The manager role in relation to the medical profession

Background: Managers and physicians have two important roles in healthcare organisations. However, several studies have identified problems in the manager–physician relationship and more knowledge is needed to improve the situation. Using theories on organisation, professions, and role taking to inform thinking, this thesis addresses one aspect of the manager-physician relationship, namely how managers handle their role in relation to the medical profession. This was studied in the context of sickness certification, a frequent and problematic task for many physicians in Sweden. Aim: The aim of this thesis was to increase the knowledge about how managers in Swedish healthcare organisations handle their manager role in relation to the medical profession. Methods: The empirical studies (I-IV) build on one another. Focus group discussions with 26 physicians (I), two questionnaires to all board-certified specialists in Stockholm county (n=2497, resp. n=2208) (II), individual interviews with 18 county council chief executive officers (CEOs) (III), and interviews with 38 healthcare managers (20 clinical department managers (CDMs) and the same18 CEOs as in study III) (IV) constitute the database for the thesis. Qualitative methods were used to analyse data in three of the studies: content analysis (I), grounded theory (III), and linguistic discourse analysis (IV). Descriptive statistics were used in study II. Results: The problems physicians described in their work with sickness certification could be classified into four categories: the design of the social insurance system, the organisation of healthcare, the performance of other stakeholders, and the physicians’ own work situation. Although all of these concern policy issues and managerial responsibility on different structural levels in healthcare, the role of managers was absent in the physicians’ discussions (I). When specifically asked about management of sickness certification issues, the majority reported lack of both substantial management support and a well-established workplace policy (II). With these findings as a point of departure, studies III and IV addressed managers’ role taking. In many ways managers themselves contributed to making the manager role weak and absent in relation to the medical profession (III, IV). The CEOs had a strong focus on physicians and physicians’ behaviour rather than on their own managerial behaviour or that of their subordinate managers. When strategies for managing physicians were addressed, many described physician-specific strategies that led to a paradox of control in relation to the medical profession - the pragmatic strategies helped managers to manage physicians in daily work, but seemed to weaken the manager role in the organisation (III). Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse was predominant, where managers frequently used the attributes “physician” or “non-physician” to categorise themselves and other managers in their manager roles. Some managers also combined the two discourses in a “yes, but...” approach to management in the organisation. Expressions of a mutually shared manager community were almost totally missing in the managers’ statements (IV). Conclusions: The results show that managers have a weak, partially absent, and rather ambiguous manager role in relation to the medical profession. How the manager role is handled and regarded within healthcare organisations constitutes part of the organisational conditions for the role taking of managers, physicians, and other healthcare professionals. The findings indicate that there is a need to support healthcare managers in their role taking in the organisation - both those managers who also are physicians, and managers with other underlying professions. Management aspects regarding sickness certification tasks also need to be strengthened. A weak and ambiguous manager role may have negative consequences not only for the work of managers, but also for that of physicians and other healthcare professionals, and for the quality of care

Managers' perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare

<p>Abstract</p> <p>Background</p> <p>This study focused on the manager role in the manager-physician relationship, considered from the manager perspective. The aim was to understand how top executives in Swedish healthcare regard management of physicians in their organisations, and what this implies for the manager role in relation to the medical profession. Abbott's theory of professional jurisdiction was used to inform thinking about managerial control and legitimacy in relation to physicians.</p> <p>Methods</p> <p>Data from semi-structured individual interviews with 18 of the 20 county council chief executive officers (CEOs) in Sweden were subjected to qualitative analysis.</p> <p>Results</p> <p>The results show that, when asked about their views on <it>management </it>of physicians, the CEOs talked about "how physicians are" rather than describing their own or their subordinate managers' managerial behaviour or strategies. Three types of descriptions of physicians were identified: 1) they have high status and expertise; 2) they lack knowledge of the system; 3) they do what they want in the organisation. The CEOs seldom reported that general management strategies were used to manage physicians. Instead, they described four types of physician-specific management strategies that were used in their organisations: organisational separation of physicians; "nagging and arguing"; compensations; relying on the physician role. These strategies seemed to reflect pragmatic behaviour on behalf of the managers that helped them to maintain control over physicians in daily work. However, in a longer perspective, they seemed to decrease the legitimacy of the manager role and also contribute to weakening of that role in the organisation.</p> <p>Conclusions</p> <p>Many CEOs seemed to regard the manager role in their organisations as weak and described difficulties in both taking and defining that role (for themselves or others) in relation to the physician role. Further research is needed to elucidate how managers in healthcare organisations assume the manager role in relation to the medical profession. Studies indicate that lack of clarity concerning manager role authority and responsibility may have negative consequences not only for the working conditions of managers, physicians, and other healthcare professionals, but also for the quality of care.</p

