Since the clinician providing this service recently
left the area, Miki is actively recruiting others to fill this position, viewing it as a much-needed
service that she would like to provide to her clients. This organizational structure is represented
in Figure 1 of Appendix A.
Fir Creek Pediatrics 4
In terms of building her practice, Miki began by networking with midwives offering to
make house calls to help new mothers with their newborns. She taught birthing classes and
offered parent/child groups to further her recognition in the community and from there much of
the growth has occurred due to word of mouth. Miki called insurance companies asking to
become one of their preferred providers, which she found out takes many years. Her network
has grown from having initially worked with an area pediatrician after earning her PNP degree,
but before opening her own practice.
Patient services are provided to those with private insurance, military insurance, as well
as those on Medicaid. She does her best to serve her community, and she adapts her practice to
her patients‟ needs. Miki does not like to turn people away and will exchange services instead of
money if that is what the client has to offer. Her patient community includes some well-off
families, some military, some DSHS, and in her own words “many hippie, granola-types” who
appreciate her low pressure attitude on immunization requirements/scheduling.
Currently her patient load is over 2,000 and growing. The expanding patient base requires
additional clinic space, including larger administrative staff working areas, as well as storage
space for the ever-increasing number of medical records. Their current location has three patient
rooms, though Miki is hoping to move to a new site with at least four. In addition to the dreams
of a more comfortable and effective working environment, the prospect of a more attentive
landlord is attractive to the group.
Miki has admittedly never taken a business class herself, and has had to rely on the help
and advice of friends, as well as learning “on the fly”. Theresa (the office manager), despite her
lack of formal business training, has been praised by her mother for performing a “phenomenal
job” with regards to billing and insurance issues – an enormous improvement from her
Fir Creek Pediatrics 5
predecessor (discussed later in the paper), who was ineffective in this role. Although she has
proven her skills in this arena, Theresa is looking to gradually expand her role into social work,
which she does have an educational background in. If the practice continues to expand,
sufficient work would be available in that area, necessitating the need to hire additional office
staff to assist with the billing component.
As can be visualized in the organizational diagram shown in Figure 1 of Appendix A, the
structure of Fir Creek Pediatrics is very flat. Cowen, Halasyamani, McMurtie, Hoffman, Polley,
and Alexander (2008) found that successful healthcare organizational structures must have,
among other things, “ a configuration around care-providing clinical micro-systems and a strong
connection between the micro-systems and leadership” (pg. 408). While Fir Creek Pediatrics is
by no means a corporate health care conglomerate, they do share the goal of successfully
providing quality patient care. When compared to larger health care organizations, Fir Creek
Pediatrics is in and of itself is a micro-system, or a collaborative practice team (Cowen et al.,
2008). All elements of the Fir Creek micro-system work toward the goal of providing patient
care. Each element of the micro-system also has strong connections and direct communication
with the leadership.
What’s Working Well
Vision/Leadership/Entrepreneurship. A vision statement differs from a mission statement in that
it is less about the present and more about what the organization wants to become (Winans,
2008). The establishment of the first nurse practitioner-run pediatric clinic in the country is in of
itself visionary. A considerable amount of research has been conducted on the role of the NP in
Fir Creek Pediatrics 6
increasing both access to and quality of health care, but little exists on the independent nurse
entrepreneur. The emergence of such practices is long overdue, and a welcome addition by
many. A recent survey of health care purchasers indicated that not only would a vast majority of
patients accept unsupervised (e.g. in collaboration with a physician) service by an NP, but over
30% expressed interest in changing care from a physician to that of an NP in private practice
(Brown, 2007). In envisioning the goal of Fir Creek Pediatrics, Miki and her team expressed an
unwritten vision statement of providing quality holistic pediatric care in family centered manner,
giving parents the opportunity to make informed choices about their children‟s health care. This
emphasis on screening, education, and health maintenance is consistent with the goals and
outcomes sought in Healthy People 2010 (Miller, Snyder, & Lindeke, 2005). They also want to
expand and be able to provide more services to more patients, as seen in their efforts to get a
larger location and to add an additional NP to the practice. Not only is this vision a source of
inspiration and ideals to strive for, it also sets a clear criteria for future organizational decisions.
It keeps the team at Fir Creek Pediatrics focused on working towards common organizational
goals. It defines what the next steps are to lead into the future (Runy, 2007).
Hayman (2006) states the leader of an organization can help the employees follow a
vision not by making them memorize it, but helping them to believe in it. In his words “[by]
unleashing the passion within a person” (p. 50). From what was observed at the practice it is
safe to say that Miki is very passionate about what she is doing, as well as what she hopes the
practice will achieve in the future. It is her dedication and passion that ignite in her team similar
feelings and dedication for their work. These qualities identify Miki as a transformational leader
and mentor. According to Robbins and Judge (2009), transformational leaders inspire followers
to transcend their own self-interests for the good of the organization. Other characteristics
Fir Creek Pediatrics 7
include idealized influence (instills pride in followers, gaining respect and trust), inspirational
motivation through communicating high expectations, promotes intellectual stimulation, and
provides individualized consideration to employees/followers. Her role as a transformational
leader in the clinic is readily apparent to even the casual observer. Her employees have a great
deal of love and respect for her, both as a professional and an individual. They are committed to
the organization and its vision, are stimulated by the day-to-day challenges encountered in their
business, and, obviously, receive a great deal of individualized attention!
