Managing healthcare services: Are professionals ready to play the role of manager?

Abstract

Health professionals are now required to develop skills that help them to achieve better organizational performance, in addition to the skills necessary to carry out their professional activities. The role of clinician-manager has thus grown rapidly in all the main industrialized countries. The purpose of this study is to investigate how healthcare professionals perceive their level of preparation in managerial skills. Analysing literature on managerial skills in the health sector, ten domains of skills emerged and were used to construct a questionnaire. A survey analysis was conducted among professionals from health organizations in two Italian regions. Independent t-tests were conducted and a one-way analysis of variance was performed in order to compare the self-assessment competency levels in selected subgroups of participants. Findings show that healthcare professionals feel sufficiently prepared in all managerial areas identified. However, they also suggest that health organizations should invest more in all managerial areas. Differences between self-perception of competence and need for training occur among managers and non-managers. The findings will be useful for top management and policy makers designing operational tools for intervention in human resource development, with the aim of providing appropriate training and skills for clinician-managers.

Keywords

clinician-manager health management healthcare service Italian National Health System managerial skills

Introduction

Health management and managerial skills are constantly evolving in response to challenges of today and tomorrow. These challenges include cutbacks in resources, technological innovation requiring increasingly costly investment, rising demand for quality healthcare; and lastly, reforms enacted in many OECD countries which have altered administration and financing of healthcare systems.¹

These factors are forcing healthcare organizations to search for increasingly efficient and efficacious management. They have widely abandoned the traditional organizational model based on professional bureaucracy, where professionals are outside the administrative hierarchy,² to replace it with a model in which clinicians possess and put into practice different managerial skills.³ Thus, in addition to the skills necessary to carry out their professional activities, clinicians today have to develop skills to manage resources and achieve better organizational performance.⁴

The new role of the clinician-manager has thus become rapidly more important in all the main industrialized countries.⁵ For example, in 1983, the Griffiths Report supported that hospital doctors in United Kingdom should take responsibility for management together with clinical tasks.⁶ In 1984, in Denmark, a White Paper suggested a new organizational model based on the clinician-manager for improving hospital performance.⁷ France has made several attempts to strengthen the management of hospitals. The first was as far back as 1983, and subsequent reforms in 2002 and 2007 led to the adoption of a system similar to the one implemented in the UK.⁸ In Australian and New Zealand hospitals, clinicians are required to manage their colleagues and organizational processes.⁵ In Germany too, physicians have always had great power in managing healthcare organizations, with leadership responsibility including for strategic issues.⁹ In the United States, the Joint Commission requires specific managerial certification of healthcare suppliers for the accreditation of an institution.¹⁰ The turning point for Italy was 1992, when a reform laid down that health organizations were legally independent entities, which led to increasing attention to costing, management and efficiency. Currently the Italian Chief of Unit is responsible for running and organization of the structure, human resource management, clinical outcomes, planning and scheduling projects, and financial, technical and administrative goals.

However, combining clinical and managerial skills is not a simple matter⁵; and various studies have found that clinicians do not believe they have adequate preparation to fill the role of manager.^5,11

The purpose of this study is therefore to investigate how healthcare professionals perceive their level of preparation in managerial skills. Our research question is: “Do health professionals feel ready to play the role of managers?”

The research is performed in Italy and focuses on middle management (the head of department, the head of operating unit, chief nursing officer, etc.) in the healthcare sector. As noted above, professionals working in the Italian National Health System (NHS) have both clinical and managerial skills, as is the case in most Western countries. The results of this study should therefore be of interest to all those healthcare organizations intending to invest in the development of managerial skills of their professionals.

Theoretical framework

Clinicians as managers

Historically, hospital governance was characterized by a dual organizational structure, where managerial and professional structures coexisted side by side.² Clinicians and managers however follow different paths of reasoning. Clinicians, being professionals, organize their activities and practices according to the rationale of their profession. Hospital managers, on the other hand follow the logic of management science or bureaucracy.¹² There is often conflict between the two types of thinking, which can generate tensions between clinicians and managers. Involving clinicians in the management of the hospital could ease this tension, and bring general improvement for the hospital.¹³ In addition, there is a widespread view that if hospitals are managed by those who are also producers of clinical care, the quality of care improves thanks to their professional expertise and deep knowledge of processes.¹⁴ In this view, there are two main reasons for the involvement of clinicians in organization management. First, it is believed that hospitals can improve performance by involving participants in the treatment process. Second, there is a desire to lower tensions in governance arising from the fact that the old professional bureaucratic model comprised a decision making structure set apart from the professional structure.

