Journal of Health Organization and Management Managing between the agendas: implementing health care reform policy in an acute care hospital Roslyn Sorensen Glenn Paull Linda Magann JanMaree Davis

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To cite this document: Roslyn Sorensen Glenn Paull Linda Magann JanMaree Davis , (2013),"Managing between the agendas: implementing health care reform policy in an acute care hospital", Journal of Health Organization and Management, Vol. 27 Iss 6 pp. 698 - 713 Permanent link to this document: http://dx.doi.org/10.1108/JHOM-11-2011-0119 Downloaded on: 30 January 2016, At: 20:14 (PT) References: this document contains references to 38 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 655 times since 2013*

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Managing between the agendas: implementing health care reform policy in an acute care hospital

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Roslyn Sorensen Griffith University, Southport, Australia, and

Glenn Paull, Linda Magann and JanMaree Davis Downloaded by UNIVERSITAET OSNABRUCK At 20:14 30 January 2016 (PT)

St George Hospital, Sydney, Australia Abstract Purpose – This paper aims to assess administrative and clinical manager stances on health system reform. Understanding these stances will help to identify cultural differences and competing agendas between these two key health service stakeholders and contribute to developing strategies to improve organisational performance. Design/methodology/approach – A qualitative methodology was used comprising in-depth open-ended interviews conducted in 2007 with 26 administrative and clinical managers who managed clinical units. Findings – This paper provides empirical insights into the ways that administrative and clinical mangers conceive of their managerial roles in relation to health care reform and performance improvement in health services. The findings suggest that developing a hybrid clinical manager culture as a means to bridge the gap between administrative and clinical manager stances on reform objectives, while possible, is not yet being realised. Research limitations/implications – The research has relevance for health services that are experiencing organisational transformation. However, its location in one health service limits the generalisability of findings to other sites. Further research is needed to assess the opportunities for a hybrid culture to emerge as well as its effect. Practical implications – While attention is predominantly directed to clinician groups as a key stakeholder in implementing health reform policies, this paper has implications for how administrative managers also structure their roles and responsibilities to create an organisational climate conducive to change. This will include strategies to support clinical managers to make the transition from a predominantly clinical, to a clinical managerial, orientation. Originality/value – This paper addresses a significant problem in health service governance, namely the divide between the value stances of dual hierarchies. This problem is only now gaining prominence as a significant barrier to health reform. Keywords Organizational culture, Clinical governance, Health services, Hospital managers, Managerialism Paper type Research paper

Journal of Health Organization and Management Vol. 27 No. 6, 2013 pp. 698-713 q Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-11-2011-0119

Introduction Health systems worldwide are under pressure to perform. Performance in this instance is defined as efficiency, service quality and patient safety (Sorensen and Iedema, 2008). However, quality failures and costs continue to mount, and government focus turns increasingly on the performance of health services themselves as the problem. As it does, political agendas pervade ever more deeply in to the operational realms of clinical workplaces, traditionally the preserve of the health professions. Health service delivery

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thus becomes a contested arena as powerbrokers vie for control. As instruments of government policy, health administrators seek to limit cost increases to keep spending on health care within sustainable limits. Clinicians, on the other hand, accustomed to more permissive practice environments, resist such constraints, aiming instead to maximise their professional autonomy and minimise organisational accountability. The impact of these different stances on health service performance can be profound. Health reform policy attempts to bridge the gap between these seemingly opposing aims, and research interest is turning to the impact of policy implementation, as fertile grounds for exploration. One research direction quantifies the differences between sub-cultures to highlight the problems (Degeling et al., 1998); our interest is to describe them, to understand where the differences lie so as to lessen the distance between the stances of powerful stakeholder groups, specifically the relationship between administrative and clinical managers. We believe that by doing so, health service performance will improve. In this paper, we report on a qualitative study of senior administrative and clinical managers in a large tertiary referral hospital in Sydney Australia to gauge their stances on aspects of health reform policy and its implementation. We contextualise the paper with a selected literature review of reform policy and its implementation, the environments within which health services operate, the tenor of the relationship between administrators and clinicians and the strategies commonly used to improve health service performance. Background Implementing health reform Health systems worldwide experience similar failures in quality, notably in the developed systems of the US, UK and Australia (Forster, 2005; Kennedy, 2001; Kohn et al., 1999). Policies to address these failures also tend to be similar (NHS Executive, 1998). In Australia, health reform policy is structured around key themes that aim to improve access to services, redesign the system to meet emerging challenges, learn through organisational self-improvement and reform system and service governance (Bennett, 2009). Involving clinicians directly in redesigning the systems and implementing change is seen as a means to achieve these aims. Clinical governance has become the policy vehicle through which the aims of service quality are currently being channelled, to manage poor professional performance and to address wide differences in clinical practice and patient outcomes (Hogan et al., 2007). Within this conceptualisation of policy and strategy, culture is a core element of a reforming policy framework (McSherry and Pearce, 2002). In the Australian case, failure to implement intended reforms is sheeted home to a professional culture not attuned to creating a modern, well trained, flexible hospital workforce able to work and train others within an interdisciplinary team-based model of patient care (Garling, 2008, p. 3). The absence of this culture is generally attributed to clinicians’ intransigence to policy imperatives (Currie et al., 2009; Freidson, 1994), yet their continued existence is regarded by some as a virtue, to be maintained and defended (Freidson, 1994; Iedema, 2003). While policy documents can frame broad policy intentions, they are less useful in guiding policy implementation in the face of such strident opposition. This dilemma arises when those who are regarded as the problem are also those on whom the solution rests. More useful for implementing policy objectives are the “warts and all” reports that detail actual conditions on the

