Paper to the International Labour Process Conference, Routgers University, New Jersey, USA, March 15th – 17th 2010
Helge Ramsdal and Mona Jerndahl Fineide,
Østfold University College, Norway
,
Backstage Decision-Making - standardizing professional work performance while coping with uncertainty.
Abstract.
For several decades the organization of health work has been influenced by new developments in the standardization of work processes. In recent years this has been informed by Business Process Reengineering and Lean-Production related approaches. In the health sector, scientific knowledge, IT-systems and “Best-Practices” have been combined in order to standardize work performance by Integrated Clinical Pathways (IPCs), potentially changing not only the quality of services but also the strategic positioning of professionals in the work place. The ICPs are intended to prescribe and control professional work. In theory, the introduction of ICPs contradict the professions’ distinctive mark of autonomy and discretionary powers. Here we discuss to what extent the process of producing and implementing standardized performance models like ICPs change professional work, reporting from “backstage” decision making processes by studying the construction and implementation of ICPs in mental health. In the paper, we identify organizational mechanisms that facilitate construction and implementation of the ICPs in three phases where uncertainties are eliminated or reduced. The introduction of ICPs are based upon the presupposition that a firm knowledge base can be constructed. In the study we analyze how this knowledge base is made by the creation of ”initiated ignorance”, thereby facilitating the design process as ”contextualization”, and finally changing work performances when the ICPs are implemented.
Work in Progress – Please do not quote
Introduction.
This paper addresses discusses the issue of to what extent and how standardization of work processes by means of Integrated Clinical Pathways (ICPs) change inter-professional relations and professional work performance. The health sector has been subjected to extensive organizational changes for several years. These changes are partly related to NPM approaches of political governance and management structures, partly to developments in technological and medical knowledge. In Norway the hospital reform of 2002 reflects NPM approaches in the first sense, while the concept of “high-tech 48 hours” hospitals are embedded in ideas of lean hospitals (Ramsdal and Skorstad 2004, Sykehuset Østfold HF 2008). Here, the standardization of work processes through the introduction of integrated clinical pathways (ICPs) has become the main strategy in order to provide high quality and cost-efficient service provision (Timmermans and Berg 2004, Ramsdal and Ramsdal 2007, Vikkelsø and Vinge 2004). “Process perspectives” on hospital organization designs now is the main approach in planning new hospitals and restructuring excisting health services in Scandinavia, including Norway. These developments leave several questions to research regarding the nature of ideas of organizational design, implications for professional work performances and working conditions, and how to cope with standardization and flexibility in cure and care.
In our case study, as in mental health generally, disagreements, uncertainties and ambiguities are prevalent, and paradigmatic controversies (over explanations and treatment of mental disorders) is a major challenge for service provision (WHO 2002, Ramsdal 2009). In addition the welfare state service system is highly complex, with several agencies at both specialist and local levels, and with a number of professions taking part in treatment and care for clients. And finally, the clients are differentiated regarding mental health illnesses and problems, very often with more than one diagnosis, and also with health conditions that change profoundly over time. These peculiarities of mental health work create an obvious need for coordination and flexibility in service provision, but also represent dilemmas and ambiguities in organizational matters. The introduction of ICPs thus potentially faces problems when standardization of work performance reduces flexibility - in order to obtain coordination. The paper reports from research on ICPs related to ADHD in Norway, this being one of the first ICPs constructed in the health services of that country.
The processes of knowledge production, organizational designing and implementation of ICPs are complex, often controversial within the professional community, interconnected and usually non-linear. To obtain insights into these processes case studies seems the most fruitful approach. Here, we report from a research project were these “backstage” processes were studied by participant observation, in-depth interviews and document analyses.
Background.
An important reason for developing ICPs for ADHD patients is a 2004 report from Sintef Health Services Research in Norway, arguing that children and youth suffering from ADHD did not achieve the services needed from the health and social sector. To improve better coordination and collaboration between service providers a ”pathway” approach to the flow of tasks with respect to referrals, clarification, and diagnosis was perceived necessary. The hospital in charge of specialist health services invited in one county invited the municipalities to participating in establishing anICP for this group of patients. The state run specialist health services, represented by the Department of Children and Youth Psychiatry (CYP), managed the project. The participants from CYP and the municipalities were recruited by an open invitation or an individual invitation to attend one of five CYP-led local teams (the total number of participants taking part in the project was about forty 40).
The five teams of “ICP makers”, along with the other agents in the project, were directly involved in the production-process transforming knowledge and interests into rules as they were assigned to produce an instrument making prescription for professionals work performance regarding children with ADHD. The ICP is not merely reflecting the relationship between the professional and the individual patient, the instruments encompasses a generic function as making a standard for professional work regarding the group of patients with symptoms of ADHD. The ICP was established in 2006 by an agreement by representatives of the municipalities and the specialist health services. The ICP is described online and in pamphlets and manuals, tailoring each specific service such as Municipal Educational and Psychological Counselling Services (EPCs), Family doctors (GPs), Child and Youth Psychiatry (CYP), Schools, Kindergartens and Health centres.
