February 03, 2008

Organizational (In)consistency: Twelve Feet Make a Big Difference

clip_image002By Janis Prince Inniss

In a previous post, I recounted the horrors I experienced when my mother was hospitalized. These difficulties could have been prevented if the hospital staff—the nurses and technicians—had done their jobs! (Two nurses were notable exceptions). clip_image006Unfortunately, I have been able to observe a lot more in that same hospital ward, as my mother has been hospitalized twice more since her surgery. Stunningly—and mercifully—these two later experiences have been as different from the first as chalk is to cheese. 

The ward floor is separated into “East” and “West”. I suspected that there was a substantial difference in the quality of care between East and West when I heard the surgeon request a specific side after Mum’s surgery; if they are the same, why ask for one and not the other? 

clip_image005I remembered that during her initial hospital stay Mum did not get a room on the side he requested. After that initial stay I thought that the lack of care must be endemic to that hospital and likely an indication of the state of medical care in the U.S. (The lack of data to make such broad generalizations did not faze me in my traumatized state!) It was inconceivable to me that a room a few feet away would result in different care. 

Stay II has made me a believer in the differences between East and West! The night before Thanksgiving Day, Mum experienced such excruciating pain that her doctor admitted her to the hospital. Out of her sight, I wept, remembering the lack of care awaiting her in the hospital. Recognizing that I could neither provide her relief, nor did I have the ability to diagnose the problem, we headed for the hospital. By the time we arrived, Mum was looking better than she had in the hours since her ordeal had begun and I fantasized that she no longer needed medical attention. Although reluctant, I escorted her to admitting.

When we got up to the ward floor, I realized that Mum’s room was “on the other side”. clip_image007In an effort to orient her nurse staff to Mum’s needs, I began with the truth—that her last hospitalization had so traumatized me that I cried upon learning that she was to return to the hospital. The nurse was sympathetic, and promised that they would take very good care of Mum. The staff seemed to encircle Mum and in less than two hours all of the x-rays and other tests had been completed, an NG tube and an IV were inserted and Mum was resting comfortably.

I had never seen such responsiveness during Stay I. I went home that night feeling surprisingly relaxed based on the care being shown to my mother. As was my practice during Stay I, early the next morning I called the hospital to “orient” the new nurse (I knew that most of the nurses work 12 hour shifts – from 7 to 7) to my expectations and concerns and was told by that nurse that she had read about my fears in Mum’s chart! Again, this nurse was reassuring. When I went to visit the next day, I was disappointed that one of the nurses I knew from “the other side” was assigned to Mum. To my surprise, Mum said the nurse had actually nursed her: touched her, gave her pain medication promptly when it was requested, visited the room without being called, and even scolded Mum for going to the bathroom without calling for her help. I became so comfortable with the care Mum was receiving that I no longer kept my detailed field notes about her stay and even stopped logging the name of every single nurse and technician assigned to her. Mum came home that Saturday afternoon—and I was filled with nothing but gratitude for the staff!


In case I was fooled into thinking that the Stay II staff was unusual, I have had a chance to observe that unit for an even longer period. Mum returned to the hospital and remained there for four weeks. The staff has been wonderful, but when Mum underwent surgery again all of the anxiety I felt about her care during Stay I resurfaced.

The vision of her chapped lips and yearning for ice chips haunted me from Stay I, but my silent concession to going home was to call and orient her night nurse to my expectations. “To Do List” in hand, I called, but before I could complete my warm-up chat, the nurse was smoothing my feathers by saying, “Don’t worry I’ll take good care of her.” I recognized the nurse’s voice and demeanor from Stay II and with a word of thanks, hung up, crumpling my list. I slept well that night and the next day Mum looked great! She said the nurse was in her room all night, moistening her lips, swabbing her tongue with cold water and attending to all her other needs.

How are such enormous differences in one unit, let alone one institution? Theorist Michel Foucault highlighted the idea that organizational architecture is related to authority. Foucault noted that subordinates are easily seen and supervised when under surveillance. As is typical of many organizations, hospitals are designed with many open spaces, although there are private ones such as patient rooms. Indeed, the open nurses’ station where I saw staff congregate was the site of much time wasting on “the bad side”. The fact that staff did not try to hide their time wasting is an indication that floor staff conformed to what was expected and accepted within that side’s culture.clip_image011

Structurally, a few factors have created and reinforced the differences between East and West: Staff is assigned to one or the other side (although they may go to another side when there is a shortage); they socialized separately and even had separates staff meetings. Although there has been no predictability across the two sides, for the most part there is predictability within each side—one side is predictably poor the other is predictably good. A change in unit leadership has meant challenging the low performers of “the bad side” to step up their work ethic and tearing down of structural factors to create one predictably stellar unit.


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