Chapter 04: Nursing Administration and a New Setting of Multi-Disciplinary Teams
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Description
Ms. Houston sketches the next phase in her career (’79 – ’97): her move from Associate Director of Nursing, to Director of Nursing, and then into the position of Center Administrative Director of Hematology. (She was the first Center Administrative Director.” She summarizes the scope of her responsibilities in each role and then focuses on the restructuring MD Anderson was going through at the time to create “centers” for Radiation Therapy, Hematology, and other services in order to create continuity of care as patients shifted from being in-patients to out-patients or vice versa. This was part of a general institutional push to create “multi-disciplinary care environments.” Ms. Houston describes the reporting chains in these centers and the teams –made up of a surgeon, a medical oncologist, a radiation oncologist and a nurse, among other service providers. She confirms that giving clinics autonomy in this manner represented a cultural shift in MD Anderson, and its goal was greater cost effectiveness. She explains why this goal was not achieved. She then describes the roles that nurses served within the new structure. At the time, leaders in the field of nursing were becoming more vocal about the importance of nurses. At MD Anderson, however, she feels that nurses were involved as an afterthought and because individual physicians understood the role nurses play in organizing patient care, helping the physician to assess the patient, and supporting the patient who must ask the physician about his/her care. At the end of this segment, Ms. Houston talks about her role on the selection committee for the Ethel Fleming Arceneaux Outstanding Oncology Nurse Award, which recognizes the central role nurses play in patient care.
Identifier
HoustonDA_01_20120726
Publication Date
7-26-2012
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The Administrator; MD Anderson History; Institutional Processes; Professional Path; The Administrator; Multi-disciplinary Approaches; Growth and/or Change; The Clinician; Critical Perspectives on MD Anderson; Career and Accomplishments; Overview
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
So as you moved into the Director of Nursing role—that was in 1986.
Deborah Houston:
Right. I had been a clinical nurse specialist for several years, and it was kind of like, what did I want to do next? A director position became available in the outpatient area, so one of the other directors said, “You know, you ought to consider it.”
Tacey Ann Rosolowski, PhD:
Who was the person who encouraged you?
Deborah Houston:
A friend of mine, Virginia Ramsdell and the man that turned out to eventually be my husband, Gary Houston. I applied, and I became the director for the outpatient medical clinics. I don’t remember what I said last.
Tacey Ann Rosolowski, PhD:
Okay. You were talking about how you moved into the role of the director of nursing. Now just let me say, was that—were you looking for a new challenge or feeling like you had leadership skill? What was probably the motive?
Deborah Houston:
I would say I had leadership skills because I was—I guess, yes, to answer the question. I had—it wasn’t that I didn’t enjoy what I did because I did. It was like an opportunity to do something a little different but still be involved with patients and still be involved with clinical care.
Tacey Ann Rosolowski, PhD:
So what was your role?
Deborah Houston:
I was—I think the title then was actually associated director and then I became director for medical—for the medical clinics. So, I was over—there was probably ten different medical clinics. At the time, what is now our Ambulatory Treatment Center and Emergency Center, but that wasn’t what it was called back then.
Tacey Ann Rosolowski, PhD:
What was it called back then?
Deborah Houston:
Station nineteen.
Tacey Ann Rosolowski, PhD:
Oh, yes.
Deborah Houston:
We had a relatively small Infusion Center, compared to what it is today, and an area—we had Station nineteen, A, B, and C. A was for ambulance. That was sort of a stretcher area. B was some other beds, and C was a chair area. There were maybe eight beds and six chairs or something like that. Then we had medical clinics that were down a hallway, which now is full of—I think it’s full of radiation therapy offices or something—down in the Anderson Building—part of the hospital. There was the GI center and the leukemia center and the lymphoma—they weren’t centers—clinics. The Breast Clinic. They were all in kind of a hallway. Activity was much, much less than it is today.
Tacey Ann Rosolowski, PhD:
Oh, I bet. I bet.
Deborah Houston:
So I had nurse managers reporting to me—head nurse—whatever we call them and staff. Then, during that process is when we sort of began to divvy up and do the more multidisciplinary in- and outpatient kind of things. We consolidated inpatient units and outpatient clinics together in our organization with nursing.
Tacey Ann Rosolowski, PhD:
Help me understand that a little bit better. It sounds like—really important.
Deborah Houston:
We had inpatient nursing directors, and we had two outpatient nursing directors. We were going to go with this new multidisciplinary idea. At the time, I had all the medical clinics, so what we did was we switched. We would have somebody that would just have the head and neck inpatient unit and the surgery inpatient unit and the associated outpatient clinics or we had—that’s what we did. We had the inpatient hematology units and the outpatient hematology clinics.
Tacey Ann Rosolowski, PhD:
What was the advantage of doing it that way? The idea was that we were going to be able to—well, which we did—promote care across and communication across the in- and outpatient continuum. At the time, I went and I was over the infusion therapy team and then ambulatory treatment center—was my assignment, at that point. That was when we first expanded the old Station nineteen in to the area that is in the Rose Zone today.
