تردید و اقدام سریع : اصلاحات جدید مدیریت عمومی در بخش بیمارستان نروژی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|8643||2001||21 صفحه PDF||سفارش دهید||9782 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Scandinavian Journal of Management, Volume 17, Issue 1, March 2001, Pages 19–39
This paper focuses on the transition of governmental management innovations from the national, political level to the local, institutional level. In order to throw some light on the complex process of two-level reforms in public sector financial management, I discuss the case of introducing prospective payment systems in Norwegian hospitals during 1987–1999. The empirical studies are based on official documents and statistics at the national level together with surveys and case studies with a view to understand how hospitals adjust to the new payment systems. The main finding can be described in terms of slow adjustments on the institutional level, and slow and rapid action on the political level. These systemic interactions between different logics at the different levels may obstruct the implementation of reforms.
The last 10 years have witnessed an international trend to impose new and more market-orientated management systems in the public sector. The aim of this paper is to deal with the transition of a governmental management innovation from the national, political level to implementation at the local, institutional level. The hospital sector is one of the main areas where such reforms have been introduced as part of a search for greater efficiency in service production. The case of introducing prospective payment systems (PPS) in Norwegian hospitals in the period 1987–1999 is discussed, and the main focus is on the two levels of implementation, since reforms of this kind are created in interaction between the government and the institutional levels. PPS as a management technique is associated with the term new public financial management (NPFM), a global reform movement that introduces accounting-based techniques such as cost-improvement programmes, performance indicators, financial management information systems, financial targets, delegated budgets, resource allocation rules and different methods for per-case payment into the public sector (Hood, 1995). The NPFM reforms have been criticised for adopting too narrow and deterministic an implementation perspective (Lapsley, 1996). It has been argued that this may be one reason why the evidence in favour of accountable management ideas and new public management reforms is not very convincing (Hopwood, 1984; Olson, Guthrie, & Huphrey, 1998). This literature questions the neo-classical belief in the mechanistic techniques of management that are supposed to make public organisations more efficient. Because of the interplay between politics and administration, reform processes such as those associated with NPFM are not characterised by simple adjustments to current international administrative doctrines. The reform concepts are filtered, interpreted and modified on their journey from political decisions to administrative implementation. This complex process can be illuminated by the changes in the payment system of the Norwegian hospitals that have been planned over the last 10–12 years. To understand such change processes, which are generated on a political level and implemented locally, it is necessary to study both the central, governmental activities and the local initiatives. Consequently, the theoretical platform of this study is an assumption that accounting practices should not be studied as an organisational practice isolated from the wider social and institutional context in which it exists (Hopwood & Miller, 1994; Roberts & Scapens, 1985). In analysing the empirical data a framework is therefore used which identifies a set of contextual and behavioural variables to help us to understand the reform processes. The transformation process between countries (Czarniawska & Sevon, 1996) will not be discussed here. Consequently, this paper does not address the question of the cultural or norm dimensions within a country, or its specific historical frameworks. The paper is organised as follows. First the broad theoretical framework is presented. The empirical data is then discussed, as applying to the national and the hospital levels of reform efforts. The last part of the paper offers a brief analysis of the empirical findings.
نتیجه گیری انگلیسی
4.1. Reform paths and levels of action This paper has focused on the complex patterns in the two levels of the public sector reform process. An analytical framework is used which includes such dimensions as the source of the reform initiative, the site of the reform (central or decentralised level), contextual elements, the content of the reforms and the characteristics of the implementation process itself. As has been shown above, these dimensions assume a different appearance at the political and institutional levels. The story started 12 years ago, emerging from the idea that public sector management was old-fashioned and that a market orientation would solve the sector's problems. A long period of planning, political decisions and re-decisions, ended in a rapid political action driven by a strong Minister of Health. It was found, however, that regardless of the government's decisions and re-decisions, the intentions of the reform were not implemented at the institutional level, despite the strong governmental authority behind the last reform decision in 1996. The difference in the reform paths on the two levels of action can be partly explained by the different contingencies prevailing there. The NPFM reform described above presupposes reform as being introduced at the central level and implemented locally. This accords with the Norwegian political structure in which the central national government has a strong and historically legitimated position that carries substantial political power and an accepted role as “problem-solver” (Olsen & Peters, 1996). Decisions made on this level have direct consequences for each of the 19 counties that formally own the hospitals (except for three central state hospitals). But the problem is now that the structural conditions in Norway as a stable and relatively wealthy country, seem to have reduced the flexibility of the hospitals and their ability to develop the necessary variation in their interpretations, their behaviour and their structures to tackle the new situation with its greater focus on market thinking. Partly because Norway has been one of the most successful welfare states, it is now unable — under the new public market ideology — to unlearn certain dysfunctional beliefs, attitudes and values. Consequently, there is a gap between some of the external conditions applying to the hospitals such as the centralized wages negotiations that are based on the 75-year-old beliefs and norms belonging to the social democratic tradition of solidarity, and new reforms that involve the hospitals in a more market-orientated approach. This gap has created a paradoxical situation. The hospital managers are caught in a kind of “managerial trap” in which deep-rooted traditions come up against demands for a rapid adaptation to the new market logic. This paradox illustrates the complex interplay between the conditions and assumptions of the political and institutional levels. 