Posted: June 17th, 2022
Report Of Research Project (10,000 Words) assignment
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Poor Working Relationship between
Doctors and Hospital Managers
– A Systematic Review
A Dissertation submitted in part fulfilment of the requirements
for the degree of Master of Business Administration (MBA) in
Healthcare Management of the Anglia Ruskin University, UK
Date: January 2020
Word Count: 9,428
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ABSTRACT
Background: At a time when healthcare organisations worldwide including the United
Kingdom’s (UK) National Health Service (NHS) are faced with limited financial
resources, changes in patients’ demographics, rising aging population and rapid
technological advancement, the need for doctors and hospital managers to work
effectively together for the successful running of the organisation has become vital
now, more than ever. Previous studies have drawn attention to the poor working
relationship between doctors and hospital managers on the quality of healthcare they
provide, however, despite the significance of the problems, there is limited systematic
review in this area.
Objectives: This study is a systematic review, investigating the organisational factors
contributing to the poor working relationship between doctors and hospital managers
with a view to recommend potential solutions to address them.
Methods: A comprehensive search was undertaken of AMED, MEDLINE, CINAHL
Plus with Full Text, SportDiscus and EBSCO Ebooks from January 2000 to July 2019
and updated in November 2019. Mixed methods, qualitative studies and quantitative
studies that explored doctors and managers working relationship in hospital or
healthcare services were included in this review. The settings of the included studies
were hospitals or healthcare service centers. Studies that were published in English
language in peer reviewed journals between January 2000 and December 2016 were
included. Study selection, data extraction and appraisal of study were undertaken by
the researcher (PO). Quality criteria were selected using CASP (Critical Appraisal
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Skills Programme, 2013), which is a Qualitative Research Checklist comprising 10
questions, used in assessing the rigor and quality of the selected papers.
Results: A total of 49,340 citations were retrieved and screened for eligibility, 41
articles were assessed as full text and 15 met the inclusion criteria. They include 2
mixed method studies, 8 qualitative studies, and 5 quantitative studies. The studies
were analysed qualitatively as meta-analysis of these multiple studies was not
possible.
Conclusion: This study found that poor collaboration and effective communication,
cultural issues, power and autonomy, finance and resources issues, as well as
educational differences were among the organisational and professional factors that
contributed to poor working relationship between physicians and hospital
administrators. This study recommends that healthcare policy makers, administrators
and funding providers should create and implement strategic plans such as a
consensual agreement that is flexible and includes frequent dialogue and greater
organisational transparency in decision making to improve doctor-manager
relationships – which ultimately could lead to improved quality of care, better work
performance and job satisfaction.
Key Words: Doctors, physicians, hospital managers, administrators, poor relations,
poor working relationship.
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TABLE OF CONTENTS ABSTRACT ………………………………………………………………………………………………….. i
CHAPTER 1 INTRODUCTION ……………………………………………………………………… 1
1.1 Introduction ……………………………………………………………………………………. 1
1.2 Purpose of the Study ………………………………………………………………………. 9
1.3 Research Question …………………………………………………………………………. 9
1.4 Chapter Summary …………………………………………………………………………. 10
1.5 Introduction to Chapters Two to five ………………………………………………. 10
CHAPTER 2 METHODS ……………………………………………………………………………. 11
2.1 Introduction ………………………………………………………………………………….. 11
2.2 Data Source and Search Strategy …………………………………………………… 12
2.3 Inclusion and Exclusion Criteria …………………………………………………….. 16
2.3.1 Inclusion Criteria …………………………………………………………………….. 16
2.3.2 Exclusion Criteria ……………………………………………………………………. 16
2.4 Search Strategy and Search Outcome ……………………………………………. 17
2.5 Quality Appraisal …………………………………………………………………………… 19
2.6 Data Extraction and Synthesis ……………………………………………………….. 20
2.7 Chapter Summary …………………………………………………………………………. 20
CHAPTER 3 RESULTS ……………………………………………………………………………… 21
3.1 Organisational Causes of Poor Doctor-Manager Working Relationships ……………………………………………………………………………………..30
3.1.1 Theme 1: Poor Collaboration and Communication…………………….. 30
3.1.2 Theme 2: Cultural Issues …………………………………………………………. 31
3.1.3 Theme 3: Power and Autonomy ……………………………………………….. 33
3.1.4 Theme 4: Finance and Resources Issues ………………………………….. 35
3.1.5 Theme 5: Education Differences/Challenges …………………………….. 37
3.1.6 Chapter Summary ……………………………………………………………………. 38
CHAPTER 4 DISCUSSION ………………………………………………………………………… 39
4.1 Chapter Summary …………………………………………………………………………. 47
CHAPTER 5 CONCLUSION ………………………………………………………………………. 48
REFERENCES …………………………………………………………………………………………… 51
APPENDICES: …………………………………………………………………………………………… 61
Appendix 1: Critical Appraisal Skills Programme (2013) Qualitative Research Checklist ……………………………………………………………………………………………………. 61
Appendix 2: Summary of Main and Subthemes of Included Studies …………………… 67
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LISTS OF TABLES Table 1: Qualitative Search – Combined Results of Electronic Database Searches of AMED, CINAHL, CINAHL Plus with Full Text, eBook Collection (EBSCOhost), MEDLINE, SPORTDiscus ……………………………………………………………………………. 15 Table 2: Inclusion and Exclusion Criteria ……………………………………………………….. 17 Table 3: Summary of the Included Studies ……………………………………………………… 23 Table 4: Summary of Thematic Analysis: Organisational Factors Causing Poor Doctor-Manager Relationships ……………………………………………………………………… 28 List of FIGURES Figure 1: Proposed PRISMA Flow Diagram ……………………………………………………. 18
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CHAPTER 1 INTRODUCTION
1.1 Introduction
The problem of poor relationship between doctors and hospital managers is a common
feature of many healthcare systems worldwide, including the United Kingdom’s (UK)
National Health Service (NHS) (Edwards, 2003, Drife and Johnston, 1995). According
to Powell and Davies, (2016), good working relationship between physicians and
hospital executive are essential ingredients for the effect performance, improved
patients’ wellbeing and quality of the NHS care (Powell and Davis, 2016). Therefore,
a poor working relationship could have a significant impact on the quality of healthcare,
as it could lead to higher mortality rates, near misses, low staff performance as well
as low patient satisfaction (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).
Several authors (Powell and Davis, 2016 and Rundall and Kaiser, 2004), have
suggested that the lack of understanding and agreement between managers and
doctors in the management of hospital services is not only common but that they have
negative impact on healthcare services. They have also suggested that the problem
is likely to deteriorate in the coming years. Furthermore, despite the significant impact
poor working relationship between doctors and managers could have on quality of
care, staff performance and patient experience, there is limited systematic review in
this area (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998). This is one of my
motivations for this study.
Previous healthcare models involved government appointment of hospital board of
administrators with members not necessarily working in the hospital for example,
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former military officers or politicians with a level of experience as public servants
(Vlastarakos and Nikolopoulos, 2007). However, one of the criticisms of these
practices is that it was not effective because it lacked competent technocratic leaders
who have the requisite knowledge and experiences of long-term planning and better
management of hospital systems (Vlastarakos and Nikolopoulos, 2007). Furthermore,
with the growth of healthcare management and the emergence of healthcare
professionals in hospital administration, the acceptance of these models among
hospital professionals have been limited, more so that they lacked multidisciplinary
collaboration and cooperation (Vlastarakos and Nikolopoulos, 2007, Spurgeon, 2001).
However, according to Spurgeon (2001), growth in healthcare and involvement of
managers who are empowered to enforce government policy and the role of hospital
professionals such as doctors in hospital administration have led to tensions or poor
working relationships between the two groups.
A study on doctor-manager relationships in the United States (US) and the United
Kingdom (UK), found that both groups agreed that relations between them were poor.
In the UK study, both the hospital administrators and clinical executive were optimistic
about the state of their relationships (Rundall and Kaiser, 2004). About 76% of hospital
executives rated the quality of current relationships between the two groups as very
good, compared with just 37% clinical directors. Furthermore, 78% of chief executives
believed the communication and interactions between doctors and hospital managers
would improve over the coming year, compared with just 28% of clinical directors
(Rundall and Kaiser, 2004). Similarly, in the US study, managers were perceived more
favourable regarding their relationships with the doctors (Rundall and Kaiser, 2004).
The researchers also observed that 26% of clinical directors and 29% physician
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executives were of the view that the relationship between them and their chief
executive counterparts would likely deteriorate over time. Despite the obvious
differences between the US and the UK system of healthcare delivery, the survey
revealed how doctors in both countries were more pessimistic than managers about
the state of their working relationships. A strength of this study is that a significant
percentage of doctors and managers (24% to 44%) were unhappy with the time,
resources and energy committed to developing effective relationships locally (Rundall
and Kaiser, 2004).
Similarly, a recent UK research by Nuffield Trust (Powell and Davies, 2016), found
that 72% of chief executives were more optimistic about their relationship compared
with only 50% of clinical directors. Although 80% of hospital executives believe that in
the coming year, progress would be made, only about 35% of clinical directors held a
similar viewpoint. Surprisingly, more than half of the clinical directors (51%) and only
18% of chief executives were of the view that physician-hospital manager relationships
were likely to decline in the coming year. Although both the clinical directors and chief
executives were dissatisfied about the relationship between the two groups, the
number was higher in the clinical director group.
Although both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studies
used a questionnaire survey method for data collection, the former utilised a face to
face interviews and focus groups for data collection. While questionnaires are a very
useful survey tool for gathering information from a large cohort with relative ease, they
require extensive planning, time and effort (Jones, et al., 2013). A strength of the
Powell and Davis, (2016) study is that it involved a larger cohort (472 respondents)
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compared to the study by Rundall and Kaiser (2004), which had only 117 respondents.
