Lars Erik Kjekshus

Clinicians’ experiences of becoming a clinical manager: a qualitative study

BackgroundThere has been an increased interest in recruiting health professionals with a clinical background to management positions in health care. We know little about the factors that influence individuals’ decisions to engage in management. The aim of this study is to explore clinicians’ journeys towards management positions in hospitals, in order to identify potential drivers and barriers to management recruitment and development.MethodsWe did a qualitative study which included in-depth interviews with 30 clinicians in middle and first-line management positions in Norwegian hospitals. In addition, participant observation was conducted with 20 of the participants. The informants were recruited from medical and surgical departments, and most had professional backgrounds as medical doctors or nurses. Interviews were analyzed by systemic text condensation.ResultsWe found that there were three phases in clinicians’ journey into management; the development of leadership awareness, taking on the manager role and the experience of entering management. Participants’ experiences suggest that there are different journeys into management, in which both external and internal pressure emerged as a recurrent theme. They had not anticipated a career in clinical management, and experienced that they had been persuaded to take the position. Being thrown into the position, without being sufficiently prepared for the task, was a common experience among participants. Being left to themselves, they had to learn management “on the fly”. Some were frustrated in their role due to increasing administrative workloads, without being able to delegate work effectively.ConclusionsPath dependency and social pressure seems to influence clinicians’ decisions to enter into management positions. Hospital organizations should formalize pathways into management, in order to identify, attract, and retain the most qualified talents. Top managers should make sure that necessary support functions are available locally, especially for early stage clinician managers.

Do hospital mergers increase hospital efficiency? Evidence from a National Health Service country

Objectives: To analyse the effects on technical and cost efficiency of seven hospital mergers over the period 1992–2000 in Norway. The mergers involved 17 hospitals. Methods: First, efficiency scores were generated using Data Envelopment Analysis for 53 merged and non-merged hospitals over the nine years. Second, the effect of mergers was estimated through panel data analysis. Results: In general, the mergers showed no significant effect on technical efficiency and a significant negative effect of 2–2.8% on cost efficiency. However, positive effects on both cost and technical efficiency were found in one merger where more hospitals were involved, and where administration and acute services were centralized. Conclusion: The findings indicate that large mergers involving radical restructuring of the treatment process may improve efficiency as intended, but most mergers do not.

Survival of the project: A case study of ICT innovation in health care

From twenty years of information and communication technology (ICT) projects in the health sector, we have learned one thing: most projects remain projects. The problem of pilotism in e-health and telemedicine is a growing concern, both in medical literature and among policy makers, who now ask for large-scale implementation of ICT in routine health service delivery. In this article, we turn the question of failing projects upside down. Instead of investigating the obstacles to implementing ICT and realising permanent changes in health care routines, we ask what makes the temporary ICT project survive, despite an apparent lack of success. Our empirical material is based on Norwegian telemedicine. Through a case study, we take an in-depth look into the history of one particular telemedical initiative and highlight how ICT projects matter on a managerial level. Our analysis reveals how management tasks were delegated to the ICT project, which thus contributed to four processes of organisational control: allocating resources, generating and managing enthusiasm, system correction and aligning local practice and national policies. We argue that the innovation project in itself can be considered an innovation that has become normalised in health care, not in clinical, but in management work. In everyday management, the ICT project appears to be a convenient tool suited to ease the tensions between state regulatory practices and claims of professional autonomy that arise in the wake of new public management reforms. Separating project management and funding from routine practice handles the conceptualised heterogeneity between innovation and routine within contemporary health care delivery. Whilst this separation eases the execution of both normal routines and innovative projects, it also delays expected diffusion of technology.

Primary health care and hospital interactions: effects for hospital length of stay.

