Clinicians in management: a qualitative study of managers' use of influence strategies in hospitals

Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study

BACKGROUND

Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

METHODS

This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach.

RESULTS

Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: 'structure', 'culture', 'education', 'emotional', and 'physical and technology'. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients.

CONCLUSIONS

Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, 'politics'. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations' structure, culture and practices.

Trustworthy management in hospital settings: a systematic review

BACKGROUND

Trustful relationships play a vital role in successful organisations and well-functioning hospitals. While the trust relationship between patients and providers has been widely studied, trust relations between healthcare professionals and their supervisors have not been emphasised. A systematic literature review was conducted to map and provide an overview of the characteristics of trustworthy management in a hospital setting.

METHODS

We searched Web of Science, Embase, MEDLINE, APA PsycInfo, CINAHL, Scopus, EconLit, Taylor & Francis Online, SAGE Journals and Springer Link from database inception up until Aug 9, 2021. Empirical studies written in English undertaken in a hospital or similar setting and addressed trust relationships between healthcare professionals and their supervisors were included, without date restrictions. Records were independently screened for eligibility by two researchers. One researcher extracted the data and another one checked the correctness. A narrative approach, which involves textual and tabular summaries of findings, was undertaken in synthesising and analysing the data. Risk of bias was assessed independently by two researchers using two critical appraisal tools. Most of the included studies were assessed as acceptable, with some associated risk of bias.

RESULTS

Of 7414 records identified, 18 were included. 12 were quantitative papers and 6 were qualitative. The findings were conceptualised in two categories that were associated with trust in management, namely leadership behaviours and organisational factors. Most studies (n = 15) explored the former, while the rest (n = 3) additionally explored the latter. Leadership behaviours most commonly associated with employee's trust in their supervisors include (a) different facets of ethical leadership, such as integrity, moral leadership and fairness; (b) caring for employee's well-being conceptualised as benevolence, supportiveness and showing concern and (c) the manager's availability measured as being accessible and approachable. Additionally, four studies found that leaders' competence were related to perceptions of trust. Empowering work environments were most commonly associated with trust in management.

CONCLUSIONS

Ethical leadership, caring for employees' well-being, manager's availability, competence and an empowering work environment are characteristics associated with trustworthy management. Future research could explore the interplay between leadership behaviours and organisational factors in eliciting trust in management.

Power sources among district health managers in Ghana: a qualitative study

Background

In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is dependent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions.

Methods

A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice-recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach.

Results

The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts.

Conclusions

The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system.

Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?

BACKGROUND

Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems.

METHODS

We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning.

RESULTS

Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making.

CONCLUSION

Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.

Linking resilience and regulation across system levels in healthcare – a multilevel study

Background

The Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system.

Methods

The multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers.

Results

Based on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework.

Conclusions

The Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are “hopeless opposites”. However, governmental expectations to implementation and external inspection were not fully linked with changes in hospital management. Thus, the study identified a missing link in the current regime. We suggest that macro, meso and micro-levels should be considered collaborative partners in obtaining system-wide adaptive capacity, to ensure efficient risk regulation in quality improvement and patient safety processes. Further studies on regulatory processes could explore how hospital management and implementation are influenced by regulators’, inspectors’, and managers’ professional backgrounds, positions, and daily trade-offs to adapt to changes and maintain high quality care.

Governance tensions in the healthcare sector: a contrasting case study in France

Background

Political and managerial reforms affect the health sector by translating into governance tensions. As identified in the public management literature, these tensions come from the diffusion of management principles and practices from the business world. These tensions manifest at four levels: institutional, organisational, managerial and instrumental. The aim of this research is to understand how these tensions are expressed in healthcare organisations of different status.

Methods

We conduct a contrasting case study exploring the cases of two French healthcare organisations, one private for-profit (clinic) and one public not-for-profit (cancer treatment centre). Our analyses are mainly based on the content analysis of 32 semi-structured interviews conducted with staff (nurses, doctors, management and administrative staff) of these two organisations.

Results

Our results show that these tensions can be distinguished into three categories (tensions on professional values, standards and practices) which are expressed differently depending on the type of healthcare organisation and its main management characteristics.

Conclusions

Unexpectedly, in the for-profit organisation, the most intense tensions concern professional standards, whereas they concern professional practices in the not-for-profit organisation. These analyses can help guide policy makers and healthcare managers to better integrate these tensions into their political and managerial decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07401-4.

