HC’s – Communication, organization and management
HC’s - Communication, organization and management
HC 1 – Trends affecting organizations in health care
Health care organizations live in an ecosystem; they are compared at treating and diagnosing
disease. You want to help as many patients as possible, and have the best and newest techniques
and technology. But at the same time, there is shortage of personnel (the now working staff is ageing
(so they won’t work for a long period + they don’t know the new knowledge/techniques)), and the
healthcare costs are rising. We need smarter ways to work. Next to this there is a growing number of
chronic diseases, and multimorbidity. And outsourcing and privatization are new concepts.
The current structures are the result of past decisions. And because of this it is very difficult to adapt
to new challenges. Previously, the health care system needed to respond to infectious diseases;
biomedicine; measure what is abnormal; blood, etc. Next, we started to specialize, certain people
become good at certain fields. Finally, we see the development of evidence-based medicine;
decisions are based on scientific experiments/knowledge. Because we are so successful at treating
infectious diseases, we now have chronic diseases. How do we cope with the negative side effects of
previous success? So the high health care costs, shortage of personnel, and the complexity of health
care demand.
The health care provision market (triangle) has 3 important actors: the health insurers, the
insurers/patients, and the health care providers.
There are a couple possible solutions;
- Markets. Government should not intervene in the market. This is because people only work out
of self-interest; maximisation of own wealth. But this is not really the case in health care.. Health
care is not a business. And there is insufficient ‘competition’ to offer high quality care at the best
price. There is no direct interaction between supply and demand (patients do not choose), but
this is mediated by a third party (insurers). So how can people judge the quality of care?
- Bureaucracy. Bureaucracy is a model that came after the industrial revolution; organizations
became larger and more complex. The operating principles of a bureaucracy are: rationalisation
(procedures, rules), formality (focus on standardisation of processes), specialisation, hierarchy,
universal access but no individual control. Bureaucrats work slowly; there is a hierarchy; the
person you contact often has no decision making power, so he/she needs to contact others for
permission first, and this takes a lot of time. But in some organizations bureaucracy makes a lot
of sense! So its not only negative. It can be a very effective business model, e.g. in conveyor belt
jobs. In this there is one job, top-down management, and work is regulated by rules.
Health care organizations are very bureaucratic! There are a lot of rules in health care work; it is
very serious work (so a lot of rationalisation). There also is a lot of formality; focus is on
standardisation of processes. And a lot of specialisation, and hierarchy. You need to ask people at
the top for permission. But; professional are used to having autonomy. And lastly; a bureaucratic
organization is very good for universal access, but not good for individual control! The doctor
decides what product goes out to the patient; what if you want/need something else? We have
the supply-driven health care, but we want to move into the demand-driven system. This change
is difficult.
Pagina 1 van 43
,HC’s – Communication, organization and management
o To give patients more control in the decisions, we now (2006) have markets in the health care
system. Competition in health care! ‘Go-Dutch’. Since 2006 the Dutch government decides
what happens in the market; rules, regulations, what care is reimbursed by insurances? First
we want consumers to choose their health care insurance (offer a nice deal). The insurance
companies do this by making a good deal with health care providers. But not a lot of people
switch; only 10% (most often healthy young and highly educated people). Secondly, this gives
competition between insurance companies. There are a lot of small health care insurance
companies to choose from, but actually, all of these companies are owned by 4 big
companies. So there is not really competition. They have a powerful role in the market.
Thirdly, are they really negotiating good quality care for a good price? To get more power
against the big insurance companies, hospitals want to grow bigger, so they merge. So there is
not a lot of provider competition. But there is still competition because of the privatisation!
This can happen within hospitals, our outside (entire disciplines).
o Is a hospital an organization? An organization has a common purpose. A hospital is a very
complex organization. They work towards a common goal, but this is quite challenging.
- Professionalism. The market and bureaucracy systems took a lot of power away from the
professionals, this caused a lot of distrust in the patients. We need to give the power back to the
professionals. Only in this way, patients can trust them again. But are doctors good managers?
