VIII. Data gathering and reporting
The interviews for this study took place at the offices of each participant. The author, as CMO (Chief Medical Officer), informed the participants that the questionnaire, send in December 2017, was part of his thesis work for INSEAD and that it would also be part of the yearly discussion between CMO and heads and chiefs of departments with or without the presence of a head nurse. Participation in discussing the questionnaire was not compulsory, there was no pressure to participate. No one declined the invitation to go into discussion. We summarize the conclusions made by physicians or nurses and the consensus conclusions by the chiefs of the paramedical departments. By observing and listening to these stakeholders and by doing the computerized qualitative analysis, we recognized neutral general observations and comments but also elements that allows for a structured approach in the form of a SWOT analysis structure. The comments below of the individuals we interviewed are their actual quotations. They offer a rich understanding of the core processes of ‘PEGASOS’ and the perceptions it created. As suggested in the paper by Braun we grouped our observations on questionnaire 1 by themes as if it would be a SWOT analysis. During phase 2, in generating initial codes we ended up with singularities. We refocused our analysis and sorted the different codes, to end up with overarching themes. Next, we reviewed the themes and went to refinement. We agreed that defining and naming themes still corresponded with an extended SWOT analysis and we present the data as such as we will use them for the interpretative analysis and what it actually entails for the future of ‘PEGASOS’ when we want to share our knowledge of the undercurrent in the organization with the participants, without exposing anyone.
For questionnaire 2 and 3, we describe the narratives of the interviewees when asking for how much collaboration and matrix is needed.
VIII.1 Observations in general on Research question 1 whether change has led to transition
– ‘PEGASOS’ also means differentiation and not only integration. The sectors can specify and act as more autonomous entities by the development of their own characteristics and competencies that are visible on the sector-specific interactions, integration and collaborations between the different stakeholders. The next important goal is to emphasize cooperation across the borders between sectors and other healthcare providers.
– ‘PEGASOS’ does not mean: six hospitals on one campus. The interaction on a regular basis between the different sectors, the various Sector Bureaus, the chairmen of the sector with the CMO and the care managers with the director of nursing guarantees a global and integrated approach.
– In addition, the company supportive sector takes up its part of the job and is able to deliver management information in the form of indicators, which are also followed by the Board of Governors.
– There are unique points of contact for each specific sector in the various administrations, there is a defined recruitment process, and the roll-out of the electronic medical records (EMR) is progressing. A policy cycle within the format of an integrated budget form is implemented.
– We have moved to a more process-oriented thinking and to the development of care paths at sector level which make for higher quality and more efficient care.
– Sectors offer a unique forum to solve problems that may seem insurmountable for individual services. Making agreements on the priority of investments has led to the acceptance of the introduction of multiannual budgets where not all medical services at the same time can invest, but have the guarantee that needed investment will be done at the appropriate time.
– The sectors were started as planned. There is a central organization structure which is controlled by the Sector Council. The Sector Bureau is responsible for the implementation of the decisions taken by the management.
– The Sector Council is the supreme decision-making body in the sector. There was an integration of hospitalization and Medical Technical Departments and Divisions. These formerly separated pillars, are now working together. The goal to build an integrated policy around the patient and his needs was realized by the new model of control: doctors and nurses together organize highly qualitative care.
– Integration and differentiation can be realized: the sectors can specify and develop specific competencies, there is more autonomy for entities with their own characteristics, and the communication is improved.
– A department of clinical psychology has been established within the University Hospital. The duty is twofold: to promote a constructive dialog between the various professional groups, but also to develop principles of exchange, confrontation, self-reflection within the profession itself. We must bear in mind that psychologists embedded in various teams always differ from each other: the team structure, work processes and performance are different. We have to see them in their context of services.
The weaknesses
– Some departments experienced too little support from the business support department and their processes, but this appreciation has changed in recent years for most others as well as for the Management Committee.
– The hospital offers too little or no rewards for high performing services or sectors
– People experience little impact on the operational functioning of particular services that are important for supporting the clinical departments.
– Medical-hierarchical, all physiotherapists in the Ghent University Hospital, are directed and controlled by the medical service “Physical Medicine and Rehabilitation Medicine”. In practice, however, the treating physiotherapist has little affinity with this service. For example, for a physical therapist who works at the department of cardiovascular surgery it is logic to go to the cardio surgeon for consultation. Especially for mono-disciplinary performance there is a discrepancy, given the fact that there is no real presence of the medical-hierarchical discipline. Therefore, it is for the physiotherapist difficult to understand that their policy is determined by a medical discipline which they basically don’t know.
