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Issues in the Operating Room

Questions:

Case Study

Lincoln Hospital: Third Party Intervention

Soon after the election of a new chief of surgery, the president of Lincoln Hospital faced a crisis. Lincoln, a 300 bed for-profit hospital in south-western United States, was experiencing severe problems in its operating room (OR). Forty per cent of the OR nurses had quit within the previous eight months. Their replacements were significantly less experienced, especially in the specialty areas. Furthermore, not all could be replaced; when the crises came to a head, the OR was short seven surgical nurses.

Also, the necessary equipment often was not available. On several occasions, orthopaedic surgeons had already begun surgery before they realised the necessary prosthesis (for example, an artificial hip, finger joint or knee joint) was not ready, was the wrong size or had not even been ordered. Surgery had to be delayed while equipment was borrowed from a neighbouring hospital.

Other serious problems also plagued the OR. For example, scheduling problems made life extremely difficult for everyone involved. Anesthesiologist’s often were unavailable when they were needed, and habitually tardy surgeons delayed everyone scheduled after them. The nursing shortage exacerbated these difficulties as the lack of staff required impossibly tight scheduling. Even when the doctors were ready to begin, the scheduled nurses might still be occupied in one of the other operating rooms.

The surgeons were at odds among themselves. Over 30 of them were widely regarded as prima donnas who considered their own time more valuable than anyone else’s and would even create emergencies in order to get ‘prime time’ OR slots – for which they were often late.

Worst of all, the doctors and nurses were virtually at war. Don, the new chief of surgery, was at war with Mary, the veteran OR director; he had even campaigned on a promise to get her fired.

Lincoln’s president was faced with a difficult choice. On one hand, he needed to satisfy the physicians, who during the tenure of his predecessor had become accustomed to getting their way in personnel matters, by threatening to take their patients elsewhere. The market was increasingly competitive, and the hospital was also faced with escalating costs, changes in government regulations, and strict Join Commission on Accreditation of Hospitals standards.

Could the president afford to alienate the surgeons by opposing their newly chosen representative – who had a large practice of his own?

On the other hand, could he afford to sacrifice Mary?

She had been the OR director for 13 years, and he was generally satisfied with her.

 As he later explained;

Mary is a tough lady, and she can be hard to get along with at time. She also doesn’t smile all that much. But she does a lot of things right. She consistently stays within her budget...

Furthermore, whereas Don had long been an outspoken critic of the hospital and was generally distrusted by its administrators, Mary was loyal, a strict constructionist who adhered firmly to hospital policies and procedures:

She is supportive of me, of the hospital, and of our interests. She doesn’t let the doctors get away with much. She has been an almost faultless employee for years, in the sense that when she comes to work, gets the job done, never complains, and doesn’t make any waves. I really don’t understand the reason for the recent problems. I trust her and want to keep her. It would be extremely difficult to replace her.

Difficult Decision: Choosing Between Don and Mary

The last point was a key one; a sister hospital had spent almost three years trying (unsuccessfully) to recruit an OR director.

After talking with both nurses and doctors, the president decided not to fire Mary. Instead, he told both Mary and Don that they must resolve their differences. They were to begin meeting right away and keep on meeting, however long it took, until they got the OR straightened out.

The results were predictable. Neither party wanted to meet with the other. Mary thought the whole exercise was pointless, and Don saw it as a power struggle that he could not afford to lose. The president, who wanted an observer present, chose Terry, the new executive vice president and chief operating officer. Mary didn’t know Terry very well so she asked that her boss, the vice president of patient services, sit in. Don, who didn’t trust either Mary or her boss, countered with a request for a second of his own, the vice president for medical services.

When the meeting finally occurred, it quickly degenerated into a heated argument, as Don and Mary exchanged accusations, angrily defended themselves, and interpreted any interventions by the three ‘observers’ as ‘taking sides’ or favouritism.

At this point, Lincoln’s president called me. We negotiated a psychological contract, where the president share the above historical information, described the problem as he saw it, and identified his expectations of me and for the project. Then, I expressed my expectation of the president. When then agreed to take no steps until I had interviewed both Don and Mary.

