Mattila Kari and Virjo Irma Department of General Practice, Medical School, Tampere University, Tampere, Finland

Transcription

1 The current issue and full text archive of this journal is available at Doctor-managers as decision makers in hospitals and health centres Viitanen Elina, Lehto Juhani and Tampsi-Jarvala Tiina School of Public Health, Tampere University, Tampere, Finland Mattila Kari and Virjo Irma Department of General Practice, Medical School, Tampere University, Tampere, Finland Isokoski Mauri School of Public Health, Tampere University, Tampere, Finland Hyppölä Harri General Practice, Kuopio University Hospital, Kuopio, Finland Kumpusalo Esko Department of Public Health and General Practice, Kuopio University, Kuopio, Finland, and Halila Hannu, Kujala Santero and Vänskä Jukka Finnish Medical Association, Helsinki, Finland Decision makers in hospitals and health centres 85 Abstract Purpose This paper describes factors influencing doctor-managers decision making in specialised health care, health centres and at different levels of management. Design/methodology/approach Data were collected as part of a survey on physicians graduating in as drawn from the register of the Finnish Medical Association. The study sample was formed by selecting all physicians born on odd days (n ¼ 4,144) from the baseline group (n ¼ 8,232). The category of doctor-managers comprised physicians reporting as their main occupation: principal or assistant principal physician of hospital, medical director or principal physician of health centre, senior ward physician of hospital, and health centre physician in charge of a population area. Findings Independent of gender, all doctor-managers responding to the survey reported that the most important base for decision making was personal professional experience. Position in organisation (first-line manager, principal physician) had no impact on the base of decision making. Doctor-managers in primary health care utilised knowledge on norms and knowledge available from their organisation in support of their decision making to a greater degree compared with doctor-managers in specialised health care. Research implications Evolution discourse from public administration is not yet receiving much response in Finnish doctor-managers activities, instead, they still act as clinicians. Originality/value Facing the growing challenges of the future, the paper shows that doctor-managers should reconstruct their orientation and to act more like managers. Keywords Health services, Decision making, Doctors, Finland Paper type Research paper Journal of Health Organization and Management Vol. 20 No. 2, 2006 pp q Emerald Group Publishing Limited DOI /

2 JHOM 20,2 86 Introduction In terms of its institutional structure, financing and goals, the Finnish healthcare system belongs to the same family as the other Scandinavian countries and the UK. One of its leading strategic principles has been justice, with a purpose that health services are targeted on the basis of real needs instead of factors related to personal background. Finnish health services receive their primary funding through general taxation (Häkkinen and Lehto, 2005; Teperi, 2004). Over recent decades, one of the powerful factors influencing the Finnish public healthcare service system has been the law that has set standards for the planning of social and health services and allocated their proportion of state subsidies (1992). It obliges municipalities to provide their inhabitants with social and health services, but without prescribing details for the scope of activities or for the structure of arrangement. In Finland, municipalities range in size from small areas with approx. 1,000 inhabitants to large cities with 200, ,000 inhabitants. They deliver the services in varying ways: through local facilities independent from other municipalities, through participation in a municipal federation, or through purchase from other municipalities or private service providers. As a result, the amount of services delivered by organisations and corporates has increased over the past decade in particular, and at present they provide one fifth of all social and health services (Kauppinen et al., 2004). University hospitals are, however, accountable for specialised health care within their special districts. For municipalities, the social and health service system represents a major share of their expenditure and service production. Being part of a multilevel political system and local democracy is considered a special feature and a strength of the Finnish public health care. Further, separation of organisational activities from financial accountability is emphasised in healthcare planning and decision making. Healthcare professionals are in charge of activities while the municipal administration carries the responsibility for funding. Here, politicians who drive the public system and represent the citizens also introduce their views as decision makers (Häkkinen and Lehto, 2005). The arrangement differs from that of the UK where the government control exerts a substantial impact on local health services as well, and where the NHS has for decades played the role of the central organiser and developer (Ham et al., 2003). In discussing reforms of healthcare organisations, voices in favour of the new public management model are clearly audible. The reforms have been linked for their part with a broader administrative reform of the public sector, which advocates efforts to improve efficiency in the sector, restrain expenditure growth and reduce bureaucracy and expert power (Pollit and Bouckaert, 2000; Farrel and Morris, 2003). In the sphere of health care, besides improving efficiency of financial activities, goals have included development of means that will enable to foresee and control expenditure as well as to gather feedback on the effectiveness of performance and on factors related to quality (Haveri, 2002; Kraghjespersen, 2001; Saltman et al., 1998; Ham and Alberti, 2002). The reform has then introduced changes not only to administrative practices and policies but also especially to management practices for which models have been looked for in the private sector (Haveri, 2002). According to the Finnish National Healthcare Project (2002), a productive, efficient and effective, and functionally capable service system requires that the organisation and its management will undergo extensive reforms. Demands set on management and managers are substantial and partly controversial. Besides underlining accountability

