Chapter 09: The Philosophy behind CADs [Center Administrative Directors]

Chapter 09: The Philosophy behind CADs [Center Administrative Directors]

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In this chapter, Mr. Brewer provides an overview of the CAD role [Center Administrative Director] that was created by Donna Sollenberger [oral history interview] in nursing at MD Anderson in the mid-nineties, and that resulted in a general reorganization of nursing. He explains that this role brought a new philosophy of nursing management. This model was designed to address the fragmentation of clinics by organizing groups of clinics into centers administered by key decision makers (CADs) in charge of budget, staff, operations, and clinical care. He then talks about the advantages of this organizational structure and the fact that all the CADs are nurses. He explains challenges of instituting this new structure, which required individuals to reapply for their jobs and train for them. He notes that, twenty years later, the system is still in place.

Next, Mr. Brewer talks about the impact of the CAD system on patient care, citing patient safety as an example. He also gives examples of where the system could be improved. Reflecting on the community of nurses as a whole at MD Anderson, he explains that it can be difficult for nurses to see beyond the boundary of their own specialty and gives the example of differences between in-patient and out-patient nursing care.

Identifier

BrewerCC_02_20190606_C09

Publication Date

6-6-2019

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Overview; Professional Practice; The Professional at Work; Leadership; On Leadership; MD Anderson Culture; Working Environment; Definitions, Explanations, Translations

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 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, Ph.D. Mm-hmm. So the role that you were talking about before, which is when you were doing all this process improvement, was that your role as center administrative director?

Cecil C. Brewer, RN, BSN, MS:

Yes, in the Ambulatory Treatment Center. In 1996, titles changed on the ambulatory side. I went from being a director of nursing on the inpatient to becoming one of the first center administrative directors. Tacey Ann Rosolowski, Ph.D. Yeah, the CADs,—

Cecil C. Brewer, RN, BSN, MS:

CAD, I was— Tacey Ann Rosolowski, Ph.D. —(overlapping dialogue; inaudible)—

Cecil C. Brewer, RN, BSN, MS:

In other words I was a charter member. Tacey Ann Rosolowski, Ph.D. Okay. All right, well, that clarifies things. So let me just make a note of that, so I don’t forget.

Cecil C. Brewer, RN, BSN, MS:

And all of that was under the umbrella of the multidisciplinary care program implemented by—under Donna Sollenberger’s— Tacey Ann Rosolowski, Ph.D. Under—

Cecil C. Brewer, RN, BSN, MS:

—leadership. Tacey Ann Rosolowski, Ph.D. —Donna Sollenberger. Okay, so what was the significance in your mind of creating that role of center administrative director? How did that reflect sort of a new vision of nursing leadership?

Cecil C. Brewer, RN, BSN, MS:

The CAD role was created with the aspect that the center—no, the clinics were converted from being a clinic with many fractions to a center where there is one whole and there is a—and there are key leaders, key decision makers in those positions. Moving from director to center administrative director from inpatient to outpatient, the CAD was now known as an executive in the executive branch of the organization where the director on the inpatient was not. Tacey Ann Rosolowski, Ph.D. So that meant that you had a whole new level of liaison with people above you.

Cecil C. Brewer, RN, BSN, MS:

Right. Tacey Ann Rosolowski, Ph.D. So tell me about that change in relationship, what that meant in terms of decision making, resources, all that sort of thing.

Cecil C. Brewer, RN, BSN, MS:

Well, when you became a CAD, the buck stopped with you so that means that the—your relationship at all levels was very—the expectation was very high. You were collaborative with a medical director. In a center, you have a medical director, a center administrator or the CAD, and you had a business manager. Those are the executives of that center. No one’s looked—overlooking, you had no one looking over your back with that. You have oversight from Donna—from the VP’s office, but you were expected to operate your center. You’re in charge of your own budget, in charge of your staff, in charge of all the operations, and you’re in charge of clinical care, so make it happen. And so you work, you work hand in hand with your medical director who managed, if you will, or provided leadership for the physician group in that center. You work with your business manager who provided management for the ancillary staff in that center and the budget preparation, and as a CAD, you are responsible for making sure all of this was organized and executed. Tacey Ann Rosolowski, Ph.D. What were the advantages and disadvantages of this new system?

