CLINICAL LEADERSHIP AND THE CHANGING GOVERNANCE OF PUBLIC HOSPITALS: IMPLICATIONS FOR PATIENT EXPERIENCE
| Author | GIANLUCA VERONESI,IAN KIRKPATRICK,ALI ALTANLAR |
| Date | 01 December 2015 |
| Published date | 01 December 2015 |
| DOI | http://doi.org/10.1111/padm.12183 |
doi: 10.1111/padm.12183
CLINICAL LEADERSHIP AND THE CHANGING
GOVERNANCE OF PUBLIC HOSPITALS: IMPLICATIONS
FOR PATIENT EXPERIENCE
GIANLUCA VERONESI, IAN KIRKPATRICK AND ALI ALTANLAR
A growing evidence base suggests that increasing the involvement of clinical professionals on gov-
erning boards of hospitals has a positive impact on organizational performance. However, less is
known about the wider conditions that inuence this process and whether recent moves to restruc-
ture the governance of public hospitals, extending their formal autonomy,has made any difference
to the outcome of clinical involvement on patient experience. Using four years of data and concen-
trating on the acute hospital sector in the English National Health Service, this study shows that
clinical participation on hospital governing boards can signicantly improve the patient experience
of the care provided. Yet, whereas a more autonomous organizational form (Foundation Trust sta-
tus) does not seem to produce positive effects on its own, patient experience appears to markedly
improve in those organizations that have both higher levels of clinical involvement in their strategic
apex and greater exibility in decision-making.
INTRODUCTION
A distinctive feature of New Public Management (NPM) reforms over the last two decades
has been the drive to co-opt professionals such as clinicians, social workers, and head
teachers into the management of services. Professionals taking on these roles have been
considered ‘hybrids’, owing to the fact that they straddle both professional and managerial
domains, often bridging the gap between two occupational groups with different interests
and priorities (Noordegraaf 2011).In health services this trend has been especially marked,
with doctors and other clinical professionals becoming more active in the strategic man-
agement of public hospitals and other organizations through membership of governing
boards (Numerato et al. 2012; McGivern et al. 2015).
In the health context, debates about the likely consequences of this management turn
have become increasingly polarized. On the one hand it has been argued that recent
trends are undermining the autonomy of clinical professions, reinforcing divisions
between senior doctors and nurses (who take on management roles) and the rank and
le (O’Reilly and Reed 2010). On the other hand, there is a growing body of research that
highlights the positive impact that clinical leadership and management can have on a
range of service outcomes (Conry et al. 2012). This is especially true of studies that have
focused on the governance of public (and private) hospitals in the USA and (increasingly)
Europe. With some exceptions this research has consistently found that greater clinical
participation in hospital board-level discussions can have an impact on clinical quality
outcomes (Jiang et al. 2009; Goodall 2011; Veronesi et al. 2013).
Notwithstanding the growing body of evidence on the impact of clinical (especially
medical) leadership, our understanding of the wider conditions that inuence this process
remains undeveloped. Potentially important here are NPM reforms around the world
that have led to the restructuring of (vertically integrated) public bureaucracies to create
Gianluca Veronesiand Ali Altanlar are in the Department of Accounting & Finance, Leeds University Business School,
The University of Leeds, UK. Ian Kirkpatrick is in the Work and Employment Relations Division, Leeds University
Business School, The University of Leeds, UK.
Public Administration Vol.93, No. 4, 2015 (1031–1048)
© 2015 John Wiley & Sons Ltd.
1032 GIANLUCA VERONESI ET AL.
semi-autonomous organizations with their own (corporate style) boards (Pollitt and
Bouckaert 2011). In the health sector,for example, Saltman et al. (2011) note the emergence
of public hospitals in a number of European countries that have been re-designated as
state-owned enterprises with greater nancial and institutional autonomy. It might be
argued that these moves to extend the formal autonomy of some public hospitals will have
a positive impact on the inuence of clinical professionals in strategic decision-making
and outcomes. This assumption seems especially valid given the fact that one of the
aims of these governance reforms has been to encourage managers and clinicians locally
to become more responsive to patient needs and innovate with patient-centred care.
However, to date, only limited attention has been given to addressing whether or not this
is indeed the case.
In this article we address this gap, focusing on the acute hospital sector of the English
National Health Service (NHS). Specically, we investigate two questions. First, in line
with other studies, does increased participation of clinical professionals on hospital boards
impact positively on performance outcomes? Here we depart from previous research(that
measures clinical and/or nancial outcomes) and focus on the issue of patient experience.
This, we argue, represents a more substantial outcome measure than ofcial quality rank-
ings/indicators, which are limited in a number of respects.
It has been noted, for example, that performance indicators often fail ‘to capture qual-
ity in the sense of impact or outcome’ (Bevan and Hood 2006, p. 529), due to intentional
output distortion (achieving targets at the expense of other unmeasured aspects of per-
formance), effort substitution (decreasing effort on performance dimensions that are not
explicitly measured) or,more generally, because they do notprovide a sufciently rounded
view of hospital performance (Mannion et al. 2005). Patient experience is also a measure
which is known – from a variety of international studies – to be inuenced by the ‘quality
orientation’ of senior hospital management teams and the extent to which they respond
to clinical concerns about service improvement (Marley et al. 2004).
Second, we focus on the question of whether any impact of clinical participation on
boards is moderated by organizational differences between hospitals and, specically,
the extent to which they have been granted higher formal autonomy in their governance.
To address this question, we use the move towards Foundation Trust (FT) hospital
status in the English NHS (from 2003 onwards) as a proxy for increased formal auton-
omy – autonomy which, as we shall explain later, may not always be exercised (Anand
et al. 2012).
CLINICAL PARTICIPATION ON BOARDS AND PERFORMANCE: THE EVIDENCE
BASE
There is now a growing evidence base to suggest that increasing the involvement of clinical
professionals (particularly doctors) on boards of hospitals has an impact on performance.
This is notably the case in the North American literature. With some exceptions (Succi
and Alexander 1999), this research overwhelmingly suggests that clinical participation at
board level has yielded higher quality performance in the process of care and mortality
(Jiang et al. 2009), higher quality rankings of hospitals (Goodall 2011), and greater hospital
occupancy and operating margins (Molinari et al. 1995).
In the European context, the development of corporate style boards is a more recent
phenomenon in the public sector, with variations between countries (Kirkpatrick et al.
2013). However, here too, a small number of studies point to an association between
Public Administration Vol.93, No. 4, 2015 (1031–1048)
© 2015 John Wiley& Sons Ltd.
To continue reading
Request your trial