It is also worthy to note that in the study by Powell and Davis (2016), the inclusion of
face to face interviews and focus group as additional methods of data collection
improved the trustworthiness of their research findings.
Both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studies have
highlighted the need to further investigate the poor working relationships between
doctors and managers because it is likely to deteriorate over the coming years. This
is one of motivations for this study. Furthermore, despite the significant impact this
poor relationship could have on the quality of care, there is limited research in this
area (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).
Globally, the role doctors and hospital managers’ play in the administration of
healthcare service has more than ever before, continued to be in the spotlight of both
the general public and the media due to the increasing demands for improve quality
of life, quality of healthcare and cost effectiveness (Vlastarakos and Nikolopoulos,
2007). These difficulties may be attributed to the modern expensive high-technological
medicine, to the growing demands and awareness of patient’s rights and to the
increasing financial constraints facing hospital administrators, which include both
doctors and managers (Stadhouders, et al., 2018, Vlastarakos and Nikolopoulos,
2007, and Pollitt, 1996). Furthermore, with the introduction of the market into the
healthcare industry, increasing the drive for efficiency, there is a well-established shift
in public sector management for improved quality of healthcare, better clinical
outcomes and improved patient satisfaction (Degelin, et al., 2003). In order to meet
these growing demands facing healthcare services, which is not only unique to the
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National Health Services (NHS), both hospital doctors and managers must collaborate
and work in harmony. However, differences in opinion between doctors and managers
have not only led to poor working relationships between the two groups, but also
affected their ability to meet these healthcare demands.
A study by Gallup found that physicians who were fully engaged with hospital
administration were 26% more productive than physicians who were dissatisfied
(Burger and Giger, 2014). This increase equates to an average of $460,000 in patient
revenue per physician per year’ (Burger and Giger, 2014). The study also found that
when physicians are fully engaged with hospital administration, the outpatient and
inpatient referrals increased on average by 3% and 51% respectively. One particular
strength of this study is that it highlights the benefits of physician involvement with
hospital administration in the delivery of healthcare services. Conversely, lack of
physician-manager engagements could not only lead to decrease in hospital revenue
from low physician productivity, but it could also ultimately affect the quality of patient
care.
Besides, with the current unsustainable growth in the UK NHS healthcare expenditure
that is characterised by higher scarcity of resources, fiercer competition with a
monumental shift towards public-private partnerships and strict cost-containment
policies, managers and physicians must work collaboratively to achieve better
outcomes for the healthcare industry, members of the public and funding providers
(Stadhouders, et al., 2018, Powell and Davis, 2016 and Kaissi, 2005). This partnership
between doctors and managers together could be under a conjoint responsibility or a
shared authority (Kaissi, 2005). According to the Guardian publication by William
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(2017), “with an army of more than 1.5 million NHS staff, a £11 billion budget and
millions of patients and service users to look after, it is very important that the NHS is
well managed by doctors and managers”
Although the success of healthcare services in efficiently and effectively achieving
these outcomes is theoretically pursued by all involved in hospital function, differences
in understanding between doctors and managers may jeopardise this objective
(Kaissi, 2005). Several factors have been argued to be associated with poor working
relationship between doctors and managers such as cultural and behavioural
differences, as well as differences on philosophy of managing care strategies (Kim, et
al., 2017, Kaissi, 2005, Drife and Johnston, 1995).
Powell and Davies, (2016), suggested that financial constraints in the NHS were
associated with poor working relationship between managerial and clinic staff such as
doctors; and that the situation is likely to continue to deteriorate if nothing is done to
prevent it. These economic challenges are associated with the challenges in
healthcare delivery arising from economic liberalisation policies such as privatisation,
deregulation, and cuts in government spending in order to increase competition in
public services such as the NHS (Powell and Davies, 2016, Schultz, 2004). It has been
argued that there are fundamental differences between the mentality of doctors and
non-medically educated managers who are often responsible for hospital
management (Freidson, 1972). Another source of tension between doctors and
managers as noted by Freidson (1972) is the huge gap between the mentality of
physicians (doctors) and that of non-medically educated managers who often are
responsible for oversight functions of the doctors. It has been argued that doctors hold
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this clinical mentality as they believe that their fundamental role or allegiance is to their
patients. On the other hand, managers typically have a managerial mentality as they
believe their primary duty is to the organisation and they are responsible for the
financial management and organisational strategy (Freidson, 1972).
The traditional roles of physicians and hospital administrators are similar, however,
the root causes of poor working relationships between these two groups and the
manner in which this issue is manifested may vary from one country to another
depending on the specific arrangements for financing, organising, and delivering
healthcare services (Rundall and Kaiser, 2004). For instance, in the US, there are
some states where hospitals are prohibited from hiring doctors as employees due to
corporate practice of medicine laws in those states. In those instances, doctors remain
in private practice, but they are permitted by hospital staff to refer patients to the
hospital (Rundall and Kaiser, 2004). The doctor who referred the patient to the
hospital, manages the hospital care of the patient as the “visiting medical doctor”
(Rundall and Kaiser, 2004). The services provided by the private doctor are
reimbursed by the hospital depending on their health insurance policy (Rundall and
Kaiser, 2004). In this example, the doctors are independent from corporate control and
they exercise the autonomy of being able to admit patients to any hospital where they
have credentialing privileges (Rundall and Kaiser, 2004). This is in contrast to the UK,
where most hospitals are managed by the NHS Trusts, patients who are referred to
the hospital by their general practitioner (referring physician), are overseen and
managed by hospital-based doctors employed by the hospital or under contract with
the NHS, and the care provided is free of charge to patients (Rundall and Kaiser,
2004).
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These differences in the management systems, professional relationships and
financial responsibilities between the U.S. and UK healthcare models are likely to
affect the way doctors and managers interact. In 2003, a U.S. study by the Governance
Institute (2003) involving 60 hospital managers, revealed that competition between
hospitals and doctors for outpatient services and physicians covering on-call duties
without compensation were two significant factors that affected the working
relationships of these two groups. The study found that because of the poor manager-
doctor relationships, some of the doctors who were displeased with the hospital
administration thought of referring patients elsewhere, while some attempted to
compete with the hospital (The Governance Institute, 2003). In the UK, a study (Davies
et al, 2003) found that the rejection of the NHS medical consultant contract in England
and Wales by the doctors was partly due to doctor’s mistrust of managers and fear
that might lose their autonomy. In both countries therefore, doctor-manager
interactions have consequences not only for policy and funding providers but also for
the efficiency of local patient care processes (Rundall and Kaiser, 2004).
Previous studies (Powell and Davis, 2016 and Rundall and Kaiser, 2004) have
highlighted the need to investigate the lack of cooperation between doctors and
managers further because of the impact on healthcare provision. Furthermore, despite
the significant impact that a poor working relationship between the two groups could
have on quality of care, there is limited systematic review in this area (Schultz, 2004,
Edwards, 2003 and Aiken et al, 2003). The problem does not only persist, but it is
likely to deteriorate with the growing risks of doctors disengaging from management.
Therefore, further research is necessary to investigate organisational factors, which
contribute to the poor working relationship between doctors and managers with a view
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of recommending potential solutions to address them. This is my main motivation for
undertaking this study.
1.2 Purpose of the Study
The purpose of this study is to undertake a systematic review of literature on the
evidence regarding poor working relationships between doctors and managers in
hospitals with a view to identify possible root causes of the problem and suggest ways
to overcome them. The expectation is that this study will add to the body of knowledge
required to help improve doctor-manager relations, which in turn could potentially lead
to better outcomes for patients and their families, healthcare services, policy makers
and funding providers.
In order to address the gap in the current knowledge regarding poor working
relationships between doctors and hospital managers, a main research question was
formulated which is: “what are the organisational factors which contribute to the poor
working relationship between doctors and hospital managers?”
1.3 Research Question
1. What are the organisational factors that contribute to poor working
relationship between doctors and hospital managers?
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1.4 Chapter Summary
Chapter 1 has introduced the research topic and presented why poor working
relationships between doctors and managers is a problem. It discussed the background
literature on this issue, highlighted some of the causes and consequences of the
problem on healthcare services, the knowledge gap and the purpose of this current
study. This chapter also stated the research question. The remainder of the study is
organised into four chapters.
1.5 Introduction to Chapters Two to five
Chapter 2 presents a systematic review of the literature on poor working relationships
between doctors and managers in hospitals. Chapter 3 presents the results of peer-
reviewed journal articles that were included in this systematic review including the
summary of the included studies and the identified key themes. In Chapter 4 the
discussion on the findings of the systematic review are presented. Chapter 5 contains
the conclusion, the limitations of the study, and recommendations for further research.
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CHAPTER 2 METHODS
2.1 Introduction
This chapter deals with the study design, which is a qualitative systematic review, the
data source and search strategy, the inclusion and exclusion criteria, as well as the
search outcome. It includes quality appraisal of the included studies, data extraction
and synthesis.
Research designs are different, and they include a single observational case study, a
cohort or case-controlled design, non-randomised and randomised controlled trials
(RCTs), qualitative studies and systematic reviews. Each method has its own
advantages and disadvantages. The choice of which method to adopt is dependent
on factors such as the research question, ethical issues, sample size and funding
(Hicks 1999). Therefore, the choice of this research methodology, which is a
systematic review was because this is a secondary research – that is a review of
previous studies, as well as a result of the research question. According to Higgins
and Green, (2011), “a systematic review is a secondary research (study of studies)
that seeks to gather all primary studies that fit prespecified eligibility criteria in order to
address a specific research question, aiming to minimize bias by using and
documenting explicit, systematic methods” (Higgins and Green, 2011).