At the same time, however, it should be emphasized that the involvement of the healthcare professional as a manager also has disadvantages. In fact, focus on managerial tasks may not allow the professional to focus on the provision of care¹⁵ and on the improving of interprofessional teamwork, which are two fundamental activities of the clinician’s role.

In many countries the dualism between clinician manager is no longer clear, and the managerial merges with the professional role, creating new professional figures requiring different skills. Healthcare organizations thus need to promote a managerial culture among healthcare professionals, so that they can be ready to make decisions in both clinical and managerial fields.¹⁶

Managerial skills for clinicians

At this point, it is necessary to clarify what managerial skills a clinician should possess. There is a great deal of literature on the clinician-manager, but no shared opinion on what the skills should be.¹⁷ However, analysing published research, recurring areas or domains of skills can be identified.

Recently, Fanelli et al. have carried out a systematic literature review to define the domains of competences for middle management in the healthcare sector.¹⁸ They identified 8 main topics: Human resource management, Leadership, Communication, Organizational design, Quality, Analysis (operation and project management), Programming, and Costing. However, other authors have argued that other skills are also relevant to those in a managerial role, including the ability to solve problems or measure results in terms of output and outcome.^19–21 Thus, to define the domains of managerial skills for this study, we started from the work of Fanelli et al. and also analyzed other research to outline a more complete picture. In our research we included studies made on doctors and on nurses. Generally, doctor-managers are responsible for the operating units and collaborate within their units with the nursing management. More specifically, doctor-managers are responsible for the organization and clinical activities as well as on output and outcome. Responsibilities of the nursing management concern the organizational aspects of activity planning and other aspects supporting the diagnosis and treatment processes.²² Given these differences, however, the literature has not highlighted different types of managerial skills between doctors and nurses,^21,23,24 and it is thus reasonable to believe that doctors and nurses have a shared vision on the issue of managerial skills.

P1. Doctors and nurses perceive their own level of preparation on managerial skills in a similar manner.

Conversely, a different level of perception of managerial skill is expected between those who already hold a managerial role and those who are solely clinicians.^4,25,26 The literature finds that managers feel more competent in managerial issues, and require less improvement from their organization. On the other hand, non-managers feel themselves less competent, but almost always require improvement.²⁷ This led us to distinguish between the perceptions of managerial skills of managers and non-managers and to test a second proposition.

P2. Healthcare managers feel more confidence in their own competences than non-managers, but non-managers more frequently aim to develop their competences.

Ten frequent domains emerged from our analysis. They were used to construct a questionnaire for this research and are briefly described below.

Human resource (HR) management

Managing personnel is one of the most critical activities for all organizations, and is even more important in healthcare organizations, where the quality of the service provided depends heavily on the contribution of employees.²⁸ HR management practices which pay more attention to the needs of individuals are in fact found to generate better results for the whole organizations. This domain includes all skills aimed at recruiting and retaining the best workforce. A good manager should be able to recruit and select his or her collaborators appropriately, develop their knowledge and competences, and evaluate and reward good performance.²⁹

Leadership and internal communication

In healthcare organizations, teamwork and coordination of people on the basis of mutual adjustment are widely used forms of organizational integration. In comparison with industrial companies, where standardization of work processes prevails, the manager healthcare plays a crucial role of coordination and leadership.⁴

External communication

Managerial activity is not limited to the organization of internal services but goes beyond the organization boundaries. According to Longest and Rohrer,³⁰ effective communication between healthcare organizations and their external stakeholder is important for at least two reasons. First, these communications help healthcare organizations in obtaining the necessary resources to sustain themselves. Second, effective communication with external stakeholders is a key aspect of their core mission of protecting and enhancing public health.