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ground that aid both problem analysis and solution generation (Braithwaite et al., 2010). If the problem is one of shaping an organisational environment within which all stakeholders accept and actively implement reform objectives, including particularly clinical stakeholders, then a different set of strategies may be needed to address the problem. For health reform to be implemented successfully, and taking the NHS modernisation agenda as an example, Degeling et al. (2003) assert that key stakeholder groups must accept four main propositions: that clinical decisions intersect with resource implications, the need to balance clinical autonomy and accountability, the need to systematise clinical work and the power sharing implications of team based care (Degeling et al., 2003). Although Degeling et al’s conceptualisation respond to in situ conditions, such strident assertions may have unintended consequences. According to Fitzgerald and Dadich (2010), attempts to force alignment of organisational and professional ideologies in this way will only result in conflict, poor performance and increased staff turnover – the very problems that health reform policy intends to overcome. Thus, for clinicians to accept the propositions outlined, more subtle strategies for change are indicated. Health service performance environments A body of literature grounded in public health sector reform proposes that service provider agreement about organisational purpose enhances performance (Alvesson, 2002; Carney, 2007; Obholzer, 2005). Even though meeting national performance targets is the health service priority in most developed health systems (Busse and Wismar, 2002), such agreement cannot be assumed. Failure to meet performance targets can trigger “command and control” style management, hierarchical decision making and information surveillance as methods to bypass obstructive clinical cultures (Alvesson, 2002; Crichton, 1990; Degeling et al., 2004). However, if administrators push too hard, they may alienate the very clinicians on whom they rely from the goals they are trying to meet (Degeling et al., 2004; Garling, 2008). For Mannion et al. (2005) implementing a modernisation agenda means addressing the cultural characteristics that foster dysfunctional behaviour and malpractice. Obholzer (2005) and others describes the type of institutional problems that can result in dysfunctional organisations, such as aggressiveness, passive-aggression, myopia and employee alienation, and the negative influence they have on workers’ capacity to perform effectively (Neilson et al., 2005; Obholzer, 2005). These institutional problems can be analysed using methods more traditionally associated with pathologies in individuals. Such pathologies are functional in helping individuals to maintain a positive self-image as they struggle with feelings of inadequacy. They become pathologised in organisations where pressure to perform in the absence of the skills and resources necessary to do so is unrelieved. If not addressed by bringing problems in to the open, feelings of inadequacy can result in burnout, leaving caregivers to perform in an emotionally blunted way, cut off from the care they deliver and from their relationships with others. As with individuals, organisational pathologies can serve to mask the anxieties of the workforce as a collective. The resulting conflict can deny the supportive environment necessary for workers to reflect on their own and organisational opportunities for learning (Alvesson, 2002). Important for the position that we take in this paper, these pathologies are not unique to clinical domains, but

