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Challenging operations: implementing medical reform in surgery (continued)

Implementing—and defeating—reform at three hospitals

In order to reduce work hours, all three hospitals introduced “night float teams.” Previously, surgical interns had often worked back-breaking shifts, arriving at the hospital at 4 a.m., leaving at 10 p.m., and staying overnight on call every third night. Under the new system, first-year residents handed off any work not completed by 6 p.m. to the night float team, did not return to the hospital until 6 a.m. the next morning, and were rarely on call overnight.

This new system was a win-win situation; interns were no longer exhausted by their 36+ hour shifts, and patients were less likely to be endangered by half-awake interns. And yet, these reforms were vigorously resisted at all three hospitals and were successfully implemented at only one. How can one account for this extraordinary outcome?

I discovered that reforms proved difficult because they disrupted the established authority relations and challenged long-standing beliefs about proper medical care and the appropriate roles of interns and surgeons. At all three hospitals, defenders of the status quo resisted change, punishing those who attempted to implement the reforms. Cowed by the defenders’ superior positions in the surgical hierarchy, interns at all three hospitals stopped attempting handoffs.

Mobilizing for change at Advent and Calhoun

But after this initial defeat, reformers at Advent and Calhoun rallied and began to build coalitions to challenge the status quo. Advent and Calhoun were successful, because, unlike Bayshore, they had relational spaces—spaces where, isolated from defenders, reformers could meet face-to-face to try out new tasks, play new roles, and discuss nontraditional ideas without fear of retaliation.

Failure at Calhoun, success at Advent

And yet, only at Advent were reformers able to face down defenders’ renewed attempts to defeat them. Calhoun reformers folded under pressure. Why?

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