The Benefits
– The benefits of ‘PEGASOS’ are subsidiarity: participation and responsibility. The decisions are taken on the level with the most added value. Unnecessarily referring to the upper management level has to be avoided.
– Another innovation are the core teams for high-quality and efficient care with a dual control from doctors, nurses, sometimes aided by allied health professionals.
– Evidence-based management based on business indicators has been implemented.
– An integrated control and an aim to “best practices", consolidated through regular consultations between the Sector Bureaus and the Management committee has been established.
– Cooperation within and across services has become smooth and is putting the patient in a central role. The sector structure promotes the prioritization of major investments.
– The relationship between the department of clinical psychology and the sectors and services in which psychologists are employed is an exemplary model of consultation and coordination. Broad lines and objectives need to be attained and determined in mutual agreement. Sectors and services are responsible for the decisions on organization and operation at the ward level. It cannot be the intention to go back to a previous situation, where psychologists like islands, worked independently of each other. There is a cohesion between the various psychologists or groups of psychologists because the clinical psychology department provides service and cross-cutting tools which are all aimed in the same direction and encourage them to continue to look at themselves and the others (psychologists and other care providers).
– The relationship between doctors and physiotherapists within the Ghent University Hospital can be considered as well-functioning. Physiotherapists take an active role in both the implementation and the guidance of the care process because they participate in the decision-making within the areas of their particular experience. Different professional groups discuss the treatment or rehabilitation protocol, and the knowledge and expertise of the physiotherapist is considered an 'added value'.
The Threats
– Management-by-delegation requires more preparatory work from the management committee. The duration of the meeting increases and it is necessary to ensure that every participant actively contributes to the meeting.
– We observed a positive evolution in the interaction of clinical units with the business support departments but attention is still needed to the administration at sector level.
– We experienced a shortage of investments in medical and non-medical projects which delays the hospital’s objectives towards better care. The ongoing as well as the announced reforms in the hospital financing (budget cuts) make a decent financial and infrastructural management almost impossible.
– The matrix structure that is employed in the group of physiotherapists becomes fuzzy when members of the same profession need to be active in various medical departments. A simple question becomes a complicated one. Who is the doctor in charge of the patient? For example, in the Department of Neurology it is the neurologist. However, when rehabilitation has to be started, by law it can only be initiated on the order of a rehabilitation doctor, who, at that point in time, has supervision over the full specter of treatment, rehabilitation, physiotherapy, occupational therapy and speech therapy. For occupational therapists on the wards for acute medical services it may mean that they need to work with a dual medical control, sometimes without clear instructions.
The opportunities
– Thanks to the integrated control systems, the systematic consultation on the different levels (management committee individually with separate sectors and sectors interactionally) and a common business support system, major opportunities may arise in the field of translational medicine and for the support and further development of new and existing cross-sector initiatives such as the Biobanking, the Center for Translational Medicine, the Heart Center, the Oncology Center, the Allergy Network, the dermatopathology units etc.
– And not in the least: thanks to the efforts in the sectors, the quality label of the NIAZ/QMentum accreditation was obtained with high marks in 2016.
– Insidiously, a fourth industrial revolution is in the making with the internet of things, Big Data and Artificial Intelligence (AI). It will arrive at our organization and we need to evolve accordingly to these new norms and standards. A multidisciplinary approach in the proper sense of the word will become the norm. Likely we need to expand our universe to professions and groups that up to now were involved in cure and care to a very limited degree. Multidisciplinary teams will include an engineer in the field of sensor-based technology and data science, promoted by occupational therapists.
– The heterogeneous composition has as a consequence that the group is not such a pillar as a group of doctors or nurses. Literature, however, stresses the importance of cohesion and synergy on inter- and intra-disciplinary level. Without connectivity there is a chance that real separate entities may exist with the focus on the subsystem's behavior rather than on that of the greater whole. Without cohesion in a group, there is no benefit when compared to its individual constituent parts.
– We are looking for a clarifying framework as the philosophy behind ‘PEGASOS’ was insufficiently explained to the para-medical disciplines and hence was not mentalized. The exercise that was made 10 years ago may need a repeat for a different audience.
Storytelling from semi-structured interviews.
