Span of Control (Final)

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Leading Practices for Addressing

Clinical Manager Span of Control in Ontario

February 2011

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Foreword

The Ontario Hospital Association (OHA) Provincial Health Human Resources Strategic Plan 2008-2011, developed through OHA member and stakeholder consultations, identified the need to provide resources and support to members on Manager Span of Control.

Following a scan of existing studies on the topic, the OHA decided to best meet members’ needs with a practical study approach that identifies leading practices health care organizations have introduced to assist in alleviating the negative impacts of large spans of control.

This study was conducted by the Hay Group and guided by OHA staff and the OHA Strategic Human Resources Provincial Leadership Council. This Council includes Chief Executive Officers, human resources, nursing, and patient care leaders in hospitals as well as representatives from the educational, long-term care, and community care sectors.

The following report is written by the Hay Group and proposes a number of recommendations from their perspective.

Today, health care organizations consist of flatter organizational structures and larger managerial spans of control as a result of restructuring over the past twenty years. Clinical Managers often have responsibility for large numbers of direct reports. The 2010 OHA-PricewaterhouseCoopers HR Benchmarking survey reveals that the median Nurse Manager Span of Control (SOC) ratio was one manager for every 56.9 employees, with many managers overseeing over 100 workers. This often leaves little time for staff mentorship, coaching, or performance evaluation. Other studies have documented the impacts of wide spans of control on staff and patient satisfaction, staff turnover, and other metrics. The focus of this study is practices or strategies that health care organizations have introduced to address and alleviate some of these impacts.

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The Ontario Hospital Association (OHA) sought the assistance of the Hay Group to conduct a study to identify key and practical leading practices, strategies or tools for employers to alleviate the negative impacts of large clinical manager span of control on the workforce and patients. The study included health care organizations in Ontario from across the three health sectors; hospitals, community care, and long-term care.

The objectives of the study were to:

• Summarize key findings from the existing literature related to span of control in health care;

• Identify the most critical leading practices/strategies that are feasible and affordable and provide guidance on the implementation of those practices for employers to reduce the negative impact of large spans of control on unit and patient outcomes through surveys and key informant interviews; and

• Provide recommendations on how the OHA and health care organizations can use existing metrics on span of control and unit outcomes to measure the impacts of span of control province-wide and within individual organizations.

Over the past two decades, healthcare in Canada has experienced significant downsizing and reform. Many hospitals were required to make difficult decisions in order to manage their fiscal restraints while balancing patient care needs. One common cost reduction strategy has been to flatten the organization structure and reduce the number of managerial positions.

Manager span of control has increased, with many

managers often responsible for more than one unit, which significantly reduces the time available for staff mentorship, motivation, coaching and evaluation. One Ontario study

1.0 _{Executive Summary}

and performance and included seven hospitals found that manager span of control ranged from 36-151 workers, with a median of 67 workers10_.

There have been a handful of Canadian studies related to span of control in the health care context. A scan of the literature reveals that definitions for span of control can be grouped into two broad categories: total number of “workers” being supervised by a manager and total number of full-time equivalent (FTE) positions being supervised by a manager. For the purposes of the study, the OHA has defined span of control as the total number of “workers” reporting to a manager.

The literature further suggests that span of control is a more complex phenomenon and additional factors such as the overall authority that falls within a manager’s responsibility should be considered.

There are no studies which identify what constitutes an appropriate span of control for a clinical manager. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization:

• frequency and intensity of the relationship between the manager and staff,

• complexity of the work, capabilities of the manager, and

• complexity of the work and capabilities of the staff. There is some evidence which identifies methods to assess span of control and the impact of the relationship between the clinical manager’s span of control and staff, unit, and patient outcomes.

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The Ottawa Hospital Span of Control Assessment Tool (See Appendix B, Table 1) recognizes the complexities in evaluating manager span of control and is currently being validated by the University of Western Ontario/Children’s Hospital of Eastern Ontario study.

In order to obtain a comprehensive understanding of span of control trends, challenges and leading practices of healthcare organizations in Ontario, stakeholder input was solicited through an online survey and via key stakeholder interview. A list of stakeholders can be found in Appendix D.

Based on the findings from the literature, the online survey was structured to capture the impact of span on the following nine dimensions:

1. Impact on effectiveness and/or frequency of communication

2. Impact on manager accessibility to staff

3. Impact on staff retention

4. Impact on staff attendance (levels of absenteeism)

5. Impact on staff injury rates

6. Impact on staff engagement

7. Impact on staff satisfaction

8. Impact on client/patient/resident safety

9. Impact on client/patient/resident satisfaction

Managers were asked to provide information on initiatives that had been implemented to alleviate the impact that span of control. The following initiatives were most frequently reported as strategies that were used across the nine dimensions:

• Manager access and visibility

• Performance appraisals

• Manager/administrative walkabouts

• Staff involvement in decision making/unit activities

• Appreciation and recognition

• Manager flexibility

• Staff forums/town halls

• Use of Email/Other IT tools for communication and accessibility

Managers also indicated whether they had narrow or wide span of control based on their own perceptions. Managers of long-term care homes were most likely to report a wide span of control (90%), followed by hospital managers at 73% and CCAC managers at 65%. Managers who reported a wide span of control were more likely to have:

• Greater than 80 staff members reporting to them

• Responsibility for three or more units

• Budgetary responsibility

• Budgets exceeding $7 million

Structured interviews were conducted with a small sample of Senior Nurse Leaders from the three health sectors (hospital, long-term-care and community care). The purpose of the interviews was to provide further insight into the practices, strategies, and tools that organizations have implemented to minimize or alleviate the potentially negative impacts of large manager span of control on their workforce and patients.

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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.

The most frequently reported strategy was the redesign of the patient/client services organization structure (67%). This strategy was inherent in both the long-term-care and hospital sector. The next most frequently reported strategy was changing the model of care (33%) which was isolated to the hospital sector. The redesign of the manager role (25%) was reported in both the community and long-term-care sectors. Full scope of practice (17%) was identified in only the hospital sector. Some sample documents can be found in Appendix E.

