Management and medicine: Odd couple no more. Bonding through medical management research

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1 Scandinavian Journal of Public Health, 2010; 38: EDITORIAL REVIEW Management and medicine: Odd couple no more. Bonding through medical management MATS BROMMELS Medical Management Centre, Karolinska Institute, Stockholm, Sweden According to conventional wisdom, management and medicine do not mix well. Organizational studies tend to confirm this view [1]. Health care is a professional service, and the professional experts who offer their services are licensed practitioners with a knowledge monopoly and professional autonomy. They are driven by a moral code to always do what is best for the patient, implicitly, without limitation or exception. To bring professional experts together in a concerted action, to motivate them to contribute their expertise in collaboration and to accept that limited resources need to be allocated in a way that grants the best return, is a very real challenge. That is the task of management. This begs the question if medically informed management would fare better? Enter medical management. Medical management is mentioned in two forms in cyberspace. It can refer to organized care programmes ideally evidence-based i.e., care management, which includes, in addition to identifying diagnostic and recommended therapeutic interventions and programmes designed accordingly, activities like patient advocacy and support, health information, and the education of the involved professionals. We can also find commercial companies offering medical management as a professional support service to a medical group or hospital. In short, medical management needs to cover both the micromanagement of the clinical processes, and the macromanagement of the organizational structures in which they are embedded. In the UK, medical managers are medically qualified managers doctor managers. Their distinct advantages are said to be greater credibility among colleagues, deeper knowledge of how health care works and less trammelled ability to speak out [2]. The British National Health Service has since the introduction of general management in the 1990s and clinical governance in the 2000 s actively tried to increase the interest among physicians to engage in management [3]. When the Medical Management Centre (MMC) was established at Karolinska Institutet, Stockholm, Sweden, in 2001, its ambition was to focus on and training in healthcare management and thus establish the area as an academic discipline in its own right. A stronger standing was expected to raise interest among physicians (and other health professionals) in management and make a management career a credible alternative to a clinical one. In addition to the MMC, two programmes in medical management were identified through an internet search. The master of medical management at the Carnegie Mellon University, Pittsburgh, USA, is offered to physician executives and focuses on three core competencies: effective leadership, strategy and management of information. The University of Washington in Seattle, USA, grants a certificate in medical management to mid-career physicians and healthcare administrators. It is a 12-month part-time programme covering strategy, marketing, quality measurement, techniques for efficient medical and management practices, leadership, and financial tools. What s in a name? What is medical management? A simple answer is medically informed on the Correspondence: Mats Brommels, Medical Management Centre, Karolinska Institute, Stockholm, Sweden. mats.brommels@ki.se ß 2010 the Nordic Societies of Public Health DOI: /

2 674 M. Brommels organization and management of health services, which follows the same line of reasoning as was applied to medical managers [2]. There is a certain overlap with health services (HSR), which is defined by Academy Health, the US scientific HSR society, as the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organisational structures and processes, health technologies, and personal behaviours affect access to health care, the quality and cost of health care, and ultimately, our health and well-being. Medical management deals specifically with organisations, institutions and communities, and less with individuals, families and populations, all of which are considered to be HSR domains. Medical management utilizes knowledge and methods from organizational and political science, behavioural sciences, management science and economics. It needs a staff familiar with those disciplines, but also with deep theoretical insights into and practical knowledge of health care. Some of its members should have a health professions background, which will give them unrestricted access to healthcare organizations. The MMC writes in its mission statement that it focuses on the interface between medical knowledge and the delivery of healthcare services. It seeks a deeper understanding of how new knowledge and technologies can more rationally and rapidly be implemented in order to make better use of resources, to improve human health and to meet the needs and preferences of patients and other stakeholders. Real world There are a number of characteristics and trends in the discipline of medical management that should be highlighted. Managing health services is a complex and still not very well understood task. Practising managers have a number of challenges where they turn to for answers. Medical management ers need to address this demand and engage in practical problem-oriented studies and communicate actively with managers both to learn about which problems needed to be studied and how to make subsequent results actionable. The specific interest in medical knowledge transfer and successful forms of adopting advances in biomedical technology naturally directs medical management towards issues of application and implementation. Such studies are carried out in real life and call for a into practice approach which requires collaboration with practitioners and managers to be contrasted with a mere observational method. Collaboration guarantees the necessary access to study internal processes of the organization. The medical management er has to adopt a range of roles from detached objective through collaborative and action to consultancy. The implementation of results and innovation inevitably requires change of individual clinical practice, patient processes, organizational structures and systems of care. Documented change is the most important indicator of a successful implementation (a necessary condition for better patient outcomes), and the implementation should be planned and organized and the evaluation study informed by a relevant theoretical framework and plausible assumptions about pathways of influence. Merger mania hits health care An example of medical management addressing both change on an organizational level and manager behaviour on an individual level is a recent study on the merger of the two university hospitals in Stockholm. This multi-method case study utilized document analysis, interviews and participant observation to analyze the premerger process which led to the decision among county politicians to merge two hospitals, how the top management team handled the merger, and whether clinical integration (at the department level) was achieved. The premerger process was found to have begun 10 years before the decision for the merger compared with what could have been expected from the three months of formal preparations before the political decision. That last phase was greatly enhanced by a meansconvergence among the scientific professional (striving for excellence through collaboration) versus the administrative political (seeking cost-containment by reducing overlapping services) stakeholder groups. A critical incident in the form of an administrative court order to balance the county budget triggered the final events and shortcircuited the political process, usually slow because of the need to reach compromises [4]. The new hospital s top-management team was initially successful in establishing a new organizational structure thanks to the medical managers accepting a uniquely managerial role and agenda. As low-hanging fruits were picked, greater challenges had to eventually be addressed and the one-sided management agenda was shown to have