The participants were invited to tell stories. This permitted them to relate to and reflect on their particular experiences with the organization. Some stories were histories and others referred to recent events. Stories can be interpreted in different ways. They can be interpreted as “elements of organizational symbolism, culture, expressions of unconscious wishes and fantasies, vehicles for organizational communication and learning, as expressions of political domination and opposition, as dramatic performances, as occasions for emotional discharge, as narrative structures, and so forth” (Gabriel, 2000, p. 4).
I selected some of these stories (in italics) to give the reader a flavor of the organizational culture.
The first story is about 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 the chairman of a group of elected deputies for all physicians in the organisation or a medical director who manages services across an organization, earning the support of colleagues by demonstrating how change will improve quality of care.
‘I think of the time that you had invited the senior medical staff of the hospital in a new communication center along one of the city’s waterways during the December days. Both you, as Chief Medical Officer, and the Chairman of our medical council gave an end-of-the year talk in which both put their combined efforts to inform and motivate that great bunch of strong egos. The Chairman of the medical council did a good job in briefly stressing solidarity and cooperation between the senior staff members. You on the contrary had taken the trouble of preparing a rather (but not too) lengthy document in which you had brought together the main points of focus and action you hold high for the coming years. In this vision you made a clear point of implementing translational medicine in areas such as: regenerative medicine, chronic diseases, oncology, quick diagnostic methodology and telemedicine. I thought it was a good piece of leadership to show that your efforts are not based on fashion or a sloganesque approach but on well-thought principles and a deep and coherent vision. I would have liked to reread your text.’
Service leaders are accountable for the overall performance of the service, both clinically and financially.
Oncology care in Belgium is organized by a number of federal laws. Each hospital has to set up its “Oncology Program”. In our hospital it was estimated that this could be converted into a so-called “Oncology Centre”. The coordinator of the Oncology program had written a proposition text but this text was in conflict with the usual autonomy of a medical department. This had led to a conflict between two groups of physicians. In order to resolve this conflict a sector chairman organized a meeting, outside the hospital, in a neutral environment, and summarized the conflict by putting together a set of 10 questions to be answered by each party. He chaired the meeting and by restricting the discussion to the essential points, which were translated into the set of 10 questions, we came to a solution, acceptable for each group. The solution included also a timeline for implementation of the answers.
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.
‘Recently a patient was sent to the technical unit for an investigation, but rather late. Two doctors (the head of the medical service and another one, who is also on the Board of Trustees) were very upset and yelling at the nurses. One even threatened to sanction the nurses by an official complaint. The nurses were very much in turmoil and they came to see me. I described the whole situation to a sector chairman and he admitted that the doctors’ behavior was shameful. He also discussed this with the two doctors. For me the way the chairman acted in this case is a proof of great integrity. He acted in an objective and transparent way according to social and ethical principles.
VIII.2 How do doctors, nurses and paramedics view collaboration and their roles and how to assess the opportunity of a matrix model for para-medical services that were not included in the startup of ‘PEGASOS’.
As “core teams” were implemented, we were interested in the opinion of the change leaders on collaboration. We give voice to the responses on the questionnaire on “collaboration”. Interprofessional collaboration is a key factor in initiatives designed to increase the quality of health services in view of the philosophy of ‘PEGASOS’. It is important that the concept of collaboration be well understood, because although the increasingly complex health problems faced by health professionals are creating more interdependencies among them, we still have limited knowledge of the complexity of interprofessional relationships. We did a survey to sense the spirit at Ghent University Hospital on “collaboration” by analyzing with NVivo 11 software. The predominant themes that emerged were: perceptions of patient safety, what promotes and hinders patient safety, aspects of psychological working environment, organization and structuring of the hospital services as well as the medical department, collaboration between staff from different departments. We describe the experiences as they were reported by the participants.
Collaboration between staff from different departments is not easy and does not need to be based on egalitarian values. Egalitarian values will facilitate collaboration but are not necessarily required. As important are aspects such as mutual respect, complementary and mutual appreciation. A team functions better when there is a clear definition of roles and hierarchy. Clearly, the best collaboration includes everyone in a group and the voices of everyone are heard. In the same vein one has to think about whether collaboration is possible whenever great power imbalances exist. The analogy of the gradient in the power imbalance between the pilot and the co-pilot is very interesting.. People bring to the table their status and their roles outside of the current forum of collaboration. Thus, the specialists bring their knowledge as well as their symbols of that knowledge, documents, graphs etc. The one who shows up with most of the gadgets at the first meeting can often take the lead, if him /her so wishes. But this can also create a divide, that will hinder true collaboration and thus be detrimental to the best outcome.
