Introduction
Background
Conceptual framework of the study: Public Governance Tensions (PGTs)
Methods
Presentation of the French context and the two cases studied
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Public health organisations (1,389 organisations in 2019 [42]). These are legal persons under public law with administrative and financial autonomy. They are subject to State control. Their main vocation is neither industrial nor commercial. These university hospital centres are involved in both medical and pharmaceutical research and medical and paramedical education.
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Private not-for-profit establishments (689 organisations in 2019), generally from religious, charitable or mutualist movements. These are private health establishments. They are qualified as being of collective interest as long as they provide a public hospital service.
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Private for-profit organisations (1,014 organisations in 2019). These are private clinics with a health and commercial vocation managed by private funds and management. Nevertheless, they have a close link with public reforms and policies, since Public Social Security reimbursements represent more than 60% of their revenues in 2020 [36].
Contextual and organisational factors | CLCC | CLINIC |
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Status | Public, but close to public structures such as university hospitals (care, research and teaching missions) | Private care mission |
Connection entity | Member establishment of Unicancer federation of 20 establishments | Establishment of the Elsan group which is the leading operator of private clinics in France |
Location | Conurbation of of more than 290,000 inhabitants | Town of 25,000 inhabits |
Organisational specifity | Specialist in the management of cancerous pathologies Model of care for cancer patients | Multi-specialty community medicine and surgery |
Number of related professionals | 724 staff members including 102 doctors | 212 staff members: 62 doctors and 150 non-medical staff (care staff, administrative staff, etc.) |
Annual number of patients treated | 32,000 | 8000 |
Method of data collection
Design and recruitment
Clinic | CLCC | ||||
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Code | Function | Duration (min) | Code | Function | Duration(min) |
Ia1 | Care Assistant | 42 | Ib1 | Director of Care | 65 |
Ia2 | Human Resources Manager | 42 | Ib2 | Medical assistant | 36 |
Ia3 | Financial Manager | 39 | Ib3 | Intensive Care Nurse | 28 |
Ia4 | Pharmacist | 31 | Ib4 | Nurse | 39 |
Ia5 | Coordinating Officer | 44 | Ib5 | Emergency Doctor | 54 |
Ia6 | Doctor | 34 | Ib6 | Medical Secretary | 39 |
Ia7 | Anaesthesiologist | 54 | Ib7 | Administrative logistical Manager | 42 |
Ia8 | Hospital Services Agent | 32 | Ib8 | Medical Assistant | 44 |
Ia9 | Healthcare Manager | 27 | Ib9 | Medical Secretary | 37 |
Ia10 | Care Assistant | 29 | Ib10 | Surgeon | 48 |
Ia11 | Quality Engineer | 44 | Ib11 | Computer Scientist | 57 |
Ia12 | Care Assistant | 45 | Ib12 | Senior Health Executive | 57 |
Ia13 | Coordinating Manager | 39 | Ib13 | Imaging Department Manager | 51 |
Ia14 | Executive secretary | 33 | Ib14 | Deputy Director | 73 |
Ia15 | Nurse | 24 | Ib15 | Doctor | 38 |
Ia16 | Nurse (surgery) | 29 | Ib16 | Financial Affairs Director | 39 |
Data collection
Method of data coding
Levels of governance (Mazouz et al., 2012) | Governance tensions (Mazouz et al., 2012. Hudon and Mazouz, 2014) |
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Institutions (values, beliefs, cultures) | Ethical tensions (in terms of values and standards) |
Organisatons (supply structures) | Organisational tensions (at the level of work organisation and coordination mechanisms) |
Official management frameworks (laws, rules, procedure) | Managerial Tensions (in the application of laws, rules and procedures) |
Management tools (HRM, accounting, logistics tools, etc.) | Artifactual tensions (at the level of management instruments) |
Results
Ethical tensions and changing institutional values
"We have common representations, common values such as "yes, we provide better care in the public sector than in the private sector where profitability and medicine do not mix" Ib11.
"We are asked to do this or that, to review the way we work with patients. I think it's essential to have these management tools to be able to explain to the teams why we do this. We can't say that we have pressure on the results, but we are aware of what is at stake and what the clinic has to do to exist. "Ia9
"I am quite flexible as long as their work is done, … mutual trust. "Ia3
"The advantage of a CLCC is that the management is entrusted to a doctor, unlike a university hospital. Production, which is care, is then at the origin of the strategic thinking, how to provide better care and not exclusively, how to increase the volume of activity. "Ib17.