As stated by Porter O‟Grady (2003), “the leader is differentiated from the follower in that
the leader derives the preponderance of his or her role within the scope of potential reality. It is
the leader‟s role to engage unfolding reality in advance of others experiencing it” (p. 59). As
previously mentioned, Miki‟s willingness to break new ground in establishing her nurse-owned
practice characterizes her as a leader exploring her role as a provider in the rapidly expanding
potential reality of advanced practice nursing. What is particularly notable is how her quiet,
inspirational leadership transcends her immediate office – cherished by patients and families, as
well as fledgling NPs that look to her and her practice as a model of what is achievable with the
right vision and drive.
Organizational climate. Organizational climate is defined as “shared perceptions of employees
regarding an organization‟s policies, procedures, and practices, as well as the types of behavior
that are rewarded and supported in work settings. (Zohar & Tenne-Gazit, 2008) At Fir Creek
Pediatrics, the organizational climate is considered “family-oriented.” This phrase was coined
by Miki herself because of the closeness felt between she and the staff. Miki is the actual mother
of the office manager Theresa, but is also seen as the figurative mother of other staff due to this
Fir Creek Pediatrics 8
familial pattern of person-to-person interaction. Miki‟s employees feel comfortable at work and
this encourages a more positive work environment.
There is a climate of trust among the staff, which allows the staff to feel respected.
Members of effective teams trust their boss and Miki works hard to keep this trust and respect
from her staff. She offers guidance to her employees when needed. She also encourages the
development of their intrapersonal growth because this is recognized as something positive and
beneficial to Miki.
Fir Creek Pediatrics had wonderful benefits for the employees to reward their loyalty to
the vision of Fir Creek. Miki realizes that all her employees are working mothers and therefore
offers substantial health care options and a monthly stipend for child care. The employees are
also rewarded for being continual learners. When any want to go back to school she is willing to
work with their schedules and has offered her practice multiple times as the place for internships
and preceptorships to occur. In fact, that is how Peaches first found out about Fir Creek.
Zohar and Tenne-Gazit (2008) found that leadership directly and indirectly effected the
climate of the organization. Their style directly did so, and the creation of a positive atmosphere
with open communication indirectly did so. Miki‟s own personality traits and leadership style
have promoted the growth of her business. She is a resilient person. After losing her job from
taking disability, Miki did not give up hope or doubt her abilities, she decided to go back to
school to obtain her NP with the ultimate goal of beginning her own practice. She is extraverted,
charismatic, and conscientious, thus allowing her to constantly promote her practice among
many different groups (patients, other professionals, insurance companies). She is not afraid of
exploring new avenues in order to make her practice better, which illustrates the vision for her
career aspirations. She also cultivated her nursing practice as an NP among other specialized
Fir Creek Pediatrics 9
physicians, gaining knowledge that may have otherwise taken much longer to acquire. She is
also currently able to call on these specialists for advice because she established a solid network
early on in her practice.
Directly she transcends these leadership characteristics trough her employees affecting
the climate to be one like she is: open, agreeable, ready to learn, and accepting of all. Indirectly
her personality has allowed for the atmosphere to develop into a climate where communication is
nurtured and sought after. She wanted to repeat, however, that she was the final decision maker.
Peaches also commented in regards to communication that while she felt free to say anything
sometimes “How can you argue with your mom?”
The employees of Fir Creek Pediatrics seem to be very happy with where they work.
From their descriptions of their job roles and discussion of what happens at Fir Creek Pediatrics,
one can see many of the predictors necessary for job satisfaction. These include positive
organizational climate, pay, support, and most importantly the nature of the work (Murrells,
Clinton, & Robinson, 2005; Price, Mueller, 1981). One of the things that is working well is that
there is a strong positive organizational climate seen. Within the climate there is a lot of support
for one another, strengthening their familial relationship. Pay is adequate for the positions and
employees gain the added value of full medical insurance coverage which is so hard to come by
these days, particularly in an organization the size of Fir Creek.