3 for cost-effectiveness, managements await their managers to display knowledge on expert, personnel, quality and financial managements, and on network management in particular. Indeed, healthcare organisations are expected to employ model managers who are committed to meet the requirements of the new public management, and who will serve as regional and local social and health politicians as well. They will know how to lead the reform within the framework of economy and efficiency, and to simultaneously manage multiprofessional staff along pedagogic guidelines while applying the latest knowledge of medical practice. The demands of healthcare reforms have changed the professional autonomy of medical practice through tighter financial guidance and managerial supervision. Guidance is implemented with the aim to increase transparency through financial and management control systems in terms of regulations, evaluations and auditings. As participants in this process, members of the medical professions perceive that their right to self-regulation is suffering and opportunities for influence are diminishing (Edwards et al., 2002; Davies and Harrison, 2003). Pre-existing research on doctor-managers have brought up an issue of motivational conflict between personal clinical orientation and the management role (Tuomiranta, 2002; Sahlin-Andersson and Östergren, 1996; Viitanen et al., 2002; Lehto et al., 2003). Doctors professional identity essentially incorporates clinical and biomedical knowledge with focus on personal performance, authority over individual patient care, and a pursuit of wide professional autonomy in relation to the power of authority exerted by parties outside the medical profession or by the management of the organisation (Kumpusalo et al., 2002; Ham and Alberti, 2002). Managements based on other than the influential power of the professional medical authority in the personal work environment may be considered as alien to doctors professional identity. The demands of the new public management are creating fear of losing the autonomy, discontent and loss of motivation among doctors. This phenomenon is international (Edwards et al., 2002; Doolin, 2001; Edwards et al., 2003; Degeling et al., 2003). In their daily work, doctor-managers make numerous decisions about diverse and multi-level issues. Such decisions are often based on their own personal experience as medical professionals (Forma et al., 2004), but in face of future challenges, doctors will also need new kind of knowledge and a wider orientation to support management. Evolution of the definition of knowledge among doctors has been studied in the UK, for example, by Harrison and colleagues whose framework is shown in Figure 1 of this paper. This paper explores doctor-managers and the choices behind their decision-making. We have asked the following questions:. What kind of knowledge is utilised by doctor-managers in support of personal decision-making?. Is the basis of decision-making different between first-line managers and principal physicians?. Is the basis of decision-making different among doctor-managers in specialised vs primary health care?. Is the basis of decision making different among doctor-managers depending on the gender? Decision makers in hospitals and health centres 87

