Who should see the patient? on deviations from preferred patient-provider assignments in hospitals

In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.

Two sides to every coin: Assessing the effects of moving physicians to employment contracts

There is a growing trend of physicians becoming employees of hospital systems and employment is viewed as a mechanism to help achieve health system goals. Yet, the research is mixed on the effects of moving physicians to employment models. While the literature has traditionally placed such forms of employment relationships in opposition to professional autonomy, it has often overlooked the effects on other professional values and there is little empirical work that actually assesses how such a shift affects and is perceived by clinicians themselves. To address these gaps, we conducted a mixed method study at one hospital that recently moved all formerly self-employed physicians to employment contracts. We interviewed physicians to understand how the shift into employment was perceived to influence their work in three domains: the patient domain, the individual domain and the organizational domain. We then conducted a follow-up survey across both formerly employed and self-employed physicians to test our initial findings. We find both positive and negative effects in different domains, offering insights into the mixed results found in the current literature.

The tensions of defining and developing thought leadership within knowledge-intensive firms

Purpose

A major part of knowledge management for knowledge-intensive firms such as professional service firms is the increasing focus on thought leadership. Despite being a well-known term, it is poorly defined and analysed in the academic and practitioner literature. The aim of this article is to answer three questions. First, what is thought leadership? Second, what tensions exist when seeking to create thought leadership in knowledge-based organisations? Third, what further research is needed about thought leadership? The authors call for cross-disciplinary and academic–practitioner approaches to understanding the field of thought leadership.

Design/methodology/approach

The authors review the academic and practitioner literature on thought leadership to provide a rich oversight of how it is defined and can be understood by separating inputs, creation processes and outcomes. The authors also draw on qualitative data from 12 in-depth interviews with senior leaders of professional service firms.

Findings

Through analysing and building on previous understandings of the concept, the authors redefine thought leadership as follows: “Knowledge from a trusted, eminent and authoritative source that is actionable and provides valuable solutions for stakeholders”. The authors find and explore nine tensions that developing thought leadership creates and propose a framework for understanding how to engage with thought leadership at the industry/macro, organisational/meso and individual/micro levels. The authors propose a research agenda based on testing propositions derived from new theories to explain thought leadership, including leadership, reducing risk, signalling quality and managing social networks, as well as examining the suggested ways to resolve different tensions.

Originality/value

To the best of the authors’ knowledge, they are the first to separate out thought leadership from its inputs, creation processes and outcomes. The authors show new organisational paradoxes within thought leadership and show how they can play out at different levels of analysis when implementing a thought leadership strategy. This work on thought leadership is set in a relatively under-explored context for knowledge management researchers, namely, knowledge-intensive professional service firms.

SMEs strategic networks and innovative performance: a relational design and methodology for knowledge sharing

Purpose

In the context of resource scarcity, the affiliation of small and medium-sized enterprises (SMEs) to strategic networks has emerged as a fruitful path towards knowledge sharing as a reaction to fierce competition and with a view to enhance their innovative performance. In this framework, this paper aims to investigate the influence exerted by a specific relational design (i.e. types of strategic networks) and methodology (i.e. channels and content) of knowledge sharing on SMEs innovative performance.

Design/methodology/approach

A questionnaire-based survey with 102 top managers of European SMEs in the industrial field was conducted from June to August 2019 and a partial least squares structural equation modelling technique was used. The database was initially filtered to ensure the adequacy of the sample and data was analysed using the statistics software package SmartPLS 3.0.

Findings

The results concluded that the structural model explains 38.5% of the variance in SMEs innovative performance, indicating the positive effects exerted by offline and online and by competitive knowledge sharing on the dependent variable.

Research implications

The study has both theoretical and practical implications in that it sets out a reference point for the key performance indicators for strategic networks structure, formation and development and, implicitly, for the selection of the most efficient relational design and methodology.

