Talking towards excellence: a theoretical underpinning of the dialogue between doctors and managers

Managing healthcare services: Are professionals ready to play the role of manager?

Health professionals are now required to develop skills that help them to achieve better organizational performance, in addition to the skills necessary to carry out their professional activities. The role of clinician-manager has thus grown rapidly in all the main industrialized countries. The purpose of this study is to investigate how healthcare professionals perceive their level of preparation in managerial skills. Analysing literature on managerial skills in the health sector, ten domains of skills emerged and were used to construct a questionnaire. A survey analysis was conducted among professionals from health organizations in two Italian regions. Independent t-tests were conducted and a one-way analysis of variance was performed in order to compare the self-assessment competency levels in selected subgroups of participants. Findings show that healthcare professionals feel sufficiently prepared in all managerial areas identified. However, they also suggest that health organizations should invest more in all managerial areas. Differences between self-perception of competence and need for training occur among managers and non-managers. The findings will be useful for top management and policy makers designing operational tools for intervention in human resource development, with the aim of providing appropriate training and skills for clinician-managers.

Ignorance management in hospitals

Purpose

The purpose of this paper is to investigate how professionals, like doctors, deal with their ignorance? Which strategies do they apply? How can the organization support activities that encourage dealing with ignorance in a positive way? The paper shows how ignorance can be managed in professional organizations like hospitals.

Design/methodology/approach

To explore this touchy subject, the research follows a sequential mixed method design. The advantage of combining research methods is the opportunity to explore an uninvestigated research field. In the first exploratory research sequence (empirical study 1) preliminary questions were defined by means of 43 qualitative semi-structured interviews with hospital physicians and literature analysis. The results of the qualitative content analysis also served as a starting point for the development of a Germany-wide online-questionnaire survey with more than 2,500 physicians (empirical study 2).

Findings

The results show that breaks, a lack of negative organizational constraints, collective learning, positive role models and intrinsic motivation have the highest impact on ignorance sharing of physicians in hospitals. In reverse, negative organizational constraints, distrust, a lack of intrinsic motivation and omitting the implementation of evidence-based insights in terms of collective learning have the highest impact on hiding ignorance. These findings help to manage ignorance in a positive way.

Originality/value

Physicians all over the world have to deal with incomplete information and ignorance in their daily work. Mostly, they have no time and/or resources to gather all relevant information before they make a diagnosis or administer a therapy. It is quite evident that scientific discourses on knowledge management and professions mostly emphasize the power of expertise and knowledge, whereas research on ignorance is currently more or less neglected. This paper is one of the first attempts to overcome this research gap.

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.

Nursing experiences of clinical governance implementation: a qualitative study

Purpose

– Clinical governance (CG) was used as a driver to improve safety and quality of healthcare. CG implementing is a change in health system and all the stakeholders must be participating. The purpose of this paper is to study nurses’ experience about CG movement in Tabriz hospitals.

Design/methodology/approach

– A qualitative study using Focus Group Discussions (FGD) was done. Purposeful Sampling was used to select the objectives including 65 participants. Actually seven FGD’s were held. Content analysis was used to extract the meaningful themes.

Findings

– It is revealed that nurses are the focal point in CG implementation in hospitals. Low commitment of managers and lack of physicians’ contribution was experienced by nurses. However, personnel education and development and patient safety have got more attention. Blame culture and increased work stress was reported as challenges.

Originality/value

– CG as a change in healthcare system, especially in low- and middle-income countries, is faced by several challenges and its implementation would have different experiences. Nursing staff, the major group in hospitals, would be having interesting experiences through CG. Their practical opinions could guide the policy makers to employ proper plans to effectively implement CG. Considering the result of this study in practice would lead to improve CG implementation.

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.

The implementation of process orientation at a Swedish hospital

During the last decade, as a response to the need for inter- as well as intra-organizational integration, management models initially developed for industry have been spread to health care organizations. Based on 62 in-depth interviews, this qualitative study aims at describing and analyzing the limited success of implementation of process orientation at a Swedish hospital and in doing so, the traditional and the critical approaches are combined. Applying a traditional approach, the limited success of the implementation of process orientation is explained in terms of difficulties to challenge deeply institutionalized organizational routines and the inter-disciplinary boundaries. This might be condensed to the dilemma of how to maintain and develop the specialization of the medical profession while focusing process rather than function and how to enhance inter-organizational integration without hampering intra-organizational collaboration. Applying a critical approach, the limited success is explained in terms of a differentiated translation process and in terms of separation of talk and practice. This means that process orientation, notwithstanding that it might be an efficient tool for the type of integration needed, might be regarded as part of a change discourse, aiming at conveying a picture of an efficient and modern organization.

The dynamics of commissioning across organisational and clinical boundaries

PURPOSE

The purpose of the paper is to investigate the inter- and intra-organisational relationships in the commissioning of secondary care by primary care trusts in England, using a principal-agent framework.

DESIGN/METHODOLOGY/APPROACH

The methodology is a qualitative study of three case studies. A total of 13 commissioning-related meetings were observed. In total, 21 managers and six consultant surgeons were interviewed.

FINDINGS

There are a number of different levels at which contractual and managerial control take place. Different strengths of control at one level can affect willingness to comply with agreements at other levels. Agreements at one level do not necessarily result in appropriate or expected action at another.

RESEARCH LIMITATIONS/IMPLICATIONS

The system for commissioning in the National Health Service (NHS) has changed with the introduction of payment by results and practice-based commissioning. However, the dynamics of the inter- and intra-organisational relationships studied remain.

PRACTICAL IMPLICATIONS

Incentives within organisations are as important as those between organisations. Within a chain of principal-agent relations, it is important that a strong link in the chain does not result in the exploitation of weaknesses in other links. If government targets and frameworks are to be met through commissioning, it may be advantageous to concentrate efforts on developing incentives that align clinician with NHS trust objectives as well as NHS trust with primary care trust (PCT) and government objectives.

ORIGINALITY/VALUE

This paper is based on original empirical work. It uses a principal-agent framework to understand the relationships between PCTs and NHS trusts and highlights the importance of internal NHS trust governance systems in the fulfilment of commissioning agreements.