4 JHOM 20,2 VALID KNOWLEDGE DERIVED MAINLY FROM PERSONAL EXPERIENCE 88 IMPLEMENTATION MAINLY INTERNALLY MOTIVATED Critical appraisal model Reflective practice model Professional consensus model Scientific bureaucratic model IMPLEMENTATION MAINLY DRIVEN BY EXTERNAL PROCESSES Figure 1. Models of medical practice Source: Harrison et al. (2002) VALID KNOWLEDGE DERIVED MAINLY FROM EXTERNAL RESEARCH FINDINGS Subjects and methods The baseline group for the study was retrieved from the register of the Finnish Medical Association. The age cohort seniors comprised doctors graduating during the years (n ¼ 8,232). The study sample was formed by selecting all doctors born on odd days from among the baseline group. The study was conducted as a mail survey by sending altogether 4,144 questionnaires to the selected senior doctors. Data collection began in August 2003 and continued through January Final data contained 2,733 responses from physicians graduating in , and the response rate was 66.4 per cent. Doctor-managers were identified as physicians reporting that their main occupation was principal or assistant principal physician of a hospital (N ¼ 379), medical director or (assistant) principal physician of a health centre (N ¼ 117), senior ward physician or medical specialist in a hospital (N ¼ 604), and health centre physician in charge of a population area (N ¼ 59). In the analysis, principal and assistant principal physicians of hospitals together with medical directors and (assistant) principal physicians of health centres were defined as doctors in management positions. Ward physicians or medical specialists together with health centre physicians in charge of population areas were defined as first-line managers on assumption that all persons in these positions need to make decisions about their work and to act at least as a team leader or equivalent. Factors influencing the decision making of doctor-managers as superiors were measured with a 15-question panel. The panel had a scale of 1-5 (1 ¼ very little, 2 ¼ little, 3 ¼ moderately, 4 ¼ much, and 5 ¼ very much). Questions were divided into five categories/groups, and each category was represented by 1-4 questions. We calculated the percentual proportion of doctors answering much and very much (Table I). The significant differences between first-line managers and principal physicians and between doctors in management positions of specialised healthcare and primary healthcare were determined using the x 2 test for independence. For the test, frequencies of categories 1 and 2 (little) and 4 and 5 (much) were added.

5 Total (n ¼ ) Specialised health care (n ¼ ) Primary health care (n ¼ ) Knowledge on norms Laws and decrees * Care recommendations Official instructions * Professional knowledge Personal professional experience Regional and national interaction within own profession Scientific research related to own sphere Journals related to own sphere Organisational knowledge Statistics and measures of own organisation Documents of own organisation Examples of similar organisations Hospital disctrict s training and other events * Knowledge available on service users Patient demands and needs Comments from media Knowledge available from care personnel Knowledge available on service buyers Financiers (e.g. municipality) demands * Scientific research related to own sphere Knowledge available from care personnel Journals related to own sphere Notes: * Statistically significant deviation at 1 per cent risk. Proportions (per cent) of doctors answering much and very much by organisation Decision makers in hospitals and health centres 89 Table I. Sources of knowledge influencing the decision making of doctors who graduated in and held leading positions in 2003 Results Personal professional experience is the most important basis for decision making Despite the organisation or whether the respondent was a first-line manager or a middle management doctor-manager all respondents reported that their personal professional experience was the most important basis for decision making (Table I). An almost equal prominence was reached by knowledge related to norms like various official instructions, healthcare legislation, decrees and care recommendations. Position in organisation has no effect on the basis of decision making In the present study, no differences emerged in the basis of decision making between first-line managers and doctor-managers in middle management. Management work was reported to rely on clinical management and personal professional experience in decision making (Table I). We may well ask at what level of organisation a doctor-manager s orientation changes from a clinician to a manager if it does not occur even in the management position of a principal physician. Doctor-managers in primary health care share a broader basis for decision making Compared to doctor-managers in specialised health care, doctor-managers in primary health care utilised knowledge of norms and knowledge available from the