Cecil C. Brewer, RN, BSN, MS:

The advantages of being a CAD versus that of a director is that autonomy. You had total control of your budget. You had a relationship with the medical director who then could—who could, “work” with the physician group, the ones that were positive and the ones that weren’t so positive. As you know, it’s very diffi—you as a nurse, as an administrative, it’s very difficult for a non-physician to provide certain levels of direction to a physician. Tacey Ann Rosolowski, Ph.D. Oh, yeah.

Cecil C. Brewer, RN, BSN, MS:

And for medical practice issues, you definitely don’t provide that to physicians, only physicians. When you got medical issues, as physician to physician. As the nurse or someone brings to your attention medical practice issues, the beauty of it, you have medical director you can go to directly and hand off the issue, “This is a medical practice issue.” Or vice versa if someone, a doctor or another clinician identifies an issue, then that’s handed off to nursing, to me as the clinical because clinical administrative directors are nurses. That’s how it’s designed. And so you got a nursing component, an administrative component, and medical component, and that is the operating unit of the center. Tacey Ann Rosolowski, Ph.D. So it’s building in kind of a mirror of the workflow at the administrative level—

Cecil C. Brewer, RN, BSN, MS:

Yes. Tacey Ann Rosolowski, Ph.D. —basically. Yeah, very interesting. So it was Donna Sollenberger who came up with that, kind of brought that model?

Cecil C. Brewer, RN, BSN, MS:

Yes, she brought that model, and I still have a copy of the original program. And it was programmatic; it wasn’t just some idea. Everything was documented. Everyone received training on their roles. All job descriptions were redone. Every nurse in the clinics was retitled, every clerk was retitled, the reception retitled. All titles were retitled, and everyone had to reapply for the jobs. Tacey Ann Rosolowski, Ph.D. Wow. Oh, man, I bet (laughs) that created some stress.

Cecil C. Brewer, RN, BSN, MS:

Well, it was very stressful because in certain job roles, they had to test out, and some people who had worked for years didn’t test out, very stressful. And the staff couldn’t understand the new expectations of the roles. The new salary structure was good. Most staff got pay raises to go along with the new expectation, and there were a number of councils set up. It was very programmatic. It was a very good process. It’s 20—almost 20 years later, 20-plus years later, the center—the process is still in place, multidisciplinary care centers. Tacey Ann Rosolowski, Ph.D. Wow, that’s pretty amazing. So what were you seeing, I mean kind of continuing with the advantages but how... What was the positive and problematic impact on actual patient care? We talked about how nurses were reorganized, but how did that flow down and have an effect on the patients themselves?

Cecil C. Brewer, RN, BSN, MS:

I think if I can use the Ambulatory Treatment Center and emergency center as my point of discussion, the main philosophy in our care was safety. Safety and then you’ve got to be compassionate, you have to be very personable, efficient, and knowledgeable, educated, but patient safety is number one. We just don’t make mistakes with chemotherapy. It’s life or death. We have to be efficient because patients would come into the emergency center, some have minutes to determine whether they’re going to have a tragic event, minutes not hours, so you got to be efficient. We keep safety at the center of your attention, and everything else flows out. We provide safe care and competent care, competent, education, competent, education. New protocol, you’re educating them, and you practice it, and now, you go out and execute, and you follow up safety. We’ve got a five-men check on the floor. Most people do a two-men check, so one person takes the medication, another person looks at it and say, “Yes, that’s right.” But we practice it starting with the pharmacist, the integrated process with the pharmacist. Before that medication makes it to that patient, it’s been checked by five people. That’s safety. That’s overboard safety to make sure that we are not going to compromise the patients in any way. Excuse me. Tacey Ann Rosolowski, Ph.D. Now, as you look back, I had asked you about some disadvantages. Were there any problems that arose as a result of this or ways that it could even be further improved as a model?

