The changing organisation of hospitals: the influence of care pathways
Centre of Health Economics Research (COHERE),
Department of Business and Economics,
University of Southern Denmark
Hospitals are often considered the archetype of a professional organisation, thereby emphasising professional autonomy and specialisation. However, patient demands along with financial, clinical and quality considerations has directed great attention towards implementing standardised care pathways. At present, however, it remains unclear how the advent and increasing use of care pathways as an instance of standardised and formalised work procedures influence the hospital as an organisation, and potentially clash with the autonomy and attitude of health care professionals. This paper closes this gap. The analysis uses Mintzbergs’ professional and machine organisation and Lega & DePietro’s care-focused organisation as the backdrop for understanding and analysing the changing organisation of hospitals. The organisational influence of care pathways is discussed against this backdrop by drawing on insights from the literature on standardisation and formalization of work procedures. The paper extends the understanding of hospitals as care-focused organisations further beyond that of the professional organisation. It is analysed that if care pathways are used in enabling and bottom-up ways hospitals can become effectively ambidextrous, thereby supporting innovation capabilities while at the same time meeting the control requirements needed to achieve and sustain high quality care. As regards the attitude and autonomy of health care professionals, care pathways need not be infringed if the enabling logic is used. Future areas of research are put forward.
Keywords: hospitals, professional organisation, machine organisation, care-focused organisation, ambidextrous organisation, care pathways, standardisation, and formalization
The changing organisation of hospitals: the influence of care pathways
The hospital is often considered the archetype of a professional organisation 1. Defining characteristics include professional autonomy, extensive specialisation, and organisation into functional departments and units based on speciality. However, patient demands and financial, clinical and quality considerations have increasingly called for hospitals to organize around patients and care processes 2. Hospitals, as a result, increasingly depend on processes that flow horizontally across inter-organisational boundaries. This changes the organisation from being organized primarily around specialities and speciality based departments (functional silos, that is) and instead focus on cross-functional organisation and work 3 4. This change prompted Lega & DePietro 2 to characterise hospitals as care-focused organisations. Nevertheless, characteristics important to the professional organisation permeate hospitals, in particular, specialisation and autonomy.
Care pathways (or clinical pathways, integrated care pathways, patient pathways) represent a telling example of the core ideas of the care-focused hospital 2. This because the actions of different caregivers in different stages of a specific care process is systematically reorganized to optimize health care delivery 5-10, thereby mirroring standardised and formalized work procedures 11. This approach to health care delivery is increasingly utilised within hospital sectors internationally, be it diagnosis, treatment, surgery, care or rehabilitation 12-15. In Denmark, for example, hospitals are required to implement cancer pathways that by and large standardise many types of cancer care 16. Similarly, one newly established shared acute admission in Denmark provides care to approximately 97% of all incoming acute patients using a total of thirty-six standardised pathways 17
So far, care pathways is found to facilitate relational coordination, thereby strengthening interactions between participants 18, improve professional documentation 19, influence the nursing and midwifery professions 20, and challenge doctors’ emotional codes of conduct 21. However, to the best knowledge of the author it has not been analysed how the increased focus on care pathways and hence standardisation and formalization of work procedures influence the hospital as an organisation, in particular in the classical form presented by Mintzberg. Moreover, standardisation and formalization is virtually left unaddressed in the framework of the care-focused organisation 2. This paper closes this gap. In analysing this, the influence on professional attitude and autonomy is also singled out, and addressed by highlighting distinctive traits of (health care) professionals 22 23. This is timely and relevant because the characteristics of specialisation and autonomy of the professional organisation still are dominating features.
The aim of this paper is thus twofold: (1) “how does care pathways influence the hospital as an organisation” and (2) “how does care pathways influence the attitude and autonomy of health care professionals and hence, indirectly, influence the organisation of hospitals”. The paper uses Mintzbergs’ 24 professional and machine organisation, and Lega & DePietro’s 2 care-focused organisation as the backdrop for understanding and analysing the hospital as an organisation. The influence of care pathways is discussed against this backdrop by juxtaposing care pathways with standardisation 25 26 and formalization 27 of work procedures.