Tacey Ann Rosolowski, PhD:
I’m sorry. I missed that. You expanded Station nineteen into what?
Deborah Houston:
The area that is now on the second floor of the Rose Zone—the Ambulatory Treatment Center that is on the second floor of the Rose Zone and the Emergency Center was there, as well. It’s all expanded since then, as well. I had that for several years. Then we had other directors—other directors of nursing had other areas, and then we switched around. From that, I went over and I had another assignment, which was thoracic inpatient and outpatient, which I was very, very familiar with, and the Radiation Oncology Clinic. Then someone retired, and I got added to that—the hematology inpatient and outpatient areas. About that time, which was probably early ‘90s, probably by then, mid-‘90s—I don’t remember the dates exactly—was when we had the whole push to develop multidisciplinary clinics—the outpatient environment reinvented itself. That’s when I—up until this time I had been in the Division of Nursing. At that point, I became the first Center Administrative Director. I was over the Hematology Center.
Tacey Ann Rosolowski, PhD:
What is the significance of that—the first center division director? Educate me on that.
Deborah Houston:
I don’t know that there’s any significance to it, other than we had—the previous way we were organized was the clinic administration—the nurse manager of the clinic or the director of the clinic reported to nursing. When we went to the multidisciplinary clinic, and we developed the center administrative director, the center business manager, the center medical director concept, that person no longer reported solely to the division of nursing. You reported to clinic operations, as well, hospital and clinic operations, which was a different reporting mechanism. You were then charged with the overall, which technically you were as the manager or director, as well, but you were then responsible for the business operation of the clinic, as well.
Tacey Ann Rosolowski, PhD:
What was the advantage of that and maybe what were some of the disadvantages that showed themselves?
Deborah Houston:
I think the goal was that you had a team—the medical director of the clinic and the clinic administrative director, which was a nurse, and they all still are nurses—were a team and were responsible for the collaboration and the cohesiveness and the output of the work of that clinic. You made it work. You worked very, very closely with that person. There was a team of three—usually three physicians: a surgeon, depending on the clinic you were in, a medical oncologist, and a radiation oncologist. All three disciplines within the multidisciplinary care center were represented. One of those positions was the director. Then you had a nurse person, as well, so you were the leadership team of the clinic.
Tacey Ann Rosolowski, PhD:
In your experience, how did that work?
Deborah Houston:
I think it worked—and it works well today—it worked well. It was a culture shift for the institution. There was a lot of restructuring, reorganizing, people re-interviewing for jobs. Some people lost jobs. Some people got promoted into jobs. Some people were moved to other areas. It was a—people were influx. It was one of those unsettling times for the institution, I think. I think in the end it was good. They changed the whole way the clinics were operated, and they were given a lot of autonomy to be successful, which has been good. However, that meant that lots of people did things different ways. We still struggle with that today—trying to get things consistent across clinics or centers continues to be a struggle today in some areas.
Tacey Ann Rosolowski, PhD:
Now this period that you are referring to in the ‘90s was really that period when MD Anderson was trying to survive with managed care?
Deborah Houston:
Correct.
Tacey Ann Rosolowski, PhD:
So what was the goal for—there was this restructuring, and one goal is certainly to create more collaboration to deliver patient care?
Deborah Houston:
The other goal was to be more cost effective.
Tacey Ann Rosolowski, PhD:
How did that work?
Deborah Houston:
I don’t think it worked at all. That was when we had—well, I shouldn’t say that probably—that was when we did have a lay-off of staff. In the clinics that I was over—the areas I was over—we did have to lay people off. Luckily, they all came back in other jobs and probably are better off in the end. It was frustrating because they wanted every—and this has been struggle and is still a struggle today—they wanted everybody to use the same staffing model. Clinics work differently. It is very different to—physicians all work differently. Depending on the kind of patient that you’re taking care of, if you’re taking care of a quick post-op visit followup, you turn patients over pretty quickly. If you’re in another clinic where you’re doing lots of complex chemotherapy planning or whatever, patients take longer to be seen. There are more issues. There are more complications for those patients. They have to be scheduled for additional tests—it’s like, does that need more or less staff? Are you staffing based on number of patients, are you staffing on level of care needed? There is no real good outpatient ambulatory staffing model. They are working on and are about to roll one of those out now, which I haven’t seen, but it will be interesting to see if that makes a difference.
Tacey Ann Rosolowski, PhD:
Now, when you said, “They want everyone to use the same.” Who is “they?”
Deborah Houston:
They—well, the big “they”—administration.
Tacey Ann Rosolowski, PhD:
Okay, this administration in general.
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
So that problem has really been ongoing since the ‘90s. It is just a continuing challenge?
Deborah Houston:
Oh, I think so. Again, we downsized, in theory. We did. We cut a bunch of positions. You look back now. We are way over that—we’ve come back. We added positions—added back more than what was originally eliminated, and it continues. I think we have managed it—not being part of operations officially—it seems like we’ve managed it. It’s a struggle, I think, for people to get the resources they need in some instances—to convince people of the resources they need because there is no real easy way to justify it.
