HLTH 4100 Week 8 Department Conflict Case Paper Example

Two Departments That Need Each Other and Are Measured on Different Things: Explaining the Emergency Department and Medical Unit Conflict Through Structure

Student Name

Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

Instructor Name

Month Day, Year

Two Departments That Need Each Other and Are Measured on Different Things: Explaining the Emergency Department and Medical Unit Conflict Through Structure

The Conflict

Relations between the emergency department and the busiest medical unit at our hospital have become openly hostile. Emergency department nurses describe the unit as refusing patients for no reason. Unit nurses describe the emergency department as dumping unstable patients upstairs at the worst possible times. Calls about admissions often end with raised voices, and twice in the past quarter, nurses from the two areas filed formal complaints about each other. The usual explanation, offered by staff on both sides, is personalities: a few difficult people who do not get along. This paper explains the conflict through structure instead, using the evidence gathered across this course. If the structural explanation is right, replacing the people would not end the conflict.

The stakes are not only interpersonal. Every hour of hostility on the phone is an hour a patient waits on a stretcher, and staff on both sides have begun to avoid calling each other until they must, which slows admissions further.

Interdependence

The two departments are tightly interdependent. The emergency department cannot move admitted patients without the unit's acceptance, and the unit's census, workload and risk depend on what the emergency department sends. Each depends on the other to do its own work. Interdependence alone does not cause conflict, but it raises the stakes of any difference in goals, because each department's success depends on the other's decisions.

The tighter the dependence, the more each department experiences the other's choices as decisions made about its own work by people who do not answer for the results.

Different Measures

The departments are measured on different things. The emergency department's leadership reports monthly on door-to-provider time, length of stay for discharged patients and boarding hours for admitted patients, and its director's annual goals include reducing boarding. The medical unit's dashboard reports falls, hospital-acquired pressure injuries, patient experience scores and the percentage of discharges before noon; boarding hours do not appear. Each department is pursuing what it is measured on. For the emergency department, a fast admission is a success. For the medical unit, a fast admission during a busy hour is a risk to falls and pressure injuries, which are its measures, with no offsetting credit. Kerr (1975) described the general problem of rewarding one behavior while hoping for another; here, two departments are rewarded for behaviors that work against each other.

Different Orientations

The departments also differ in how they think about time and patients. Lawrence and Lorsch (1967) found that departments facing different tasks develop different orientations, toward time, goals and relationships, and that the greater those differences, the harder integration becomes. The emergency department works in minutes and focuses on getting the next patient seen. The medical unit works in shifts and days and focuses on the patients already in its beds. When an emergency nurse says a patient is stable for transfer, she means stable enough to leave the emergency department; when a unit nurse hears it, she asks whether the patient will be stable through a night with one nurse caring for five patients. Both are correct by their own orientation, which is why conversations so often end in frustration.

No Mechanism for Resolving Disagreements

Finally, the structure provides no regular way to resolve disagreements between the two. As the structure analysis showed, no one below the vice presidents has authority over both. Disputes are therefore resolved, or not, in individual phone calls between charge nurses under time pressure. Conflict research distinguishes between conflict that is managed through structured processes and conflict left to the parties involved, and finds that unmanaged conflict between interdependent groups tends to escalate (Thomas, 1992). The formal complaints filed this quarter are one sign of escalation.

Testing the Structural Explanation

If personalities were the cause, the conflict would follow particular people. It does not. When a new charge nurse transferred to the medical unit from a surgical unit last year, she was initially described by emergency department staff as easy to work with; within three months, she was described in the same terms as her colleagues, and she described the emergency department the same way they did. The conflict also appears, in milder form, between the emergency department and two other medical units with similar measures. At the comparison hospital, where a bed manager has authority over placement and unit dashboards include boarding time, staff describe the relationship as tense on busy days but not hostile. These patterns are what a structural explanation predicts.

What Each Side Would Need to Hear

Explaining the conflict structurally changes what each side needs to hear. Emergency department staff need to hear that unit nurses are not refusing patients out of indifference but are protecting the measures they are judged on, with no credit for helping downstairs. Unit staff need to hear that emergency nurses are not dumping patients but are judged on boarding hours that the units never see. A joint meeting that presented both dashboards side by side, before any discussion of particular incidents, might do more to calm the relationship than any number of individual conversations about specific calls. It would also make the structural problem visible to leaders, who could then change it.

What Would Reduce the Conflict

Three structural changes follow from the analysis. First, give both departments a shared measure: add boarding hours for the unit's admitted patients to the unit's dashboard and add the unit's fall and pressure injury rates for recently admitted patients to the emergency department's, so each sees the other's stakes. Second, create a resolution mechanism: a bed manager with authority to decide disputed placements, or at least a daily meeting where both departments review the next 24 hours. Third, build a shared language for stability, an agreed checklist for when a patient is ready for a unit, so that the word means the same thing on both ends of the phone. None of these requires changing the people involved, which is the point.

References

Kerr, S. (1975). On the folly of rewarding A, while hoping for B. Academy of Management Journal, 18(4), 769-783. https://doi.org/10.2307/255378

Lawrence, P. R., & Lorsch, J. W. (1967). Organization and environment: Managing differentiation and integration. Harvard University, Graduate School of Business Administration.

Thomas, K. W. (1992). Conflict and conflict management: Reflections and update. Journal of Organizational Behavior, 13(3), 265-274. https://doi.org/10.1002/job.4030130307