"A manager in the minds of doctors:" a comparison of new modes of control in European hospitals

Organisational support for healthcare innovation in hospitals: Towards a commitment framework

The article investigates organisational drivers and restrainers of innovation in hospitals on the background of different institutional logics. It presents evidence from a multiple case study in Polish hospitals, which reveals different dynamics on the micro-, meso- and macro-level of organisations in enabling and implementing new procedures and technologies. In particular, the study documents an ambiguous influence of medical professionalism as a specific logic in the healthcare sector, which can affect innovation positively as well as negatively. The article therefore proposes a managerial framework based in innovation action commitment to control the effects of professionalism in healthcare.

The Case for Ethical Efficiency: A System That Has Run Out of Time

The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."

Exploring enablers of modularity in healthcare service delivery

Purpose

This paper explores the enablers of modular healthcare services.

Design/methodology/approach

A survey-based approach was adopted with specialised hospitals as the unit of analysis. A structural model was developed based on a literature review and assessed using a cross-sectional research design. A 23-indicator questionnaire was circulated among service providers in the healthcare system across India, and 286 valid responses were received. The data were analysed using partial least squares-structural equation modeling (PLS-SEM).

Findings

The results reveal that professional competence, technological versatility, clear division of tasks, channelised flow of information and professional autonomy act as enablers that may drive modular service delivery.

Research limitations/implications

By examining service providers' perspectives, this paper highlights the influence of the identified enablers on modular service delivery in healthcare organisations.

Practical implications

For practitioners, the study provides suggestions for designing patient-centric healthcare services via modular healthcare delivery. The identified structural relationships can facilitate immediate corrective actions and the formulation of future policies. The findings will help practitioners foresee opportunities for patient participation in value co-creation, meet patients' varying needs, decompose service offerings, mix and match components develop sets of rules as interfaces between service modules and design service packages on an ongoing basis.

Social implications

This study underscores the emergence of patient-centric care and may aid the design of processes that deliver health to the patient as a person.

Originality/value

This paper identifies and empirically validates relationships between healthcare service delivery processes and modular service delivery.

Confronting power in low places: historical analysis of medical dominance and role-boundary negotiation between health professions in Nigeria

Introduction

Interprofessional interaction is intrinsic to health service delivery and forms the basis of task-shifting and task-sharing policies to address human resources for health challenges. But while interprofessional interaction can be collaborative, professional hierarchies and discipline-specific patterns of socialisation can result in unhealthy rivalry and conflicts which disrupt health system functioning. A better understanding of interprofessional dynamics is necessary to avoid such negative consequences. We, therefore, conducted a historical analysis of interprofessional interactions and role-boundary negotiations between health professions in Nigeria.

Methods

We conducted a review of both published and grey literature to provide historical accounts and enable policy tracing of reforms related to interprofessional interactions. We used Nancarrow and Borthwick’s typology for thematic analysis and used medical dominance and negotiated order theories to offer explanations of the conditions that facilitated or constrained interprofessional collaboration.

Results

Despite an overall context of medical dominance, we found evidence of professional power changes (dynamics) and role-boundary shifts between health professions. These shifts occurred in different directions, but shifts between professions that are at different power gradients were more likely to be non-negotiable or conflictual. Conditions that facilitated consensual role-boundary shifts included the feasibility of simultaneous upward expansion of roles for all professions and the extent to which the delegating profession was in charge of role delegation. While the introduction of new medical diagnostic technology opened up occupational vacancies which facilitated consensual role-boundary change in some cases, it constrained professional collaboration in others.

Conclusions

Health workforce governance can contribute to better functioning of health systems and voiding dysfunctional interprofessional relations if the human resource for health interventions are informed by contextual understanding (informed by comparative institutional and health systems research) of conditions that facilitate or constrain effective interprofessional collaboration.

