Who runs hospitals? Part 1

John Menadue has for several years provocatively claimed ‘no-one runs hospitals’. On its face this is an extraordinary claim, and at once throws up several powerful images. One is of doctors and nurses, amidst bewildering technology, trying to find the patient because there are no systems in place for anyone to know what is going on. A second is of a power struggle between different staff for control of one of the most prized organisations in modern society. A third image is of everyone in hospitals pointing the finger at someone else whenever something goes wrong.

But this is speculation. We need a method to analyse an assertion as important as this. Jacques Derrida coined one in the 1960s, named deconstruction. Let us use it to review the assertion, which is readily deconstructed, as it only contains three parts, although each is multifaceted. They are, of course, ‘no-one’, ‘runs’, and ‘hospitals’. We can glimpse at how hard they are to understand, let alone manage.

Researchers have described hospitals many times.  They are social settings in which medical technology and clinical methods are applied to diagnose and treat people in need of care.  They contain different types of doctors, different types of nurses, and many kinds of allied health personnel (for instance, pharmacists and speech pathologists).  They also employ a range of non-clinical staff (accountants, cooks, cleaners, epidemiologists, human relations practitioners and others).   

Various studies have explained how, collectively, all these people deliver care through a great deal of clinical technology, scientific equipment and electronic gadgets. Other technologies exist to aid communication and support staff in their work (email, computerised test results and electronic patient information systems). Staff need to be both ‘high tech’ and ‘high touch’ – that is, capable with both technology and hands-on care.

Hospitals may provide other various services, or be linked to related services offered by community health organisations. These include research, teaching, patient education, health promotion and prevention programs.

Three features overwhelm people when they go into hospital, apart from anxiety at what will happen to them. These are the multiplicity of roles of the staff, the high tech nature of the clinical setting, and the jargon – especially the technical language, even about quite normal parts of your body. So hospitals are quite confusing both to outsiders and insiders.

Hospitals can be small (such as in rural areas) or very large, with more than 600 beds, and in excess of 3,000 staff, treating perhaps 50,000 inpatients and a quarter of a million outpatients each year. They can also be very expensive, with budgets of more than $250 million per anum.

In short, a university teaching hospital (usually the largest type) can be thought of as one of the most complicated, costly organisations you could design – and typically, several hospitals are clustered together so as to provide a range of networked services across a geographical area or state. So who runs all of this?

There are many stakeholders with a finger in the pie. Hospital services are managed in the first instance largely by clinicians in charge of wards, units and departments. Each service represents the professionals who are grouped together to treat similar patients with similar conditions. Each of these clinical groups coordinates their patients’ care and exerts subtle influence to try and get a bigger share of resources to achieve their multiple clinical goals.

The evidence from research conducted by my own Centre shows that medical clinicians continue their specialist work at the same time as taking on responsibility for the management of their service. They are therefore asked to be the leader on a part-time basis while they retain a large clinical load. This can be highly stressful. Some report they have compromised loyalties between what senior managers want on the one hand (typically, efficiency and productivity) and their clinical colleagues want on the other (more resources and better technology from management). This is often not the most comfortable place to be. Figure 1 illustrates this.

Figure 1:
Clinician-managers and their pressures

Source: Braithwaite (2004)

Beyond this, senior administrators and the general manager are ultimately responsible for the hospital’s performance. They can be sacked if things go wrong, especially if budgets are blown. Beyond that again, area administrators (or in the private sector, the owners, or Board on behalf of shareholders) are responsible for strategic decisions such as long term planning, new services and the bigger financial commitments.

Despite the fact that there are clinicians in front line management positions to bridge the gap, the research evidence points to there being levels of distrust between clinicians and the senior managers. Clinicians and managers have differing perspectives, training and views about the health system, and differing levels of power, and the disconnection between them can be quite debilitating. Most experts believe that changing the culture to be jointly productive is the answer, but it is easy to underestimate how long this can take, and the magnitude of the task.

The academic literature has also shown that hospitals have what most experts think are unacceptably high rates of error, also labelled ‘adverse events’, or ‘iatrogenic’ (medically-caused) injury or illness. This means a proportion of patients sustain an injury or illness caused by their stay in hospital. This could be due to the wrong treatment, a drug error, or an infection acquired from the hospital. These are entrenched systems problems.

No one person, you might think, can possibly run all of this, let alone fix all the errors and systems complexities. There does not seem to be any one obviously in charge in practice, either, and the whole enterprise we call the hospital system is professionally and organisationally fragmented.

So in deconstructing this fascinating conundrum, we could say we are left feeling vaguely uneasy about the acute care system. Menadue’s claim is upheld. No one does run hospitals if by that we mean that there is one person, or even one group, clearly and identifiably in charge. The larger question is what can be done about this, and although there is lots of restructuring, as yet there is no consensus on how to tackle the issue decisively. We do need a better-connected, less fragmented health system, and more clearly delineated management processes. This is a core task for health system reformers.

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