6 JHOM 20,2 90 organisation to a greater degree to underpin their decision making (Table II). Further, they were more attentive to financiers requirements than doctor-managers in specialised care did. Specialised health care managers relied in their decision making not only on personal professional experience but also on research evidence from their own sphere. Contextual differences in health centre and hospital work may explain the finding that, in health centres, a continuous interrelationship with other leading officials of the municipality or municipalities and with general knowledge on norms was more pronounced. Specialised health care in turn laid emphasis on scientific research- and evidence-based care. Doctor-managers decision making is not affected by gender In comparing female and male doctor-managers, the basis for decision making was found to be nearly identical. In both genders, the most important factor influencing decision making was personal professional experience. Compared to men, however, women managers took better advantage in their decision making of national and regional knowledge, knowledge available through education and knowledge from care personnel (Table III). Discussion In the UK, Davies and Harrison (2003) have been working on a model to illustrate the trends in doctors knowledge processing over the course of the health reforms. Total (n ¼ 1,036-1,052) Principal physicians (n ¼ ) First-line managers (n ¼ ) Table II. Sources of knowledge influencing the decision making of doctors who graduated in and held leading positions in 2003 Knowledge on norms Laws and decrees Care recommendations Official instructions Professional knowledge Personal professional experience Scientific research related to own sphere Regional and national interaction within own profession Journals related to own sphere Organisational knowledge Statistics and measures of own organisation Documents of own organisation * Examples of similar organisations Hospital disctrict s training and other events * Knowledge available on service users Patient demands and needs Comments from media Knowledge available from care personnel Knowledge available on service buyers Financiers (e.g. municipality) demands Notes: * Statistically significant deviation at 1 per cent risk. Proportions (per cent) of doctors answering much and very much by management position

7 Total (n ¼ 1,011-1,026) Females (n ¼ ) Males (n ¼ ) Knowledge on norms Laws and decrees Care recommendations Official instructions Professional knowledge Personal professional experience Scientific research related to own sphere Regional and national interaction within own profession Journals related to own sphere Organisational knowledge Statistics and measures of own organisation Documents of own organisation * Examples of similar organisations Hospital disctrict s training and other events * Knowledge available on service users Patient demands and needs Comments from media Knowledge available from care personnel Knowledge available on service buyers Financiers (e.g. municipality) demands Notes: * Statistically significant deviation at 1 per cent risk. Proportions (per cent) of doctors answering much and very much by gender Decision makers in hospitals and health centres 91 Table III. Sources of knowledge influencing the decision making of doctors who graduated in and held leading positions in 2003 The researchers describe the evolution and change in health organisations on four dimensions (Figure 1). The four dimensions serve to distinguish the essence of prevailing knowledge into tacit, individual-bound experience-based knowledge, or explicit knowledge based on research and evidence. Implementation and application of knowledge are further separated according to whether the initiation derives from individual personal motivation and interest, or from a larger source within a professional group driven by external actors. In the four dimensional figure, the reflective practice model describes the traditional model of doctors work, with the job description founded on doctors individual discretion, self-acquired empirical knowledge and experience. The arrangement resembles a personal guidebook providing instructions for activities in varying situations. Knowledge on and feedback from activities are then personal property and as such difficult to transfer. In this model, an expert acts within an organisation but unconnected to the powers that drive it. The professional consensus model likewise describes a traditional model for work and decision making in which knowledge is accumulated and distributed on the basis of common experience and by means of transferring empirical and scientific knowledge from external expert sources into own organisation. The profession will subsequently gain access to a specific knowledge base containing the best of practices to guide collective activities. Acquisition and distribution of knowledge rely on personal learning motivation without external elements to control its application.

