We carried out an inquiry in a hospital located in the south of France, at the time of the transition to the 35-hour workweek and the broader context of the modernization of hospitals, where computerization was implemented to allocate and control budgets.1
We are in late 2001. The reduction of working time, the transition to the 35-hour workweek, has to be implemented in 2002. National and regional directives have been given. Documents have been handed out for everyone to describe their activity. There are questions about losses of time. Doctors have a separate questionnaire to fill out.
The job duty of hospital practitioners (whose status is defined by relatively new written documents) is 10 half-days per week (the number of hours for a half-day not being fixed), six days per week. Sunday is a work day like any other. Duty furthermore entails one shift per week (Sunday, overnight, and standard, no more than two Sundays per month). After each shift, there is a (theoretical) obligation to recover the next day. There are three types of shifts: on-site duty where the doctor is in the ward (with a monthly ceiling cap); on-call sessions where the doctor must be able to be contacted and arrive right away; and standby, where the doctor is not on-site but quickly reachable. The on-site shift pays best, followed by on-call sessions, and lastly, standby pays the least.
The duties these different shifts refer to vary according to the hospitals and within them except for the emergency room, where there is always an on-site shift. In this hospital, doctors in on-call or on-site duty include anesthesiologists, cardiologists, surgeons, and radiologists. In infectious diseases, oncology, pharmacy, and the laboratory facilities, there are only standby shifts. During the day, the hours are 8:30 am to 6:30 pm.
We observed an increasingly overbearing accounting process for the allocation of budgets. There is a modernized measurement scheme that did not previously exist. No activity should be spared from bookkeeping austerity, even those activities which hitherto responded to needs that seemed antithetical to this kind of calculation, particularly in healthcare. The reasons for this are multifaceted: obviously financial, in an attempt to cut back by controlling constantly rising healthcare spending, which are digging into a growing Social Security deficit; but also legal, in order to protect against future complaints and lawsuits in the case of failed operations, misdiagnoses, or wrong prescriptions. And managerial: because administrative officials are trained in modern management techniques and look to apply rigorously monitored follow-up measures
The procedures proliferate, formalization is generalized; everything must be communicated, verified, accounted for. Moreover, since there is a wariness of the pitfalls [dérives] of excessive bureaucratization, there is a doubling down on the process of multiple audits, checks of various kinds intended to evaluate the effects of these numerous procedures. Some of these procedures, always time-consuming, can be useful to medical staff, particularly doctors, with records becoming more easily accessible for instance with information technology and office automation. And knowledge storage improves too, as a Department of Medical Information (DIM) secretary explains: “the encoding of the records made it possible to see what was really happening. For example, people thought that we were seeing a lot more elderly patients, but in fact we were seeing a lot of young people, so we have a more precise view of what we are doing. For example, there are no longer heart attacks but more cardiac arrhythmias.” In addition, it makes it possible to set up comparisons between hospitals based on normed criteria and thus eventually reduce funding inequalities. But beyond this aspect, which might ultimately turn out to be positive, there are effects and risks which are widely perceived by the hospital staff. Apart from the time it takes away from everyone, to constantly fill out paperwork, this transparency allows responsible bodies and officials to set objectives, giving them a legitimacy to get these objectives done which does not always correspond to reality. The point is that this transparency does not always reflect the complexity of the work that medical staff perform. Measurement, objectivation, the search for uniform standards, all tend to diminish [estomper] some of the many facets of the specific people-oriented labor that is health care. The standards selected, in the official records of the time spent on a particular task, do not respond to certain still-fundamental concerns of medical workers. Again, we are faced with the different kinds of practical investments and choices of the time worked. The DIM secretary explains that “at times people have difficulty understanding the point of all this encoding; they believed the effect of the PMSI (French Medical System Database) would be more significant, in other words that it would allow for the hiring of more staff where the need arose; to hire more staff or gain better skills in infectious diseases, they call on us but, for example, we are doing more outpatient visits but its not having the desired effects.”