Originality/value

The pivotal originality elements reside in the advancement of a more comprehensive conceptual and structural model combining a two-fold operationalization of SMEs strategic networks (founded on business abilities or on the personality of the partner) and in the investigation of knowledge transfer processes at the inter-organizational levels within a context-centric approach.

Diversification, Branding, and Performance of Professional Service Firms

This article analyzes the effects of diversification and brand breadth on firm performance for professional service firms (PSFs). The research aim is two-fold. First, we test whether moving into products may put at risk the core resources that sustain PSFs' competitive advantage. Second, we study which branding strategies best match their diversification attempts. Broad (narrow) brands characterize a branding strategy with scarce (plentiful) associations to specific product characteristics. We analyzed trademark portfolios of 47 U.S.-based management consulting firms in the 2000 to 2009 time period. Panel regression results suggest that (1) PSFs always benefit from diversification when they remain pure-service providers; (2) performance is positively related to a strategy of specialized narrow brands.

Managerial Networks and Exploration in a Professional Service Firm

A firm’s growth and survival depends on the ability of its managers to explore for new business and knowledge; yet, exploration is challenging for most large, established firms. Extending prior research into networks and exploration, we propose that a key characteristic of managers’ external networks – the extent to which their networks include relationships built using predominately individual rather than firm resources – is positively related to managers’ abilities to explore for new business and knowledge in large firms. We propose that networks with more individual ties provide more diverse knowledge, enable greater autonomy and ease access to resources from contacts, hence facilitating exploration. Analysis of an original dataset of external networks of 77 senior managers in a large global consulting firm provides support for our arguments. We find that individual ties are positively related to exploration and, furthermore, that the positive (negative) relationship between sparse (dense) networks and exploration increases with the number of individual ties in managers’ networks.

Knowledge Sharing Research

In response to the calls for more context-aware theorizing, in this essay we review the empirical research on individual knowledge sharing behavior in organizations, with a specific focus on the context in which employees share knowledge. We build on the “Who? / Where? / Why? / What?” framework to “flesh out” the contexts of the empirical studies on individual knowledge sharing published in top-level journals. Mapping the researched contexts, we indicate several biases of the literature as well as point to under-investigated spaces, suggesting theoretical dimensions, their contrasts, and new empirical settings that are missing from the major stream of knowledge sharing studies. We also find that context has been scarcely accounted for in the existing literature, discuss the reasons for it, show how accounting for context can be used to re-interpret some contradictions in existing literature, and suggest some ways to move forward.

Transnational organizing: Issue professionals in environmental sustainability networks

An ongoing question for institutional theory is how organizing occurs transnationally, where institution building occurs in a highly ambiguous environment. This article suggests that at the core of transnational organizing is competition and coordination within professional and organizational networks over who controls issues. Transnational issues are commonly organized through professional battles over how issues are treated and what tasks are involved. These professional struggles are often more important than what organization has a formal mandate over an issue. We highlight how ‘issue professionals’ operate in two-level professional and organizational networks to control issues. This two-level network provides the context for action in which professionals do their institutional work. The two-level network carries information about professional incentives and also norms about how issues should be treated and governed by organizations. Using network and career sequences methods, we provide a case of transnational organizing through professionals who attempt issue control and network management on transnational environmental sustainability certification. The article questions how transnational organizing happens, and how we can best identify attempts at issue control.

Competence Regimes in Professional Service Firm Internationalization and Professional Careers

Professional service firms (PSFs) are dependent on the competence of their employees to develop and retain new business. We investigate how PSFs utilize professional competence for strategic goals such as business internationalization and simultaneously facilitate professionals’ career mobility. We examine over a 5-year period the careers of 29 lawyers working in a large corporate law firm and identify four different competence regimes: technicians, project managers, competitive analysts, and global strategists. We argue that these competence regimes enable PSFs to pursue organizational business strategies while advancing or constraining or even undermining professional employees’ career goals and aspirations. Specifically, we show how the four competence regimes facilitate the PSF’s strategy to internationalize its business and support high performing employees’ social mobility goals to develop their professional competence and advance their career. We then give suggestions for future research studies on competence regimes in professional organizations.

