Governance and Strategy
Lectures, Working groups and literature
May 2018
MSc. Health Care Management 2017-2018
Week 1
- Lecture + Workgroup
- Literature:
o Peters
o Rhodes
o Van Bovenkamp
o Riley
Week 2
- Lecture + Workgroup
- Literature:
o Mintzberg
o De Korne
o Pearce
Week 3
- Lecture + Workgroup
- Literature:
o Lowndes
o Saltman
o Vrooman
Week 4
- Serious game
- Literature:
o Wirtz
o Kruse
o Okumura
o Philips
Week 5
- Lecture + Workgroup
- Literature:
o Singleton
o Bochove
o Ansell
Week 6
- Lecture + Workgroup
- Literature:
o Denis
o Wijngaarden
o AP Spee
1
, Week 1 - Lecture
Outer context can influence the inner context (budget guts in the past from governance has influence on the
healthcare in hospitals nowadays)
Rhodes: Other actors gain power as well
Aim of the course: To provide HCM students with theoretical lenses as well as practical knowledge to the
understanding and dealing with governance and strategy issues in healthcare organizations
Different concepts of governance theory in the literature of week 1.
Guest lecture
Key perspectives and distinctions
- Looking Out and Looking in - Two faces of management
- Or, perhaps, “scanning” and “oversight”
- “Managers” and “Operators”
- The people who think they’re responsible for organizational action and the people who do the
work
- “Management” or “Government” as “Control” vs. “Influence”
- Central to the Governance perspective
- Dimensions of “Authority”
- From above or below? Authority is from below (the person below makes the decision)
- Position vs. Expertise - authority of position and authority of expertise (administrative worker
tells dean what he has to do → authority is based on expertise)
Four management situations
To manage something you have to be able to tell/assess what’s going on.
1. ...
2. Can you observe the work people are doing.
Ability to observe outcomes: high or low.
2
,You are going to observe the outcomes and to observe the process.
- Traditional production line: manager knows everything (all the steps) → easy situation to manage
A process is easy to observe but you can’t tell a thing about the outcomes. Sometimes it has no outcomes,
it doesn’t do anything.
- High outcome/low process: wartime army → you can tell winning the battles or losing,
- Process low/Outcomes low: police, education, hospitals → Too much is going on to exactly know it.
Measuring the performance of a hospital is very very hard.
Further important considerations
- Critical task(s) for organization and its operators
- What has to be done to satisfy organization’s or its members’ beliefs about mission or purpose,
or simply to attract resources.
- Four dimensions of complexity (among many)
- Organizational: coordinating what and who
- Technical complexity of a specific task e.g. safe nuclear power plant
- The package of tasks creating much more to observe and manage
- Whether failure can be identified
- What is failure in a hospital? Patient die (but you expect patients to die, a lot of patients
die in a hospital), → failure is not easy to identify in an hospital → hospitals/healthcare
are much more complex!!
- Hospitals are much, much, more complex than almost any other organization. Services plus
care/teaching/research
- What people want: resources and autonomy (you will too) Which not go necessarily go together.
- Conflict between organizational and personal values
Factors that apply in virtually all systems
- Conflicting authority - Physicians and managers
- Managers not helpless → There are tasks MDs can’t do (only physicians can)
- Managers links to outsiders (government and insurance company) Though MDs too..
- Attempts to manage by measuring
- Measuring are tools in a power struggle
- Measure outcome or process? Doesn’t work very well either way
You measure because you don’t trust. Doctors don’t want to be measured, because they are
trusted. Who has the right to measure has the right to interfere with the one being measured.
- But outsiders everywhere want measurements → It’s “rational”. Governance: we need to
measure. A culture: we have to measure.
- Patients are governance or management problems
- Patients are the raw material for organizational tasks but can’t be standardized (you work on
patients, you can’t standardize, because they are all different)
- Create costs for third-party payers and sometimes providers (that depends on payment system)
- Don’t manage selves as they should. “Non-adherence”
- Changing them may require expanding organizational boundaries
3
, Some differences in governance context
- How many relevant governments - and relevant to what?
- E.g.: Federal vs. unitary states - but is unitary coherent
- Government Owns or Purchases Services
- Difference can be exaggerated. But an owner can fire you.
- How Many Payers? How Many Sellers?
- And can the payers collude? Basic issue is market power
- But there are complexity effects also
- Regulation of or Interference With Core Business Decisions
- Labor: regulations on who can be hired, or compensation
- Capital: who determines investments, and access to funds
- Prices: who sets them?
- Partnerships – any limits (e.g. competition law)?
- What is the Partisan Dimension?
- Are elections likely to change policy much?
- What Interests are Organized to Pressure Decisions?
- Provider interests all want more money but can be rivals…
- Specialists vs. primary care, profit vs. non-profit hospitals…
- Organized business – related to employer role in coverage
- Labor, though gets less important everywhere.
- “The people”: patient groups, community groups…
- Broad Public Attitudes or Mores
- Don’t make policy but constrain it or provide impetus for change
- Trust (or not) and the potential for scandal. What can get you in really big trouble?
Illustrating variation with US examples
- Baseline Horrifying Data: Or, Good Government Matters!
- Unless the goal is to spend lots, inefficiently
- Opportunities for and Constraints on Managers Effects of U.S. Payment Systems on Outcomes, Behavior
- Bizarre billing practices. Expensive and exploitive
- “Cost-shifting,” diagnosis creep, and patient dumping
- Effects on measurement – what the EHR is really for.