Theoretical perspectives.
(Integrated) Clinical Pathways (ICPs) is one important strategy in the introduction of “evidence based medicine”, often labelled ”scientific-bureaucratic medicine” related to the development of “soft regulation” in modern welfare states (Timmermanns and Berg 2003, Dent 2008, Brunsson 2000). The research on these developments in professional work organizations – and the political implications – have been extensively studied (for an overview in Norwegian: Ramsdal and Ramsdal 2007). The mechanisms by which knowledge production takes place, the tranference from knowledge to organizational designs and implementationare generally processes whithin the “the black boxes” of professional communities - often inaccessible for social scientists. In the process of constructing an ICP a selected group of professionals and staff/managers are assigned to decision making “backstage”. This is a process of problem solving that is crucial in the overall creation of the ICP, intended to improve the quality of health services by influencing inter-professional relations and professional autonomy. Health care involves “expert labour” by professional groups with an historical background of autonomy in work performance. But since the quality of services increasingly depends upon multi-professional coordination in complex service provision systems Integrated Clinical Pathways (IPCs) is now a global strategy embraced by governments in most Western countries. However, several issues arise from thes strategies, not at leats about how standardization of professional work performance is produced and implemented in a context of ambiguous and contested terrain. This paper intends to identify elements of uncertainty and explore how ICP-makers are coping with the problem-solving processes in “backstage” decision making.
The medical profession has a key role in the structuring of services and the performance of health work in the Nordic countries as these welfare states have been described as “profession states” (Byrkjeflot 2005, Eriksen 1996). However, since the 1980’s neo-liberalist ideas on the organization and provision of health and social services have been introduced, primarily as “privatization from within” – i.e. by importing theoretical concepts, steering models and organization structures from private business enterprises (Ramsdal and Skorstad 2004). The trust (in professional/medical settlements) has been replaced with Government-led, external regulation of the health profesions. Referring to Harrison and Smith (2003) he points out to “clinical governance as a key instrument for managing clinical work, including clinical guidelines” (Dent in Munzio, Ackroyd and Chanlat 2008: 103).
Clinical guidelines are seen as “species of bureaucratic rule, (reflect)… a transition … to… neo-bureauracy, in which… clinical activity has become the subject of surveillance and/or incentives and sanctions aimed at securing compliance with the rules” (Cited from Harrison and Smith (2003:249) in Dent (op.cit: 104). Courpasson (2000) understand these developments as aspects of a new rationalist discourse which is not one of direct managerial control, but more a case of “soft bureaucracy” where control is exercised through the imposition of performance targets and other output measures. According to Fournier (1999) this changes the professions position from institutional autonomy of self-regulation to a situation of bargaining over autonomy. Fournier (1999) refers to this process as “responsibilisation”, which could be understood as a new disciplinary technique inculcating an internalized self-discipline, based upon a bargained legitimation of the (scientific) knowledge base, and the “articulation of knowledge around the notions of efficiency and technical competence” (op.cit:105).
The emphasis is now primarily on New Public Management (NPM) related governance, and strategies in order to subordination of professions to state managed systems of surveillance (what is labelled “Governance I). Governance Irefer to the fact that “scientific bureaucratic medicine” was embraced by the medical profession as a response to loss of legitimacy and public condfidence. New Public Management governance initiatives included the introduction of Evidence Based Medicine (EBM) and ICPs, thus directing clinical performances in ways that are transparent – and thus potentially exposed to political and managerial control. The idea was that ICPs are introduced “to be obeyed rather than as navigational aides. Directing rather than informing clinical practice” (Dent op cit: 108). Governance II refers to “knitting together”of guidelines of the different professional groups involved along a common timeline with the aim of delivering effective and efficient care. This is regarded as the next stage in the erosion of medically controlled clinical autonomy. They cross the “Governance I/II border from professionally autonomous systems of clinical governance to inter-professional and state-managed (or at least guided) systems of prospective management of patient care and treatment.
The difference between Governance I and II approaches to CPs seems, however, difficult to decide regardless of (national) contexts and the organization of health care systems (Dent refers primarily to UK experience). The answer to the question on whether CPs should be regarded as a managerial instrument targeted at reducing medical professional autonomy (Governance I) at the workplace or whether the expansion of the CP approach (from the clinic/uniprofessional) by ICPs - “integrated pathways” (to a number of health services as a tool for obtaining coordinated services provided by several agencies, should be regarded as a (further?) erosion of medical professional autonomy seems to be open. Clinical Governance II thus, is not exclusively an evidence-based approach within the control of medical doctors, but an instrument for coordination of health services based upon “best practices”, and – in relation to state policies – as an example of “soft regulation”.