Organizing as negotiation: the construction of a pathway in Norwegian mental health services

BACKGROUND

In 2015, a decision was made to implement clinical pathways in Norwegian mental health services. The idea was to construct pathways similar to those used in cancer treatment. These pathways are based on diagnosis and evidence-based medicine and have strict timeframes for the different procedures. The purpose of this article is to provide a thorough examination of the formulation of the pathway "mental illness, adults" in Norwegian mental health services. In recent decades, much research has examined the implementations and outcomes of different mental health sector reforms and services in Western societies. However, there has been a lack of research on the process and creation of these reforms and/or services, particularly how they emerge as constructs in the contexts of policy, profession and practice.

METHODS

A qualitative single case study design was employed. A text and document analysis was performed in which 52 articles and opinion pieces, 30 public hearing responses and 8 political documents and texts were analysed to identify the main actors in the discourse of mental health services and to enable a replication of their affiliated institutional logics and their views concerning the clinical pathway. Additionally, ten qualitative interviews were performed with members of the work group responsible for designating the pathway "mental illness, adults".

RESULTS

This article shows how the two main actor groups, "Mental health professionals" and "Politicians", are guided by values associated with a specific logic when understanding the concept of a clinical pathway (CP). The findings show that actors within the political field believe in control and efficiency, in contrast to actors in mental health services, who are guided by values of discretion and autonomy. This leads to a debate on the concept of CPs and mental health services. The discussion becomes polarized between concern for patients and concern for efficiency. The making of the pathway is led by the Directorate of Health, with health professionals operating in the political domain and who have knowledge of the values of both logics, which were taken into consideration when formulating the pathways, and explains how the pathway became a complex negotiation process between the two logics and where actors on both sides were able to retain their core values. Ultimately, the number of pathways was reduced from 22 to 9. The final "Pathway for mental illness, adults" was a general pathway involving several groups of patients. The pathway explains the process from diagnosis through treatment and finalizing treatment. The different steps involve time frames that need to be coded, requiring more rigid administrative work for compliance, but without stating specific diagnostic tools or preferred treatment strategies.

CONCLUSIONS

This article shows that there is also a downside of having sense making guided by strong values associated with a specific institutional logic when constructing new, and hopefully better, mental health care services. This article demonstrates how retaining values sometimes becomes more crucial than engaging in constructive debates about how to solve issues of importance within the field of mental health care.

Professionalism in Science: Competence, Autonomy, and Service

Some of the most significant policy responses to cases of fraudulent and questionable conduct by scientists have been to strengthen professionalism among scientists, whether by codes of conduct, integrity boards, or mandatory research integrity training programs. Yet there has been little systematic discussion about what professionalism in scientific research should mean. In this paper I draw on the sociology of the professions and on data comparing codes of conduct in science to those in the professions, in order to examine what precisely the model of professionalism implies for scientific research. I argue that professionalism, more than any other single organizational logic, is appropriate for scientific research, and that codes of conduct for scientists should strengthen statements concerning scientific autonomy and competence, as well as the scientific service ideal.

Os médicos e a gestão do cuidado em serviços hospitalares de emergência: poder profissional ameaçado?

Resumo: O Kanban é um arranjo tecnológico de organização do cuidado hospitalar orientado para a gestão de leitos e da clínica, que visa à qualidade e integralidade da assistência, maior rotatividade dos leitos, com consequente redução do tempo de internação e custos hospitalares. O constante e atualizado acompanhamento do paciente, compartilhado pela equipe profissional em reuniões sistemáticas é seu elemento mais marcante e inovador. O objetivo foi caracterizar os prováveis impactos da adoção de tal arranjo no poder profissional (autonomia e autoridade) dos médicos. Estudo qualitativo em hospital de urgência-emergência municipal com uso das seguintes técnicas de produção de dados: etnografia do cotidiano do hospital, com observação e registro em diários de campo, e realização de seminários compartilhados entre pesquisadores e equipes. Os médicos valorizam o trabalho multiprofissional como um qualificador de sua prática, em uma linha auxiliar e complementar. Acresce que o Kanban tende a ser controlado por “híbridos” (médicos que acumulam funções gerenciais e clínicas) que traduzem sinergias entre “gestão clínica” e “gestão de leitos”. Assim, interferências no trabalho dos médicos não são exercidas de fora, e as suas decisões clínicas continuam a condicionar o trabalho dos demais grupos profissionais. Os médicos não percebem sua autoridade e autonomia ameaçadas pelo Kanban, dada a articulação entre a autoridade administrativa e a autoridade profissional. Contudo, aspectos relacionados à hibridização e estratificação interna da profissão médica precisam ser mais convocados para o debate do poder profissional em saúde.