Left Atrial Appendage Printing Process

The left atrial appendage senior design team aims to assist in closing off the left atrial appendage that is susceptible to coagulation due to non-valvular atrial fibrillation. Coagulation in the left atrial appendage (LAA) can be life threatening as it can lead to a stroke. Dr. Chris Porterfield performs a procedure that uses the Boston Scientific Watchman to close the appendage. He finds that sizing the Watchman properly is difficult with limited visuals from live CT scans. He proposed converting the CT scans into a 3D printed model of the left atrial appendage and left atrium so he can visually measure the opening and predict the trajectory angle of the Watchman device into the left atrial appendage. He currently has a base algorithm and procedure to convert and modify the CT scan into a .stl file, which can then be printed with standard PLA material using a 3D printer on Cal Poly’s campus. The project is limited to the printers and their material capabilities on Cal Poly’s campus. There are currently many programs that convert CT scans to printable files and this project aims to evaluate each to conclude which produces the most accurate 3D model. The procedure to create the model must also be quick to perform, repeatable and reproducible as well as easy to follow. After researching the various programs, we concluded that 3D Slicer allows us to print anatomically accurate models of the left atrium and LAA. Using this software, the user uploads CT scans obtained from the radiologist as a DICOM file. Once uploaded, the user will proceed to setting the threshold parameter to the designated values. The user will then scroll through the CT scan to identify the left atrium and LAA in one of the views. After locating the anatomies, the user will use the scissors tool to extrude out any unnecessary anatomy. Once isolated, the model will need to be hollowed out and set to the defined parameters. After a final cut is made to open the model for internal viewing, is it saved as a .stl file and sent to a 3D printing software such as Cura. From this point on, the user will refer to the printer’s manual for the printing procedure while using the parameters we listed as a guide. After the print is concluded, the user will be able to measure the opening of the LAA and determine which entry angle is most optimal. The key customer requirements we aimed to achieve were ease of use, time, production cost, shape/accuracy, repeatability and reproducibility. For ease of use, we had users go through our MPI, Training Guide and Operations Manual and had them rate between 1-10 on how clear and concise our directions were. We scaled the range so that 1 meant that our procedure was clear and concise enough to replicate while 10 meant it was near impossible to follow. We aimed to achieve an average score of less than 3. For time, we were given a timeframe of 24 hour to fully slice and print the model. Since this procedure is not officially ICD-9 billable yet, the cost of production must remain below $50 per print. Based on the sizing chart provided by Boston Scientific for the various sizes of the Watchman device, we decided that the shape/accuracy must be less than 10% variation from the CT scan, while the repeatability and reproducibility must have no statistical difference in variation from the ANOVA. After running ANOVA on the data obtained from measuring the 9 testing prints, the results showed that our slicing/printing procedure and the measurements taken for testing were adequate enough to prove the functionality of all our protocols. The results of ANOVA showed that there were no significant differences in our data except for depth reproducibility which means that our customer requirements of reproducibility and repeatability were almost met. For the ease of use requirement, Dr. Porterfield and his clinical specialist, Sarah Griess, went through our Manufacturing Process Instructions, 2 Training Guide, and Operations Manual and performed the feedback survey we provided. Based on those results, we concluded that our protocols are functional and easy to follow which is essential to producing an accurate model. To prove model accuracy, we had Dr. Porterfield size the Watchman device as he currently does and confirmed that our printed models were accurate

a multi-centre cross-country comparison of women in management and leadership in academic health centres in the European Union