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equally apply to those of administrators (Willmott, 1997, p. 1347). For example, administrative managers may fail to appreciate the effect of their own behaviour on others or the capacity of others to respond as expected. If managers interpret burnout in negative terms, such as opposition or disinterest, a vicious cycle of distrust can result in a desire to control “the enemy within” (Gouldner, 1955; Willmott, 1997). The tenor of health administrator and clinician relationships Professional sub-cultures strongly influence members’ values and attitudes that affect how well people work and how well they work together (Degeling et al., 1998). Each profession has its own conception of health care goals, that do not necessarily accord with those of the myriad other professions who share patient care. Degeling et al’s (2003) propositions cited earlier are instructive in this respect. Where administrative, nursing and medical managers largely agree that clinical decisions have resource implications, medical clinicians do not. In terms of organisational transparency, where nursing and medical clinicians reject such accountability, nursing and medical managers do not. Medical clinicians and medical managers disagree on the core organising principle of systematising clinical work that administrative and nursing managers support. Finally, and in the face of evidence to the contrary (Lemieux-Charles and McGuire, 2006), medical managers reject multidisciplinary teams as the basis for effective health service delivery that nursing managers and clinicians support. This apparent inability of stakeholder groups to negotiate, compromise and reach consensus around key organisational objectives (Carney, 2006) augurs poorly for developing the trust necessary for constructive working relationships. In the Australian case, it is this divide between clinicians and managers that impedes good, safe care and infects the whole public hospital system (Garling, 2008, p. 11). The divide is instrumental, it is believed, in creating the types of cultures within which the resistance to change foments, ideological positions harden and the types of professional cultures that Garling advocates to save the system, do not emerge. Where Degeling et al. (2003) see clinicians as mainly at fault, others see the problem as more complex. Managers, it appears, are also at fault, as they fail to “hear” the issues that impede the quality agenda (Hogan et al., 2007). Some believe that it is the very values of health service organisations and health professions that are in conflict (Carney, 2006). Not only are the structures and processes to support clinical governance implementation not present within this organisational climate, nor are the basic foundations for effective organisational communication present (Hogan et al., 2007, p. 614). Such views bring a reappraisal of the capacity of health service managers to implement change. Traditionally managerial work was thought to primarily concern universal functions, such as directing, organising, etc. (Willmott, 1984). This functional approach encouraged a view that management meant domination and the arbitrary use of power (Alvesson, 2002). More recently, the roles and relationships of managers have come under scrutiny (Mintzberg, 1992; Willmott, 1984), and managers themselves have become the objects of change. As discussed earlier in relation to clinicians, managers now also fall into the ambivalent position of being both agents and targets of change (Willmott, 1997). This raises a dilemma for health reform policy implementation, in

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that neither clinicians nor managers appear to control the implementation of the health reform agenda, even though they control the means of production. Improving stakeholder relationships If these organisational tensions and pathologies are common throughout the system, there are compelling reasons to resolve the conflict between administrative and clinical manager domains and to put the control of change implementation into the hands of those who control resources. A range of solutions is identified in the literature to avoid the downward spiral into dysfunction that Gouldner and Willmott identify. Psychological solutions, such as those advocated by Neilson et al. (2005), propose that managers develop insight into their own behaviour in relation to others to arrest a decline into aggression and bullying (Neilson et al., 2005). Others promote organisational solutions, such as those of Hallier et al. (2005) based on findings that role experience influences clinical managers’ attitudes to managerialism within health services in both positive and negative ways (Hallier and Forbes, 2005a). Vera and Hucke (2009) add to this picture, with their findings that a clinician’s orientation to clinical management is positively associated with career progression (Vera and Hucke, 2009). Thus, a managerial orientation per se is not distasteful to clinicians. Rather, their positive orientation to clinical management can lead to a sense of achievement (McAlearney et al., 2005) and assist clinicians to move through the organisational hierarchy, thereby potentially spanning the disciplinary boundaries that stubbornly persist in health services. From this brief review of strategies, we can conclude that any actions to improve the relationship between clinicians and managers must move beyond a focus on individual traits and professional orientation to encompass organisation-wide strategies to engage clinicians constructively in the managerial work of the organisation. We take this as the point of our research: to identify the different stances of the key stakeholder groups in health system reform, in this case administrative and clinical managers, and to assess opportunities to bridge the cultural divide as the means to health reform. We take as our theoretical framework Pope et al’s conception of innovation as the changing of cultural mindsets and behaviours so that people “think and do” in different ways (Pope et al., 2010). Method This paper reports on one part of a multidimensional study to present evidence of administrative and clinical managers’ stances on health system reform and our interpretation of their effects. A qualitative methodology was employed for this part of the study. Our evidence is drawn from a survey of 23 administrative and clinical managers (included here are administrative and general managers both with and without clinical qualifications and medical, nursing and allied health managers all with clinical qualifications) in a major public metropolitan referral hospital in Sydney Australia undertaken in 2007. This number represents the total population of clinical managers of six wards in which our study was undertaken (respiratory, oncology, cardiology, renal, aged and neurology) and of the senior administrative managers in the health service (general manager, director of nursing, director of medical services, chief financial officer, clinical governance and casemix director, nursing and medical education managers). Managers in our study were defined as “administrative” if they

