Medicine and management in European hospitals: a comparative overview

Involving clinicians in management: assessing views of doctors and nurses on hybrid professionalism in clinical directorates

BACKGROUND

Hybrid professionalism is one of the most effective ways to involve clinicians in management practices and responsibilities. With this study we investigated the perceptions of doctors and nurses on hybridization in clinical directorates (CDs) in hospitals.

METHODS

We investigated the attitudes of healthcare professionals (doctors and nurses) towards eight hospital CDs in the Local Health Authority (LHA) of Bologna (Emilia Romagna, Italy) 6 years after their implementation. We used a validated questionnaire by Braithwaite and Westbrook (2004). Drawing on Palmer et al. (2007), we added a section about the characteristics of department heads. In all, 123 healthcare professionals in managerial roles completed and returned the questionnaire. The return rate was 47.4% for doctors and 31.6% for nurses.

RESULTS

Doctors reported an increase in clinical governance, interdisciplinarity collaboration, and standardization of clinical work. Hybridization of practices was noted to have taken place. While doctors did not see these changes as a threat to professional values, they felt that hospital managers had taken greater control. There was a large overlap of attitudes between doctors and nurses: inter-professional integration in CDs fostered alignment of values and aims. The polarity index was higher for responses from the doctors than from the nurses.

CONCLUSION

The study findings have implications for policy makers and managers: mission and strategic mandate of CDs; governance of CDs, leadership issues; opportunities for engaging healthcare professionals; changes in managerial involvement during the COVID-19 pandemic. We also discuss the limitations of the present study and future areas for research into hybrid structures.

What is the performance in public hospitals? A longitudinal analysis of performance plans through topic modeling

BACKGROUND

Both the concept of performance and the role of hospitals in health systems evolved significantly in the last decades. Today, the performance in health could be defined as the ability to create 'population value,' and the hospitals' role is to support this aim by providing acute care and by integrating and coordinating their activity with other settings of care. This research aims to assess how and with what degree the management of public hospitals have embraced in practice the updated concept of performance and their new role.

RESULT

The paper analyses 181 performance plans of 48 Italian autonomous public hospitals over a nine-year period through the topic modeling algorithm called Latent Dirichlet Allocation (LDA). This is a method that allows for analysing large textual corpora that generates a representation of the latent topics discussed therein. The concept of performance in public hospitals was framed into 15 topics resulting from the analysis of the hospitals' performance plans. The prevalence of each topic was analysed through the period considered so as to understand the evolution of performance-related practices over the last decade.

CONCLUSION

In recent years, the concept of performance in hospitals evolved toward the adoption of an outcome-based and population-based perspective. Additional effort should be devoted toward improved collaboration and integration of care with other settings.

The role of professional elites in healthcare governance: Exploring the work of the medical director

Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014–2019), we elaborate the role of medical directors in healthcare governance as ‘translation work’, ‘diplomatic work’, and ‘repair work’. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional ‘political elites’, and as ‘corporate elites’ in publicly-funded healthcare systems.

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Medical Directors affect quality through translation, diplomatic, and repair work.

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Medical Directors are regional ‘political elites’ on the frontstage and backstage.

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Some Medical Directors are ‘corporate elites’ aligned with organisational interests.

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Service change has enduring emotional effects that can negatively affect quality.

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.

Involving hybrid professionals in top management decision-making: How managerial training can make the difference

Hybrid professionals have a two-fold – professional and managerial – role, which requires appropriate management skills. Investing on managerial training programs aims to empower professionals with managerial skills and competencies. Does this pay back? Assessing the impact of such training programs is still a limited practice. This paper explores whether participation in managerial training programs in healthcare can enhance the involvement of hybrid professionals (namely, clinical directors) in top management decision-making. The mediational effects of knowledge of performance information and its use are explored.

Survey data were collected from more than 3000 clinical directors of 69 public health authorities from five regional healthcare systems in Italy. Relationships between participation in managerial training programs, performance management practices (i.e., knowledge and use of performance information) and the level of clinicians’ involvement by the top management were studied using a three-path mediation analysis with structural equation modelling. Propensity score matching was also performed to mitigate selection bias.

Knowledge and use of performance information positively mediate, both independently and sequentially, the relationship between clinical directors' participation in managerial training programs and the level of their involvement in decision-making.

The results of the study suggest that managerial training can support hybrid professionals in engaging with managerialism and playing upward influence on top management decision-making.

Priorities and challenges for health leadership and workforce management globally: a rapid review

BACKGROUND

Health systems are complex and continually changing across a variety of contexts and health service levels. The capacities needed by health managers and leaders to respond to current and emerging issues are not yet well understood. Studies to date have been country-specific and have not integrated different international and multi-level insights. This review examines the current and emerging challenges for health leadership and workforce management in diverse contexts and health systems at three structural levels, from the overarching macro (international, national) context to the meso context of organisations through to the micro context of individual healthcare managers.