Enablers and barriers were identified to support the strategies, with leadership education being cited by all three sectors as the most significant enabler. Other enablers included communication, staff education, technology, manager role clarity and a professional practice structure. Only a few barriers were identified and included staff accountability, recruitment and manager supports. Based on findings of the literature, survey and interviews the Hay Group has identified key recommendations they suggest/recommend organizations implement. These recommendations are grouped in the following categories:

• Defining span of control

• Leading practices to address span of control

• Measuring the impact of span of control

Defining Span of Control

A consistent definition of span of control is required for monitoring and measuring span of control. The OHA currently utilizes the definition of span of control as identified in the OHA-PricewaterhouseCoopers (PwC) Human Resources Benchmarking Survey. The Hay Group recommends that the OHA membership use this definition and that OHA take the lead in gaining consensus for a consistent definition of span of control that can be used across all three sectors.

Leading Practices to Address Span of Control

The three leading practices that are most important for organizations to address the negative impact associated with manager span of control include:

• Assessing manager span of control

• Clarifying the manager role(s)

• Assessing manager supports

Measuring the impact of Span of Control

The Hay Group recommends the following categories of metrics be used to monitor and measure the impact of manager span of control:

• Safety Metrics

• Satisfaction Metrics

• Human Resource Metrics

Further details of each of the leading practices and metrics can be found in section 6.0 of the report.

Specific recommendations were provided to further guide the OHA Strategic Human Resources Provincial Leadership Council and the OHA in next steps and are as follows:

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RECOMMEnDAtiOnS:

It is recommended that:

(1) The OHA and its’ members use their current definition of span of control as identified in the OHA-PwC Human Resources Benchmarking Survey for the purposes of consistency of reporting.

(2) The OHA work collaboratively with leaders from the long- term-care and community care sectors to adopt the current OHA-PwC Human Resources Benchmarking Survey definition and/or develop a consensus definition of span of control that would allow for consistency of reporting across all three sectors.

(3) The OHA together with its members and using the

results of the University of Western Ontario/Children’s Hospital of Eastern Ontario led span of control project determine criteria and a tool for assessing manager span of control.

(4) OHA members organizations define and clarify the role of the manager within their organization to minimally include:

• identifying leadership competencies,

• determining responsibilities and deliverables,

• ensuring managers have adequate authority to act, and

• describing how the manager role relates to other professional staff in delivering care.

(5) Organizations within the three health sectors, through existing data collection tools such as incident reporting system and the OHA-PwC Saratoga HR Benchmarking Survey, collect the following metrics to monitor and measure the impact of span of control:

• Safety Metrics

o Patient falls rate

o Medication error rate

o Infection control rate (from one of the

commonly reported hospital acquired infection rates)

• Satisfaction Metrics

o Overall staff satisfaction rate

o Overall patient satisfaction rate

• Human Resource Metrics

o Voluntary turnover rate

o Staff absenteeism rate

(6) The OHA communicate the results of the UWO/ CHEO span of control project to its’ members with regard to the relationship between clinical manager span of control and manager and unit work outcomes in Ontario academic hospitals as well as the reliability of The Ottawa Hospital span of control assessment tool.

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2.0 _Introduction

Over the past two decades, healthcare in Canada has experienced significant downsizing and reform. Many hospitals were required to make difficult decisions in order to manage their fiscal restraints while balancing patient care needs. Many organizations chose to flatten their organization structure and reduce managerial positions in order to retain the maximum number of caregivers possible43_{. As a result, there has been a reduction of 6,849}

(29%)5, 20_{nursing leadership positions in Canada since}

the 1990s.

This reduction in the number of managers has resulted, in many instances, in an increase in the remaining clinical managers’ span of control (SOC). One Ontario study that evaluated the impact of span of control on leadership and performance and included seven hospitals found that manager span of control ranged from 36-151 workers, with a median of 67 workers10_.

In addition, the work environment of clinical managers is more complex with the implementation of new technologies, electronic documentation, “research, increased complexity of patient care, recruitment and retention of multidisciplinary healthcare staff and redesign of professional practice37_.”

Over the past decade there have been a handful of Canadian studies related to span of control in the health care context (see Appendix B for the literature review). Some of these studies have identified elements to include in a definition of span of control; however there are no studies which identify what constitutes an appropriate span of control for a clinical manager.

There is some evidence which identifies methods to assess span of control and the impact of the relationship between the clinical manager’s span of control and staff, unit, and patient outcomes.

The 2002 final report of the Canadian Nursing Advisory Committee20_{encouraged employers to examine and assess}

characteristics of reasonable and manageable span of control for clinical managers that allows them to complete assigned functions and be present to meet nurses’ and patients’ needs.

The membership of the Ontario Hospital Association (OHA), through the Strategic Human Resources Provincial Leadership Councili_{, has suggested there is a need for a}

practical summary of leading practices, successful strategies and tools to alleviate the impact of a clinical manager’s large span of control.

The Strategic Human Resources Provincial Leadership Council and the OHA have identified “researching span of control tools, guidelines and impacts for front-line managers” as one of its strategies in the OHA Provincial Health Human Resources Strategic Plan 2008-2011ii_.

The OHA sought the assistance of Hay Group to conduct a study to identify key and practical leading practices, strategies or tools for employers to alleviate the negative impacts of large clinical manager span of control on the workforce and patients. The study includes health care organizations in Ontario from across the three health sectors; hospitals, community care, and long-term care.

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The objectives of the study were to:

• Summarize key findings from the existing literature related to span of control in health care;

• Identify the most critical leading practices/strategies that are feasible and affordable and provide guidance on the implementation of those practices for

employers to reduce the negative impact of large spans of control on unit and patient outcomes through surveys and key informant interviews; and

• Provide recommendations on how the OHA and health care organizations can use existing metrics on span of control and unit outcomes to measure the impacts of span of control province-wide and within individual organizations.

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With growing pressure on fiscal resources, many

hospitals and health care organizations have undergone restructuring and have undertaken aggressive cost cutting initiatives and sought ways to decrease costs. One common cost reduction strategy has been the reduction of management positions across organizations.

This has resulted in decision making being decentralized with increasing demands being placed on management. The responsibility of unit managers has generally expanded to include the management of finances, operations, and human resources often across multiple clinical areas in a program management structure. Manager spans of control have increased, with many managers often responsible for more than one unit and significantly reduced time for staff mentorship, motivation, coaching and evaluation.

In this chapter, an overview of findings from the literature is presentediii_{. A more detailed account of findings is}

included in Appendix B.

3.1 _{Span of Control Defined}

A scan of the literature reveals that definitions for span of control can be grouped into two broad categories:

total number of “workers” being supervised by a manager

Most typically, span of control has been defined as the number of people supervised by the manager i.e. the number of people assigned to a manager, not the number of full time equivalents (FTEs)38_.

iii The following key words were used for an online search in Ovid Medline and a more general

total number of “FtEs” being supervised by a manager

The alternative definition proposes that span of control is measured by the number of FTEs under the jurisdiction of a manager14_{. Similarly, in Altaffer’s study}2_{of two complex}

health care organizations, the following definition was provided; “number of people supervised by a manager as measured by the total number of FTEs.”