An Intrusive Informatization
The setting of the annual budget at the hospital’s disposal has since 1985 been based on spending over the prior three years, carrying out an equalization across the different services and proposing for the following year an overall allowance for operating costs (dotation globale de fonctionnement, or DGF) with some adjustments. Previously, there was a daily pricing scheme, by specialization (general medicine, maternity, surgery, intensive care), and when a patient was discharged, their bill went to social security for reimbursement. At the same time as the DGF system was being implemented, information on treatments had to be gathered. Hospitals have had to provide the information to the ministry since 1989, every six months: admissions, ages, length of care, diagnostics, records, other illnesses covered, outpatient care, prescription for costly medications. Then came the PMSI. This system allowed for greater precision in expenditure reporting and comparisons between hospitals. In principle, it should have also made it possible to reduce inequalities between hospitals, but those inequalities remain. As the doctor in charge of computer tracking explains: “everything comes from an American, [Robert] Fetter, who has consolidated a wide variety of diagnosis codes, with 50,000 locutions at the start, that the WHO has transformed into 10,000 rubrics. In France, with the PMSI, we crunched all that together to arrive at 580 diagnosis-related groups: the DRGs.” This means that illnesses that generally have the same diagnoses at the same costs are grouped together. “This consolidation obviously poses several problems, as within each group there exists a greater or lesser spread, but if you multiply the groups, that becomes too complicated, so there’s a compromise. The PMSI involves sending each illness in a DRG. Each DRG has a scale of costs. You then look at the costs by DRG and by patient, on the basis of 30 healthcare institutions that serve on a panel. Everything is included: doctors, staff, laundry, meals, care, medications, etc. At the end, you have a relative scale in Francs or in Composite Index of Activity (ISA) points, totaling so many Francs. When you have arrived at an overall total of ISA points according to the hospital’s activity, you estimate a theoretical DGF which makes it possible to compare the expenditures of one hospital to another. You look at the average point value in the region and compare the expenditures between hospitals. This is also the basis of discussion for the DGF. In other words, you come up with the total PMSI expenditures, then you calculate in DRGs and ISA points which provides the ISA point for a given hospital. At our hospital the ISA point is low, which means we are underfunded; this system should make inequalities disappear, but at the same time it is the region that redistributes budgets, but the rich ones never have enough. They only leave us crumbs, so you never make up the gap since the DGF are capped according to what was previously spent.”
This DIM lead aptly reconstructs the digitization, monitoring, and supervision imposed on their hospital. All this translates in reality to the fact that “there are fewer of us, and we always need more: to be careful, to spend less, plan for the 35-hour workweek, all while being more effective, more available, more friendly. It’s hard to deal with.” The young doctors struggled to accept this change. “They were tense, they were angrier than we were about their working conditions. Before, there had been more bonhomie, things were calmer, we had better recognition of patients, the public, of the administration, we felt less threatened.”
The overall situation is deteriorating. The population is aging and is consuming care at a higher rate. In this hospital with more than 1,000 employees, a new director introduced at the beginning of 2001 an even more accounting-based vision (it may be noted that the director is not a doctor, but has management training). Faced with accreditation requirements, and in the framework of a quality improvement process, he has given precedence to a demand for discipline that does not come easy to staff confronted with humanly complex, sometimes nearly inextricable, situations. There is a repository of activities in a certain number of areas (like patient care, the efficacy of prescriptions, service delivery) and accreditation visits have taken place, performed by an independent accreditation and health evaluation agency, which includes peers, administrators, and executives it has recruited. They come to evaluate the findings in relation to the objectives, spending several days, and release a public report which contains recommendations according to the findings. A deadline is then set for solutions to be provided. But the situation is all the more precarious since the hospital is chronically understaffed, incidentally a result of the formalized aspect of the ISA points. There is a ratio between the number of staff according to patient-time or per ISA point. “We realize that we are less staffed, which means fewer nurses in services.”
An ongoing obsession with measurement, objectivation, and calculation. A transition from a culture of spoken communication to that of writing and statistics. To render work measurable, to return comprehensive and quality data – such is the overarching aim of modernization in the hospital as well as other sectors of activity. Here, the trap of over-information [la sur information] must be avoided. “When the patient is discharged, you close the record, you classify it by date of birth. Then, there are retention policies: lifetime or longer (for hereditary conditions), for 40 years (HIV), or 70 years (gynecology). You indicate how long it must be retained, you put a barcode on the record with the patient’s Permanent Patient ID number, you check the placement of documents in the record, and you update the information on where the record is. We input it on Castor, we try to avoid inputting too many things, because the more things there are to do the greater the chance for mistakes: errors can arise in classification, date of birth and date of admission next to each other, you switch them. We’ve had a hard time conveying to reception that you don’t have to fill in too many details, that’s the source of duplicates.” Furthermore, it is not always the same people who enter the data: depending on the length of stay, sometimes it is nurses first, then doctors, then physical therapists.
