Scenario
At the end of 2014, a large university hospital in the Netherlands launched a procurement tender exercise for surgical suture material. The rationale for hospital management to initiate this procedure was cost-cutting and standardization. The award criteria were focussed on the most economically advantageous tender. There were different suppliers on the market that were able to produce and deliver high-quality surgical suture material for a lower price than was currently being paid. Consequently, the tender was awarded to a new supplier. The top managers and purchasing manager who initiated the tender trod carefully and implemented this relatively small-scale change initiative according to some basic change management principles (e.g. Kotter, 2012): they built a guiding coalition that incorporated renowned medical specialists, they consulted department heads and they communicated the change to surgeons through different channels. Furthermore, it was recorded in the tender that the new supplier should provide value-adding services such as e-learning modules for surgeons, facilitate lengthy trial-use periods and offer workshops and support to the operating theatre. Hospital management conceived this first initiative as a test case for more extensive cost-cutting operations that were to follow. This project was supposed to be relatively easy, both in scale and in complexity. However, in the preparations ahead of the trial phase, a concern was raised by the cardiac surgeons to one part of the tender package involving sutures specifically used for cardiac surgery. Nevertheless, surgeons were forced to participate in testing the products supplied in the whole tender, including those products used in their specific specialities. Meanwhile, the initiators of the project felt that careful preparations of the testing phase had been made.
So, what went wrong? In mid-2015 – when this research project started – hospital management eventually met with fierce resistance from some of the hospital’s cardiothoracic surgeons. They adamantly refused to work with the new suture material. The resistance took the form of surgeons expressing anger at management, stockpiling their own supplies of surgical suture, refusing to operate, holding managers accountable for patient deaths that could arise from use of the new suture and threatening to go to the press if such a thing indeed were to happen. Hospital management had anticipated some resistance, but not of this intensity. The end result was that the contract was eventually cancelled for sutures specifically used in cardiac surgery.
Data collection
Data collection took place in a year starting from mid-2015. In total, 17 in-depth interviews were conducted that each lasted approximately 1 h. The respondents were targeted through maximum variation sampling until saturation was achieved and are listed in Table I. Patients were excluded beforehand. The interviews were audio-recorded after verbal consent was given. All but one interviewee agreed to be audio-recorded. This interviewee was comfortable, though, with the interviewer (EG) taking notes. The interviews were transcribed and anonymized. Apart from formal interviewing, extensive informal conversations on the topic took place with surgeons from different medical specialities.
Field notes were made on the observations of a trial session and a workshop facilitated by the new supplier. These notes were divided into four categories: observational notes, theoretical notes, methodological notes and reflective notes (Baarda et al., 2013).
Economic/managerial discourse
Transitioning to new surgical suture was often constructed by members of the hospital management as a test case for more extensive cost-cutting operations to follow:
We are confronted with an enormous challenge. We have to drastically cut costs. This was an important test case, because more and bigger cuts are pending. This appeared to us as an easy win. However, …[1]. (Head of operating theatres)
This construction is embedded in an economic discourse that provides a legitimate rationale for the change. A prerequisite for providing sustainable, high-quality health care is a financially healthy position. Some managers were genuinely astounded by how inefficient the current purchasing policies of the hospital were. Often managers posited the professional autonomy of medical surgeons as the main barrier to change. Other perceived barriers to change were constructed in ways that characterize particular professional roles. The purchasing manager, for example, typically suggested another barrier:
Not only with surgical suture, but in general medical specialists resist change. That is because these suppliers have a powerful and very effective sales force. It is what we call vendor lock-in. (Purchasing manager)
As evident in the aforementioned quotation, depending on the formal positions participants took up in this change initiative, they came up with their own hypotheses of why they thought new surgical suture was resisted by medical professionals. In another instance, a proponent of the initiative to replace surgical suture suggested people were being overly emotional:
I get that those boys [cardiothoracic surgeons] … what they are doing is very precise and technical. And surgical suture and needles are of crucial importance. On the other hand, there are always these sentiments. I mean, there are many medical centres, also abroad, where cardiothoracic surgeons suture with XXX [brand name of new supplier] and it is not turned into a complicated affair. But you cannot take away these sentiments just like that. We took note of these feelings, and nudged our staff to give it [the new surgical suture] a try and comply as much as possible. But to be honest, according to me at cardiac surgery there is a lot of emotion involved surrounding suture, … and it is not working for me. (Department head, surgery)
However, some surgeons, especially cardiothoracic surgeons, presented other considerations as motivating their unwillingness to change, using arguments of quality of the new sutures:
