In this chapter of the thesis I will describe and discuss the findings. In paragraph IX.1 I briefly describe the realizations during the decade after the implementation of ‘PEGASOS’. In paragraph IX.2 I evaluate whether we experienced a change or a transition, the fundamental question of this thesis. As to research question 2, in paragraph IX.3 I explore the meaning of “collaboration” between various stakeholders in a complex adaptive system and finally in paragraph IX.4 the matrix model for para-medical services that were not included in the startup of ‘PEGASOS’ is discussed.
IX.1 Project realizations
The integration of in-patient clinic (hospitalization) and Medical Technical Services (out-patient clinic) has been realized. Formerly two separate columns, they now have shown for the first time a clear desire to cooperate and this is an opportunity to leave the silo mentality behind. Organizational silos are defined as vast psychological spaces of compartmentalization, segregation and differentiation (Diamond, Stein, & Allcorn, 2002). Organizational silos do not only refer to conscious structures, but also to an unconscious state of mind and mentality that takes up a life of its own. Silos result in the splitting of organizational artefacts and relationships, and impact negatively on relationship forming between individuals and within teams (Cilliers & Greyvenstein, 2012).
One of the major goals of ‘PEGASOS’ was to improve the quality of care. The accreditation of Ghent University Hospital by an international organization for the accreditation of hospitals (NIAZ-QMENTUM) was obtained in 2016. Patient-centered care has been another objective. The implementation of ‘core teams’ where a doctor and another healthcare professional join forces to solve specific problems in issues of patient care and governance may be considered as an alternative way of spanning the boundary between doctors and other healthcare professionals. The teams act as ‘facilitator’ to alleviate problems. The sector chair and the care manager acting in concert may also be considered ‘boundary spanners’ as they also bear responsibility for all four types of activities described by Glouberman and Mintzberg (Casanova, 2008; Glouberman & Mintzberg, 2001a, 2001b): the realization of optimal medical treatment (cure), quality of care and the wellbeing of patients (care), efficacy and efficiency (control), as well as for public accountability (community). By integrating actors from the worlds of cure (sector chair) and care (care manager), we aim to bridge the vertical cleavage that separates those irretrievably connected to the organization (such as nurses) from those involved with it but not so formally connected to it (physicians).
We realize that other groups, mainly paramedics such as the physiotherapists, occupational therapists, psychologists, engineers, laboratory technicians and others need to be included. Since the implementation of the model in 2009, a huge change happened in the way cure and care are organized towards a multidisciplinary process that crosses boundaries between specializations and organizations, with the patient as the beholder of this endeavor. Individual teams in physical medicine and rehabilitation, also called physiatrist, care for some of the most medically complex and vulnerable patients following severe injuries, all while maintaining an inclusive focus on medical management, quality of life, and long-term goals for community participation. Effective collaboration by care teams in acute, post-acute, and ambulatory settings alike undoubtedly contributes to patient care improvements. Collaborative relationships across settings are critical for optimizing care, yet they are very difficult to achieve. This is where physiatrists play a key role in integrating care for patients with severe injuries and complex medical needs, by maintaining a focus on improving function and helping patients return to their communities. Therefore, in order to achieve a conceptual framework to integrate paramedics in the ‘PEGASOS’ conceptual model, input was asked from their chiefs (psychologists, physiotherapists, occupational therapists).
This paper underscores the professional boundaries and rivalries between two cultures, but it also offers suggestions on how to handle this seeming paradox in present day healthcare. Following are some of the ideas that were launched during the one-on-one meetings about collaboration as this is the hallmark to be able to work in teams. The responses can be applied as well to an inter-personal collaborative situation as to inter-sectorial or inter-professional work.
Medicine is undergoing a transformation like none other in its history. We are moving from a pay for service to a pay for performance model. This perspective will inevitably impact both inpatient and outpatient practices. The latter will drive competition and give consumers greater decision-making ability as to where they choose to receive care. Organizations that fail to effectively prepare themselves, and execute a successful strategy for the evolving pay for performance initiative will have a hard time surviving (10 IHI Innovations to Improve Health and Health Care, 2017; Bauchner, Berwick, & Fontanarosa, 2016; Berwick, 2016; Khanna, Wachter, & Blum, 2016; Powers, Milstein, & Jain, 2016). Today, health systems operate on a spectrum of how involved patients are in the delivery of their care. On one end, traditional providers inform patients of their options, make a recommendation, and proceed to deliver care to a relatively passive patient. On the other, patients and their families are engaged in conversations with care teams, discussing goals and creating care plans together — with patients taking a more active role in the decision-making process (Anderson, Martin, & KS, 2017, June).