Beyond hybrid professionals: evidence from the hospital sector

Background

The involvement of doctors in managerial roles seems to be the solution to reducing the friction between traditional professionalism and modern organizational paradigms. However, these “hybrid” professionals responded in different ways to these conflicting demands, and we need to better understand the contextual factors that explain such variation.

Methods

The paper studies hybrid professionals in a hospital characterized by numerous organizational changes. The site is located in Italy, a country in which healthcare organizations have been exposed to managerial reforms for years but where the degree to which professionals embraced management varies. A longitudinal case study was performed that involved gathering data through multiple sources of evidence to understand the complex organizational dynamics that take place in the hospital.

Results

The analysis shows that the taking up of hybrid managerial roles is enabled by a number of interrelated features of the social/organizational context. Professionals willing to become hybrids were favored by the support provided by the organization. While for those doctors initially more reluctant towards medical management, distinctive contextual factors, in particular, the presence of space for interaction with colleagues within the professional domains but beyond disciplinary boundaries, was of key importance. This second group also proved capable of interiorizing organizational values and practices in a reconfigured way.

Conclusions

In order to understand hybridization, it is necessary to look beyond hybrids at the context surrounding them. This study provides evidence for scholars and practitioners willing to understand how medical management is evolving and how this transition can be supported, and it contributes to the literature on hybrid managers by showing how contexts facilitating social interactions enable professionals’ hybridization.

Trial registration

The article does not report the results of a health care intervention on human participants, and material used in the research did not need ethical approval according to Italian law.

New public management, physicians and populism: Turkey's experience with health reforms

Recent debates on the rise of right-wing or neoliberal populism globally have prompted public health and health systems researchers to explore its implications in the healthcare systems. This case study of Turkey's recent health reform initiative, the Health Transformation Program, aims to contribute to this debate by examining the nexus among populism, professionalism and the contemporary market and managerial reforms, often described as New Public Management (NPM). Building on document analysis and secondary sources, this article introduces a framework to explore whether and how populist agendas grow up in the shadow of NPM policies. We aim to deepen our understanding of the governance settings that might be used in different ways by right-wing populist leaders to advance their agendas. Our research reveals that the NPM reforms in Turkey have opened a 'backdoor' through which right-wing populist agendas were supported and the position of the medical profession as an important stakeholder in the institutional settings was weakened. However, what mattered most in the reform process was not the policies themselves but the ways new managerialist policies were implemented. Our analysis makes blind spots of the NPM reforms and healthcare governance research visible and calls for greater attention to implementation processes.

Understanding the role of physicians within the managerial structure of Russian hospitals

This article examines the role of physicians within the managerial structure of Russian hospitals. A comparative qualitative methodology with a structured assessment framework is used to conduct case studies that allow for international comparison. The research is exploratory in nature and comprises 63 individual interviews and 49 focus groups with key informants in 15 hospitals, complemented by document analysis. The material was collected between February and April 2017 in five different regions of the Russian Federation. The results reveal three major problems of hospital management in the Russian Federation. First, hospitals exhibit a leaky system of coordination with a lack of structures for horizontal exchange of information within the hospitals (meso-level). Second, at the macro-level, the governance system includes implementation gaps, lacking mechanisms for coordination between hospitals that may reinforce existing inequalities in service provision. Third, there is little evidence of a learning culture, and consequently, a risk that the same mistakes could be made repeatedly. We argue for a new approach to governing hospitals that can guide implementation of structures and processes that allow systematic and coherent coordination within and among Russian hospitals, based on modern approaches to accountability and organisational learning.

Physicians' professional autonomy and their organizational identification with their hospital

Background

Managing medical professionals is challenging because professionals tend to adhere to a set of professional norms and enjoy autonomy from supervision. The aim of this paper is to study the interplay of physicians’ professional identity, their organizational identity, and the role of professional autonomy in these processes of social identification.

