Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal.

BACKGROUND: The need of improving the governance of healthcare services has brought health professionals into management positions. However, both the processes and outcomes of this policy change highlight differences among the European countries. This article provides in-depth evidence that neither quantitative data nor cross-country comparisons have been able to provide regarding the influence of hybrids in the functioning of hospital organizations and impact on clinicians' autonomy and exposure to hybridization. METHODS: The study was designed to witness the process of institutional change from the inside and while that process was underway. It reports a case study carried out in a public hospital in Portugal when the establishment of a clinical directorate was being negotiated. Data collection comprises semi-structured interviews with general managers and surgeons complemented with observations. RESULTS: The clinical directorate under study illustrates a divisionalized professional bureaucracy model that combines features of professional bureaucracies and divisionalized forms. The hybrid manager is key to understand the extent to which practising clinicians are more accountable and to whom given that managerial tools of control have not been strengthened, and trust-based relations allow them to keep professional autonomy untouched. In sum, clinicians are allowed to profit from their activity and to perform autonomously from the hospital's board of directors. The advantageous conditions enjoyed by the clinical directorate intensify internal re-stratification in medicine, thus suggesting forms of divisionalized medical professionalism grounded in organizational dynamics. CONCLUSION: It is discussed the extent to which policy change to the governance of health organizations regarding the relationship between medicine and management is subject to specific constraints at the workplace level, thus conditioning the expected outcomes of policy setting. The study also highlights the role of hybrid managers in determining the extent to which practising professionals are more accountable to managerial criteria. The overall conclusion is that although medical and managerial values link to each other, clinicians reconfigure managerial criteria according to specific interests. Ultimately, medical autonomy and authority may be reinforced in organizational settings subject to NPM-driven reforms.

'Linking research to action' in Iran: two decades after integration of the Health Ministry and the medical universities.

OBJECTIVE: To examine the impact of integration of the Iranian Health Ministry and medical universities, which took place in 1985, on 'linking research to action'. STUDY DESIGN: A qualitative study including 18 in-depth interviews and 10 focus group discussions with different stakeholders ranging from researchers, policy makers and service providers in medical and non-medical groups. METHODS: A thematic framework was used to identify various positive and negative aspects of the integration on 'linking research to action' to date. RESULTS: The positive influences on universities that have been established since integration and/or in the peripheral provinces are more prominent. Distribution of health manpower in various parts of the country has almost unanimously been stated as a positive aftermath. On the other hand, the negative influence most agreed upon was the deviation of larger universities from their main commitment of knowledge production, due to overindulgence in service delivery. CONCLUSIONS: Before making any decisions about changing the current structure of the health-research system, the country's national innovation system should be defined. This is because national research problems are not confined to integration and health research, and cover more general aspects. Therefore, any change in integration and health research should be considered secondary to the latter.

Marginal voices in the media coverage of controversial health interventions: how do they contribute to the public understanding of science?

While the media are a significant source of information for the public on science and technology, journalists are often accused of providing only a partial picture by neglecting the points of view of vulnerable stakeholders. This paper analyzes the press coverage of four controversial health interventions in order to uncover what voices are treated marginally in the media and what the relative contributions of these voices are to the stories being told. Our empirical study shows that: 1) patterns of source utilization vary depending on the health intervention and less dominant stakeholders are in fact represented; and 2) the use of marginal voices fills certain information gaps but the overall contribution of such voices to the controversies remains limited. In order to strengthen the media coverage of science and technology issues, we suggest that further research on journalistic practices: 1) move beyond the dichotomy between journalists and scientists, and 2) explore how different categories of readers appraise the meaning and relevance of media content.

[Development and application of a clinical vignette to assess the quality of cancer care]. / Développement et application d'une vignette clinique pour apprécier la qualité des soins en oncologie.