Nature of the work has been seen in multiple research studies over time to be the best
predictor of job satisfaction. Nature of the work includes the amount of autonomy, job
challenges, variety, and scope (Saari & Judge, 2004). Autonomy has been shown to be the most
important of these (Mrayyan, 2003). Price and Mueller (1981) also found it to include job
Fir Creek Pediatrics 10
related decision making and being informed about job issues. At Fir Creek Pediatrics each
employee has a very autonomous role. They are the only ones that truly know their role and are
counted on to fulfill it without help. Therefore, within their role there is as much variety as they
feel is necessary. Also within their role they are allowed to make job related decisions. Miki
frequently asks for input from others to help her make decisions that effect the whole
organization. There are, however, mixed feelings as to whether their input is helpful or actually
utilized as Miki is quite frank about the fact that she ultimately has the final say. These
discussions, and communications in general, are very informal as with tight quarters “meetings”
happen in hallways or news rapidly disseminates because you can hear everything being said on
the phone of the person with whom you share your office.
Job satisfaction is very important to an organization because it is positively linked to
many other crucial factors including: turnover, absenteeism, and outcomes (Murrells et al., 2005;
Garon & Ringl, 2004). Turnover has not been an issue for this organization. They have lost
only two employees in the past eight years they have been open. One was because she was not
in tune with the vision of the organization. The other was due to the long commute from Seattle
to Tacoma, an external complication, and out of the hands of Fir Creek Pediatrics.
Absenteeism and outcomes are measurements of productivity. Absenteeism is correlated
with job performance because if you care about what you are doing you are likely to work as
often as you possibly can. Although there is no data for when or how often employees called in
sick at Fir Creek Pediatrics, it was noted during interviews to not be a considerable issue. This
lack of absenteeism should result in increased productivity.
Fir Creek Pediatrics 11
Productivity can also be measured in the outcomes of the organization. Since its inception
the outcomes of Fir Creek Pediatrics have been steadily increasing as seen by the change in
number of clients over the years. Fir Creek Pediatrics started with two patients and over the
years this has grown to over 2,000. Of those patients that have left the practice clients, most
have done so because of a move. According to Miki, complaints of dissatisfaction have only
occurred on very rare occasions. The increase patient load has led the organization to out grow
its space and Miki feels confident that it is doing well enough to take on the risk of moving her
practice to a bigger more expensive building.
Efficiency is an important aspect of productivity as well (Robbins & Judge, 2009).
Theresa has increased the monetary efficiency of the organization by ensuring that billing is done
correctly, timely, and paid out accordingly, allowing for more free cash in order to advance the
Due to the dynamics and relationships amongst the staff there is a strong feeling of
cohesion. They work well together and take care of each other. An example of this is when
Peaches stayed late at work as to not leave Miki alone in the building until Theresa came back
from an emergent errand. Cohesion explains the degree in which employees want to be involved
with each other (Robbins & Judge, 2009). This example, and others, daily, show that there is a
commitment at the organization to the members and to its values and vision.
Team effectiveness model. To further explain the cohesion and the positive dynamics of the Fir
Creek employees it is best to look at their synergy as a functioning team. One way to do this is to
use the team effectiveness model to see the interplay between each employee (Robbins & Judge,
2009). The team effectiveness model looks at indicators within the organization that have been
Fir Creek Pediatrics 12
correlated with effective teams (Myette & Conway, 2008). Three of the team effective model
indicators are: clear job roles, positive relationships, and strong leadership. In all three of these
areas Fir Creek Pediatrics excels. Myette and Conway (2008) also explain that underlying these
indicators is the core goals of the organization. The organization‟s vision is a larger part of the
core goals. Myette and Conway (2008) feel that the goals of the organization must be defined in
order to have an effective team. Fir Creek possesses that quality also and so should overall be
considered an effect team.
Areas for improvement
Runy (2007) argued that to be a successful organization the leaders must acknowledge
that it is an ongoing and dynamic process that required constant exploration of what could be
improved upon. When asked what needed improvement at her clinic, Miki was quick to say “we
need more space”. The need for a larger work space is definitely an issue for the business, but
perhaps not necessarily for the organization. Despite having what many would consider cramped
quarters, that, at this time, does not seem to be negatively effecting the employees‟ abilities to
accomplish their work or the interpersonal relationships, or at least not in an perceivable manner.
Perhaps they have gotten to know each other better and gotten closer because they have had to
share offices. Plans are in the works to move to a larger facility when an appropriate site is
found and adequate funding acquired.
Business orientation. The business knowledge of all members of Fir Creek Pediatrics is an area
that could use improvement. As noted, no one in the practice has any formal business training or
education. It is her inexperience in that area that has made Miki keenly aware that, in her words,
“good people are key”. You must surround yourself with people who are strong in areas where
you are weak. Miki feels that she isn‟t very business savvy. Despite the fact that she too lacks
Fir Creek Pediatrics 13
formal training, Miki is lucky to have found „a good one‟ in Theresa. Accurate and timely
billing and subsequent reimbursement is a crucial component of any health care organization,
large or small, as revenue generation is what keeps any business going. Theresa realized this
when she stepped into the position. Additionally her personality has added to her success in her
position. She is hard-working, resourceful and a quick learner. She takes a lot of initiative and
is always looking for new ways to help the organization. If Theresa is able to move into more of
a social worker role for the practice then her position could potentially be filled with someone
with an educational background in business. It would be a strategically sound move to bring in
someone with experience in marketing, development and financial planning for further
optimization of organizational management.