A qualitative study of hospital clinical staff perceptions of their interactions with healthcare middle managers

PURPOSE

The authors explored clinical staff perceptions of their interactions with middle management and their experiences of the uncongeniality of their working environment.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews of clinical staff from an Australian public health service's Emergency, Surgery and Psychiatry departments. Volunteer interview transcripts were inductively coded using a reflexive thematic content analysis.

FINDINGS

Of 73 interviews, 66 participants discussed their interactions with management. Most clinicians considered their interactions with middle management to be negative based on a violation of their expectations of support in the workplace. Collectively, these interactions formed the basis of clinical staff perceptions of management's lack of capacity and fit for the needs of staff to perform their roles.

PRACTICAL IMPLICATIONS

Strategies to improve management's fit with clinicians' needs may be beneficial for reducing uncongenial workplaces for healthcare staff and enhanced patient care.

ORIGINALITY/VALUE

This article is among the few papers that discuss interactions with management from the perspective of clinical staff in healthcare. How these perspectives inform the perception of workplace uncongeniality for clinicians contributes greater understanding of the factors contributing to adversarial relationships between clinicians and managers.

Do expert clinicians make the best managers? Evidence from hospitals in Denmark, Australia and Switzerland

Introduction

Hospital quality rests on the morale and productivity of those who work in them. It is therefore important to try to understand the kinds of team leaders that create high morale within hospitals.

Methods

This study collects and examines data on 3000 physicians in hospitals from Denmark, Australia and Switzerland. It estimates regression equations to study the statistical predictors of levels of doctors’ job satisfaction, their intentions to quit or stay in their current hospital and their assessment of the leadership quality of their immediate manager. A particular concern of this study is to probe the potential role played by clinical expertise among those in charge of other physicians.

Results

When led by managers with high clinical expertise, hospital physicians are (1) more satisfied with their jobs, (2) more satisfied with their supervisors’ effectiveness and (3) less likely to wish to quit their current job. These findings are robust to adjustment for potential confounders, including age and job seniority, and pass a variety of statistical checks (including clustering of SEs and checking for omitted variable bias). They are replicated in each of the three nations.

Conclusion

Physicians are happier with their jobs when led by outstanding clinical experts. It is not sufficient, it appears from this evidence, for leaders merely to be clinicians. This suggests that—though only an idealised and presumably infeasible randomised experiment could allow complete certainty—there is a natural case for managers within a hospital hierarchy to be drawn from the ranks of those who are themselves outstanding clinicians.

The challenges of becoming and being a clinician manager: a qualitative exploration of the perception of medical doctors in senior leadership roles at a large Australian health service

BACKGROUND

In Australia, activity-based funding models have emphasized the need for hospitals to be accountable for their clinical performance. Clinician managers, with medical backgrounds are essential to ensuring high quality clinical performance and operational management of hospital services. The purpose of this study is to 1. Identify factors influencing doctors to become clinician managers in the Australian healthcare setting. 2. Understand the pathways and challenges faced by doctors in becoming clinician managers.

METHODS

We undertook a qualitative study with semi-structured interviews of 18 clinician managers (who have medical practitioner backgrounds) with formal leadership administrative roles. Interview transcripts were analysed with systematic text condensation.

RESULTS

All eligible participants approached in this context, agreed to participate and over 80% of the participants were male. We identified five themes: 'Motivations for leadership', 'Pathways to managerial role', 'Challenges faced in management roles', 'Credibility through clinical practice' and 'Management skill cultivation and support'. Clinician managers progressed from being doctors to leadership roles through being encouraged to take on roles, while others felt pressure to take on leadership roles even if this was not a personal goal. Clinician managers described challenges such as feeling under-prepared, maintaining respect form colleagues through still participating in a clinical load, along with juggling priorities such as administrative tasks, managing budgets and performance managing other doctors.

CONCLUSIONS

There needs to be an intentional and more structured approach to training and supporting clinician managers that considers the complex challenges faced by individuals (especially women) as they progress into these roles in the Australian tertiary health services context. There is a need to consider ways of supporting clinician managers to focus on management skills, effective mentorship and address perceptions around losing respect from colleagues if clinician managers cease their clinical loads. Further research is needed among the female medical workforce, along with research to understand if maintaining clinical loads when undertaking a clinical management role in fact leads to better effectiveness in contributing to better patient safety and quality outcomes. Such evidence may assist in addressing these social pressures among clinician managers, and contribute to addressing gender inequality among the clinical management workforce.