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spent 100 per cent of their time on administrative duties; clinical managers were defined as spending 50 per cent of their time on administrative duties. The interviews were around an hour-long, tape recorded, transcribed by an external service and analysed by the four members of the research team. Interview structure was an open ended survey validated in previous research (Sorensen et al., 2003, #1546), designed to ascertain the attitudes and practices of administrative and clinical managers to aspects of health care reform. Our interest is in gauging the environment of health reform and whether the capacity to innovate as outlined by Pope et al. (2010) was present. Specifically, the survey asked questions about: . How respondents perceived the roles and responsibilities of health service management in improving the quality of care, defined in clinical governance terms. . The criteria used in health services to assess performance. Managers were prompted to consider this question in efficiency and effectiveness terms, if they appeared to be unsure. . The effect of these performance criteria on health care managers’ actions in the context of innovation and organisational change. . The direction of health care reform and strategies to achieve organisational objectives. We took as our reference, Degeling et al’s (2003) our reform factors. . Managers’ attitudes to reform construed as above. The transcripts comprised 276 pages of data that were coded and analysed for thematic content using the constant comparative method of iterative inquiry to identify convergences and divergences in the respondents’ views (Glaser, 1992). We use excerpts from the data emblematic of the main themes arising from the analysis and interpret them in the light of our interest in assessing the stances of administrative and clinical managers to health system reform and their capacity for innovation. Our analysis and interpretation of de-identified excerpts from respondents’ comments foreground one of the main themes emerging from the data, namely: managing between the separate agendas of administrative and clinical domains in implementing health sector reform. We do so under four headings: organisational purpose, managerial orientation, delegating responsibility and engaging the clinical workforce. Results Organisational purpose We present here a selection of excerpts describing how health service managers perceive their formal roles and responsibilities. To implement reform, a degree of consensus about organisational goals is required. This consensus will rely on bringing health care professionals together, through a structured and supportive process, allowing them to make the transition from a predominantly clinical role to a clinical managerial role. This transformation requires an insightful approach from both clinicians and managers about what management entails in terms of responsibilities and accountabilities. The first excerpt below is the general manager’s conceptualisation of organisational purpose, followed by that of a senior clinical manager:

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It’s about providing leadership, building a team, and providing the leadership to the team to manage performance within the organisation, and clinical performance and therefore care to patients in particular, but also performance in terms of management of human resource performance and financial physical management of resources in order that all of that comes together to support patient care really (Administrative (General) Manager (allied health qualifications) (CM 1)).

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The general managers of the hospitals have one agenda, which I’m sure is heavily dictated by Area Health Service [a section of the Department of Health responsible for multiple health services within a defined geographic area], whereas the clinical stream leaders, almost certainly, have a different agenda, which is our patient care, patient access, delivery of service, service organisation, that sort of thing, and where those two agendas cross is going to be very interesting (Clinical Manager (medical qualifications) (CMM 1).

The health service general manager, CM1 speaking above, describes senior manager performance responsibility in abstract and formal terms, removed from its in situ conditions. In contrast, CMM1, a senior divisional clinical manager, describes it in concrete patient-centred terms. As Fitzgerald and Dadich (2010) affirm, these conceptions of purpose from organisational and professional perspectives do not align. Overwhelmingly, respondents identified “meeting budget” as the main performance criteria for this health service (Sorensen et al., 2008, #18866): The clinical manager speaking above, understands this, and their reference to “where those two agendas cross” acknowledges the difference. Their next reference to the intersection of the agendas being “very interesting” is ironic, suggesting that they expect and are ready for the struggle for ascendency. Where there is no agreement on organisational purpose, no leadership authority can be established, and hence no legitimacy for the general manager’s conception of purpose that Degeling, Mannion and others believe is a procurer for health care reform (Degeling et al., 2003). Managerial orientation As discussed earlier in the paper, a managerial orientation within the clinical manager cadre can encourage and reinforce acceptance of administrative authority to implement organisational goals (McAlearney et al., 2005). We assessed the orientation of managers from responses to questions on health service performance criteria and their actions in response to the criteria. The administrative manager speaking first in the next bracket suggests that while clinicians are expected to subscribe to such an orientation, the clinical manager who speaks next is clear that such an orientation is not yet present: This concept that we just deliver patient care in some sort of vacuum is a nonsense. We only deliver care because we work in a system and that system has to be managed and we each have a role in managing it. We have people we have to supervise, we have people we have to communicate with, we have our own time we have to manage, we have our own professional development we have to manage, so in a sense we’re all managers and each of us has to facilitate with our colleagues up and down a range of activities, like professional development, supervision, teaching, self-assessment, assessment of others (Administrative Manager (medical qualifications) (CM 2)). [. . .] there’s also department heads, they’re clinical people, and they’re supposed to have accountability for the medical staff within their department. However, my understanding from observing is that it’s a far more collegiate arrangement and that the department head is

