Managerial clashes disrupt hospitals
Economists and accountants want to manage health services in one way – medical professionals another. Conflicts arise when the two principles compete for control of hospital administrations.
“Problems arise when the administrators of a hospital are operating with disparate types of management logic,” says Elsa Solstad.
Solstad is an associate professor at Harstad University College in North Norway. She has investigated five Norwegian hospitals together with Professor Inger Johanne Pettersen at Sør-Trøndelag University College. They uncovered what occurs when disparate management principles compete simultaneously under one roof.
It’s a matter of corporate financial principles on the one side and health profession concerns on the other. Or, as Solstad describes it:
“On the one hand there is a rationalistic logic, guided by efforts of effectivisation and bottom-line results. On the other – a value and norm based logic that places the patient up front.”
“The professionals in a hospital organisation, doctors and nurses, are being given tasks linked to administrative and financial concerns. They are shouldered with new objectives. A new logic follows what we can call managerialism,” explains Elsa Solstad.
“This requires much more focus on economic efficiency, whereas the professionals start out with a completely different understanding of their daily work tasks,” she says.
Public health costs, funded mainly by taxes, tend to grow year by year. Hospital administrators are expected to give priority to cost-effective operations and try to curb patient costs.
“It’s challenging when the clinically educated middle management further down through the organisation is expected to run things by means of this type of logic. They are have to adhere to a managerial logic which is essentially alien to them,” Solstad.
She refers to doctors and nurses whose hearts are in their profession and whose loyalty is toward the patients.
Protect their colleagues
A common occurrence when medical professionals in middle management are required to toe the line and adopt the logic of accountants and the administration is that they try to shield the colleagues they supervise.
“Leaders of base-level personnel in clinics, sections and departments don’t want to bother them with financial problems. They think: ‘They can get on with their jobs and I’ll try to deal with this financial focus,’” explains Elsa Solstad.
“But when they encounter situations where they have to make priorities, their patients come first in spite of the potential overruns. Their loyalty is to their profession,” she says.
Hard to solve
Solstad doesn’t see any simple solution to this collision of cultures.
“Hospitals have tried to solve this by establishing additional administrative positions lower down in the hierarchy. But at hospitals the chief concern is for the patients,” she says.
Another problem is that hospitals are not adept at learning from one another. Sharing of experiences and improvements that yield financial savings can even be lacking within the same public health divisions.
“They live in their own individual silos,” as Solstad expresses it.
The crash between economists and professionals is not just a problem in Norwegian hospitals.
“I have also done research on high schools and much of the same is evident there. But a lot of reforms have been made in hospitals and they have had to change directions very fast,” says Elsa Solstad.
Translated by: Glenn Ostling
- Inger Johanne Pettersen and Elsa Solstad: Managerialism and Profession-Based Logic: The Use of Accounting Information in Changing Hospitals, Financial Accountabitity & Management 2014, doi: 10.1111/faam.12043 (abstract)