CHAPTER 24 Health managers in a changing system
Management is often defined as getting things done through other people (Iles 1997: 1–16). This is a good shorthand definition, but it needs a second element — the manager needs to be responsible for (and have authority over) the work of the other people. When doctors write prescriptions, they are not managing the pharmacists. The pharmacist who dispenses the medicine is obliged to follow the instructions of the doctor about that particular prescription, but the doctor is not held responsible for the work of the pharmacist. Management is getting things done through other people with authority to direct them and with responsibility for the results of their work. One of the earliest ways of defining the functions of management is summed up as ‘plan, organise, lead, control (POLC)’ (based on Fayol 1949).
A third important element is that management is done in the context of a company or organisation or team. Authority is part of the job — the manager’s mandate to control the work of others is included in the job description and often drawn in an organisation chart. It is the organisation that defines the authority of the managers, and sets the limits of their authority, sometimes called delegation. For example, a nurse unit manager will usually have authority (or a delegation) to order supplies and equipment to a certain monetary value. Of course, the limits of authority are also given by laws and regulations of the society and the industry. For example, your boss cannot direct you to do something illegal, or something that is unsafe for you or others, or something that is not part of the manager’s responsibility as a manager. These three elements — getting things done through others, taking responsibility for their work, and doing it within an organisation — define management in the health and community services industries.
Clinicians and politicians sometimes wonder ‘why do we need managers?’ (e.g. Khadra 2007: 176–84) but managers are needed in all but the smallest of organisations (e.g. a self-employed plumber with an apprentice and a bookkeeper). They are needed because the work of organisations must be divided up into job roles, and then the work of the individuals in those jobs must be coordinated in order to achieve the organisation’s purposes or goals. The underlying goal of most organisations can be stated as some version of ‘to deliver services or products that meet consumer needs at the required standards and costs’. Government health authorities may define this as ‘to provide policy advice and administer programs in accordance with government requirements and policies’, but even this is a specialised version of the general statement. All organisations of any size need managers to coordinate the work (‘organise’), to solve problems that arise (‘control’), to adapt the organisation to changes in the environment (‘plan’) and to enable staff to work together towards the organisation’s goals as effectively as possible (‘lead’).
Management in health care is both similar to management generally (e.g. managing people is usually the most challenging task in any industry) and different in important ways. First, health care organisations tend to be more complex than others of equivalent size. The complexity arises from the complicated nature of illness and injury, the wide range and technological complexity of treatments and other interventions that are used, and the fact that the work is done by many different and highly skilled professionals, who need to coordinate their work for the patient.
Second, decision-making power in health care organisations is often shared among more people. If you are the senior manager of a business that makes shoes, you will take advice from your line managers, and from your own experts in materials, finance, logistics, design, and marketing. They will expect you to set the direction and in the end to make the hard decisions. Should the business move its production offshore? This is a decision that will be made after much investigation and consideration, but the boss will make the call.
However, if you are a senior health care manager you are more like the mayor of a small town than the boss of a factory. Mayors can only get their preferences implemented if they can get the support of other councillors. Health care managers often only have as much real power to set directions as they have support among important stakeholders in the organisation. The range of professions of those stakeholders makes this a complicated process indeed.
Third, health policy is one of the most important responsibilities for governments. In practice, this means that everything health care organisations, and their managers, might want to do or change has some sort of policy or political dimension. Difficulties arise when there is a conflict between management attempts to deal with a problem, and political goals of ensuring that voters are happy with their access to, or the quality of, their health services. This is more likely to be the case in the public sector, but even private hospitals or practitioners are also influenced in their management by this kind of interaction with the political world.
Pause for reflection
Think about how often you see stories in the media about people having to wait for a health care service, or a Minister over-ruling the decision of a hospital to close beds or stop a service to save money, or there being too few general practitioners (GPs) to meet a particular need. Do the ideas above about tension between the goals of managers and those of politicians help with understanding how the issue emerged in the media?
To understand the current management workforce, a little history about the role of hospital managers is useful. In Australia, the traditional management structure of a hospital (until about the 1970s) had a senior doctor (called a medical superintendent), a senior nurse and an ‘administrator’, all reporting to a board. Making this triumvirate work was a challenge for all of the senior managers, and for the board. Administrators generally had a finance background, and many were accountants. The chart in Figure 24.1 was typical of the structure of hospitals in Australia until the 1970s.
The departments within health organisations have traditionally been defined according to professional groups (e.g. Social Work Department). So one of the career paths for all health professional groups is through the management stream within their disciplines; for example, head of the physiotherapy department, or chief orderly, or head of medical records (now called ‘health information managers’ or HIMs).
Starting in the 1960s and 1970s, there was a move to make management more professional and give managers more authority. Influenced by general business models, hospitals and other health care organisations moved from having administrators to having chief executive officers (CEOs), to whom all staff reported, including the medical, nursing and finance directors.
Chief executive officer professional backgrounds have since become more diverse (although there is a recent trend towards having doctors or nurses in these roles). There has also been increasing emphasis on postgraduate management qualifications, such as the Master of Business Administration (MBA) and the Master of Health Administration (MHA). New positions have also emerged, such as chief operating officer (COO), chief finance officer (CFO) and chief information officer (CIO).
Similarly, there has been a shift in the way that staff groups are organised to deliver care, with less emphasis on single profession departments. There has been more of a focus on the importance of the multiple clinical needs of patients; for example, maternity patients will need access to midwives, sometimes obstetricians and physiotherapists, ultrasound, and so on. Those with an interest in management in all the professions and occupations have thus had some opportunities to broaden their scope, and to take on managing operating theatres or laboratories, a community health team, a division of allied health, a division of general practice or a clinical stream. Management qualifications are also well regarded for these jobs and careers. A typical large structure would now look more like that shown in Figure 24.2.
There are two main professional associations for health care managers in Australia. The Australian College of Health Service Executives (ACHSE) is the professional body for health and aged care managers. It was founded in 1945 and has about 2000 members. Members need a recognised qualification in health care management (MHA or MBA or other), or senior management experience. Student membership is open to those studying in a recognised health care management program. The membership profile of the college includes the full range of disciplines working in health care, and is no longer dominated by people with a financial background. The gender profile has also shifted to a more even balance (ACHSE 2007).
The Royal Australasian College of Medical Administrators is the professional body for medical managers. The college was founded in 1968, and has over 800 members in public and private health service organisations. Fellowship is recognised as a medical specialist qualification.
These colleges provide ongoing professional development opportunities for their members, an annual conference, and an assessment process for advancement to fellowship. At the end of this chapter, we will ask you to consider your own potential for a career in management, but this will make more sense if we first examine what makes a good manager, and the challenges health care managers face now and in the likely future development of the health system.