ER THAT BECAME THE EMERGENCY 8

ER THAT BECAME THE EMERGENCY 8

Background and Introduction

In the case, The ER That Became an Emergency - Managing the Double Bind,

Community Memorial Hospital’s (CMH) emergency room (ER) activity appears to be

celebrating the hospital’s increased marketing activities in the recent campaigns. The case

presents that five months earlier, the health care facility had made financial arrangements to set

aside significant resources for the purpose of marketing itself and its clinical services. For two

and half months, CMH saw a dramatic increase in its emergency room visits, which it initially

associated with increase in demand due to its marketing efforts. However, upon scrutiny, the

facility has learned that the increase in ER activity is the result of someone else’s effort rather

than its advertising budget. More precisely, City Hospital, a local public facility, has been

diverting medically indigent patients to CMH’s ER. Rather than being a positive increase for

CMH in patient hospital admissions through the ER as was initially celebrated, the increase in

ER activity is actually creating an unbearable financial deficit for the facility. The case accounts

how the irregularity is discovered and the resulting double bind that the facility’s CEO faces

(Rakich, Longest, & Darr, 2004).

Analysis of Case Issues

This case has several stakeholders facing different dilemmas with various respective

potential outcomes. CMH’s profitability is at stake due to the influx in diverted medically

indigent patients. If the hospital continues losing money, the job of the CEO, Ralph Peterson,

may be at risk. City Hospital’s profitability is also at stake because of a high number of

medically indigent patients in addition to what it understands as underfunding. Besides treating a

high number of these patients, City Hospital undertakes physician training programs, which
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further stretches its costly operations. Despite its costly operations, if the hospital loses money,

the job of Jim Harding, its CEO, is at risk. In protecting their jobs, if the CEOs decide to go

public over the city authorities’ incapacity to solve the problems faced by the hospitals, the

controversy may affect public opinion, leading to Middleville’s mayor and city commissioners

losing votes. Public opinion may influence the votes otherwise if the public servants solve the

dilemmas successfully.

Indigent patients are also stakeholders in this case. Whatever decision the affected

hospitals’ CEOs or the city’s mayor and commissioners make will influence their access to

medical care. The dilemma may affect many more hospitals besides CHM and City Hospital—all

the hospitals in Middleville that surround CHM and City Hospital, together with their CEOs may

be affected by CMH’s decision. This is because CMH may make a decision that may potentially

lead to more indigent patients being diverted to the surrounding hospitals. In other words, if the

market inefficiencies are not addressed comprehensively, the bottom lines of all the hospitals in

Middleville may be affected, hence affecting regional medical care significantly. Depending on

how all these stakeholders address the matter, it may affect yet another stakeholder accordingly

—CMH’s decision may affect the surrounding community, particularly in terms of the quality

and availability of emergency medical care.

As it stands, CMH’s CEO has knocked all the doors he would have imagined in his

efforts to address the dilemma as it affects his hospital, and eventually, other hospitals, the

surrounding community, and the city administration. He has not achieved anything other than

disappointment and worry over the next cause of action. He is not without options on the next

cause of action, though. He may choose to do nothing—as Hunink, Weinstein, Wittenberg,

Drummond (2014) and other researchers discuss—hoping that the situation will stop. Since he
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has consulted all the people he would possibly need to and there is no remedy yet, CMH’s CEO

may decide to go to the press, blowing the whistle on City Hospital’s diversion tactics (Firtko &

Jackson, 2005), then offer that CMH is compelled to restrict its admission of City Hospital’s

surfeit of indigent patients. The other option is for the CEO to return the mayor, this time to

threaten him that he would go public to expose the inefficiencies (Van Aken & Berends, 2018),

citing the facts surrounding the issue, including the mayor’s inability to offer a solution.

While attempting to solve the problem in his hospital, Ralph has learned a lot, some of

which he may decide to apply at CMH. One of such is the option to wait until the next staff

meeting and propose that since there is no other solution yet, CMH should adopt the diversion

approach in the same manner as City Hospital. He will then ask his team members to develop a

criterion to govern when and how the hospital’s ER will implement the diversion. CMH may also

choose to accept the situation as it is, and instead, look for alternative sources to fund for the

diverted indigent patients. In the meantime, since City Hospital is aware of its actions and their

impact on CMH, CMH may made a decision to send all the diverted indigent patients back to

City Hospital, as long as the patients are not in life-threatening conditions. While all these

options comprise potential cause of action for CMH, a critical analysis of each of the decision’s

pros and cons is required to determine the best of all.

Intervention to Address Identified Issues

CMH’s CEO may bank in the possibility that the problem may end if the demand for

emergency medical services drops and therefore, take the first option—do nothing. This, unlike

other options, may not threaten relationships with external stakeholders or even result in their

negative PR. If Ralph chooses to implement this option, all the indigent patients, the diverting

hospital and other hospitals, and city mayor and commissioners will be happy, even if it would
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be for a short while, as long as CMH remains open. However, it is highly improbable that this

problem will go away on its own. In fact, by unattendance of the meeting Ralph calls for, all the

other hospitals have demonstrated that they are happy and unwilling to volunteer as long as

CMH continues bearing the burden of City Hospital’s excess indigent patients. Besides, CMH’s

financial risks need urgent attention, without which the hospital will close down, or at least, with

this option, the CEO risks losing his job. In fact, Bardach and Patashnik (2015) do not think

doing nothing is always a viable option.