METHODS

A rapid review of evidence was undertaken using a systematic search of a selected segment of the diverse literature related to health leadership and management. A range of text words, synonyms and subject headings were developed for the major concepts of global health, health service management and health leadership. An explorative review of three electronic databases (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content between January 2010 to July 2018. A search strategy was then applied to the key journals identified, in addition to hand searching the journals and reference list of relevant papers identified. Inclusion criteria were independently applied to potentially relevant articles by three reviewers. Data were subject to a narrative synthesis to highlight key concepts identified.

RESULTS

Sixty-three articles were included. A set of consistent challenges and emerging trends within healthcare sectors internationally for health leadership and management were represented at the three structural levels. At the macro level these included societal, demographic, historical and cultural factors; at the meso level, human resource management challenges, changing structures and performance measures and intensified management; and at the micro level shifting roles and expectations in the workplace for health care managers.

CONCLUSION

Contemporary challenges and emerging needs of the global health management workforce orient around efficiency-saving, change and human resource management. The role of health managers is evolving and expanding to meet these new priorities. Ensuring contemporary health leaders and managers have the capabilities to respond to the current landscape is critical.

Successful Curriculum Change in Health Management and Leadership Studies for the Specialist Training Programs in Medicine in Finland

In Finland, the specialization programs in Medicine and Dentistry can be undertaken at all five university medical faculties in 50 specialization programs and in five programs for Dentistry. The specialist training requires 5 or 6 years (300–360 ECTS credits) of medical practice including 9 months of service in primary health care centers, theoretical substance specific education, management studies, and passing a national written exam. The renovation of the national curriculum for the specialization programs was implemented, first in 2008 and officially in August 2009, when theoretical multi-professional social, health management and leadership studies (10–30 ECTS credits) were added to the curriculum. According to European Credit Transfer and Accumulation System (ECTS), 1 ECTS credit (henceforth, simply “ECTS”) means 27–30 h of academic work¹ National guidelines for the multi-professional leadership training include the basics of organizational management and leadership, the social and healthcare system, human resources (HR) management, leadership interaction and organizational communication, healthcare economy, legislation (HR) and data management. Each medical faculty has implemented management studies autonomously but according to national guidelines. This paper will describe how the compulsory management studies (10 ECTS) have been executed at the Universities of Tampere and Turku. In Tampere, the 10 ECTS management studies follow a flexible design of six academic modules. Versatile modern teaching methods such as technology-assisted and student orientated learning are used. Advanced supplementary management studies (20 ECTS) are also available. In Turku, the 10 ECTS studies consist of academic lectures, portfolio and project work. Attendees select contact studies (4–6 ECTS) from yearly available 20 ECTS and proceed at their own pace. Portfolio and project comprise 2–5 ECTS each. The renovation of medical specializing physicians' management and leadership education has been a successful reform. It has been observed that positive attitudes and interest toward management overall are increasing among younger doctors. In addition, management and leadership education will presumably facilitate medical doctors' work as managers also. Continuous development of medical doctors' management and leadership education for physicians and dentists is needed while the changing and complex healthcare environment requires both professional and leadership expertise.

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark

BACKGROUND

Patient-centred care based on needs has been gaining momentum in health policy and the workforce. This creates new demand for interprofessional teams and redefining roles and tasks of professionals, yet little is known on how to implement new health policies more effectively. Our aim was to analyse the role and capacity of health professions in driving organisational change in interprofessional working and patient-centred care.

METHODS

A case study of the introduction of interprofessional, early discharge teams in stroke rehabilitation in Denmark was conducted with focus on day-to-day coordination of care tasks and the professional groups' interests and strategies. The study included 5 stroke teams and 17 interviews with different health professionals conducted in 2015.

RESULTS

Professional groups expressed highly positive professional interest in reorganised stroke rehabilitation concerning patients, professional practice and intersectoral relations; individual professional and collective interprofessional interests strongly coincided. The corresponding strategies were driven by a shared goal of providing needs-based care for patients. Individual professionals worked independently and on behalf of the team. There was also a degree of skills transfer as individual team members screened patients on behalf of other professional groups.

CONCLUSIONS

The study identified supportive factors and contexts of patient-centred care. This highlights capacity to improve health workforce governance through professional participation, which should be explored more systematically in a wider range of healthcare services.

Closing the gender leadership gap: a multi-centre cross-country comparison of women in management and leadership in academic health centres in the European Union

BACKGROUND

Women's participation in medicine and the need for gender equality in healthcare are increasingly recognised, yet little attention is paid to leadership and management positions in large publicly funded academic health centres. This study illustrates such a need, taking the case of four large European centres: Charité - Universitätsmedizin Berlin (Germany), Karolinska Institutet (Sweden), Medizinische Universität Wien (Austria), and Oxford Academic Health Science Centre (United Kingdom).