8 JHOM 20,2 92 With the critical appraisal model Davies and Harrison describe activities in which a knowledge base derived from external sources and with reliance on effectiveness is added to the operating principles of the preceding models. Here, knowledge provides a background from which doctors can draw to facilitate decision making and to obtain guidance towards adopting such care practices that lean on evidence-based effectiveness. In this model, knowledge underpins experience-based knowledge while its utilisation depends on doctors motivation to accept it. Scientific evidence and metaknowledge are components of the scientific-bureaucratic model. The model involves a tighter regulation over the shape of service delivery through external drive processes and normative protocols. This model aims at explaining the variations encountered in care patterns and at channeling them to a more uniform direction, while it simultaneously sets priorities to care practices and evaluates them. In British hospitals, the focus of traditional rationalities is shifting towards systematisation of medical knowledge, a process referred to as the new bureaucratic model. Driving mechanisms as defined by the scientific-bureaucratic model may create problems, since they challenge the significance of experience-based knowledge and limit opportunities for independent decision making. Moreover, conflicts are born implying loss of autonomy in regard to flexibility, professional development and professional values. The presented model is not directly applicable to Finnish healthcare organisations. We would add a new level to tacit and evidence-based knowledge: utilisation of knowledge derived from doctors own organisation. Should we try to fit the findings of this study into the Harrison et al. (2002) model presented above, however, the basis of decision making among Finnish doctor-managers would primarily espouse the utilisation of knowledge derived from doctors personal medical experience and personal motivation to exploit external sources of knowledge. Transition into engaging more of the knowledge available from within and without the organisation for decision making would seem to be more dominant among doctor-managers in primary health care than in specialised health care. Our previous studies have indicated that ward physicians or doctors in corresponding positions regard themselves as senior level consultants rather than managers. Management is more frequently seen as part of the tasks belonging to principal physicians and physicians in higher positions (Viitanen et al., 2002; Lehto et al., 2003). According to the present study, decision making and management orientation among first-line managers and middle level doctor-managers are quite uniform. The results of this study give more support to the findings from the Finnish Physician 1998 Study, in which doctor-managers emerged as clinicians rather than management oriented managers. In 1998, the work of the majority of the principal and the assistant principal physicians in hospitals and health centres consisted mainly of patient care with management duties taking only one-sixth of their work time (Lehto et al., 2003; Hyppölä et al., 2000). The results presented in this paper give weight to the assumption that the situation has not changed in this respect. No transition can be observed like in the UK where the reforms appear to be leading towards the scientific-bureaucratic model. According to our findings, the evolution discourse from the public administration is not yet receiving much response in Finnish doctor-managers activities. The most

9 eminent of the performance, quality and reform managers in the Finnish healthcare system have not succeeded in turning the new models of practice, objectives, organisational changes and evaluations over to doctor-managers to initiate changes in their activities. None the less, doctor-managers are in need of a broader orientation to support the management of healthcare services, as well as of additional management training. References Davies, H. and Harrison, S. (2003), Trends in doctor-manager relationships, British Medical Journal, Vol. 326 No. 7390, pp Degeling, P., Maxwell, S., Kennedy, J. and Coyle, B. (2003), Medicine, management and modernisation: a dance macabre?, British Medical Journal, Vol. 326 No. 7341, pp Doolin, B. (2001), Doctors as managers, Public Management Review, Vol. 3 No. 2, pp Edwards, N., Kornacki, M. and Silversin, J. (2002), Unhappy doctors: what are the causes and what can be done?, British Medical Journal, Vol. 324 No. 7341, pp Edwards, N., Marshall, M. and McLellan, A. (2003), Doctors and managers: a problem without a solution, British Medical Journal, Vol. 326 No. 7390, pp Farrel, C. and Morris, J. (2003), The neo-bureaucratic state: professionals, managers and professional managers in school, general practices and social work, Organization, Vol. 10 No. 1, pp Forma, L. and Viitanen, E. (2004), Lähiesimiehenä Pirkanmaan Sairaanhoitopiirissä (Work as a First-line Manager in the Pirkanmaa Hospital District), Pirkanmaan sairaanhoitopiirin julkaisuja 2, Tampere. Ham, C. and Alberti, K. (2002), The medical profession, the public, and the government, British Medical Journal, Vol. 324 No. 7341, pp Ham, C., Kipping, R. and McLeod, H. (2003), Redesigning work processes in health care: lessons from the national health service, The Milbank Quarterly, Vol. 81 No. 3, pp Harrison, S., Moran, M. and Wood, B. (2002), Policy emergence and policy convergence: the case of scientific-bureaucratic medicine in the USA and UK, British Journal of Politics and International Relations, Vol. 4 No. 1, pp Haveri, A. (2002), Uusi julkisjohtaminen kunnallishallinnon reformeissa ( New public management in the reforms of municipal administration ), Hallinnon Tutkimus, Vol. 21 No. 1, pp Hyppölä, H., Virjo, I. and Mattila, K. (2000), Lääkäri 98 (Physician 98), Sosiaali-ja terveysministeriön julkaisuja 10, Helsinki. Häkkinen, U. and Lehto, J. (2005), Reform change and continuity in Finnish health care, Journal of Health Politics, Policy and Law, Vol. 30 Nos 1/2, pp Kauppinen, S., Niskanen, T., Hämäläinen, H. and Nylander, O. (2004), Yksityissektori sosiaali-ja terveyspalveluissa, in Heikkilä, M. and Roos, M. (Eds), Sosiaali-Ja Terveydenhuollon Palvelukatsaus (Private Sector in the Social and Health Services), WSOY, Saarijärvi, pp Kraghjespersen, P. (2001), New public management reformer i det danske sjukehusfelt. udfordringer til de professionelle styringsrationaler?, Nordisk Administrativt Tidskrif, Vol. 1, pp Kumpusalo, E., Halila, H. and Hyppölä, H. (2002), Lääkärien ammatti-identiteetti ( Doctors professional identity ), Suomen Lääkärilehti, Vol. 35 No. 57, pp Decision makers in hospitals and health centres 93