OHA’s Working Definition of Span of Control

The OHA’s working definition of span of control is the “total number of workers reporting to a manager.” This definition is based on the Saratoga US Hospital metrics definitions which the OHA uses in its’ HR Benchmarking survey (see Appendix B – span of control defined).

3.1.1 Additional Considerations for Span

of Control

Although in its simplest form, span of control refers to the number of employees or FTEs being supervised by a manager, the literature suggests that span of control is a more complex phenomenon. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization2,17,31,36,43_:

• Frequency and intensity of the relationship between the manager and staff. This would require

considerations of the number of interactions that a manager is required to have with staff to support the day to day performance of staff and functioning of the unit. This would also include consideration of the depth and quality of interaction i.e.: requirement for clinical teaching, mentorship etc.

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• Complexity of the work, capabilities of the manager: Complexity of work would require consideration of whether the work of the manager is routine, has a calm and predictable workflow, the level of automated processes etc.; capabilities of the manager would require consideration of experience, skill level, ability to delegate, leadership style, alignment with

organization etc.

• Complexity of the work and capabilities of the staff. Complexity of work of staff would include routine versus complex work, degree of decision making in day to day job, level of independence etc., capabilities of staff would require consideration of level of experience, skill level, qualifications, morale,

alignment with manager goals, familiarity with the organization etc.

Additional factors for consideration include:

• The combination of people, skills and variety of tasks that they perform

• Scope of responsibility of the manager (range of duties, size and number of units, number of sites etc.)

• Planning organizational, budgetary and leadership responsibilities

• Presence of managerial support are critical factors to be considered when evaluating a manager’s span of control

3.1.2 Ideal Span of Control

Span of control is a multidimensional concept that, as noted above, is influenced by many factors. An evaluation of the optimum number of staff that should report to managers requires a multifaceted evaluation of the work, worker, manager and the organization.

Although the literature does not provide a “formula” to calculate the number of direct reports in an optimal span of control, it should be noted, however, that span of control

theory34_{proposes that there is a certain size at which span}

of control reaches its maximum capacity to be effective, and increasing beyond that capacity may in fact be harmful. While classic organizational theory13_{proposed that}

every 5-6 workers needed a first line supervisor, Del Bueno and Pabst suggest current management opinion is that a supervisor could manage between 100 and 200 individuals9,43_{. Indeed, the studies reviewed as part of the}

literature review and that provided information on span of control included managers with a broad range in the number of employees under their supervision.

3.2 _{Tools to Assess Manager Span}

of Control

Although a review of the literature confirms that span of control is a complex phenomenon, requiring consideration of many factors beyond the number of staff reporting to the manager, there is little information on how to assess manager span of control.

The development of the Michigan Leadership Model (2005)8_{included an assessment matrix designed to assess}

the span of control or scope of work. Information gathered from this matrix was used to determine the level of clinical and administrative staff required to support the work of a manager. This matrix recognizes the complex role of nurse managers and includes factors in addition to the number

of staff reporting to a manager. Key items included in the matrix are:

• Experience of the nurse manager

• Strength and stability of staff (including staff nurse years of experience)

• Morale/turnover and independence

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• Cooperation of ancillary departments

• Physician support

• Support from senior leadership

The Ottawa Hospital has developed span of control assessment tools for various leadership positions in the hospital. The Management Span on Control Assessment Tool, presented at the OHA’s Skill Mix: Work and Redesign Conference (December 2009) includes assessment in three broad categories which are further broken down into specific areas of focus (See Appendix B, Table 1). To determine the impact on manager span of control, each area of focus is rated as low, medium and high. Listed below are each of the three categories and areas of focus:

• Unit Focused:

o Complexity

o Material management

• Staff Focused:

o Volume of staff

o Skill level/autonomy of staff

o Staffing stability

o Diversity of staff

• Program Focused:

o Diversity

o Budget/Statistical

The Ottawa Hospital span of control assessment tool is currently being tested for reliability. The project is funded through the Ontario Ministry of Health and Long term Care Nursing Research Fund and sponsored by the Council of Academic Hospitals of Ontario. The OHA will communicate the results of the study upon project completed anticipated in late 2012.

3.3 Span of Control and Impact on

Managers, Staff and Patients

A handful of health care specific studies have examined the impact of span of control on various managerial, staff and patient dimensions. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates as well as patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings.

The research study being led by the University of Western Ontario and the Children’s Hospital of Eastern Ontario will examine the relationship between clinical manager span of control and manager/unit outcomes in 15 Ontario Academic Hospitals including:

• Staff absenteeism

• Staff turnover

• Overtime hours

• Work injury rates

• Patient satisfaction

3.3.1 Impact on Managers

Over the last several years, there have been increasing demands on individuals in management positions, with the role of unit managers expanding to include the management of finances, operations, human resources often across multiple clinical areas in a program management structure. Many managers spend a large amount of their day coordinating staffing issues, patient flow and working on committees8,32,37_{. As a result, not}

only do they feel increasingly overwhelmed48_{, but they}

consequently have little time left for staff development and quality improvement activities37,41_{(see impact on staff}

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concluded that it was “not humanly possible to consistently provide positive leadership to a very large number of staff while at the same time ensuring the effective and efficient operation of a large unit on a daily basis.”

3.3.1.1 Stress Levels and Burnout

With front line managers taking on increasing responsibility, more work and more employees, there are growing reports of managers being overwhelmed and experiencing high levels of stress and burn out. In a qualitative study of nurse managers, complexity, conflict and ambiguity were often identified as sources of stress. Large SOC was seen as adding complexity to nurse manager roles47,48_{. The findings are re-enforced in stress}

and coping literature related to the nurse manager role in the “post re-engineering” period46_.

3.3.1.2 Communication between Managers

and Workers

There is mixed evidence of the impact of large spans of control on communication. However, a review of the literature produces greater evidence of the negative impact of large span of control on communication. Larger spans of control impact communication patterns and inevitably impact the number of interactions that a manager must undertake43_.

3.3.1.3 Management and Decision Making

Altaffer’s study2_{that compared span of control of first line}

nurse managers (large spans of control) with first line non-nurse managers (smaller spans of control) found that in all dimensions except one measuring effectiveness, nurse managers were less likely to report that they were highly effective in fiscal management, negotiation and conflict management as well as change management.

