ORGANIZATIONAL CHANGE AT ST.
JOSEPH HOSPITAL
a case study from a student=s lab assignment
Background and Change Processes
When I came to St. Joseph Hospital in 1993, 1
was hired as chief resident to build up an oncology
unit in the Department of Gastroenterology, which
had not existed until that date. While the hospital had
treated cancer patients before, it was not prepared to
do this on a larger scale and basically referred the
respective patients to other hospitals. This changed
with the arrival of a new director of the department
who had some experience with the treatment of
gastrointestinal (GI) malignancies at his former post.
With regard to the growing incidence of cancer in the
over-aged population of the city, he also saw a
chance to increase the attractiveness of the hospital
for the community.
Subsequently we rededicated a ward with 18
beds to be the assigned 'Cancer Unit' (CU), after the
nurses working on that ward had agreed to that
change. (Actually, the unit was planned for another
ward in the beginning but the nurses on that ward had
refused the change.) Within a short time, an attending
physician board-certified in hematology/oncology
was hired and we both started to train the nursing
staff for the special requirements that cancer patients
have. We also were able to hire a psychologist for the
counseling of the patients as well as for supervision
of a Balint group (an exchange between staff about
their experience and to cope with the stress) and
counseling of the staff. Then we concentrated all
cancer patients, who were already treated in the
hospital, on this ward. Word of the new unit spread
and was met mostly with skepticism in the hospital
and applause by the surrounding health practitioner
community. Patients started being referred to us more
and more and within six months after its' erection the
ward was completely filled with cancer patients.
Until the arrival of the new head of the
department the cancer patients had been spread over
all wards in the two internal medicine departments,
which did not ensure a high quality of their treatment
because of the inexperience of the respective
residents in hematology/oncology. The preparation of
the chemotherapy, mostly very toxic substances, until
that time was taken over by the respective nurses of
the wards, who previously had just been given a short
introduction to take special care with the preparation.
Since the chemotherapy was prepared on all medical
wards in the hospital, a number of special laminar
airflow benches had to be bought to comply with
federal regulations regarding toxic substances and
their use in me country.
Module 5: Organizational Change & Development: 20
However, one precondition of the nurses working
on the new CU was, that they did not have to handle
preparation of the chemotherapy. Thus, it fell to the
already over-worked physicians to prepare the
treatment solutions every day and they also had to be
trained to do this. It became rapidly clear that with the
success and rising number of cancer patient
admissions to the CU, this professional group was
simply overwhelmed with the task. Therefore, we
suggested that the hospital pharmacy, which
distributed and prepared all other medications, should
take over the preparation of chemotherapy solutions.
The head pharmacist objected to this vigorously and
nothing happened for a year. However, in the
meantime the management of the hospital saw the
success of the CU, which more and more was able to
reach out to the community through cancer survivors
who founded self-help groups and therefore gained in
popularity. In addition, the special benches for the
preparation of chemotherapy became outdated and
therefore, had to be replaced. We made the argument,
that the buying of new benches for all wards (since
some cancer patients were still treated on other units)
would not be necessary if the hospital pharmacy
would take over the preparation centrally. After
another six months the head pharmacist finally gave
in, got a special bench installed and started with the
central preparation of chemotherapy solutions.
Stage of Change
The process, as far as I know, is still in the
maintenance stage. All changes have taken place and
are perceived as success. The physicians have more
time to concentrate on their special clientele and the
ordering and distribution of chemotherapy is smooth.
Even the pharmacist and especially his assistant (who
right from the beginning was much less opposed to
the idea) are satisfied since they got the new bench
and felt that the preparation now is in good hands.
Organizational Diagnosis
The Technical Factor
Chemotherapy: toxic substances, dangerous to
handle
The logistics: distribution , utilization of larger
amounts of medications
Erection of a laminar airflow bench in the
pharmacy
Information systems: recording and reporting
Necessary overhaul of existing chemotherapy
 benches on wards patients could now be treated nearby. This impressed
the conservative hospital council, which was initially
The Human Element
opposed to a special ward for the disease (fear of
Resistance of nurses to prepare drug solutions stigmatization ) and of the administration who
initially feared rising costs. While the costs indeed
Reluctance of pharmacy to introduce central rose, the hospital still made more money since cancer
preparation treatment is rewarded more generously in the country
Workload of physicians and due to the more complete treatment offerings and
increased popularity of the hospital more patients
Decreasing chance for mistakes by professionals came, also for other illnesses.
and central handling of toxic substances
A problem was the inner-hospital structures of
Conservatism of catholic hospital leaders => power. While the parallelism of structures may
skepticism towards change obstruct changes (especially those concerning two or
The Environment more of the structures), it is the reality nowadays in
most hospitals in the country and has it s advantages
Attractiveness/reputation of the hospital for (better teamwork between nurses and physicians,
referring health practitioners nobody feels superior). Since the pharmacy and the
Popularity/reputation of hospital with nursing section were 'emancipated' with regard to the
surrounding community physicians, the only way to achieve change was
gradual persuasion. The success of the CU and the
Location of hospital in a district with many older backing by the hospital management certainly helped
citizens in convincing the head pharmacist to take over the
Space-Time coordinates task. At the same time, there was fortunately political,
scientific, and technical pressure for more
Timing of inputs: training of people who prepare professionalism in handling chemotherapy
solutions, drug supply for perceived need preparation in the country.
Timing of distribution of chemotherapy to CU
Locations of 'players' in the building
(communication)
Location of hospital with regards potential
clientele (mostly older people)
Policy Factors
Federal regulations regarding preparation and
handling of chemotherapy drugs
Necessity of hospital in our city - increased
chance to survive 1990s 'hospital dying'
Application of chemotherapy - lucrative business
for the hospital
Competition among heads of departments for
resources (human and financial)
Cost of new laminar airflow benches for all
wards
Pressure for professional handling of hospital
affairs by government, medical associations etc.
Conclusions and Lessons
In my opinion the approach to the problem was
appropriate. The new CU was a success and meant an
increase of popularity of the hospital for the referring
health care providers an d the community, since

Module 5: Organizational Change & Development: 21

Organogram of St. Joseph Hospital

Hospital Council and Board of

Trustees

Medical Director Head of Head of Administrative

Nursing Pharmacy Director

Directors of Director of Director of

other depts Medical Medical
Department II Department I

other Depts: Departments of Depts of Nurses Pharmacy Administration

Obs/Gyn, Neurology, Gastro-
Surgery, Cardiology enterology,
Radiology, Hematology,
etc. Oncology

Diagnostic Other Wards Cancer

Procedures Unit

Module 5: Organizational Change & Development: 22