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Quality in healthcare: medical or managerial?
Quality in healthcare: medical or managerial?
New ideas in public management
A cluster of ideas borrowed from the private sector has contributed to dramatic changes in the conception of the public sector during the past two decades. Referred to as "new public management" (NPM), these changes include an emphasis on:
the autonomization of organizational sub-units;
the decentralization of management authority; and
the creation of market and quasi-market mechanisms, separating purchasing and providing functions and their linkage via contracts (Ferlie et al., 1996; Osborne and Gaebler, 1993; Power, 1997).
NPM also recognizes the creation of performance indicators in the enhancement of accountability to customers for the quality of service (Power, 1997). Often, these indicators are being defined and operationalized in a process that is inseparably connected with the definition of performance and the installation of a management system to measure that performance (Power, 1997). This process may turn out to be particularly difficult when it comes to public service organizations. In the case of public hospitals, as illustrated later, the idea of measuring performance primarily for the purpose of satisfying customer needs constitutes a challenge to the self-proclaimed right for professionals to define the meaning and purpose of medical activities and to the historically-attributed role that doctors have played in the managerial hierarchy of hospital organizations. This paper discusses the nature and effects of this challenge.
In recent years, comprehensive attempts have been made at Astrid Lindgren's Children's Hospital (ALH), a subdivision of Karolinska Hospital in Stockholm, to replace the traditional organizational structure with a number of "functional centers" for the purpose of creating what has come to be labeled a "hospital without boundaries". The ambition is to have doctors and nurses from different medical specialties assembling around the patient for diagnosis, treatment, and care, and to gradually integrate cooperation among professionals from different medical specialties on a more formal basis within each functional center. Ideally, this will provide opportunities for patients to remain in the same bed, on the same ward, during the whole period of in-hospital treatment without having to move between different departments for varying kinds of specialist treatment. The ideal of a hospital without boundaries constitutes a break with a tradition over the past 200 years of clearly distinguishable boundaries between clinical departments defined by medical specialties (Foucault, 1973). This new model has emerged under the influence of certain aspects of the rhetoric of TQM (Womack et al., 1991), particularly its focus on the customer. Hospital organizations must be designed for the purpose of securing the taxpayer's legal right to receive good public service, but they must also be designed to satisfy the individual consumer's preferences and provide "value for money". With the customer/patient at the "center of attention" in the functional center, it is possible for the medical staff not only to observe and monitor the individual patient's medical condition, but also to be more closely attuned to his or her preferences as a consumer. Thus, the introduction of TQM ideals at the hospital has come to imply various attempts to re-direct the traditional conception of medical treatment among practitioners away from a detached and strictly professional doctor-patient relationship towards a more service-minded and customer-focused perspective. Among these efforts has been the introduction of various systems for measuring, not only the patient's pulse and temperature but also the quality of service delivery, as perceived by the patient, and to use the results of these measures as an instrument for quality management.
One such system involves the conversion of "local incident reports" into a tool for continuous improvement. As in many other countries, chief senior physicians in Swedish hospitals are legally obliged to report to the National Social Welfare Board (NSWB) in all cases involving the death of a patient during treatment or when malpractice is suspected. NSWB has the legal authority to issue sanctions against practitioners in stated cases of malpractice. The local incident report is a special formula for this purpose with questions about time and place of the incident, participants, consequences, etc. Still, serving its original purpose as an "incident report" and with no changes to the original design of the formula or the procedures for documentation and reporting, this formula may now also be used as an instrument for the management of "local deviations" in the production of health-care services at the hospital.
It would, of course, be absurd to claim that local incidents have never been discussed within the field of medical practice concerning their effects on the quality of service. However, a radically new element to this discussion emerges with the concept that incident reports can be used as an instrument for planned and systematic documentation of work processes for the purpose of achieving such TQM objectives as zero defects, continuous improvement, and customer satisfaction. From a TQM perspective, incidents are not regarded primarily as an intra-professional concern but more as an intra-organizational problem. The task of defining and identifying incidents should, therefore, not be considered as the sole privilege for medical authorities (such as the NSWB). Additionally, since every single incident is a case of poor quality management, not to mention poor customer satisfaction, the production of health care must be continuously monitored with the aim to prevent incidents from ever occurring in the first place ("zero defects").
The ideological clash between medical and managerial aspects of quality raise two important observations. First, the ambition to use "local incident reports" for TQM purposes illustrates a conceptual break with a tradition in which the authority to define and interpret the meaning of medical (mal)practice has been located solely within the field of the medical profession itself. Evidence from the NHS in the UK shows how the politics of quality assurance has led to resistance from practitioners, not only against managerial definitions of quality but also against managerial participation in the definition process (Rose and Miller, 1992, p. 195; Power, 1997). Expert professionals and public accountability often express competing values and there is an ideal of professional self-control of quality firmly entrenched in the medical discourse. The introduction of TQM and the translation and transformation of incidents into "customer information" and instruments for continuous improvement constitute a challenge to the medical profession's historically defined monopoly in shaping the "policy agenda" concerning health and their self-proclaimed right to place certain issues beyond the reach of non-professionals (Rose and Miller, 1992, p. 195).