In fact, studies have shown that even when managers possess the desired leadership style, their ability to influence positive outcomes may be impacted by their span of control10_{. Even highly emotionally intelligent}

managers may not be able to have an impact on staff

nurse empowerment due to large spans of control which invariably results in limited opportunities to engage with staff7,38_.

Feldman’s study15_{also supports the notion that clinical}

supervision is more effective when frontline supervisors have a narrower span of control) i.e. a smaller, more easily identifiable group of nurses whose care delivery must be monitored on a regular basis.

Organizations with large spans of control that effectively delegate responsibility to employees are often associated with managers feeling more fulfilled and rewarded17_{. On}

the other hand, multi-layered organizations, typically identified with smaller spans of control, are seen to have a significant (negative) impact on decision making. It is argued that when there are multiple levels in a chain of command, the likelihood that decisions and problems will be forced to a higher level is increased. As the number of layers increase, responsibility is “diluted and diffused” and ultimately, decisions are made in a vacuum, absent of context and at a distance from where they originated31_.

3.3.1.4 Mentorship, Access and Visibility

Increasing demands and changing responsibilities of frontline managers has meant that mentorship and guidance traditionally provided to staff nurses is no longer available6_{. How much time a manager spends interacting}

with employees is dependent on other competing demands and the overall distribution of managerial resources36_.

Managers who are over extended and have overly wide spans may limit access to staff and the mentorship that managers wish to offer1_.

Growing spans of control limit the attention, support, clinical supervision and feedback the manager can provide to an employee often with detrimental impacts.

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3.3.2 Impact on Staff Performance

A study in the airline industry supports the notion that narrow spans of control improve performance through positive effects on group processes.

3.3.2.1 Staff Engagement & Empowerment

Several studies address the impact of large spans of control on employee engagement. Cathcart’s study7_{found a fairly}

consistent decline in employee engagement scores as work group size increased. At two points in particular, employee engagement dropped considerably – when work group sizes grew larger than 15, and then again when work group sizes grew larger than 40.

Large spans of control are also thought to influence employee perceptions of empowerment7,29,38_{. As}

demonstrated in Lucas’ study29_{of two Ontario community}

hospitals, while emotionally intelligent nurse managers were able to promote empowering work environment, span of control was a significant moderator of the relationship between nurses’ perceptions of their emotionally intelligent behaviors and feelings of workplace empowerment.

3.3.2.2 Staff Satisfaction & Retention

Smaller spans of control have consistently been linked to higher levels of staff satisfaction and higher rates of employee retention. While Doran’s study10_{of seven}

Canadian teaching and community hospitals (51 units), did not find span of control to be a predictor of nurses’ job satisfaction, it did find that span of control decreases the positive effect of transactional and transformational leadership styles on nurses job satisfaction. The study also found empirical evidence that the wider the span of control, the higher unit turnover rate. The study reported a 1.6% increase in turnover for every increase of 10 in span of control.

3.3.2.3 Staff Safety

Hechanova’s study22 _{of span of control and safety}

performance in teams revealed that large spans of control resulted in less monitoring of safety by supervisors. The study concluded that span of control was positively correlated to unsafe behaviors and safety accidents.

3.3.3 Impact on Patients

3.3.3.1 Patient Satisfaction

Doran et. al’s study10_{of Canadian hospitals, found that}

managers who had a large number of staff reporting to them had lower levels of patient satisfaction. Further, the researchers found that having a large span of control reduced the positive effect of positive leadership styles on patient satisfaction.

3.3.3.2 Patient Safety

Griffiths’ review16_{of infection control literature concluded}

that excessive spans of control among clinical leaders were a risk for increased infection and infection control problems in hospitals. This finding is consistent with findings in other professions. Nurses who reported that reduced access to the support and resources from nurse managers limited their ability to provide high quality care19_.

3.3.3.3 Strategies to Mitigate the Negative Impacts of Large Spans of Control

A review of the literature provides very few case examples of organizations that recognized the negative impacts of large spans of control, identified and implemented solutions and monitored outcomes.

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• The development of a Management Infrastructure (Michigan Leadership Model) at the University of Michigan Health System (UMHS) was prompted by an analysis of organizational metrics and indicators that revealed that downsizing strategies (resulting in larger spans of controls) in the 1990s had negatively impacted employee satisfaction and the quality of nursing care. After a comprehensive review of current nurse manager responsibilities, members of the re-design team identified key elements of an ideal nurse manager role (ensuring quality of care,

providing leadership, coaching and mentorship to staff, and managing operations). The team also identified the need for clinical infrastructure support and administrative/operations infrastructure support for responsibilities that were not identified as key elements and that could be easily delegated8_{. For}

detailed information on the outcome see Appendix B.

• Another strategy, implemented by Huntsville Hospital System in Alabama in response to a changing health care environment and larger spans of control was the implementation of a unit-based shared governance model on a Mother/Baby-GYN. By allowing staff nurses to have an active role in the decision-making process, the Hospital sought to increase staff participation, improved communication and increased job satisfaction. For more information on the outcome see Appendix B.

• At Fairview Health Services in Minneapolis, the organization responded to managers concerns about large spans of control. After studying the issue within their health care system, Fairview found a strong relationship between manager span of control and employee engagement. They subsequently added four nurse managers to observe the effects of smaller spans of control and realized positive improvement in employee engagement in all four areas7_.

• There recent work by The Ottawa Hospital relative to span of control at is referenced only in the Morash article37_{. High level details regarding the Span of}

Control Assessment tool were presented at the OHA’s Skill Mix: Work and Redesign Conference in December 2009. For more information of the Span of Control Assessment Tool see Appendix B, Table 1. Specific strategies to mitigate the negative impact of large spans of control were not cited in either of these references.

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In order to obtain a comprehensive understanding of Span of Control trends, challenges and leading practices of healthcare organizations in Ontario, stakeholder input was solicited through an online survey and via key stakeholder interviews. The process of survey development and distribution as well as overall findings from the survey is described below. Detailed tables of survey findings can be found in Appendix C and an analysis of stakeholder interview findings is presented in Section 5.0.

