Doctors and managers: poor relationships may be damaging patients-what can be done?

The managerial role of healthcare professionals in public hospitals: a time-driven analysis of their activities

BACKGROUND

New Public Management theory affected reforms of public sectors worldwide. In Italy, an important reform of the healthcare sector changed the profile of public hospitals, creating new management related positions in 1992. The reform defined the role of the clinician-manager: a hybrid figure, in charge of managing an entire unit. This paper aims to investigate how much clinician-managers feel like managers and how much they still feel like professionals, using time as a driver to conduct the analysis.

METHODS

A survey-questionnaire was administered to a set of 2,011 clinician-managers employed in public hospitals, with a response rate of 60.42%. The managerial role of healthcare professionals in public hospitals: A time-driven analysis of their activities. The questionnaire aimed to identify the difference between how much time clinician-managers actually spend on daily activities and how much time they would think be appropriate. To better cluster different type of management styles, subgroups were identified based on the type of organisations respondents work for, geographical location, and professional specialty.

RESULTS

Findings suggest that clinician-managers spend more time on clinical activities than management. Clear differences are found according to professional specialty, and there are fewer differences in geographical location and the type of organisation.

CONCLUSIONS

The absence of clear differences in the responses between different geographical areas implies that a shared organisational culture characterizes the whole sector. However, differences in how the clinician-manager role is perceived based on the professional specialty suggest that closer integration may be needed.

Physicians' and nurses' attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega

Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners.

Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery.

Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data.

Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery.

Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.

The doctor-manager relationship

The different cultures of doctors and managers and the impact of these on their working relationships are described. A historical resumé tracks organisational change, the evolving nature of the relationship and the stresses it engenders. The phenomenon of scapegoating and an approach to managing risk is explored. Vignettes describing familiar problems, with suggested strategies for analysing them and resolving difficulties, are presented.

Suggested methods to improve physician-hospital relationships in Canada

This article focuses on the suggested methods to improve the quality of Physician-Hospital Relations (PHRs) in the Canadian healthcare system based on the opinions and perspectives of healthcare leaders across all provinces and territories who participated in the Canadian National Study of Interprofessional Relationships between Physicians and Hospital Administrators (CANSIRPH). Improving PHRs equals higher patient care quality, error reduction, well-managed budgets, and professional satisfaction of clinical and non-clinical leaders.

Physician' entrepreneurship explained: a case study of intra-organizational dynamics in Dutch hospitals and specialty clinics

BACKGROUND

Challenges brought about by developments such as continuing market reforms and budget reductions have strained the relation between managers and physicians in hospitals. By applying neo-institutional theory, we research how intra-organizational dynamics between physicians and managers induce physicians to become entrepreneurs by starting a specialty clinic. In addition, we determine the nature of this change by analyzing the intra-organizational dynamics in both hospitals and clinics.

METHODS

For our research, we interviewed a total of fifteen physicians and eight managers in four hospitals and twelve physicians and seven managers in twelve specialty clinics.

RESULTS

We found evidence that in becoming entrepreneurs, physicians are influenced by intra-organizational dynamics, including power dependence, interest dissatisfaction, and value commitments, between physicians and managers as well as among physicians' groups. The precise motivation for starting a new clinic can vary depending on the medical or business logic in which the entrepreneurs are embedded, but also the presence of an entrepreneurial nature or nurture. Finally we found that the entrepreneurial process of starting a specialty clinic is a process of sedimented change or hybridized professionalism in which elements of the business logic are added to the existing logic of medical professionalism, leading to a hybrid logic.

CONCLUSIONS

These findings have implications for policy at both the national and hospital level. Shared ownership and aligned incentives may provide the additional cement in which the developing entrepreneurial values are 'glued' to the central medical logic.

Effective cooperation influencing performance: a study in Dutch hospitals

OBJECTIVE

This study focuses on cooperation between physicians and managers and aspects of that cooperation that can provide leads for interventions aimed at enhancing hospital performance.

DESIGN

We performed a qualitative study on cooperation between physicians and managers and the influence of that cooperation on hospital performance, and structured the resulting data according to the conditions of Allport's theory on intergroup conflicts.

SETTING

General hospitals in the Netherlands.

PARTICIPANTS

Thirty physicians (surgical and internal) and managers (strategic, tactic and operational) working in five different hospitals.

INTERVENTIONS

In-depth interviews exploring the influence of cooperation between physicians and managers on hospital performance.

MAIN OUTCOME MEASURES

Respondents confirmed the complexity of the relationship between physicians and managers and the link between their cooperation and hospital performance. Mentioned aspects such as power and status differences, clarity in decision-making and personal click, are important in determining the effectiveness of the cooperation between physicians and managers.

RESULTS

Our study suggests that the effectiveness of cooperation between physicians and managers is related to the uptake of quality initiatives and hospital performance.

CONCLUSIONS

The complex relationship between physicians and managers can be referred to as an intergroup conflict situation. We combined Allport's Contact theory conditions with aspects found in our study leading to the following facilitating conditions: address common goals; create interdependent tasks; arrange the support of authorities and respect the medical domain. They will enhance intra-hospital cooperation and therewith hospital performance.