In the emergency room, they do not always have the time to fill out the documents. A DIM secretary says: “Right now we are behind on the revaluation [revalorisation] of what is done in the ER. There are not enough people. There are four-page documents to fill out just for a minor injury.” There are quality checks every quarter. “They take records drawn at random and they look at how we are coding. If we code highly, that brings in more to the hospital: as an example, for HIV, when it is detected, you input the code and then you reenter the same code each time the patient returns. But we are criticized for coding on the lower end. For example, in heart attack cases we do not know which DRG it falls under and we follow the doctor’s diagnosis, we mark what he tells us, but he forgets the associated diagnoses. And we lose money. We call the secretaries ten times to get more information, but in some instances they invoke confidentiality,” the DIM secretary laments. Moreover, secretaries and doctors who do not always see the stakes of the DRG often indicate the symptom instead of the disease.
“When you say it must be done this way for everyone,” says the DIM doctor, “it backfires a little bit, a malaise sets in, you enter into the culture of the check list2 and that takes time, you enter into a formalized thing that is not as easy as what was done previously.” Procedures and criteria are stepped up, but in the same movement you become wary of them and thus checks are carried out even more frequently. “The North American experiences which increased the development of useless procedures led to the idea of better controlling what we do and seeing if we are progressing, rather than applying an ISO 9000-type standard.3 It is a matter of disclaiming measures implemented to improve patient satisfaction, to show we are concerned with that.”
To reduce costs and meet goals, quick fixes are tested. With the goal to reduce patient bed-days, day hospitalizations and home care increase, “which makes it possible to manage lines, but these are additional services, required of the hospital, with the illusion of costing less.” This is not visibly the case: “day hospitalization consists in cramming tests often done over three days into one day: the patients turn around faster.” For staff, the work is more intensive, time is increasingly overloaded; for the patients, it is often more exhausting. “Staff do not have any reprieve, equipment is being used day and night, orderlies are coming in three times instead of one. In fact it’s a matter of paying less for more work. More staff have to manage this increased amount of work. This isn’t taken into account and it’s implied that everything can be done with outpatient care.”
The aim of computerization is to have one record per patient whereas previously there were records according to the services where the patient was treated. There is now a single record for all visits in general medicine, obstetrical care, and short visits elsewhere. For each patient, there is a diagnosis coded by disease according to GRMs, which allows for an understanding of who is treated and at what cost. In principle, this procedure aims to lessen the differences between hospitals, but according to the DIM secretary, we have the lowest funding and what’s more, we are penalized because the next time a new hospital is built, half the operating credits serve the new hospital.”
From now on, accounts are permanently retained, and medical staff see their time regulated according to these accounting criteria, and no longer only on the basis of what seems most urgent to them, medical priorities or patient care. Staff are liable for their time, outside of critical response situations.
One of the prerogatives of the profession disappears since an external monitor, an intermediary, intervenes in the evaluation of how that time is used. This apparatus, this formalization, has profound effects. Not only are the staff accountable, but they possess an understanding of what they are doing, of what is being done to them, and that fact introduces a distance. “There is no quality measurement,” the DIM secretary says, “and information is unreliable because all the staff is not convinced of the utility of these ongoing measures. They do not lead to more credits. Doctors are not interested in the quality of information they provide because it is burdensome for staff to manage and there are no repercussions.”
In this way, the job is changing for doctors. As one pulmonologist explains: “You are supposed to be paid for work as a doctor, but that’s only 60% of the time, the other 40% is administrative work. We’re between a rock and a hard place, between the budgetary constraints demanded by management on the one hand and patients on the other.” Economic rationality imposes its rule and weighs heavily on everyday life. “What’s excruciating is daily experience, when we can no longer operate, when we ask for some piece of equipment or other that takes eight months to arrive, like a small computer for endoscopy applications to type reports directly.”