The Span of Control Survey was developed based on findings from the initial literature review. The survey was sent to:

• Chief Nursing Executives (CNEs) of Ontario Hospitals, with a request to forward the survey to front line managers;

• Executive Directors (EDs) of all 14 Community Care Access Centres with a request to forward the survey link to the Senior Director of Client Care who in turn would forward the survey link to the front line managers; and

• Directors of Care (DOCs) in Long-Term Care (LTC) Homes with a request to forward the survey link to front line managers. A representative sample of 51 LTC (large, small, for profit, not-for-profit, municipal etc.) distributed across the five OHA regions were utilized as the sample for long-term-care.

For the purposes of the survey distribution, managers were defined as: “those having Registered Nurses (RNs) or Registered Practical Nurses (RPNs) actively engaged in the practice of providing patient care reporting directly to them, and may as well have direct reports who are not RNs or RPNs.”

As noted earlier, the literature revealed two broad definitions of span of control: 1) the total number of

For the purposes of the survey, span of control was defined as “the number of people supervised by a manager.” As noted in the earlier chapter, the literature review revealed that span of control is a complex phenomenon that requires, among other things, consideration of the:

• Number of people reporting to a manager

• Combination of people, skills and variety of tasks that they perform

• Scope of responsibility (including duties, size and number of units, number of sites)

• Frequency of interaction with staff

• Planning and budgetary responsibilities

• Managerial supports

The first few sections of the survey including the manager’s demographic profile and staff profile were developed to gain an understanding of the current state analysis of the various factors contributing to Ontario manager’s span of control. Given the complexity of factors that influence span of control, the survey did not define “wide” and “narrow” span of control; instead, managers were asked to identify the scope of their span of control based on their own impressions. Characteristics of managers who reported a “wide” span of control are described in section 4.3. The literature review also revealed a handful of studies that have examined the impact of span of control on various managerial, staff and patient safety. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff turnover rates as well as patient and staff safety and satisfaction.

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1. Impact on effectiveness and/or frequency of communication

2. Impact on manager accessibility to staff

3. Impact on staff retention

4. Impact on staff attendance (levels of absenteeism)

5. Impact on staff injury rates

6. Impact on staff engagement

7. Impact on staff satisfaction

8. Impact on client/patient/resident safety

9. Impact on client/patient/resident satisfaction In the sections that follow, findings from the survey, including the overall response rates, organizational and manager profile and a profile of the staff being supervised are described. The impact of the span of control on each of the nine dimensions identified above, as well as strategies that have been implemented by organizations and their relative impact are described in detail in the sections below. All findings are presented on a sector specific level to provide meaningful opportunity for analysis and to ensure that the responses from the hospital sector (that accounted for the most individual responses) did not artificially skew findings. Findings for the manager and staff profile as well as span of control impact on nine dimensions are presented for managers who reported “narrow” and “wide” span of control. An explanatory note precedes the exhibits presented in each of the sections.

Note of caution: The results for the LTC homes that are presented as “narrow” versus “wide” span of control should be interpreted with caution given the small number of LTC managers who reported that they had a narrow span of control (n=3).

4.1 Response Rates

Given that initial communication regarding participation in the OHA’s Span of control surveys was sent to CNOs, EDs and DOCs, with a request to forward the survey link to appropriate managers, the total number of managers that the survey was ultimately sent to is not known. As such, it is not possible to determine the manager response rate. Based on survey results, however, it was possible to determine the response rate by sector. The highest response rate was for CCACs with 79% of CCACs who received this survey submitting at least one response to the survey, followed by 75% of hospitals submitting at least one response. The lowest participation rate was from the LTC sector. It should be noted that during the survey period, the LTC sector was highly involved with other activities such as implementation of new requirements of the Long-Term Care Act.

Although the CCAC sector had the highest response rate, given the large number of hospitals to which the survey was sent, and the total number of individuals responding to the survey, hospital managers accounted for the largest number of responses to the survey (86%).

It should be noted that although 733 respondents started the survey, not all individuals completed the survey. For each of the tables presented in the survey, the percentage calculation is based on the actual number of individuals responding to the survey question (shown as “Total n” in each table) and not on the number of individuals who

started the survey.

Exhibit 1: Survey Response Rates

Responses by Sector Sector total “n” Sector Response Rate % of Survey Respondents

Community Care Access

Centre 73 79% 10%

Hospital (including Complex Continuing Care and Rehab)

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Managers in the hospital sector were also asked to provide information on the types of unit(s)/service(s) that they were responsible for. As demonstrated in Exhibit 2, the top 3 services that hospital managers responding to the survey had accountability for were: Ambulatory units (22%), medicine units (17%) and emergency departments (16%). 21% of respondents were responsible for hospital units/ services not presented in the options below.

Exhibit 2: Units/Areas Supervised by Hospital Managers

Hospital Managers - Areas Supervised

Areas Supervised total “n” % of Respondents

Ambulatory 128 22%

Cancer Care 54 9%

Complex Continuing Care 87 15%

Critical Care 81 14%

Emergency Department 94 16%

Medicine 101 17%

Medicine/Surgery 55 9%

Mental Health 78 13%

Peri-operative Services (all OR

related services including day surgery) 72 12%

Rehabilitation/therapies 73 12%

Surgery 75 13%

Women’s and Children’s 59 10%

Other Hospital Unit 121 21%

total Managers Responding to

Question 585 nA*

*note: this question allowed respondents to select multiple responses. As such the total “n”s and percentages is greater than the number of unique individuals responding to the survey questions. Percentage calculations for this question were made accordingly.

4.2 _{Organizational Culture}

Survey respondents were asked to describe their organization’s culture based on four culture types

identified in Duxbury, Higgins and Lyons recent article12_.

Respondents from Long-Term Care Homes were most

• Cohesive culture: Experienced leaders who have a clear sense of direction and vision for the future and who are accessible to employees. There is a culture of respect in the organization and a sense of trust between managers and staff. There is high morale in the organization.

• Culture of appreciation and respect: The organization fosters a positive attitude and celebrates successes; mistakes are seen as an opportunity to learn. The workplace is safe and secure and there is sufficient time for training and development. People are appreciated.

• Culture of teamwork: People work as a team and work is fairly distributed. There is good and ongoing communication in the team.

• Balanced work life culture: There is recognition that employees have personal commitments outside of work and employees who leave on time or do not take extra shifts are not made to feel guilty.

48% of LTC respondents reported that their organization espoused the characteristics of all four cultures above, compared to 38% of hospital respondents and 29% of CCAC respondents. A breakdown of responses for each culture type is provided in Appendix C, exhibits 22-25.