Background Women’s participation in medicine and the need for gender equality in healthcare are increasingly recognised, yet little attention is paid to leadership and management positions in large publicly funded academic health centres. This study illustrates such a need, taking the case of four large European centres: Charité – Universitätsmedizin Berlin (Germany), Karolinska Institutet (Sweden), Medizinische Universität Wien (Austria), and Oxford Academic Health Science Centre (United Kingdom). Case The percentage of female medical students and doctors in all four countries is now well within the 40–60% gender balance zone. Women are less well represented among specialists and remain significantly under-represented among senior doctors and full professors. All four centres have made progress in closing the gender leadership gap on boards and other top-level decision-making bodies, but a gender leadership gap remains relevant. The level of achieved gender balance varies significantly between the centres and largely mirrors country-specific welfare state models, with more equal gender relations in Sweden than in the other countries. Notably, there are also similar trends across countries and centres: gender inequality is stronger within academic enterprises than within hospital enterprises and stronger in middle management than at the top level. These novel findings reveal fissures in the ‘glass ceiling’ effects at top- level management, while the barriers for women shift to middle-level management and remain strong in academic positions. The uneven shifts in the leadership gap are highly relevant and have policy implications. Conclusion Setting gender balance objectives exclusively for top-level decision-making bodies may not effectively promote a wider goal of gender equality. Academic health centres should pay greater attention to gender equality as an issue of organisational performance and good leadership at all levels of management, with particular attention to academic enterprises and newly created management structures. Developing comprehensive gender-sensitive health workforce monitoring systems and comparing progress across academic health centres in Europe could help to identify the gender leadership gap and utilise health human resources more effectively

Tecken som alternativ och kompletterande kommunikation : ett hjälpmedel för barn med/i kommunikationssvårigheter

Abstract The purpose of this paper was to examine preschool teacher’s thoughts about using Manual Signs as Alternative and Augmentative Communication as an aid for children in/with communication disabilities. The method I’ve used in the survey is qualitative interview. The three interviewed preschool teachers use Manual Signs foremost for those children who have a poorly developed spoken language. Manual Signs are used as a complement to the spoken language and the preschool teachers use it to increase the children’s power of concentration. They use Manual Signs also as an aid for those children who have difficulties to communicate with others. The most common way for the preschool teachers to teach the children to use Manual Signs is by using cards. The cards have a picture and a sign on it and the preschool teachers and the children make the sign together. The use of Manual Signs mostly occurs in structured situations, e.g. gatherings and food situations. Lack of time can be an obstacle for using Manual Signs as Alternative and Augmentative Communication. The result are that it is important as pre school teacher to have a good theoretical foundation to lean on to make sure that Manual Signs are used in the right way, i.e. to give the child un opportunity to learn how to communicate. It is important that pre school teachers are united in the way that Manual Signs are used. Keywords: Manual Signs as Alternative and Augmentative Communication, pre school, language, communication.

Leading top-down implementation processes: a qualitative study on the role of managers

Abstract Background Leadership has been identified as an influential factor in implementation processes in healthcare organizations. However, the processes through which leaders affect implementation outcomes are largely unknown. The purpose of this study is to analyse how managers interpret and make sense of a large scale top-down implementation initiative and what implications this has for the implementation process. This was studied at the implementation of an academic primary healthcare initiative covering 210 primary healthcare centres in central Sweden. The aim of the initiative was to integrate research and education into regular primary healthcare services. Methods The study builds on 16 in-depth individual semi-structured interviews with all managers (n = 8) who had operative responsibility for the implementation. Each manager was interviewed twice during the initial phase of the implementation. Data were analysed using a thematic approach guided by theory on managerial role taking based on the Transforming Experience Framework. Results How the managers interpreted and made sense of the implementation task built on three factors: how they perceived the different parts of the initiative, how they perceived themselves in relation to these parts, and the resources available for the initiative. Based on how they combined these three factors the managers chose to integrate or separate the different parts of the initiative in their management of the implementation process. Conclusions This research emphasizes that managers in healthcare seem to have a substantial impact on how and to what extent different tasks are addressed and prioritized in top-down implementation processes. This has policy implications. To achieve intended implementation outcomes, the authors recognize the necessity of an early and on-going dialogue about how the implementation is perceived by the managers responsible for the implementation