3 created resistance among clinical staff, causing the medical managers to retreat to their medical roles and focus on the concerns of their medical constituencies [5]. This problematic hybrid position of medical managers was also demonstrated at the departmental level. In one case, a medical manager using a topdown approach to implement directives from top management according to a management agenda ran into difficulties. Contrast this with another department where leadership was shared between the heads of the two merged units and clinical staff were seen as a constituency of equal importance with top management. Here, managers succeeded in engaging staff, and clinical integration took place. In that department, an informal leader was able to create a meaningful rationale for the merger by emphasizing its benefits to the department s standing [6]. Another example of medical management is a study on whether the application of a certain medical decision support model (clinical care guidelines) is a useful way of engaging physicians in an administrative task (sickness certification) and improving their performance (writing correct certificates according to current legislation). According to preliminary results the decision support was seen as useful by primary care physicians and a clinical audit showed improvement in terms of better formulated certificates (study to be published). Editorial Review 675 No pain, no gain The biggest potential impact of medical management will be in the area of implementation. Implementation inevitably requires painstaking change. With its knowledge base in change and change management, and with ease of access to health services and proficiency with real life methods, medical management can cover the third and final phase of the innovation cycle, application. In parlance of translational, medical management addresses the second step following from bench to bedside, which is from bedside to clinical practice and beyond [7]. Indeed, according to the 3T s model, clinical effectiveness studies uncovering who benefits from promising care (T2) should be followed by studies into what type of systems redesign is triggered by implementation and how effective interventions should be scaled-up and spread (T3) [8]. In my 2006 position paper, I presented a model similar to the 3T s (see Figure 1) [9]. I also made the case that a major reason for the fading of translation beyond efficacy (clinical trials, T1) is that the process is not linear in nature, i.e. simply requiring an extended experiment. The largest review lately of the literature on innovation diffusion in health care states: Context and confounders lie at the very heart of the diffusion, dissemination, and implementation of complex From translational to implementation Application on human being Implentation in clinical practice Translation Transformation Cell and molecular biology Translational Implementation Improved health Clinical trials Observational studies Diagnostic methods with assessed accuracy Efficacious therapies Knowledge transfer and professional behaviour change New work practices and procedures Figure 1. From translational to implementation.

