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Adopting an intra-organizational viewpoint is essential to grasp legal intermediation. To deepen our understanding of such phenomena, this chapter proposes a qualitative and “multi-level” approach drawing on insights from the neo-institutional literature, policy ethnography analysis and the research on legal intermediaries. Such a perspective is particularly suited to capture the complexity and the depth of institutional change. Using the 12-hour work legal mechanism of derogation in the context of French public hospitals as an example, this chapter highlights how both macro-level actors (actors of a “reform network”), and micro-level ones (hospital directors) contribute to the shaping and framing of legality in French public hospitals. Results show that variation in how those actors use law depends on the local configuration. Second, results demonstrate that the legal games they play are not merely based on symbolic and superficial compliance with the law, but also on outright manipulations and conscious rule-breaking.

Purpose: This chapter describes the main features of the financing of health care expenditure in the French health care system.

Methodology/Approach: This chapter presents key reforms that have been implemented to make the health care system more sustainable in the main dimensions of care: ambulatory, hospital, pharmaceuticals and insurance coverage.

Findings: Overall, French public authorities have followed three paths to improve the sustainability of the health care system: reducing public expenses, generalising access to complementary health insurance and streamlining care toward the most disadvantaged individuals. Looking in the future, the sustainability of the French health care system will mainly rely on two areas of recommendations. The first area is to respect the national annual target for health insurance spending, with a focus on responsible prescriptions, optimised care pathways and increased use of primary and ambulatory care where possible. The second area is to increase efficiency on the short to medium terms. This includes an increased quality of the care toward patients with a disability or special needs, a clearer engagement of patients within their care pathways to increase treatment compliance, and more generally a search for coordinated care that is fair and appropriate.

This paper aims to characterize the French public hospitals (FPHs) according to their strategic behaviour. Until recently, FPHs used to ignore strategic issues, for their mission was clearly defined by regulating authorities and their activities were quasi‐automatically funded by the latter. This situation fundamentally changed as the environment of all “health care providers” became more demanding: FPHs have now to engage in a strategic process. The paper seeks to focus on the content of FPHs' strategies, and compare our results with standard findings of the strategic management literature, notably the strategic behaviour typologies established by Miles and Snow and Zaleznik and Kets de Vries.

A three‐stage empirical approach is conducted, mixing qualitative and quantitative methods. The measurement stage, based on a questionnaire survey realized with the support of a professional union, gathered the answers of 276 FPHs' decision‐makers, representing 51 per cent of the target population. This stage allows the formation of classes among these respondents, according to the environmental, organisational, and strategic features they describe.

The results are globally consistent with Miles and Snow's and Zaleznik and Kets de Vries' typologies. This is noteworthy since they were obtained in a different context and with different methodological approaches.

This article tackles the issue of the universality of the strategic process.

Finally, implications for policy makers and hospitals' managers are drawn from the study.

What mostly differentiates the paper' results from the standard typologies is that FPHs can be separated according to the alliances criterion.

This study aims to understand whether and how the use of performance measures in the context of healthcare organizations facilitates the dynamics of compromise or whether it creates moral struggles among a wide variety of actors. It offers novel insights into the concept of hybridity by investigating its underlying moral dimension. Drawing upon the sociology of worth theory (Boltanski and Thévenot, 1991, 2006), this paper examines how actors negotiate and compromise over time concerning issues of justice, involving the use of performance measures on a day-to-day basis.

The article presents a single case study of a medical unit in a French public hospital. Data were obtained through the ethnographic method, semi-structured interviews and internal financial and accounting documents.

Unlike earlier accounting studies, the authors analyze whether, and how, accounting, on one hand, contributes to the dynamics of compromise between actors with divergent values that characterize hybrid organizations, and, on the other hand, increases tensions among actors with convergent values involved in caregiving. This offers practical insights into three relational mechanisms underlying the dynamics of compromise and their limits through the time dimension.

The authors use a single case study in a country-specific context.

This study helps managers of healthcare organizations to understand the relationships between the use of performance measures and their impact on the evaluation of worth in practice.

In terms of theoretical contribution, the authors show how the sociology of worth (Boltanski and Thévenot, 1991, 2006) complements the analysis of hybridity and develop an original approach to understanding the ambivalent role of performance measures in bringing together divergent values within French public hospitals.

The perpose of this paper is to analyse recent changes in the management of French public hospitals, following a reform enacted in 2009 and aimed at bolstering the managerial roles of doctors.

The paper is exploratory and is based on both the analysis of French literature dealing with the results of the 2009 reform, and ten semi-directed interviews with clinical managers and top leaders in the public hospital sector.

The author reports on the major hospital management reforms of 2009 and analyse the implications for the medical profession and management. The author shows that the involvement of the classical clinical leaders has become less regulated as the units no longer have a clear legal basis. The governance of the newly introduced “medical poles” appears to be shaped by various factors: there is high correlation between centrality, prestige and “clan involvement”, which suggests that professionals holding new responsibilities obtain power and legitimacy by consolidating pre-existing networks. While it is often argued that high-quality clinical leadership is a key factor of organisational success, the findings suggest that the performance of clinical managers relies on this network and legitimacy acquired from it.

