Abstract
BackgroundHospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals.MethodsThe research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources.ResultsThe findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management.ConclusionsOur comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.
Highlights
Hospital governance increasingly combines management and professional self-governance
We draw on a broad definition of ‘control’ that includes a wide range of bureaucratic measurements and managerial tools, such as target setting and performance indicators, and interventions where doctors have oversight, such as evidence-based guidelines and continuing professional development (CPD)
We bring cross-country comparison to the meso-level of the organisation in a range of European countries. This brings a novel perspective into comparative research, because comparison traditionally focuses on institutions on the macro-level and often uses Anglo-American countries and/or National Health Service (NHS) systems as examples [10]
Summary
Hospital governance increasingly combines management and professional self-governance. The linkage between macro-level (countries) and meso-level (organisations) governance through the lens of country comparison is innovative for two reasons: firstly, this makes it possible to move beyond a discourse of ‘hybridisation’ of medicine and management and to analyse how the context matters and secondly, how this creates specific forms of control. This approach may contribute to a ‘deepening’ of our understanding of complex interventions into clinical management [3] and explore new directions for cost-efficient and quality-effective hospital governance. This brings a novel perspective into comparative research, because comparison traditionally focuses on institutions on the macro-level and often uses Anglo-American countries and/or National Health Service (NHS) systems as examples [10]
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