IX.2 Change or transition
In “Managing Transitions”, William Bridges explains that change in itself does not cause problems so much but rather the transition from ‘old’ to ‘new’ (Bridges, 1986). Change is situational: the move to the new site, the retirement of the founder, the reorganization of the team, the revisions of the pension plan. Transition, on the other hand, is psychological; it is a three-phase process that people go through as far as they are concerned). We experienced that helping people through the transition is essential if the change really wants to work as intended. If a change takes place without people going through that transition, only something superficial has changed.
Situational changes are already complicated enough, but not as far-reaching as transitions: the psychological process that people experience when faced with changes in their organization. It is the people who matter in change; their willingness to change is essential for succeeding. These transitional phases can be recognized by major changes at work. Insight into these transitional phases and the psychological aspects that play a role in radical changes can help make changes more successful.
Transition is psychic: it is a process in three phases that people go through when they internalize and accept the details of the new situation. The change only goes according to plan if you guide people through the transition. Therefore, the exercise of this thesis is useful in bringing together the observations of over more than a decade.
When looking at the ‘SWOT’ analysis we think that transition has been reached in some, but not all areas. Transition is a process whereby people break ties with their old world and enter into other ties with a new world. People are asked to give up their attachment and security and changes into uncertainty. Loyalty is being mixed. Without it being clear what the new situation will bring. It is often the trust that is requested by the organization that is changing, which is often difficult to achieve, because the psychological contract has been violated (Dennis & Mike, 2009). We experienced that the effect that organizational change produced on the perceived increase in clinicians’ overall satisfaction is moderated by some personal traits of the professionals who are affected by the change, as was reported by others (Mascia, Morandi, & Cicchetti, 2014).
How do we read this Bridges model? People will be in the different phases at any moment in time. For management it is important to be aware of this in approach and communication. There are no turning points to indicate. The transition phases indicate psychological processes of connection, attachment and detachment. These psychological processes do not care about deadlines and planned or fixed dates on a calendar or spreadsheet. It is important for the change agent not to want to move forward too fast. We cannot skip any phases. It is reminiscent to the theory on death and dying (Kübler-Ross, 1972). We cannot praise the new beginning if we have not dared to stand still when saying goodbye to the old situation. People will only be willing to travel to the new future, through the uncertain phase of the neutral zone, if we have enabled them to leave the old situation behind. Bridges’ description of “the Neutral Zone” as that place between the way things are done now and the way they will be done in the future provides an excellent way to understand the bridge that must be built in order for people to undertake the transition with confidence rather than fear. On hindsight, I think it took somewhat a decade to reach the phase of transition, but not for the hospital in general. I realize that we need to respect the often overlooked level of compassion and trust it takes to ask people to give up what they know and go down an uncertain path. Something of the old will have to be included in the new, if people want to be able to connect to the new. The old is over, but not taboo. Where, in this model do we fit with ‘PEGASOS’?
This analysis is the main research question of this paper: change or transition. Based on the qualitative analysis of the discussions, we can reasonably state that we reached our goal on process improvement, communication, autonomy of chiefs and heads of departments, relationship with sector bureau with mutual confidence and comprehension. On the other hand, a gap remains between line managers and nurses. Efficiency and management are in some cases problematic as suggestions to improve the efficiency of sector meetings have been made as well as on how the sector bureau may be more supportive. Quality of care is in the neutral zone as most respondents assign the lack of improvement to individuals and disciplines, and less to the Sector. This is in stark contrast with the NIAZ-QMentum accreditation that was obtained in 2016. We need to clarify the difference between the internal appreciation and the appreciation by external auditors but it has been reported that structural aspects of change influence overall job satisfaction and hence the appreciation of change (Mascia, Morandi, & Cicchetti, 2014).
Decision making is considered as a problem and this is ascribed to the added layer of hierarchy. Let us not forget, however, that our origins were in a governmental supervised system, in which autonomy nor responsibility was the final goal.
IX.3 Collaboration in a Complex Adaptive System (CAS)
During the ‘PEGASOS’ exercise” we observed that, whilst individual physicians and nurses frequently collaborate to care for a particular patient, and while the Chief Medical Officer and the Chief Nursing Officer may work collaboratively, there has generally been no mechanism in place for these professions to exercise leadership and direct the clinical work of the hospital jointly, as unique and complementary experts with a common goal (Casanova, 2008). It is the recognition that it is not what people have in common but their differences that makes collaborative work more powerful than working separately. Working together means acknowledging that all participants bring equally valid knowledge and expertise from their professional and personal experience. Working “together” rather than working “alongside” can energize people and result in new ways of tackling old problems (Davies, 2000).