- Government Efforts to Shape Practice Effects of Stronger “Market Forces”
- Why real “integration” is a flawed business model
- A Shortage of Shame
Healthcare spending as a percentage of GDP, 1980 - 2014
4
Lectures, Working groups and literature
May 2018
MSc. Health Care Management 2017-2018
Week 1
- Lecture + Workgroup
- Literature:
o Peters
o Rhodes
o Van Bovenkamp
o Riley
Week 2
- Lecture + Workgroup
- Literature:
o Mintzberg
o De Korne
o Pearce
Week 3
- Lecture + Workgroup
- Literature:
o Lowndes
o Saltman
o Vrooman
Week 4
- Serious game
- Literature:
o Wirtz
o Kruse
o Okumura
o Philips
Week 5
- Lecture + Workgroup
- Literature:
o Singleton
o Bochove
o Ansell
Week 6
- Lecture + Workgroup
- Literature:
o Denis
o Wijngaarden
o AP Spee
1
, Week 1 - Lecture
Outer context can influence the inner context (budget guts in the past from governance has influence on the
healthcare in hospitals nowadays)
Rhodes: Other actors gain power as well
Aim of the course: To provide HCM students with theoretical lenses as well as practical knowledge to the
understanding and dealing with governance and strategy issues in healthcare organizations
Different concepts of governance theory in the literature of week 1.
Guest lecture
Key perspectives and distinctions
- Looking Out and Looking in - Two faces of management
- Or, perhaps, “scanning” and “oversight”
- “Managers” and “Operators”
- The people who think they’re responsible for organizational action and the people who do the
work
- “Management” or “Government” as “Control” vs. “Influence”
- Central to the Governance perspective
- Dimensions of “Authority”
- From above or below? Authority is from below (the person below makes the decision)
- Position vs. Expertise - authority of position and authority of expertise (administrative worker
tells dean what he has to do → authority is based on expertise)
Four management situations
To manage something you have to be able to tell/assess what’s going on.
1. ...
2. Can you observe the work people are doing.
Ability to observe outcomes: high or low.
2
,You are going to observe the outcomes and to observe the process.
- Traditional production line: manager knows everything (all the steps) → easy situation to manage
A process is easy to observe but you can’t tell a thing about the outcomes. Sometimes it has no outcomes,
it doesn’t do anything.
- High outcome/low process: wartime army → you can tell winning the battles or losing,
- Process low/Outcomes low: police, education, hospitals → Too much is going on to exactly know it.
Measuring the performance of a hospital is very very hard.
Further important considerations
- Critical task(s) for organization and its operators
- What has to be done to satisfy organization’s or its members’ beliefs about mission or purpose,
or simply to attract resources.
- Four dimensions of complexity (among many)
- Organizational: coordinating what and who
- Technical complexity of a specific task e.g. safe nuclear power plant
- The package of tasks creating much more to observe and manage
- Whether failure can be identified
- What is failure in a hospital? Patient die (but you expect patients to die, a lot of patients
die in a hospital), → failure is not easy to identify in an hospital → hospitals/healthcare
are much more complex!!
- Hospitals are much, much, more complex than almost any other organization. Services plus
care/teaching/research
- What people want: resources and autonomy (you will too) Which not go necessarily go together.
- Conflict between organizational and personal values
Factors that apply in virtually all systems
- Conflicting authority - Physicians and managers
- Managers not helpless → There are tasks MDs can’t do (only physicians can)
- Managers links to outsiders (government and insurance company) Though MDs too..
- Attempts to manage by measuring
- Measuring are tools in a power struggle
- Measure outcome or process? Doesn’t work very well either way
You measure because you don’t trust. Doctors don’t want to be measured, because they are
trusted. Who has the right to measure has the right to interfere with the one being measured.
- But outsiders everywhere want measurements → It’s “rational”. Governance: we need to
measure. A culture: we have to measure.
- Patients are governance or management problems
- Patients are the raw material for organizational tasks but can’t be standardized (you work on
patients, you can’t standardize, because they are all different)
- Create costs for third-party payers and sometimes providers (that depends on payment system)
- Don’t manage selves as they should. “Non-adherence”
- Changing them may require expanding organizational boundaries
3
, Some differences in governance context
- How many relevant governments - and relevant to what?
- E.g.: Federal vs. unitary states - but is unitary coherent
- Government Owns or Purchases Services
- Difference can be exaggerated. But an owner can fire you.
- How Many Payers? How Many Sellers?
- And can the payers collude? Basic issue is market power
- But there are complexity effects also
- Regulation of or Interference With Core Business Decisions
- Labor: regulations on who can be hired, or compensation
- Capital: who determines investments, and access to funds
- Prices: who sets them?
- Partnerships – any limits (e.g. competition law)?
- What is the Partisan Dimension?
- Are elections likely to change policy much?
- What Interests are Organized to Pressure Decisions?
- Provider interests all want more money but can be rivals…
- Specialists vs. primary care, profit vs. non-profit hospitals…
- Organized business – related to employer role in coverage
- Labor, though gets less important everywhere.
- “The people”: patient groups, community groups…
- Broad Public Attitudes or Mores
- Don’t make policy but constrain it or provide impetus for change
- Trust (or not) and the potential for scandal. What can get you in really big trouble?
Illustrating variation with US examples
- Baseline Horrifying Data: Or, Good Government Matters!
- Unless the goal is to spend lots, inefficiently
- Opportunities for and Constraints on Managers Effects of U.S. Payment Systems on Outcomes, Behavior
- Bizarre billing practices. Expensive and exploitive
- “Cost-shifting,” diagnosis creep, and patient dumping
- Effects on measurement – what the EHR is really for.
- Government Efforts to Shape Practice Effects of Stronger “Market Forces”
- Why real “integration” is a flawed business model
- A Shortage of Shame
Healthcare spending as a percentage of GDP, 1980 - 2014
4