Drawing on the “sociology of translation” and actor-network theory (Callon and Latour, 1991), this paper provides a new conceptual framework for the analysis of the transformation of the role of clinical leaders, arguing that this transformation depends highly on their abilities to build and use networks. The findings challenge the French tradition of public management that presupposes a clear division of power between doctors and administrative staff.

We utilise the actor-network theory (ANT) – based especially on Latour (2005) – to examine how management accounting tools affect physicians’ representations and new managerial practices in French public hospitals currently undergoing reform.

We conducted a longitudinal case study – based on interviews and observations – in a large French public hospital in which dashboards are diffused to physicians and nurses dealing with both medical and managerial activities.

The case shows that head physicians and nurses are implicated in their new managerial tasks and spend time analysing dashboards. Management accounting tools thus play a role, as mediators, in organising new managerial practices, and dashboards are a means of materialising and giving structure to new managerial practices and enabling discussions and exchanges to take place between actors who were previously separated.

The case shows that management accounting tools are not necessarily useful because they help in decision-making or control – as in the dominant paradigm; rather, they are beneficial because they may help in changing representations and building a new collective organisation. Future research should therefore expand on the organisational and social roles of management accounting tools, especially in the healthcare field.

Most ANT-inspired studies in management accounting focus on explaining changes in accounting practices, which are perceived as a consequence of an ANT process. This chapter, however, analyses the practices by which management accounting tools act as a vehicle to organisational change.

This paper aims to describe relationships among healthcare professionals in a French public hospital using social network analysis (SNA) and to improve health service quality by strengthening health service management and leadership.

This study was based on a questionnaire sent to randomly selected French public hospital professionals and administrators. Network composition measures were obtained using a name generator. Analysis focused on three main indicators: “centrality”, “prestige”, and “clique participants”. The SNA was carried out using UCINET^® and statistical analyses were performed with SPSS version 15.0.

A total of 104 questionnaires were returned and analysed. Centrality, prestige and clique indicators were highly correlated (all p‐value were less than 0.01). Physicians had the highest scores for the three indicators. Older age (≥45 years) was associated with higher centrality and clique numbers scores. Transversal activity was associated with higher scores than other specific activities (hospitalisation, ambulatory care), except for emergency care.

The paper shows how networks and SNA techniques provide novel and useful means to understand communication and collaboration between hospital professionals.

Purpose: As specific emotional arenas, hospitals are characterized by the interweaving of various emotional requirements, arising from different sources of norms, rules, or guidelines. This study aims to highlight an often-overlooked dimension of emotional labor in healthcare by describing the coexistence of emotional rules (i.e. feeling and/or display rules) through a multilevel perspective (institutional level, cluster/department level, service level, ward level, professional level). Study Design/Methodology/Approach: These emotional requirements for nurses and nursing assistants are investigated through three sets of data (observation, interviews, and internal documents) in a French public hospital, focusing on two hospital services: three long-term care units (primary field of investigation), and five adult medical emergency wards (secondary field of investigation). Findings: The results of the analysis show the pervasive nature of emotional requirements which are intertwined and more or less implicit/explicit according to the level analyzed. In addition to organizational rules, professional and social emotional rules contribute to shaping emotional requirements, particularly through rules of “empathetic expression” and those of retenue bienveillante. Research Limitations/Implications: This research has contributed to showing the dynamic nature of emotional requirements and their appropriation and modulation by healthcare professionals. The qualitative methodology used allows for unique insights but limits the generalization of results. Originality/Value: This research has addressed various gaps in the existing literature by describing emotional requirements through a multilevel analysis, by outlining a set of rules that had not been previously described (retenue bienveillante) and by including the population of nursing assistants as well as nurses in a study on hospital emotional labor. Future research could envisage spatial analysis of emotional labor to help better understand emotional requirements' variability according to emotionalized zones.

Concern over the rising cost of medical care has caused many countries to investigate and implement different methods of cost containment, particularly for hospital services. In the United States, Medicare replaced its ‘cost‐based’ reimbursement system, in which hospital payments were based on the actual costs incurred in treating patients, with a system that pays hospitals a fixed price per case. Under this new system, all hospital discharges are classified into 467 Diagnosis Related Groups (DRGs) or types of cases based on the patient's age, sex, principal diagnosis, additional diagnoses (comorbidities and complications), surgical procedures performed, and the discharge status. During the first three years of the programme, the payment rate for each DRG is a function of a DRG weight (reflecting relative resource consumption), the hospital's historic costs of treating patients in that DRG, and a federally established rate adjusted for urban/rural differences and census region. In the fourth year the price will be based only on the DRG weight and the federally established rate.