To undertake a systematic review, the researcher usually develops a protocol, which
guides the whole process of the review. This is to ensure that the findings of the review
are of a high-quality evidence (Butler, et al., 2016). Therefore, the qualitative
systematic review defined by Ring and her colleagues (2010) and the York Centre for
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Reviews and Dissemination (2019) guided the methodological protocol for this study.
It also ensures that both the inclusion and exclusion criteria follow logically from the
review question. It has been suggested that an important step in the development of
a qualitative systematic review is to have a research question (Bettany-Saltikov, 2012).
The framework for developing a research question in qualitative studies that was
suggested by Stern, et al., (2014) was adopted by this review and it involves the
Population, Exposure, Outcome (PEO) framework, which is readily used by qualitative
studies.
2.2 Data Source and Search Strategy
The aim of the search strategy was to maximally retrieve relevant papers that were
appropriate to the research question, as well as reduce retrieval of papers that are not
relevant (Higgins & Green 2006). To achieve this objective, several widely accepted
databases were searched. These include:
I. A search for papers was conducted through the search engine of the Anglia
Ruskin University Ebscohost, using AMED (Allied and Complimentary
Medicine), MEDLINE (Medical Literature Analysis and Retrieval System),
CINAHL (Cumulative Index to Nursing & Allied Health Literature) Plus with Full
Text, SportDiscus and EBSCO Ebooks from January 2000 to July 2019 and
updated in November 2019.
II. Reference Lists: These were searched from the relevant primary and review
studies
III. Grey Literature: The following was searched via –
a. SIGIE (System for Information on Grey Literature in Europe)
IV. Conference Proceedings: These were searched via:
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a. ZETOC
b. ISI (Institute for Scientific Information) web of science
V. Cochrane Library
VI. The Internet: The following were searched
a. Department of Health (http://www.dh.gov.uk)
b. Google Scholar (http://www.scholar.google.co.uk)
c. Google (http://www.google.co.uk)
In addition to the above, relevant healthcare management textbooks were consulted
for information on manager-doctor relations.
The search was limited to studies published in English language. Non-English
language studies for example, French and Chinese were not included because of the
constraints of translation into English language such as time and money. According to
Bettany-Saltikov., (2012), an electronic search strategy should in general have three
sets of terms. These include terms to search for –
1. The population of interest – Doctors and managers
2. The exposure – Working relationships in hospital or healthcare service
3. The types of study design to be included – Mixed methods, qualitative studies
and quantitative studies
The search strategy began with the use of key words and multiple terms that describe
the population such as doctors, managers and physicians. The Boolean operator “OR”
was used to link these terms in order to retrieve articles that contained at least one of
the search terms. The same process was repeated for a second and a third set of
terms related to the exposure (working relationships in hospital or healthcare service)
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and the study design (Mixed methods, qualitative studies and quantitative studied)
respectively. These three sets of terms were then combined with the Boolean operator
“AND”. This allows for the retrieval of articles that are relevant to the study design, and
address both the population of interest and the research question.
The following lines: S5, S15, S26 and S27 of the updated search through the Anglia
Ruskin University Ebscohost were used respectively to identify records related to the
population (doctors and managers) and exposure (working relationships in hospital or
healthcare service) and studies of the appropriate design. See Table 1 below for
detailed description.
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Table 1: Qualitative Search – Combined Results of Electronic Database Searches of AMED, CINAHL, CINAHL Plus with Full Text, eBook Collection (EBSCOhost), MEDLINE, SPORTDiscus
# Search Terms Combined Results from above Database Searches
S1 Doctors 499.000 S2 Physicians 1,546,371 S3 Physicians or doctors or clinicians 2,214,757 S4 Medical doctors or practitioners 1,406,777 S5 S1 OR S2 OR S3 OR S4 2,634,181 S6 Manager or managers 318,119 S7 Manager or leadership 561,491 S8 Manager or leader or executive or
administrator 881,949
S9 Hospital manager or managers 318,119 S10 Hospital management or administration 4,526,489 S11 Hospital directors 2,162 S12 Trust management 319 S13 Trust administrators 18 S14 Trust managers 321 S15 S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR
S12 OR S13 OR S14 5,246,569
S16 Poor relations or relationships 2,776,115 S17 Conflict 300,258 S18 Differences in opinion 3,600 S19 Dispute 120,739 S20 Disagreement or argument or conflict 492,086 S21 S16 OR S17 OR S18 OR S19 OR S20 3,134,782 S22 Mixed method 55,689 S23 Qualitative method 38,649 S24 Quantitative method 24,596 S25 Mixed or qualitative or quantitative 1,821,590 S26 S22 OR S23 OR S24 OR S25 1,821,590 S27 S5 AND S15 AND S21 AND S26 49,340
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2.3 Inclusion and Exclusion Criteria
A properly formulated inclusion and exclusion criteria provides the researcher with
clearly defined boundaries for a review, which helps in determining the studies that will
be potentially included or those to be excluded (Stern, et al., 2014). Furthermore, a
properly formulated selection criterion removes possible selection bias that the
reviewer may have thus ensuring that the studies that are selected are mainly on the
basis of predefined, justified standards excluding the personal interest of the
researcher (Aromataris and Pearson, 2014).
2.3.1 Inclusion Criteria
Mixed methods, qualitative studies and quantitative studies that explored doctors
and managers working relationships in hospital or healthcare service were included
in this review. The settings of the included studies were hospital or healthcare
services. Studies that were published in English language in peer reviewed journals
between January 2000 and July 2019 were included. See Table 2 for details.
2.3.2 Exclusion Criteria
Studies were excluded if the target populations were not doctors (physicians) and
managers (hospital administrators, executives, directors), who were working in
hospital or healthcare settings. Studies that were not focussed on doctors-manager
relationships were excluded from this review. Studies that were not published in
English language before January 2000 were also excluded. See Table 2 below for
details.
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Table 2: Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Population Doctors and managers Not doctors and managers
Exposure Doctors and managers working
in hospital or healthcare service
Not doctors and manager working in
hospital or healthcare settings
Outcome Studies on doctors and
managers working relationships
in hospital or healthcare service
Studies not centred on doctors and
managers working relationships in
hospital or healthcare service
Type of studies Mixed methods, studies,
qualitative studies that are
published appropriately
Full texts of Studies
Research studies in English
Language or translation to
English from other languages
Studies with clear Ethical
Approval
Abstracts or summaries
Commentaries
Studies not in English Language
Studies without ethical approval
will not be included
2.4 Search Strategy and Search Outcome
A total of 49, 340 citations were initially identified and retrieved from the Ebscohost
electronic databases and additional 15 papers were also found from the reference lists
and grey literature. There were 29,126 citations after removal of 20,229 duplicates.
After careful evaluation of the titles and/or abstracts, a total of 29,085 articles that were
not related to the study design were excluded from the 29,126 citations and 41 articles
were left. Full texts of the 41 potentially eligible articles were reviewed. Upon full text
review, 21 studies were excluded with the following reason: they were exploratory
studies that described the relationships between doctors and nurses. 20 full text
articles that were possibly relevant to this study were identified and reviewed for quality
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appraisal and five articles that were commentaries were excluded. (See Figure 1
below for details).
Figure 1: Proposed PRISMA Flow Diagram
E lig
ib ili
ty
Id en
ti fi
ca ti
o n
S
cr e
en in
g
In c
lu d
e d
Additional Studies identified through other sources n = 15
20,229 duplicates removed from the combined searches (n = 49,355
29,126 potential relevant studies screened
Citations excluded at title or abstract with reasons n = 29, 085
21 full text articles excluded with reasons: Not population and exposure of interest = 21
41 Full text studies retrieved for detailed assessment for eligibility
15 studies included as part of the quality appraisal and synthesis
5 Commentaries excluded
20 Full text studies reviewed for quality appraisal
49,340 Citations identified through database searching:
a. CINAHL Plus with Full Text (45,075)
b. eBook Collection (EBSCOhost) (118)
c. CINAHL (1,917) d. MEDLINE (2,177) e. SPORTDiscus (38)
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15 studies were included as part of the quality appraisal and synthesis. Titles and
abstracts of these remaining articles were then hand searched for studies that
investigated poor working relationships between doctors and managers in hospital or
healthcare services.
2.5 Quality Appraisal
Although it has been argued that quality assessment is not a major requirement for
qualitative systematic review, however, it is recommended that studies that are
retrieved should not have methodological issues (Butler, et al., 2016). The quality
appraisal of the studies that were included in this review were conducted using the
Critical Appraisal Skills Programme (2013) Qualitative Research Checklist (see
Appendix 1 for details), which is a tool that has been developed and commonly used
by researchers for checking the trustworthiness and rigor of qualitative research. The
tool enables the assessment of a qualitative study’s aim, methodology, sampling
process, data collection and analysis, ethics and findings. The tool contains 10
questions and each question was categorised as either ‘yes’, ‘can’t tell’ or ‘no’. If one
question was scored ‘yes’, it was counted as 1 point. If all questions were assessed
as ‘yes’, the total quality score for a study was maximum of 10 points. If the question
was assessed, as ‘can’t tell’ or ‘no’ it was counted as 0. Since this current study is part
of an MBA degree programme, the researcher conducted the quality appraisal with
guidance of the programme supervisor (SF). This is to ensure that all the studies
included in this review had adequate methodological rigor. After the quality
assessment, all the 15 studies selected for full review have a quality score of 8 points
or more.
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2.6 Data Extraction and Synthesis
A data extraction form by Bethany-Saltikov, (2012) was used as a data registry and as
a guide for identification studies on poor working relationships between doctors and
managers. Details of the author, year of publication, country, aim of study, study
population, study design, quality appraisal, methods of data collection/data analysis
and key findings were included in the data extraction form.
After extraction, data analysis and synthesis began. This qualitative systematic review
adopted the thematic synthesis of qualitative findings. According to Ring, et al., (2010)
thematic synthesis involves identifying and coding recurring concepts from the
selected studies’ textual findings, synthesising the codes into themes, and generating
higher level themes. The concept of the framework not only enabled the researcher to
gain an overview and make sense of the data, but to also manage, synthesise and
interpret the data in a structured and systematic manner using descriptive and
illustrative accounts. See Table 4 for details of codes and synthesised themes.
2.7 Chapter Summary
This chapter discussed the study design, which is a qualitative systematic review, the
data source and search strategy, the inclusion and exclusion criteria, as well as the
search outcome. It also included quality appraisal of the included studies, the process
of data extraction and synthesis.
The next chapter presents the results of the studies included in this review. It also
includes the key themes that were identified.
21
CHAPTER 3 RESULTS
Fifteen peer-reviewed journal articles were included in this systematic review. Six
studies discussed factors affecting doctor-manager working relationships (Berenson,
et al., 2006, Klopper-Kes, et al, 2010, Knorring, et al., 2010, Morana, 2014, Rundall
and Kaiser, 2004, and Samadi-niya, 2015). Four studies explored perceptions of
physicians-managers’ relationships and discussed their different viewpoints (Davies,
et al., 2003, Klopper-Kes, et al., 2009, Powell and Davis, 2016, Spaulding, et al.,
2014). One study focussed on the involvement of clinical professionals (physicians)
with hospital administrators in hospital management (Dalmus, 2012). Two studies
focussed on work-related conflicts between physicians and managers’ relationships
(Tengilimoglu and Kisa, 2005, Viastarakos and Nikolopoulos, 2007). One study
investigated the role of educational qualifications between medically educated and
managerially educated senior manager relationships (Waldman, 2006). One study
explored the cultural dynamics between physicians and hospital administrators (Keller,
et al., 2019). Two studies were conducted in the UK, five in the US, one study was
conducted in both the UK and the US, two studies were from the Netherlands, one
study each in Malta, Sweden, Norway, Turkey and Greece. Four studies were
quantitative, seven were qualitative and four used mixed methods.
See Table 3 below, which summarises all the studies included in this review. The
studies’ details, design, samples, data collection, data analysis and key findings were
summarised in the Table 3.
22
Five key themes were identified from the data analysis (see Appendix 2 for details of
the process for data extraction using thematic approach) and they are related to
organisational factors that caused poor doctor-manager relationships (see Table 4).
These key themes and sub-themes are discussed in the next session below.
23
Table 3: Summary of the Included Studies
Author (year), country
Purpose of study Study Population Study Design
Quality Appraisal
Methods of Data Collection/Data Analysis
Key Findings
Berenson et al, 2006, Washington, U.S.
To examine hospital and physician relations in terms of changes in financial, organisational and healthcare delivery
296 respondents – Hospital CEOs, chief medical officers, single and multispecialty medical group CEOs and medical directors
Qualitative study
8 Semi-structured interviews in persons and by telephone
The study showed that increasing expectations on healthcare system such as market forces and finance were organisational factors that affected physicians and hospital administrators’ collaboration and ability to work together.
Dalmus, 2012, Valletta, Malta
To investigate the role of clinicians in hospital management
16 professionals – eight medical/clinical professionals and eight – hospital management or department
Qualitative method/8
8 Convenience sampling method, Unstructured in- depth interviews/groun ded theory approach
The study showed that although medical doctors have complete autonomy on all decisions related their patient care, however they do not have such control over financial and human resources. This issue affected doctor-manager relationships. All participants acknowledge that more involvement of clinicians in the strategic, decision-making and resource allocation processes of hospital management will improve collaboration.
Davies et al, 2003, London, UK
To understand the current perceptions of doctor-manager relationship by examining areas of agreement and disagreement of views among the two groups in the NHS
103 chief executives, 168 medical directors, 445 clinical directors, and 376 non-medical directorate managers
Mixed method/9
9 A postal questionnaire survey method and interview method
Doctors were dissatisfied with their relationship with managers because of issues of professional autonomy, bureaucracy and lack of trust. However, senior managers and non-physician managers were more positive about the relationship than staff at directorate level and medical managers. Clinical directors were easily the most disaffected, with many holding negative opinions about managers’ capabilities. They also believe that the respective balance of power and influence between managers and clinicians affected their working relationships.
24
Author (year), country
Purpose of study Study Population Study Design
Quality Appraisal
Methods of Data Collection/Data Analysis
Key findings
Keller et al, 2019, Chicago, U.S.
To efficiently characterise the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement
40 participants – 20 physicians and 20 healthcare administrators
A qualitative mixed method
9 Purposive sampling/qualita tive mixed method analysis
A professional cultural disconnect between managers and physicians was undermining efforts to improve physician engagement. This disconnect was further complicated by the minority (10%) who did not believe that the issue existed.
Klopper-Kes et al, 2009, Enschede, Netherlands
To understand the complex relationships between hospital managers and doctors
166 respondents – 109 physicians and 59 managers
A quantitative mixed method
8 Quantitative questionnaire and interview methods
The data showed three variables – professional status, power and goals, responsible for the differences between physician and managers relationships. Hospital administrators consider doctors as higher in professional status and power and having different goals. Physicians on the other hand, think hospital administrators have higher power, lower status, and different goals.
Klopper-Kes, et al 2010, Dutch, Netherlands
To provide practical tools to improve cooperation between manager and physicians in order to enhance hospital performance
1239 participants – 929 physicians and 310 managers
Quantitative design method
9 Questionnaire method/Paired sample T-tests and ANOVA were used to determine significant differences between physicians and doctors’ responses
There were statistically significant differences between physicians and managers’ relationship (ANOVA, p-value < 0.05) in three categories. Differences between current safety concerns, quality of care and professional autonomy were some of the issues that caused tensions between doctors and managers. Physicians were more satisfied about the current safety and quality of patient care than managers. While managers, preferred computer-based registration of patients, physicians on the other hand, prefer more informal consultations. Professional autonomy and collegiality among physicians also contributed to discontent in the relationships between doctors and managers.
25
Author (year), country
Purpose of study Study Population Study Design
Quality Appraisal
Methods of Data Collection/Data Analysis
Key findings
Knorring et al, 2010, Stockholm, Sweden
To understand how the top managers in Swedish healthcare regard management of physicians in their organisations and what this implies for the management role in relation to the medical profession
18 Chief executive officers – seven physicians and 11 other professional background.
Qualitative semi- structured interview method
9 Semi-structured individual interviews/groun ded theory approach
In this study, managers identified three key issues that affected their working relationship with doctors. Managers believe that doctors had very high opinion of themselves, but they lacked knowledge of the system and they do what they want in the organisation. Therefore, the differences in opinion in perceptions of daily practice and value of professional autonomy between doctors and managers affected their relationships.
Morana, 2014 To investigate the working relationship among physicians and their practice administrators
N = 15 – physicians Qualitative phenomenol ogical study/10
Interview method
Physicians reported that open and honest communication, dependability, trust, honesty, collaboration and knowledge were factors that affected their relationship with practice administrators.
Powell and Davis, 2016, UK
To investigate current perceptions of the working relationships between hospital chief executives who are non-clinical and clinical directors and the factors affecting their ability to work together, and to assess if and in what ways these perceptions have changed since the 2002 UK survey.
A total of 472 respondents – 59 Chief executives, Medical directors, 132 Directorate managers and 150 Clinical directors
A mixed method designs/10
Online and postal survey, telephone and face to face interviews and focus group
The study showed that financial issues, professional autonomy, lack of trust and lack of training were detrimental to effective working and to developing and nurturing sound relationships between physicians and hospital executives for the medium and long term. Surprisingly, more than half of the clinical directors (51%) and 18% of chief executives were of the view that doctor- manager relationships were like to deteriorate over the next year.
26
Author (year), country
Purpose of study Study Population Study Design
Quality Appraisal
Methods of Data Collection/Data Analysis
Key findings
Rundall and Kaiser, 2004, US and UK
To investigate manager-physician relationships looking at the data collected in both US and UK surveys for possible similar factors affecting the relationships and those specific to each country’s health services
In US – 65 Senior managers and 52 Physician executives, in UK – 103 Chief executives, 168 Medical directors, 445 Clinical directors, 376 Nonmedical directorate managers
Quantitative design method
8 67 item postal questionnaires using a four- point Likert scale. Data analysis using Chi-square tests were used to determine the statistical significance of differences between across all sampled groups.
This study concluded that power and autonomy, and cost cutting measures were some of the organisational factors that affected manager- physician relationships. The study also found that physicians were more pessimistic than hospital managers regarding their relationships.
Samadi-niya, 2015
To investigate the effects of interprofessional doctor-manager relationships on patient care quality
N = 137 (Physicians and hospital administrators
Quantitative study
9 Multivariable correlational study
This study showed organisational factors such as relative power, lack of resources, financial issues, differences in role capability, communication and clinical priority, affected the relationships between doctors and managers. Consequently, this could impact on the quality of patient care.
Spaulding, et al., 2014, Florida, U.S.
To identify perspectives regarding physician-manager engagement
Health system administrators and physician administrators
A qualitative interview
8 Open-ended interviews
The lack of open dialogue, transparency, communication and lack of collaboration created a huge gap in the physician-manager engagement. The study recommended that the identification of success factors such as effective communication was critical to improving physician and management relationships.
27
Author (year), country
Purpose of study Study Population Study Design
Quality Appraisal
Methods of Data Collection/Data Analysis
Key findings
Tengilimoglu and Kisa, 2005, Turkey
To outline the key features of conflict in a large modern hospital that can be targets for successful management
204 Hospital staff completed the questionnaire – 30.9% were physicians and 12.5% were administrators; 61.5% were female and 38.5% were male.
Quantitative design method
8 A questionnaire method. A convenience sampling method. Statistical analysis was by Chi-square and P-values.
Educational differences among physicians and administrators were a major barrier to good communication and relationship between the groups. Another source of conflict was that resource allocation was considered unfair across departments. A lack of career development was mentioned by 52% of the respondents as source of conflict. 48.4% felt that bureaucracy was a source of conflict because their performance was less than optimal due to presence of multiple supervisors.
Vlastarakos and Nikolopoulos, 2007, Greece
To access health practitioner’s views on the issue of hospital administration and explore possible conflicts
124 Doctors and 15 hospital managers
Qualitative method
8 Questionnaire- based multi- stage cluster sampling technique
Differences in the educational qualification of hospital administrators and doctors, lack of flexibility and collaboration were factors that affected their relationships. The perception of doctors was that hospital administration by the managers was ineffective, because they lacked the necessary educational qualification to manage. The interdisciplinary model, with a manager having both health sciences and economics degrees and exercising the role with flexibility and collaboration with physicians were suggested as ways of improving doctor-manager relationships.
Waldman, 2006, New Mexico, U.S.
To establish common ground between Chief executive officers and physicians
670 hospital and health system Chief executive officers
A qualitative survey
8 Survey method
The system-wide dysfunction that affected relationships of physicians and hospital executives were reimbursement/cost issues (77%) and shortages of critical personnel (66%), both of which reflected imbalance between resources and commitments, contradictory obligations and ineffective systems. The study suggests that effective alliance of managers and care providers could turn their diversity of talents and experience into a powerful tool for solving health care problems.
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Table 4: Summary of Thematic Analysis: Organisational Factors Causing Poor Doctor-Manager Relationships
Main Themes Code in the texts Poor collaboration between managers and doctors
Lack of open dialogue, transparency, communication in physician-manager relationships (Powell and Davis, 2016, Spaulding, et al., 2014) Competition as a potential source of disagreement between managers and doctors (Berenson et al, 2006) There needs to be more partnering and more physician driven models (Spaulding, et al., 2014) Without involving the physicians in defining that positive environment, the organisation runs the risk of developing wrong model (Spaulding, et al., 2014) Management structures, which focus on the patient rather than on professional hierarchies (Dalmas, 2012) Disconnection between the board and divisional or doctorate level (Powell and Davis, 2016) Lack of development initiatives for cross-professional collaboration (Dalmas, 2012) Communication issues (Davis, et al., 2003, Morana, 2014, Spaulding, et al., 2014) Engagement survey (Keller, et al., 2019) Trust, respect and shared values and objectives (Dalmas, 2012, Morana, 2014) Bureaucracy- presence of multiple supervisors (Tengilimoglu and Kisa, 2005)
Finance and resource issues Competition over services between doctors and managers (Berenson, et al., 2006) Increased public expectation for improved patient safety and quality of care (Berenson et al, 2006, Dalmus, 2012) Physicians are asked to do more for less pay (Samadi-niya, 2015) The use of hospitalists rather than physicians and specialists (Berenson et al, 2006) Management is more focused on financial than clinical priorities (Powell and Davis, 2016, Rundall and Kaiser, 2004, Tengilimoglu and Kisa, 2005, Samadi-niya, 2015) Financial arrangement of hospitals and physicians with payers (contract) (Samadi-niya, 2015) Adequacy of resources (Waldman, 2006 and Samadi-niya, 2015)
Power and autonomy Physicians think hospital manager are pushing the limits by trying to go as far as possible (Klopper-Kes, et al.,
2009) The influence of the trust board (Powell and Davis, 2016) Physicians see hospital managers as threat to their status and power, and vise versa (Klopper-Kes, 2009) Hospital managers think physicians ruthless and try to stay in power as long as they are the biggest and strongest (Klopper-Kes, et al., 2009) Lack of proper and clear definition of roles and responsibilities (Dalmas, 2012) Doctor-manager differences in value of professional autonomy (Davis, et al., 2003, Klopper-Kes, et al, 2010)
29
Disagreement on the relative power and influence between management and physicians (Rundall and Kaiser, 2004, Samadi-niya, 2015) Management exert pressure on physicians to discharge or transfer patients early (Rundall and Kaiser, 2004) CEO’s thought physicians were reluctant to abide by rules, avoid participating in group meetings (Von Knorring, et al., 2010) “Half of administrators and physicians oriented themselves as bosses and islands” (Keller, et al., 2019) Non-medical managers were perceived to hold all of the power (Powell and Davis, 2016)
Cultural issues Culture of medicine versus culture of management (Samadi-niya, 2015, Keller, et al., 2019) Cultural views of managers are business and profit oriented, while doctors’ views are clinical and patient focussed (Morana, 2014, Samadi-niya, 2015) Both managers and doctors showed differences in perceptions of daily practice (Klopper-Kes, et al, 2010) Differences in physicians’ and administrators’ professional backgrounds, values and thought processes (Keller, et al., 2019) Differences between physicians and hospital managers with regards to loyalty to organisation and profession (Keller, et al., 2019)
Educational differences/challenges Differences in educational qualification of doctors and managers (Tengilimoglu and Kisa, 2005, Vlastarakos and Nikolopoulos, 2007) Impact of training on relationships between senior clinicians and management (Powell and Davis, 2016) Educational differences led to communication problems between different professionals (Tengilimoglu and Kisa, 2005) Lack of development initiatives for cross-professional collaboration (Dalmas, 2012) Training in management skills (Dalmas, 2012) Lack of opportunity for career development (Tengilimoglu and Kisa, 2005) Physicians lack knowledge of the system (Von Knorring, et al., 2010) Physicians do not respect opinion of managers with education in history or geography (Samadi-niya, 2015)
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3.1 Organisational Causes of Poor Doctor-Manager Working Relationships
3.1.1 Theme 1: Poor Collaboration and Communication
To ensure that the core values of healthcare, which include quality of patient care,
patient satisfaction and prevention of adverse effects, are achieved, interprofessional
relationships between physicians and hospital administrators should be collaborative.
The notion of professional permeability and the spread of ideas by osmosis between
the two groups will foster mutual understanding and agreement on core hospital values
(Mascie-Taylor, 2003, Wilson and Sweeney, 2003).
Nine studies reviewed, reported lack of collaboration and communication as
organisational factors affecting the relationships between physicians and hospital
managers (Berenson, et al, 2006, Dalmus, 2012, Davis, et al., 2003, Keller, et al.,
2019, Morana, 2014, Powell and Davis, 2016, Samadi-niya, 2015, Spaulding, et al.,
2014 and Tengilimoglu and Kisa, 2005). Furthermore, three studies (Morana, 2014,
Powell and Davis, 2016, Spaulding, et al., 2014) found that lack of open dialogue,
transparency, communication resulted in a ‘we versus them’ type of relationship
between the two groups. In the study by Powell and Davis, (2016), many doctors felt
they had a distant relationship with the hospital trust board because the board did not
include them in decision making. Similarly, in the study by Spaulding, et al., (2014),
one of the managers interviewed stated “the physicians have to feel that they are
partners within the group and valued participants…you treat them inappropriately and
separately, then you are not going to have a great success” (p.69). In the same study,
the connection between communication and staff engagement, was noted in the words
of one of the hospital administrators: “I think we need to do a better job of listening to
our physicians…not just listening to them, but really hearing them…what their core
31
values are, and engaging with them” (Spaulding, et al., 2014, p.69). Equally, Samadi-
niya (2015) found that lack of teamwork and communication has significant impact on
interprofessional relationships between the two groups.
One study found that bureaucratic involvement of multiple supervisors was a source
of conflict between physicians and hospital administrators leading to poor work
performance (Tengilimoglu and Kisa, 2005). Lack of development initiatives for cross-
professional collaboration, trust, respect and shared values and objectives were
identified as some of the barriers to physician-administrator rapport (Dalmas, 2012,
Morana, 2014). This point was re-echoed by Weiner, et al., (1997), stating that lack of
collaboration does not only have a negative effect on interprofessional relations
between the two groups, it also hinders the improvement in the quality of patient care.
To reduce this problem, some researchers have suggested the development of
strategic communication and collaboration plans (Baker, et al., 2004 and Powell and
Davis, 2006).
3.1.2 Theme 2: Cultural Issues
Organisational culture is centred on the values, views and aspirations that members
of an organisation share (Hirayama and Fernando, 2018). Therefore, organisational
culture within the healthcare service has the potential to influence the pattern of
behaviour of healthcare professionals such as physicians and hospital
administrators/managers working within the organisation (Morgan and Ogbonna,
2008). This view resonates with the statement by Taylor and Benton, (2008), advising
“that all the problems that exist in interprofessional relationships between physicians
and administrators are cultural barriers to effective healthcare”.
32
Three other studies described cultural issues as barriers to the relationship between
doctors and managers’ (Keller, et al., 2019, Klopper-Kes, et al., 2010, Morana, 2014
and Samadi-niya, 2015). Keller, et al., (2019), reported that physicians’ and
administrators’ professional backgrounds, values and beliefs differed considerably.
Furthermore, the researchers reported that the differences in their professional
backgrounds, values and beliefs affected their working relationships. For example,
while administrators believe that excellent patient care can be achieved by promoting
the organisation and its brand, physicians on the other hand were of the view that
excellence in patient care was attainable by advancing profession/specialty through
education and research (Keller, et al., 2019).
Another key cultural difference that affected the relationships between the two groups
was their different approaches to decision making. The physicians’ viewpoint was that
patient care occurred in high acuity, with short clinical decision-making time, and
where a lot of information were shared in a single best course of action (Keller, et al.,
2019). On the other hand, administrators follow a lot of bureaucratic process with
regards to organisational care, and this takes much longer time and involves multiple
channels (Keller, et al., 2019). These views compared favourably with Bujak, (2003)
who reported that “physicians have an expert culture and administrators have an
affiliative culture”.
According to Samadi-niya, (2015), the cultural views of managers are business
oriented, rooted on profitability and having the big picture in view. In contrast,
physicians have dissimilar cultural views, which are clinical, and patient focused
(Samadi-niya, 2015).
33
3.1.3 Theme 3: Power and Autonomy
Nine studies cited the complexity of power and autonomy as a barrier to doctor-
manager relationships (Dalmus, 2012, Davis, et al., 2003, Keller, et al., 2019, Klopper-
Kes, et al., 2009, Klopper-Kes, et al., 2010, Von Knorring, et al., 2010, Powell and
Davis, 2016, Samadi-niya, 2015, Rundall and Kaiser, 2004). Physicians saw hospital
administrators as having powers while hospital administrators saw doctors as having
greater powers (Klopper-Kes, et al., 2009). This implies both doctors and managers
felt relatively “powerless” in the same organisation and the practical implication of this
is that there could be lack of proper and clear definition of roles and responsibilities in
achieving organisational goals such as improved quality of patient care and staff
performance (Dalmas, 2012, Davis, 2003 and Klopper-Kes, et al., 2009). In one of the
studies, a hospital administrator was quoted saying, “if they understand what I am
capable of doing and how useful I could be, our relationship and cooperation would
not be such a problem” (Klopper-Kes, et al., 2009, p.221).
Doctor-manager differences in value of professional autonomy was another reason
cited as a barrier to a harmonious working relationship between the two groups (Davis,
2003, Klopper-Kes, et al., 2009, Von Knorring, et al., 2010). For example, hospital
administrators described how doctors were reluctant to abide by rules, avoiding
participating in group meetings with them, and in many respects, choosing to follow
their own agendas (Von Knorring, et al., 2010). This type of “do-what-you-want”
mentality was perceived by the administrators as “strong” and not limited to clinical
matters. One respondent put it directly:
“They very much guard how they exercise their own professional practice. That they
have the professional right of interpretation, that it is not the deliverer of care, from
34
some holistic picture, who has the preferential right of interpretation, but rather it is the
individual physician who has that in all situations, not only in the direct consultation
with the patient where you make an assessment, but in all matter” (Von Knorring, et
al., 2010, p.5)
Similarly, Keller, et al., (2019) reported that half of the administrators interviewed
described their relationship with physicians as living in isolated “islands’ with doctors
working in ‘silos’ and acting as ‘bosses’. This implies that there was increasing
communication gap and lack of engagement between both parties. In the study by
Powell and Davis (2016), hospital administrators were perceived by physicians as
having too much authority. However, hospital managers thought doctors are ruthless
and try to stay in power for as long as possible since they are the largest and strongest
group within the hospital (Klopper-Kes, et al., 2009). On the contrary, in the study by
Rundall and Kaiser, (2004), physicians felt management exerted too much pressure
on them to discharge or transfer patients early. Furthermore, the physicians believe
that hospital managers are pushing the limits by trying to go as far as possible by
instructing them on what to do (Klopper-Kes, et al., 2009). The practical implication is
that since the above-mentioned challenges constitutes major barriers to physician-
hospital administrator relationships, it is important therefore, to find ways of resolving
them so that patient experience, clinical outcomes and hospital performance are not
adversely affected.
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3.1.4 Theme 4: Finance and Resources Issues
In seven studies, financial and resource challenges were reported as barriers to
relationships between doctors and managers (Berenson, et al., 2006, Dalmus, 2012,
Powell and Davis, 2016, Rundall and Kaiser, 2004, Samadi-niya, 2015, Tengilimoglu
and Kisa, 2005 and Waldman, 2006). A directorate manager in the study done by
Powell and Davis, (2016) cited the negative impact of financial and resource
constraints on relations between the two groups, stating that “the rising financial
pressures and increasing expectations of patients on the service are affecting their
relationships with doctors” (p.25). It was noted that both the physicians and hospital
administrators agreed that the bond between them is negatively affected by the nature
of financial targets set by the funding providers. For example, Powell and Davis, (2016)
stated:
“The punitive financial nature of targets set by, for example, the clinical commission
group has a negative impact on all NHS establishments. It leads to a deepening of the
divide between management and clinicians as NHS trusts strive to maintain financial
balance. Whilst all targets should be based on good clinical practice they are inevitably
interpreted as being financially driven and this disengages clinicians which
exacerbates the manager clinician interface” (p.25).
Four studies (Powell and Davis, 2016, Rundall and Kaiser, 2004, Tengilimoglu and
Kisa, 2005 and Samadi-niya, 2015) found that part of the conflict and disengagement
between the two groups was because doctors felt management was driven more by
financial gain rather than clinical priorities. Increased public expectation for improved
patient safety and quality of care in the face of financial scarcity was identified as
another source of tension between the two groups (Berenson et al, 2006 and Dalmus,
36
2012). The disparity between managers and physicians in terms of hospital resource
and patients demand, were factors, which inevitably created conflict and disagreement
between the two groups (Powell and Davis, 2016, p.25).
Several services that are performed in acute hospitals such as management of
diabetes, hypertension and chronic obstructive pulmonary disease can safely and
conveniently be performed in ambulatory settings such as community health centers,
urgent care centers, and physician offices (Berenson, et al., 2006, Powell and Davis,
2016, Waldman, 2006. Competition between the hospital administrators and
physicians over such services that had once been managed within the sphere of the
hospital, caused a strain in their relationship (Berenson, et al., 2006, Powell and Davis,
2016, Waldman, 2006. Although the expectation is that such health system challenge
will lead hospital managers and physicians to collaborate more, in many instances the
willingness and ability for the two groups to work together is actually declining
(Berenson, et al., 2006). For example, one hospital executive was noted saying “we
are in competition with our own physicians”. Whilst a physician stated “everyone ……
is opening an ambulatory surgery or diagnostic centre today, there is more and more
movement of services from acute hospital control to non-medical physicians’ control”.
Furthermore, there is growing tension between non-medical physicians and medical
physicians because of the growing reluctance of medical physicians to take on
emergency department duties, and the consequence is that hospital administrators
are hiring non-medical physicians instead of medical physicians to cater for their
inpatients.
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3.1.5 Theme 5: Education Differences/Challenges
Four studies cited differences in educational qualifications of doctors and managers
as a source of tension and lack of engagement between the two groups (Dalmus,
2012, Von Knorring, et al., 2010, Tengilimoglu and Kisa, 2005, Vlastarakos and
Nikolopoulos, 2007).
According to Powell and Davis, (2016) lack of management training for doctors and
executive coaching on leadership style could hamper the relationship between doctors
and managers. Hence, the presence of joint training events for the groups have been
shown to improve their collaboration (Powell and Davis, 2016). For example, one Chief
Executive (CEO) said that the individual executive coaching on leadership style that
was organised by management for both senior physicians and hospital administrators
had a positive effect on their relationship (Powell and Davis, 2016).
In the study by Vlastarakos and Nikolopoulos, (2007), 61% of the doctors working in
the hospitals being reviewed ignored the basic degree of the hospital manager, while
71% of the doctors felt the degrees were inadequate for the efficient management of
the hospital. Furthermore, Tengilimoglu and Kisa, (2005), concluded that educational
differences between physicians and administrators were a major barrier to effective
collaboration and integration between the groups. Similarly, it has been stated that
through professional training, regulation, medical licensing and certification,
physicians have this communal type relationship within the hospital, which Kaissi,
(2005) termed “occupational community”. This occupational community relationship
among doctors influence their interaction with hospital managers who on the other
hand are not viewed as part of that community because they are individuals from
38
various educational backgrounds such as business, public administration and
accounting (Kaissi, 2005).
3.1.6 Chapter Summary
This chapter presents the findings of the studies included in this review. It described
the different studies, their details, design, methods of data collection/data analysis and
important findings including the five key themes that were identified from the data
analysis.
The next chapter is centred on the discussion of the findings of the included studies in
this review, which are the barriers to doctor-manager working relationships.
39
CHAPTER 4 DISCUSSION
This qualitative systematic study found considerable evidence of organisational
factors that contributes to poor working relationships between doctors and managers.
This review identified five major themes from the studies that were reviewed. The first
was poor communication and collaboration amongst physicians and hospital
administrators. Several authors have reported that there are well known challenges in
the communication and group work between hospital executives and doctors (Davies,
et al., 2003, Edwards, 2003, Kaissi, 2005, and Shortell, et al., 2005). In this review,
respondents highlighted lack of open dialogue, transparency, communication as
factors that created a rift in the relationship between doctors and hospital
administrators. Doctors felt that their inability to access hospital executives created a
“we versus them” adversarial type relationship (Chhetri, 2017, Powell and Davis,
2016). Doctors also felt they were not being listened to by the hospital executives
(Powell and Davis, 2016).
Previous research in healthcare settings (Degeling and Maxwell, 2004, Bartunek,
2011, Kaissi, 2014) suggested that if there is concentrated effort and resources in
creating and maintaining effective working relationships between different groups such
as doctors and managers working within healthcare services, communication and
collaboration between them is likely to improve. Furthermore, it would also foster
development of initiatives for cross-professional collaboration, development of
systems and processes that will function well for both groups and improve mutual trust,
respect and shared values and objectives (Degeling and Maxwell, 2004, Bartunek,
2011, Kaissi, 2014, Dalmas, 2012 and Morana, 2014). However, insufficient time and
40
resources was cited as challenges to nurturing physician-hospital administrator’s
relationship (Powell and Davis, 2016). Nevertheless, if health services such the NHS
are mainly depending on doctors and managers to make this crucial relationship to
work, then it is important that specific attention, effort and resources including time
incentives should be committed to specifically nurturing the relationship, as this will
enhance staff performance and provide better quality of care (Powell and Davis, 2016).