Ghent University Hospital is a CAS that differs from a multi-agent system by its homeostasis, communication, collaboration, specialization and organization. This is proven by the evolving paradigm exemplified in 2017 when rehabilitation medicine became on the forefront of patient-centered thinking and when all stakeholders agreed to join. The idea of refocusing to chronic care overcame the idea of hyper specialization. Cooperation and collaboration are of the utmost importance. The awareness that stakeholders need to have a common and shared vision on what organization we are and how it will function now and in the future is important. By focusing attention on processes and projects that are working well we create an environment where organizational changes are accepted in a positive way. Ultimately the integration of the medical and nursing department is aimed to create added value for the patient by organizing services around medical conditions and care cycles. The process is led by physicians but the collaboration of nurses, technicians and various specialists is absolutely required to succeed. In order to collaborate, we need to get the professionals to work together, proposing new models for coordination, collaboration and cooperation. This includes: valuing input by each participant equally, encouragement and recognition of the creative power from diversity, a transformational network leadership allowing for emergence of a vision from dialogue, the welcoming of challenge and appointment of a facilitator to permit minority opinions to be heard (Barker, Bosco, & Oandasan, 2005; D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005). With the move toward value based, population-focused models for payment and care delivery, problem solving that integrates all sorts of professionals in efforts to confront the challenges facing a community will be increasingly important. Whereas the fee-for-service model emphasizes deployment of complex technical skills, value-based models reward working together to untangle knotty societal problems (Dow & Thibault, 2017).
Different gradations and intensities exist in collaborative relationships. Two stories (in italics) will illustrate this.
Collegial relationships are characterized by equal trust, power, and respect. Nurses and physicians frequently used the words peers or equals in describing these relationships. The words do not always mean the same thing.
A document with a particular view of a clinical pathway was being discussed during an extended core-team meeting. After three meetings, the physician in charge is convinced of its’ value but the head nurse and the other nurses are not convinced yet and they suggest waiting before implementing the document. They are convinced that the doctor wants to go too fast. The doctor is convinced that nurses are not supportive enough. During the next extended core team meeting, this seemingly paradoxical situation is addressed again by a junior head nurse. It provokes anger from the doctor who claims that the document has been discussed and decided upon. The nurses feel threatened and they tell the doctor that you don’t create a team by shouting ‘we are a team’. Finally, an agreement is reached: the expertise of the doctor is in the content of the project; the expertise of the nurses lies in the operational and executive part. The meeting ended in mutual understanding.
Collaborative relationships are marked by mutual trust, power, respect, and cooperation and are based on mutuality rather than equality.
Cooperation or collaboration may mean different things and could be misunderstood
A hospitalized patient with multiple co- morbidities is suffering excruciating pain at night. The nurse calls the doctor on call several times and the analgesics are adjusted. According to the nurse, treatment is inadequate, but the doctor refuses to call his supervisor, whose night rest he does not wish to disturb. The nurse then calls the chaplain of the hospital who in his turn calls the nursing supervisor. The supervisor then sends the head nurse on call to the ward for an evaluation and the medical supervisor for critical care is also called. Medication is consequently adjusted by the critical care physician. Months later, the course of this case is discussed by the Advanced Care Planning team at the ‘Ethics Committee’ in the presence of the actors. Nobody was blamed, the event was treated as a case study, lessons were drawn and this resulted in a new, more pro-active approach for similar complex cases.
Given that role is intricately connected with authority and boundaries, a misperception of the role may result in a misperception of authority and boundaries. In ‘Practical Recommendations: How to Achieve Effective Clinical Engagement and Leadership when Working Across Organizational Boundaries’, Woodard offers good practices aimed to fill the current knowledge gap around what is required for good clinical engagement and leadership when working across organizational boundaries. It aims to be a useful source of information for front-line practitioners, offering new knowledge and evidence for clinicians and managers to consider when embarking on a cross-organizational project (Woodard, 2007). Some of her recommendations are reflected in the ‘PEGASOS’ project that is itself aimed at extending management responsibilities across the clinical divide.
The paper by Green adds insights on this issue (Green & Molenkamp, 2005).There are many tools available to assist in the observation on how we function best. Just to mention:
– Active listening not only shows respect and thus is likely to enhance collaboration, but also and not least will elicit information otherwise not accessible.