Organizational design

Taking on a managerial role means having a certain hierarchical power, and therefore responsibility for part of the organization. Managing a business unit or department, the clinician-manager fixes objectives at an organizational and individual level.³¹ Responsibilities also include defining the organizational structure, allocating resources consistently with objectives, assigning tasks and responsibilities to collaborators, and negotiating resources and objectives with top management.^4,10

Quality improvement

The World Health Organization³² defines quality care as follows: “Care that is effective, efficient, accessible acceptable/patient-centred, equitable and safe”. The clinician-manager needs to translate these principles into objectives. Skill in “quality improvement” entails identifying errors and hazards, measuring quality, and designing and testing procedures of care to improve them. This domain covers methodologies, tools, and techniques central to quality improvement.³³

Operation and project management

Operations in general are the core activity of an organization, and concern the transformation of inputs into outputs. The operations manager thus understands and applies the knowledge and techniques of operations management to transform inputs into outputs efficiently.⁵

Problem solving

Problem solving and decision making are outcomes of strategic thinking. Problem solving aims to identify root problems, and uses time and energy to identify decisions that need to be made to solve the problem. Lyles and Joiner³⁴ define problems as “obstacles, conditions, or phenomena that either stand in the way of achieving objectives or cause a deviation from the desired status”. A decision can be defined as a choice made between alternatives. Obviously, making a decision presupposes the ability to analyse the problem through an appropriate evaluation of the strengths and weaknesses of alternative solutions. Health management is required to make decisions and solve problems on the three levels of organizational planning: strategic, administrative and operational level.

Output and outcome assessment

Measuring outputs and outcomes has historically been a challenge with regard to public organizations, including health organizations, because of their focus on bureaucratic aspects. The New Public Management paradigm has sought to shift attention towards results by promoting a managerial culture typical of private firms.³⁵ The clinician who is a manager is therefore the promoter of this change.

Financial management

Rising pressures to contain costs in hospitals have led to an increased emphasis on financial management.³⁶ To avoid waste of resources as well as inefficiencies in production processes, it is important for clinicians involved in management to develop skills in the financial area. For example, a clinician-manager should apply appropriate financial and business management techniques to assure efficient delivery of cost-effective health services.³⁴ She/he should be also able to draw up a business plan that includes basic accounting principles (e.g., analysis of balance sheet, income statements, statement of cash flow) and know economic techniques.

Planning

Sperry³⁷ categorises planning in healthcare organizations into three levels: strategic, administrative, and operational. Operational planning is the most relevant to the clinical manager and concerns daily activities, that is, those at the lowest level of the organization.

The clinician-manager in the Italian context

In Italy, as in many other Western countries, the clinical and managerial components are currently merging into a single professional figure. The management of hospital operating units is entrusted to medical staff, and there are also nurses who have managerial responsibilities. Today it is estimated that about 1 in 15 professionals also hold a managerial role, although the ratio of managers to non-managers depends a lot on the specialty. Historically, the role of manager has been assigned through a procedure that mainly evaluates acquired clinical skills, and very often the best clinician is chosen as manager. However, the need to develop managerial skills today requires professionals to follow specific post-graduate training courses.

In Italy, although the health service is national, responsibility for hospitals, other health services, as well as the development of managerial skills for clinicians is held by Regional Authorities.¹⁷ As a result, Regions can implement organizational and managerial models that best suit their needs but they leave the task of supporting professionals in their managerial growth to the healthcare organizations. For this reason our study takes into account that inter-regional differences may create disparities, and focuses on two different Regions located in the north of Italy. Previous health management studies have also focused on these two regions.³⁸ Although similar in terms of size, health needs, and territorialities, the Lombardy and Emilia-Romagna regions have adopted very different health system models. Both however achieve excellent performance in terms of clinical outcomes and quality of care. Emilia-Romagna is characterized by a structure which links hospitals to local services (e.g. local clinics, primary care, prevention services, etc.). In Lombardy, on the other hand, the focus is on hospitals and the Agenzia della Salute [Agency of Health]. Thus, Lombardy orients its services to the area, while Emilia-Romagna seeks closer integration between local health authorities. Furthermore, Emilia-Romagna is characterized by a central governance system, while in Lombardy the model is based on competition between different entities, reflecting the higher number of private health organizations.

In light of the above, we can formulate a third proposition:

P3. Different regional health systems lead to different development of managerial skills of professionals.

Research design and method

To answer the research question and test our propositions, a survey analysis was conducted among professionals from health organizations in two regions of Italy: Emilia-Romagna and Lombardy. The study covered a time period of one year (July 2018 to July 2019). A questionnaire was administered over several major Italian health organizations of Emilia-Romagna and Lombardy regions, in order to test how health professionals self-assess their managerial skills and identify areas they would like the organizations to improve in (Appendix 1). The validity and effectiveness of the questionnaire were tested on over 50 healthcare professionals, and feedback from this piloting was used to improve its internal consistency. The questionnaire was then sent online to 793 healthcare professionals (doctors, nurses and other health professionals).

