This case represents the collaborative type in an early stage of development. The effort centered heavily on the strong leadership of a doctor cardiologist who emphasized a strong focus on patient care, the primary professional value shared across a wide range of levels and functions. Like Hightown, this unit relied on a set team of highly skilled practitioners working for the lead physician cardiologist who helped spread and reinforce the message; unlike Hightown, these key agents in this case were Fellows (physicians in undergoing specialized training in cardiology) rather than Advanced Practice Nurses. There were two interesting and potentially fruitful aspects of the United effort. The first ran directly counter to our expectations: although the role of the lead physician was (as predicted) very strong, he did not play the role of guardian and protector against other parts of the hospital, as did his counterpart at Hightown. Rather than trying to seal off his unit as a special domain, he engaged in intensive networking with other areas and tried to draw them into his vision of cardiac care. There was some evidence that this approach was having good effects. Relations to other units were relatively cooperative, and there was a smoother relationship with the nursing hierarchy than at our other sites. Second, this initiative focused at the start on standardization of a very clear set of procedures – the “8-scope” processes – rather than on a broader vision of relations. But this was driven by the doctor, rather than administrators, and engaged a wide variety of actors at all levels in the pursuit of this objective. There were strong interdisciplinary elements, including two formal committees
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Table 1: three general models of organization Traditional / autonomous professional Bureaucratic Collaborative Key characteristics Norm of individual autonomy for lead practitioner Accountability to professional organization or guild Formal organization small or absent Strong status hierarchy (usually): Personal relation to clients Strong hierarchical organization Strong boundaries Jobs defined in relation to organization structure Power based on position Resources linked directly to accountability Two dimensions: hierarchical control & systematic processes Porous boundaries reconfiguration around problems / processes Influence on knowledge / contribution rather than status or position Differentiation of resources from accountability General business history Dominant from medieval period through 19th century Rise of large firms at end of 19th century, consolidated by Gradual emergence of complex teams and process organization from still incomplete
Health care history Dominant model until recently, now under pressure from specialization and cost increases growth of administrative control mechanisms (insurance, HMOs, etc) from 1980s, has not displaced craft organization at patient interface Much recent experimentation, little clarity of vision or practice Table 2: Distribution of cases (pseudonyms are used throughout for the hospitals) “rich” payer mix “poor” payer mix High performing Hightown United Low performing