Aims: Norwegian healthcare services are divided between primary and secondary care providers. A growing problem is that every third patient of 75 years of age or more experiences an extended stay in a somatic hospital while waiting to be sent to primary healthcare services. The interaction between these two levels of healthcare services is analysed to examine the effect on a patients length of stay in hospital. Methods: Recent studies have asserted that research on length of stay in hospital should include influential factors such as system variation and system characteristics, in addition to standardizing for casemix. New organizational routines are identified in 50 Norwegian somatic hospitals. A multivariate linear regression is used in both a static and a dynamic model to explain variations in hospital length of stay and in additional length of stay (5% of stays are defined as outliers). Results: The study shows that newly specialized structures constructed to enhance the interaction between the two levels have had no effect. Length of stay is dependent on the capacity of the primary healthcare provider and on the share of elderly in the hospital catchment area, the type of patients, the procedure performed, and the characteristics of the hospital. Conclusion: Variation in length of stay between hospitals is primarily explained by the capacity of primary healthcare providers. However, some support is found in the dynamic model that introduces the proposition that a hospital-owned hotel would decrease the length of stay of patients in hospital.

Clinicians in management: a qualitative study of managers’ use of influence strategies in hospitals

BackgroundCombining a professional and managerial role can be challenging for doctors and nurses. We aimed to explore influence strategies used by doctors and nurses who are managers in hospitals with a model of unitary and profession neutral management at all levels.MethodsWe did a study based on data from interviews and observations of 30 managers with a clinical background in Norwegian hospitals.ResultsManagers with a nursing background argued that medical doctors could more easily gain support for their views. Nurses reported deliberately not disclosing their professional background, and could use a doctor as their agent to achieve a strategic advantage. Doctors believed that they had to use their power as experts to influence peers. Doctors attempted to be medical role models, while nurses spoke of being a role model in more general terms. Managers who were not able to influence the system directly found informal workarounds. We did not identify horizontal strategies in the observations and accounts given by the managers in our study.ConclusionsManagers’ professional background may be both a resource and constraint, and also determine the influence strategies they use. Professional roles and influence strategies should be a theme in leadership development programs for health professionals.

Leading during change: the effects of leader behavior on sickness absence in a Norwegian health trust

BackgroundOrganizational change often leads to negative employee outcomes such as increased absence. Because change is also often inevitable, it is important to know how these negative outcomes could be reduced. This study investigates how the line manager’s behavior relates to sickness absence in a Norwegian health trust during major restructuring.MethodsLeader behavior was measured by questionnaire, where employees assessed their line manager’s behavior (N = 1008; response rate 40%). Data on sickness absence were provided at department level (N = 35) and were measured at two times. Analyses were primarily conducted using linear regression; leader behavior was aggregated and weighted by department size.ResultsThe results show a relationship between several leader behaviors and sickness absence. The line managers’ display of loyalty to their superiors was related to higher sickness absence; whereas task monitoring was related to lower absence. Social support was related to higher sickness absence. However, the effect of social support was no longer significant when the line manager also displayed high levels of problem confrontation.ConclusionsThe findings clearly support the line manager’s importance for employee sickness absence during organizational change. We conclude that more awareness concerning the manager’s role in change processes is needed.

The effect of hospital mergers on long-term sickness absence among hospital employees: a fixed effects multivariate regression analysis using panel data.

BackgroundHospitals are merging to become more cost-effective. Mergers are often complex and difficult processes with variable outcomes. The aim of this study was to analyze the effect of mergers on long-term sickness absence among hospital employees.MethodsLong-term sickness absence was analyzed among hospital employees (N = 107 209) in 57 hospitals involved in 23 mergers in Norway between 2000 and 2009. Variation in long-term sickness absence was explained through a fixed effects multivariate regression analysis using panel data with years-since-merger as the independent variable.ResultsWe found a significant but modest effect of mergers on long-term sickness absence in the year of the merger, and in years 2, 3 and 4; analyzed by gender there was a significant effect for women, also for these years, but only in year 4 for men. However, men are less represented among the hospital workforce; this could explain the lack of significance.ConclusionsMergers has a significant effect on employee health that should be taken into consideration when deciding to merge hospitals. This study illustrates the importance of analyzing the effects of mergers over several years and the need for more detailed analyses of merger processes and of the changes that may occur as a result of such mergers.