Interpersonal dynamics/conflict. The interpersonal dynamics between the employees at Fir
Creek Pediatrics is a large part of what makes the organization so attractive to the customers (the
patients and families), as well as creating a positive, “feel good” environment for Miki and the
staff. It is a family business in the true sense, where non-related employees such as Peaches are
viewed as part of the family. However, the same dynamics that work well in interpersonal
relationships can potentially have a detrimental effect in a business. Managing such interpersonal
relationships is a major issue in running a family business.
According to management academic Jennifer Sequira, The first
thing the founder or owner needs to establish is the boundaries of
the business…often times, many of the smaller family businesses
are not managed like a true business, meaning that the structure
found in a non-family business is missing. Delineation of specific
tasks, titles, goals and formal expectations are sometimes unclear.
Fir Creek Pediatrics 14
(as cited in Lofton, 2008)
The collegial, informal nature of the office led to a significant problem a few years ago. A
lack of clearly specified, written protocols, combined with Miki‟s well-intentioned trust in her
employees enabled the then-secretary/office manager to take advantage of the personal power
inherent in her position. In answering the office phone, this individual represented the first
contact (and initial impression) with Fir Creek Pediatrics that many potential families
encountered. She would often tell families that no appointments were available on a given
afternoon, so that she and the office staff would be able to go home early. Obviously, this led to
missed opportunities for revenue, as well as alienating families that felt they were unable to
obtain an appointment in a timely manner. Ironically, she would argue with Miki over other
business policies that she (the office manager) felt would be detrimental to generating revenue.
For example, she disagreed with Miki‟s insistence that immunizations be given freely to families
that were unable to afford them (the cost of the immunizations were offset in part by state
funding), so would simply tell families over the phone that the clinic would not be providing free
immunizations. Upon finding this out, Miki, in her own words, uncharacteristically “lost it”, and
engaged in “a screaming match out in the parking lot”. After regaining her composure, she
apologized to the employee for speaking to her in an unprofessional manner, but informed her in
no uncertain terms that a formal discipline policy would be implemented immediately. The
employee resigned the following day.
The subsequent introduction of Miki‟s daughter Theresa into the clinic as office manager
was a welcome change, as not only was she extremely capable, but also was able to seamlessly
integrate into the existing dynamics of the business. The existing staff now interacts as “one big
happy family”. However, this seemingly utopian scenario of complete harmony among
Fir Creek Pediatrics 15
coworkers can potentially be detrimental to the organization in the long run. Although the
traditional view holds that conflict is something to avoid, it can be constructive when it improves
the quality of decision-making. Often, individuals in close-knit organizations exhibit avoidance
behavior – either withdrawing from conflict, or attempting to suppress it altogether (Robbins &
Judge, 2009). Accommodating behavior is commonplace as well in these types of environments,
resulting in one individual placing another‟s interest above his or her own in attempting to avoid
conflict. The interactionist theory of conflict states that “conflict is not only a positive force in a
group, but that it is also an absolute necessity for a group to perform effectively” (Robbins and
Judge, p. 487). This view recognizes that conflict can benefit an organization‟s performance by
increasing options, by preventing premature consensus, and by increasing involvement and
motivation of family firm members (Tjosvold, 1991). Therefore, business leaders are encouraged
to maintain at least a minimal level of functional conflict in order to keep the group “viable, self-
critical, and creative” (Robbins & Judge, 2009, p. 486). A lack of conflict may encourage the
phenomenon of groupthink, in which the desire for consensus overrides the realistic appraisal of
alternative courses of action (Robbins & Judge, 2009). A tremendous amount of conformity
pressures exists in close-knit groups. The sometimes subconscious need for group members to
be accepted can result in the absence of any overt disagreement – even when such dissent would
be beneficial to the group by introducing arguably better strategies or ideas.
Three specific types of organizational conflict have been identified in the literature: task,
process, and relationship conflict (Kellermanns & Eddleston, 2004). Each of these has the
potential to affect family-run businesses. Task conflict focuses on the ongoing discussion
between group members on goals and strategies. In addition to identifying diverse perspectives
from different group members, it increases the understanding of the tasks, and how they are
Fir Creek Pediatrics 16
related to the larger goals (Amason & Schweiger, 1994; Jehn, 1997). Organizations with very
low levels of task conflict have the potential to become stagnant, lacking in the development of
new strategies. By maintaining the status quo, which may have worked quite well in the past, it
may ultimately prevent growth in the business. A moderate level of task conflict is seen as
particularly important in family businesses, where family and business interests compete. By
encouraging these moderate levels of task conflict, organizations gain greater commitment of the
employees to mutually agreed-upon strategies, and improve the quality of their decision-making.