4.2. The process The reform process described in this paper, did not start from any evaluations of the possible efficiency gains to be achieved by introducing PPS in Norwegian hospitals, or from any indications that such gains would accrue. On the contrary, data gathered from the hospitals in the course of the reform process gave no evidence of any increase in efficiency at the hospital level. But there was a widespread assumption that slack resources existed in the hospitals (Government Note No. 44, 1995–1996). Despite this lack of evidences from inside the hospital world, parliament voted in favour of a new payment system for hospitals for the second time in 1996. This vote was triggered by a strong political actor, namely the Minister of Health at the time. This minister moved among the most prominent members of the academic world at both the national and the international level, and had belonged for many years to the political elite in Norway. Our data support the argument that members of such networks, also referred to as “epistemic communities” (Haas, 1992), are crucially important in guiding the direction of politics, irrespective of evaluations or experience. Consequently, the reform processes are de-coupled from the experiences of the organisations and seem to live a life of their own in the political and institutional spheres. The reform was initiated by a central government initiative and was based on the political idea that “a per-case system will promote efficiency in the delivery systems in the hospitals” (Government Note No. 41, 1987–1988). The changes in payment systems were introduced by the central government, and were to be implemented at the hospital level. The implementation process was top-down organised, and the practitioners in the hospital did not actively participate in the process. The situation thus resembled the process that has been described as colonialisation (Broadbent & Laughlin, 1997), where by changes in an organisation's archetype are imposed externally on the local level. Our data support the observation that the medical practitioners did not respond to the new systems of incentives at any phase in the reform process. Consequently, the accountable management paradigm can hardly be said to have become a part of the less tangible elements of the organisation, that is to say the interpretative schemes. The accounting system as tangible organisational elements has been changed, as has the rhetoric in budget documents and plans. These are elements in the organisations’ communication processes. But neither the physicians nor the nurses included the management reforms in the beliefs, norms and values which guide actions at the clinical level. The interpretation of information can vary greatly among the members of an organisation, due to people's different cultural orientations. This is illustrated by our interview data at the clinical level. The quotations from the hospital managers, the physicians and the nurses revealed big differences in their comments on the new payment system. And their statements were also very different from the prescriptions of the PSS as originally formulated by the government (Government Note No. 41, 1987–1988). 4.3. Organisational fragmentation Taken together, the differences between statements in the government documents, statements in the budget document of the hospitals and statements made by key informants during interviews in the hospitals, provide strong evidence of organisational fragmentation. The concept of fragmentation is to be found in Weick (1979), where it is held that loose couplings allow an organisation's sub-cultures to respond to environmental changes in their own different ways. In the present case fragmentation is manifest in the fact that the hospitals in the 1991–1993 experiment period, and the university hospital in the 1997–1999 case study, all had budget documents and plans based on the PPS logic with its per-case statistics, whereas the physicians and the nurses ignored or failed to respond to the related information at the clinical level. To some extent this gap between the clinical and administrative cultures can explain the lack of adjustment to the payment system at the level of the hospital. This implies a de-coupling between hospital cost and clinical activity, which can have a damaging effect on a hospital's ability to adjust to budget restrictions. When changes can be noted in the rhetoric used by a hospital in its budget documents and plans, while at the same time very few changes can actually be observed at the clinical level, this can be interpreted as a tool for acquiring the legitimacy that seems necessary since the reforms were introduced externally by the central state government (Olsen & Peters, 1996). 4.4. Different levels and different logics The two levels of reform processes in public sector management have been studied according to an analytical framework in discussing the differences between these levels. The main finding can be described in terms of slow adjustments at the institutional level, and slow and rapid action at the political level. The two levels are both interactive and separate in a number of paradoxical ways. The political world view does not necessarily correspond to the view held by the institutions. Belief and norm systems at the two decision levels are not the same. Politics can produce a rapid change in visions, but institutions are slower to act. This implies that political leadership becomes the “management of meaning”, its task being to define reality by creating, sustaining and changing meaning in an uncertain world (Olsen & Peters, 1996), while the institutional leaders become the “managers of action”. Political actions are judged by public opinion and are accountable to it, which means that political actors will adhere to changing popular beliefs and attitudes. Public sector institutions like hospitals are associated with routinisation, repetition, continuity and predictability, rather than with political change and flexibility. Hospitals are slow changers, and their actions are stabilised by their deep-rooted patterns of norms, beliefs, routines and rules. They are well-established institutions that are unlikely to adapt rapidly to changes in their environment. Hospitals legitimise their actions through their importance to life and health in a country, rather than through changing their behaviour or their images. But this institutional competence can also become a barrier to change, when contextual factors are undergoing radical reorganisation. The lessons to be drawn here are that public sector reforms are significantly affected by political actors and by the current context of reforms and change processes at the institutional level. One step towards a better understanding of institutional change is to call attention to the inadequacy of the concept of change as based on rational adaptation. There are different paths to change at the political and the institutional levels. This mismatch has been studied in this paper, and it has been found that structural and situational factors are both important in explaining the diverse outcomes of reform efforts.