Management in Healthcare; overview of management theory and practice Alastair Mitchell-Baker using some materials prepared by Paul Parkin, Brunel University
Meaning of management Management derives from the Italian maneggiare meaning to control, from the Latin, manus, the hand, and hence to the mundane meaning of management to handle a situation or thing (Grey, 2005:53)
Definitions of management The fundamental task of management remains the same: to make people capable of joint performance through common goals, common values, the right structure, and the training and development they need to perform and to respond to change. (Drucker, 1989:214)
Definitions of management As soon as we ask someone else to do something, rather than undertaking ourselves, we become a manager (Iles 1997) Probably the most succinct definition is: Management is getting things done through other people (attributed to Follett, 1949)
Other related terminology Organisation - collection of people working together within a division of labour to achieve a common goal (organisations can be defined through their product, size, purpose, ownership) Complexity - division and specialization of labour; number of hierarchal levels; geographical dispersion Formalisation - degree of reliance on rules and procedures to direct behaviour Centralisation - locus of decision-making authority
Operational management Operational management is concerned with shorter term decision-making and routine, dayto-day problem solving Responses to activities and issues such as staffing levels, scheduling work, ensuring quality, customer relations and staff training. Mainly covered by middle managers, team leaders and supervisors
Operational management Managers working in this area have responsibility for: The day-to-day organising and coordinating of services and resources Short-term decision making and routine, day-to-day problem solving Liaising with clinical staff and other professionals, Dealing with the public and managing complaints; Anticipating and resolving service delivery issues. Staffing levels, scheduling work, ensuring quality, and staff training Planning and implementing change. (www.nhscareers.nhs.uk 2008)
Simple process model INPUTS TRANSFORMATION [NB significant events] OUTPUTS Insert Project/Workshop Name 8
Strategic management Generally undertaken at senior/executive levels Strategic management concerns larger scale and longer term plans and objectives: major decisions in the nature, direction, emphasis and structure of the organization (Stoney, 2001)
Strategic management A more corporate approach concerned with resource allocation & spending, mission development, performance review and reward Concerned with positioning the organization within the changing external political and policy environment
Roles of managers (Mintzberg, 1973 classic study) Interpersonal roles Figurehead, Leader, Liaison = Leading Informational roles Monitor, Disseminator, Spokesman = Administrating Decisional roles Entrepreneur, Disturbance handler, Negotiator = Fixing
Management in healthcare Healthcare tends to be highly politicised Obamacare in USA NHS in UK Appearance of the NHS being strategically and operationally managed by the government of the day remains a strong criticism. A British Medical Journal editorial suggests that the NHS is unusual in not having a leader and claims that if there is a leader then it is the Secretary of State for Health (Smith, 2003a)
Management in healthcare Since inception of NHS, the Secretary of State has been held accountable for every dropped bedpan, trolley wait, cancelled operation or long waiting list This is a managerial nonsense but a political reality, and caused a need to centralize and manage every detail creating an ever tightening cycle of control and hyper-interventionist style of micromanagement (Walshe, 2003:108)
Managerialism Managerialism comprises a set of beliefs and practices, at the core of which is the assumption that better management will prove an effective solution for a wide range of personal, economic and social ills (Pollitt, 1993) It has been promoted in healthcare in UK by successive governments
Managerialism revisited Criticised as lacking sensitivity to the caring aspects of health work (Currie, 1998) Exposed the incompatibility of managerially determined targets with the essence of professional practice (Winyard, 2003) Linked to attempts to privatize, commercialize and de-regulate public sector services (Pollock, 2004) Criticized as being inappropriate for the organizational complexities and ethos of public services (Thorne, 1997)
Managerialism Managerialism demands: the setting of targets and priorities; analyzing activities; monitoring and appraising performance against criteria; setting and controlling budgets and workforce targets, implementing management information systems (Pollitt, 1993)
Managerialism Hence managerialism curtails clinical freedom and professional autonomy. This is the hub and the rub of health service management (Scrivens, 1988:1754) where the fundamental problem is a paradox between calls for a common set of values and the need to recognize that doctors and managers do and think differently (Edwards et al., 2003)