– By looking at the situation from the perspective of night vision, and ask what does it look like when its right and how can we get there, we are able to reframe some situations and work towards a positive solution from a new point of view (Lehman & Van de Loo, 2016). People in teams frequently tend to err on the side of caution when they don’t feel right about a decision or a strategy, keeping quiet instead of being the one who throws a spanner in the works. When a team puts on their “night vision” goggles, they can avoid the trap of groupthink. In my experience, on hindsight, this methodology has enabled teams to uncover obstacles in their midst and make better decisions based on input that they did not previously consider (van de Loo & Lehman, 2016). Like other forms of human relationships, collaboration can be enjoyable and it can be painful. To try to ensure that our lives are filled with more of the former and less of the latter, we strive to improve our skills for successful collaboration, by learning the easy way (e.g. reading) and the hard way (experiential learning, real practicing). It is comforting to believe that we can learn and improve.
From collaboration to close collaboration
The concept of “core-teams” is an essential part of our philosophy underlying the ‘PEGASOS’ model. It is a tool to enhance collaboration between doctors, nurses and paramedics within the distinct medical services. It applies the conceptual model of “shared governance”, a dynamic structure that is centred on four critical principles of fully empowered organizations: partnership, accountability, equity, and ownership.
The author agrees with the fundamental belief behind shared governance that staff nurses at every level in the organization should govern their practice and be included in decisions that affect their practice. And the same holds true for doctors as well. To increase acceptance of the ‘PEGASOS’ model and to improve the outcome of the change process, “core-teams” are actively being promoted with structured support in a management development program and by formal lectures on management competencies.
The objective for management competence lies in “developing a vision”. Adequate management and a performing organization are some of the basic conditions for qualitatively high- level health care. Alignment is necessary around goals with managers in the unit that understand what’s expected of them, how their work is going to change, and why standardizing work is important to sustaining quality.
Healthcare institutions are looking for specifically educated people who not only know how to deliver care but also understand the medico-socio-legal context in which they operate. However, here is need for a clarifying framework with some team members as the philosophy behind ‘PEGASOS’ was insufficiently explained to certain groups such as the physiotherapists and hence was not mentalized. The exercise that was made 10 years ago may need a repeat for a different audience.
Although we do not traditionally view them as such, our hospitals and healthcare organizations are made up of hundreds if not thousands of these microsystems. Our challenge is to identify the microsystem(s) in which we work every day and strive to identify how we can maximize its function and business aims. As we mature in our thinking, we must then turn to how a given microsystem relates to other microsystems within our organization so that our efforts maximize our overall organization’s strategic vision. This framework, although not traditionally taught in school, will be increasingly important as our organizations (and society) challenge us with improving our efficiency and reliability (Likosky, 2014).
An effective team has clear tasks and clear goals. One sees a functional membership and a clear role (number of members, status, motivation level, commitment level; rules of the game agreed and in use; behaviour in meetings with respecting time, preparation counts, listening, taking turns speaking. Also a clear functional interaction is witnessed by good functioning communication and the sharing of information, giving feedback, resolving conflicts. Equally important are mutual trust, mutual respect and appreciation and the expression of opinions. Loyalty and the commitment to implement agreed decisions are required. Efficient decision-making processes imply practical experience, theoretical knowledge and an agreement as to who decides with whom to negotiate and whom to inform. Finally, an appropriate meeting technique is necessary with agreements on the required actions, time at disposal, situation and on the ways of processing in a versatile, thorough and deep manner, accepted by all, with questions of responsibilities taken into account
An ineffective team has a weak sense of direction: it seems that nothing undermines enthusiasm for teams as quickly as the frustration of being an involuntary member of a team with no focus. This leads to high level of negativity and passivity. Infighting is a danger. Effective teams don’t have to be made up of people who like each other but there must be respect for each other. Too many win-lose situations among members create confusion and anger. Shirking of responsibilities is another issue. When members avoid taking responsibility for both the process and the course in a group the risk arises that for specific assignments a team becomes a “pseudo team”; i.e., team in name but consistently underperforming. Very important is the lack of trust. Whenever this happens, team members are unable to depend on each other. This situation is marked by strangled information flow; dominance by one or two members and power games. And finally, but obviously, when skills are lacking, teams flounder, members have trouble communicating with each other, destructive conflicts result, decisions aren’t made, and technical problems overcome the group. Mistaking silence for support leads to quick problem solving and lack of clarity about what the problem is.