BACKGROUND: In conjunction with a study focusing on the implementation and effect of an integrated care network for cancer patients in the Monteregie region in Quebec, the vignette research strategy was adopted to assess the quality of care provided by the interdisciplinary teams working with this clientele. This research strategy has only recently been used to assess professional practices. This article adopts a resolutely methodological angle in order to describe a rigorous, innovative, transferable experience from the standpoint of the elaboration of a vignette. METHODS: We adopted a six-step approach to elaborate the vignette. This vignette includes the description of collaboration with clinicians. The approach assured us of attaining high content validity from the standpoint of facets of its relevance, completeness and intelligibility to respondents. Our clinical vignette describes a sequence of events stemming from the care coordination of a 58-year-old man suffering from rectal cancer. Data were collected through group interviews with the interdisciplinary teams (n=5) under study. The professionals present were asked to describe their usual practices with respect to the events described in the vignette. We adopted two data analysis strategies: (i) a comparison of practices revealed through the interviews with anticipated responses in light of the guidelines of the "Programme québécois de lutte contre le cancer"; and (ii) an analysis according to facets of the quality of care. RESULTS: Team professional practices seem to evolve towards the care package valued by the "Programme québécois de lutte contre le cancer". Differences were also observed between the teams from the standpoint of the continuity of care. CONCLUSION: Our study shows that it is possible to develop a vignette that enables us to understand professional practices in an interdisciplinary context provided that a rigorous approach is adopted. This approach, which can be transferred to the study of similar phenomena, makes it possible to document the care offered and contribute to the renewal of professional practices.

Program sustainability: focus on organizational routines.

Program sustainability is an ongoing concern for most people in health promotion. However, the current notion of sustainability in organizations, namely routinization, needs refinement. This article examines organizational routines. In so doing, it refines the notion of sustainability and the assessment of routines. Drawing on the organizational literature, a routinized program is defined by the presence of routinized activities, meaning that these activities exhibit four characteristics of organizational routines: memory, adaptation, values and rules. To answer the question of how these characteristics are useful, we conducted an empirical study of the routinization of the Quebec Heart Health Demonstration Project in five community health centers. Our method consisted of a multiple-case study. We observed project activities in each center in 2000. The data came from documents and interviews with project actors. Our results show that, in one of the centers, no resources had been officially committed to project activities. Even so, the actors continued some activities on an informal basis. In another center, the activities satisfied three of the four routine characteristics. In the three others, activities satisfied all of the characteristics. These results suggest focusing the study of program sustainability on the routinization of activities resulting from it. They indicate four distinct degrees of sustainability: (1) the absence of sustainability; no program activity is continued; (2) precarious sustainability; some residual activities are pursued, at least unofficially; (3) weak sustainability; the program produces some official activities that are not routinized; and (4) sustainability through routinization; routinized activities result from the program.

[The nursing labour market in Canada (1985-1999)]. / Le marché du travail en soins infirmiers au Canada (1985-1999).

This literature review analysed both published and unpublished scientific and professional studies on the nursing labour market in Canada within the period of 1985 to 1999. The goal was to conduct a situational analysis utilising statistical data and canvassing all concerned parties to extract their points of view. The analysis revealed significant cyclical variations in the evolution of the workforce, particularly with respect to auxiliary nurses, such as the perceived existence of major problems in recruiting new professionals in the field and retaining existing professionals in their organisations, the lack of homogeneity in educational training programmes, and the co-existence of several operational structures for organising nursing care, of which there is a lack of evaluation on their effectiveness. The results of the literature review identify the necessity to further develop the knowledge base on such a relevant dimension of the nursing labour market.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.

Organizational and professional characteristics predicting external communications in Canadian public health units.

This study is a survey of administrative divisions involved in tobacco programs in Canadian public health units. It aims to identify correlates of public health units' contacts and collaborations with external agencies, as predisposing factors in their capacity to innovate. Heads of 124 divisions involved in tobacco control completed a questionnaire about their budgets, staff, and management practices. In each of these divisions, professionals involved in tobacco programs also completed a questionnaire about their characteristics and experience. Results showed a high level of contacts and collaborations with external agencies. Four variables emerged as correlates of external communications: professionals' degree of access to public health information sources, the diversity of disciplines within the administrative division, the decentralization of authority, and the level of professionals' participation in decision-making. Because of the potential relationship between innovation and external communication, public health units should consider fostering external communication by management practices and policies, such as favouring professional diversity, increasing access to sources of information, and adopting more decentralized, participatory management.

[Evaluation in the health sector: concepts and methods]. / L'évaluation dans le domaine de la santé: concepts et méthodes.