Later that afternoon, Don expressed his anger and frustration with the hospital administration and, most of all, Mary:

I don’t want to have anything to do with this lady. She is a lousy manager. Her people can’t stand to work for her. We don’t have the equipment or the supplies that we need. The turnover in the OR is outrageous. The best nurses have quit, and their replacements don’t know enough to come in out of the rain...All we want is to provide quality patient care, and she refuses to let us do that. She doesn’t follow through on things.

He particularly resented Mary’s lack of deference.

Mary’s behaviour is so disgraceful it is almost laughable. She shows no respect whatsoever for the physicians...She thinks she can tell us what to do and order us around; and I am not going to put up with it any longer. When I agreed to take this job as chief of surgery, I promised my colleagues that I would clean up that mess that has plagued the OR for years. I have a mandate from them to do whatever is necessary to accomplish that. The docs are sick and tired of being abused, and I am going to deal with this lady head on. If we go rid of her, 95 per cent of our problems would go away. She has just gone too far this time.

In his cooler moments, Don admitted that Mary was only partly to blame for the OR problems, but he still insisted she must be fired, if only to prove to the doctors that the hospital administration was concerned about those problems, and that something was being done. I am always a bit suspicious about the objectivity of someone who has reached the conclusion that someone must be fired. There is always something else that is going on that requires more investigation, such as personal bias perhaps.

Third Party Intervention

Clearly, both Mary and Don had strong needs to control other people’s behaviour, while remaining free of control exacted upon themselves.

It was obvious from these initial interviews that Don and Mary were largely contributing to the OR problems; but it was also obvious that many others had a stake in the outcome of their battle.

Most of the doctors blamed the high turnover on the nursing managers’ inability to retain qualified personnel, whereas the managers blamed it on the doctors’ verbal abuse. A significant number of doctors were widely regarded by some of their peers as well as by the nurses as impatient, intolerant perfectionists who demanded for higher standards of others than they did of themselves.

The next step was to identify specific problems for Mary and Don to address. They wrote their response on a sheet of paper, assigning directions to represent the relative seriousness of the problem. Some of the most serious problems could be solved immediately; others were going to take longer, but at least Don and Mary now knew what their priorities had to be.

Finally, it became possible for them to agree on specific behavioural changes that might help. Don and Mary each defined what they wanted from the other and negotiated what they themselves were willing to undertake; the meeting was moderated and they wrote down the decisions. Since Mary and Don were interdependent, either could have easily sabotaged the other’s efforts. Therefore, in defining each action item, they were reminded to specify responsibilities for both parties:

What will Don (Mary) do to resolve this problem?

What will Mary (Don) do to help the other succeed?

This technique made both parties jointly responsible for resolving each problem and thus changed the whole dynamic of the relationship – from mutual isolation to collaboration, from denial of responsibility to acceptance of responsibility, and from a focus on problems to a focus on solutions.

During the next year, there were four more meetings with Don & Mary. Before each meeting, each participant was interviewed privately. At the beginning of each meeting, the participants gave general reports on what was going on, between Mary and Don and in the OR in general. In particular, each one was asked to list positive events and specific behaviours on each other’s part that they appreciated. They then reviewed the commitments they had made during the previous meeting.

In almost every case, both Mary and Don had kept these commitments, thus building a basis of trust for further commitment during the latter part of the meeting. Where they had not kept the commitments, plans were made to ensure follow-through before the next meeting.

Part A

1. If you had been called by Lincoln’s president to help resolve the problems described in the case, how would you have carried out the process? What would you have done differently than the OD consultant?

2. Is third-party intervention an appropriate intervention in this case? What were other possible OD interventions”

Part B

Discuss two lessons from the case study that you could put into practice in your own work or previous work experience. State why these lessons are important to you and outline a plan for implementing them in your future or current work situation. You do not need to identify your specific situation or details of individuals or organisation.

Your discussion should include the following:

• Descriptions of specific actions, interventions or approaches that would be more effective in similar situations in the future, and the improved outcomes that you would expect.

• The criteria and processes that you would use to evaluate the effectiveness of these actions and
interventions.