Without the challenging of existing belief structures, organizations may have difficulty adapting
their strategies and goals when environmental changes are detected (Kellermanns & Eddleston,
Process conflict refers to disagreements over the “how” and “when” tasks should be
accomplished, as well as the responsibility of individuals in the organization (Jehn & Mannix,
2001). Due to their status as a family member, individuals in a family business are often
appointed to positions regardless of educational background or experience. In such and
environment, an organization with a low level of process conflict may have difficulty balancing
family members‟ abilities and responsibilities with the organization‟s resources. In addition, the
business may fail to modernize their operations in response to changing technology, commonly
found in family-owned businesses (Kellermanns & Eddleston, 2004).
The third, and perhaps most obvious, type of conflict addressed is relationship conflict.
Common in family businesses, it has been defined as the perception of personal animosities and
incompatibility (Simons & Peterson, 2000). Unlike task and process conflict, relationship
conflict decreases the quality of decision making (Jehn & Mannix, 2001). In addition, in
organizations where relationship conflict is present, performance is affected by the redirecting of
Fir Creek Pediatrics 17
work-related efforts toward the reduction of threats, politics, coalition, and cohesion building
(Simons & Peterson, 2000).
In a family business, relationship conflict can arise from the
dominant presence of the family--setting the rules and having
ultimate power, the lack of formalized systems and structures to
deal with conflict, and having no formal organizational structure or
operative systems and the co-mingling of business and family roles
(Harvey & Evans, 1994, p. 345).
In addition to the potential for a suboptimal level of functional conflict at Fir Creek
Pediatrics, the potential for role conflict exists as well. Role conflict exists when “an individual
finds that compliance with one role requirement may make it difficult to comply with another”
(p. 290). Although unequivocally viewed as the leader of the organization, Miki also has the
role of “mother hen” as she puts it – the literal mother of one employee, and the figurative
mother of the others. The intersection of the two systems of family and business is a problem
inherent in family-run businesses. The goals of the business (i.e. collecting revenue) and the
goals of the family (i.e. to support and develop family members) are often in competition with
one another. The business leader can be faced with the dilemma of how to reconcile these two
goals (Dyer, Gibb, & Handler, 1994). For example, Theresa is able to bring her children (Miki‟s
grandchildren) to work in lieu of having to find childcare elsewhere. Although this arrangement
epitomizes the concept of a family-centered organization, supervision of the children
undoubtedly takes time away from business responsibilities. In providing an opportunity for her
children and grandchildren, Miki must balance the simultaneous roles of business leader, mother,
and grandmother. If, and when, interpersonal conflict arises, the roles may be difficult to
Fir Creek Pediatrics 18
separate. As mentioned earlier, Peaches views Miki as a figurative mother, leading to a potential
blurring of boundaries. As Peaches stated, “How can you argue with your mom?” According to
Shelton (2006), assuming multiple roles can result in both work and family enhancement as well
as conflict. However, “work-family interference still must be managed because the existence of
enhancement does not eliminate role conflict”.
In summary, the dominant organizational culture at Fir Creek Pediatrics could best be
described as having extremely high “people orientation” - the degree to which management
decisions take into consideration the effect of outcomes on people within the organization
(Robbins & Judge, 2009). Although that in and of itself could be considered beneficial, the
combination of a high degree of people orientation and a lack of conflict may come at the
expense of business growth or willingness to adapt to changing market forces. At the present
time, the interpersonal dynamics seem to be adequate. However, as stated by Robbins & Judge
(2009), “culture is a liability when the shared values are not in agreement with those that will
further the organization‟s effectiveness. Strong cultures may become barriers to change when
“business as usual” is no longer effective” (p. 557).
Risk for ineffective staff interpersonal relationships and altered organizational integrity
related to the informal, familial structure of the group and lack of official company policies and
procedures as manifested by historically ineffective conflict resolution and expressions by staff
members about uncertainty in dealing with conflict should it arise and tendencies not to engage
Fir Creek Pediatrics 19
It is our recommendation that Fir Creek Pediatrics prepares itself to ward off the
potentially detrimental consequences of the organizational structure/culture as previously
detailed, as well as allowing for the maintenance of organizational integrity by formalizing
systems and structures. To augment this plan the following goals have been developed:
1) Development of an employee handbook of policies and procedures by December 1,
2009. This handbook should contain, among other topics, written policies addressing
employee benefits, role descriptions/expectations, performance guidelines,
disciplinary actions, and employee grievance processes.
2) Instatement of mandatory, formal monthly staff meetings to address issues affecting
the clinic by January 30, 2009. These staff meetings should have a predetermined
agenda, with allowances for any “new business” points of interest to be voiced.
As the clinic looks to continue to increase in size in both clientele and staff, a handbook
would allow clear expectations to be laid out for those entering the organizational team.
