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.