The practice of evaluation has existed in one form or another for as long as one can remember and is central to all processes of learning. Today, evaluation is a popular concept grouping together multiple and diverse realities. This article aims to propose a conceptual framework for evaluation that is broad and universal enough to allow all those concerned with evaluation of health services (regardless of their disciplines and interests) to better understand each other, to perform better evaluations, and to use them in a more pertinent manner. We will begin by defining evaluation as the process which consists of making a judgement on the value of an intervention by implementing a system which can provide scientifically valid and socially legitimate information on regarding this particular intervention (or any of its components) to the different stakeholders concerned, such that they can form an opinion from their perspective on the intervention and reach a judgement which can translate into action. We define "intervention" as any organized system of action (a structure, actors and their practices, processes of action, one or many finalities and an environment) aiming to, in a given environment, during a given time period, modify the foreseeable course of a phenomenon to correct a problematic situation. An intervention can be a technique, a medication, a treatment, an organisation, a program, a policy or even a complex system like the health care system. Various interventions, regardless of their nature, can be the object of two types of evaluation. Normative evaluation is based on appreciation of each component of the intervention according to criteria and standards. This type of evaluation is defined as an activity which consists of making a judgement regarding an intervention by comparing the resources utilized and their organisation (structure); services and goods produced (process) and results obtained to criteria and standards (in other words, summaries of what is good and right). Did the intervention correspond to what should have been done according to the standards utilized? Evaluative research aims to employ valid scientific methods to analyze relationships between different components of an intervention. More specifically, evaluation research can be classified into six types of analysis, which employ different research strategies. Strategic analysis allows appreciation of the pertinence of an intervention; logical analysis, the soundness of the theoretical and operational bases of the intervention; productivity analysis, the technical efficiency with which resources are mobilized to produce goods or services; analysis of effects, effectiveness of goods and services in producing results; efficiency analysis, relations between the costs of the resources (or the services) used and the results; implementation analysis, appreciation of interactions between the process of the intervention and the context of implementation in the production of effects. The official finalities of all evaluation processes are of four types: (1)strategic, to aid the planning and development of an intervention, (2) formative, to supply information to improve an intervention in progress, (3) summative, to determine the effects of an intervention (to decide if it should be maintained, transformed or suspended), (4) fundamental, to contribute to the advancement of empirical and theoretical knowledge regarding the intervention. In addition, experience acquired in the field of evaluation suggests that evaluation is also productive in that it allows actors, in an organized setting, to reconsider the links between the objectives given, practices developed and their context of action. This task of achieving coherence is continuous and is one of the intrinsic conditions of action in an organized setting. In this perspective, evaluation can have a key role, given that it is not employed to legitimize new forms of control but rather to favor debate and th

[Implementation and effects of regional plans of organization of services as a strategy implementing the mental health care reform in Québec: an assessment.]. / Bilan de la mise en oeuvre et des effets des plans régionaux d'organisation des services (PROS) comme stratégies d'implantation de la réforme des services de santé mentale au Québec.

As a main strategy of implementation of the new mental health policy (MSSS, 1989), regional plans of organization of services (RPOS) are put into effect in every region in Québec. This exercise in planning activities and mental health care aims at democratizing, decentralizing and redesigning the mental health system according to more diversified services. These RPOS also aim at improving integration of health care services, related activities as well as efficiency of this network. With a case study carried out in the Montérégie region and a descriptive analysis conducted in other regions, this article evaluates the validity and potential that these RPOS modify the mental health system along the lines of the new policy. The authors conclude to the relative structuring power of the planning instrument to regulate and transform organization of services given the scope of goals and its context of development. The article also questions the process of planning, decentralization and coordination related to the intervention. In a context where change is strongly claimed, strategies and mechanisms aiming at consolidating regional management are yet to be completed.

[Evaluation of the reform of psychiatric services destined to adults at the Pavillon Albert-Prévost.]. / Evaluation de la réforme des services psychiatriques destinés aux adultes au pavillon Albert-Prévost 1.

This case study analyzes the implementaion of the reform of care destined to clienteles at the Pavillon Albert-Prévost. The level of implementation and the effects of the new systme have been measured and the influence of the political and structural contexts have been analyzed. At the end of the observation period, the implementation of the intervention was not yet completed but had already entailed interesting effects especially concerning access and efficiency. These effects were achieved through some mechanisms not previously planned for in the reform project. The authors have also identified several environmental facors facilitating the implementation of the reform and the realization of expected effects.

The computer-based patient record challenges towards timeless and spaceless medical practice.

Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project ($50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

The computer based patient record: a strategic issue in process innovation.

Reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project ($45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Resource constraints and strategic change in a public hospital system.

It has been suggested that strategic management in public services tends to be oriented towards preserving and perpetuating current patterns of service provision, rather than changing priorities. However, faced with severe resource constraints combined with growing demand and rapidly developing technology, public hospitals in Canada have come under increasing pressure. Based on an empirical study of strategic management and change in 32 Montreal hospitals, this paper examines the relationship between financial adversity and the extent and nature of strategic change in these organizations. Strategic change indicators considered in the study include overall product mix, product diversity, product complexity, market demographics, efficiency, and revenue diversification. Results suggest that resource constraints have indeed stimulated changes within these organizations. In particular, hospitals suffering more severe financial difficulties have reduced their size and focused on a narrower range of services. Moreover, there is evidence that greater complementarity has been achieved among the entire sample of hospitals.

The role and impact of formal strategic planning in public hospitals.

In recent years, formal strategic planning methods originally developed for private business have been increasingly adopted by health care institutions, including publicly funded hospitals. Yet, as a technocratic management process, formal planning may seem at first sight to run counter to the natural mode of strategy formation in these organizations where negotiation and mutual adjustment between powerful groups of professionals, managers and government agencies traditionally control decision-making. This article describes an exploratory study aimed at understanding how formal strategic planning has become integrated and adapted into the management practices of a group of 23 Canadian hospitals. The context, processes and impact of planning are first examined over the entire sample of hospitals (descriptive analysis), and an attempt is then made to explain different planning outcomes in terms of a variety of contextual and process design characteristics (comparative analysis). The descriptive analysis shows that in practice formal strategic planning is easily absorbed into the political process: political and symbolic motives often drive the initiation of planning, the processes themselves are highly participative and the resulting plans often reflect the difficulties of obtaining consensus on goals in these complex organizations. The comparative analysis suggests that in general, contextual factors (eg, stimuli behind planning) appear to be more significant than process design factors (eg, extent of participation) in determining outcomes. In conclusion, it is noted that the confrontation between technocratic rationality and professional bureaucracy gives rise to a number of paradoxes that make both the use and the subsequent evaluation of formal strategic planning a difficult task in these organizations.

[Innovation in the Quebec's community health departments]. / L'innovation dans les départements de santé communautaire du Québec.

Following the reform of the health care system in Quebec at the beginning of the 1970s, 32 Community Health Departments (départements de santé communautaire or DSC) were created; these new organizations were administratively and physically integrated into 32 acute care hospitals throughout the province. Our study investigates to what extent variations in the implementation of DSCs and in the way they have fulfilled their mandate influence the degree of innovation of their practices. The results show that DSCs devoting greater efforts to research activities and to their relationships with other health care establishments and agencies achieve a higher level of innovation in their practices.

Organizational and environmental determinants of the performance of public health units.

In the wake of the reform of the Quebec health care system in the early 1970s, thirty-two public health units (DSCs) were created. They were administratively and geographically integrated into short-term care hospitals throughout the province. This study aimed at determining: (1) the influence of environmental and organizational factors on the way in which those public health units carried out their mandate; (2) the influence of these same factors on their performance in terms of level of innovation and in terms of the fulfillment of their mandate as assessed by their main clients; and (3) the influence of their activities on their performance. Our results show that the most innovative units appear to be those that have directed a large part of their efforts toward research and that have maintained close ties with other institutions and agencies. The public health units main clients differ however on their perception of the DSCs' performance.

The reform of the Quebec health care system: potential for innovation?

The recent reform of the health care system in Quebec can be viewed as the result of a continuous process that originated with the first reform launched in the early 70s. The reform focuses on three elements: decentralization, citizen participation, and outcome-centered management. The context in which the reform is being launched contains both favorable conditions and obstacles to its successful implementation.

Determinants of a merger in a publicly-funded health system: a political-economy perspective.

This article reports the results of a case study, spanning a period of 10 years, of the merger of two hospitals in a publicly-funded health system. A political economy model was used to analyse the determinants of the merger. Results show that external political economy factors, mainly pressure from the state to rationalize health services and the organization's needs to acquire critical resources, significantly contributed to the merger decision. At the internal political economy level, groups and individual strategies also played a determinant role. Our study suggests that merger in the public sector may not necessarily result from efficiency motives.