Turbulence in the Management of Health Services: Change, Inertia, Power and the Professions

Greenhill, Jennene Ann (2006). Turbulence in the Management of Health Services: Change, Inertia, Power and the Professions PhD Thesis, School of Business, The University of Queensland.

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Author Greenhill, Jennene Ann
Thesis Title Turbulence in the Management of Health Services: Change, Inertia, Power and the Professions
School, Centre or Institute School of Business
Institution The University of Queensland
Publication date 2006-12
Thesis type PhD Thesis
Supervisor Callan, Victor J.
Graham, Philip W.
Rooney, David
Subjects 350000 Commerce, Management, Tourism and Services
Formatted abstract Using a longitudinal, critical ethnographic approach this research explored how a change process was managed over a five-year period at a large Australian hospital. This thesis aims to explain how power dynamics that operate in the health system actively generate systemic inertia making organisational change difficult and complex. The thesis questions the efficacy of the rise of the new public management agenda and clinical management as valorised practice among clinicians. The context for the research was the construction of a $300 million hospital that was intended to introduce a new approach to health service management. The hospital redevelopment created an opportunity for redevelopment beyond the new infrastructure. A particular goal for the redevelopment was to bring about change in organisational design to create an integrated model for service delivery and a new organisational culture. Although the redevelopment was completed the new model of service delivery and culture change were not realised.
The research is shaped theoretically by Bourdieu’s theory of practice and is informed by literatures about institutional inertia, organisational change, sociology of power and the professions, complexity theory and health services management. In particular, this research applies a model of systemic inertia as a means to critically reflect on change in health services. The model of systemic inertia involves six mechanisms of reproduction that it is proposed create paradoxical tension in organisations. The six mechanisms of reproduction identified are loose coupling, path dependency, cascading, discontinuity, dissonance and indeterminacy. The findings of the research are organised around these key constructs.
The most important contributions of this thesis are findings that reveal how new public management infiltrated political, professional and bureaucratic fields of power strengthening pre-existing power structures that underpin a dominant discourse, which is reproduced through systemic inertia. Loose coupling facilitated the emergence of clinical management and the preservation of clinical dominance via a gradual adoption of business principles and practices by clinical managers. Path dependency in particular explains how power structures perpetuate medical dominance. Thus clinical management emerged as an extension of medical dominance and clinical managers became the new elite relegating other non-clinical departments to support services. The research also observes that cascading explains how the accumulative effects of power differentials led to the implementation of clinical management but not to culture change or the new model of service delivery. Power differentials resulted in cost shifting between acute and community services that consumed vast resources and generated systemic inertia. An understanding of how cost shifting operates through hospital centrism is a valuable insight of this thesis.
Terms such as “collaboration” and “integration” are common in clinical management discourse, but such practices are undermined by an enthusiasm for competition in new public management. Indeed, competition, coercion and manipulation practised by managers and threats of commercialisation caused industrial conflict, job insecurity and increased workloads that created paralysing organisational tensions. In this way, systemic inertia is generated by dissonance resulting from power and domination. Indeterminacy as a construct explains how clinical managers covertly influence an organisation through the shadow system. In addition, the shadow system observed was self-organising because it enabled the system to generate new structures and patterns based on its own internal power dynamics, logics and imperatives. Hence, decision making processes about health services often appeared to be invisible to those outside and usually remained unquestioned. This invisibility assisted the preservation of traditional power relations and the blocking of culture change and the integrated model of service delivery.
In the model that emerged from this research, discontinuity describes the disruption linked to, for example, rapid turnover of managers, restructuring and reviews, and inadequate training and planning that generated systemic inertia. Discontinuity was most evident over the course of this research in terms of disrupted decision making as the health department restructured three times in less than five years. It is argued that cyclical discontinuity occurred because of the associated bureaucratic and political power struggles that are prominent during perpetual cycles of health ‘reform’. Respondents reported that restructuring not only consumed massive resources, it causes discontinuity at every level of the organisation.
Systemic inertia as a construct explained the underlying relationship between power and inertia in organisations. This study reveals the habitus of the clinical manager gives rise to discursive organisational practices as the means through which the dominant ideologies that create systemic inertia are constructed and maintained. In terms of applications for practice, the thesis proposes that health service managers need to take systemic inertia into account in their planning. The findings suggest the current top down approach to planning needs to be reversed if a more integrated Australian health system is to be established. To hear and act upon the muted voices of patients and the wider community it is necessary to unmask and disrupt the power of dominant groups such as clinicians and clinical managers.

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