Building team capability increases the capacity for and rate of improvement and reinforces the expectation that improvement is everyone’s job, every day, and not just a one-off project. Building team capability encompasses four activities and methods. First, core leaders need strong coaching skills. Coaching increases staff members’ skills so they can perform better at their own work and improve the work of others. This growth, in turn, accelerates organizational improvement and the achievement of operational control. Second, leaders must optimize the use of all staff members by creating workflows that are clear, standardized and waste free and that use all staff at their highest level of training and experience. Third, effective communication must be practiced at all levels and within teams to establish priorities, provide feedback and ensure successful coordination of care and patient handoffs. And fourth, building team capability depends on leaders promoting respect and accountability. If leaders give their staff time, tools, coaching and other support, including respect, they can expect staff to be accountable for performance. Without this support, assigning accountability to them becomes unreasonable. Sustaining this management system requires engaging leadership at all levels— with attention to building core leader competency and a trusting, healthy, respectful culture where problem solving can occur openly and honestly (Mate, Rakover, Munch, & Pugh, 2017). Therefore, it is important to involve employees early in the process when implementing organizational changes in hospitals. It is imperative to invest the necessary resources to create consensus and ownership among employees and departments, to create a common goal and shared understanding directed toward the new initiative before the daily work situations begin (Pedersen, 2018).
The authors’ observations and thoughts on effective and ineffective teams and their leaders are supported by others (De Vries, 2007) who states that a key point is that archetypes result from an individual’s response to the environment. De Vries points to eight leadership archetypes: strategist, change-catalyst, transactor, builder, innovator, processor, coach, and communicator. There is no one great man or woman but different leadership styles are needed at different times in the organization. Appropriate behaviour in one situation will be unsuitable in another; obvious strengths in one role will handicap performance in others. Understanding personality makeup, competencies, and roles is a powerful tool in the hand of an organizational designer. Understanding people’s preferred style will be useful when building management teams, where members can help each other, leveraging their strengths and allowing colleagues to compensate for their weaknesses.
Leadership, as illustrated by some stories above, is not easy to define. Many people associate clinical leadership with highly visible, formal leadership roles. These are certainly part of the equation, but research suggests that there are at least three distinct types of clinical leaders (Mountford & Webb, 2009).
The most obvious are the institutional leaders: sophisticated clinical leaders who often occupy formal, executive-level roles. They can communicate a powerful, clinically based vision and have wide-reaching skills in both leadership and administration. These skills are both “hard,” such as strategic thinking and planning, and “soft,” such as negotiation and influence. A typical institutional leader might be a medical director who manages services across an organization, earning the support of colleagues by demonstrating how change will improve quality of care.
Service leaders are the second type: passionate advocates of their own units or teams, who are also aware of the context and requirements of the whole organization. Chiefs and heads of departments. They have detailed knowledge of the relevant clinical evidence base and constantly innovate to improve patient care. Service leaders are accountable for the overall performance of the service, both clinically and financially.
Thirdly, frontline leaders are great clinicians who focus squarely on the direct delivery of patient care but also see continuous improvement in the way the organization delivers care as their responsibility. If, for example, clinical records repeatedly go missing from consultations, or if patients frequently fail to show up for appointments, frontline leaders take ownership in solving the problem. To do so, they need some awareness of system- and quality-improvement techniques and must know the basics of leadership, such as an awareness of their personal style and how to work well in teams.
These three categories might suggest that leadership is organized into a hierarchy, but all levels are needed and none has greater value than the others. The last thing clinical leaders should do is devalue a clinician’s core activity of direct patient care. Indeed, clinicians on different “levels” are likely to be peers, with similar remuneration and professional status but varying degrees of leadership focus and specialization. Although institutional and service leaders have greater overall responsibility, the far more numerous frontline leaders ultimately hold the key to realizing the organization’s vision by using their day-to-day experience to achieve the constant improvement of services (Mountford & Webb, 2009). However, leaders do not act in a vacuum states Petriglieri, that “leadership is the courage, capacity, curiosity and commitment to work with, learn from and give voice to the other” (Petriglieri, 2015).
X. Limitations
As coordinator for ‘PEGASOS’ throughout the years, I may be biased towards the benefits of this organizational change. I have a vested interest in seeing a positive trend over time. Therefore my conclusions might be too enthusiastic. Also, as CMO, the process of information gathering may be influenced. Moreover, as a qualitative study with a small sample, set in one organization, the findings of this study cannot be generalized. Our findings are however supported by the literature that indicates that organizational strategy and adaptation is critical for changing the nature of the interactions among professionals.