The initiator – the manager that came up with the idea to supposedly cut costs – does not know that suture curls and curls more-or-less depending on the brand. He does not know whether needles are round or angular. And he doesn’t care. But for my work this is very relevant. It has nothing to do with professional autonomy. (Cardiothoracic surgeon)
One might argue with this cardiothoracic surgeon that this is exactly what the notion of professional autonomy refers to; in this case, the autonomy to decide for yourself, as a medical professional, which materials to work with. But that is not the point this cardiothoracic surgeon is making per se. Apparently, in the daily jargon of healthcare managers, the notion of professional autonomy is employed as a stopgap explanation for resistance so often that this surgeon anticipated its negative connotation related to changing surgical suture and change more general. For him at least, the superimposition of professional autonomy as an explanation does not do justice to how he relates to the issue of changing surgical suture. For him it is not an abstract affair, but genuinely felt, both in a tactile and in an emotional sense. Also note that academic definitions of professional autonomy (conceptual) do not always correspond to how such notions are employed in daily usage (performative). The cardiothoracic surgeons spoken to frequently drew upon a competitive/professional discourse in relation to surgical suture, enriched with examples and in far less abstract manner than those that posited professional autonomy as the main cause of change resistance.
Competitive/professional discourse
In formal interviews and casual conversations with surgeons, the comparison with practicing sports – and the physicality that characterizes both practicing sports and conducting an operation – was frequently made. One cardiothoracic surgeon compared his surgical suture to the shoes of soccer player Zlatan Ibrahimović. Another surgeon name-dropped a famous tennis player in the following manner:
He [Roger Federer] goes down in the history books as the best professional tennis player ever. And that is because he has spent endless hours on the court practising and refining his skills. His tennis racket has become a natural extension of his arm. His tennis racket is his instrument. My instrument is my suture … suture and needles. (Cardiothoracic surgeon)
Whilst conversing with surgeons, it became evident that performing cardiothoracic surgery is perceived as practicing a top-level sport. It is both physically and mentally challenging, only the stakes involved are much higher. Surgical suture is embedded within an arrangement that specifically characterizes members of the cardiothoracic speciality. As such, attempting to change or replace this single tactile element feels like tearing down the entire arrangement. It might seem a bit far-fetched or exaggerated, but the emotions and feelings that were triggered by pushing forward with this initiative were real and so were the consequences of attempting to bypass these emotions and feelings. One cardiothoracic surgeon detailed his professional involvement in the following manner:
I didn’t just go to medical school. After that I have done my residency, with a Ph.D., et cetera. All in all an extra 10 years. Everything that you are supposed to do, I did that, to become the best possible professional and to be able to deliver the best possible care for the patient. This is not some quick course. This is really … six years of medical school and then postgraduate for another six years. That isn’t nothing. You have to be motivated, driven and persistent. And you hope to end up working for an institution that enables you to profess your passion. (Cardiothoracic surgeon)
It is important to note that the cardiothoracic surgeons quoted here did not exclusively drew upon this competitive/professional discourse that implies sacrifice, persistence and drive. But when they did, they challenged the economic/managerial discourse without actually talking about finances. In a way, to put it bluntly, money from this perspective should not be an object, or, at least, it should never be a priority.
Discourse on patient care
It would be too one-sided to emphasize the aforementioned competitive/professional discourse that the surgeons frequently drew upon without pointing out another manner in which surgical suture was spoken about. During the interviews and casual conversations with surgeons, it became evident that the well-being of their patients was a primary concern. One cardiothoracic surgeon positioned himself as the patient’s main advocate – as opposed to hospital managers, who only maintain quality in a more general, abstract manner – by asking the following rhetorical question:
Let’s say … I am going to operate your father with XXX [brand name of new supplier], but I am not used to working with that suture. It curls more and the needles go blunt quicker and the needles are square and therefore more difficult to position in the needle holder. So I need to focus more and I need to stress … I need to work [with the utmost precision]. Well, I am curious whether that manager would let me operate on his father. (Cardiothoracic surgeon)
Surgical suture was constructed as a lifeline on which the cardiothoracic surgeon relies on behalf of the patient. Replacing surgical suture is perceived as an unacceptable potential cause of failure. So whereas the competitive/professional discourse places the concerns and aspirations of the medical professional front and centre, this discourse on patient care places the concerns of the patient front and centre by means of the medical professional as his advocate. Implicit in both discourses, though, is that money should not be an object. As such, these discourses are counter-discourses to the economic/managerial discourse that legitimizes replacing surgical suture by that of a cheaper brand.