• Possible obstacles to implementing your improvement plan (e.g. lack of time, insufficient resources, unsupportive colleagues), and how they can be overcome.
Presentation

Interviewing Don and Mary

Change Management-It is a loom towards transitioning individuals and teams, as well as organizations towards a well desired future plan and situation. In any project that is related to the management context actual change management might even refer to the project management procedure where in the changes to scope of any project are officially introduced as well as approved. Properly communicating anticipated positive results can also help a person to excite his/her team plus increase the ownership in project. Any vital management of change initiative must also be tracked towards determining effectiveness of the strategies as well as towards identifying the fields that must be enhanced upon at the time of next situation demanding change management (Cameron & Green, 2004).

Third party intervention- these terms said as "third party" plus "intermediary" are actually both used when it is referred to any person otherwise team of the people who also get involved in any kind of conflict towards helping disputing parties for management otherwise or coming down to a solution of the issue. These third parties or party might also act like consultants, who would help the one side otherwise both the parties through analysing conflict as well as planning a very effective and successful response. On other hand, they also might act like a facilitator, who arranges the meetings and sets proper agendas, as well as guides the productive talking and discussions (Green, 2007). These facilitators also often record things that are said, and might even sometimes write a short study summarizing discussions as well as any agreements which were reached. While several different forms of mediation also are common, majority of them have conflicting parties sitting down together towards explaining each other about their views regarding nature of problem as well as the way in which they actually think the problem might get solved. While few mediators take very stronger role within option identification plus selection rather others, mediators also do not have power to oblige a solution (Pugh & Mayle, 2009).

About the case- Lincoln Hospital is facing an issue of shortage of human resources and even equipments and tools. The organization has employed a new chief of the surgery and soon after his joining the firm has suffered the issue. About 40% of OR nurses have actually left the job in last eight months. And also the replacements were considerably less experienced. OR lacked 7 surgical nurse. Scheduling also was a problem for people involved. Anesthesiologist’s generally were unavailable while they were required. Don, was new chief of the surgery and had some war with Mary who was the veteran OR director. Later the management department took several step to solve their issues and within a single year both Mary and Don were interviewed somewhat four times. Also other staffs were asked to submit their views on the relation amid Mary and Don. It was very obvious from the interviews that Don and Mary the technique has made them jointly accountable for resolving every problem plus changed whole dynamic of relationship right from the mutual isolation till the collaboration, and from denunciation of the responsibility till acceptance of the responsibility.

Don's Concerns

Change in reality occurs when anything ends and then something novel or somewhat different initiates. The phase or the period in the hospital was somewhere amid the two points and this is called transition. This also is situation where people actually have to attain knowledge and strength to understand and adapt something new and let go the old. Embracing the new wholeheartedly gives a positive outcome whereas incapability in the adaption leads to problems and conflicts. Usually this situation takes people away from familiar to something unknown. Probably this was happening in the Lincoln Hospital. A new chief of surgery was not being totally accepted by some employees specially Mary and this created a vast conflict and also hampered the firm badly. Many operating room staffs also left their jobs and the result was ridiculous for the organization (Randolph, Ferrie & Palmer, 1976). Even though Don’s joining of the organization was positive, this psychologically affected many staffs. Several had very strong response towards this change and some even reacted calmly. One of such was the feeling of actual loss, with struggle towards accepting a novel joiner. Change also produced many physical symptoms like emotional distress, loss of staffs, lack of nurses and most vital was the reemployment of the staffs which also affected quality of the work. The major error in the management of change was underestimating affect it actually had on the people. Actually the supervisors might have thought merely informing the staffs about the change would be sufficient for them to handle the alteration and adjust to the change. Not only the coming of the new chief but less supply of equipments also has frustrated the staffs and was seen a vast reason behind the problem of turnover taking place in the firm. Mary’s lack of respect and leniency towards her job also created several issues and even the management was responsible for certain problems like, lack of tools, mismanagement of time and schedules and many more.

Several forms of Loss were found, they are:

Security-Staffs no longer felt in control otherwise know what future holds, and even were not interested in their tasks.

Co-operation-There was lack of co-operation among the staffs. Employees were not ready to help each other. Everyone behaved selfishly and this hampered the firm

Relationships- Staffs in the firm were having bitter relations among themselves and were not seen very happy with each other. The best example were, Don and Mary

Sense of Direction- The meaning and mission of the job in the employees was very unclear. People were never motivated and also were never encouraged towards good performance.

There could be few helpful management plans and strategies for every phase of the transition that was seen in the firm.