Exhibit 3: Percentage of Respondents Reporting all Four Cultures in their Organization

Cohesive Culture, Culture of Appreciation and Respect, teamwork and Balanced Worklife by Sector

Sector total “n” % Agree or Strongly Agree

Community Care Access Centre 66 29%

Hospital (including Complex

Continuing Care and Rehab) 563 38%

Long term Care Home 29 48%

Authors of this study were interested in whether these findings varied by span of control reported by managers. Responses from the hospital sector were consistent for managers who reported narrow or wide span of control. For

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were less likely to report agreement in all four culture dimensions, whereas for the CCAC sector, the opposite was true. As mentioned in the introductory notes, given the small “n”, caution should be used when interpreting findings for LTC narrow versus wide span of control. It should be noted that not all individuals who responded to the culture question (earlier in the survey) responded to the span of control question, so the total “n”s for the question when categorized by narrow and wide span of control do not total the numbers in the earlier exhibits.

Exhibit 4: Percentage of Respondents

Reporting all Four Cultures by “narrow” Span of Control

Cohesive Culture, Culture of Appreciation and Respect, teamwork and Balanced Worklife for Managers Reporting a “narrow” Span of

Control by Sector

Exhibit 5: Percentage of Respondents Reporting all Four Cultures by “Wide” Span of Control

Cohesive Culture, Culture of Appreciation and Respect, teamwork and Balanced Worklife for Managers Reporting a “Wide” Span of

Control by Sector

Responses for hospital managers reporting “wide” span of control were further analyzed to determine if responses varied by the number of staff reporting to managers with wide spans of control. No material differences were noted in the following cultural dimensions: culture of teamwork, culture of appreciation and respect and cohesive culture. In the cultural aspect related to balanced work life, managers with wide spans of control who had greater than 100 employees were less likely to report a culture of balanced work life.

Similar analysis for CCAC and LTC managers reporting a wide span of control was not undertaken, given the small “n”s when categorized at this level.

4.3 _{Manager Profile}

Managers were asked to identify whether they had narrow or wide span of control. As stated earlier, narrow and wide span of control were not defined in the survey; managers responded to this question based on their own perceptions of their span of control. Managers of LTC homes were most likely to report a wide span of control (90%), followed by hospital managers at 73% and CCAC managers at 65%.

Exhibit 6: Percentage of Respondents Reporting narrow and Wide Spans of Control

Reported Span of Control by Sector

Sector total “n” narrow Span of

Control

Wide Span of Control

Community Care Access

Centre 63 35% 65%

524 27% 73%

Long term Care Home 29 10% 90%

As seen on the next page, the number of staff supervised by managers varied greatly by sector; Exhibits 26 & 27 in Appendix C provides the breakdown of this information by managers reporting narrow and wide spans of control.

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4.3.1 Characteristics of Managers with Wide Span

of Control

As stated previously, while many factors are considered to influence a manager’s span of control, a review of the literature did not provide a set definition of what constituted narrow and wide spans of control. Based on the responses provided by managers, those who reported a wide span of control were more likely to have:

• Greater than 80 staff members reporting to them (39% compared to 15% for managers reporting a narrow span of control)

• Responsibility for three or more units (62% compared to 29% for managers reporting a narrow span of control)

• Budgetary responsibility (94% compared to 79% for managers reporting a narrow span of control)

• Budgets exceeding $7 million (41% compared to 15% for managers reporting a narrow span of control) Detailed survey results on number of staff reporting to managers, number of units/service per manager, budgetary size and responsibility can be found in Appendix C, exhibits 26-31.

4.3.2 Manager Background and Education

There was no material difference in the respondent background for managers who reported narrow and wide span of control. Over 80% of CCAC and hospital respondents had a nursing background; and 100% of LTC managers had a nursing background (See Appendix C, exhibit 32).

In addition, managers who reported a wide span of control had a higher percentage of Master’s/PhD completion for all three sectors (34% of compared to 26% of managers who reported a narrow span of control.) See Appendix C, exhibit 33.

Managers were also asked if they had received any leadership education (e.g. facilitation, negotiation, coaching, mentoring, emotional intelligence etc.) and/ or management/operations education (e.g. finance/ budgeting, human resources etc.). Although over 85% of CCAC managers had received leadership education, managers who reported a wide span of control were more likely to have received both leadership and management/ operations education. No real differences were noted in hospital respondents.

Exhibit 7: number of Staff Reporting to Managers

number of Staff Reporting to Managers

Sector total “n” Less than 40 40 - 60 61 - 80 81 - 100 101 - 125 126-150 Greater than 150

Community Care Access Centre 59 83% 15% 2% 0% 0% 0% 0%

Hospital (including Complex Continuing

Care and Rehab) 509 24% 22% 19% 15% 11% 6% 4%

Long term Care Home 28 25% 7% 25% 7% 4% 21% 11%

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4.3.3 Years in Management

For all three sectors, managers who reported a wide span of control were more likely to have over five years in management experience compared to colleagues who reported a narrow span of control; 71% compared to 36% in CCACs, 65% compared to 17% in hospitals and 46% compared to 0% in LTC homes (See Appendix C, exhibit 34).

4.3.4 Multi-site Responsibility

CCAC managers who reported a wide span of control were more likely to report multisite responsibility compared to those that reported narrow span of control (90% compared to 68%). There were no real differences in multi-site responsibility for hospital respondents.

Note: High percentage for LTC managers with narrow span of control is not as material given the small number of respondents in this category (n=3).

Exhibit 9: Percentage of Respondents Reporting Multi-site Responsibility

Multi-Site Responsibilty by Sector

Sector narrow Span of Control Wide Span of Control total “n” % “yes” total “n” % “yes”

Community Care Access Centre 22 68% 41 90% Hospital (including Complex Continuing Care and Rehab) 143 21% 381 28%

Long term Care Home

3 67% 26 23%

Exhibit 8: Leadership and Management Education of Managers

Leadership/Management Education in the Last two Years by Sector

Sector

narrow Span of Control Wide Span of Control

total “n” Leadership Education Management/ Operations Education BOtH Leadership and Management/ Operations Education total “n” Leadership Education Management/ Operations Education BOtH Leadership and Management/ Operations Education

Community Care Access Centre

22 86% 50% 50% 41 88% 71% 68%

143 76% 57% 50% 381 79% 59% 52%

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4.3.5 Manager Supports

The survey findings did not reveal any material differences in the manager supports present for managers who reported a narrow or wide span of control. The only exception to this category in CCACs and hospitals was the presence of educators (See Appendix c, exhibits 35-36). Managers were also asked “what supports would you find most helpful to manage your span of control?” Responses received were grouped into three broad categories: administrative, clinical and other.

