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I use the notion of multilateral boundary spanning to refer to the involvement of inter-organizational boundary spanners in intra-organizational developments and vice-versa. I stress the word “involvement” here, as not all of the identified boundary spanners played an active role at both inter- and intra-organizational levels. Specifically, although the Regos ward nurses and the aftercare care coordinators interacted both inter-organizationally (for instance, with each- other) and intra-organizationally (for instance, with their superiors, when they were informed about the new Regos handover procedure), they were only passive players in the intra-organizational developments of the network (that is, they were involved in the developments, but did not actively influence them). That being said, this double involvement in issues both inter- and intra- organizational – whether actively influencing network developments or not – still gives us insights into how network- and organizational-level developments influence each other. Namely, the ties between the levels would seem to rest in the hands of actors who, by being involved in both inter- and intra-organizational concerns, tacitly span both levels.

Comparing the results of the actions of boundary spanners who interacted multilaterally to those who did not suggests that doing one or the other does have an impact on the development of inter-organizational collaboration. The boundary spanners who interacted multilaterally during the network’s set- up and implementation – Ellen and her aftercare counterparts, Anna, and the care coordinators – benefited from a virtuous cycle where their positive results in one area of the network’s development led to further positive results in another area, and so on. This virtuous cycle resulted from the fact that these actors operated both within and across organizations. For instance, Ellen could successfully contact and negotiate with potential aftercare partners because of

her position in the Regos hierarchy, which afforded her both the authority to deal on behalf of Regos (granted to her by the CEO) and sufficiently in depth knowledge of patient handover processes to understand the subject matter she was negotiating. At the same time, her deep understanding of the (potential) inter-organizational agreements afforded her the knowhow to successfully bring them to the attention of the CEO and take steps to ensure their execution. This also held for the aftercare middle managers. Finally, Anna’s contact with the aftercare care coordinators gave her a better understanding of the patient handover requirements, which in turn helped her to instruct her own ward nurses – who conducted the best handovers – and the other ward leaders.

This was not the case for the Regos ward nurses, who were only involved intra-organizationally before the network’s kick-off. The new tasks they were expected to enact were thoroughly new to them, to the extent that one care coordinator referred to these tasks as part of a different discipline than the one the nurses had been trained in. Thus, in contrast with the actors I previously addressed, the nurses’ intra-organizational experience at that time did not ensure sufficient knowledge to help them understand their new inter- organizational tasks. The actors I interviewed in several organizations (both managers and operational employees) considered the ward nurses’ problems with the new handover procedure to directly result from the procedure’s rushed intra-organizational implementation in the Regos wards. While this was indeed the case, I would argue that not giving the nurses the opportunity to interact with the aftercare care coordinators before the network’s kick-off – and thus not giving them access to the care coordinators’ own understanding of the patient handover procedure and its requirements – aggravated the situation. Pre-kick-off contact with the care coordinators would have been a significant help, which is confirmed by a number of facts. First, by the example of the care coordinators themselves, who supplemented the information they had received from their own superiors about the network with their inter-organizational contact with Anna and Ellen. Second, by the fact that the ward nurses eventually gained the knowhow they needed to enact the new handover procedure through the consistent guidance they received from the care coordinators. And finally, by the fact that the surgery ward – the most successful one in terms of patient handovers – attributed its results to two factors: the fact that it featured nurses with dedicated patient handover tasks (who therefore interacted more often with the care coordinators), and the fact that these nurses had visited the

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Inside the black box

Figur

e 2.1. Multilat

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al boundary spanning in the healthcar

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different facilities of the aftercare organizations after the network’s kick-off to get a better understanding of the aftercare half of the patient handover workflow. As Figure 2.1 illustrates, the middle managers, Regos ward leader, and aftercare care coordinators all engaged in multilateral boundary spanning, by being involved in both inter- and intra-organizational developments. As a result, the outcomes of all their activities were successful – as indicated by the arrows with a continuous line. The Regos ward nurses, instead, were only involved intra-organizationally before the network’s kick-off (at t1), which led to their unsuccessful execution of the patient handover procedure (at t2) – as indicated by the arrow with a discontinuous line. This situation improved over time through their inter-organizational interaction with the aftercare care coordinators, which eventually helped them to successfully enact the patient handover procedure (at t3). Overall, with multilateral boundary spanning leading to successful actions in all three instances illustrated in Figure 2.1, and with its single absence leading to an unsuccessful action, I would argue that my case yields the following implication: boundary spanners who act multilaterally are more likely to lead to successful network outcomes than those who do not do so. Acting multilaterally seems to be a prerequisite for successful network development.