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really just a token, a figurehead, and often doesn’t actually adhere to the principles of that position that they should be attending to (Clinical Manager (nursing qualifications) (CNM 1)).

Each of the managers speaking above refers to the competencies and responsibilities of clinical (medical) managers at the departmental or divisional head level. These heads control multimillion dollar enterprises with a multidisciplinary workforce and extensive patient care responsibilities. CM2 above, the Director of Medical Services, has successfully made the transition from a clinical to an administrative manager role, has achieved career success in doing so and embodies a managerial orientation as the literature predicts (Vera and Hucke, 2009). In contrast, CNM1’s experience is that clinical (medical) managers have yet to come to grips with their part in managing a modern health service. Making the transition from a traditional clinical to a managerial role is not necessarily straightforward. CNM1 above, a senior nurse manager, observes that clinical (medical) manager accountability for medical clinicians’ performance is absent, attributing this to “departmental headships” being sinecures without organisational responsibility. Moving between sub-cultures, an essential attribute as clinical managers learn to value managerial skills, means accepting managerial responsibility and accountability and knowing what it entails. Achieving this objective therefore becomes a responsibility of administrative managers. Managerial skills include accepting the interdependence of clinical and administrative units including the intersection between clinical decisions and resource implications as Degeling et al. (2003) propose. The Administrative Manager speaking first in the following extract outlines the rationale for such accountability that is in contrast with the views of the Clinical Manager speaking next in the bracket: [. . .] it’s important that each area doesn’t design their own policy . . . that there’s some uniformity around the development of protocols and policies, that there’s also some evidence to demonstrate that they [clinicians] are following what is considered best practice . . . . Not that we don’t trust each department to do that but there are instances of solo clinicians coming out saying: “This is a policy, I used to work at x and this is what we did there” . . . and unfortunately what can happen is one discipline comes up with a fantastic clinical practice that affects directly another discipline with no consultation [. . .] (Clinical Governance Director (nursing qualifications) (CM 3)). An interesting example – three or four years ago I started a [named] service here. It’s totally unfunded, and I took the risk of being instrumental in starting (the) service, because I knew it was new, I knew that [named condition] was being detected earlier at a much more curable stage. The problem is that that took a few resources away from (named clinical services) and that has contributed to some extent to the waiting list problem, but only to a minor extent. . . . Because it is very frustrating when you know what people want, and you know what effective treatments there are, but the area health service would have the audacity to say “well it should never have been started in the first place” (Clinical Manager (medical qualifications) (CMM 3)).

CM3 speaking above, the Clinical Governance Director, has also made the shift from a clinical nursing to a managerial orientation. They outline the process for developing new services, i.e. as evidence based and organisationally aligned. Clinician’s individual judgements about patient need are no longer sufficient to commit resources. This excerpt establishes the interrelatedness of organisational units in performance terms that medical managers may not appreciate. Thus, a managerial orientation will include

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an awareness and ability to link clinical units strategically, to consult with others before committing resources, and integrating clinical and organisational goals. CMM3 speaking above, the manager of a large division, describes in aggrieved terms their experience of having their clinical decisions questioned. This manager does not appreciate how organisational decisions are made, or the sensitivity around waiting lists, a key performance area for health services. Disciplining clinicians who stray outside organisational rules and curtailing their decision making autonomy falls within the organisational control strategies that Mannion et al. (2005) describe. We see here an inkling of the pathologies that Obholzer (2005) describes that can impede effective performance of work. Survival for clinicians comes from their socialisation within a predominantly clinical milieu (Freidson, 1994). If learning about the value of a managerial orientation is too long delayed, organisational pathologies can perpetuate and be reproduced from continuing negative experiences as trainee clinicians’ progress through the hierarchy (Hallier and Forbes, 2005b). In this context, we highlight an administrative manager’s description of junior medical staff’s experience as they grasp the meaning of clinical care delivered within an organisational framework: You pick up the administrative side of stuff as you go, and as you get higher in the hierarchy, you learn more about how a hospital runs. As an intern you have no idea, but by the time you become a consultant you start to understand how a hospital runs. [. . .] doctors will need to put in more action or input to get things changing in our health system, so they do need to understand it. [. . .](but) I’m not sure for the hours the doctor works that they want to spend more time learning about the hospital (Administrative Manager (medical qualifications) (CEM 1)). I think all too often we leave a lot of our young doctors to fumble around without adequate supervision. We don’t provide a safe working environment for them, for example, we don’t have good mechanisms of assuring ourselves of their skills and competencies before we say, “You’re on tonight” (Clinical Manager (medical qualifications) (CMM 2)).

In the view of CEM1 above, the manager of continuing education for junior medical officers, staff learns how a hospital runs through experiences that are not always positive. If negative perceptions are encountered early and reinforced by influential senior staff, there is a risk that these perceptions continue throughout the clinicians’ career. While acknowledging the central role that doctors are expected to play in changing the health system, CEM1’s comments suggest that junior medical clinicians’ experiences will dissuade them from learning about the organisation or how they can make it work better. The often brutal initiation of junior medical staff to hospital-based clinical practice that CMM2 describes above suggests how individual and organisational pathologies begin early, as trainee doctors struggle with a bewilderingly complex environment that they are not only expected to survive, but to enhance. Delegating responsibility The theme of balancing autonomy and accountability is continued here. The Administrative Manager speaking first in the bracket below describes the place of surveillance and discipline of clinicians who operate outside the boundaries of

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organisational expectations, in this case exceeding their peers’ levels of resource use. This excerpt illustrates a manager’s action in response to health service performance criteria expressed in efficiency terms. The Clinical Manager speaking next in the bracket indicates just how complex it is to meet efficiency expectations that in this case relate to decreasing patient length of stay:

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[. . .] if you want to look at practically how I would do that (manage performance differences) . . . you say - Dr A, B, C, D, E and F – and look, Dr F has got the worst figures and they know who they are, they may not know who their colleagues are but if they know if they’re F . . . they’ll pick up their game very quickly. Again, that’s not exclusive to medicine but I think that looking at the way they see their practice in comparison to their peers is very important (Administrative Manager (nursing qualifications) (CM 3)).

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[. . .] and that gets back to the fact that if you look for example at length of stay, and people are criticised because they have an increased length of stay and they can’t get patients in and don’t have staff to get tests, they can’t clear beds in casualty and you have to look at reasons for that – what often happens is that people say “your length of stay is three days longer than Xs” but what are the mechanisms underlying that? (Clinical Manager (medical qualifications) (CMM 4)).

The strategy outlined by CM3 above, who spoke earlier in this section, relies on clinicians’ competitive instincts to bring their practices into line with peers; CMM4, a clinical departmental manager, asserts that this is not a simple matter. The use of competitive strategies to improve performance is meaningful only if individual clinicians control resource inputs and if different service functions are integrated. Thus, monitoring and managing performance, the responsibility of divisional and departmental heads, requires management skills and political acumen. Integrating the work of units that treat patients in common, and ensuring efficient patient flow, timely test results and available beds is a complex undertaking. This coordination is often beyond the capacity of individual clinicians to achieve, both organisationally and conceptually. It requires a strategic overview of the organisation, the technical knowledge of clinical managers and the organisational authority of administrative managers to achieve, in this case, a reduced length of stay. Just how far administrative managers are prepared to go to support clinical units to achieve expected efficiencies is evident in the next bracket of excerpts. Where managerial skills and organisational support is absent, coercion and bullying get results. The excerpts below spoken by two clinical managers explain the difficulties clinicians experience in achieving complex structural change: I had an example today, where [a named manager position] said to my senior nurse manager “you are over budget in this in wages in (named ward)” and that is because we have beds open that are unbudgeted. [They] said “you have got beds at X Hospital, beds at Y Hospital, make it happen”. Now that is not sufficient as far as I’m concerned, to a senior NUM at Y Hospital, to say: “make it happen”. That needs help from the executive level. It doesn’t need the executive level to simply say “you have got the resources – make it happen” (Clinical Manager (medical qualifications) (CMM 2)).

In the bracket above, CMM2 describes a service restructuring task that necessitated closing beds and terminating duplicated functions as two facilities amalgamate. This is a complex process; as resources in one facility are decreased, so too are its profile and status, while those at the receiving facility are enhanced. Negotiating such resource

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reallocations requires a high degree of political and organisational skill to manage the expectations and disappointments of powerful clinical stakeholders while achieving service objectives. CMM2 does not employ a multidisciplinary approach to unit management, that presumably would have facilitated the routine negotiation of clinical and resource issues between peers and professions. In its absence, the nursing manager is expected to achieve bed closures without either organisational authority or control of resources. Engaging the clinical workforce In relation to implementing reform, the general manager no longer has sole discretion to make decisions about health service objectives and strategies. As the clinical manager (CMM1) at the outset of this section alludes, and as the general manager (CM1) confirms, administrative managers are the agents of others, with decisions made beyond the boundaries of an individual health service. The goals articulated by the general manager (CM1) at the outset of this section do not accord with those of the majority of our respondents’ or their experience of the organisation. The absence of meaningful goals and manager complacency with organisational dysfunction reinforces clinicians’ alienation and becomes a breeding ground for individual and collective pathologies that our literature review identifies. The Clinical Manager speaking in the next bracket expresses this dysfunction and the disengagement it brings for many clinicians – but they also express hope: There is a view that for many years they’ve [clinicians] been working exceptionally hard to drive and improve patient journey times through ED KPI’s [emergency department key performance indicators], and there’s a system view that they need to be providing more clinical hours but I think they’re disenfranchised now and I guess not engaged, or less engaged than they were [. . .] [. . .] where we got the most traction [for improvement] is where people actually realised what it was all about. They understood the key message in all of this. It’s about patient journeys and effective patient care, and their role in it (Clinical Manager (nursing qualifications) (CNM 3)).

Notwithstanding the negativity expressed in many of the foregoing excerpts, not all clinical managers despaired of change. While some had become disenfranchised by attempting to keep faith with their ethical principles as they implemented corporate objectives, others had not yet retreated from an active role. They remained engaged, steering towards organisational goals that they could articulate in patient care terms. These clinical managers created the traction for genuine improvement by understanding the corporate history, articulating purpose, generating shared meaning around concrete patient care objectives and connecting others to them. For CNM3, patient-focussed objectives linked clinicians’ work to organisational goals and their part in it. We turn next to discuss how this dialogue and consensus can connect the disparage agendas of administrative and clinical manager domains. Discussion In this paper, we sought to identify and understand the different stances of administrative and clinical managers about key dimensions of health care reform. Our reasons for doing so were to assess opportunities to lessen the distance between these

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key stakeholders to enhance organisational performance as health reform policy intends. We found the culture divide that Degeling et al. (2004), and Davies (2003) describe, both between administrative and clinical domains as well as within them. Our study adds value in illuminating the organisational pathologies that impede building the trust relationships through which problems can be identified, articulated and solved, and conditional to performance improvement. Our study adds further value in articulating the managerial competencies that underpin health reform implementation, not only for clinical managers, but also for administrative managers. Our findings are limited by their location within a single health service. Nonetheless, they will be useful to others attempting to interpret professional attitudes and practices as an element in implementing reform policy, particularly given the pervasiveness of the administrative/clinical divide that our literature review has revealed. Policy as a locus of conflict In our study, we found a small group of engaged but frustrated administrators prioritising goals externally-defined. This external focus prevented them from constructively engaging with the immediate, urgent and difficult problems being faced by professionalised and socialised workforces, such as those promoted by Freidson (1994), with accountability for complex patient care. The organisational goals of our two major stakeholder groups were not aligned, as Fitzgerald and Dadich (2010) also found, but characterised by control on the one hand and resistance on the other. Clearly evident within our organisation is the polarisation of positions that encapsulate Gouldner’s idea of enemy within (Gouldner, 1955), but notable in this case in being mutually perceived. While our results largely reflect the sub-culture divide that Degeling et al. (2003) found, our analysis reinforces the importance of understanding why each stakeholder group acts as they do, often in diametrically opposed ways, rather than simply quantifying the difference. Although we did not find the cabal style management that Mannion et al. (2005) conceptualise, we did find a cohesive administrative manager group, pushing against the seeming intractability of clinical manager stances, with a paucity of skills to engage with the political dimensions of rapid organisational change. The problems and tensions inherent in delivering patient care within a corporate, professionally bureaucratised milieu, but not addressed, left both manager groups angry, frustrated and emotionally blunted. We believe this to be the fertile ground for organisational dysfunction to grow, as Obholzer (2005) has observed. The degree of distance of administrative manager stances from clinical domains, including of those from the clinical ranks, from which most had come, was an unexpected finding. Clinical qualifications, whether nursing or medical, did not explain the cultural divide and polarisation of values, as Davies (2003) contends. Rather, these managers had “changed camps”, solidly identifying with the interests of administrative managers distinctly separate from those of clinicians. In moving to a different social category and strongly identifying with it, this group had distanced themselves from clinicians’ experiences, pushing to meet externally imposed priorities seemingly regardless of the consequences. We see exhibited here the traits that Willmott (1997) alludes to of a failure to appreciate the effect of one’s own behaviour on others, or the capacity to appreciate others’ limits and limitations Thus, a negative view of clinical managers developed as administrative managers demanded

