The Soft Side of Knowledge Management in Health Institutions

Jon-Arild Johannessen

• Publisher: Emerald Publishing Limited
• Year: 2021
• ISBN:
  9781801179263
• Topic: Business
• Subtopic: Management
• Index: Business

Why are hospitals so difficult to manage?

It is agreed that cost-effectiveness is important, but knowledge-effectiveness is as equally essential as knowledge, skills and attitudes are the most critical competence factors in hospitals. Managing, controlling, and communicating knowledge within social systems, from the management perspective, as well as integrating information processes, vision, goals and altering the course which the system is leading can help ease the task of hospital management.

The innovative contribution of The Soft Side of Knowledge Management in Health Institutions lies in its exploration of how a knowledge perspective and knowledge-effectiveness can contribute to improving hospital leadership and organisation from a continuous-change perspective. Focused on knowledge management, information, communication, organizational learning, tacit knowledge, and negotiations within hospitals, the lessons and insights in this volume will appeal to both researchers and hospital managers alike.

1

Introduction to the History of Hospital Leadership

In recent years, there has been considerable debate at times about forms of hospital leadership. Among other things, this debate conveys the engagement of political stakeholders and health professionals in both hospital and academic settings.

Over the past 30 years, hospital management models have developed in four stages. In the 1970s, when there was a relatively low level of internal and external complexity, the bureaucratic model was predominant. As far as leadership was concerned, members of the medical profession were dominant to a large extent. From a political point of view, the prevailing watchwords were equality and democracy. In general, the value-creation logic was oriented around the value chain (see Porter, 1985).

In the 1980s, when hospitals became more complex internally, the ‘professions’ model became more and more prominent. There was also a growing debate about shared versus unified leadership. The professions model was the predominant management model, even though during this period the bureaucratic model continued to be strongly represented in the conceptual models being applied by individual actors. From a political point of view, productivity and effectiveness were the prevailing watchwords. To a large extent, the logic for value creation was oriented around competence and the linking of competences, a value-creation logic that is known as value workshop (Stewart, 1997).

In the 1990s, external complexity increased, among other things, as a result of increasing expectations, because technological opportunities made it possible to satisfy more needs and wishes than before. The demand for new and better services increased and the pressure on hospitals and professionals grew significantly. This led to a debate where one sought to find a balance between expectations and possibilities. The management model that evolved during this period can be called the ‘divisional’ model, where the focus was on leadership and management within relatively free units. The political catchphrase employed at the time can be summed up as ‘greater freedom of choice for the individual’. The value creation logic that came to the fore was the value network (Stewart, 1997), with network connections in a larger network of hospitals.

Throughout the 2000s, internal and external complexity increased. The management model that crystallized from the 2000s up until today (2022) can be termed the ‘communication’ model, because the prevailing coordination mechanism, in situations where both internal and external complexity is great, is communication. The value-creation logic that emerged can be termed the ‘value dialogue’ and ‘value community’. This can be explained by the fact that knowledge development, knowledge transfer, communication and social responsibility are necessary prerequisites for increasing value creation at a time when turbulence is great, the rate of change is great and there is an increasing demand for knowledge production; for example, innovations that can meet the needs and wishes of the growing expectations that hospitals are facing.

The division into different management models (and different value creation focuses) should only be understood as ideal models for clarifying developments for analytical reasons, and not as a situation where one model replaced the other. This is not what occurred. All the management models and value focuses still exist today, side by side. It is the gradual change we wish to explain in this brief review (shown in the figure below). In other words, there was no dramatic shift between management models. The changes came about gradually and people's conceptual models change even more slowly, so that the different management models exist side by side over a long period of time. This increases the complexity of the management context, but also the diversity (Fig. 1.1).

Fig. 1.1. The Management Models of Hospitals: A Typology.

The arguments that have been used for ‘shared’ as opposed to ‘unified’ leadership may be summarized as follows:

Arguments in relation to shared leadership in hospitals:

• Equal dialogue
• Negotiated agreement results in greater commitment and goal orientation
• Promotes diversity and pluralism
• Consensus can hamper decision-making efficiency
• Bureaucratization, because unsolved issues can be sent further up the hierarchy
• Develops a culture of negotiation.

Arguments related to ‘unified’ leadership in hospitals:

• Promotes financial management
• Greater problem focus
• Increased ability to act
• Does not support segmentation of the professions
• Can lead to friction between the professions
• Develops a performance culture.

The power and the convention perspectives regarding shared, in contrast to unified, management of hospitals can be framed in relation to three elements: technology, profession and ideology.

• Power and influence can be understood as a process in which people hold positions and form relationships with others, thus gaining influence in the health sector or more specifically in the hospital sector.
• New technology leads to new professions, which will also be able to exert influence.
• The ideological perspective is related to developments in society from the 1980s up until the present day. This concerns a transition from a focus on collective solutions to an emphasis on individual solutions. This change in mind-set may also be related to the management of hospitals. The ideological perspective is also related to the fact that external institutional forces, political influence, pressure groups, trade unions and so on, can all largely be said to contribute to the development of the framework conditions for the management of hospitals.
• The professional perspective is related to the fact that old and new professions compete with each other for power and influence. Historically, there have been three dominant professional groups in the hospital sector: doctors, nurses and hospital administration (mainly economists and lawyers). However, recent developments have led to an increase in the number of professions and professional categories in modern hospitals.

The demand and supply of health services is governed by several factors. Some of these are mentioned below.

