Background
Over the last several decades, there has been an increasing focus on discharging hospital patients more quickly. This reflects economic pressures arising from a combination of advances in medical technology, demographic changes and, increasingly, scarce resources for welfare spending [
1,
2], together with New Public Management reforms and their concern for greater efficiency [
3]. At the same time, technological, organisational, medical and pharmaceutical progress also means that hospitals are no longer the only location for delivering medical care [
2]. Indeed, timely discharge has emerged as one of the key components of contemporary hospital governance [
2].
The focus on timely discharge includes not only patients who have had surgery, but also patients who are in programmes following a major illness like cancer. There is growing evidence that follow-up programmes based in hospitals do not necessarily work well: studies show that they can have a poor record of detecting the recurrence of illness and do not improve survival rates [
4‐
6]. Other studies have found that the follow-ups do not meet patient needs, for example related to dealing with the side effects of treatment and the fear of reoccurrence of the illness [
7,
8]. Moreover, patients can also experience the continued contact to hospitals as stressful. Taken together, this has prompted reviews of follow-up programmes with one strategy to move programmes out of hospitals as part of shared care arrangements [
9‐
12].
The organisation of explicit discharge arrangements is one milestone in shared care arrangements for follow-up programmes which typically involves changes in professional practice across different medical specialties and/or health professions, including administrative staff within hospitals. The issue is who takes on the new tasks of identifying patients, coordinating patient discharge and auditing the discharge letters. Altering discharge arrangements, therefore, involves organisational changes which closely intersect with professional interests. The literature on hospital discharge acknowledges the importance of professional groups for the organisational changes involved [
13‐
17] by examining the views of health professionals in relation to a range of issues: the challenges and solutions of organisational processes [
13], outcomes [
14], the quality of discharge arrangements [
15,
17] and guidelines [
16]. However, the literature says little about the specific roles played by professional groups. Recent contributions to the literature on organisational studies of the professions help specify how professional groups in hospitals contribute to the introduction and routinisation of discharge arrangements.
The underlying idea is that professionalism is part of a complex set of governance arrangements, that include hierarchical and (possibly market) forms of governing as well as professional self-regulation [
18‐
21]. Going beyond the traditional dualism between professions and organisations/management, professionalism and managerialism are conceptualised as two different modes of governing, one ‘internal’ and the other ‘external’, that are concerned with improving the control over professional knowledge. Following this, Munzio and colleagues [
22,
23] argue that professional projects closely interact with institutional projects of the organisation and thus are embedded in negotiated settlements. Indeed, professions are important actors in organisational change, in as much as organisations need to accommodate professional practice. Building on this view of interdependence, Noordegraaf [
24] introduces the notion of ‘organized professionalism’, where professionals take up organising roles and where organisations structure professionalism.
From this perspective, in the move toward explicit discharge arrangements, professional and organisational projects intersect and this mobilises professional groups, who, in conjunction with management, adapt the generic model of discharge arrangements to the local context of the individual outpatient department. This occurs through interpreting and translating the specific changes in the work flows into local models [
25]. The present analysis is built on a case study of the introduction and routinisation of explicit discharge arrangements for patients with prostate cancer in two hospitals in Denmark and addresses the following questions: What are the specific roles of professional groups in the making of local models of discharge arrangements and how does the involvement of professional groups affect the introduction and routinisation of discharge arrangements?
Discussion
One strength of our study is that we were able to compare two departments with many contextual similarities: they were part of the same regional healthcare system and related funding arrangements, they had similar patient populations and they also had the same mix of doctors, nurses and secretaries. At the same time, including additional hospitals in other regions, would have captured a greater variety of types of hospitals and, therefore, increased the robustness of the study. Another strength is that the study was embedded in an implementation project, which allowed us to follow the process of organisational change from its early to its later stages. We analysed the emergence of organisational routines two months after the end of the project period, but such processes can take time; studying the sustainment of organisational change ideally requires a time lapse of at least one year. A follow-up study would offer further insights into the relative level of routinisation. Finally, the present study focused on hospital discharge and it would have been interesting to assess if professional groups play a similar role in comparable organisational changes such as clinical pathways and fast track diagnoses, which affect but do not directly target professional practice. This would increase the generalisability of the present study.
Our theoretical point of departure was to look at the hospital departments as professional organisations, and this is also the basis for our final discussion. Other approaches, for example with a focus on differences in systems and organisational contexts or with a focus on overall processes of organisational change would provide additional insights.
Our analysis revealed two very different local models of discharge arrangements for patients with prostate cancer. Hospital A operated with an ‘add-on’ model, which relied on extra resources, special activities and enforced change. This was reflected in the project nurse who played a prominent role in the discharge arrangements, although she was not part of the day-to-day practice of the outpatient department. On the part of the professional groups, the local model involved either taking on new tasks that were added onto existing practice (like nurses sitting in on consultations) or discontinuing existing practice (like secretaries not contacting doctors in case of queries). In contrast, the local model in Hospital B built on existing ways of working, current resources, and perspectives of professional groups, while the local model evolved gradually and became ‘embedded’ in the existing professional practice.