CASE

The percentage of female medical students and doctors in all four countries is now well within the 40-60% gender balance zone. Women are less well represented among specialists and remain significantly under-represented among senior doctors and full professors. All four centres have made progress in closing the gender leadership gap on boards and other top-level decision-making bodies, but a gender leadership gap remains relevant. The level of achieved gender balance varies significantly between the centres and largely mirrors country-specific welfare state models, with more equal gender relations in Sweden than in the other countries. Notably, there are also similar trends across countries and centres: gender inequality is stronger within academic enterprises than within hospital enterprises and stronger in middle management than at the top level. These novel findings reveal fissures in the 'glass ceiling' effects at top-level management, while the barriers for women shift to middle-level management and remain strong in academic positions. The uneven shifts in the leadership gap are highly relevant and have policy implications.

CONCLUSION

Setting gender balance objectives exclusively for top-level decision-making bodies may not effectively promote a wider goal of gender equality. Academic health centres should pay greater attention to gender equality as an issue of organisational performance and good leadership at all levels of management, with particular attention to academic enterprises and newly created management structures. Developing comprehensive gender-sensitive health workforce monitoring systems and comparing progress across academic health centres in Europe could help to identify the gender leadership gap and utilise health human resources more effectively.

Securing the Continuity of Medical Competence in Times of Demographic Change: A Proposal

BACKGROUND

University hospitals make up the backbone of medical and economic services of hospitals in Germany: they qualify specialist physicians, ensure medical research, and provide highly specialized maximum medical care, which other hospitals cannot undertake. In addition to this assignment, medical research and academic teaching must be managed despite a growing shortage of specialist physicians. By the year 2020, the need for the replacement of retired physicians and increased demand will total 30,000 positions. The situation will become more difficult because, on the whole, patients are becoming older and sicker and because specialist physicians are able to find more attractive working conditions in smaller hospitals, abroad, or outside of curative medicine.

OBJECTIVE

In order to retain sufficient qualified employees, major improvements in quality are required in terms of working and training conditions. For this purpose, a sustainable innovation process is necessary, which incorporates solutions from outside of the health care sector in order to be able to learn from experiences and mistakes from other industries. The FacharztPlus project aims to find suitable measures in order to retain specialist physicians for more years after the completion of 5 years of professional training. This should determine the suitability of additional qualifications alongside the professional career and an expertise-related work organization oriented to different stages of life.

METHODS

Structured interviews, surveys, and repertory grids are used as preparation for cross-industry expert panels to create future work scenarios for university hospitals. Industries involved are harbor logistics (container terminal), airports, and digitized industrial production ("industry 4.0") because these industries are also facing a shortage of qualified staff and have to respond to rapidly changing demands. Based on the experts' scenarios, consensus groups will be established in each university hospital trying to reach consensus about the implementation of relevant factors in order to improve employee retention.

RESULTS

We expect these consensus groups to develop and introduce measures for more structured training procedures, individual and team incentives, organizational guidelines for better recruiting and retention in hospitals, models of flexible and attractive working conditions including shift work and vacation planning, and use of new learning tools (eg, tablet PCs and mobile phones).

CONCLUSIONS

All measures are implemented in the Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine at the University Hospital Muenster (UKM) with approximately 150 physicians and in the further 44 departments of the UKM and 22 teaching hospitals, which all together employ more than 5000 physicians. The measures will also be implemented at the university hospitals in Aachen, Rostock, and Greifswald. All decisions and measures will be discussed with representatives from hospital management and professional associations. Results will be presented at conferences and published in journals.

Patient involvement in Europe--a comparative framework

PURPOSE

The purpose of this paper is to provide and explain the model that underlies most of the research reported within this special issue on "Patient involvement in health care across Europe".

DESIGN/METHODOLOGY/APPROACH

This introduction provides a literature review and a conceptual framework for the understanding of patient involvement and its potential development within health care across Europe.

FINDINGS

Patient involvement can be characterised in terms of three ideal types: voice, choice and co-production. Policies for developing user involvement in healthcare can have disempowering as well as empowering consequences. The pattern of dissemination of user involvement across Europe varies in form and content largely due to path dependency.

RESEARCH LIMITATIONS/IMPLICATIONS

The paper provides a template for future comparative research on user involvement in health care and one that could be extended to social care as well as other varieties of human services. This introduction and the special issue highlights the need for further comparative research in this area.

ORIGINALITY/VALUE

The paper presents a robust model for comparative research. The findings may well be useful not only to researchers but also to policy makers and analysts.