Methods

We test hypotheses generated according to social identity theory using a survey of physicians working in public hospitals in Italy in 2013.

Results

Higher degrees of organizational and economic professional autonomy are correlated with higher organizational identification. Identification with the profession is positively correlated with identification with the organization.

Conclusions

Although the generalizability of our results is limited, this study suggests that organizations should support the organizational and economic autonomy of their physicians to project an organizational identity that preserves the continuity of a doctor’s self-concept and that is evaluated as positive by doctors. As a result, organizations will be able to foster organizational identification, which is potentially capable of inducing pro-social organizational behavior.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3582-z) contains supplementary material, which is available to authorized users.

Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine

Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such ‘hybrid’ doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation.

Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change.

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Responsible Officers are a new governance elite group in the UK medical profession.

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They work at the nexus of professional, managerial and regulatory spheres.

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Differ from other doctor-managers due to accountability for medical performance.

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Organisational context shapes experiences of this new role.

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Regulatory reform has engendered a new form of hybrid professionalism.

Managerial strategies to make incentives meaningful and motivating

Purpose

Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care.

Design/methodology/approach

The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data.

Findings

The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers’ strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements.

Originality/value

Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers’ multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.

Medical authority, managerial power and political will: A Bourdieusian analysis of antibiotics in the hospital

Antibiotic resistance poses a significant global threat, yet clinically inappropriate antibiotic use within hospitals continues despite the implementation of abatement strategies. Antibiotic use and the viability of existing antibiotic options now sit precariously at the nexus of political will, institutional governance and clinical priorities ‘at the bedside’. Yet no study has hitherto explored the perspectives of managers, instead of focusing on clinicians. In this article, drawing on qualitative interviews with hospital managers, we explore accounts of responding to antimicrobial resistance, managing antibiotic governance and negotiating clinical and managerial priorities. We argue that the managers’ accounts articulate the problematic nexus of measurement and accountability, the downflow effects of political will, and core tensions within the hospital between moral, managerial and medical authority. We apply Bourdieu’s theory of practice to argue that an understanding of the logics of practice within the ‘hospital management classes’ will be critical in efforts to protect antibiotics for future generations.

Rethinking clinical governance: healthcare professionals' views: a Delphi study

OBJECTIVE

Although the guiding principle of clinical governance states that healthcare professionals are the leading contributors to quality and safety in healthcare, little is known about what healthcare professionals perceive as important for clinical governance. The aim of this study is to clarify this by exploring healthcare professionals' views on clinical governance.

DESIGN

Based on a literature search, a list of 99 elements related to clinical governance was constructed. This list was refined, extended and restricted during a three-round Delphi study.

SETTING AND PARTICIPANTS

The panel of experts was formed of 24 healthcare professionals from an academic hospital that is seen as a leader in terms of its clinical governance expertise in the Netherlands.

MAIN OUTCOME MEASURES

Rated importance of each element on a four-point scale.

RESULTS

The 50 elements that the panel perceived as most important related to adopting a bottom-up approach to clinical governance, ownership, teamwork, learning from mistakes and feedback. The panel did not reach a consensus concerning elements that referred to patient involvement. Elements that referred to a managerial approach to clinical governance and standardisation of work were rejected by the panel.

CONCLUSIONS

In the views of the panel of experts, clinical governance is a practice-based, value-driven approach that has the goal of delivering the highest possible quality care and ensuring the safety of patients. Bottom-up approaches and effective teamwork are seen as crucial for high quality and safe healthcare. Striving for high quality and safe healthcare is underpinned by continuous learning, shared responsibility and good relationships and collaboration between healthcare professionals, managers and patients.

Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe

BACKGROUND

Over the past decade the healthcare workforce has diversified in several directions with formalised roles for health care assistants, specialised roles for nurses and technicians, advanced roles for physician associates and nurse practitioners and new professions for new services, such as case managers. Hence the composition of health care teams has become increasingly diverse. The exact extent of this diversity is unknown across the different countries of Europe, as are the drivers of this change. The research questions guiding this study were: What extended professional roles are emerging on health care teams? How are extended professional roles created? What main drivers explain the observed differences, if any, in extended roles in and between countries?

