"Enterprise within the enterprise" : a study of management and performance in a public health care delivery organisation

Abstract: Background The challenges in healthcare are an everyday struggle for managers. Efficiency and responsiveness of public sector services have been of interest over the past decades. Different reforms have been launched. One important factor that has been identified is the degree of autonomy in decision-making, typically calling for a decentralised management model. Aim The overarching aim of this thesis is to explore decentralisation of management authority and accountability in a public healthcare provider organisation in primary and community care, and to assess its impact on organisational outcomes and how managers perceive a decentralised management model in ordinary and pandemic conditions. Methods Study I was a scoping review to explore the impact of decentralisation as evidenced by the literature. In the empirical studies II, III and IV qualitative research approaches were used with an explanatory case study research design. Purposive sampling, data collected in semistructured, in-depth interviews and analysed with directed content analysis guided by theoretical frameworks. Balance score card data were used in study III. Findings In study I, a theoretical model was developed from Bossert’s decision space conceptual framework to be used in the further empirical studies. Study II found support in the scientific literature for the underlying assumptions that increased responsibility will empower managers, since clinical directors know their local prerequisites best and are able to adapt to patient needs. In study III managers’ perceptions of the decentralised management model supported the intentions to enable the front-line to make decisions to better meet customer needs and flexibly adapt to local conditions. In study IV we found a high grade of operational effectiveness, which is imperative in an emergency situation, and also a driver of new strategic positions to even better meet new demands. Conclusions Decentralisation can create conditions that support innovation and improvements locally. Activities for decentralisation have to be consistent with underlying assumptions, supported by evidence, and timely planned to give managers decision space and the ability to use their delegated authority, not disregarding accountability and fostering necessary organisational and individual capacities to avoid sub-optimisation. Congruence between the rationale of a management model, the managers’ perceptions of the authority and accountability as well as management practices is crucial. The empirical findings of our case study are synthesised into a theoretical model potentially possible to apply in other organisational settings too.

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