Strategies for each phase:

Some instances are scheduled below of few things which were observed in every phase. This might help in the diagnosis:

Denial- Both Don as well as Mary could have been shown the past results of the firm and could have been asked that this can also be attained by both of them work with proper co-operation and support

Conclusion

Resistance- Here anger, blame and anxiety as well as depression plus also irritation has been observed in the staffs. The employees need to be trained and their resistance power needs to be enhanced by the management.

Commitment- A lot of commitment and feeling of loyalty towards the organization needs to be developed in the staffs so that they think twice before leaving their job.

During the denial phase the management must confront people involved in the conflict and issue and proper information needs to supply to them. it was also necessary for the firm to properly inform the change to the staffs beforehand for avoiding the issues but this was not done and result was all negative. During the resistance stage staffs must be taught to listen, feel and acknowledge as well as respond empathetically plus even encourage support.

Yes, third party intervention to some extent was appropriate in this case. Though it has its own disadvantages and side effects yet it worked properly in the situation that occurred in the hospital (Morris, 2008). After the interference the situation calmed down to some extent and both Don as well as Mary at least agreed to talk to each other can the condition came down from selfishness to selflessness. Other OD interventions that could have been applied in the case are:

This is a change method that mobilizes the organization members towards identifying the issues, set of the action and targets, as well as initiate working on such problems. Organizational confrontation meeting in this case might typically involve following steps:

1. A proper group meeting can be held where of the staffs involved is the process of OR will be included. Usually the task here will be to identify issues about work ecology and effectiveness of firm (Watts, 1982).

2. Groups will be selected from staffs working in the operating room as basic issue has been observed in the operating room.

3. The members of the group might be asked to supply full detail and data regarding the issues amid Don and Mary and also what they think is the basic reason behind the vast turnover taking place in the firm (Beckhard, 2000).

4. The group will be given appropriate time to recognize the problem and then supply data on the same.

5. The set of people will then reconvene within meeting place. All the members will need to report problems which will be identified and also then provide solutions.

6. Either then otherwise later, master catalog of issues will be broken into several categories.

7. Participants also will be divided into groups like problem-solving sets whose composition might, and generally will, differ from the one of original problem-reorganization groups.

8. The group will be asked to, develop a proper tactical plan for action, as well as determine proper timetable intended for the completion of this phase of process.

9. The group then will be periodically asked to reports list of the priorities as well as tactical strategies of action towards the management (Plutchak, 2009).

Result might have been good and even better as the confrontation meetings would actually have been combined with some other approaches like feedback and also survey as well as observation.

There are several things that a analyser can learn from above issues:

  • Every firm must carry a proper employee retention plan and scheme for making staffs stayin the organization for longer period of time
  • A proper change management process must be followed by all the organization undergoing any king of change

These lessons are vital as they provide a path for proper management and control in the organization and also help the firm to avoid any further conflict or issues taking place in the firm. Also the learning about such lessons will make me understand the change management in better way and will be helpful to me in career perspective.

Organization confrontation meeting-

This can be extra effective in such a situation. Here several surveys can be made to know the relation amid Don and Mary and also to seek data on actual problem existing in the firm which is leading to such a large turnover of nurses from the OR section. Such an approach can enable the firm to know the viewpoints of all the staffs and this will also make staffs feel as part and parcel of the firm’s problem solving procedure which will as a result encourage the employees to some extent (Brinkerhoff, 1996).

Interpersonal interventions could also have been useful in this case where two staffs are fighting with each other and are in a situation where they are totally against each other. This intervention can be designed to improve as well as enhance the individual skills, efficiency, knowledge, as well as effectiveness of both Don plus Mary. Very popular interventions within this cluster are the T-groups that would help the staffs become extra aware about their own as well as their co-worker’s skills and behaviour plus their issues and problem patterns (Imanipour, Talebi & Rezazadeh, n.d.). A characteristic T-group will also consists of some 10 to 20 volunteers who will meet at very specific time within proper duration. The meetings will also be unstructured and will leave group to recognize subject matter with context to a fundamental goals that will be stipulated by the facilitator. Also as group members will try to put forth structure upon fellow members the anxiety ensues as well as the group will become extra aware of about own as well as other's feelings plus behaviors.