10 JHOM 20,2 94 Lehto, J., Viitanen, E. and Autio, V. (2003), Minkälaiset lääkärit nousevat johtaviin asemiin? ( What kind of doctors rise to leading positions? ), Suomen Lääkärilehti, Vol. 58 Nos. 51/52, pp Pollit, C. and Bouckaert, G. (2000), Public Management Reform, Blackwell, Oxford. Sahlin-Andersson, K. and Östergren, K. (1996), Chefövläkarens roll i en förändrelig sjukvärd, Socialmedicinsk Tidskrift, Vol. 19 No. 4, pp Saltman, R.B., Figueras, J. and Sakellarides, C. (1998), Introduction, in Saltman, R.B., Figueras, J. and Sakellarides, C. (Eds), Chritical Challenges for Health Reform in Europe, Open University Press, Buckingham, pp Teperi, J. (2004), Kuka saa terveyspalveluita?, in Heikkilä, M. and Roos, M. (Eds), Sosiaali-Ja Terveydenhuollon Palvelukatsaus (Who Receives Health Services?), WSOY, Saarijärvi, pp Tuomiranta, M. (2002), Lääkärijohtaja-Lääkäri Vai Johtaja? (Doctor-Manager, a Doctor or a Manager?), Acta Universitatis Tamperensis 854, Tampereen yliopistopaino, Tampere. Viitanen, E., Wiili-Peltola, E. and Lehto, J. (2002), Osastonlääkäri lähiesimiehenä ( Ward physician as a first-line manager ), Suomen Lääkärilehti, Vol. 57 No. 38, pp Further reading Laki sosiaali-ja terveydenhuollon suunnittelusta ja valtionosuudesta (Law on Social and Healthcare Planning and State Subsidy), (733/1992) available at: Sosiaali-ja terveysministeriö (2002), Kansallinen Projekti Terveydenhuollon Turvaamiseksi (The National Project to Secure Health Care), Sosiaali-ja terveysministeriön työryhmämuistio, Helsinki. Corresponding author Viitanen Elina can be contacted at: elina.viitanen@uta.fi To purchase reprints of this article please reprints@emeraldinsight.com Or visit our web site for further details: