Foretak, management og medikrati. En sektorstudie av helseforetaksreform og ledelse i spesialisthelsetjenesten
Torjesen, Dag Olaf
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This thesis consists of four articles that deal with the introduction of unitary management from 2000 and health enterprise reform from 2002 in Norwegian specialist health care (hospitals). The first of the articles (”Knowledge, professions and management. Knowledge perspectives on management in Norwegian healthcare”) focuses on the historical traditions and formations of the old collegiate management structure in Norwegian hospitals and how these collegiate forms were founded on the medical profession’s extensive autonomy, bio-medical knowledge and health planning. The article also examines how Norwegian nurses in the post-Second War period adopted knowledge from the field of general management in US universities, and how this knowledge adopted by the nursing profession is an early indication of how the nurse adopt to the present professional management regime in Norwegian health enterprises. This also gave nurses access to management positions and legitimacy as managers within this regime. The second article ( ”State ownership and enterprises, new conditions for management in Norwegian hospitals”) studies the question of whether hospital managers have gained more autonomy after the introduction of the health enterprise reform. Even though Norwegian authorities have invested a great deal of effort in reforming hospitals into autonomous enterprises by means of empowered general management, medical management and the professional logic still have a strong standing in hospitals. If general management has become more important in Norwegian hospitals, this is in the administrative top management, where it has become centralised and empowered according to an economic logic. Most of the managers in the reformed Norwegian hospitals are still managing in accordance with a professional, medical logic. The exception is nurses who hold new management positions. Nurses are adapting through more involvement in and commitment to the new managerial expectations, more so than the physicians who more or less are ignoring the managerial reform attempts. The third article (”Management between autonomy and transparency”) investigates how the recent Norwegian hospital reform can be seen as a vehicle to transform the mode of managing a hospital. The traditional collegiate form of management characterizing Norwegian hospitals has been challenged by deliberate efforts to implement general management, including the principle of unity of command. A simultaneous development, however, has been efforts at increasing transparency, giving the public better information about the costs and quality of the hospitals. This article sets out to show how an executive group of hospital managers dealt with these new organizational constraints. In accordance with the reform ideology, the managers unanimously accepted performance unit accountability, unity of command, and the distinction between professional and general management. However, they also pointed out dissonance between their assumed accountability and their lack of power. To resolve this paradox, they cleverly set out to exploit the financial incentive system to increase revenues. This was revealed by investigative reporters taking advantage of publicly accessible databases concerning the operations performed in hospitals. The fourth article (”Hospital managers’ perceptions of the conditions of management in Denmark and Norway”) compares hospital managers’ perceptions of their management context in Denmark and Norway. Survey data from recent Danish and Norwegian studies are used to compare and contrast the two countries particularly in regard to four themes: 1) perceptions of the hospital’s relation to its environment, 2) perceptions of staff motivation, 3) perceptions of stimuluses for change, and 4) value orientations. The main purposes of the article are, thus: 1) to investigate variation in perceptions of management conditions in two countries that may appear very alike in cultural terms; 2) based on this, to investigate the impact of the Norwegian hospital management reform in 2002; and finally 3) to develop more general statements about hospital management based on data from the two countries.
Paper I: Tidsskrift for Samfunnsforskning 48(2), Torjesen, D. O., Kunnskap, profesjoner og ledelse. Kunnskapsperspektiver på ledelse i norsk helsetjeneste, pp. 275-290. Copyright 2007 Universitetsforlaget. Reproduced with permission. Accepted version.Paper II: Torjesen, D. O, 2008, Statlig eierskap og foretaksmodell, nye rammebetingelser for ledelse i norske sykehus. Draft.Paper III: Nordiske Organisasjonsstudier 7(2), Gammelsæter, H.; Torjesen, D. O., Ledelse mellom autonomi og innsyn i helseforetaket, pp. 77-94. Copyright 2005 Fagbokforlaget. Reproduced with permission. Accepted version.Paper IV: Nordiske Organisasjonsstudier 7(2), Vrangbæk, K.; Torjesen, D. O., Sygehuslederes opfattelse af ledelsesvilkår i Danmark og Norge, pp. 37-57. Copyright 2005 Fagbokforlaget. Reproduced with permission. Accepted version.