Tacey Ann Rosolowski, PhD:
When you were part of the—sort of the process at the moment in the ‘90s—of trying to re-structure all this, who did you work with and how—were your part of kind of coming up with ideas for how to resolve these problems?
Deborah Houston:
Well, when we first had the—well, I don’t know that I was part of the idea of coming up with part. There were the people that were over—the physician in chief and the person that was over the main hospital operations and clinic operations people were primarily doing that. When we got involved in interviewing for jobs, and I was one of the first CADs and Wenonah Ecung was one of the first CADs. The medical directors were all appointed because they were physicians that were already working in those clinics. Now, we had to identify the nurse leaders, so we were involved in a lot of the discussions in the beginning because we’re having meetings as a group with these medical directors and CADs.
Tacey Ann Rosolowski, PhD:
What’s a CAD?
Deborah Houston:
Center Administrative Director, I’m sorry.
Tacey Ann Rosolowski, PhD:
That’s right, yeah.
Deborah Houston:
We had educational sessions and all that, and we were part of that. It has been good because that role has been considered as key as the medical director role for the success of these clinics, and that continues today. They’re involved in the education planning and activities and things like that—so that’s been good.
Tacey Ann Rosolowski, PhD:
Where does MD Anderson sit vis-à-vis other institutions—if you can comment on it—with involving nurses in those processes? Did you feel like you had more of a voice than your colleagues at other institutions in those kinds of upheavals?
Deborah Houston:
During that time, nursing was going through transition, as well. We had—Ms. [Renilda] Hilkemeyer [Oral History Interview], who was the original director of nursing, had retired. We had a second director of nursing, Joyce Alt. We were going through a transition period where we got another director of nursing, John Crosley, in there. There was some—I wouldn’t say upheaval, but kind of upheaval—in that, at the time. I would say originally there probably wasn’t a lot of nursing—nursing got involved—we got involved because we got in the middle of it, but was our leadership at the table? I don’t know. I think now that’s much more they are—definitely at the table and definitely there. I think nursing, in some instances, was an afterthought back in the early ‘90s, but now not so much.
Tacey Ann Rosolowski, PhD:
To what do you attribute that change?
Deborah Houston:
I think the people in the role, and then I just think the growth of nursing, in general. The growth of the specialty—I think physicians realizing the value of the nurse and what they can provide them and their patients.
Tacey Ann Rosolowski, PhD:
How would you characterize what you provide to the physician? You’ve talked a little bit about what you provide to the patient, but what about the physician?
Deborah Houston:
Well, I think you help him—in an outpatient setting—you help him with his organization. You help him with prioritizing what he needs to talk to the patient about. If you’ve assessed the patient first, you can then say, “He’s got concerns about this, this, and this,” and “Make sure you talk to him about that.” You have prepped the patient to ask the physician the right questions, in many instances, which helps facilitate their visit. Then you also can then try to make sure at the end of the visit that that’s been done.
Tacey Ann Rosolowski, PhD:
It’s really facilitating communication in a lot of ways?
Deborah Houston:
Yeah. I think that’s definitely it—facilitating what you—what they patient needs and you’re facilitating the information to the physician, the physician to the patient, and the patient back to the physician and coordinating their care, coordinating everything else around it—coordinating what the physician needs. If the patient is here and you don’t have the information the physician needs to make a decision about what he is seeing the patient for you’re wasting everybody’s time.
Tacey Ann Rosolowski, PhD:
Right.
Deborah Houston:
Trying to help make sure the patient was scheduled correctly so that when he comes back you’ve got the results there or that you haven’t missed something.
Tacey Ann Rosolowski, PhD:
As you were talking about this, I was just thinking if you’re evaluating a nurse for performance, it seems like that facilitating communication can be one of those real slippery qualitative things that’s real difficult to put a metric on.
Deborah Houston:
Yeah, and when you talk about—on of the things I’ve been able to do the last couple of years is I have been on the selection committee for our Arceneaux Outstanding Nurse Oncologist Award. One of the things that the candidates do—is a packet of material is presented and some of that is from the people that they work with. This past year, most of the—well, actually, all of the candidates were from the ambulatory setting, so it was very, very interesting to read the letters from the physicians, even though they were blinded and we didn’t know who was who. I mean, which physician was writing them, but they were from their medical director or physicians that they worked with—how they talked about how “they facilitated my ability to see patients—they were always there to answer the questions,” and that kind of thing. The physicians, I think, see that now with nurses.
Tacey Ann Rosolowski, PhD:
Is there some mechanism to integrate that kind of information about a nurse’s performance into her official record—beyond applying for a special award? I’m just curious because it does seem so key.
Deborah Houston:
We get evaluated on things like team work, communication.
Tacey Ann Rosolowski, PhD:
So it is there.
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
That’s really interesting. That’s really interesting.
Deborah Houston:
Yeah.
Recommended Citation
Houston, Deborah A. and Rosolowski, Tacey A. PhD, "Chapter 04: Nursing Administration and a New Setting of Multi-Disciplinary Teams" (2012). Interview Chapters. 887.
https://openworks.mdanderson.org/mchv_interviewchapters/887
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