METHODS

We performed a case-based comparison of the extended roles in care pathways for breast cancer, heart disease and type 2 diabetes. We conducted 16 case studies in eight European countries, including in total 160 interviews with physicians, nurses and other health care professionals in new roles and 600+ hours of observation in health care clinics.

RESULTS

The results show a relatively diverse composition of roles in the three care pathways. We identified specialised roles for physicians, extended roles for nurses and technicians, and independent roles for advanced nurse practitioners and physician associates. The development of extended roles depends upon the willingness of physicians to delegate tasks, developments in medical technology and service (re)design. Academic training and setting a formal scope of practice for new roles have less impact upon the development of new roles. While specialised roles focus particularly on a well-specified technical or clinical domain, the generic roles concentrate on organising and integrating care and cure.

CONCLUSION

There are considerable differences in the number and kind of extended roles between both countries and care pathways. The main drivers for new roles reside in the technological development of medical treatment and the need for more generic competencies. Extended roles develop in two directions: 1) specialised roles and 2) generic roles.

Optimizing antibiotic usage in hospitals: a qualitative study of the perspectives of hospital managers

BACKGROUND

Antibiotic optimization in hospitals is an increasingly critical priority in the context of proliferating resistance. Despite the emphasis on doctors, optimizing antibiotic use within hospitals requires an understanding of how different stakeholders, including non-prescribers, influence practice and practice change.

AIM

This study was designed to understand Australian hospital managers' perspectives on antimicrobial resistance, managing antibiotic governance, and negotiating clinical vis-à-vis managerial priorities.

METHODS

Twenty-three managers in three hospitals participated in qualitative semi-structured interviews in Australia in 2014 and 2015. Data were systematically coded and thematically analysed.

FINDINGS

The findings demonstrate, from a managerial perspective: (1) competing demands that can hinder the prioritization of antibiotic governance; (2) ineffectiveness of audit and monitoring methods that limit rationalization for change; (3) limited clinical education and feedback to doctors; and (4) management-directed change processes are constrained by the perceived absence of a 'culture of accountability' for antimicrobial use amongst doctors.

CONCLUSION

Hospital managers report considerable structural and interprofessional challenges to actualizing antibiotic optimization and governance. These challenges place optimization as a lower priority vis-à-vis other issues that management are confronted with in hospital settings, and emphasize the importance of antimicrobial stewardship (AMS) programmes that engage management in understanding and addressing the barriers to change.

Comparing medicine and management: methodological issues

Background

In the study of medicine and management, there is a strong interest in cross-country comparison. Across healthcare systems in industrialised countries, New Public Management has provided a similar reform template, but new governing arrangements exhibit significant national variations. The comparative perspective also offers a leverage to overcome the resistance focus of earlier studies. Comparison raises two overall questions: in what similar and different ways are relations between medicine and management changing across industrialised countries? Why is change occurring in different ways? The questions reflect exploration and explanation as the two basic rationales for comparison.

Methods

The aim was to provide a critical discussion of different approaches to comparing medicine and management across countries. The analysis was based on a narrative review of relevant studies from several bodies of literature.

Results and discussion

The majority of studies exploring medicine and management adopt macro level approaches to comparison. Studies draw on a range of notions, including area specific ideal types of professionalism, professionalism as countervailing powers and governmentality. There are much fewer studies exploring relations between medicine and management at the meso level. Analyses treat comparison as a two-dimensional exercise looking across both countries and levels. The majority of studies draws on institutional explanations. These are variations of the path dependency argument and studies include both sector specific and broader political and administrative institutions. There is an emerging body of process-based explanations which connect macro level institutions to organisations and which promote more non-linear comparisons.