The introduction of “process perspectives” on health services rests upon the combination of three approaches to knowledge: the knowledge of “best practice” in medical treatment, based upon “evidence-based medicine”, new IT technologies based upon modern versions of Business Process Engineering, and contextual knowledge, as (Integrated) Clinical Pathways ((I)CPs) where the global knowledge related to EBM and ICPs is translated in order to fit in a a local context (Ramsdal and Ramsdal 2007). Notwithstanding the history of standardization of procedures in medical (and other health) work, the introduction of ICPs represent challenges for professional autonomy in work performance for two reasons: they are intended to restrict individual professionals’ opportunity to consider what to do, when and how, and it organizes collective work processes in order to achieve coordinated action, primarily by standardizing actions at each “work station” sequentially. Standardization of work processes by the introduction of ICPs rests upon some fundamental assumptions: firstly, that an unambiguous (scientific) knowledge base can be established (as a basis for “best practice”), secondly, that there is a successful contextualization of procedures by IPC design, and thirdly, that professionals accept that performance must change according to standardized procedures.
In spite of the political and professional implications of these processes, producing and implementing standardized performance models usually take place as “backstage” decision making where actors representing technological, (medical) professional and organizational knowledge construct and respond to the regulatoryinstruments. In this paper we report from case studies intending to shed some light upon the actual processes by which standardization of professional work take place, by studying the construction and implementation of Integrated Clinical Pathways (ICPs) in mental health.
The process of making and implementing ICPs take place through the use of high level professionalexpertice. For analytical purposes the process might be separated into three parts, reflecting the major decisions that take place in the process. Even though different approaches are seen in the process decisions in the initial phases are often made by a small selected group of professionals.These individuals are “ICP-makers”, directly involved in the production process transforming knowledge and interests into rules presented as “ready to use” for utilization by professionals at the work place. To what extent the process of producing and implementing standardized performance models changes professional work thus take place ”backstage” where actors representing (medical) professional, IT technological and organizational knowledges construct the ICPs.
In accordance with Fernler and Helgesson (2006) and Timmermanns and Berg(2003)the process of making ICPs takes place in three stages: Firstly, the knowledge basis must be defined. “Knowledge” is a social contruction, and in this context at least, ambiguous and contested. The way the knowledge basis is established consequently implies a selection process. As mentioned above, ICPs are generally based upon “evidence-based medicine” for best practice – i.e. medical treatment/therapies, either produced by expert comittees within the professional (medical) community or – increasingly - by RTCs, presented in global medical data bases like Cochrane and Campell (Ekeland 2009). ICPs presuppose a medical diagnosis as a “starting point” for the next phase, and the design thus represents the contextualization of “best practice”. In ICPs the knowledge base is not necessarily a diagnosis, and often multi-professional knowledge must be integrated in the design process. Fernler and Helgesson emhasize the necessity to make the knowledge base “firm”, and defines “knowledge selection and exclusion” and “knowledge compromise” as mechanisms of creating what they call “initiated ignorance” where ambiguity and disagreements over the knowledge base is reduced or eliminated. These mechanisms are partly expressed as exclusions of professionals with alternative views in the ICP groups, or as neglect of or compromise between differing views in the discussions “backstage”. The third phase is the implementation of the ICPs by professionals working in the services. Reviews of the research on ICPs clearly indicate that this phase is most problematic as professionals often find the ICP guidelines uneccessary as they do not change practices already being used or disagree with the paradigmatic approaches to treatment. Often – which is often the case when ICPs encounter the peculiarities of mental health work – the guidelines are considered too rigid as experience makes the professional resting more on “Kunst” than Cochrane” in their work performances (Ramsdal 2009). Thus, on line with Ackroyd and Thompson (1999) the responses to the introduction of ICPs might vary from commitment, engagement, compliance, to withdrawal, denial and even hostility.
Research design/methods.
The research was undertaken in one Regional Health Enterprise (specialist health services) and eight municipalities in a NorwegianCounty in 2008 and 2009 as these organizations have created a methodology of developing ICPs for the past few years. In the hospital ten ICPs have been put into practice as of January 2009, and new ones are continuously being produced (the total is estimated to be 44). The ICPs in this enterprise is considered as a frontrunner in strategies to improve quality by the introduction of ICPs countrywide.
We used qualitative methodological principles for research. Data were gathered from nineteen “semi structured”/open-ended interviews of maximum one and a half hour.[1] The professionals interviewed are from three divisions of specialist health services and eight municipalities.[2] With the exception of one person holding a managerial function and another person being involved in project management the professionals all worked closely with patients or clients on a daily basis. All of the informants had experience with at least one specific ICP within the past two years. Furthermore, we used participant observations ofthree meetings (recorded audio including one meeting videotaped) and participant observations of three conferences arranged by Regional Health Enterprise. The professions represented as informants are clinical psychologists, clinical pedagogues, psychiatrists, paediatricians, health visitors, supervisor pedagogue, nurses holding further education within mental health and one council physician. Supplementary to the interviews and observations, we gathered policy documents of reforms, reports and presentations from conferences, and archival recordsfrom the organizations e.g.organizational charts and minutes from meetings. Most of the data are collected from the ICP for children with ADHD (Attention-Deficient hyperactivity disorder) and the ICP for adults with ADHD.