The paper is structured as follows. Firstly, distinguishing traits of health care professionals and their work are emphasised because it make hospitals distinctive compared to other types of organisations. Secondly, the organisational frameworks of the professional, machine, and care-focused organisation are presented, and differences are highlighted. Thirdly, care pathways are presented with focus on standardisation and formalization of work procedures. This highlights likely implications for the attitude and autonomy of health care professionals. Fourthly, against the backdrop of the organisational frameworks (section two) and care pathways as standardised and formalized work procedures (section three) it is analysed how care pathways influence the hospital as an organisation. Finally, the paper is concluded and future areas of research are put forward.
TRAITS OF HEALTH CARE WORK AND PROFESSIONALS IMPORTANT TO UNDERSTAND HOSPITALS
Three distinctive traits from the functionalistic theory of professions are important to the present context: practice is based on abstract theory, work autonomy, and service-orientation with regards to patients 22 p.2-4 23 p.63-5. However, in order to take dynamic aspects into account, for instance, the interplay and power games among and between professionals the static (or descriptive) perspective of functionalistic theory needs broadening. The neo-weberian theory of profession does this by understanding professions on the basis of the professional project (for example, the medical domain) it solves and aspires to, and its effort to maintain or expand the professional project. It follows that the professional project of one profession potentially conflict with that of another, thereby giving rise to power struggles over the boundaries of the professional projects 22 p.4-12 23 p.65-8.
As regards health care (or hospital) work, it is important to emphasis that it is unique compared to other types of work. The decisive differences important to the present paper can largely be attributed to the nature of healthcare and how it is delivered. As regards the nature, health care is stochastic 28 p.8, thereby making work contingent on internal and external factors, for example, patient input uncertainty 29. This requires flexibility (or customization) in the delivery of health care 30. With regards to the delivery of health care, health care professionals and departments are highly specialized in order to meet patient demands 30. One important implication, among others, is that a large number of work sites are established and embedded within different departments. This leads to different and potentially conflicting approaches to the division of labour 28 p.5-6, just as different mental models are likely to challenge coordination 31 and learning 32.
Clearly, in understanding the hospital, and analysing the influence of standardised care pathways on the changing organisation of hospitals it is important to take these traits into account because it makes hospitals unique compared to other types of organisations.
THE PROFESSIONAL, MACHINE AND CARE-FOCUSED ORGANISATION
Mintzbergs’ 24 professional and machine organisation, and Lega & DePietro’s 2 care-focused organisation serves two purposes: (1) understand the hospital as an organisation, and (2) form the backdrop for analysing how care pathways influence the hospital as an organisation.
As regards Mintzbergs’ framework, Figure 1 presents the conceptualization of organisations into five basic constitutive parts: strategic apex, middle line, technostructure, support staff, and operating core. Depending on the combination and relative size of the five parts, five organisational archetypes are configured, including the professional and machine organisation outlined below. Table 1 summarises the defining characteristics of the professional, machine, and care-focused organisation.
[FIGURE 1 ABOUT HERE]
[TABLE 1 ABOUT HERE]
The professional organisation
The hospital is traditionally viewed as a professional organisation, cf. Figure 1 1. Professionals—within hospitals mainly doctors, and to a lesser extent nurses—dominate by making up the powerful operating core, which also constitute the key part of the organisation. This primarily follows from the unique and complex character of the work the professional carry out. That is, professionals make competence claims in particular areas because they possess the knowledge and skills to define problems, determine solutions, and monitor the functioning of the system 33. This effectively excludes non-professionals from carrying the work out. This partly makes standardisation of skills the preferred coordination mechanism. Such standardisation is closely related to the education, training, and professional norm professionals primarily receive outside the organisation. For example, medical schools greatly determine doctors’ repertoire of skills, that is, the standard programs used by health professionals in the delivery of health care 1.