While implementing the approaches and process I might face several issues:

  • Many staffs won’t provide real data and original information with a fear of losing job
  • Time will be a big hurdle as collection of data and information will indulge a lot of time
  • Money will also be needed to conduct meetings
  • Employees will need to take out time from their jobs and attend meetings which will further create issues like lack of time (Zmud & Cox, 1979)
  • Many staffs won’t accept the process wholeheartedly
  • Lack of proper and also step-by-step planning of the change going to take place in the organization, the firm might fall apart otherwise cause extra problems rather than benefits. One needs to properly understand exactly things that the changes will bring in and the ways in which those changes can occur.
  • Communication with staffs can be another barrier
1) Identify Goals plus Objectives- The first step will be recognize what were the actual goals that were to be obtained before the process started.
  • Review the process and plan- Next i will analyse whether the whole process went through the planned procedure or not. If not then the chances of negative results actually rise (Daumit, 2001).
  • Outline how the OD intervention worked- The intervention that was planned will be evaluated and it will be seen that this intervention went on the original steps or not.
  • Analyze the benchmark- The standard of result that was expected will be put down and also the results that were thought to be obtained will be laid down
  • Find the actual result- Then the final result will be compared to the benchmark that was previously set for the attainment of the aims and goals that were set in the beginning
  • Final outcome- The analysis and evaluation of both benchmark and the final result will give the ultimate outcome. In this step all the gaps and surplus will be identified if at all it exist in the firm after the process has been undertaken (Ravallion, 2009).

Conclusion:

Intervention actually tends to solve almost all the issues and conflicts taking place in any organization. All the OD interventions help the firms to grow and develop to certain level and also supports the organization to properly analyse as well as evaluate the issue that are creating problems for the firm and for the staffs as well. A good evaluation will assess whether each of the intermediate effects was achieved. Though the creation and implementation of such processes in never an easy task for any firm yet it solves many issues like it did in case of the Lincoln Hospital that was suffering with problem of employee turnover as well as several conflicts among staffs at the same time was undergoing loss due to lower performance of staffs, less motivated employees, lack of tools and equipments and too some extent even the misleading of staffs due to lenient and loose management having very less control over the staff members. In a nutshell here is the total analysis and detail about the issue in the Lincoln Hospital and the data regarding third party intervention its advantages and its side effects as well as many other OD intervention that might help the organization in this situation. 

References

Beckhard, R. (2000). The Confrontation Meeting. Reflections: The Sol Journal, 2(2), 5-13. doi:10.1162/15241730051091966

Brinkerhoff, D. (1996). Process perspectives on policy change: Highlighting implementation. World Development, 24(9), 1395-1401. doi:10.1016/0305-750x(96)00056-3

Cameron, E., & Green, M. (2004). Making sense of change management. London: Kogan Page.

Daumit, G. (2001). A Computerized Tool for Evaluating the Effectiveness of Preventive Interventions. Public Health Reports, 116(90001), 244-253. doi:10.1093/phr/116.s1.244

Green, M. (2007). Change management masterclass. London: Kogan Page.

Imanipour, N., Talebi, K., & Rezazadeh, S. Obstacles in Business Process Management (BPM) Implementation and Adoption in SMEs. SSRN Journal. doi:10.2139/ssrn.1990609

Morris, M. (2008). Combating workplace stressors: Using work-life initiatives as an OD intervention. Human Resource Development Quarterly, 19(2), 95-105. doi:10.1002/hrdq.1229

Plutchak, T. (2009). Collaboration, not confrontation. Bulletin Of The World Health Organization, 87(8), 636-637. doi:10.2471/blt.09.069252

Pugh, D., & Mayle, D. (2009). Change management. Los Angeles: SAGE.

Randolph, W., Ferrie, J., & Palmer, D. (1976). A Simulation for Developing Od Intervention Skills. Journal Of Management Education, 2(3), 31-33. doi:10.1177/105256297600200307

Ravallion, M. (2009). Evaluating three stylised interventions. Journal Of Development Effectiveness, 1(3), 227-236. doi:10.1080/19439340903114644

Watts, G. (1982). Survey feedback: An effective OD intervention. New Directions For Community Colleges, 1982(37), 91-105. doi:10.1002/cc.36819823708

Zmud, R., & Cox, J. (1979). The Implementation Process: A Change Approach. MIS Quarterly, 3(2), 35. doi:10.2307/249085

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