“Outsiders”, or individuals that do not have similar familiar ties to the company as the original
employees, may not function as effectively in their hired role with the current informal
guidelines that the current staff operates under. Having a handbook could also benefit the
current employees understand the vision and purpose of the organization. Being so closely
linked in their day to day lives, the common understanding of their function may have become
muddled along the way. Creating a handbook would bring increased clarity to the organizational
vision. A handbook would not only bring everyone to be on the same page as one another, but
also allow employees to understand what rights they have as individuals as far as a formal
grievance process if issues arise. This would help alleviate some of the sentimentality expressed
Fir Creek Pediatrics 20
by the staff that they did not feel able to confront someone that was a mother figure in the office.
Learning how to confront and handle conflict in a professional manner, with guidelines and
processes clearly outlined in a handbook, will give opportunities for the organization to become
Walters (2004) further explained how an employee handbook can benefit an organization.
A handbook can ensure more efficient administrative time management – allowing for a clear
path to be taken on recurring issues rather than having to “rethink” the process with each
occurrence. It can provide both assistance and consistency to management decisions: by having
clear, written guidelines and executing them as such, managers are able to make consistent,
unemotional decisions that can save time, stress, and legal repercussions. A handbook can clarify
employee expectations by allowing each member of the team to fully understand their role
expectations, and how those roles affect a successful professional relationship. Benefits are
clearly communicated to employees, resulting in increased understanding of what is available to
them, as well as a sense of feeling valued by the employer. Written policies can enhance a
company‟s image – a clearly written employee handbook can make an organization appear more
professional and cohesive, subsequently attracting similarly professional and well-qualified
applicants. Finally, a handbook can communicate company‟s culture and values. This is
particularly true in small organizations, allowing the founding member to convey what his/her
vision is for the company and can be used as a tool to motivate employees through collective
Building a employee handbook from scratch can be a tedious and time-consuming
process as each section must be well thought out and is written in a manner that will not come
back to haunt the organization in any potential future litigation. Once the handbook is written
Fir Creek Pediatrics 21
and given to employees it becomes a legal document, and the magnitude of that must be fully
comprehended during the evolvement stage (Begley, 2004).
In order to meet the goal of writing an employee handbook, the following objectives are
1. Document what is perceived as the current understanding of company policies by
February 1, 2009.
2. Purchase the Lorman Education Services Writing an Employee Handbook manual
and CD by January 15, 2009.
3. Identify and contact a legal advisor to edit employee handbook by March 1, 2009.
Another goal to work towards improving the interpersonal dynamics of the office is to
initiate holding regular office meetings. The meetings can be used as avenue towards allowing
staff members to talk through issues that the office is experiencing. Currently it is a much more
casual process of relaying messages to each other. Having a formal process of having a regular
meeting that everyone can be involved in will not only pave the way towards better
communication amongst the current staff, but also build policies that will benefit the
organization as it grows.
Meetings can also be used as a means to build teamwork, as staff can collaborate to come
to an agreed upon decisions. The benefits of doing so are as Robbins & Judge (2009) outlines:
Employees contribute to a number of decisions that affect them: setting
work goals, choosing their own benefits packages, solving productivity
and quality problems, and the like. This can increase employee
Fir Creek Pediatrics 22
productivity, commitment to work goals, motivation, and job satisfaction.
Although the organization has a supportive, family atmosphere, it is inevitable that
conflict will occur. As mentioned previously, Miki admitted that she does not handle conflict
well, and usually allows things to simmer over a period of time, erupting after the proverbial
“final straw” has been encountered. The meetings can be a gateway towards expressing and
resolving conflict that arises within the office. “Task conflicts stimulate discussion, promote
critical assessment of problems and options, and can lead to better team decisions. So effective
teams can be characterized as having an appropriate level of conflict” (Robbins & Judge, 2009,
Kaplan (2004) has identified the following as key components for a successful team
meeting: 1) Recap the positive contributions and achievements that have occurred since the last
meeting; 2) keep people‟s attention by keeping the meeting to an hour long session; 3) appoint
one person to take meeting minute notes. Review the previous meeting notes at the beginning of
the meeting to see if any material needs to be reviewed or is pertinent to the current meeting; 4)
encourage employees to jot notes and questions down that arise in between meetings, so that they
can expressed at the meetings, and 5) encourage all staff members to participate in each meeting.
A key issue to be addressed at these meetings is an ongoing analysis and review of how
Fir Creek Pediatrics is achieving its stated vision and goals. As a primarily family-run business,
an important distinction must be made between the overall family goals and those of the business
(Jaffe et al, 1997). The primary goal of any parent – literal or figurative, is to nurture the
children. The goal of any business, on the other hand, is to be financially successful. As family
goals often take priority over financial goals, it is sometimes necessary to involve a more
Fir Creek Pediatrics 23
impartial third party (such as a financial advisor or CPA ) to help develop explicit goals for both
the “family” and the business – and to identify instances where conflict exist (Jaffe et al, 1997).
