Few industries are confronted with more change and more turbulence than the health care industry. As the perusal of any newspaper or news website will indi- cate, there is constant pressure on health care organizations to provide quality care in a cost-controlled environment that is characterized by ever-increasing regulation. This pressure can be seen most clearly in the advent of managed care during the 1980s and beyond. Managed care involves integrated and com- prehensive systems of health care providers, insurance companies, and government programs, coordinated around specific care plans and guidelines designed to simultaneously enhance the quality of care provided, control the cost of that care and maintain access to care for as many people as possible. As you might guess, it’s pretty much impossible to succeed in all three of these important goals of cost, quality, and access, but hospitals and other health care organizations keep on trying.

I’ve run into many such organizations in my research on communication in health care organizations. One of these organizations—we’ll call it Uni- versity Hospital—is discussed in several of my publications (Miller, 1998; Miller et al., 2000). University Hospital is a large teaching hospital that employs nearly 5,000 individuals and is responsible for half a million patient visits a year. University Hospital is acknowledged as a very high-quality medical center—for example, it typically scores extremely well on accreditation surveys. However, like all health care organizations, University Hospital needed to improve in a number of financial areas, including average length of stay and cost per discharge. My involvement with University Hospital began when I learned of changes that were occurring in the nursing department and was asked to be a part of understanding and instituting those changes. As part of a hospital-wide effort to improve financial and care performances, the nurses were beginning a pro- gram of “differentiated nursing practice” (Hoffart & Woods, 1996) in which nursing roles were defined on a variety of specific levels of responsibility. These roles would require new training, new responsibilities, and a new orientation toward the systematized provision of care. The centerpiece of this program was the “care coordinator” role.

Care coordinators were defined as registered nurses charged with coordinating care for patients “from admissions to discharge.” This coordination involved communication with relevant physicians, social work- ers, allied health personnel, insurance representatives, and families. The nurses selected for these roles were the best and the brightest that University Hospital had to offer.

That sounds like a good change, right? Coordinated care from admissions to discharge is certainly an admirable goal. However, remember that the nurses selected for these positions were trained in traditional, clinical nursing. They were then thrown into a role that required them to work with individuals from a variety of hospital disciplines (with different turf issues and different levels of power) within an incredibly complex organizational structure. And they were doing this with little or no training and with a job description that was purposefully ambiguous; nurses were asked to design the job in the best way possible. Indeed, the final line of the job description for care coordinators read “Role in development/work in progress”!

So, imagine you are me, asked to help the leaders of the nursing department take their nurses—and especially the new care coordinators—down this path of organizational change. The department is directed by two nurses—we’ll call them Hannah and Jen—who has an incredible amount of energy. Both are well-liked by the nurses they supervise. Hannah has been with the hospital for many years and knows all the ins and outs of the system. She is the steady hand guiding the nursing department, and she feels a bit overwhelmed by all the change she is being asked to institute. Jen has been with University Hospital for only a few years but has made quite an impact as a charismatic leader who wants University Hospital— and especially the nursing department—to be on the cutting edge of managed care initiatives. Jen is a pro- ponent of all sorts of New Age things, and she is particularly smitten with “chaos theory” as a way to manage organizational change. She figures that they have selected the best people they can for the care coordinator roles, and she trusts that they will use their own imagination and ingenuity to craft roles that will work for the new system. Indeed, when a care coordi- nator complained about the stress of the changes they were going through, Jen quoted her favorite chaos the- orist, saying, “Chaos is the rich soil from which crea- tivity is born” (Merry, 1995, p. 13). Oddly enough, the nurse did not feel comforted.

1. How does the nursing department at University Hospital exemplify ways that organizations often react to planned organizational change? Are there ways in which the nature of the change—or the way it is being instituted at University Hospital— differs from traditional patterns?

2. If you were taking on a “care coordinator” role at University Hospital, what kind of information would you want to have? Do you like the idea of an unstructured role that you can develop on your own? What are the advantages and disadvantages of this kind of organizational ambiguity?

3. How would you choose to lead this department through the change they are experiencing? Would you rather have Jen or Hannah as your leader in this process?

4. What are some ways that Jen and Hannah could work together to make the change process successful?

5. What are two things University Hospital should have done or could do moving forward to promote success in this change initiative? It's fine to integrate your two concepts into your answer here (but not required).