Conclusion

The lack of meso level comparisons drawing on process explanations is problematic. Empirically, we need to know more about how relations between medicine and management are different across countries. Theoretically, we need to better understand how we can transpose analytical insights from institutional explanations at macro level to studies that are multi-level and also include the meso level of organisations. Methodologically, we need to address the challenges arising from more non-linear approaches to comparison, especially how to organise close international research collaboration over an extended period of time.

Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal

BACKGROUND

The need of improving the governance of healthcare services has brought health professionals into management positions. However, both the processes and outcomes of this policy change highlight differences among the European countries. This article provides in-depth evidence that neither quantitative data nor cross-country comparisons have been able to provide regarding the influence of hybrids in the functioning of hospital organizations and impact on clinicians' autonomy and exposure to hybridization.

METHODS

The study was designed to witness the process of institutional change from the inside and while that process was underway. It reports a case study carried out in a public hospital in Portugal when the establishment of a clinical directorate was being negotiated. Data collection comprises semi-structured interviews with general managers and surgeons complemented with observations.

RESULTS

The clinical directorate under study illustrates a divisionalized professional bureaucracy model that combines features of professional bureaucracies and divisionalized forms. The hybrid manager is key to understand the extent to which practising clinicians are more accountable and to whom given that managerial tools of control have not been strengthened, and trust-based relations allow them to keep professional autonomy untouched. In sum, clinicians are allowed to profit from their activity and to perform autonomously from the hospital's board of directors. The advantageous conditions enjoyed by the clinical directorate intensify internal re-stratification in medicine, thus suggesting forms of divisionalized medical professionalism grounded in organizational dynamics.

CONCLUSION

It is discussed the extent to which policy change to the governance of health organizations regarding the relationship between medicine and management is subject to specific constraints at the workplace level, thus conditioning the expected outcomes of policy setting. The study also highlights the role of hybrid managers in determining the extent to which practising professionals are more accountable to managerial criteria. The overall conclusion is that although medical and managerial values link to each other, clinicians reconfigure managerial criteria according to specific interests. Ultimately, medical autonomy and authority may be reinforced in organizational settings subject to NPM-driven reforms.

Medicine and management: looking inside the box of changing hospital governance

Background

Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing ‘hybridization’ of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study.

Methods

We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the ‘managed’ and the ‘managing’ doctors in an organization.

Results

Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial–professional coordination at the micro-level of the organization.

Conclusion

This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management.

The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries

Background

Hospital governance is broadening its orientation from cost and production controls towards ‘improving performance on clinical outcomes’. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a ‘black-box’ thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems.

Methods

This study draws both on a quick scan amongst country coordinators in OECD’s Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals.

Results

This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems.

Conclusions

Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.

Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece

The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the 'memorandum and peripheral' Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided by Greek policy makers in close cooperation with other health and social care partners. This is the appropriate time for doing so.

The making of local hospital discharge arrangements: specifying the role of professional groups

BACKGROUND

Timely discharge is a key component of contemporary hospital governance and raises questions about how to move to more explicit discharge arrangements. Although associated organisational changes closely intersect with professional interests, there are relatively few studies in the literature on hospital discharge that explicitly examine the role of professional groups. Recent contributions to the literature on organisational studies of the professions help to specify how professional groups in hospitals contribute to the introduction and routinisation of discharge arrangements. This study builds on a view of organisational and professional projects as closely intertwined, where professionals take up organising roles and where organisations shape professionalism.

METHODS

The analysis is based on a case study of the introduction and routinisation of explicit discharge arrangements for patients with prostate cancer in two hospitals in Denmark. This represents a typical case that involves changes in professional practice without being first and foremost a professional project. The multiple case design also makes the findings more robust. The analysis draws from 12 focus groups with doctors, nurses and secretaries conducted at two different stages in the process of the making of the local discharge arrangements.

RESULTS

From the analysis, two distinct local models of discharge arrangements that connect more or less directly to existing professional practice emerge: an 'add-on' model, which relies on extra resources, special activities and enforced change; and an 'embedded model', which builds on existing ways of working, current resources, and perspectives of professional groups. The two models reveal differences in the roles of professional groups in terms of their stakes and involvement in the process of organisational change: whereas in the 'add on' model the professional groups remain at a distance, in the 'embedded model' they are closely engaged.