The multiplication of codes and checks has its setbacks, according to some. “By dint of wanting to put everything on a fixed track [sur des rails], the hospital takes away the responsibilities of [déreponsabiliser] many actors, we do what is written, we forget the rest, for example seating people in wheelchairs. We forget that elderly persons have to be given fluids,” a doctor says. A comprehensive vision is lacking, because a very limited approach to problems is on offer. “We’re always stretched. We tend to get rid of people as quickly as possible because queue management is given priority: they’re sent off. But it’s often too soon. The problem would be to provide the means.” This idea of delegating responsibility can also apply to several peer groups that work on a range of issues. Hence this caregiver who is part of a project team on equipment: “With sterilization, we look at what we are lacking, we take inventory and we have to make do so that nothing is missing, we do the small fixes ourselves. Before everyone did it, now the group serves as a reference. That’s a big word. It might take way the responsibility of others.”
There are more doctors and secretaries but the doctors do more procedures, things turn around faster. “Before, for phlebitis, we kept the patient for three weeks; now it’s three days. In neurology, we treat, we rush, we talk about quality, listening to patients when we don’t have the means and we’re going too quickly. We concentrate the examinations on one day, the patient comes out exhausted, especially if they are older.”
An Impediment to the Quality of Work
The staff, in general, continually gauge the constraints tied to the lack of time, personnel, equipment and space, the productivity/quality dilemma, to the contradictions besetting them. The emergency room crystallizes all of these difficulties. Life-saving interventions are taken there, as well as human actions in the face of people in distress. It is critical to know how to be quick and effective but also how to sacrifice, lose time [sacrifier, perdre du temps], because sometimes people have a vital need to which time is devoted. “In the ER, you listen, you don’t say ‘goodbye’ or stand in the way.” It is because the functions of ERs are gradually changing. Alongside life-threatening emergencies and routine emergencies (small fractures, fevers, etc.), there’s a sense of urgency: “They need to talk, they need creature comforts, all these emergencies have to be treated, but we’re rarely given the means. We have never so much as talked about partnerships, networks, when there are dysfunctions and we’re going until exhaustion. The ER is becoming the supermarket [la grande surface] of care, and it’s a development that we will not stop.” But they lack personnel, and the budget is delayed. There are fewer emergency medical technicians, and recruitment is impossible.
This head nurse is criticizing an organization that is not always functional even though it is adhering to the objectives of modernization. The traceability of the patient’s record seems like an interesting objective, and he contributes to it by leading a committee called the caregiver information system. “It is a matter of treating a person who is sick and not an illness alone.” Here we find a tendency toward personalization and focus on the user or client. But he does not think the hospital has the capacity to carry out this policy. In the ER, he explains, reception and referral are absolutely decisive: “Caring is about differentiating between people. You have to triage cases and subsequently negotiate with services for support. This requires having competent staff in reception, staff that is lacking. “The hospital cares for what is cheapest and we object. As luck would have it, the staff is becoming feminized and younger, we have many pregnant women who are not replaced. We need replacements but we don’t have the money. Yet reception is a fundamental job, it requires a great deal of expertise, it’s a critical relay.” The head nurse takes the objectives that have been set seriously. “Care needs to be individualized. But that has ramifications, it requires time and skilled people. The nursing assistant provides support and preventive health services. If there is an elderly person who has broken her hip, and we learn that she walked with a cane, for she spent three hours walking per day, then we know that the muscular strength is good and the physical therapist can rely on that.” He feels that the disorganization, the lack of space and staff, as an impediment [une entrave] to the quality of the work, whose victims are the patients. “The difficulties come when we no longer have a nurse at reception and it’s one secretary or someone else who opens the door. There are expectations for triage…it’s an elderly person with multiple chronic conditions: there are terrible negotiations to get them anywhere. There is a shortage of beds for everyone, plus during the summer, services close so there are additional burdens. This is when there is less internal staff and fewer fallback solutions. What is already problematic during the rest of the year becomes catastrophic in the summer” (this interview was conducted in July 2001, two years before the deadly 2003 heat wave).
In his view, what is “most urgent are the facilities, then the definition of tasks. At the same time, we are told that we are a public service and to “be profitable.” We are in structures that hide the real problems, to increase the quality of service would cost too much.” It should be said that in the ER, there isn’t the PSMI, “but filling out another sheet for the doctor is extra work, the computer system needs to be updated.”
