IF IT AIN’T BROKE, FIX IT!:Beth Israel had a strong and pervasive organization culture that supported innovation and change. The culture was created by Beth Israel's top management, notably Joyce Clifford, RN, Ph.D. and Mitchell Rabkin, M.D. Drs. Clifford and Rabkin had unusually long tenures in their leadership roles at Beth Israel, and their progressive and effective leadership styles contributed much to the culture that was established in the hospital.The OrganizationWhy Change?Care TeamsTHE ELECTRONIC HALLWAYTM NETWORK A PRODUCT OF THE PUBLIC SERVICE CURRICULUM EXCHANGEIF IT AIN’T BROKE, FIX IT!:BETH ISRAEL HOSPITAL(This case has been abridged for class discussion)Beth Israel had a strong and pervasive organization culture that supported innovation and change. The culture was created by Beth Israel's top management, notably Joyce Clifford, RN, Ph.D. and Mitchell Rabkin, M.D. Drs. Clifford and Rabkin had unusually long tenuresin their leadership roles at Beth Israel, and their progressive and effective leadership styles contributed much to the culture that was established in the hospital. The culture emphasized respect for each employee and the expectation that each can and will grow and contribute. Nurses were recognized as centrally important to patient care and were held in high esteem. The culture fostered constant incremental change through an attitude of "if it ain't broke fix it anyway." The culture encouraged people to cut across and through the traditional hierarchy to accomplish new things. Though Beth Israel was large and complex there was little bureaucratization. The culture purposely supported informal communication and coordination within its traditional hierarchy. For this reason Beth Israel saw little reason to formally change its structure in order to institutionalize the patient-centered changes it introduced. Because of Beth Israel's culture of progressive change, it "absorbed" the Strengthening Hospital Nursing grant with little fuss and no new structures. None were considered necessary at Beth Israel, just as such structural changes were considered essential in our other cases. By the same token it became difficult for the hospital or anyone else to distinguish the changes wrought by the grant from changes that would have happened anyway. In a hospital with a well deserved reputation for excellence in patient care and devoted to thoughtful change by increment, restructuring to improve patient care was bound to happen. Under these circumstances the nature and process of change at Beth Israel Hospital were different and subtle. The case reveals how "the devil was in the details.”The OrganizationDistribution of this case study is made possible through the generous contributions of The Pew Charitable Trusts as part of their support for the Electronic Hallway. This case was prepared by ProfessorsThomas Rundall, David Starkweather and doctoral student, Barbara Norrish from the University of California, Berkeley’s School of Public Health, as part of a cooperativeeffort with colleagues in the nation’s schools of public health and health administration. This case is provided to the Electronic Hallway through the courtesy of the authors and Jossey-Bass Publishers nd is excerpted from the forthcoming book, “After Restructuring: Empowerment Strategies at Work in America’s Hospitals.”The Electronic Hallway is operated by a multi-university consortium and is administered by the Cascade Center for Public Service at the University of Washington’s Graduate School of Public Affairs.This case study is intended as a basis for class discussion and is not intended to suggest correct or incorrect handling of the situation depicted. While based on field research, names may have been disguised and certain facts simplified in the interest of confidentiality and effective classroom use. Use of this case study is subject to the terms of the Subscriber Agreement (http://www.hallway.org/agree.htm). If the terms of this agreement are not acceptable to the user, user should terminate access and refrain from any storage, printout, distribution or other use of this material. This material may not be altered or copied without written permission from the Cascade Center forPublic Service. For more information, contact the Cascade Center at [email protected] or (206) 616-8777.Copyright 1998 Cascade Center for Public ServiceF96If It Ain’t Broke, Fix It!: Beth Israel HopitalLocated in the center of the Boston’s medical metropolis, Beth Israel Hospital served as one of the primary teaching hospitals for the Harvard School of Medicine. Nationally recognized as one of the nation’s premier health care institutions, BI was licensed for 408 beds in 1995. The hospital provides a full range of acute care services, including multiple medical and surgical specialties, psychiatry, obstetrics and gynecology, emergency care, and a Level I trauma service.In addition to its reputation as a leader in the field of medicine, Beth Israel Hospital (BI) isrecognized both nationally and internationally for its professional nursing practice model (primary nursing) and the quality of its nursing care. Under the leadership of Joyce Clifford, R.N., Ph.D., Vice President for Nursing and Nurse-in Chief, the nursing division at BI successfully developed and implemented primary nursing 1974. This model of professional practice has been adopted widely in hospitals throughout the United States. Elements of this model of nursing practice at BI include: continuity in nurse patient relationships over time; twenty-four hour accountability for nursing care; admission-to-discharge accountability for a patient by one nurse who cares for that patient when present; case-based management of care through the use of nursing care plans as well as direct communication between care-givers; and associate nurses who provide care in the absence of the primary nurse, consistent with the plan of care developed by the primary nurse.Underlying the primary nursing model was the value the organization placed on the clinicalpractice of nursing. Organizational leaders believed that nursing makes an important contribution to the outcomes of patient care. Mitchell Rabkin, M.D., President and CEO of Beth Israel Health System, stated that his philosophy “is that the hospital is fundamentally a nursing institution. Doctors don’t like to hear me say that. Basically we are nurturing the patients for a