Knowledge Appropriation and Identity: Toward a Multi-Discourse Analysis

Knowledge appropriation has been underpinned by an assumption of the organization’s ‘entitlement’ to appropriate knowledge and the outcomes of its utilization. Given the complexity of knowledge and the potentially conflicting views held about it, this assumption is revealed to be theoretically imprecise in the way it marginalizes alternative voices through the pursuit of competitive advantage and ‘value capture’. We attribute this approach to the functionalist analytical lens which sees knowledge as an asset appropriable almost exclusively by the organization in the form of financial/economic ‘rents’. In order to advance understanding of the multi-faceted nature of the organization-individual appropriation regime, we make the case for an expansion of the discursive space for talking about the phenomenon, and posit the concept of ‘property in knowledge’ which we tie to the way individuals construct their identities.

Knowledge-Sharing, Control, Compliance and Symbolic Violence

Recent developments in control hold that professionals are best managed through normative and concertive as opposed to bureaucratic and coercive mechanisms. This post-structuralist approach appeals to the notion of congruent values and norms and acknowledges the role of individuals’ subjectivity in sustaining professional autonomy. Yet, there remains a risk of over-simplifying the manifestations of such control initiatives. By means of an in-depth case study, this article considers the challenge of implementing a knowledge-sharing portal for a community of R&D scientists through management control initiatives that relied on a blend of presumed ‘peer pressure’ and the rhetoric of ‘facilitation’. Arguing that traditional approaches such as normative/concertive control and soft bureaucracy only partially explain this phenomenon, we draw from Pierre Bourdieu’s concept of ‘symbolic violence’ to interpret a managerial initiative to appropriate knowledge and affirm the structure of social relations through the complicity of R&D scientists. We also examine how the scientists channelled resistance by reconstituting compliance in line with their sense of identity as creators of knowledge.

The Global Professional Service Firm: ‘One Firm’ Models versus (Italian) Distant Institutionalized Practices

Through a historical case study of the internationalization of large English law firms into Italy, this paper uses Scott’s (2005) three pillars approach to look at how local institutions constrain and mediate the strategies and practices of global professional services firms. In doing so, it corrects the economic bias in the growing body of literature on the internationalization of PSFs by stressing how local regulations, norms and cultural frameworks affect the reproduction of home country practices, such as the one firm model pursued by large English law firms, in host-country jurisdictions. The paper also extends existing work on institutional duality (Kostova, 1999, Kostova & Roth, 2002) by developing a fine-grained, micro-level analysis which emphasizes the connections between institutions and practices. This is crucial, we contend, since the difficulties encountered by PSFs (and multinationals more generally) in their internationalization do not result from collisions between home- and host-country institutional structures per se, but between the diverse practices generated by distant institutional environments.

Control and Dignity in Professional, Manual and Service-Sector Employment

This study investigates implications of complex control combinations applied in manual, service and professional occupations for expressive, behavioral and emotional aspects of workplace dignity. Qualitative comparative analyses of 154 content-coded workplace ethnographies suggest that professionals encounter persuasive ‘bundles’ of control that enhance expressive and behavioral manifestations of dignity as well as pride. However, these benefits come at the expense of high levels of stress associated with internal drives and externally driven normative orientations and behaviors. Workers in manual and service occupations confront a broader array of approaches, including coercive control combinations that erode pride and effort by dehumanizing workers and inviting abuse. Furthermore, the benefits of persuasive control combinations in these settings are mitigated by supplementary constraints, which promote maintenance of a protective distance from employers that may also help to limit stress. The paper concludes with organizational strategies for curbing abuse in coercive manual and service environments and a discussion of changes necessary to address the problem of stress in the professions.