In maternity, the staff is not convinced of the legitimacy of the developments aiming to reduce costs by limiting the duration of hospital stays, either. One midwife who has worked in maternity for 28 years, for example, believes that the “limitation of the number of days hospitalized is not a guarantee of quality. If we send them home after 3, 4 days, that’s not good or else there should be home-based support. When we can keep them for longer, we do so.”
“The number of deliveries is increasing: 793 in 1997, 806 in 1998, and 856 in 2000. We’re exploding: we will have between 900 and 1000 this year.” The supervisor for the maternity ward experiences constant stress. However, she handles the obstetric PSMI herself, which she is indeed behind on, and which should in fact lead to appropriate solutions. “It is protocolized, written out, typed, but the PMSI provides nothing further, I do it to make sure that the record is really complete.” She values the team’s skills and the equipment but the understaffing exhausts them. “What is hardest is the amount of work: everything is done in a rush, we are short a midwife, a caregiver, a hospital service agent. They jump on me, we have meetings.” She wonders how long they will be able to manage to provide treatment. “The midwives are confident and motivated, but what a workload! They drop like flies, they are sometimes called back at 6 pm and they’re the ones with on sometimes they are the worried ones, so they call back.”
The staffing shortage impacts medical practices. So we induce labor most often, “because there are not many of us and we want more deliveries to take place during the day, but when we induce labor it takes longer.” Nights are hard: “When you are the only one working at night for twenty or thirty mothers, it becomes an exhausting job. Generally, there isn’t too much treatment or care except for C-sections, but after there is counseling and support, training is difficult to quantify for human resources. They are aware of it but they take a piecemeal approach.”
Here too, the reality is resistance to numbers, to quantification, And the repercussions fall on both employees and patients. Everyone is worried about the future, especially since the announced 35-hour workweek changes were not yet implemented at the time of our inquiry.
Gerontology, medium- and long-stays, is also a site where contradictions and tensions over the usage of time crystallize.
“We often have the impression of a job unfinished,” a service agent soberly notes. “We work too quickly, the people get heavier and heavier, more and more ill, and we are forced to work faster: 10 to 15 minutes to undress them, wash them, get them up, make the bed, if they are men they have to be shaved, escort them to the mess hall, make sure they drink, some have to be taken to the bathroom, those with dementia go back. Soup arrives at 11:25, we have to ensure everyone is ready, we bring them on an ongoing basis, 75% of them are in wheelchairs. Then we go to the laundry, clean the carts, empty the cabinets, and they take turns using the showers. The agent performs a frenetic set of activities aiming to be rational and time-saving without forgetting that they are dealing with people: “It’s too bad because it can be an enriching experience working with the elderly, they’ve lived a life, a past, and we don’t have the time to enjoy talking with them. We’re always pressed, tired, if we begin to take a little time with one of them it’s a coworker who has to increase their workload.” The agent experiences a great weariness: “It’s a tough job, we get run down. The reduction or limiting of staff needs to stop, there may have been abuses before, but it shouldn’t get any lower. We have people, living beings to take care of, therefore we would want to say stop!”
Another woman, a custodial service agent, complains about a reorganization that has accelerated the pace of work: “Before we were more present, we could talk with them, now it’s a mad dash.”
But what sustains them all is the group cohesion [esprit d’équipe] that resists individualizing modernization where one-on-one meetings are routine. In these very difficult workplace situations, all the agents interviewed indeed stressed the importance of the group. The existence of a genuinely solidaristic [solidaire] and very active work group functions as a shock absorber for those temporal tensions and multiple dilemmas that are the daily lot of full-time staff on the razor’s edge.
– Translated by Patrick King
This text first appeared in Danièle Linhart and Aimée Moutet (eds.), Le travail nous est compté: les constructions des normes temporelles du travail (Paris: La Découverte, 2005), 335-44.
This article is part of a dossier entitled “Robert Linhart and the Circuitous Paths of Inquiry.”
|The interviews were conducted along with Christine Jaeger. We spoke with the head of the Department of Medical Information (DIM, the service which collects all the data on what is happening in the hospital), with secretaries, doctors, nurses, caregivers, senior nurses, hospital service agents, certified and contracted midwives, nursing assistants, and a general supervisor.
|Translator’s Note: in English in the original.
|TN: ISO 9000 is set of quality management systems with the aim of standardizing services and product delivery.