Week 2 summary
Thank you for completing Week 2 of the course. In this week we aimed to develop your understanding of the organisational context and how this generates both constraints and opportunities for healthcare improvement. To make sense of this, we have encouraged you to think about these organisational contexts in terms of three inter-related levels of analysis: macro, meso and micro. This approach gets you to think about the bigger picture and how this may help us to understand what happens in hospitals and other organisations where most healthcare practitioners work.
As you might expect, the ‘macro’ level relates to the level of the whole health system in each country. To understand this we noted international variations in the performance of health systems and how outcomes are not simply a result of the amount of resources committed. We also introduced a number of frameworks for characterising health systems, for example, Moran (2000), which look at the interplay of different actors: governments, insurance providers, professions and commercial firms. An important idea here is that the characteristics of health systems are to some extent ‘path dependent’ or heavily influenced by history and prevailing institutions. This has implications for how far best practices can simply be copied from one system to another and also for the kinds of change that are feasible. To illustrate this point we also looked at the case of primary reforms in China and how healthcare improvement efforts there are to some extent shaped by decisions taken in the past with regard to the funding and organisation of hospitals.
Our second (meso) level of analysis relates more to the organisational architecture of each health system and the extent to which overall co-ordination is achieved either through hierarchies (top down planning), markets (contracts and competition) or networks, which imply some kind of middle way. Here we also drew your attention to reforms that are ongoing in health systems across the world, often referred to as the New Public Management’ (NPM). These reforms have sought to move away from established forms of hierarchy and top down planning to increase competition and management autonomy in health systems. This has generated new opportunities for healthcare improvement at local levels, such as hospitals. However, as we saw, looking at the example of the Victorian health system in Australia, NPM reforms have also led to a degree of fragmentation and problems of co-ordination, making it hard to translate learning and best practices from one part of a health system to another. Increasingly this is leading to calls for network governance to improve co-ordination, although how far this can be achieved remains open to question.
Lastly, the third (micro) level of analysis encourages us to look at the specific organisations, such as hospitals or community centres, where health care improvement initiatives are enacted. Here you were introduced to theories of professional organisation which emphasise the unique characteristics of organisations such as hospitals. We saw how hospitals might be conceptualised in terms of different ‘worlds’ of healthcare – care, cure, community and control – and how this has significant implications for the kind of management and leadership that is possible. Healthcare organisations, we argue, require a particular approach towards leadership if planned changes to improve quality are to be achieved.
It is to this theme that we now turn in the next (and third) week of the course.
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