Priorities of Hybrid Clinician-Managers: A Qualitative Study of How Managers Balance Clinical Quality Among Competing Responsibilities

OBJECTIVE

Oversight of clinical quality is only one of physical therapy managers' multiple responsibilities. With the move to value-based care, organizations need sound management to navigate this evolving reimbursement landscape. Previous research has not explored how competing priorities affect physical therapy managers' oversight of clinical quality. The purpose of this study was to create a preliminary model of the competing priorities, motivations, and responsibilities of managers while overseeing clinical quality.

METHODS

This qualitative study used the Rapid Qualitative Inquiry method. A purposive sample of 40 physical therapy managers and corporate leaders was recruited. A research team performed semi-structured interviews and observations in outpatient practices. The team used a grounded theory-based immersion/crystallization analysis approach. Identified themes delineated the competing priorities and workflows these managers use in their administrative duties.

RESULTS

Six primary themes were identified that illustrate how managers: (1) balance managerial and professional priorities; (2) are susceptible to stakeholder influences; (3) experience internal conflict; (4) struggle to measure and define quality objectively; (5) are influenced by the culture and structure of their respective organizations; and (6) have professional needs apart from the needs of their clinics.

CONCLUSION

Generally, managers' focus on clinical quality is notably less comprehensive than their focus on clinical operations. Additionally, the complex role of hybrid clinician-manager leaves limited time beyond direct patient care for administrative duties. Managers in organizations that hold them accountable to quality-based metrics have more systematic clinical quality oversight processes.

IMPACT

This study gives physical therapy organizations a framework of factors that can be influenced to better facilitate managers' effective oversight of clinical quality. Organizations offering support for those managerial responsibilities will be well positioned to thrive in the new fee-for-value care structure.

Medical hybridity and beyond: professional transitions in Italian outpatient settings

The marketization of public healthcare has brought about organizational transformations, affecting health professionals' ways of working in hospitals and outpatient organizations. As a result of the reforms in the 1990s, the principle of business-like healthcare has been introduced in the Italian health system. This paper presents the main findings of a study of specialist doctors working in two local health organizations in the Tuscany region. Drawing on semi-structured interviews with specialist doctors working in an outpatient setting, the article examines the manifold reactions to changes of the medical profession within outpatient settings. In particular, the combination of professional and organizational dimensions has been taken into consideration. The results show that a change is involving outpatient specialist doctors' identity: organizational change affects several dimensions of the medical professional ethos. The change has been understood by categorizing three major types of approaches to medical professionalism, which are aimed to understand the complexity of the domain and to summarize professionals' reactions: the first is linked to a traditional model of professionalism; the second accepts partially business-like organizational issues, while trying to create individual spaces of autonomy in daily tasks; the third co-opts new organizational issues, which become part of the medical professional ethos.

Hospital managers' perspectives with implementing quality improvement measures and a new regulatory framework: a qualitative case study

A new regulatory framework to support local quality and safety efforts in hospitals was introduced to the Norwegian healthcare system in 2017. This study aimed to investigate hospital managers' perspectives on implementation efforts and the resulting work practices, to understand if, and how, the new Quality Improvement Regulation influenced quality and safety improvement activities.

DESIGN

This article reports one study level (the perspectives of hospital managers), as part of a multilevel case study. Data were collected by interviews and analysed according to qualitative content analysis.

SETTING

Three hospitals retrieved from two regional health trusts in Norway.

PARTICIPANTS

20 hospital managers or quality advisers selected from different levels of hospital organisations.

RESULTS

Four themes were identified in response to the study aim: (1) adaptive capacity in hospital management and practice, (2) implementation efforts and challenges with quality improvement, (3) systemic changes and (4) the potential to learn. Recent structural and cultural changes to, and development of, quality improvement systems in hospitals were discovered (3). Participants however, revealed no change in their practice solely due to the new Quality Improvement Regulation (2). Findings indicated that hospital managers are legally responsible for quality improvement implementation and participants described several benefits with the new Quality Improvement Regulation (2). This related to adaptation and flexibility to local context, and clinical autonomy as an inevitable element in hospital practice (1). Trust and a safe work environment were described as key factors to achieve adverse event reporting and support learning processes (4).