At the dawn of a new millennium, we are approaching a historical situation in whichthe medico-administrative bloc is no longer resistant to all attempts to make it calculable in a non-medical vocabulary (Rose and Miller, 1992, p. 195). In this context, our second observation is that the construction of quality measures will require a shift in focus on behalf of the medical profession. We are witnessing an ongoing reconfiguration in the network of actors among which the meaning and significance of medical practice is constructed. Doctors and nurses are presented with a conception of medical practice in which the construction of auditable numbers out of local interactions (such as the actual treatment of a particular disease) is regarded as an unproblematic endeavour (Chua, 1995). The shift from an intra-professional definition of medical problems and priorities towards a more business-like concern with numerical representations entails the introduction of new techniques and systems of measurement (e.g. diagnose-related groups (DRG) and other cost models). These techniques and systems must be trusted in their capacity to:
ascribe numerical representations to the contextual character of medical treatment;
translate these numbers into monetary terms; and
translate these numbers back into a series of statements that can "stand up to the scrutiny of potential debunkers such as doctors" (Chua, 1995, p. 127).
With its capacity to produce at least two different meanings, depending on whether it addresses the NSWB or the "total quality manager" at the local hospital, the local incident report takes on a somewhat schizophrenic character. The same document can be used for the purpose of tracing, capturing, exposing, and punishing doctors and nurses that malpractice, as well as for the purpose of tracing, capturing, exposing, and rewarding good quality work(ers). This brings us to our concluding argument. Ideal conceptions are always intimately interlaced with technologies for their realization in a particular field of practice (Latour, 1987). The authority to define and interpret the meaning of medical practice may be problematized on a macro level in the name of "new public management" in debates between proponents of a "traditional", medico-scientific conception of health care and a body of "new" public managers with ideas about a more business-like and customer-focused health-care sector. The realization of these ideals on the local level of everyday practice, however, is heavily contingent on the accessibility and "dormant readiness", as it were, of different technologies, such as local incident reports and other systems for documentation. This is to say that the "managerialization" of the public sector, as illustrated here by the attempts to introduce TQM objectives in health-care organizations, should not be interpreted solely as the outcome of some grand master plan, invented and lobbied for by a body of ingenious management consultants or other interest groups. The successful implementation of a new management ideal is just as much an effect of the technological possibility for its realization. Without the availability of pre-existing technologies and standard procedures, it is simply not possible to translate management ideals into a set of meaningful concepts for local actors in a particular field of practice. Management ideals must be anchored; they must find a "host", as it were, in existing routines and procedures.
There is a "price" to be paid for this translation process, however. The empirical illustration above describes a situation in which "new public managers" are exploring the possibilities to find novel applications for local incident reports and other informational tools. These instruments were once developed for the purpose of providing the data necessary to uphold a medico-professional hegemony over the discourse of medical practice. The claim to make use of existing technologies for the purpose of re-directing the hospital's activities towards a customer-oriented focus on the quality of service delivery will inevitably disturb the temporal stability in local power relations, between the medical and the managerial profession. This upheaval is due to happen because of the logical necessity to redefine the object of medical treatment as an effect of the introduction of a new set of criteria for measuring performance (against some perceived customer value). A traditional medico-scientific conception of the "patient" and a managerialistic focus on the "customer" evoke two different sets of connotation that cannot provide a coherent picture among practitioners of what it is, really, that they are supposed to work "on" (patients?) or "with" (customers?). Such perturbations are important ingredients in the ongoing definition and re-definition of the aims and objectives of public health-care services.
Johan HanssonDoctoral Student, School of Business, Stockholm University, Sweden
Chua, W.F. (1995), "Experts, networks and inscriptions in the fabrication of accounting images: a story of the representation of three public hospitals", Accounting, Organizations and Society, Vol. 20, Nos 2/3, pp. 111-45.Ferlie, E., Ashburner, L., Fitzgerald, L. and Pettigrew, A. (1996), The New Public Management in Action, Oxford University Press, Oxford.Foucault, M. (1973), Birth of the Clinic: An Archaeologyof Medical Perception, Routledge, London.Latour, B. (1987), Science in Action, Harvard University Press, Cambridge, MA.Osborne, D. and Gaebler, T. (1993), Reinventing Governance: How the Entrepreneurial Spirit Is Transforming the Public Sector, Penguin, New York, NY.Power, M. (1997), The Audit Society: Rituals of Verification, Oxford University Press, Oxford.Rose, N. and Miller, P. (1992), "Political power beyond the state: problematics of government", British Journal of Sociology, Vol. 43 No. 2, pp. 173-205.Womack, J.P., Jones, D. and Roos, D. (1991), The Machine that Changed the World, Harper Perennial, New York, NY.
The introduction of TQM in the public health care sector suggests a conceptual break with a tradition in which the authority to define and interpret the meaning of medical practice has been located solely within the medical profession.
It also serves to shift the focus of medical practice away from its contextual and interactional character towards numerical representations and codification in monetary terms.
The realization of management ideals in everyday practice is more dependent on the availability of pre-existing technologies and standard procedures than on the ingenuity of particular organizational and institutional actors.
The reutilization for TQM purposes of "local incident reports" in a Swedish hospital organization serves to illustrate these points.