By far, the most frequently reported desired support was that of administrative/clerical/secretarial support with 52% of hospital managers, 40% of LTC managers and 37% of CCAC managers reporting this as the most helpful support to manage their span of control. Managers also requested support in the more operational tasks of budgeting, the use of data to support decision making and HR support for attendance management etc.

From a clinical perspective, managers expressed a desire for increased advanced practice nurse roles as well as clinical leader roles to support them in their day-to-day activities. Many managers specifically noted the need for clinical leader positions to be filled by “non-union” staff.

Managers also noted other supports such as management and operations training, mentorship and coaching, support in policy and procedure/best practice reviews and improved technologies to support their work.

Listed in exhibit 10 is a more comprehensive list of supports that were identified by managers:

Exhibit 10: Supports Most Useful to Managers to Manage Span of Control

types of Supports Most Useful to Manage Span of Control

CCAC Hospital LtC

n= 30 n= 335 n= 15 Administrative

Secretarial/Clerical/Administrative

Supports 37% 52% 40%

Data Manager/Decision Support/

Quality Management 13% 1% 0%

Scheduling Support 0% 2% 0%

HR Support 7% 4% 13%

Occupational Health Support 0% 1% 0%

Financial/Business Analyst Support 13% 4% 0%

Material Management Coordinators 0% 1% 0%

Senior Management Support

(Directors, Regional Managers etc.) 7% 2% 0%

Assistant Managers, Supervisors,

Additional Managers 17% 5% 13%

Clinical

APn Roles 10% 26% 40%

Advanced Practice nurse 3% 5% 13%

Clinical nurse Specialist 0% 1% 0%

nurse Practitioner 0% 0% 0%

nurse Educator 7% 20% 27%

Care Leaders 17% 16% 73%

team Leader 10% 2% 0%

Clinical Care Coordinator 7% 14% 73%

Patient Flow/Patient Care Facilitator 0% 1% 0%

Consistent Charge nurse 0% 13% 13%

Professional Practice Leaders 3% 5% 0%

increase Allied Staff Support 0% 1% 0%

increase Front Line Staff 0% 0% 0%

Other

technology Enablers 0% 3% 0%

Management/Operations training 7% 1% 0%

Mentorship and Coaching 3% 0% 0%

Regular Policy and Procedure Review/

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4.4 Staff Profile

4.4.1 Number of Staff in a Single Workday/Shift

and Frequency of Contact with Staff

Managers who reported wide span of control were three times more likely to have responsibility for more than 41 staff in a single workday/shift (21% compared to 7% for managers who reported a narrow span of control.) This trend was particularly apparent in the CCAC and hospital sector (See Appendix C, exhibits 37-38).

As would be expected, CCAC and LTC managers reporting wide span of control were less likely to have multiple contacts with their staff in a single workday; interestingly no difference was reported by managers in the hospital sector (See Appendix C, exhibits 39-40).

These results are consistent with the literature review that found that the amount of time a manager spends interacting with employees is dependent on other competing demands and the overall distribution of managerial resources36_{. Managers who are over extended}

and have overly wide spans may limit access to staff and the mentorship that managers wish to offer1_.

4.4.2 Skill/Autonomy and Union Status of Staff

CCAC and LTC home managers who reported a wide span of control had higher percentages of highly skilled/ specialized and autonomous staff compared to colleagues who reported a narrow span of control; no real differences were noted for managers in the hospital sector. CCAC managers reporting wide span of control also had a much smaller percentage of unionized staff compared to CCAC managers who reported a narrow span of control (See Appendix C, exhibits 41-42).

4.4.3 Types of Staff

While the percentages of regulated, registered nursing staff were similar for managers reporting narrow and wide spans of control across all three sectors, managers in the hospital sector reporting a wide span of control reported higher percentages of unregulated care providers, allied health professions and administrative/facility staff reporting to them as well.

These results are consistent with the literature review that found wide spans of control are more commonly found in flat structures and associated with managers supervising units in which the employees perform routine tasks with little variation27_{, or when managers are supervising highly}

skilled or specialized staff who have extensive knowledge of the work and require less supervision35_{(See Appendix C,}

exhibits 43-44).

There was slight variation in managers with narrow/wide span of control reporting that their professional staff worked to full scope of practice (See Appendix C, exhibit 45).

4.5 Span of Control Impact on

Specific Dimensions

A handful of healthcare specific studies have examined the impact of span of control on various managerial, staff and patient dimensions. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates, in addition to patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings.

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The online survey to Ontario managers explored the experience of Ontario managers in each of these categories. Managers were asked to provide feedback on the following:

• The impact of their span of control on each dimension

• Whether or not they had implemented specific initiatives to alleviate the impact that their span of control had on each of these dimensions

• The length of time the initiatives had been in place (if applicable)

• The impact that the initiative had had on each dimension

• A list of the initiatives that had been implemented In the sections that follow, information is provided on the perceived impact of a manager’s span of control on each dimension, whether or not initiatives had been implemented, the relative time that an initiative had been in place and the perceived impact that the initiative had on each dimension. For each sector, the time period during which the greatest positive impact of these initiatives was felt and a corresponding “menu” of initiatives provided by managers was determined. The percentage of managers citing each initiative has been provided. Given that these were free text comments, it is possible that managers may not have thought of a particular initiative at the time of survey completion and as such, the percentages under represent the number of managers who have implemented these initiatives; a pre-set multiple choice listing may have avoided this issue.

While many of the initiatives directly relate to the manager’s span of control and impact on a specific dimension, some of the initiatives provided by the managers appear to be more general in nature. These initiatives are also included

in the lists provided. Additionally, it should be noted that while a list of initiatives is provided in table form, the Hay Group has identified initiatives that they believe are the most relevant to span of control.

A summary of the overall findings of the impact of these dimensions on span of control and initiatives that have been implemented to mitigate their impact is presented below. It should be noted that the total “n” within each dimension may vary; not all respondents completed all questions within each dimension.