As far as the psychological working environment is concerned, some are convinced that often, good collaboration is a key to good results. Indeed, the hallmark of good collaboration is an outcome that exceeds what individual partners could have accomplished. The synergy and the creativity in such cases allow for a higher level of input and thus outcome, and individuals operate at their very best. However, it is not always the case. Sometimes, the gain is only in the process itself, in the learning and in the experience of the people involved. Towards the end of our work together some felt the group really came together as a team and was able to collaborate as well as to connect to create a safe environment for expressing and sharing highly sensitive and personal information.
A defined goal is essential for ‘starting’ a collaboration as long as this goal empowers a critical number of collaborators and is perceived as realistic. Still this is also no guarantee for a successful collaboration. A goal in time must also be able to evolve, if conditions change. A lot depends on human factors: the personalities have to match. Unclear and uncertain goals or no goals at all can hardly lead to a successful collaboration. A goal can unify, lead the way and collect thoughts. However, sometimes, the clarity of the goal only develops as the group moves on, it can change and even be discarded, and the collaboration can still exist and be fruitful. The outcome of the work can likewise serve as a unifying item, but sometimes an outcome is not necessary, the process itself can be the “raison d’ être”.
It is necessary to understand the undercurrent in a group that sets out to work together (Morley & Cashell, 2017). Often, it is vying for leadership, or even more often, shying away from taking any initiative in order not to become the leader in that particular circumstance. Sometimes we want to lead, and sometimes we want the luxury of being lead! So, one becomes very efficient in staring at the table and uttering non-committing phrases, hoping that someone else takes on this one! In the most difficult cases, there are some really difficult hidden agendas brought to the table that need to be understood and dealt with. Issues in the rooms should be dealt with thoughtfully but also with professionalism and then brought out of the group work. Strong animosity, for example, will not be solved at the table, and sometimes you just have to work with an adversary. If the emotions are so strong that they preclude collaboration, then you have to be very creative in finding the third way.
Organization and structuring of the hospital services comes also into play when asking for how much collaboration is needed. It sometimes feels like motherhood and apple pie. How can it possibly be anything but good? One of the major problems that we describe with collaboration is that it is indeed very time consuming and takes a lot of energy and resources. We defend this use of resources by the expected superior outcome; but what if this is not so? There are certainly instances were collaboration is not the optimal approach. This is of course the case when there is some kind of crisis, when decisions have to be taken instantly. This is also true when there is a big difference in the knowledge base of those involved, and often when there is a lot at stake for some but not for others that could partake. Sometimes we begin with a collaborative approach and realize that it will not work with the people we have gotten together for the work; they will not be able to collaborate. In such cases, it will be a difficult task to change the approach, but that has to be done rather than not face the facts. In the health care system, people often work under immense stress. The system is rarely set up for collaboration, speed is of the essence.
Although some of the skills needed are probably innate (however never proven!) we can use some tools to learn and understand, and hopefully become better, at all the different levels of collaboration. Probably the best advice is to try to understand one’s own strengths and weaknesses, both as an individual and as a part of an organization. By seeing how we function and when we function at our best or worst, we can try to enhance our own performance. In addition, it is essential for a person in a role to know how other people perceive him in that role and how that influences their behavior.
Sometimes we are put in a situation in which we have to work with people we do not particularly like and we do this for a greater good: we have a shared goal. Actually, in real life, very few of us are in a position where they can always decide on partners in a collaborative endeavor. The rewards of collaboration can be great emotionally, but greatest if something is overcome, and a group comes together to be all it can be in a collaborative spirit.
Some say they have learned that in very many instances collaboration is the way to go, for so many reasons described above. But they have also learned, in their own microcosm at work, that they will give up collaboration and split up tasks differently sooner than they have done in the past. The work involved and the emotional difficulties that many groups had even though we were role playing some of the time is really astounding. In real life, the toll can sometimes be too high, the experience too painful. Collaboration problems often reproduce themselves because of the dynamics in identification processes, where different departments or employees start to identify themselves in opposition to other departments or colleagues, whereby an “us-them relation” is created. When conflicts in the working environment of the staff remain unsolved, these conflicts continue and may potentially affect the employees and their ability to perform their jobs to the best of their ability.
Findings and discussion
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 mor