anastasia balasopoulou, msc, national school of public health ehma congress, athens, june 2008 the...
TRANSCRIPT
ANASTASIA BALASOPOULOU, MSC,NATIONAL SCHOOL OF PUBLIC HEALTH
EHMA CONGRESS, ATHENS, JUNE 2008
THE POWER GAME
IN DECISION MAKING PROCESS IN THE PUBLIC GREEK HOSPITAL
The research questions
• There is a need for major changes within the Greek hospitals, but a number of interventions designed and a lot of attempts for improvement have failed.
•The main question set is: why all these failures?
• The usual accuses of the middle level managers’ capability or of the high political orientation, seem rather general opinions than interpretation?
What is the real decision making context that influences the results? Who are the players? Is there a power game?
The Power Game is an important issue; its interpretation might be useful for a further and deeper understanding of the potential to enhance the decision making process
What is Power?
Power is a locus of will
Held by people
Measured by response
Influenced by values
Key conceptions:
Agency
Interests
Intention
Authority
Accountability
Knowledge
Culture
Power is the possibility that a man has to be in the position to influence a social relation up to the degree to adopt his/her own will for action, despite the resistance (Max Weber)
The decision making context
The decision making in a hospital organisation is a very complex process, due to the size and aim, to the different levels of rules, to the formal and informal hierarchy, to the strong interests.
The status of power among the different groups is an essential part of this context, as it is the expression of conflicting interests, the exercise of regulations, the balance to external factors that either build barriers or facilitate processes.
The public hospital is close to both direct and indirect political influence regarding the aims, the legislation framework, the hierarchy and the interests.
Hierarchy Structure
Clear Political orientation and Legitimate Authority for the Top Management
INCLUDING the Employees’ Representative as a member of the Board ,
ALSO the Nursing Director as a member of the Board
BUT
The Administrative Director as well as the Medical Director are not members of the Board
APART OF THESE
The managers’ election can’t guarantee the knowledge and the character required to play their formal role
Dpt.
Dpt. Dpt.
Economic Sub-D.
Administrative Sub-D.
Vice CEO
Politically appointed
Career managers
Chosen after MDs proposal
P S L
* Technical Service D.
The players and their power characteristics
CEO Med. D
FameD EconM
Adm.D NursD TechD Union
Political Orientation
+++
++ no ++ ++ ++ ++ +++
Agency ++ +++ ++ + + ++ + +++Authoritylegitimate
++ + +++ +++ ++ ++ no
Account ability
++ + +++ +++ +++ +++ +++ no
Technical Expertise
? +++ +++ ++ ++ +++ ++ -
Interests, Intention
+++
++ +++ +++ ++ ++ +++ +++
1. The degree of characteristics’ expression may differ depending on the personality2. “Organized unaccountability” developed, as a symptom of the organizational context
The Three Dimensions Model of Power (Luke)
Key elements 1st dimensionEpisodic Agency
2nd dimensionPower Intention
3rd dimensionReal Interests
Objects of analysis
Indicators
Fields of analysis
Study the Behaviour, that is defeated the agency’s choice
Concrete Decisions
Issues
Overt conflict
Express policy preferences based on political involvement
Interpretive understanding of Intentional actions
Non- decisions
Potential Issues
Covert conflict
Express policy preferences embodied in sub-political grievances
Evaluative estimations of real interests in action
Political agenda
Issues, potential issuesLatent conflict
Relation between expressed policy preferences and real interests
Players’ Strengthnesses and Weaknesses
All the players run the 1st dimension of the episodic agency The more mature players (in terms of expertise or clearer interests)
run in addition the 2nd dimension of the Intention to power The formal structure supports, in a way and up to a degree, the
agencies
The Doctors and the Union, as well as the Economic Managers have the characteristics to interpret the intentions and the covert conflicts as well as to deal with the political factor in a sub-political way
The Directors have a degree of knowledge and the accountability to deal with the power, as well as their authority to build on, but these characteristics are rather latent, as well as their conflicts
These latent characteristics do not seem to have the intention or to know the process to build a strong position in this power game or even consensus
Politics in Decision Making
The politics could be both the political involvement and the agencies’ strategies
The political orientation of the hospital organizations is based mainly on the high interest for the politicians, due to their size, compared to others
The absence of rules and control lead to higher dependence on politics
The structure supports agencies and, accompanied by the political influence, lead to a power game, with poor-level gains for the player
The criterion of accountability of decision makers is not stressed enough, as a factor able to link the process to the rationality
The easy decisions, which fail, is the result of the episodic agency phase, and the politically connected agencies can build on these
The non-decision is a status preferable by the mature players, may be for repositioning or even as a type of resistance, or both
The expertise and knowledge is not an issue to be developed, as a criterion of less importance
The consensus needs will, discipline, knowledge
Culture and Resistance
The interests, expressed by groups or by persons:
are not always based on clear professional or economic issues, but are also based on the perception for personal development and wide acceptance
The Resistance is a usual expression in the power game and its volume depends on both interests and culture.
The culture, both the personal and the organizational, is very important and basic aspect to build the future on.
The Culture has a close relation, conceptual and active, to the Resistance. This is based on the Dominant Ideology been developed in the person, the society and the organizational life.
In the whole Europe Marxism and sociology have played a dominant role on people’s will to change, to adopt or to resist, at least for a long time (Abercrombie et al. 1980).
Specifically the Greek organizational and social life, due to historical reasons, has developed a “Say No” Culture, expressed with resistance or at least suspicion to any decision
Thus the non-decision is accepted and the personal strategies are stronger
The circuits of Power
Social relations
AgenciesStanding conditions
Means Resources
control
Outcomes
Rules fixing relations of meaning,
membership
Obligatory passage points
Innovation in techniques of
discipline, production
Exogenous contingenci
es
Fix/ re-fix
Reproduce/ transform
Control/ contest
Empower/ disempower
Facilitate/ restrict
Level of circuit Type of power
agency causal
Social integration
dispositional
System integration
facilitative
The circuits are responsive to the Three Dimensions model, in the meaning that they present a process, leading from the 1st to the 3rd, from the episodic agency to integration –based on consensus, using the rules and the production discipline
Power reformation to enhance decisions
The players will stay in this power game but they can pass from the 2nd dimension to the 3rd, in which the real interests can be supported to be formulated and developed
The production discipline (as 3rd circuit) links the outcome to the process needed to reformulate the power game
Hospitals are “first line” organizations, thus the production and service methods are of high importance and respect
The knowledge and, even more the expertise, is a power itself and that should be used under this meaning
There is no evidence that politics are stronger than expertiseThe managers, who are more stable in the organization, must
undertake to develop their knowledge latent power
Decision Making cycles and Principles
The membership and participation in DM should be an issue of respect, apart of a play:
Roles for decision makers
Rules for the process
Responsibility of all
Responsiveness to the real problematic situation
Results close to the aim
The rational Decision Making cycles, towards the organization’s aims
SyndicateInformal hierarchy
Patients groups Stakeholders
Internal
N.D.
Committees
Conclusions
A leader or manager, of each level, has to accept that:Politics is a part of life, with their own rationality and
faces, and the only solution is to deal withThe bad situations are not somebody else’s fault Also must realize the power itself of:Knowledge for the production and service systemAnalytical techniques for the conflicts and the context Finally:Invest in the long run