The questionnaire is made up of two parts. The first part identifies the general characteristics of the respondent: the role (doctor, nurse or other health professionals), whether respondents cover a managerial position in middle management, and the region where he/she is currently employed. This information is useful for testing the first three propositions (P1, P2, P3).

The second part consists of two questions on each of the ten different managerial skills identified from the literature survey above. (Q1) “How do you self-evaluate your managerial skills?”; (Q2) “How do you think your organization should help health professionals to improve these skills?”.

The first question arises from the widespread idea that health professionals do not believe they have adequate preparation to fill a managerial role.^5,11 The second question reflects the fact that in Italy, as in most Western countries, the task of developing managerial skills is assigned to single organizations.^39–41 Healthcare organizations therefore create specific management training courses for their professionals, especially to develop those skills that are not usually part of a clinician’s background. In fact, some managerial skills may already be part of the clinician profession as they are useful and transversal to different contexts.⁴² Problem solving, planning, and leadership skills can also be developed during clinical practice, and it is reasonable to assume that professionals feel better prepared on these issues. We thus formulate a fourth proposition.

P4. Healthcare professionals feel more competent in transversal skills.

For each of the ten managerial skills identified for the purposes of this study, respondents were asked to give a score on a Likert scale ranging from a minimum of 1 point (very low) to a maximum of 10 points (very much). We opted for a 10-point scale because previous studies find that a 10 or 11-point scale is much clearer for expressing respondent’s assessments appropriately.⁴³ In particular, Preston and Colman state that a 10-point scale is preferable as it allows for a greater possibility of expressing thoughts in detail, while at the same time allowing for algebraic calculations.⁴⁴

The scale also has semantic-dimensional characteristics which allows make it possible to measure each skill with statistical significance.

Analysis was performed using STATA® software version 15.

The variables tested in the questionnaires were identified from the literature on managerial skills for clinicians, as described in the previous section. The Cronbach’s Alpha coefficient was calculated for each one. Table 1 reports Cronbach’s Alpha scores.

Table 1.

Self-assessment of managerial skills.

Ranking	Managerial skill	Mean	Std. Dev.
1	Problem solving	7.27	1.48
2	Planning	7.27	1.61
3	Operation and project management	7.12	1.49
4	Leadership and internal communication	7.10	1.52
5	Quality improvement	7.09	1.60
6	Output and outcome assessment	6.89	1.62
7	External communication	6.85	1.68
8	HR Management	6.82	1.66
9	Organizational design	6.49	1.77
10	Financial management	6.18	2.20

All variables tested, in every dimension, satisfy the hypothesis of Cronbach’s test, and all scored above 0.9 and show high levels of consistency, with the sole exception of Variable 10 “Planning” for Q1, which showed a score of 0.5836.

Results are described below. First, scores for the whole sample are reported, and each item is ranked.

Independent t-tests and a one-way analysis of variance were then performed in order to compare the self-assessment competency levels in selected subgroups of participants. Subgroups comprised doctors vs. nurses; professionals covering a managerial position vs. not covering a managerial position; and professionals working in Emilia-Romagna vs. professionals working in Lombardy.

Because medians did not correspond to the means, the asymmetry index was calculated in order to test the hypothesis of normality. All analysis yielded were carried for alpha ≤10%.

Findings

Of the 793 questionnaires administered to healthcare professionals, 366 were returned (54.98%). 166 respondents are doctors (45.36%), 131 nurses (35.79%) and 69 other health professionals (18.85%); 157 subjects stated they held a managerial position (42.90%), while 209 did not (57.10%). Professionals employed in Lombardy returned 108 (29.51%) whilst professionals in Emilia-Romagna returned 258 (70.49%).

The following tables reports descriptive statistics about how health professionals self-assess their managerial skills (Table 2) and areas which they would like their organizations to improve (Table 3).

Table 2.

Managerial skills to improve in professionals’ healthcare organization.