Following this, professionals’ value decision-making autonomy, for example, as regards care decisions. The autonomy (or power) is largely the result of pigeonholing processes, that is, organisation is designed around professionals’ skills and knowledge. Thus, organisation mainly occurs vertically by function (medical speciality, for example) and less by process (for instance, patient groups), service or product 1. This is considered an asset and Achilles’ heel because innovation and adaptability capabilities are limited, for example 34. This, however, does not necessarily need to be the case within organisations 27, cf. below. Still, pigeonholing is prone to lead to a lack of collective action and cooperation 2, which could extend into why coordination is difficult across departmental or professional boundaries.
The machine organisation
In contrast to the professional organisation, the machine framework differ along important dimensions 35. In the machine organization coordination is achieved primarily at the top of a vertical hierarchy. This effectively preserves the specialization and focus of each functional area. In terms of grouping, workers are mostly organized according to function, not process or product. As regards coordination, standardisation of work processes makes up the preferred coordination mechanism because it allows processes to be carried out efficiently and without depending heavily on the skills of workers. Along these lines, formalization of work procedures is also much more prevalent. In fact, the high degree of standardization and formalization of work procedures, in contrast to the professional organisation, makes the technostructure the key part of the organisation, that is, the part concerned with designing the formal planning and control of work. It effectively follows that workers have limited discretion and control over tasks. This also limits the importance of training and indoctrination as regards the modus operandi of workers.
The care-focused hospital, and the bureaucratized professional
Recently, Lega & DePietro 2 argue that hospitals have developed into care-focused organisations, thereby moving beyond the professional organisation in certain regards. This movement is attributed to financial, clinical and quality considerations on the one hand and patient demands on the other.
A central part of this framework—and a contrast to the professional and machine organisation—is that grouping primarily occurs around care processes, and not vertical functions such as specialities or departments. The utilization and advent of care pathways exemplifies and amplifies this trend. A further contrast to the professional organisation is that health care professionals, primarily doctors, should act as bureaucratized professionals, not professional bureaucrats. This is considered necessary when hospitals organize care processes horizontally around patient needs. This calls for integrating values usually attributed to the managerial culture into the professional. This, among other things, requires that health care professionals should support new organisational design, act cost-consciously, and share organisational goals that go beyond individual functions 2. In terms of management, this development has been increasing since the mid-eighties among doctors 23 p.91-113.
Moreover, compared to the professional organisation the care-focused hospital and the focus on horizontal care processes to a greater extent also require liaison devices in the operating core 2. Interestingly, the care-focused framework does not (or only in passing) discuss the role of standardisation and formalization even though it is fundamental in Mintzberg’s framework and increasingly utilized within hospitals. The present paper addresses exactly this by discussing the changing organisation of hospitals by focusing on the organisational impact of standardisation and formalization of work procedures in the form of care pathways.
CARE PATHWAYS AS STANDARDISATION AND FORMALIZATION OF WORK PROCEDURES
A care pathway—usually a written artefact 36—is defined as “a complex intervention for the mutual decision-making and organisation of care processes for a well-defined group of patients during a well-defined period 10”. As regards this, multidisciplinary teamwork and standardisation is central 5-9. In fact, the explicit focus on (re)organisation and standardisation of processes make them different from ordinary care processes 37 and clinical guidelines 38. Central objectives of care pathways include quality improvements 39 p.138, and resource and clinical efficiency 12. This is ideally achieved by:
(i) An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics; (ii) The facilitation of the communication among the team members and with patients and families; (iii) The coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; (iv) The documentation, monitoring, and evaluation of variances and outcomes 10”.
The degree of detail, however, varies from being detailed (less discretion) to generic (more discretion) 8 9 40 p.179. In the words of organisation theory, care pathways resembles standardised and formalized work procedures, which thus in turn represent a coordination mechanism 11. Therefore, care pathways are juxtaposed with standardisation 25 26 and formalization 27 of work procedures because it, firstly, provides insights into the influence on the hospital as an organisation and, secondly, provide answers to the likely influence on professional attitude and autonomy, cf. Table 2.