4.3. Interpersonal interactions, overcoming interpersonal boundaries for combined expertise

In the first case, ongoing interactions take place between care managers and medical managers at the middle management level: ”We consulted each other every day, we thought things through together, we suggested things so that we could make decisions quickly. We combined our skills to come up with the best organization ” (head of intensive care unit); ”we talked a lot together, we asked each other what you thought, and above all we decided quickly ” (intensive care anesthetist); “We had to review our organization quickly, we had to act fast and decide all together, we were all concerned ” (intensive care anesthetist).
In the second case, the middle-level managers from various professional categories promptly collaborated to devise a plan for implementing this dual flow. The safety manager played a crucial part in this process. The middle-level managers from different categories, including caregivers, medical staff, and logisticians, worked together to establish complementary rules. Once again, decisions were taken in the field: ”We did what had to be done, we set up the checking points. Management let us get on with it. We even changed our organization several times a day ” (safety manager); ”We acted very quickly, we didn’t wait for directives or approvals, there was no time to lose ” (emergency doctor).
In the first two cases, the transformation process was initiated by professionals in the field who were faced with an influx of patients requiring specific care and management. Middle managers from various professional categories, including nursing, medical, administrative, and logistical, discussed the situation and collaborated to develop rules and resources for managing the transformation. These rules were based on a combination of professional expertise and knowledge of the virus, its mode of transmission, and therapeutic recommendations. As the transformation process progressed, the rules and resources were adapted to reflect the evolving situation and the actions taken by the professionals involved. Middle management is responsible for planning and control activities, and they employ various tactics to facilitate organizational transformation. By fostering transparency, trust, and effective leadership, middle management can effectively steer actions towards positive change. At times, middle management may seek information from external sources, such as their own network, to gain a better understanding of the situation and changes in the environment.
The third transformation involved the decision to establish a reception service for patients who do not require intensive care. This decision was made in consultation with political authorities and the heads of other hospitals, and management was responsible for determining the capacity and associated resources required. The rules and guidelines for the new service were collectively defined by middle management, who drew on the expertise of various categories within the organization.

4.4. Interaction mechanisms

The following statement describes the presence of various mechanisms that support inter-professional and inter-hierarchical interactions, which are interdependent and intricate in nature.
First, they were supported by an extensive communication:At every shift change, we had a briefing. It lasted 10 minutes. I explained what I knew and what I didn’t know. And I filtered a lot, because there was too much information coming in ” (head of intensive care unit). The institutional establishment of crisis cells within the facility facilitated the provision of support for communication. These cells enabled paramedics to devise organizational solutions to address the challenges arising from the crisis. Discussions were held to address various aspects, such as health directives, the management of resources, both material and human, and the allocation of tasks within the facility.
The urgency of the situation on the ground has necessitated a change in the decision-making process. This transformation was initiated by middle managers in the field, who were granted autonomy by management and entrusted with making decisions. The intensive care anesthetist declare that he had the impression of having freedom of decision: ”They had no idea what to do, they had no choice but to let us decide ” (intensive care anesthetist); ”we had contact with the general manager, he trusted me completely and told me to listen and take things in hand ” (intensive care anesthetist, head of department). Members of the top management team said they had placed their trust in the professionals in the field and in middle management: ”They knew better than we did what was going on, there were no longer any cost constraints, so we gave them the keys ” (Director of Care). Middle management was able to exercise judgment and utilize their expertise and understanding of the field, which was bolstered by the confidence placed in them by senior leadership. This empowered them to establish regulations and request the necessary personnel and resources to provide medical care to patients.