Ranking	Managerial skill	Mean	Std. Dev.
1	Organizational design	8.34	1.77
2	Quality improvement	8.31	1.90
3	HR Management	8.29	1.96
4	Leadership and internal communication	8.28	1.94
5	Output and outcome assessment	8.26	1.96
6	Problem solving	8.26	1.95
7	Planning	8.23	1.97
8	Operation and project management	8.19	1.99
9	External communication	8.18	1.96
10	Financial management	7.95	2.15

Table 3.

Self-assessment of managerial skills by managers and non-managers.

Managerial skill	Mean ± Std. Deviation		RANK (managers/non-managers)	T	P	Difference between means
Managerial skill	Manager	Non-manager	RANK (managers/non-managers)	T	P	Difference between means
HR Management	7.22 ± 1.36	6.54 ± 1.79	6/8	3.54	0.00	0.68
Leadership and internal communication	7.28 ± 1.27	6.97 ± 1.66	5/4	1.98	0.02	0.31
External communication	7.04 ± 1.39	6.72 ± 1.85	7/7	1.77	0.03	0.32
Organizational design	7.32 ± 1.18	7.00 ± 1.65	4/3	2.02	0.02	0.32
Quality improvement	7.38 ± 1.36	6.90 ± 1.72	3/5	2.84	0.00	0.48
Operations and project management	7.04 ± 1.44	6.11 ± 1.88	7/9	5.17	0.00	0.93
Problem solving	7.47 ± 1.34	7.13 ± 1.56	2/1	2.14	0.01	0.34
Output and outcome assessment	7.11 ± 1.43	6.74 ± 1.72	9/6	2.17	0.01	0.37
Financial management	6.75 ± 1.94	5.78 ± 2.29	10/10	4.30	0.00	0.97
Planning	7.66 ± 1.24	7.01 ± 1.77	1/2	3.91	0.00	0.65

Results show that scores for Q2, about the areas of training required, are always higher than scores for Q1, on professionals’ self-assessment.

As reported in the tables, all variables show a generally high score, all >6 for Q1 and all >8 for Q2, with the exception of variable “Financial management” for Q2.

There is also a simple relation between variables: the top three skills in which professionals assess themselves as skilled are not skills which they would like their organization to provide training for and are ranked low in responses to Q2. On the other hand, skills in which health professionals feel themselves weaker are ranked higher in the responses to Q2, except for “Financial management”, which is ranked last in answer to Questions 1 and 2.

The biggest disparity in responses to the two questions occurs for the variable “Organizational design” (9th position for Q1 vs. 1st position for Q2), which shows that professionals do not feel themselves competent but believe their organizations should improve training and guidance in this area. The variable “Leadership and internal communication” is classified 4th in both rankings while other variables generally show similar disparity to “Organizational design”, although weaker.

Differences between groups

A t-test was conducted on two different clusters of sub-groups: (a) doctors vs. nurses; (b) managers vs. non-managers; (c) Emilia-Romagna vs Lombardy.

Doctors vs. Nurses

To test P1, two sub-groups are identified, doctors and nurses. The analysis showed that there are no appreciable differences between the groups, and doctors and nurses have similar scores on each item. Unfortunately, the results of the analysis have no statistical significance, as the t-tests conducted showed differences between the groups with alpha >0.1. No clear conclusions can be reached and P1 cannot be confirmed.

Managers vs. Non-managers

Table 4 reports single scores in self-assessing managerial skills (Q1) over two sub-groups, managers and non-managers. The t-test showed deviations in variables between subgroups statistically different from zero (alpha <0.1). Analysing these scores, it appears that managers feel more confidence in their own competences than non-managers.

Table 4.

Managerial skills to improve in professionals’ healthcare organization by managers vs. non-managers.

Managerial skill	Mean ± Std. Deviation		RANK (managers/non-managers)	T	P	Difference between means
Managerial skill	Manager	Non-manager	RANK (managers/non-managers)	T	P	Difference between means
HR Management	8.08 ± 1.99	8.43 ± 1.93	2/5	–1.75	0.08	0.35
Leadership and internal communication	7.99 ± 1.96	8.48 ± 1.90	6/1	–2.38	0.01	0.49
External communication	7.91 ± 1.98	8.38 ± 1.93	9/8	–2.96	0.02	0.47
Organizational design	8.00 ± 2.08	8.33 ± 193	5/9	–1.56	0.11	0.33
Quality improvement	8.07 ± 2.03	8.47 ± 1.79	3/2	–1.98	0.04	0.40
Operations and project management	8.19 ± 1.86	8.44 ± 1.70	1/3	–1.36	0.17	0.25
Problem solving	7.99 ± 2.08	8.44 ± 1.87	6/3	–2.20	0.02	0.45
Output and outcome assessment	8.01 ± 2.08	8.43 ± 1.86	4/5	–1.98	0.04	0.42
Financial management	7.59 ± 2.37	8.20 ± 1.95	10/10	–2.75	0.00	0.61
Planning	7.96 ± 2.10	8.42 ± 1.86	8/7	–2.23	0.02	0.46