The emergence of two distinct local models revealed differences in the roles of professional groups in terms of their stakes and involvement in the process of organisational change, both in conjunction with support by management. In Hospital A, the professional stakes were low and the professional groups had highly mixed professional interests and mobilised hardly any resources. Not surprisingly, the professional groups engaged very little in informal processes of interpreting and adapting the local model. This was exacerbated by formal processes that did not involve professional groups, but instead focused on control and problem solving. Taken together, the professional groups were detached from the process of organisational change. The picture looked very different in Hospital B, where the professional stakes were high; all professional groups had direct and positive professional interests and this provided a lever for mobilising some resources in the case of uncertainties. Further, in Hospital B management actively invited staff to share their individual experiences. Such workplace reflection has been shown to be important in changing clinical behavior [
33] and, together with other forms of leadership support, is pivotal in facilitating change processes [
34]. Professional interests together with active management stitmulated organisational learning and offered a catalyst for multiple informal processes of interpreting and adopting the local model.
What are the broader implications of the analysis for understanding the specific roles of professional groups in organisational changes associated with moving to more explicit discharge arrangements? The analysis makes two key points: first, professional interests are an important driver for health professionals to engage in adapting discharge arrangements; and second, professional practice offers a powerful lever for turning new discharge arrangements into organisational routines. Moreover, both can be greatly strengthened by management, actively governing and guiding such developmental processes.
Concerning the first point, the analysis stressed that professional interests are key for giving meaning to individual health professionals. This is significant because meaning is a central characteristic of those health professionals willing to adapt organisational change [
35]. The analysis suggests that while professional interests in discharge arrangements could be either indirect, related to the organisation and to patient, or more direct, the latter emerged as most important. Although all professional groups in both hospitals agreed that the discharge arrangements were meaningful for the department and for patients, they strongly disagreed about the relevance for their professional practice. There was a marked difference between the two hospitals and this seemed to have repercussions for the extent to which professional groups engaged in the process of organisational change. Having positive, direct professional interests emerged as an important driver for actively interpreting and adapting the local model as part of both informal and formal processes, and, thereby, turning discharge arrangements into a routine.
At the same time, the substance of professional interests among professional groups varied. Jespersen et al. [
25] suggest that the professional interests of doctors are centred around specialisation and individualisation, whereas for nurses a collective orientation and the patient as a whole person are vital. In contrast, the orientation of secretaries is likely to be more task focused. This was underlined by the present study. Doctors in Hospital B for example, defined their professional interests as improving their own practice, whereas the nurses referred to avoiding mistakes when treating patients across sectors. The secretaries, for their part, mentioned mistakes specifically relating to writing discharge letters. Not surprisingly, among the professional groups, the nurses were most actively engaged in the formal processes and acting collectively in informal processes of interpretation and adaptation of the local model. Indeed, nurses emerged as key agents of organisational change.
In contrast, the engagement of the doctors was more individual in nature and directed at specific patient cases, while the engagement of secretaries was focused specific points of uncertainties in the process of writing discharge letters. However, it is important to remember that the construction of meaning is a complex process and is not necessarily fixed [
35].
In relation to the second point, the analysis suggests that adaptation was most successful and discharge arrangements are best sustained when embedded in professional practice. Organisational routines are repetitive patterns of multiple actions that typically involve a range of actors [
36]. Routines coordinate and simplify complex situations, and thus represent the behavioural infrastructure of any organisation. This makes organisational routines both the condition for and the object of organisational change.
The analysis demonstrates that health services routines are often specifically related to professional practice, rather than more generically to the organisation. As Kirkpatrick and Ackroyd stress [
37], health services belong to a specific type of organisation, namely ‘professional organisations’, where organisational structures are produced and reproduced by members of the profession. There are existing practices and people with whom the organisational change like discharge arrangements needs to be compatible [
38]. The embedded local model in Hospital B took account of this and the discharge arrangements were integrated into existing professional practice. Connecting new organisational routines to professional practice provides a springboard for routinized organisational change, precisely because it offers ample opportunity for what Jansen et al. call brokering [
39]. Through negotiating organisational change, professional groups not only tailor it to local contexts, but also changed their practice. The situation was very different in Hospital A, where the discharge arrangements were simply added onto existing professional practice. This approach offered few incentives for connecting organisational change to professional practice and for establishing the new discharge arrangements as organisational routines.
Timely discharge is a key component of contemporary hospital governance and this raises questions about how to organise the move to more explicit discharge arrangements. The study points to the specific roles that professional groups played in the making of local models and how their active participation affected the introduction and routinsation of discharge arrangements. Future moves to more explicit hospital discharge arrangements, and the introduction of similar organisational changes like clinical pathways or fast track diagnoses that affect but do not directly target professional practice, therefore, need to have a clearer focus on the concerned professional groups. This requires two-fold approach: involving the professional groups in the introduction and routinisation of new work arrangements and building any new arrangements on existing professional practices. The approach is based on an acknowledgement that the organisation of work practices needs to reflect the specific local contexts of individual hospitals rather than generic best practices. This is supported by recent literature on organisational change in health services [
33,
27,
40], which stresses the importance of local contexts and that organisational change is highly contingent on the specific organisation and its environment. A careful analysis needs to be carried out to identify professional groups that will have key roles in a change process. If professional interest is absent, any change will be difficult and, therefore, either the organisational change needs to approached in a different way or abandoned altogether. Also, the existing needs of professional practice have to be revealed and used as a starting point for a gradually evolving new professional practice.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
VB conceived the design of the study, collected the data and took the lead on the analysis and on drafting of the manuscript. FB contributed to the design of the study as well as the analysis and helped with the drafting of the manuscript. Both VB and FB read and approved the final manuscript.