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compliance with resource constraint without understanding how to achieve it. Bullying and coercion became the method for organisational change, interpreted here as the excess of domination that Alvesson (2002) conceptualises. These same traits were evident in the next level down of clinical managers who themselves failed to respond to the support needs of subordinate staff, that in turn impacted on staff performance and morale, and set the early seeds for a negative managerial orientation within clinical trainees. Building leadership capacity Managers need to grasp and connect the core business of patient care throughout the organisation. This requires sound managerial skills, organisational awareness and political acumen. Managers need support to tackle the complexities of health service delivery, the strategic space to engage with the conflicts and problems of modern day health care and the decision-making authority to resolve problems. In echoing Alvesson (2002), we see how one clinical manager, CNM3, develops local meaning around the patient journey to reengage professional interest. The leadership necessary to build consensus for change came not from administrative managers, but from middle clinical managers (re)interpreting organisational goals in clinical terms and creating a dialogue with clinical colleagues about the goals that are important to them. While leadership is an important theoretical construct in the literature, it is generally not well articulated in application. We detail here the leadership traits that emerged in our study. Leadership was evident in some nursing and medical middle managers who could identify organisational blockages and propose solutions. They analysed their work environments with mastery, described the problems realistically and remained practically engaged with the problems they encountered. They spanned the boundaries of their clinical domains conceptually and linguistically to align broad organisational aims with concrete clinical goals. They were passionate advocates for patient care, articulating an organisational vision that drew support from subordinate staff. This clinician re-engagement came from a “back to basics” approach that found meaning in patient care. Here we see the spark of a positive orientation to management that Hallier and Forbes (2005) propose as essential to bridging the cultural divide. These leadership qualities were less evident in administrative managers. We hypothesise that this absence may stem from their restricted decision-making capacity, distance from clinical work, strong identification with an administrative manager cadre and frustration, antagonism even, with clinical manager attitudes that narrowed their ability to lead change. From our analysis we can identify competencies needed by both administrative and clinical managers to achieve health service performance improvement. Our outline is not exhaustive, pointing more to major performance dimensions that can guide health policy implementation. Clinical managers will benefit from basic competencies in managing resources, delineating their own and others’ roles and responsibilities in line with negotiated organisational objectives, garnering the support to achieve them and monitoring and managing performance in line with these objectives. Administrative managers will benefit from the capacity to support and develop well-functioning clinical managers able to manage multimillion dollar health businesses with extensive staff complements. Important here is possessing commensurate decision making authority to collaboratively engage with clinicians to address the practical challenges

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of patient care. We foreshadow that both manager groups will find common purpose reflecting on their own and organisational learning opportunities. This means renegotiating the psychological contract (Davies and Harrison, 2003) to formulate performance goals not only in efficiency terms, but also in patient care terms.

Managing between the agendas

Conclusion Health service managers do not have the autonomy or leadership skills necessary to assess and respond to the organisational priorities that contemporary health care delivery presents. Rather, priorities set externally at more senior level of the hierarchy and that concern higher order political agendas are far removed from the conditions that clinicians face on the ground. Thus, administrative and clinical managers are responding to different goals, and without alignment of health service and patient care objectives, an innovative hybrid culture of the type conceptualised by Pope et al. (2010) to coherently link strategies for improvement is not likely to arise in the near future. Even though power retained at the administrative apex disenfranchises those who do clinical work and who are most likely to change it, clinical autonomy remains a strong cultural value. Each stakeholder group appear doomed to continue to manage between the agendas in their struggle for ascendency and control. Yet each needs the other to fulfil their own professional as well as organisational objectives, and potentially their own personal expectations, if morale and job satisfaction are regarded as desirable work outcomes. Further work is needed to gauge whether a more autonomous operating environment will encourage the emergence of an innovative culture capable of leading change by recognising and responding to essential patient care needs.

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