Director of the IAE Metz School of Management
University of Lorraine
*Faculty member of the Business Science Institute.
Article originally published on The Conversation France.
The economic news in the national press reminds us how many problems there are with the organization of hospitals. A former director of the Regional Hospitalization Agency warned in Le Figaro on April 29: "We have confused the scale of health care spending with the efficiency of our organization.
However, as early as 2003, an information report by the National Assembly on the internal organization of hospitals, known as the "Couanau" report, highlighted the risks of bureaucratization of hospitals and their consequences on the lack of pragmatism in hospital management.
My work as a researcher and my interventions on quality or risk management in public health establishments have allowed me to observe that it is the successive reforms of the hospital system that lead, step by step, to the bureaucratic phenomenon and the creation of entropy.
Caricature of hospital bureaucracies
Robert Holcman's work on the sociological analysis of hospital organizations shows that in the common understanding, bureaucracies are associated with a pejorative image, with the civil service, with multiple dysfunctions (slowness, coordination problems, unclear lines of authority, loss of meaning, absenteeism, inertia, etc.) or with an overproduction of rules (procedures, norms, standards).
In fact, professional bureaucracies are not the prerogative of the public administration but rather of all large organizations. Many consultants' accounts in the mainstream management press repeat slogans such as: "bureaucracy kills creativity"; "bureaucracy is the enemy of productivity or performance".
However, this presentation of bureaucracies should not obscure the fact that in the Weberian sense, bureaucracies are not associated with any negative connotation. They are primarily characterized by their effectiveness in achieving the mission for which they are designed.
The organization theorist Henry Mintzberg produced a detailed description of the professional bureaucracies to which he linked the hospital in his fundamental work Structure and Dynamics of Organizations (1982). All of Mintzberg's analyses of hospital bureaucracies have been widely adopted by health management researchers and have made it possible to highlight the characteristics of these bureaucracies.
Characteristics of hospital bureaucracies
Hospital bureaucracies have several defining points. On the one hand, there is a high level of qualification of professionals and a lack of control over work.
In the hospital, the "production (care) worker" is highly qualified and trained (the nurse has at least a three-year degree, plus specializations, internships and permanent evaluations). They have a large degree of autonomy in their work and, in any case, the complexity of their work makes any direct control impossible.
Furthermore, the logic of professional identity takes precedence over organizational identity and function. Thus the health executive is a nurse before being a manager, or the head of department is a doctor before being a manager. At the same time, the hospital is based on a quest for legitimacy in which ranks or functions allow for identification. This legitimacy is conferred by a status ("the doctor"), a particular expertise ("the specialist professor"), experience, diplomas or membership of a body (directors' body, doctors' body, nurses' body).
It is common for health care staff to introduce themselves using their grade ("I am a senior health care executive", "I am a senior director") rather than their function ("I am head of division X or director of logistics").
Finally, several lines of authority contribute to the inertia of the hospital system and make the decision-making organization charts difficult to read.
They stem from the logic of the various bodies (doctors, nurses, administrators and directors), statutes (a professor of medicine, even if he or she is not the head of a department, can have an influence on decision-making) or functions within the organization (the chairman of the medical committee has as much influence on strategic decisions as the director of the institution).
Textual harassment and the myth of economies of scale
The question of economies of scale in organizations is at the heart of economic thinking. In the public sector, it is illustrated at the level of local authorities by inter-municipalities, in universities by mergers of establishments and in hospitals by groupings. The New Public Management movement, which emerged in the early 1980s, is pushing for the creation of large groups in the name of economies of scale and better management. However, a report by the IGAS clearly demonstrates the limits of the relevance of large hospital groups resulting from mergers, the costs of coordination and the bureaucratic inertia induced.
The report states that the degree of economic health of hospitals seems to be inversely proportional to their size. However, all the hospital reforms carried out since the 1970s have contributed, contrary to their stated intentions, to the process of bureaucratic construction by defending the large hospital complexes with a barely disguised word. Instead of the "mergers, mutualization" of the pre-2000s period, the legislator has preferred "health cooperation groups", "territorial hospital groups" or certain other forms of cooperation such as "territorial hospital communities" reserved for public establishments only. Thus, while the private sector represents 45% of medical-surgical-obstetric establishments (MCO), on a national scale, it is the public hospital that is becoming the focal point of all forms.
As Jean-Claude Moisdon has pointed out, hospital reforms, one after the other and one on top of the other, are sometimes a matter of "legislative bricolage".
Quality, procedures and loss of meaning
The evaluation of the quality of acts and care is consubstantial with the profession of doctor and carer. It is at the heart of their preoccupation during any treatment. Quality has enabled the industrial sector to do "more with less" by implementing organizational quality approaches. These are the types of approaches that have made the Japanese automobile industry successful for companies like Toyota. These very global approaches have a common meaning: customer satisfaction.
The work of a doctoral student that we supervised, Sandrine Hayo, shows from the analysis of 623 dissertations of student managers of health care management schools between 1995 and 2015 that the semantic field related to the concept of quality has evolved over time. It has progressively moved away from care and the act of care to organizational processes and then more recently to health personnel. The coronavirus crisis has only highlighted the deep suffering of the care professions.
Loss of (good) sense
The illustrations of this quality that leads to the loss of meaning ("or common sense") are numerous and have bureaucratic consequences.
Procedural quality, i.e. the production of standards, instructions and procedures, aims to control form ("I have the form, I have the stamp") rather than relevance ("Is all the information on the form useful?"). This procedural quality is part of the inversion of the hospital value chain. What makes sense becomes the production of rules, because the hospital's structuring functions (producing care to manage patients) have given way to support functions (quality, logistics, purchasing, administrative management, etc.).
Support functions have developed to accompany the management of ever larger hospital complexes, to the detriment of medical care. The proportion of non-medical and non-healthcare staff is significant in hospitals.) A synthesis of American studies by Himmerslstein & Woolhandler questions the efficiency of hospital administration (see https://www.healthaffairs.org/doi/10.1377/hlthaff.2013.1327) and shows that the growth of administrative staff is much faster than that of doctors in American hospitals.
What about tomorrow? We find it difficult to think in terms of territory without taking better account of all the players in the territories. How can we better integrate private hospitalization? How can local elected officials (mayors, regional presidents) be better integrated into the organization and regulation of care? What role should the ARS play if local elected officials are more involved in the organization of care in their area?
Article translated from French with https://www.deepl.com/translator
Julien Husson's articles on The Conversation France.
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