We define the response network as the set of the 23 types of organizations involved in the response to the organizational crisis caused by the heat wave (more detail on the organizational crisis in section 3). Our definition of the response network is consistent with Romelaer’s definition of an organization (2002) in that it gathers individuals and groups that have regular and stable connections between each other. This enables us to study organizational improvisation – rather than inter-organizational improvisation – within a network. In the coming paragraphs, we detail the role of collaboration and hierarchy within the response network. We then present the actors of the response network.
2.I. Collaboration
We use the term network due to the multiplicity of interactions that took place between the organizations during the response to the heat wave crisis.
Some organizations had developed close ties of cooperation well before the crisis (Robelet et al., 2005). For example, health care services to the elderly were officially restructured in 1998 into a network constituted by assisted living facilities, town halls, home hospitalization services and hospitals. Some other connections between these organizations were similar to a meshing configuration. For example, the firefighter squads (BSPP) were not only under the authority of the Prefecture de Police, but also had institutionalized links of cooperation with emergency medical services such as Emergency rooms, SAMU and SMUR. Generally speaking, the functioning of the health care system is based on interindividual interaction (Destais, 2003) and interorganizational connections. Typically, the regulation of the flow of patients is predefined by procedures but also depends on the informal interactions between emergency units and friendships between professionals. Finally new links of cooperation developed between actors from diverse professional groups during the crisis response. For example, some professionals contacted the health department minister or participated in institutional meetings.
Collaboration is a widespread value within the network. Each hospital is supposed to collaborate with local private physicians. The APHP and hospitals also cooperate with the mobile emergency services by sharing tasks. Similarly, the BSPP handle a significant part of the emergency medical interventions.
187 Collaboration implies information sharing. During the heat wave, hospitals provided information to potential victims in assisted living facilities (EHPAD). Similarly, town halls were contacted by medical services to collect data about people who were likely to be hurt from the temperatures, such as old persons. Funeral parlors spontaneously contacted the Health Ministry and the prefectures as well.
2.II. Hierarchy
The response network does not only include collaboration; Hierarchical values are also important within this network. For instance top-down and bottom-up coordination coexist between the Health Ministry and other entities of the network. Hospitals have to validate the most critical decisions by the Health Ministry and the prefectures, e.g State representative in local counties. However, the Health Ministry delegates many activities to the DGS and the DHOS that are responsible for health related issues in France. The Health Ministry also relies on these organizations for the monitoring of the national health care system. At a more local level, the DGS and the DHOS delegate some of their prerogatives to the DDASS and the APHP. Similarly, hierarchy is particularly important between firefighters (BSPP), police services (the PPP local agencies and the PPP) and the Internal Affairs Ministry.
2.III. Organizational and informational barriers
The concept of complexity is prevalent within the response network. There have been more than 24 reforms within the French health care system since 1945 (Poutout, 2005), which explains why some organizations remain unknown within the response network. This was the case of the agency for health alerts (called Institut de Veille Sanitaire, also known as INVS) before the 2003 French heat wave.
As Denis, Lamothe and Langley argue, organizations related to health issue classically involves organizations with divergent objectives and values (2001). It is interesting to note the example of the Parisian firefighter squads (BSPP), under the authority of police services and governed by military values (firemen in Ile de France have a military status, on the contrary to other places in France), that were prone to withhold information based on the rationale of avoiding public panic. On the contrary, some active medical personnel such as ERT searched to transmit and publish death rates as much as possible to provoke a reaction among the public and promote civil mobilization towards the situation of the elderly.
Organizational barriers are important as the network gathers organizations with distinct missions and values. For example, field actors of the network claimed their opinion was looked down upon by the administrative organizations because they missed a global view of the health care system. As an emergency room technician explains:
“The Health ministry advisers were more or less competent. Most of the time they were honest but their interest narrowed to political and financial objectives. No minister ever had an ear to listen to professionals, unless they had the same rank” (L’urgentiste, p.26).
Organizational barriers also arise from the gap between professional values and logics within the network. Health care organizations are oriented towards saving lives where as civil
188 protection organizations look after keeping calm among citizens. As some health care institutional actor explained during the public hearings:
“My observation is that hospitals and sanitary institutions are completely disconnected from the prefect services, may it be right or wrong. I am only making an observation”.
Finally, separate information systems strengthen organizational barriers. Only one federating information system existed in 2003 to coordinate hospitals and the Health Ministry: the PMSI. The PMSI is a routine tool used to compile and store data to get an idea of the time spent by each patient in services. As the PMSI use is restricted to accounting we exclude it from our analysis. Data sharing was restricted, because IS architectures were segmented from one hospital to another in spite of the need to develop a new culture of data sharing (Fieschi, 2003). As a firefighter explains during public hearings, the lack of information sharing prevents organizations from getting a comprehensive view of their own processes.
“The firefighters’ squads have a partial view on of the state of health of the whole population that is under their protection. We do not receive information about all the deaths, in particular these that concern people who were at home but who could not call us. We do not know what happens to victims after their being transferred to hospitals”.
Finally, the frequency of ICT use differs from one organization to another, strengthening organizational barriers. Field actors, especially physicians, show modest use of emails (Brooks, Menachemi, 2006) on the contrary to administrative actors. Phones and faxes were primary means for communication in health care organizations in 2003 (Chen et al., 2010). This study focuses on four types of technology that were used before and during the organizational response to the crisis provoked by the 2003 French heat wave: the Internet, email, faxes and phones. During the 2003 French heat wave, these technologies were helpful. As parliamentary reports on the heat wave crisis response explain, the Internet, used by physicians and other actors, helped to obtain information about hyperthermia and death rates. Actors needed an overview of the situation as well. A director acknowledges in a report: “At that time, we could not know the exact number of sick people in all the emergency rooms. We strove to evaluate numbers but, given our means, we hardly managed it”.