As discussed by Scott (2002), a number of owner/entrepreneurs produce and sell products or
services with relative ease but lack the skills to pursue a long-term growth plan. Strategic and
operations planning are required, in order to answer some of the fundamental questions: Who are
we? Where are we headed? What is our game plan? Once the strategic planning is outlined and
understood, operations planning anticipates practical details such as sourcing, staffing, and
ongoing production of the final product (in this case, patient care).
Another issue to be addressed with the group as it expands is organizational design.
“Entrepreneurs build companies without blueprints, and it shows” (Scott, 2002). The
identification and definition of tasks, inter-role communication (as opposed to inter-departmental
communication in a larger company) can lead to increased efficiency and control. Clear
definitions of responsibilities and accountability are important. In addition, careful
organizational design allows for greater impartiality in evaluation and promotion decisions –
particularly appropriate in a tight-knit business where family members are involved. With a
clearly stated vision, goals, and organizational design, the evaluation of the business‟
performance is much more straightforward.
To reach the goal of initiating monthly staff meetings, the following objectives are
1. Decide on an ongoing day that will be used for the monthly meetings (e.g. the
first Monday of the month at 8 a.m.) by January 15, 2009.
Fir Creek Pediatrics 24
2. Notify staff of the meeting dates and time and to order for no appointments to be
made during the allotted time within a week of deciding when the first meeting
will be held.
3. Appoint a staff member to be in charge of the taking notes for the meeting
minutes, and outline expectations of this person at least a week before the first
4. Compose the meeting‟s agenda and distribute at the beginning of each meeting.
5. Decide as a group what the agreed upon ground rules will be for the meetings at
the beginning of the first meeting held.
In order to accomplish the aforementioned tasks, interviews will need to be conducted to
explore the employees‟ feelings regarding current company functioning and expectations for the
future. Interviews with employees will help serve to establish logistical parameters for the set up
of the staff meetings as well as determining specific aims. Format will likely evolve as time goes
on. Upon purchasing and reading the recommended book to help with the creation of a staff
handbook, a decision will have to be made about whether outside assistance will be necessary in
formulating the handbook and who in the group should be included in participating. Research
will need to be done to find an attorney to serve as legal counsel. Money will need to be
allocated to pay lawyer fees as well as purchase supplies.
Change is most effective when it is quick and to the point. After implementing the
planned improvements in the organizational workplace regarding interpersonal relationships,
Fir Creek Pediatrics 25
change should begin to be seen rather quickly. However, since these are human subjects and
changing people can often be a difficult task, it is reasonable to believe that while it would be
ideal to change quickly this organizational shift will most likely take time to establish.
Goal one was the introduction of an employee handbook. After one year this should be
in production or well on its way to being so. If it has not been completed a reassessment needs
to be done to see where the issues lie and why the handbook has not been completed. It could be
something as simple as a hold up at the printing company, or it could be the uncovering of
unresolved organizational conflict only surfaced when it was forced. Either way, it is essential
for Fir Creek Pediatrics to address the issues and create solutions to bring about change for a
The second goal has the potential to be very enlightening about group dynamics. It will
also be interesting to see how when put into practice this goal becomes a reality. While, the
handbook could be more cut and dry, interesting dialogue and freedom of expression could arise
from the implementation of monthly meetings. Understanding and assessing what the monthly
meetings have become will help in future assessments and diagnoses to fine tune the
organizational interpersonal relationships and create an optimally functioning organization.
Becoming acquainted with Miki Hayes and the subsequent analysis of her business was a
tremendous learning experience for this group. Our ability to meet with and learn from an
individual such as Miki provided us with a great deal of insight into what is possible within the
realm of advanced practice nursing. Despite its small size, the issues relevant to Fir Creek
Pediatrics are no less complex (though smaller in scale) than many issues faced by larger
healthcare organizations. This business began with the vision of its entrepreneur leader, and was
Fir Creek Pediatrics 26
transformed into a successful endeavor due to continued perseverance, dedication, and above all,
passion for her work. Diagnosing a specific problem or set of problems within the business
proved to be challenging for the group. Although lack of conflict can lead to potential problems
and stagnation within an organization as discussed, it is truly rare in this day and age to find a
group of individuals that work so well together, and are so committed to the vision as set forth by
their transformational leader. Our critique and recommendations for change are offered to
reinforce what is already a successful business. As a healthcare provider, Miki embodies the
holistic approach to care, emphasizing the importance and autonomy of the family unit. As
stated on the clinic‟s website, “…remember, YOU are the most important decision maker in your
child‟s life”. While this statement rings true, Fir Creek Pediatrics, its staff, and most
importantly, the families that have chosen this clinic for their children are fortunate indeed to
have a decision maker such as Miki in their corner.
Fir Creek Pediatrics 27
Administration Support Patient Support
Alicia Theresa Peaches
Receptio Office MA Dev.