The advantage of taking the option to whistle-blow in press is that it would compel all the

various stakeholders to solve the problem. For instance, the city politicians may be compelled to

increase funding for indigent patients, and City Hospital may be forced to halt its diversion

tactics, which are resulting to CMH’s financial woes. Other hospitals may also be compelled to

admit more indigent patients, hence sharing the burden, and partly solving CMH’s financial

problem. However, this solution would destroy CMH and its CEOs’ relationships with the city

politicians, City Hospital, and with other hospitals, hence, dimming the possibility of solving the

problem collaboratively. In addition, despite being proactive, there is a likelihood of negative

reactions from the public, which would result in even higher admissions into the CMH’s ER. If

the hospital refuses to take the extra numbers, it would not only risk patients’ health, but also

face lawsuits.

What if Ralph chooses to threaten the mayor that he would go public with the

inefficiency and the facts surrounding it? Given the mayor’s political interest, he might find

alternative funding. If he so does, Ralph may not need to go public to risk eliciting negative

public response. This is an efficient alternative so far because it solves the problem in the long

run for all the stakeholders. The solution would save CMH’s CEO time that he would spend
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finding alternative additional funding. Indigent patients, on the other hand, will not experience

interruption of services because they will not be diverted from City Hospital or turned away from

CMH and other facilities. This alternative will also forestall the likely negative publicity of City

Hospital and its CEO for their diversion tactics. The mayor and city commissioners’ relationship

with the public will not be affected negatively, and eventually, CMH’s financial problems will be

solved. This solution, however, has high risks, first because threats rarely solve any problem

permanently (Bardach & Patashnik, 2015). If he takes this option, Ralph risks destroying his

relationship with the mayor and city commissioners, who may take revenge by holding press

conferences that are favorable to themselves or take subtle political decisions against CMH and

its CEO. The repercussion may be worse if the mayor is truly unable to solve the problem.

Ralph may choose to implement a diversion tactic as well. This option is likely to solve

the hospital’s financial problem quickly. The justification would be that City Hospital started the

practice and has been holding onto it even after the discovery and realization of the problems it

causes CMH. The second justification is that the surrounding hospitals are aware of CMH’s

financial problems and their cause but have been unwilling to collaborate in solving them. This

option will automatically involve the hospitals because they will also have a surge in diverted

indigent patients. The hospitals’ CEOs will have an incentive to collaborate in finding a solution.

By so doing, Ralph would avoid confrontations with the surrounding hospitals’ CEOs and the

politicians, hence preserving their relationships.

This may seem as a viable option, but it is also ridden with a couple of cons. First, while

City Hospital is diverting indigent patients, CMH may have to deal with negative public opinion

and press if it does the same thing. Even if City Hospital may as well face the same predicament,

CMH may be seen as intentionally endangering the lives of indigent patients in the process of
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averting losses. City Hospital may get exposed and subsequently get bad PR because it receives

tax money to take care of indigent patients but resolves to using diversion tactics. The hospital’s

CEO may be angered by CMH’s action, while the other CEOs may not be happy CMH is

diverting indigent patients to their hospitals. While this option has a potential of solving CMH’s

financial problems, it is also likely to affect City Hospital financially and its public image, hence

straining the relationship between the two hospitals and their CEOs. What if the surrounding

hospitals decide to take the same actions as City Hospital and CMH? Patients’ lives would be

greatly endangered due to multiple diversions.

Conclusion

When looked at deeply, although CMH is affected most financially, its solution would

need collaboration of various stakeholders. The hospital’s CEO understands this and has made

efforts to meet the various stakeholders. Some of these stakeholders are unwilling to even meet,

while others are not giving solutions. Regardless of the action CMH’s CEO decides to take, the

problem will eventually affect the city health care. Of all the options, the only one that would

force all the stakeholders to feel responsible in solving the dilemmas is implementing the same

diversion tactic City Hospital is practicing. Despite the consequences, this action will force all

the CEOs, politicians, and if necessary, the media and public to converge with a view to finding a

solution. When they all come together, a new option would be a policy change, even if it means

conducting a referendum. It would be easier this way since every stakeholder will be aware of

the risks associated with the current market inefficiency.

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References

Bardach, E., & Patashnik, E. M. (2015). A Practical Guide for Policy Analysis: The Eightfold

Path to More Effective Problem Solving. CQ press.

Firtko, A., & Jackson, D. (2005). Do the Ends Justify the Means? Nursing and The Dilemma of

Whistleblowing. Australian Journal of Advanced Nursing, The, 23(1), 51.

Hunink, M. M., Weinstein, M. C., Wittenberg, E., Drummond, M. F., Pliskin, J. S., Wong, J. B.,

& Glasziou, P. P. (2014). Decision Making in Health and Medicine: Integrating Evidence

and Values. Cambridge University Press.

Rakich, J. S., Longest, B. B., & Darr, K. (Eds.). (2004). Cases in Health Services Management.

Health Professions Press.

Van Aken, J. E., & Berends, H. (2018). Problem Solving in Organizations. Cambridge University

Press.