La « gouvernance clinique » : sur un mode de travail particulier chez les directeurs d’hôpital

Abstract

ContextThe public healthcare system in France is in search of a new “spirit” to address the symptoms of disaffection it currently experiences. Management sciences are exploring how leadership can enhance workplace well-being, emphasizing “salutogenic” approaches and caring leadership. In contrast to previous interpretations of “clinical governance,” often focused on the use of evidence-based clinical data, we investigate the potential use of psychoanalytic theories to shed light on clinical governance practices attentive to the diverse elements contributing to organizational atmosphere. ObjectivesWe aim to return to the conceptions and practices of hospital administrators themselves. The demonstration will revolve around identifying the objects of the specific work done by clinical governance, and the actions taken by hospital administrators practicing this way. Our aim is to extend to the healthcare field the path laid out by institutional psychotherapy in psychiatry, ensuring healthcare institutions do not perpetuate, at their highest hierarchical level, the social symptoms of their time. MethodOur approach is rooted in empirical interpretation sciences and relies on a qualitative analysis methodology that emphasizes proximity to the lived experience of our interviewees. Our field investigation has been ongoing for several years, conducted in collaboration with management teams from institutions of various sizes and regions. The abductive hypothesis of a form of clinical governance gradually emerged while working closely with two well-known hospital administration teams. We engaged in co-thinking with the involved directors to validate our interpretations. ResultsWe revisit the concept of “clinical governance” to describe a way of managing hospitals which symbolically and attentively, though sometimes unconsciously, works with a number of identified objects. We define these objects as related to the organization: hierarchy, space, resources, information, the “scope” of action, and time. Others elements are related to the institutional network: speech, the Self, the perception of others, conviviality, and affects. Each of these elements is examined from the perspective of its symbolic significance, beyond its material or practical aspects, with the understanding that their circulation is of particular interest to clinical governance. InterpretationOur results call for a renewal of institutional psychotherapy in general hospitals, through the perspective of daily “asepsis” of the milieu as facilitated by clinical governance. This involves a recognition by hospital administrators of the symbolic value of the objects we have listed. Clinical governance enables administrators to interpret the symbols behind the apparent materiality of what healthcare professionals discuss. While our results are partial and exploratory, they pave the way for a psychoanalytic clinical perspective regarding hospital governance, alongside management sciences.