4 676 M. Brommels innovations. They are not extraneous to the object of the study; they are an integral part of it. The multiple (and often unpredictable) interactions that arise in particular contexts and settings are precisely what determine the success or failure of a dissemination initiative [10]. I proposed that the second phase of the translation calls for a shift in the paradigm and the application of implementation methodology. This is illustrated by the detour in Figure 1. An appropriate approach focuses on the local context and utilizes primarily observational data. Unfortunately, this needed change could represent an unfamiliar approach and may prevent natural-sciences-oriented health professionals both from utilizing the existing evidence on workable implementation strategies and conditions for practice change as well as from getting involved in implementation programmes. I draw two conclusions. First, there is a specific role for medical management to establish collaboration with clinical scientists and, during shared implementation projects, to enhance their understanding of implementation methodology and increase their interest in extending their into application. Second, by liaising with practitioners and supporting their implementation programmes with a into practice approach, medical management ers can provide guidance on workable strategies and enhance chances of success. In addition, the field can acquire generalizable knowledge on the role of contextual factors in implementation, central to application of the insights elsewhere. Realism reigns Studies on innovation implementation actually require going beyond the observational. A into practice approach resembles action or action evaluation [11]. Active collaboration with involved practitioners enables ers to provide continuous feedback on implementation strategies. Conditions for experimentation are created and interventions are adjusted according to continuous measurements on outcomes. Insights about the complexities of innovation diffusion [9] can be conceptualized using the strategic change management model proposed by Pettigrew and Whipp [12] as a methodological framework. The model defines four determinants of change: the local environment (context), the innovation, intervention or knowledge to be implemented (content), the change process and the outcome. Collecting data on all four dimensions allows the er to identify empirical patterns that explain their interrelations. This approach has recently achieved the status of method of choice [13] in case-based implementation, and resembles what is called realist(ic) evaluation [14]. In summary, medical management seeks active collaboration with clinical practitioners and managers, it engages those in and development who address their managerial challenges, it contributes to the adoption and implementation of biomedical as well as organizational discoveries and innovations, and it adds to the general knowledge about successful management of health services. This knowledge not only benefits a high quality service interested in utilizing its resources to optimally provide health benefits, it also has the potential to unveil the conditions that optimize continuous improvement and renewal. Not a bad wedding gift to two parties in an unavoidable partnership. References [1] Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: a danse macabre? BMJ 2003;326: [2] Simpson J, Smith R. Why healthcare systems need medical managers. BMJ 1997;314: [3] Dickinson H, Ham C. Engaging doctors in leadership. A review of the literature. London: NHS Institute for Innovation and Improvement; [4] Choi S, Brommels M. Logics of pre-merger decision-making processes. The case of the Karolinska university hospital. J Health Org Manage 2009;23: [5] Choi S, Holmberg I, Löwstedt J, Brommels M. Executive management in radical change the case of the Karolinska university hospital merger. [Accepted] Scand J Management [6] Choi S, Löwstedt J, Holmberg I, Brommels. Managing clinical integration two approaches to change in the Karolinska university hospital merger. Manuscript. [7] Zerhouni EA. Translational : moving discovery to practice. Clin Pharmacol Ther 2007;81: [8] Dougherty D, Conway PH. The 3T s road map to transform US health care. The how of high-quality care. JAMA 2008;299: [9] Brommels M. Dags för det tredje steget? Implementering är den kliniska forskningens största utmaning. [Time for the third step? Implementation is the main challenge of clinical ]. Läkartidn [Swedish Medical Journal] 2006:103: [10] Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82:

5 [11] Øvretveit J. Action evaluation of health programmes and changes. Oxon: Radcliffe Medical Press; [12] Pettigrew AM, Whipp R. Managing change for competitive success. Oxford: Blackwell; [13] Stetler CB, Ritchie J, Rycroft-Malone J, Schultz A, Charn M. Improving quality of care through routine, successful Editorial Review 677 implementation of evidence-based practice at the bedside: an organizational case study protocol using the Pettigrew and Whipp model of strategic change. Implementation Sci 20072:3 doi: / [14] Pawson R, Tilley N. Realistic evaluation. London: Sage; Mats Brommels Professor of Health Services Management, University of Helsinki; and Guest Professor and Director, Medical Management Centre, Karolinska Institute. Previously Mats Brommels was Professor and Course Co-Director in Health Care Administration at the Nordic School of Public Health, Gothenburg, Sweden. He served on the Board of the European Health Management Association from 1989 to 1994, and was President in 1991 to Since 1998 he has served as Chairman of Samfundet Folkhälsan, a 17,000 member voluntary organization engaged in health promotion, which also runs a large centre. Between 2000 and 2009 he was Board Chairman of the Finnish Institute of Occupational Health.