CONCLUSIONS

This study suggests that a lack of time, competence and/or motivation, impacted hospitals' implementation of quality improvement efforts. Hospital managers' autonomy and adaptive capacity to tailor quality improvement efforts were key for the new Quality Improvement Regulation to have any relevant impact on hospital practice and for it to influence quality and safety improvement activities.

The association between supervisor support and ethical dilemmas on Nurses' intention to leave: The mediating role of the meaning of work

AIM

To examine the association between supervisor support and ethical dilemmas on nurses' intention to leave health care organisations, both directly and through the mediating role of the meaning of work.

BACKGROUND

The shortage of nurses makes it vital that organisations retain nurses and so reduce the costs associated with replacing experienced nurses.

METHODS

This cross-sectional study samples 2,946 registered nurses from a selected health region in Norway. Structural equation modelling was used to test a hypothesized model.

RESULTS

Social support from the supervisor and ethical dilemmas is associated with nurses' intention to leave, both directly and indirectly through the mediating role of the meaning of work.

CONCLUSION

Health care organisations should enhance social support from supervisors and the meaning of work, and reduce the level of ethical dilemmas in hospitals.

IMPLICATIONS FOR NURSING MANAGEMENT

Health care organisations should continuously develop and offer training in nurse manager skills, such as being empathic, understanding employees' needs and how to communicate and handle ethical dilemmas. Managers should value staff contributions, encourage staff involvement in ethical questions and highlight the impact of nurses' work on improving the welfare of others.

Exploring the role of managers in the development of a safety culture in seven French healthcare facilities: a qualitative study

BACKGROUND

Numerous studies have been conducted over the past 15 years to assess safety culture within healthcare facilities; in general, these studies have shown the pivotal role that managers play in its development. However, little is known about what healthcare managers actually do to support this development, and how caregivers and managers represent managers'role. Thus the objectives of this study were to explore: i) caregivers and managers' perceptions and representations of safety, ii) the role of managers in the development of safety culture as perceived by themselves and by caregivers, iii) managers' activities related to the development of safety culture.

METHODS

An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in France. Semi-structured interviews were conducted with managers (frontline, middle and top level) and caregivers (doctors, nurses and nurse assistants) and on-site observations of two managers were carried out in all facilities. A thematic analysis of semi-structured interviews was performed. Observed activities were categorised using Luthans' typology of managerial activities.

RESULTS

Participants in semi-structured interviews (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants. However, caregivers' expectations of their managers and managerial perceptions of these expectations only partially overlapped.

CONCLUSIONS

The present study highlights current categories of managerial activities that foster safety culture, and points out an important gap between caregivers' expectations of their managers, and managerial perceptions of these expectations. The findings underline the need to allow more time for managers and caregivers to talk about safety issues. The results could be used to develop training programs to help healthcare managers to understand their role in the development of safety culture.

Making a career in hospitals: Determinants of registered nurses' aspirations to become a manager

AIM

To examine seven determinants of Registered Nurses' aspirations to become a manager in four Norwegian public hospitals.

BACKGROUND

Research evidence shows that nurses submit few applications to management positions. Understanding the determinants that influence nurses' aspirations to become managers can provide healthcare organizations with important knowledge on the drivers and barriers in recruitment and on the development of nurse managers.

DESIGN

This study adopted a cross-sectional web-based survey design.

METHOD

Logistic regression analysis based on 2,630 Registered Nurses' responses to a self-completion survey in a Norwegian regional health authority collected during October 2014. The overall response rate was 40%.

RESULTS

Findings indicate that men and younger nurses are most likely to report an aspiration in management. The social support of an immediate supervisor and institutional stress are positively associated with an aspiration to become a manager; however, high experienced workloads have the opposite effect.

CONCLUSION

Healthcare organizations should work strategically to develop a human resource management policy that ensures that the organization develops the nurse managers it needs now and in the future.

IMPACT

This study addresses the challenge of having enough qualified nurse managers. The main findings indicate that job demands can have both a negative and positive impact on nurses' aspirations to become a manager. Healthcare organizations should, however, reduce demands and consider increasing job resources. The results should have an impact on the human resource department, managers, and other key personnel in healthcare organizations.