Figure 1. Organizational Structure of Fir Creek Pediatrics
Fir Creek Pediatrics 28
Amason, A.C. & Schweiger, D.M. (1994). Resolving the paradox of conflict, strategic
decision making and organizational performance. International Journal of Conflict
Management, 5, 239-253.
Begley, M.M. (2004). Creating the Employee Handbook. Business West, 20(11), 69.
Brown, D. (2007). Consumer perspectives on nurse practitioners and independent practice.
Journal of the American Association of Nurse Practitioners, 19 (10), 523-529.
Cowen, M.E. Halasyamani, L.K. McMurtie, D. Hoffman, D. Polley, T. Alexander, J.A. (2008).
Organizational Structure for Addressing the Attributes of the Ideal Healthcare Delivery
System. Journal of Healthcare Management. Vol 53. No 6. Pg 407 – 418.
Dyer, W., & Handler, W. (1994) Entrepreneurship and family business: Exploring the
connections. Entrepreneurship: Theory and Practice 19(1), 71-83.
Edwards, B.D., Bell, S.T., Arthur, W.Jr., & Decuir, A.D. (2008). Relationships between facets
of job satisfaction and task and contextual performance. Applied Psychology: An
International Review, 57(3), 441-465.
Harvey, M. & Evans, R.E. (1994). Family business and multiple levels of conflict. Family
Business Review, 7(4), 331-348.
Hayman, P. (2006) Unleashing the Passion Toward the Vision. Franchising World, 38(2),
Jehn, K.A. (1997). A quantitative analysis of conflict types and dimensions in
organizational groups. Administrative Science Quarterly, 42(3), 530-558.
Jehn, K.A. & Mannix, E.A. (2001). The dynamic nature of conflict: A longitudinal study of
intragroup conflict and group performance. Academy of Management Journal, 44(2),
Fir Creek Pediatrics 29
Kaplan, E. (2004). Keep your team on track with staff meetings. The American Chiropractor,
Kellermanns, F., & Eddleston, K. (2004). Feuding families: When conflict does a family
firm good. Entrepreneurship: Theory and Practice, 28(3), 209-228.
Lofton, Lynn (2008). Relationships extra special when they're on the job and at home.
Mississippi Business Journal, May 5-11, p. B7.
Miller, M., Snyder, M., & Lindeke, L. L. (2005). Nurse practitioners: Current status and future
challenges. Clinical Excellence for Nurse Practitioners, 9(3), 162-169.
Mrayyan, M. (2003) Nurse Autonomy, Nurse Job Satisfaction and Client Satisfaction with
Nursing Care: Their Place in Nursing Data Sets. Nursing Leadership,16(2), 74-82.
Murrells, T. Clinton, M. Robinson, S. (2005). Job Satisfaction in Nursing: Validation of a New
Instrument for the UK. Journal of Nursing Management, Vol 13, p296-311.
Myette, A. Conway, T. (2008) Team Effectiveness Model. University of Victoria, Human
Resources Department. As retrieved on December 11, 2008 from
Price, J.L. & Mueller, C.W. (1981). A Causal Model of Turnover for Nurses. Academy of
Management Journal, 24 (3), 543-565.
Porter-O‟Grady, T. (2003). Of hubris and hope: Transforming nursing for a new age. Nursing
Economics 21(2), 59-64.
Saari, L.M. & Judge, T.A. (2004). Employee Attitudes and Job Satisfaction. Human Resource
Management, 43(4), 395-407.
Saunders, D. (2007). Creating a Climate for Communication. Credit Union
Fir Creek Pediatrics 30
Management, Sep, 30(9), 13-13. Retrieved December 1, 2008, from Business Source
Scott, R. (2002). Offer family-business solutions: Guidance in 10 key areas can help private
businesses succeed. Journal of Accountancy, Vol 194, 55.
Shelton, L. (2006). Female entrepreneurs, work-family conflict, and venture
performance: New insights into the work-family interface. Journal of Small Business
Silverthorne, C. Wang, T. (2001) Situational Leadership Style as a Predictor of Success and
Productivity Among Taiwanese Business Organizations. Journal of Psychology,
Simons, T.L. & Peterson, R.S. (2000). Task conflict and relationship conflict in top
management teams: The pivotal role of intragroup trust. Journal of Applied Psychology,
Robbins, S., & Judge, T. (2009). Organizational Behavior. Pearson Prentice Hall: New
Runy, A.L. (Ed.) (2007) Attributes of a High Performing Culture. Hospitals & Health Networks,
Tjosfold, D. (1991). The Conflict-Positive Organization: Stimulate Diversity and Create
Unity. Reading, MA: Addison-Wesley.
Walters, C. (2004). Employee handbooks for small businesses: How formal must they be? The
Central New York Business Journal, 18(10), 9-12.
Winans, P. (2008). How Do You Start a Business Plan? Professional Remodeler, 12(1), p17.
Fir Creek Pediatrics 31