Skip to 0 minutes and 4 seconds IAN KIRKPATRICK: Today we’re going to be talking about some of the distinctive characteristics of organisations such as hospitals where healthcare improvement activities take place. In the organisation theory literature, these organisations are often described as a distinct type of professional organisations, and hospitals are not just one form of this type. We can also include law firms, accounting firms, schools and universities under this category. Broadly speaking these organisations, what they have in common are three things. One, they tend to be knowledge intensive, which means that they rely on an expert labour force or an intellectually skilled labour force to deliver their services.
Skip to 0 minutes and 49 seconds Two, they tend to have low capital intensity, relying less on machinery or equipment to deliver services, although obviously in the case of hospitals, that’s not entirely true. And lastly and most importantly, they are staffed by a professional work force. This means that the people who work in these organisations, doctors or academics or accountants, are professionally qualified. They’re members of external professions that have control over their training and education, maybe they also sign up to an ethical code. Now these organisations are incredibly complex. In fact, Mintzberg and Glouberman, two authors who we will refer to later, say that “Running even the most complicated cooperation must sometimes feel like child’s play when compared to trying to manage any hospital.”
Skip to 1 minute and 43 seconds Henry Mintzberg in particular is known for the concept of what he calls the professional bureaucracy. He uses this idea to describe professional organisations and how they run and how they’re managed. A professional bureaucracy, Mintzberg says, is like a normal or a machine bureaucracy in a sense that it provides standardised, routine services, such as standard forms of training, education, diagnosis or treatment in a hospital. However, the difference between this bureaucracy and a normal bureaucracy is that coordination is achieved in a different way. Rather than try to write down lots of rules and procedures for people to follow, standardisation by rules, if you like, this form of organisation keeps standardisation through common training, common socialisation outside the organisation.
Skip to 2 minutes and 38 seconds So professionals come into the organisation already trained, and then they apply their knowledge to specific complex problems. This is what Mintzberg describes as standardisation by skills. Now this key difference between a professional bureaucracy and other forms of bureaucracy has certain implications. One, it means that the producers of services, the professionals, the front line doctors, nurses, or teachers, whatever it may be, have a lot of autonomy and discretion in the way they work. It also means that their work is hard to manage externally. These professionals tend to regulate and supervise themselves. Another feature of a professional bureaucracy is that decision making tends to be highly decentralised. Instead of top down decision making, decision making is bottom up.
Skip to 3 minutes and 31 seconds In fact, sometimes these organisations are described as inverse pyramids. And last but not least, this has implications for how these organisations are managed. The idea that managers can control things and direct things and exercise their authority does not work in a professional bureaucracy, rather management becomes more about persuasion, influence. In fact, it has been described as ‘cat herding management’ by one author.
Skip to 4 minutes and 0 seconds Now we can take this idea step further. In fact, Mintzberg and Glouberman describe hospitals as a particular type of professional bureaucracy, which is the most complex form of professional bureaucracy. In fact, they say a hospital is not one organisation at all, but actually four organisations, four worlds, they say, coinciding with each other and not necessarily working with each other effectively all the time. These worlds referred to separate activities, discrete activities, discrete ways of working and mindsets. Specifically, they talk about four worlds of cure, care, control, and community. So the world of cure, this is the world of medicine, the world that the diagnostic and treatment decisions of doctors, the activity of doctors based on scientific, evidence-based practise.
Skip to 4 minutes and 56 seconds This is the world that absorbs the bulk of resources in any hospital or health system. Doctors organise themselves through very specific medical specialities, career chimneys. The world of care refers more sometimes to the work of nurses, more focused on the softer aspects of care and the psychological well-being of patients within the hospital. Nurses organise themselves more through team working rather than the specialisation of doctors. The world of community refers to the trustees who are responsible to external payers or stakeholders or policymakers, people who sit on the boards of hospitals. And lastly, the world of control refers to the world of managers, who in theory at least have formal authority over the direction of the hospital and control over its resources.
Skip to 5 minutes and 48 seconds However, as we said before, managers only control this system in theory, not in practise. Now this particular organisation creates many challenges. As you can imagine, these four worlds operate in discrete spheres and are hard to coordinate, so one is immediately faced with a very difficult coordination challenge within hospitals or health systems more generally. Another problem is that there are horizontal divisions. Sometimes these cohere around the world of community and control, which maybe are about cost containment and control versus the worlds of care and cure, which are downward looking and focused on the interests of the patients and providing operational services. Sometimes this is described as the great divide within health organisations. However, that’s not the only division.
Skip to 6 minutes and 39 seconds There may also be vertical divisions, and this is a division between the worlds that inwardly focused and those which are outwardly focused. So whereas, managers, the world of nurses may be focused on the organisation and its interests, care and control. The world of doctors and community representatives may be outwardly focused in terms of networks, and this is especially true when doctors are not employed by the hospital itself, for example, in the United States. To conclude this lecture then, we can say that professional organisations, hospitals in particular, are extremely complex organisations. These organisations cannot be managed in a conventional way. In fact, Mintzberg describes trying to top down manage these organisations as a dysfunctional response.
Skip to 7 minutes and 28 seconds Rather, these are organisations that require an appropriate style of management and leadership, one which is focused on mutual adjustment, persuasion, and collaboration to get things done. And this, of course, has very important implications for healthcare improvement and how we deliver healthcare improvement in these settings.
Understanding the organisational context for healthcare improvement
This video, presented by Professor Ian Kirkpatrick, introduces the basic theory of professional organisations.
Professor Kirkpatrick explains that the settings where healthcare improvement activities take place (such as hospitals) might usefully be described as ‘professional’ organisations. These organisations - which are also found in areas such as law, accounting and education - are characterised by “knowledge intensity, low capital intensity and a professionalised workforce” (von Nordenflycht, 2010). Professor Kirkpatrick introduces the notion of the ‘professional bureaucracy’ (Mintzberg, 1992) to understand the special challenges that these organisations pose for management. He also draws on the ideas of Glouberman and Mintzberg (2001) to explore how hospitals (and health systems) represent a particularly complex form, characterised by four competing ‘worlds’ of care, cure, control and community.
Glouberman, S. & H. Mintzberg (2001) Managing the Care of Health and the Cure of Disease. Part I: Differentiation and Part II: Integration. Health Care Management Review, 26 (1): 56-84.
Mintzberg, H. (1992) Structure in Fives: Designing Effective Organisations, London: Prentice Hall.
von Nordenflycht, A. (2010). What is a professional service firm? Toward a theory and taxonomy of knowledge intensive firms, Academy of Management Review, 35: 155–74.
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