Social & Cultural Basis for Community and Primary Health Programs

ORGANIZATIONAL CHANGE AT ST. JOSEPH HOSPITAL a case study from a student=s lab assignment

However, one precondition of the nurses working on the new CU was, that they did not have to handle preparation of the chemotherapy. Thus, it fell to the already over-worked physicians to prepare the treatment solutions every day and they also had to be trained to do this. It became rapidly clear that with the success and rising number of cancer patient admissions to the CU, this professional group was simply overwhelmed with the task. Therefore, we suggested that the hospital pharmacy, which distributed and prepared all other medications, should take over the preparation of chemotherapy solutions. The head pharmacist objected to this vigorously and nothing happened for a year. However, in the meantime the management of the hospital saw the success of the CU, which more and more was able to reach out to the community through cancer survivors who founded self-help groups and therefore gained in popularity. In addition, the special benches for the preparation of chemotherapy became outdated and therefore, had to be replaced. We made the argument, that the buying of new benches for all wards (since some cancer patients were still treated on other units) would not be necessary if the hospital pharmacy would take over the preparation centrally. After another six months the head pharmacist finally gave in, got a special bench installed and started with the central preparation of chemotherapy solutions.

Background and Change Processes

When I came to St. Joseph Hospital in 1993, 1 was hired as chief resident to build up an oncology unit in the Department of Gastroenterology, which had not existed until that date. While the hospital had treated cancer patients before, it was not prepared to do this on a larger scale and basically referred the respective patients to other hospitals. This changed with the arrival of a new director of the department who had some experience with the treatment of gastrointestinal (GI) malignancies at his former post. With regard to the growing incidence of cancer in the over-aged population of the city, he also saw a chance to increase the attractiveness of the hospital for the community.

Subsequently we rededicated a ward with 18 beds to be the assigned 'Cancer Unit' (CU), after the nurses working on that ward had agreed to that change. (Actually, the unit was planned for another ward in the beginning but the nurses on that ward had refused the change.) Within a short time, an attending physician board-certified in hematology/oncology was hired and we both started to train the nursing staff for the special requirements that cancer patients have. We also were able to hire a psychologist for the counseling of the patients as well as for supervision of a Balint group (an exchange between staff about their experience and to cope with the stress) and counseling of the staff. Then we concentrated all cancer patients, who were already treated in the hospital, on this ward. Word of the new unit spread and was met mostly with skepticism in the hospital and applause by the surrounding health practitioner community. Patients started being referred to us more and more and within six months after its' erection the ward was completely filled with cancer patients.

Stage of Change

The process, as far as I know, is still in the maintenance stage. All changes have taken place and are perceived as success. The physicians have more time to concentrate on their special clientele and the ordering and distribution of chemotherapy is smooth. Even the pharmacist and especially his assistant (who right from the beginning was much less opposed to the idea) are satisfied since they got the new bench and felt that the preparation now is in good hands.

Until the arrival of the new head of the department the cancer patients had been spread over all wards in the two internal medicine departments, which did not ensure a high quality of their treatment because of the inexperience of the respective residents in hematology/oncology. The preparation of the chemotherapy, mostly very toxic substances, until that time was taken over by the respective nurses of the wards, who previously had just been given a short introduction to take special care with the preparation. Since the chemotherapy was prepared on all medical wards in the hospital, a number of special laminar airflow benches had to be bought to comply with federal regulations regarding toxic substances and their use in me country.

Organizational Diagnosis

The Technical Factor

Chemotherapy: toxic substances, dangerous to handle

The logistics: distribution , utilization of larger amounts of medications

Erection of a laminar airflow bench in the pharmacy

Information systems: recording and reporting

Necessary overhaul of existing chemotherapy

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benches on wards

The Human Element

Resistance of nurses to prepare drug solutions

Reluctance of pharmacy to introduce central preparation

Workload of physicians

Decreasing chance for mistakes by professionals and central handling of toxic substances

Conservatism of catholic hospital leaders => skepticism towards change

The Environment

Attractiveness/reputation of the hospital for referring health practitioners

Popularity/reputation of hospital with surrounding community

Location of hospital in a district with many older citizens

Space-Time coordinates

Timing of inputs: training of people who prepare solutions, drug supply for perceived need

Timing of distribution of chemotherapy to CU

Locations of 'players' in the building (communication)

Location of hospital with regards potential clientele (mostly older people)

Policy Factors

Federal regulations regarding preparation and handling of chemotherapy drugs

Necessity of hospital in our city - increased chance to survive 1990s 'hospital dying'

Application of chemotherapy - lucrative business for the hospital

Competition among heads of departments for resources (human and financial)

Cost of new laminar airflow benches for all wards

Pressure for professional handling of hospital affairs by government, medical associations etc.

Conclusions and Lessons

In my opinion the approach to the problem was appropriate. The new CU was a success and meant an increase of popularity of the hospital for the referring health care providers an d the community, since

patients could now be treated nearby. This impressed the conservative hospital council, which was initially opposed to a special ward for the disease (fear of stigmatization ) and of the administration who initially feared rising costs. While the costs indeed rose, the hospital still made more money since cancer treatment is rewarded more generously in the country and due to the more complete treatment offerings and increased popularity of the hospital more patients came, also for other illnesses.

A problem was the inner-hospital structures of power. While the parallelism of structures may obstruct changes (especially those concerning two or more of the structures), it is the reality nowadays in most hospitals in the country and has it s advantages (better teamwork between nurses and physicians, nobody feels superior). Since the pharmacy and the nursing section were 'emancipated' with regard to the physicians, the only way to achieve change was gradual persuasion. The success of the CU and the backing by the hospital management certainly helped in convincing the head pharmacist to take over the task. At the same time, there was fortunately political, scientific, and technical pressure for more professionalism in handling chemotherapy preparation in the country.

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Organogram of St. Joseph Hospital

Hospital Council and Board of Trustees

Medical Director

Head of Nursing

Head of Pharmacy

Administrative Director

Directors of other depts

Director of

Medical Department II

Director of

Medical Department I

other Depts: Obs/Gyn, Surgery, Radiology, etc.

Departments of Neurology, Cardiology

Depts of Gastro- enterology, Hematology, Oncology

Nurses

Pharmacy

Administration

Diagnostic Procedures

Other Wards

Cancer Unit

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