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Demands for Managers of Health Organizations

These contradictory expectations (see Figure 21.1) indicate that the management of health organizations should supply access to health care for everyone at the best price as well as the best individual trust-based treatment for patients and their relatives. Also necessary is to give freedom for experts to make continuous improvements to reach scientific excellence. Understanding health organizations as one of society's subsystems, the assumption indicates that they reproduce environmental complexity internally (Willke, 1982). They do so by reflecting the external variety of different perspectives regarding scientific excellence (doctors, medical-technical staff), trust based and individual treatment of patients (nursing, medical-technical staff), effective process and cost control (administration, owners) and authority-based decisions and regulations (owners) internally.

Considering these contradictions, the management has a delicate task: If it emphasizes the economical side (e.g., by introducing performance measurements), resistance from medical and nursing experts may occur, thereby leading to its own marginalization. If it emphasizes the expert side, the organization could be economically endangered—when medical excellence becomes an end in itself and a translation to the process for patient treatment is not successful. If the management primarily represents the patients' perspective, higher costs can be the consequence.

The internal and external subsystems of health organizations need coordination efforts so that their different logics and expectations do not threaten one another. Management should aim for mutual understanding, thereby increasing the reliability of expectations regarding operational activity. A functional management has to cover the requirement for intermediary processes of coordination and negotiation (Grossmann & Scala, 2002).

The described conflicting expectation cannot be balanced hierarchically, but rather by negotiation processes with the stakeholders of the relevant internal and external environments. Managers must be enabled to function as transmitters and as bridge builders between the contradictory expectations represented by different subsystems in and outside of the health-care organizations.

These have to prove their capability to understand the different subsystems of health organizations and to meet the specific needs of all key players involved. Acting as reliable role models for trust-based dialogues, being an "alien equal" among equals as well as keeping professional distance from all different stakeholders of the health-care organizations turn out to be success factors for managers in finding new ways of supporting the health-care organization's paradigm shift from a bureaucratic-hierarchical expert organization to a more dialogue-based expert organization with professional management.

Demands for Leadership Learning

Most of the managers in health care organizations experience the different environments' expectations as a high pressure on a personal level. Contradictions often lead to conflict escalations embedded in situations without free space for maneuver planning. They often neglect or fight against conflicts without trying to utilize them as a resource for learning.

However, the new leadership role as a transmitter and bridge builder between different subsystems firstly requires the managers' reflection and modification (unlearning and relearning) of mental models and the acquisition of specific qualifications to form change and negotiation processes (individual learning). Second, communication and operational routines between the hospital's subsystems as well as specific structures and procedures have to be modified (organizational learning) by leaders acting as change managers.

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