The biggest deviations in variables between the two sub-groups occur in “Financial management” (0.97 points) and “Organizational design” (0.93 points), and the smallest in “Leadership and internal communication” (0.31 points), “External communication” (0.32 points) and “Operation and project management” (0.32 points).

Differences between scores are significant, but differences between ranking positions are not as clear. Skills sometimes differ by one or two positions, but not more than this, except for “Output and outcome assessment”.

A t-test was conducted in the analysis of responses to Q2 (Table 5). All variables except for “Organizational design” and “Operation and project management” appear significant, with an alpha <0.1.

Table 5.

Managerial skills to improve in professionals’ healthcare organization by managers vs. non-managers.

Managerial skill	Mean ± Std. Deviation		RANK (managers/non-managers)	T	P	Difference between means
Managerial skill	Manager	Non-manager	RANK (managers/non-managers)	T	P	Difference between means
HR Management	8.08 ± 1.99	8.43 ± 1.93	2/5	-1.75	0.08	0.35
Leadership and internal communication	7.99 ± 1.96	8.48 ± 1.90	6/1	-2.38	0.01	0.49
External communication	7.91 ± 1.98	8.38 ± 1.93	9/8	-2.96	0.02	0.47
Organizational design	8.00 ± 2.08	8.33 ± 193	5/9	-1.56	0.11	0.33
Quality improvement	8.07 ± 2.03	8.47 ± 1.79	3/2	-1.98	0.04	0.40
Operations and project management	8.19 ± 1.86	8.44 ± 1.70	1/3	-1.36	0.17	0.25
Problem solving	7.99 ± 2.08	8.44 ± 1.87	6/3	-2.20	0.02	0.45
Outcome assessment	8.01 ± 2.08	8.43 ± 1.86	4/5	-1.98	0.04	0.42
Financial management	7.59 ± 2.37	8.20 ± 1.95	10/10	-2.75	0.00	0.61
Planning	7.96 ± 2.10	8.42 ± 1.86	8/7	-2.23	0.02	0.46

Scores for managers are overall lower rather than for non-managers, with the biggest differences occurring for variables “Financial management”, “Leadership and internal communication” and “External communication”. Smaller differences in scores occur for variables “Operations and project managements, “Organizational design” and “HR management”. However, only “HR Management” shows a significant score with alpha <0.1.

For Q2, unlike for Q1, differences between rankings show consistent disparity.

These results confirm P2.

Emilia-Romagna employees vs. Lombardy employees

Table 6 reports scores in self-assessing managerial skills (Q1) differentiating professionals in Emilia-Romagna from professionals in Lombardy. The t-test found that only 2 variables showed statistical significance with alpha <0.1: “External communication” and “Financial management”, so little comparison can be made.

Table 6.

Self-assessment of managerial skills by Emilia-Romagna vs. Lombardy.

Managerial skill	Mean ± Std. Deviation		RANK (Emilia-Romagna/Lombardy)	T	P	Difference between means
Managerial skill	Emilia-Romagna	Lombardy	RANK (Emilia-Romagna/Lombardy)	T	P	Difference between means
HR Management	6.83 ± 1.57	6.78 ± 1.77	8/7	0.26	0.39	0.05
Leadership and internal communication	7.16 ± 1.39	7.03 ± 1.67	3/4	0.75	0.22	0.13
External communication	6.91 ± 1.61	6.61 ± 1.82	6/8	1.54	0.06	0.30
Organizational design	7.13 ± 1.39	7.07 ± 1.17	4/3	0.80	0.38	0.06
Quality improvement	7.11 ± 1.51	6.96 ± 1.71	5/5	–0.43	0.20	0.15
Operations and project management	6.53 ± 1.65	6.36 ± 2.01	9/9	–0.12	0.21	0.17
Problem solving	7.23 ± 1.42	7.30 ± 1.59	1/1	1.57	0.66	–0.07
Outcome assessment	6.85 ± 1.54	6.87 ± 1.71	7/6	–0.00	0.54	–0.02
Financial management	6.24 ± 2.08	5.83 ± 2.29	10/10	0.54	0.05	0.41
Planning	7.23 ± 1.57	7.22 ± 1.66	1/2	0.83	0.50	0.01