This is consistent with the assertion by Baker, et al., (2004) who in a study of
healthcare leaders from various professional groups suggested a governance plan
that puts collaboration among medical staff, senior leadership teams and boards at
the heart of doing healthcare business, necessary to improving the quality of patient
care. The practical implication of such a strategic plan is that, not only will there be
agreement on key issues that bothers on service provision but there will also be
enhanced cooperation and collaboration in achieving set objectives (Klopper-Kes, et
al., 2009).
Cultural issues were the second theme cited by majority of the studies included in this
review. It has been reported that cooperation and communication between physicians
and managers are affected by differences in their professional and organisational
cultures (Klopper-Kes, et al., 2010 and Kaissi, 2005). Furthermore, differences in
organisational values, views and aspirations between physicians and hospital
administrators were reported as obstacles for successful relationships between the
groups. Although both doctors and managers agree on guaranteeing the safety of
patients and improving their quality of care, they disagree on the level of involvement
in the implementation (Klopper-Kes, et al., 2010). This disagreement is based on
41
differences in meaning, values, and behavioural norms which are generally not
comparable by the same standards (Kaissi, 2005). For instance, in current review,
physicians’ primary loyalty was to their patients, while managers had strong allegiance
to the organisation they serve.
The different socialisation and training that managers and physicians receive results
in varied worldviews, value orientation and expectations, which can hinder harmonious
relationships between them (Kaissi, 2005, Klopper-Kes, et al., 2010). However, if
these differences in perceptions are recognised and harnessed, they can become a
veritable tool in enhancing their relationship, more so that subsistence in the current
health care environment requires a diversity of skills, orientations and thought
processes (Kaissi, 2005).
This is consistent with the suggestion by Brockschmidt (1994), advising that
organisations should adopt a corporate culture that allows both physicians and
hospital managers to play important roles in solving conflicts of views, values and
behavioural beliefs between them. However, it has been argued that if doctors are to
be involved in such process, a “cultural change” may be necessary (Kaissi, 2005).
According to Spurgeon (2001), “the cultural change” should recognise, involve and
accept that doctors are part of a managed healthcare community and that
management is a valued and important process”. One of the strengths of his
suggestion is that the cultural divide between doctors and managers regarding
business profitability and patient centred care could be a potential source for
discussion and corporate engagement between the two groups. More so, the
42
continuity of an effective patient centred care and quality improvement are hinged on
a formidable and successful business continuity plan (Spurgeon, 2001).
The third theme identified was power and autonomy. In the studies under review,
physicians viewed administrators as superiors with higher administrative powers,
while managers perceived doctors as being higher with clinical decision-making
powers. These perceived differences in professional autonomy and power does not
only create tensions that can sometimes be counterproductive to the attainment of
shared objectives but can also negatively affect the relationship between the two
groups (William, 2007). According to Klopper-Kes, et al., (2009), if hospital
administrators and physicians understand clearly each other’s roles and
responsibilities in achieving organisational goals such as improved quality patient care
and staff engagement, any perceived differences between the two groups could
become key strengths in their relationship.
This review highlighted the fact that physicians, compared to hospital administrators
were more focussed on clinical autonomy – that is taking independent decisions on
patient care, whereas hospital administrators were more concerned about
organisational bureaucracy and accountability. While physicians are patient-oriented,
practicing their specialty well and treating more patients, they are easily frustrated by
organisational bureaucracy (Edwards, 2003, Porter 2007 and William, 2007). On the
other hand, hospital managers are mindful of managing the organisation, balancing
the needs of specialty areas and physicians against each other, in the face of declining
revenues (Edwards, 2003 and William, 2007). These differences create tensions in
their working relationships.
43
Furthermore, increasing competition, rising consumer expectations and the growing
costs of healthcare means that the decisions of physicians have come under scrutiny
with increasing attempts by hospital administrators to control it (Edwards, 2003 and
William, 2007). Another significant challenge to physicians’ autonomy is the increasing
pressure from governments and hospital executives for them to be transparent and
systematic in aspects of their clinical work such as scheduling, follow-up and
communication (Edwards, 2003 and William, 2007). This is consistent with the
suggestion by Davies and Harrison, (2003), that there should be a paradigm shift from
doctor’s basic understanding of medicine and work pattern to a model that is evidence
based in which the emphasis is on how to reduce cost and improve patient and
organisational outcomes. It is in view of this that Edwards (2003) recommended that
both physicians and hospital administrators should develop guidelines, protocols and
develop the use of information to feedback utilisation data, cost effectiveness and
clinical outcomes.
In addition, it has been suggested that mutual respect for physician-hospital manager
differences, responsible autonomy between the two groups, avoiding personal attacks
and keeping to the principles of shared decision making – particularly in difficult areas
such as resource control and accountability, could potentially improve relations
between the two groups (Succi, et al., 1998, Degeling, et al., 2003, Edwards, 2003
and Spaulding, et al., 2014). However, more research is required on the relative
effectiveness of strategies involving physicians in shared decision making in areas of
resource control and accountability.
44
The fourth theme identified in this qualitative systematic review was related to finance
and resource challenges. Doctors and hospital managers/directors do not only face
significant financial challenges, they also struggle to align behaviours to achieve cost
and quality goals in today’s healthcare environment (William, 2007). Several authors
have cited the role of administrators in the management of hospital resources as
financial bookkeepers (Nash, 2003, Edwards, et al., 2003 and Rundall, et al., 2004).
However, this role may affect physician-administrator relationships as doctors do not
accept the accounting mind-set of managers, as this may suggest critical evaluation
of their practice (Nash, 2003, Edwards, et al., 2003 and Rundall, et al., 2004,
Vlastarakos and Nikolopoulos, 2007). Multicentre studies both in the UK and USA
demonstrated that doctors are sceptical about hospital administrators in handling
hospital resources because they believe that the resources provided are insufficient
for effective hospital function (Davis, et al., 2003 and Rundall, et al., 2004. This implies
that for hospital administrators to achieve efficiency in the services provided by
doctors, they need to adopt a management style that is flexible, which takes into
account the widest consent of all healthcare professionals such as medical doctors
(Edwards and Marshall, 2003 and Marshall, et al., 2003). It is for similar reasons that
Rundall, et al., (2004), recommended that managers can implement several
strategies to improving their relationships, including greater organisational
transparency in decision making; frequent dialogue between managers and
doctors; and more physician involvement in decision making, especially with regard
to important resource-related decisions, and in organisational governance.
45
Competition between doctors and managers over services that were usually
performed in hospitals was reported as one of the reasons for poor working relations
between them. This notwithstanding, competition could be a potential source of
cooperation, as some physicians thought that using hospital-physician joint ventures
where both physicians and managers had similar interest and stake was a way to
avoid risky head-on competition between them and the hospital (Berenson, et al.,
2006). Hospital employment and involvement of physicians to have greater role and
control on service provision and marketing of services that are of mutual interests and
benefits is also another avenue that competition could be used as a potential source
of cooperation and collaboration between them (Berenson, et al., 2006 and Dalmas,
2012).
The final theme identified by this review was educational differences/challenges
between doctors and hospital executives/managers. This systematic review found that
majority of doctors felt that the hospital administration is ineffective because the
hospital managers do not have a health sciences degree. Their point of view is that
managers should have some sort of health sciences degree and where possible
combined with a post graduate studies in healthcare economics (Vlastarakos and
Nikolopoulos, 2007). In contrast, majority of the administrators consider economics as
the best basic degree for hospital management, however, they agree on the
combination of both health and economic sciences (Vlastarakos and Nikolopoulos,
2007). By way of resolving these issues some researchers have recommended a
combination of medical doctor/master’s degrees in business administration training
programmes or a post graduate training programme in healthcare administration for
46
healthcare professionals such as physicians and hospital executives (Atun, 2003 and
Nash, 2003).
This suggestion resonates well with the statement made by Kaissi’s, (2005) on the
manager-physician relationships from an organisational perspective. The researcher
noted that more and more physicians are taking business courses and acquiring
master’s in business administration (MBA) degrees in order to become a physician
executive, however once they attain this role, their loyalties shift from their colleagues
to that of the organisation. This shift in loyalty by the physician-administrator negatively
affects their relationship with other practicing physicians (Kaiser, 2005). Conversely,
Chhetri, (2017) argues that because doctors share a common educational and
professional background, they naturally respect and trust other physicians including
those in administrative positions, compared with non-clinical hospital executives with
different educational and professional experiences. These differences between
practising doctors and non-physician managers creates a great difficulty in reaching
mutual understanding regarding the process of healthcare delivery and quality
improvement (Chhetri, 2017). Thus, communication breaks down, suspicion heightens
and the cultural gulf that is formed between the two groups becomes a difficult bridge
(Chhetri, 2017). This suggests that hospital administrators need to pay enough
attention to a mutual but different viable educational and career development path for
both doctors and hospital managers. Some researchers stressed that the training of
doctors in multidisciplinary management education early in their careers is necessary
to appreciate key managerial and organisational issues that may impact on physician-
administrator relationships, affecting patient care (Mitchell, 1998, Simpson, 2000 and
Atun, 2003).
47
Lack of management training for doctors and executive coaching on leadership style
for hospital administrators have been cited as factors that not only limited the smooth
working relationship between them but were also a major barrier to effective
engagement between the groups. However, this review also found that if both
physicians and hospital managers are properly trained on leadership skills that it would
enhance the communication, collaboration and agreement between them. (Powell and
Davis, 2016). Furthermore, future researches are needed to investigate the effects of
these trainings on the physician-administrator relationships. This systematic review
was only focused on organisational factors, which contributed to the poor working
relationship between the two groups.