Organizational constraints as root causes of role conflict

PURPOSE

The purpose of this paper is to gain a better understanding of the difficulties encountered in the hybrid roles of physician-managers (P-Ms), examine the impact of organizational constraints on the role conflicts experienced by P-Ms and explore the different ways their two roles are integrated.

DESIGN/METHODOLOGY/APPROACH

A qualitative approach was adopted, using six focus groups made up of clinical co-managers, medical directors and P-Ms. In all, 43 different people were interviewed to obtain their perceptions of the day-to-day realities of the role of the P-M. The data collected were subsequently validated.

FINDINGS

Although the expectations of the different groups involved regarding the role of P-Ms are well understood and shared, there are significant organizational constraints affecting what P-Ms are able to do in their day-to-day activities, and these constraints can result in role conflicts for the people involved. Such constraints also affect the ways P-Ms integrate the two roles. The authors identify three role hybridization profiles.

PRACTICAL IMPLICATIONS

The results afford a better understanding of how organizational constraints might be used as levers of organizational change to achieve a better hybridization of the dual roles of P-Ms.

ORIGINALITY/VALUE

This paper seeks to reach beyond a simple identification of constraints affecting the dual roles of P-Ms by analyzing how such constraints impact on these professionals' day-to-day activities. Results also enable us to further refine Katz and Kahn's (1966) role model, in addition to identifying hybridization profiles.

Competitive Advantage of MBA for Physician Executives: A Systematic Literature Review

In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one's competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership (n = 17), career advancement opportunities (n = 12), understanding of financial aspects of medicine (n = 9) and team-building skills (n = 10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work-life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Physician leadership development: towards multidisciplinary programs?

Background

The format and content of leadership development programmes for physicians is a theme for discussion in the literature.

Objectives

The aim of this study is to explore healthcare executives’ perspectives on physician leadership development, focusing on perceived benefits and negative effects associated with multidisciplinary programmes.

Methods

We did a qualitative study based on data from semistructured interviews with 16 healthcare executives in US healthcare systems.

Results

We found that one group perceived programmes targeting one profession as advantageous, promoting openness and professional relationships among peers. Other executives argued that multidisciplinary programmes could add value because they could bridge professional boundaries, strengthen networks and build leadership capacity throughout an organisation. Costs, timing, organisational culture and a lack of knowledge about how to run multidisciplinary programmes were challenges our informants associated with multidisciplinary leadership development programmes.

Conclusion

This study identifies topics and challenges that can inform organisational policies and decisions about leadership development activities.

Medical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors?

INTRODUCTION

Despite common assumptions that doctors are well placed to lead hospitals and healthcare organisations, the peer-reviewed literature contains little evidence on the performance of doctors in leadership roles in comparison with that of non-medical managers.

OBJECTIVES

To determine whether there is an association between the leader's medical background and management performance in terms of organisational performance or patient outcomes.

METHODS

We searched for peer-reviewed, English language studies using Medline, Embase and Emerald Management between 2005 and 2017. We included quantitative, qualitative and mixed method empirical studies on the performance of senior healthcare managers where participants were described as doctors or leaders and where comparative performance data were provided on non-medical leaders. Studies without full text available, or no organisational, leadership behaviour or patient measures, were excluded.

RESULTS

The search, conducted in Medline (n=3395), Embase (n=1913) and Emerald Management (n=454) databases, yielded 3926 entries. After the application of inclusion and exclusion criteria, 16 studies remained. Twelve studies found that there were positive differences between medical and non-medical leaders, and eight studies correlated those findings with hospital performance or patient outcomes. Six studies examined the composition of boards of directors; otherwise, there were few common areas of investigation. Five inter-related themes emerged from a narrative analysis: the impact of medical leadership on outcomes; doctors on boards; contribution of qualifications and experience; the medical leader as an individual or part of a team and doctors transitioning into the medical leadership role.

DISCUSSION AND CONCLUSION

A modest body of evidence supports the importance of including doctors on organisational governing boards. Despite many published articles on the topic of whether hospitals and healthcare organisations perform better when led by doctors, there were few empirical studies that directly compared the performance of medical and non-medical managers. This is an under-researched area that requires further funding and focus.

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.