EVALUATION OF THE VAS PILOT PROGRAM IN INSTITUTIONAL REORGANIZATION TOWARD PRIMARY AND AMBULATORY CARE .2. A STUDY OF ORGANIZATIONAL STRESSES AND DYNAMICS

Background. Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educatio nal programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and managem ent issues involved in implementing these changes. Method. The authors carried out a qualitative evaluation of the process of change in an a cademic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters indep endently evaluated written transcripts of focus-group sessions and ide ntified themes. Results. The main problems identified were difficulty with administrative integration between inpatient and outpatient servi ces; need for training, retraining, and orientation; tensions due to c hanges in roles and organizational culture; and inefficiency due to th e need for frequent negotiations in daily work life. These four proble ms reflected tensions associated with new demands imposed by matrix ma nagement, changing job descriptions, policies and procedures, and chan ging patterns of communication and record keeping. Conclusion. During the process of implementation of a primary care focus throughout a med ical center, extra demands upon staff are inevitable and should he ant icipated and planned for. Twelve key factors for successful organizati onal change are discussed.