Organizational Environment - Case Study

Beth Israel Hospital Case #2 Organizational Environment, p. 89-90.

B E T H I S R A E L H O S P I TA L

Boston ’ s Beth Israel Hospital is a restructuring effort in health care that

sought to move toward greater autonomy and teamwork. When Joyce

Clifford became Beth Israel ’ s director of nursing, she found a top - down

structure common in hospitals:

The nursing aides, who had the least preparation, had the most contact

with the patients. But they had no authority of any kind. They

had to go to their supervisor to ask if a patient could have an aspirin.

The supervisor would then ask the head nurse, who would then

ask a doctor. The doctor would ask how long the patient had been

in pain. Of course the head nurse had absolutely no idea, so she ’ d

have to track down the aide to ask her, and then relay that information

back to the doctor. It was ridiculous, a ludicrous and dissatisfying

situation, and one in which it was impossible for the nurse to

feel any satisfaction at all. The system was hierarchical, fragmented,

impersonal, and [overmanaged] [Helgesen, 1995, p. 134].

Within units, the responsibilities of nurses were highly specialized: some

assigned to handling medications, others to monitoring vital signs, still

others to taking blood pressure readings. Add to the list specialized

housekeeping roles — bedpan, bed making, and food services — and a

patient witnessed interruptions from a multitude of virtual strangers. No

one really knew for sure what was going on with any individual patient.

With the support and cooperation of Mitchell Rabkin, Beth Israel ’ s

progressive CEO, Clifford instituted a major structural change, from a

pyramid with nurses at the bottom to an inclusive web with nurses at

the center. The concept, called primary nursing, has each primary nurse

monitor the care of a specific patient. The nurse takes information

when the patient is admitted, develops a comprehensive plan, assembles

a team to provide round - the - clock care, and lets the family know

what to expect. A nurse manager sets goals for the unit, deals with

budget and administrative matters, and makes sure that primary nurses

have ample resources to provide quality care.

As the primary nurse assumed more responsibility, connections with

physicians and other hospital workers had to be revised. Instead of simply

carrying out physicians ’ orders, the primary nurse became a professional

partner, attending rounds and participating as an equal in treatment

decisions. Housekeepers reported to primary nurses rather than to housekeeping

supervisors. The same housekeeper was assigned to make a

patient ’ s bed, attend to the patient ’ s hygiene, and deliver trays. Laundry

workers brought in clean items on demand rather than making a once -

a - day delivery. Beth Israel ’ s inclusive web was further strengthened by

sophisticated technology that gave all network points easy access to

patient information and administrative data.

Primary nurses learned from performing a variety of heretofore

menial tasks. Bed making, for example, became an opportunity to

evaluate a patient ’ s condition and assess how well a treatment plan

was working. Joyce Clifford ’ s role also was transformed from top - down

supervisor to a web - centered coordinator. Rather than telling people

what to do, she focused on keeping everyone informed:

At the center of all patient care at Beth Israel, Joyce Clifford linked

the various intersecting points of the inclusive web: “ A big part

of my job is to keep nurses informed on a regular basis of what ’ s

going on out there — what the board is doing, what decisions are

confronting the hospital as a whole, what the issues are in health

care in this country. I also let them know that I ’ m trying to represent

what the nurses here are doing — to our vice - presidents, to our

board, and people in the outside world . . . to the nursing profession

and the health care field as a whole ” [Helgesen, 1995, p. 158].

Beth Israel ’ s primary nursing concept, initiated in the mid - 1970s, produced

significant improvement in both patient care and nursing morale. Nursing

turnover declined dramatically (Springarn, 1982) and the model ’ s success

made it highly influential and widely copied both in the United States and

abroad. But even successful change won ’ t work forever. Over the years,

changes in the health care system put Beth Israel ’ s model under increasing

pressure. More patients with more problems but shorter hospital stays

made nurses ’ jobs much harder at the same time that cost pressures forced

reductions in nursing staff. Beth Israel chose to update its approach by creating

interdisciplinary “ care teams. ” Instead of assembling an ad hoc collection

of care providers for each new patient, ongoing teams of nurses,

physicians, and support staff were created to provide interdisciplinary support

to primary nurses (Rundall, Starkweather, and Norrish, 1998).

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