1. Introduction

It is the role of every healthcare facility to find strategies likely to result in the best patient care possible. Krisna Hospital, one of the largest and multi-specialty healthcare facilities in India, developed a new role to improve patient care. Many patients have struggled to understand doctors’ diagnoses and recommendations; as a way of creating a solution to this problem, Krisna Hospital designed the patient care executive (PCE) role to act as a liaison between physicians and patients. Initially, the strategy was expected to create a win-win solution but ended up having highly satisfied patients with high demotivated physicians. The following essay describes the physicians’ experience in psychological contract breach, the variations of PCEs and physicians’ sources of power, and the primary reasons why physicians resisted the PCE program. Additionally, the essay outlines a step-by-step plan based on organizational change theories that would lead to a better implementation of the program.

2. A Case Study Based on Organizational Change Theories

Psychological contract theory is based on the assumption that is a particular level of cooperation and commitment that exists between employers and employees (Rousseau, 2011) ^[1]. While most contracts are written and signed, psychological contracts are intangible agreements, which are based on individuals and perceptions. Physicians’ experience in psychological contract breach in the case study emerged through the denial of fully experiencing the physician-patient relationship. It is anticipated that doctors should create an effective relationship with their patients, but with the PCE in the middle, it was impossible for the physicians to develop the required relationship with their patients. Secondly, the PCEs also took much of the advisory role from the doctors and ended up creating some unwanted consequences on the patient-physician relationship. From the case study, it was evident that patients lost their trust in doctors, and increased their confidence in the PCEs.

Psychological contract breach has several negative outcomes; first, it led to employee dissatisfaction. The physicians were less satisfied with their role in the healthcare facility as evidenced in the interview between Dr. Vishnu Patel and Amrita Rajesh, the head of human resources. Employee dissatisfaction eventually leads to increased turnover rates, which created an alarm in Krisna Hospital (Li and Chen, 2018) ^[2]. The rate of attrition increased over time, leading to the Chief Executive Officer (CEO) calling for a quick meeting with Amrita and Jai Srinivasan, the head of patient services and the chief proponent of the PCE program. Increased burnout was another impact of psychological contract breach because the doctors had to report to the PCEs, in addition to their normal reporting roles to patients, their families, and the administration. Social exchange theory explains the impacts of the breach observed from the case study; based on the theory, people make decisions by weighing both the costs and rewards of a relationship or action (Cropanzano et al., 2017) ^[3]. The reactions by most doctors were as a result of careful consideration of the role of PCEs and other opportunities available in other healthcare facilities, hence leaving the healthcare organization proving to be the best alternative.

From the case study, it was evident that the PCEs played a crucial role in improving patient satisfaction scores, patient retention, and referrals; however, these came at cost of decreased physician motivation. For Krisna Hospital to manage the outcomes effectively, there is a need to address the gap that exists between the physicians and PCEs. The PCEs need to understand that their role is to complement physicians' work at the hospital. They should be answerable to the doctors and must implement the instructions provided by the doctors to avoid any form of confusion. Training on collaboration between doctors and PCEs would be crucial to ensure these two sets of employees can work in a seamless manner (Morley and Cashell, 2017) ^[4]. Patients should see a united workforce ready to offer care, hence avoiding the impacts of a breach. 

The situation at Krisna Hospital was worsened by the dynamics of power different sets of employees have. Positional and Personal Powers were the two major sources of power at play in the situation at the healthcare facility. While positional power originates from one’s authority within an organization’s hierarchy, personal power is individual and can either be referent or expert power (Yoon, 2016) ^[5]. PCEs exhibit positional power that slightly allows them to have some power above the physicians. According to Dr. Patel in the case study, doctors have to be answerable to the PCEs, who have a direct relationship with the patient. The positional power held by the PCEs gave them an edge over the doctors in influencing treatment options for the patients, despite lacking medical practice training. On the other hand, physicians possessed personal power, and specifically expert power because of their role in treating patients. Without doctors, a healthcare facility cannot operate effectively, hence giving the physicians the expert power they possess.

According to Yoon (2016) ^[5], positional power is positively linked with harm while personal power is positively associated with building and helping others. The situation is observed in the case study, whereby the role of the PCEs has created some instability at Krisna Hospital, which in the long run could lead to organizational failure. Positional power gives broad authority, hence leading to delayed consequences for bad behavior (Sanders, 2014) ^[6]. From the case study, several doctors complained of the roles of PCEs in the hospital; however, the cases were not addressed because of the other benefits the PCEs brought to the organization. Rather than working effectively with the doctors, PCEs used their positional powers to benefit themselves by affecting the physician-patient relationship. Personal power held by the doctors made some of the doctors remain committed to their work as caregivers due to its association with helping others. It was also through personal power that some of the doctors decided to find other opportunities and leave Krisna Hospital. Through expert power, the doctors knew it was possible to find other opportunities in India where there wouldn’t be an intermediary between them and the patients.

According to Kuzhda (2016) ^[7], it is normal for organizations to experience resistance whenever there is change. There are various underlying reasons why employees are likely to resist change. In the Krisna Hospital case, lack of stakeholder involvement was one of the biggest reasons for physicians’ resistance to change. The doctors were not involved in the change from the start, hence failing to understand the role of PCEs effectively in the healthcare sector. Lack of stakeholder engagement further led to a misunderstanding concerning the need for the change. From the case study, it is evident that several physicians agreed that the PCE role was unnecessary. They viewed the role as an additional complexity to their work since they had to report to an additional unit. The doctors further resisted the change because of their link to the status quo. In most hospitals, it is the role of the physicians to speak directly to the patients. The proposed change was perceived as robbing the doctors of some of their important roles, which entails creating a treatment relationship with the patients. Other possible causes of the resistance were poor communication, changes in routines, exhaustion, and low trust in management (Burnes, 2015) ^[8].

As stated above, resistance to change is normal; therefore, it is upon the organization’s management to find strategies to reduce or avoid resistance to change. Kotter’s eight-step change process is one of the most commonly used theories in managing change. Krisna Hospital ought to have implemented this theory before rolling out its PCE program. The first step in implementing the change would be the creation of a sense of urgency by identifying future repercussions or possible opportunities likely to come because of the proposed change. For example, the PCE program would highlight the possibility of an increased number of clients and a higher retention rate. Secondly, forming powerful guiding coalitions that would include all stakeholders affected by the change (Kotter, 1995). Doctors, patients, the management, and crucial people in the healthcare sector must be involved in the development of the coalition.

Thirdly, the change must possess a vision and strategy; becoming an effective patient-centered organization is an example of a vision Krisna Hospital would create. The vision must be communicated to all people within the organization. In case of any concerns, it would be important to handle them honestly. The fifth step according to Kotter (1995) ^[9] entails removing possible obstacles; it is at this point that the hospital would have noticed the clashing of roles between doctors and PCEs, hence finding a strategy to address the gap. Creating short-term wins would provide the employees with a feeling of early victories thus motivating them more to pursue the change. Consolidating gains and finally anchoring the change in the company's culture would lead to a successful change process (Kotter, 1995) ^[9].

3. Conclusion

In summary, it is unfortunate that Krisna Hospital developed an important strategy to improve overall patient experience but ended up affecting the role of physicians. Failure to focus on the change from a holistic perspective led to the clashes experienced between the PCEs and the doctors. The use of a change management plan such as Kotter's eight-step process would be crucial in reversing the negative impacts Krisna Hospital experienced in its attempts to improve patient care. Change management models help organizations in identifying possible sources of resistance and address them accordingly, hence resulting in a successful change process.

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