4.1 Chapter Summary
This chapter provided in-depth discussion on the key organisational barriers to
physician and hospital administrators working relationship such as poor collaboration
and effective communication, cultural, finance and resource issues. It also included
discussions on some recommendations to resolve these challenges.
The next chapter is the conclusion of this systematic review including some of its short
comings and future recommendations.
48
CHAPTER 5 CONCLUSION
This qualitative systematic review sets out to investigate the evidence in relation to
poor working relationships between doctors and managers in hospital settings, with a
view of identifying possible root causes of the problem as well as suggesting ways of
overcoming them.
In summary, this study found that poor collaboration and effective communication,
cultural issues, power and autonomy, finance and resource allocation, as well as
educational differences were among the organisational and professional factors that
contributed to poor working relationships between the two groups. However, despite
previous studies on the topic highlighting problems in the relations between the pair,
no solutions on how to resolve the problems were proposed, which is disappointing
considering the fact that poor working relationship between physicians and hospital
administrators is an important issue currently in healthcare organisations worldwide
including the UK’s National Health Service. In addition, some of the included studies
lacked sufficient details on the consequences of poor working relationships between
physicians and hospital managers on the quality of service they provide, clinical and
business outcomes.
Furthermore, the studies did not use any theoretical framework to conceptualise the
psychosocial factors of intergroup relationships such as those involving doctors and
hospital managers. It is assumed that a theoretical model that considers the social and
psychological aspects of inter-communication between doctors and managers could
have helped to understand the problems better. Therefore, future research should
49
consider these aspects because solutions could be easier when the problems are
investigated through a theoretical lens.
It is worthy to note that no previous study has systematically explored organisational
factors affecting doctor-manager relationships. To my knowledge, this systematic
review is the first qualitative synthesis study to explore organisational barriers to
cordial working relationship between doctors and managers. Based on the challenges
identified in the studies under review, it was recommended that a hospital governance
plan that involves both doctors and managers in the decision-making process
regarding the quality of patient care, could potentially enhance the relationships
between the two groups as it would build trust between them. It was also
recommended that recognising and harnessing the differences such as diversity of
skills, orientations and thought processes that exist between the two groups and using
them as a viable tool in improving their relationship. In addition, the use of shared
developed guidelines, protocols and information to feedback utilisation data, cost
effectiveness and clinical outcomes were recommended to enhance consensus and
improve relationships between physicians and hospital administrators regarding
resource control and accountability.
A consensual agreement that is flexible and includes frequent dialogue and greater
organisational transparency in decision making was also regarded as an important
means of improving physicians and hospital administrators’ relationships. Another
recommendation is that management training for doctors and executive coaching on
leadership style for hospital administrators would enhance the working relationship of
both parties. It is anticipated that if these recommendations are adopted by healthcare
50
policy makers, funding providers and hospital administrators, the relationship between
the two groups could potentially improve – ultimately leading to improved quality of
care, better outcomes for patients, better work performance and job satisfaction.
However, future studies are required to further examine the effectiveness of these
recommendations on physician-hospital administrator relationships. In addition, it is
recommended that further research is carried out to explore the consequences that
poor working doctors-managers’ relationships could have on the quality of care,
patient safety, patient experience and staff performance.
Finally, there are some limitations to this study; one of the limitations is that there are
few primary UK studies on poor working relationship between doctors and hospital
managers, therefore this review looked at this issue from a global perspective.
Furthermore, to reduce the risk of bias, systematic reviews are carried out by two or
more researchers, however, in this case, this study was carried out by a lone student
under the guidance of the course supervisor, as part of a final dissertation research
project in partial fulfilment of a Master’s Degree programme.
51
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APPENDICES:
Appendix 1: Critical Appraisal Skills Programme (2013) Qualitative Research
Checklist
62
63
64
65
66
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Appendix 2: Summary of Main and Subthemes of Included Studies
Study Main Themes Subthemes Berenson et al, 2006 Hospitals perceptions of relations with physicians Service line strategy
Purchasers’ expectations Physician-hospital competition
Competition over services Emergency department call Hospitalist programs Competition as a potential source of cooperation Hospital-physician joint ventures
Hospital employment of physicians Dalmas, 2012 Recognition of the fact that key decisions are typically taken at two levels –
corporate and departmental – and that the hospital management process must aim to build effective linkages and flows between the two roles
Levels of decision-making
Decentralisation of services and delegation of authority to the lowest appropriate level, i.e. at or near the point of delivery of care
Decentralisation of services
Management structures, which focus on the patient rather than on professional hierarchies
Focus on the patient
Recognition that clinical involvement will come from doctors, nurses, allied health professionals and others, in partnership to serve patients
In partnership to serve
Availability of good quality, accurate and timely information as a basis for informed dialogue and decision-making
Management information
Trust and respect on both sides between clinicians and managers, and common focus on shared values, goals and organisational objectives
Trust, respect and shared values and objectives
Proper and clear definition of roles and responsibilities, both of individuals and of groups within the hospital
Definition of roles and responsibilities
Integration of the executive management of the hospital’s business with the clinical/medical management of services
Executive management’s involvement in the management of clinical services
Effective training and development plans for staff involved in taking on new managerial and resource management responsibilities
Training in management skills
Comprehensive team-building and organizational development exercises to improve cross professional collaboration between staff
Development initiatives for cross-professional collaboration
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Study Main Themes Subthemes Davies, et al., 2003 Issues of relative power Perceptions of staff calibre Views on goals, decision making and team working Communication issues Resource issues ***Keller, et al., 2019 Organisational growth pains Perceived issues
Compensation plan Centralised call centre Support staff Engagement survey Physician lounge Maternity leave
Observed cultural differences Virtues/values Background Identify Goals Time horizon Problem-solving Professional success
Conflicting connotations Interventions Klopper-Kes, et al., 2009 Perceptions Professional status
Power Overall goals: delivery of care Subgoals Scope
Klopper-Kes, et al., 2010 Cultural gaps Collegiality Information emphasis Quality emphasis Management style Cohesiveness Business emphasis Organisational trust Innovativeness Autonomy
69
Study Main Themes Subthemes Von Von Knorring, et al., 2010
Descriptions of physicians’ behaviour by CEOs Physicians have high status and expertise Physicians lack knowledge of the system Physicians can do what they want
Strategies to manage physicians General management strategies
Physician-specific strategies Implications for the manager role
Management control Motivational strategies Line management Organisational separation Nagging and arguing Compensation Relying on physician role General management strategies
Morana, 2014 Open and honest communication Dependability Trust Honesty Collaboration Knowledge
Powell and Davis, 2016 Differences in doctor-manager relationships between trusts and within individual trusts
The influence of the trust board Disconnection between the board and divisional or doctorate level
How medical managers and managers perceive each other Are there common goals between doctors and managers? General managers: serving two masters? Recognition of additional challenges for non-medical managers
The status of medical management among doctors Increasing status of medical directors and some chief executives Clinical directors: continuing challenges with the role Improving services as a key motivator for medical managers
The impact of the external context on doctor-manager relationships Tension between financial and quality of care targets External regulation Lack of unified medical leadership bodies The impact of external reports
70
Study Main Themes Subthemes Public esteem of doctors and managers Local initiatives to support doctor-manager relationships The trajectory in doctor-manager relationships since the 2002 survey Rundall and Kaiser, 2004 Perspectives on hospital resourcing
Management organises the structures and procedures need to support cost effectiveness (UK) The hospital provides the needed structure and resources to support cost-effective care (U.S.) Are there an adequate number of consultants to provide quality of patient care? (UK) The hospital provides the personnel needed to support quality care (U.S.) Within this organisation there are generally sufficient clinical resources (UK) There is adequate availability of beds (U.S.) There is adequate number of nurses to provide quality patient care (U.S.) Management provides the information technology need to support quality care
Perspectives on teamwork and communication Doctors and managers work well together as a team Hospital managers and doctors are largely in agreement on the overall goals of the institution There is good communication between hospital management and clinical leaders Doctors are adequately involved in hospital management and clinical leadership Doctors are adequately involved in hospital management activities
Perspectives on role capacity Medical staff in this hospital are consistently of high quality Managers have confidence in clinical leadership capabilities Management encourages clinician leadership development Doctors have confidence in management leadership capabilities
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Study Main Themes Subthemes Perception on issues of relative power Managers allow doctors sufficient autonomy to
practice medicine effectively Management exerts pressure to not use certain tests or services Manager exert pressure to discharge or transfer patients early The relative power and influence between management and medical staff is about right Doctors view the management decision-making process to be fair
Perspectives on financial versus clinical priorities Management is driven more by financial than clinical priorities (UK)
Barriers to improved doctor-manager relationships The hospital is more interested in financial survival than clinical quality (U.S.)
Samadi-niya, 2015 *****Culture of medicine versus culture of management Relative power Adequacy of resources Role capability: leadership Teamwork and communication Financial drivers versus clinical priority Healthcare technology: information technology (IT) Financial arrangement of hospitals and physicians with payers (contract)
Spaulding, et al., 2014 Relationships and communication Providing positive experience Integration Accountability and quality
Tengilimoglu and Kisa, 2005
Participants’ concerns about the factors causing conflict Participants’ concerns about organisational factors Participants’ concerns about group factors in conflict
Educational differences Resource control Lack of career development Bureaucracy
Vlastarakos and Nikolopoulos, 2007
Differences in educational qualification of healthcare professional – doctors and managers
Waldman, et al., 2006 Personal reasons for becoming CEO Prior job positions Critical issues facing medical care
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