(1)Demographic trends: Demographic trends indicate that there will be a growing need for health services in the years to come. We are facing a situation where, in a relatively short period of time, we must either increase the volume of health services or make the health sector more efficient. Another alternative is of course to do both, both increase resource use and at the same time improve the economic efficiency in healthcare. Automation and new technology, such as artificial intelligence, may provide opportunities to achieve this.

(2)Technological opportunities: Recent years have witnessed rapid technological developments, and it is anticipated that new technological innovations in health-related technology will emerge in the future, where artificial intelligence, intelligent robots and intelligent algorithms will play a crucial role in hospital automation processes. This will enable procedures to be performed that were previously characterized as very difficult. Another consequence is that with the new technology, new specialist groups will emerge that utilize the technology. Relationships of power will change and new positions and relationships will develop. The new technology will thus lead to both opportunities and challenges for both the management of hospitals and the various professions.

(3)Increased expectational pressure: Technological and economic factors have both contributed to a rise in expectational pressures for hospitals. This can quickly develop into a conflict between perceived opportunities and the perception of what is actually being delivered by hospitals. Much of the expectational pressure crystallizes at the interface between expectations and the perception of what is actually delivered.

(4)Increased informational pressure: The level of knowledge among the general public has increased, while at the same time there is greater and easier access to information, for example via the Internet. This has equipped patients to challenge doctors and nurses, who are thus put under increased everyday stress, because they feel that they have to be able to provide reasonably expert responses to their patients' questions. A form of information competition further increases the level of pressure in these professionals' stressful everyday working lives.

(5)The threshold problem: In a society where our expectations are increasing due to many factors, such as new technology, political promises and economic progress, a trend can easily develop where the threshold for what constitutes a ‘health problem’ is falling. When and if this happens, the pressure on hospitals will increase further. This will also increase the political pressure on hospitals, because politicians will aim to fulfil the wishes of those voters who demand an improved and more diverse healthcare.

(6)Competitive tendering: For some countries, this is a relatively new phenomenon, at least if we think on a large scale. This competition, regardless of whether or not it is beneficial, causes leaderships in both private and public sector hospitals to experience additional pressure to master their roles and deliver the expected results.

(7)Socialization: The education of health professionals has a strong socialization effect. Doctors, nurses and other health professionals develop a common strong identity, which may provide one of the explanations for why changes in hospitals are difficult to implement. Without changing the socialization process in medical education, it can be difficult to change the basic management philosophies in the health sector.

(8)Professionalization: While there were few professions in hospitals in the past – for example, doctors, nurses, various nursing assistants and some support functions, in today's modern hospitals there is a large number of various professions and professional groups. All of these groups have clear expectations of having their voices heard in both professional and managerial matters. For example, many medical engineers believe that they are just as qualified as doctors and nurses to take on leadership positions at various levels within hospitals. This results in further complexity in the health sector.

(9)Different value-creation logics: In hospitals, as in other enterprises and institutions, one can typologize value creation along five axes. These are the value chain; the value network; the value workshop; the value dialogue; and the value community.¹ These value creation processes, which the management of hospitals need to deal with in one way or another, increase complexity and can be experienced as making management difficult.

(10)Different management philosophies: We have discussed above the debate concerning ‘shared’ in contrast to ‘unified’ management in hospitals. Other management philosophies are based on a stakeholder perspective, a resource perspective, an activity perspective, a bureaucracy model, a professional model, a divisional model and a communication model.² A variety of management philosophies can be viewed by hospital leadership as increasing complexity.

(11)Complexity and risk: The constant shifting between medical and economic matters increases the complexity of managing hospitals. Technology enables many new possibilities, but it also results in increasing risk to a higher level. For instance, prior to the introduction of new technology, there were many surgical interventions that could not be performed. It is now possible to perform certain surgical procedures to treat conditions that may have arisen due to lifestyle; in other words, a person's lifestyle can pose certain health risks. This ‘risk’, which was the individual's responsibility before, has now to a certain extent been ‘transferred’ to the hospital. Consequently, this ‘risk’ increases complexity and makes it more problematic to manage hospitals. Of course, this benefits many patients, but the ‘risk’ is transferred to the front-line and the hospital leadership.

The complexity also has another aspect. This concerns the fact that the management system will never be able to achieve sufficient variation in relation to the activity system in hospitals, because the complexity of the activity system will always be greater than the complexity of the management system. In other words, the operating system has greater complexity than the management system can deal with. Amongst other things, this is because the operating system has a surplus of tacit knowledge.

(12)The performance of health professionals: When an increasingly large proportion of the wealth creation in many countries is invested in the health sector, the demand for higher productivity and improved performance of health professionals will only increase. The responsibility for this will lie with the leadership of hospitals. Therefore, the pressure will increase further on the leaders at all levels in hospitals. At the beginning of the Fourth Industrial Revolution, this pressure will be linked to increasing the productivity of health professionals, as well as increasing the level of innovation in the sector.

(13)Leadership complexity: While the leadership of hospitals in the past was performed by skilled medical professionals, the requirements for the skilled leader today have changed. Leader...

Table of contents

• Cover
• Title
• Copyright
• Table of Contents
• List of Figures and Tables
• Preface
• Key Points in This Book
• Methodological and Theoretical Basis for This Book
• Abstract
• 1. Introduction to the History of Hospital Leadership
• 2. Management Philosophies in Hospitals
• 3. The Knowledge-effectiveness Perspective
• 4. Value Creation Processes in Hospitals
• 5. Technology, Innovation and Tacit Knowledge in Hospitals
• 6. Organizational Learning in Hospitals
• 7. Conflict Resolution in Hospitals
• References
• Index