"The public service character is linked to the fact that we are financed by public money. So in this context, because of our mission of collective interest, the profit must not be excessive" Ib14.
Organisational tensions generated by the diversity of professional standards
"We are arriving at a new type of care which, in my opinion, has become much more technical, standardised, classified and normalised.”Ib13
"Confidence is built on technical skills but also on the attitude we have towards the patient. The patient needs rigour and humanity" Ib1.
"Management tools make it easier to accept... heads of department are now able to anticipate whether they are actually going to replace a person or not... they say to themselves 'I'm going to have heavy patients now, I absolutely have to take on an extra person without being afraid of being reprimanded because there is a justification'. "Ia2
"Yes, profitability is a concern, there may be a temptation to buy cheaper medical devices, but you have to keep in mind that it is the patients who are behind it. Balancing the two is a challenge for me. "Ia4
"The management makes us feel that we have to be profitable, whereas for us the human side is more important. It's true that there are tensions at that level."Ia1
"You don't become a carer like you become a mechanic, you have to take care of your patients, you have to relieve them, you are a carer" Ib4.
Managerial tensions between practices and professional standards
"We are in direct opposition to the public and private sectors, but we defend the patient's pathway. In all cases, the patient goes to the clinic, to the university hospital, comes back to the CLCC." Ib1
"In the oncology sector, there are very strong friendships that develop because there are difficult situations to live through and this is part of the life of the organisations. There are human stories. "« … ». The team is a valve when we are experiencing a difficult situation in our workplace, the informal exchange times we used to have with the other people in the team allowed us to regulate, but today, the reorganisation of the work has reduced these spaces that allowed us to talk about our ethical questions" Ib1.
"Professionals who remain on the "I know" perspective for the patient and others who have understood that the patient has much to teach us" Ib1.
"Cooperating would have made sense for all of us. They refused, they were afraid. We will still manage without them, but it's sad". Ia4.
Instrumental tensions modifying professional practices and behaviour
"You have to be profitable despite everything, while ensuring quality. The quality of care is paramount. But the staffing indicators in my department also allow me to say to management, below that, you can't do less, we won't go below that staffing level, it's not possible" Ia5.
"We have to change our indicators completely because they are obsolete, we have to adapt them to changes. I am told that there is an increase in expenditure in my department, whereas we have played the game and made savings. I am being charged for expenses that are made by the anaesthetists and over which I have no control. "Ib9.
Discussion
Three forms of tension, mainly professional
Levels of governance | Clinic | CLCC | ||
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Governance tensions | Responses to tensions | Governance tensions | Responses to tensions | |
Institutional | Tensions on professional practices | - Translating steering tools | Tensions on professional practices | - Role of middle management |
Tensions on professional standards | - Acceptance of the search for profitability | Tensions on professional values | - Role of professional beliefs | |
Organisational | Tensions on professional standards | - Role of the patient pathway | Tensions on professional practices | - Enhanced cooperation between professionals |
Managerial | Tensions on professional values | - Professional beliefs focused on patient care | Tensions on professional values | - Staff sacrifice - Staff commitment to the care profession |
Tensions on professional standards | - Cooperation and teamwork | |||
Instrumental | Tensions on professional standards | - Role of wage increases - Role of management indicators | Tensions on professional practices | - Appropriation of management tools - Cooperation |
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middle management,
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the professional convictions of health workers and their personal commitment,
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cooperation between professionals inside and outside the organisation to provide the technical and relational functions of care,
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The appropriation of management tools in the professional practices of staff (Table 4).
Different intensities of professional tensions according to the type of healthcare organisation
Intensity of tensions | Private for-profit healthcare organisation | Public not-for-profit healthcare organisation |
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Strong | Tensions on professional standards (between technical and relational dimensions of work) | Tensions on professional practices (between management instrumentation and care functions) |
Moderate | -Tensions on professional values (between care values and financial values) -Tensions on professional practices (between management instrumentation and care functions) | Tensions on professional values (between care values and financial values) |