Cecil C. Brewer, RN, BSN, MS:

I think the model of inpatient and outpatient is—can be improved, but it’s very difficult. I had the opportunity in the early ’90s when I was the director of nursing. We were given the nursing arm component of the clinics and say we were the director of nursing for bilateral services. Example, if I had the GI patient population on the inpatient, then in the GI clinic, I also supervise those nurses, or if I had the sarcoma population on the inpatient, I supervise the nurses in the sarcoma clinic. That was an initiative that we tried to see if we can integrate the practice for sarcoma patients across boundaries, inpatient and outpatient. Very complex—not very complex, it’s very difficult. Tacey Ann Rosolowski, Ph.D. Why?

Cecil C. Brewer, RN, BSN, MS:

The practice is so different. The practice is just so different. You’re doing two different things. You’ve got acute care versus ambulatory care. Those are two different levels of practice. And then we never could make it work smoothly, the drawback, that’s a big drawback. Still today, it’s a drawback but I think that no—I don’t think there’s any perfect model for that because each one is a—has its own specialization, its own set of rules and regs and needs and wants and dreams. Tacey Ann Rosolowski, Ph.D. I mean this is making me think of a conversation I had not—this wasn’t part an oral history interview, but I was talking with Susan Stafford who had been here for a long time. I see you know her well, and she was saying that there was a—from her view, there was kind of a challenge among nurses that nurses had trouble—the entire community of nurses at MD Anderson had troubles envisioning themselves as a single community because of these differences. And I’m wondering if that’s something that you noticed and if that might have had—if that were something that was important to address in the institution?

Cecil C. Brewer, RN, BSN, MS:

I would totally agree with that perspective that nurses as a community. The philosophy, I believe, under the last administration of nursing prior to Dr. Porter, I believe they talk—Barbara Summers brought in the concept of nursing community. I wasn’t part of that, but I had moved on to diversity I believe. But part of that community, within the community if you look, you have different subgroups within the community. And it’s very difficult for nurses in these highly complex specialized areas to look past what their job is today. I can’t fathom what you do on inpatient, outpatient. For instance, if an inpatient nurse administers chemotherapy to a patient in a bed, changes their dressing, gets them out of bed to get them walking, ambulatory, so forth, and so on, those are tasks. The ambulatory nurse does none of that. So if you’re talking about that or you’re having discussions or planning for those type of activities, you’re talking apples and oranges. My patient walks in, I perform an assessment, we collaborate with the research nurses and the data collectors and the doctors, and we provide instructions to the patient—totally two different activities. My professional organizations are designed around the same parameter. It’s very difficult. Tacey Ann Rosolowski, Ph.D. What could be achieved if there were stronger connections, you know not—with people understanding, yes, we are part of the community?

Cecil C. Brewer, RN, BSN, MS:

I think the goal of having the community nurses working as one is continuity of care. You know continuity of care that when you hand off the patient from inpatient to outpatient that the continuum of care is not lost, and that you transfer—the knowledge transfer and the patient’s involvement is not hampered at all. Continuity of care is—was one of the goals. Tacey Ann Rosolowski, Ph.D. Interesting, yeah. Well, I’m looking at our time and we’re almost at noon, and I think you’re going to need to come back and tell me about the rest of your roles.

Cecil C. Brewer, RN, BSN, MS:

Oh, okay. (laughter) Tacey Ann Rosolowski, Ph.D. If that’s all right with you?

Cecil C. Brewer, RN, BSN, MS:

That’s fine with me. Tacey Ann Rosolowski, Ph.D. That’s great. So this maybe is a good place for us to leave it today.

Cecil C. Brewer, RN, BSN, MS:

Okay. Tacey Ann Rosolowski, Ph.D. And I thank you so much.

Cecil C. Brewer, RN, BSN, MS:

Well, thank you. Tacey Ann Rosolowski, Ph.D. This is a very interesting conversation, and it’s—really, I’m learning a lot, and this is very valuable, so... So I want to say for the record thank you, and I’m turning off the recorder at about one minute of 12:00. [1:14:13.]

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Chapter 09: The Philosophy behind CADs [Center Administrative Directors]

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