In this whole exercise, we did not involve our largest group of stakeholders: the patients. Being both a benefit as well as a challenge, our next issue needs to be focused on empowering patients. We need to involve patients in our change management by different means of engagement, as to make ‘PEGASOS’ sustainable.
The worlds of academia and the business of operating a medical center traditionally represent different cultures and often contain different reward systems. This environment challenges employees at all levels not just to think about their individual units, but to work for the success of both University and Hospital. A clear job description and a fair reward system is a key prerequisite to keep people motivated.
XI. Future research
Future research may be undertaken to look at further engagement of the allied health professionals, scientists, etc. Secondly, the medical ‘habitus’ is the attitude the physician develops towards his profession during training. Most physicians possess behavioral characteristics essential for leadership. Physicians in the lead can be a bridge between two worlds, but this bridge often lacks a solid foundation in the management world. We might need to investigate whether this is also applicable to (leading) physicians at Ghent University Hospital. We also need to look whether this change project did not move professionals from one set of inappropriate tasks to another. Obviously, a major task is waiting for the academic and the clinical HR department when we decide to pursue these ideas.
As to patients, we only recently started to measure quality with validated indicator- and scoring systems. Guided by the principles on the involvement of patients, our next important target in improvement initiatives has to put focus on empowering patients so they really are at the center stage when discussing and changing care pathways.
XII. Conclusion
The objective of the ‘PEGASOS’ model was twofold: firstly to improve quality of care and secondly to reorganize the governance structure to create a better performing organization. At the start of the ‘PEGASOS’ project the focus was mainly on working out the management structure of the sectors and the basic principles, the job descriptions for the management functions and the communication within and between the sectors and the Executive Committee. Regarding the subject of this paper: “change or transition”, I am convinced that the goal has been reached. We started a change movement and it became a transition for the organization in the hearts and minds of all members. Our observations suggest that the original goals of ‘PEGASOS’: subsidiarity and the implementation of core teams for high-quality and efficient care with a dual control from doctors and nurses, have been reached. Cooperation within and across services has become more efficient and guarantee that the patient has a central role in the care process. This qualitative study underscores that we went from ‘change’ into ‘transition’ : hearts and minds are in sync for most of the goals, but still there are some issues that need to be addressed such as efficiency in organizing meetings and the perceived insufficient support by the Sector Bureau. A major issue is the perception of the effect of ‘PEGASOS’ on quality of care: in our query half of the participants noted no significant improvement, whereas external observers gave Ghent University Hospital a pass with high marks.
The “sectorial” organization allows for more autonomy with room for a more visible positioning of the relationships between medical services, emphasizing their orientation towards patient-centered care. Consequently, reduced levels of infighting and conflict allow for greater opportunities for growth and a unified voice in confronting external threats and challenges. Accountability has become a real issue. Improvements were noted in the development of a true corporate spirit in the Sector Council, based on common experiences with particular problems or projects and enhanced by easy access to the sector chairman and care manager. Previously separated departments (medical and nursing) now act in concert and aim at an integrated form of cure and care (Sector Council) with a dual leadership (pilot and co-pilot). This form of leadership leads to a heightened financial focus and tighter budgetary control; enhanced managerial performance and better organizational focus on patients and services; all aimed at enhancing quality of care and patient outcomes. The integral reporting requires the Executive Committee to be better prepared for discussions with the sector chairman and the care manager.
The conceptual model of “core-teams” is an essential part of our Hospitals’ philosophy. It is a tool to enhance collaboration between doctors, nurses and paramedics, and it applies the conceptual model of “shared governance” and the emanation of a Complex Adaptive System, a dynamic structure that is centered on four critical principles of fully empowered organizations: partnership, accountability, equity, and ownership. Staff nurses at every level in the organization should govern their practice and be included in decisions that affect their practice. And the same holds true for doctors as well. The “core-team” spirit is highly appreciated and the interaction between the sector chairman and his care manager is exemplary and inspires other teams. Subsidiarity was made an essential way of thinking and practicing governance. Problems are approached at the right level, which gives the Executive Committee room for a broader scope.
The impact on other professions was not analyzed in detail. Historically, doctors and nurses have worked more closely together than any other clinical professions. Future research may be undertaken to look at further engagement of allied health professions, and scientists, as it is clear by our questionnaires in this study that paramedical professions are eagerly waiting to participate.