A social network analysis of healthcare professional relationships in a French hospital

PURPOSE

This paper aims to describe relationships among healthcare professionals in a French public hospital using social network analysis (SNA) and to improve health service quality by strengthening health service management and leadership.

DESIGN/METHODOLOGY/APPROACH

This study was based on a questionnaire sent to randomly selected French public hospital professionals and administrators. Network composition measures were obtained using a name generator. Analysis focused on three main indicators: "centrality", "prestige", and "clique participants". The SNA was carried out using UCINET and statistical analyses were performed with SPSS version 15.0.

FINDINGS

A total of 104 questionnaires were returned and analysed. Centrality, prestige and clique indicators were highly correlated (all p-value were less than 0.01). Physicians had the highest scores for the three indicators. Older age (> or = 45 years) was associated with higher centrality and clique numbers scores. Transversal activity was associated with higher scores than other specific activities (hospitalisation, ambulatory care), except for emergency care.

ORIGINALITY/VALUE

The paper shows how networks and SNA techniques provide novel and useful means to understand communication and collaboration between hospital professionals.

Managers' perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare

Background

This study focused on the manager role in the manager-physician relationship, considered from the manager perspective. The aim was to understand how top executives in Swedish healthcare regard management of physicians in their organisations, and what this implies for the manager role in relation to the medical profession. Abbott's theory of professional jurisdiction was used to inform thinking about managerial control and legitimacy in relation to physicians.

Methods

Data from semi-structured individual interviews with 18 of the 20 county council chief executive officers (CEOs) in Sweden were subjected to qualitative analysis.

Results

The results show that, when asked about their views on management of physicians, the CEOs talked about "how physicians are" rather than describing their own or their subordinate managers' managerial behaviour or strategies. Three types of descriptions of physicians were identified: 1) they have high status and expertise; 2) they lack knowledge of the system; 3) they do what they want in the organisation. The CEOs seldom reported that general management strategies were used to manage physicians. Instead, they described four types of physician-specific management strategies that were used in their organisations: organisational separation of physicians; "nagging and arguing"; compensations; relying on the physician role. These strategies seemed to reflect pragmatic behaviour on behalf of the managers that helped them to maintain control over physicians in daily work. However, in a longer perspective, they seemed to decrease the legitimacy of the manager role and also contribute to weakening of that role in the organisation.

Conclusions

Many CEOs seemed to regard the manager role in their organisations as weak and described difficulties in both taking and defining that role (for themselves or others) in relation to the physician role. Further research is needed to elucidate how managers in healthcare organisations assume the manager role in relation to the medical profession. Studies indicate that lack of clarity concerning manager role authority and responsibility may have negative consequences not only for the working conditions of managers, physicians, and other healthcare professionals, but also for the quality of care.

Quantifying culture gaps between physicians and managers in Dutch hospitals: a survey

Background

The demands in hospitals for safety and quality, combined with limitations in financing health care require effective cooperation between physicians and managers. The complex relationship between both groups has been described in literature. We aim to add a perspective to literature, by developing a questionnaire which provides an opportunity to quantitatively report and elaborate on the size and content of differences between physicians and managers. Insight gained from use of the questionnaire might enable us to reflect on these differences and could provide practical tools to improve cooperation between physicians and managers, with an aim to enhance hospital performance.

Methods

The CG-Questionnaire was developed by adjusting, pre-testing, and shortening Kralewski's questionnaire, and appeared suitable to measure culture gaps. It was shortened by exploratory factor analysis, using principal-axis factoring extraction with Varimax rotation. The CG-Questionnaire was sent to all physicians and managers within 37 Dutch general hospitals. ANOVA and paired sample T-tests were used to determine significant differences between perceptions of daily work practices based in both professional cultures; culture gaps. The size and content of culture gaps were determined with descriptive statistics.

Results

The total response (27%) consisted of 929 physicians and 310 managers. The Cronbachs alpha's were 0.70 - 0.79. Statistical analyses showed many differences; culture gaps were found in the present situation; they were even larger in the preferred situation. Differences between both groups can be classified into three categories: (1) culture gaps in the present situation and not in the preferred, (2) culture gaps in the preferred situation and not in the present, and (3) culture gaps in both situations.

Conclusions

With data from the CG-Questionnaire it is now possible to measure the size and content of culture gaps between physicians and managers in hospitals. Results gained with the CG-Questionnaire enables hospitals to reflect on these differences. Combining the results, we distinguished three categories of increasing complexity. We linked these three categories to three methods from intergroup literature (enhanced information, contact and ultimately meta cognition) which could help to improve the cooperation between physicians and managers.

Nurses are more than the sum of their parts

The NHS Plan (Department of Health (DH), 2000) set out the blueprint for change in health-care delivery necessitated by the combination of rising public expectations, spiralling costs and perceived under-performance. The label of ‘modernization’ was adopted in an attempt to bring about widespread change in practice throughout the NHS with targets set to measure achievement of various goals in light of the taxpayers’ ‘investment’. The perverse incentive of targets has been noted previously (While, 2003) but equally important has been their ability to strengthen resistance among healthcare practitioners to any form of change regardless of its merit and likely improvement of patient outcome.