Differences between managers and clinicians Clinicians Rooted in biological science Direct cause/effect relationships Strong academic rigour Strong evidence base (eg Cochrane) Strong written culture Ancient colleges and specialist groups Senior doctors work with patients Responsible for own patients Professional discretion in treatment Think operationally Work to short time frames Individualistic characteristics and uneasy with being led Tendency to dominate teams Operate within a professional culture Sources: Thorne, (1997); Ferlie and Shortell, (2001) Smith, (2003b) Managers Draws from economics, finance, social and behavioural sciences Less clear cause/effect relationships Weak rigour in strategy/marketing Weak evidence based management Weak written culture Short professional life-span Senior managers remote from customers Focus on groups and populations Decisions based on rational/legal policy Think strategically Plan for longer time horizons Work generally in teams More comfortable with conflict and negotiation Operate in a task or role culture
But managers care too! Management requires a population and community focus In ethical terms; Management is more Utilitarian and asks what s best for the most Clinical practice is more Kantian and asks what s best for the patient in front of me? Both are needed! Managing the polarity of caring for needs of the individual and population Insert Project/Workshop Name 19
Positive results from focusing on individuals Positives results from focusing on populations Individual and Population Negative results from too much focus on individuals and not populations Negative results from too much focus on populations and not individuals
Insert Project/Workshop Name 21
Practitioners and managers Clinical practitioners, doctors, nurses and therapists are a difficult workforce to manage because they wish to do their best and in the one-to-one relationship with their patients they resist limitations on their use of resources. Historically, clinicians in these professions have turned their backs on management roles (J. Spivey, FRCS, Times letter 8/4/09)
Engaging doctors in leadership (Dickenson & Ham, 2008) Historically healthcare has valued professional autonomy Since 1980s healthcare has become more centralised and HCPs more accountable This runs counter to traditional culture By use of power and position, clinicians (doctors) can block/confound managers and politicians efforts to impose change
Principal concerns of practitioners and managers Practitioners Patient/client outcomes Focus on individual patients/clients Optimum care for each patient/client Need for professional autonomy Desire for self-regulation Use of evidence-based practice Tendency to personal responsibility Source: adapted from Edwards et al., (2002; 2003) Managers Patient experience Emphasis on populations/organization Trade offs between competing claims Need for public accountability Preoccupied with systems Fair allocation of resources Tendency to delegation
Nurses Nurses have always had a management function within health services but this has tended to be at the operational level within consensus management rather than the strategic level Efforts mainly focused on nurse education, the organization and deployment of the nursing workforce and line management roles of training, organizing and monitoring junior nurses work (Bolton, 2004)
Nurses Another study that the management role was a hard faced one indicating the cultural differences between the professional clinical role in nursing as strongly feminised and management as equally strongly masculinised This leads to devaluing of clinical nursing knowledge in opposition to management knowledge (Reedy and Learmonth, 2000)
Doctors Doctors are losing out in modern healthcare systems because of their discomfort with: leadership, strategy, systems thinking, negotiation, genuine team working, organizational development, economics and finance. (Smith, 2003b: 611 Editor BMJ)
Doctors Smith suggests that learning about these management concepts may make doctors less lost in modern healthcare. Managers should also learn from doctors about creating an evidence base, engaging in debates about research and getting closer to patients
Management and clinical practice At the heart of this dilemma is the belief that there is an incompatibility between the characteristics of management and the essential identity of professional clinical practice creating a clash of ideologies. (Reedy and Learmonth, 2000)
Changing face of healthcare management Massive transformational challenge across globe In west demand increases with ageing populations, rise multiple chronic conditions, growing expectations and continued medical advances Funding is tight and workforce constrained More transformational leadership Emphasis on clinical leadership and managerial clinical leader partnership Insert Project/Workshop Name 30
Summary Management theories lie on a continuum from tight control to flexible participation Particular challenge in healthcare working with clinical practioners Managers care too! Healthcare management should emphasize communication, consultation, collaboration and co-ordination
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