Should they lead the transformation? We need to educate the young doctors about this.
‘Choosing wisely’ training. Can it be more efficient/logistics right/quality improved, etc? But it is
not sure if doctors will see it if something needs to be changed, they are not educated in this.
Another disadvantage of this; doctors work in the patients best interest! If they don’t do this,
they work against the ethical rules of being a doctor.
Part two: introduction to organizational structure and design
trade-offs
Structure is the sum of design choices. Structure is a stable set of processes within an organization.
Its purpose is to reduce uncertainty; it is very stable.
Centralisation vs. decentralisation:
Who is calling the shots? Is it someone at the top (only the top manager is deciding), or is it divided
among multiple people? Dictatorship vs. democracy. Centralisation = one person decides.
Decentralisation = multiple people decide. Centralisation is easier to implement, and is consistent
with the strategy. It is easier to achieve coordination and control, and is a ‘faster’ way of decision-
making (employee’s cannot object to what you decide). Decentralisation is more responsive to local
circumstances, and there are opportunities for staff development. And there is a sense of control
good for staff motivation. This works quite well if you work in an unstable/unpredictable
environment (because you need to react quick).
Control vs. autonomy
Who decides how the work is executed? Is your boss constantly watching what you are doing? Or are
there rules about how you should do your work? This is control. Autonomy is the complete opposite.
You can decide how you want to do your job. In a health care setting, there is a tense relationship
between these two. Professionals have professional autonomy, they have years of (medical) training,
Pagina 2 van 43
,HC’s – Communication, organization and management
but there are systems of control (DBC); what type of care we can give for a certain disease. And they
need to execute only evidence-based medicine; don’t make stuff up.
Differentiation vs. integration:
Differentiation is about the division of tasks; one waiter takes your drink order, the other one the
food order, and the other one brings the bill; specialising in one task. This is often done in health care
(only specialized in one field), but this is not very patient-friendly. And we have over-specialisation;
sub-specialties in each field. They (the different specialists) need to work together; not ask the
patient to come to the hospital multiple times to see different people; no more ‘health care silos’.
Integration is the opposite; align the work of people so you get an integrated end-product;
collaboration; holistic (as one) view of patients and care delivery (see the patients also as a person).
We do see integration in health care organization more often lately, because of multimorbidity
patients; patients with multiple diseases. Work together as a whole! In this way you can make it safe,
efficient; you work towards the same goal.
Three examples of structures we see in organizations:
1. Service / product line structure
a. Focuses on integration
2. Functional structure
a. Focuses on differentiation
3. Matrix structure
a. Tries to avoid the disadvantages of both systems
Functional structure
We see this in hospitals! Place professionals that are experts in the same topic together. So e.g. all
the employees that have to do with surgical care, you place under the divisional manager of surgical
care. The other employee’s, you place under divisional manager of non-surgical care. This allows you
to focus/specialize on your function and task; positive side. Is allows you (as the department) to work
very efficient. And there is importance in the general manager. Downsides: it is a quite hierarchal
Pagina 3 van 43
, HC’s – Communication, organization and management
structure of communication; it is impossible to coordinate activities across blocks (you can only
communicate vertically). So if there is an issue, and you want to coordinate across departments, this
is very difficult and takes a lot of time. And this can create an ‘us/them-culture’; only focus at your
own department, don’t think about others; tunnel vision. If departments do not work together, this
might have a negative influence on the quality of care. You can ask; are we really working towards
the same purpose? So do we feel as one organization?
Program/service line structure
Example: previously, when a mother gave birth, the child would go to neonatal care, and the mother
to postpartum care. But now we have mother-child centre; mother and child can be treated together
in the same department. So mother and child are treated within the same program; advantage.
Disadvantage; certain duplication of work is unavoidable. So it is not completely efficient. And you
focus on the niece, not on other functional structures.
Pagina 4 van 43