CONCLUSIONS

In terms of understanding the making of hospital discharge arrangements, the study contributes two sets of insights into the specific roles of professional groups. First, professional interests are an important driver for health professionals to engage in adapting discharge arrangements; and second, professional practice offers a powerful lever for turning new discharge arrangements into organisational routines.

Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark

Background

The large obstetric units typical of industrialised countries have come under criticism for fragmented and depersonalised care and heavy bureaucracy. Interest in midwife-led continuity models of care is growing, but knowledge about the accompanying processes of organisational change is scarce. This study focuses on midwives’ role in introducing and developing caseload midwifery. Sociological studies of midwifery and organisational studies of professional groups were used to capture the strong interests of midwives in caseload midwifery and their key role together with management in negotiating organisational change.

Methods

We studied three hospitals in Denmark as arenas for negotiating the introduction and development of caseload midwifery and the processes, interests and resources involved. A qualitative multi-case design was used and the selection of hospitals aimed at maximising variance. Ten individual and 14 group interviews were conducted in spring 2013. Staff were represented by caseload midwives, ward midwives, obstetricians and health visitors, management by chief midwives and their deputies. Participants were recruited to maximise the diversity of experience. The data analysis adopted a thematic approach, using within- and across-case analysis.

Results

The analysis revealed a highly interdependent interplay between organisational and professional projects in the change processes involved in the introduction and development of caseload midwifery. This was reflected in three ways: first, in the key role of negotiations in all phases; second, in midwives’ and management’s engagement in both types of projects (as evident from their interests and resources); and third in a high capacity for resolving tensions between the two projects. The ward midwives’ role as a third party in organisational change further complicated the process.

Conclusions

For managers tasked with the introduction and development of caseload midwifery, our study underscores the importance of understanding the complexity of the underlying change processes and of activating midwives’ and managers’ interests and resources in addressing the challenges. Further studies of female-dominated professions such as midwifery should offer good opportunities for detailed analysis of the deep-seated interdependence of professional and organisational projects and for identifying the key dimensions of this interdependence.

Measuring clinical management by physicians and nurses in European hospitals: development and validation of two scales

Objective

Clinical management is hypothesized to be critical for hospital management and hospital performance. The aims of this study were to develop and validate professional involvement scales for measuring the level of clinical management by physicians and nurses in European hospitals.

Design

Testing of validity and reliability of scales derived from a questionnaire of 21 items was developed on the basis of a previous study and expert opinion and administered in a cross-sectional seven-country research project ‘Deepening our Understanding of Quality improvement in Europe’ (DUQuE).

Setting and Participants

A sample of 3386 leading physicians and nurses working in 188 hospitals located in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.

Main Outcome Measures

Validity and reliability of professional involvement scales and subscales.

Results

Psychometric analysis yielded four subscales for leading physicians: (i) Administration and budgeting, (ii) Managing medical practice, (iii) Strategic management and (iv) Managing nursing practice. Only the first three factors applied well to the nurses. Cronbach's alpha for internal consistency ranged from 0.74 to 0.86 for the physicians, and from 0.61 to 0.81 for the nurses. Except for the 0.74 correlation between ‘Administration and budgeting’ and ‘Managing medical practice’ among physicians, all inter-scale correlations were <0.70 (range 0.43–0.61). Under testing for construct validity, the subscales were positively correlated with ‘formal management roles’ of physicians and nurses.

Conclusions

The professional involvement scales appear to yield reliable and valid data in European hospital settings, but the scale ‘Managing medical practice’ for nurses needs further exploration. The measurement instrument can be used for international research on clinical management.

Management and medicine: why we need a new approach to the relationship

New Public Management has affected the relationship between corporate managerialism and professional modes of governing hospitals. While doctors’ increasing involvement in management may have positive effects on health care, hospital governance, health care policies and medical education have largely failed to support this change. There is a need for new policies and approaches to support the changing connections between medicine and management that abandons both the military discourse of ‘wars’ and ‘battlefields’ and the new rhetoric of ‘clinical leadership’.