Discourse on safety and quality
Related to the aforementioned construction of surgical suture as a lifeline located within a particular discourse on patient care is the construction of surgical suture as a risk factor. This construction is located within a slightly different discourse on safety and quality, because it relates to health authorities, medical trials, accountability, transparency, statistics, performance measures, institutional reputation, safety and quality management rather than to direct and personal involvement with the patient. The direct relationship between the surgeons’ handicraft and the possibly life-threatening consequences inherent in cardiac surgery amplifies the sensitivity of the subject.
So many things can go wrong. So changing surgical suture presents an additional risk. We prefer to operate a patient’s heart only once and then never again. (Cardiothoracic surgeon)
When a medical professional draws upon this discourse, it provides a strong counter-discourse to the economic argument that is more frequently used by those working in hospital management. The Chairman of the Board, even though he formally has the power to push forward, by now has realized he had reached the limits of changeability:
If medical specialists use the argument of safety, patient safety, then you are finished. As an executive it is over. You start thinking, what if he is right; and I force him to work with this suture and something goes horribly wrong. He only has to say: “I told you it wasn’t safe!” And then you, as an executive, are gone. Of course, you have to challenge and not be naive, but ultimately it is a show stopper … that safety argument. Another factor was, that my colleague in the Executive Board and I are not [cardiothoracic] surgeons. So we could not weigh in from our own experience. (Chairman of the Board)
The best of the best: being part of an elite professional group
Among the surgeons of different specialities, the cardiothoracic surgeons stood out amongst those interviewed in this case study. A theatre nurse prided herself on being a member of this elite group in the following manner:
Those boys [cardiothoracic surgeons] – or men I should say – are so bloody good in what they do. And you [as a nurse operating theatre] also want to be part of that, to pass cum laude. They stand for their profession, each time they give it a hundred and ten percent. And they perform procedures that no one else dares to perform. For us it is a joy to assist them. You share in the pride and get into that special workflow. (Nurse, operating theatre)
The Chairman of the Board had learned that in dealing with different professional groups, especially when they are tightly-knit and its members have unique histories, training, skills and responsibilities, one does better to adopt a contextualized approach to change:
Well, our group of cardiac surgeons consists of individuals with a unique history at this hospital. They are not known to be particularly dynamic or flexible. Let’s keep it at that. So, to get them on board with our plans requires some extra effort on our part. (Chairman of the Board)
The following account of a cardiothoracic surgeon exemplifies just how difficult it is to understand the actual practice of operating on someone’s heart.
I have studied and practiced endlessly. And we [other cardiothoracic specialists] frequently consult one another. But sometimes when I have to decide fast, during a very complex operation, medicine is almost more like an art-form. I feel when something might go wrong and I anticipate what to do. And when someone later asks me: “Why did you do this or that?”, of course I will formulate an answer, but in reality I acted upon the experience I have and on what I have learned from my mentors. In these moments everyone in my team knows what to do. I do not even have to tell them. However, I cannot accept that someone who has no idea what we are doing, decides that I have to work with that suture. (Cardiothoracic surgeon)
The prediction that deeply embodied practices that are learned over time through mentorship, explicit instruction and implicit attunement of the senses are not to be changed by outsiders in a pick-and-choose manner is confirmed by this surgeon.
Instructions for scenario:
Develop a change management strategy, considering the scenario stakeholders that incorporates the following sections:
1. Conduct a stakeholder analysis for case and summarize the results in a stakeholder map highlighting interest, engagement, and influence groupings.
2. Use the results of the stakeholder analysis to identify and evaluate resistance to the change process.
3. Use the Kotter´s change management model to apply in the case.
4. Critically discuss the involvement of the functional areas in developing a change plan
5. Draft a strategic change plan for your case by applying the selected change management model with timelines and SMART progression metrics.
