CASE The vice president for patient care services ( VP- PCS) and the vice president for medical affairs ( VP- MA) at Northeast Medical Center ( NMC) were very concerned about coordination between Medicine and Nursing in the inpatient medical/ surgical units. NMC was a large tertiary- care teaching hospital, affi liated with the Northeast Schools of Medicine ( NSOM) and Nursing ( NSON). NMC participated in a joint residency program with three other hospitals affi liated with NSOM. Most residents spent six weeks at NMC. The VPs had observed that coordination sharply decreased after restrictions on resident hours were implemented. The VP-PCS noted, The residents rotate through our hospital so quickly that the nurses hardly get to know their names, much less establish a working relationship. The VPs also observed that handoffs of patients from one resident team to another were problematic and had become more so, they believed, as a result of the shorter shifts worked by the residents. The VP- MA suggested expanding NMCs hospitalist program to address the coordination problems. He argued that hospitalists would provide a consistent medical coverage that would compensate for what he called  fragmented coverage by residents. However, the chief of medicine was opposed to this proposal. He argued that it would negatively affect the educational experience of residents by reducing their responsibilities. He was backed in this argument by the chairman of medicine at NSOM. As was common in academic centers, the chief of medicine reported to the VP- MA at NMC and also to the chairman of medicine at NSOM.

1. Is it consistent with organizational theory to expect that coordination between nurses and residents would suffer as a result of the change in resident working hours?

2. Would the addition of hospitalists improve the coordination?

3. What other changes could improve coordination?

4. What are counter-arguments to the position held by the Chief of Medicine and Chairman of Medicine that hospitalists would negatively affect the educational experience of residences?