Exhibit 11: Managers Reporting negative or Very negative impact of Span Of Control on nine Dimensions

Percentage of Managers Reporting Span of Control has a negative or Very negative impact on Specific Dimensions

Dimension/Sector Community Care Access Centre Hospital (including Complex Continuing Care and Rehab) Long term Care Home Grand total Effectiveness and/ or Frequency of Communication 18% 31% 12% 29% Manager Accessibility to Staff 24% 35% 29% 33% Staff Retention 13% 10% 4% 10% Staff Attendance (Levels of Absenteeism) 11% 19% 17% 18%

Staff injury Rates 4% 3% 13% 4%

Staff Engagement 15% 23% 5% 21% Staff Satisfaction 16% 21% 5% 19% Client/Patient/ Resident Safety 2% 8% 9% 8% Client/Patient/ Resident Satisfaction 5% 7% 9% 7%

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Exhibit 12: Percentage of Managers who have implemented Strategies to Alleviate Span of Control impact on nine Dimensions

Percentage of Managers who have implemented Strategies to Alleviate SOC impact on Specific Dimensions

Dimension/Sector Community Care Access Centre Hospital (including Complex Continuing Care and Rehab) Long term Care Home Grand total Effectiveness and/ or Frequency of Communication 77% 75% 88% 76% Manager Accessibility to Staff 52% 43% 67% 45% Staff Retention 40% 55% 67% 54% Staff Attendance (Levels of Absenteeism) 66% 78% 78% 77%

Staff injury Rates 61% 78% 87% 77%

Staff Engagement 72% 66% 77% 67% Staff Satisfaction 50% 60% 73% 59% Client/Patient/ Resident Safety 69% 86% 91% 85% Client/Patient/ Resident Satisfaction 85% 68% 86% 70%

4.5.1 Impact on Communication

Managers in hospitals and LTC homes reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on communication. This was especially true for managers in the hospital sector (40% compared to 9% of managers reporting a narrow span of control.) See Appendix C, exhibit 46.

There is mixed evidence of the impact of large spans of control on communication. However, a review of the literature produces greater evidence of the negative impact of large span of control on communication. The findings from the survey add to literature findings that demonstrate a negative impact of wide span of control on communication.

The majority of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on communication. Over 85% of respondents who stated that they had implemented initiatives reported a positive or very positive impact. The greatest positive response to these initiatives was when the initiative had been in place for greater than two years in hospitals and LTC homes and between one and two years in CCACs. (See Appendix C, exhibits 47-48).

Initiatives implemented by managers and/or their

organizations are provided in exhibit 12 below. While some of these initiatives to improve communication may be directly related to span of control, other initiatives appear to be broader in nature and may have been developed for other specific purposes. A summary of leading practices is provided in section 6.2.

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Exhibit 13: initiatives Related to Enhancing the Effectiveness and Frequency of Communication

Span of Control impact on Communication

Menu of initiatives CCAC Hospital LtC n= 11 n= 127 n= 12

Regular staff meetings 55% 61% 42%

Email updates 0% 37% 17%

Administrative walkabouts/rounding 18% 25% 0%

Communication binders, bulletin

boards, posters 0% 22% 33%

Manager Visibility/Access (incl. open

door policy) 0% 17% 42%

Online communication (WebPages/

shared drives) 45% 13% 0%

newsletters 9% 13% 0%

team Huddles/Bullet Rounds 0% 12% 17%

interprofessional/professional practice/

nursing council meetings 0% 12% 8%

Staff forums/town halls 9% 9% 25%

Phone/Blackberries, tele/Video

conferencing 9% 8% 8%

Ad-hoc Staff/individual meetings 0% 7% 8%

involvement in committees/goal setting 0% 7% 0%

Admission, transfer, shift reports 0% 5% 8%

Staff educational opportunities 0% 5% 0%

Charge nurse meeting/consistent

charge nurse 0% 5% 0%

Performance Appraisals 9% 4% 0%

Appreciation/recognition/team building

days & events 0% 3% 0%

Organizational/program action plan

updates 0% 2% 8%

Management/union meetings 0% 2% 17%

Consistent charge/resource nurse 0% 0% 0%

Length of time initiative has been in place - largest positive response: CCAC: 1 -2 years

Hospitals: 2 + years LtC: 2 + years

It can be assumed that a manager’s ability to successfully implement the following initiatives would be directly impacted by their span of control:

• Regular staff meetings

• Manager walkabouts/rounding

• Manager access and visibility

• Staff forums/town halls

• Ad-hoc staff/individual meetings

• Staff involvement in committees/goal setting

• Performance Appraisals

• Management/union meetings

4.5.2 Impact on Access to Manager by Staff

Managers in CCACs and hospitals reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on the manager’s ability to be accessible to staff. CCAC managers with large spans of control were twice as likely and hospital managers were four times more likely to report a negative impact than those that reported a narrow span of control (See Appendix C, exhibit 49).

As documented in the literature, many managers spend a large amount of their day coordinating staffing issues, patient flow and working on committees etc. and as such, managers who are over extended or have overly wide spans may only provide limited access and mentorship to staff. Growing spans of control limit the attention, support, clinical supervision and feedback that a manager can provide to an employee often with detrimental impacts.

Span of Control (Final)

Leading Practices for Addressing

Clinical Manager Span of Control in Ontario

February 2011

Foreword

Table of Contents

1.0

Executive Summary

2.0

Introduction

3.0

Overview of Literature Findings

4.0

Span of Control Survey

5.0

Key Informant Interviews . . .

6.0

Recommendations

Acknowledgements

Appendix A:

Recommendations

Appendix B:

Literature Review: Definition,

Key Concepts and Emerging

Themes

Appendix C:

Additional Survey Tables

Appendix D:

Key Informant Interview

Participants

Appendix E:

Sample Documents

1.0

Executive Summary

2.0

Introduction

3.1

Span of Control Defined

3.1.1

Additional Considerations for Span

of Control

3.1.2

Ideal Span of Control

3.2

Tools to Assess Manager Span

of Control

3.3

Span of Control and Impact on

Managers, Staff and Patients

3.3.1

Impact on Managers

3.3.2

Impact on Staff Performance

3.3.3

Impact on Patients

4.1

Response Rates

4.2

Organizational Culture

4.3

Manager Profile

4.3.1

Characteristics of Managers with Wide Span

of Control

4.3.2

Manager Background and Education

4.3.3

Years in Management

4.3.4

Multi-site Responsibility

4.3.5

Manager Supports

4.4

Staff Profile

4.4.1

Number of Staff in a Single Workday/Shift

and Frequency of Contact with Staff

4.4.2

Skill/Autonomy and Union Status of Staff

4.4.3

_{Executive Summary}

_Introduction

_{Span of Control Defined}

_{Tools to Assess Manager Span}

_{Organizational Culture}

_{Manager Profile}