The biggest difference between means of significant variables occurs for “Financial management” (0.41 points). Except for the “Financial management” and “External communication” variables, data show insignificant differences (<0.2 points) which are attributable to the random effect on responses. It can thus be concluded that there are no significant differences between professionals in the two regions.

As for the results for Q2, only the variables “Operations and project management” (Emilia-Romagna 8.43 vs Lombardy 8.07) and “Financial management” (Emilia-Romagna 8.07 vs Lombardy 7.69) show statistical significance with alpha <0.1. No conclusive statements can be made, but the data suggests that there is very little difference between the two regions.

The results do not thus support P3.

Discussion

This study aimed to evaluate how health professionals perceive their level of preparation on managerial issues. Health professionals are in fact increasingly required to combine managerial activities with their clinical activities. This phenomenon affects most of the health systems of industrialized countries around the world, and although the various health systems differ in their structures and available resources, it is widely recognized that nowadays health professionals need to pay attention to both the clinical and managerial aspects of their work to improve the performance of these systems.⁴⁵

The results of our research show that healthcare professionals feel themselves to be sufficiently prepared in all managerial areas identified, as all averages are above a sufficient level (6.0). These findings appear to conflict with earlier research which found a low level of preparation among clinicians in their role as clinician-manager. Just twenty years ago, Ashmos et al.⁴⁶ found that clinician-managers did not have the right preparation or background for this role, and this affected organization performance. The problem was mainly due to poor managerial training, which generated further problems in terms of professional identity and lack of awareness of the role. However, the high average scores identified by our study show that the scenario is changing. Policies and initiatives launched to increase clinicians’ managerial skills are bearing fruits. On the other hand, it is important to take into account that these are self-perceptions, and to better assess this process, it would be necessary to correlate those self-perceptions with the actual performance of the organizations.

Findings from Q2 raise further considerations. For all managerial variables, scores associated with the organization’s need to improve these skills (Q2) are higher than the professionals’ self-assessment (Q1). On one hand this highlights the attention that clinicians pay to managerial skills in carrying out their activities, but on the other hand it suggests that health organizations need to invest more in these areas and do more to promote managerial culture internally. Medical schools have largely failed to offer sufficient managerial training,¹⁷ and today it is individual healthcare organizations that are responsible for programs to provide clinicians with management skills, in the form of in-service courses and involving certification by external bodies. This has important implications for healthcare organizations.

It is also interesting to note how managerial skills are ranked (Table 2). Professionals feel better prepared in transversal managerial skills which can be applied in different contexts,⁴² than in specific managerial skills applied to limited sectors (Last three ranked skills). This confirms and supports proposition (P4). The finding could be explained by the fact that transversal skills can be learned and developed in different contexts and during different work activities, and not necessarily exclusively on ad hoc training courses, but it confirms what was noted above: organizations should promote specific managerial training programs. In fact, the greatest need to increase managerial skills (Q2 - Q1) is found precisely in the last three ranked managerial skills: HR Management (+1.37), Organizational Design (+1.69), and Financial management (+1.77).

Focusing on manager vs. non-manager self-assessment of managerial skills, the clear general trend is that managers feel more confidence in their own competences than non-managers, which confirms P2. This is in line with several studies in different strands of literature^38,47 which find that those who already hold a position of responsibility tend to evaluate their own management skills more highly on the basis of their perception of having experience. The comparison of responses from managers vs. non-managers aims to verify whether and how managerial experience affects the self-assessment of skills. Our results confirm the hypothesis that the point of view of the respondent is linked to the position held.

The analysis of the sub-groups employed in Emilia-Romagna vs. those employed in Lombardy shows less clear results. The Emilia Romagna and Lombardy regions are contiguous and are both considered among the most virtuous in Italy in terms of performance, but they adopt very different organizational and managerial models, as described in the first part of the article.

It is important to note that these two models of interpretation of NHS directives are the focus of heated debate in the literature. In Italy the NHS is run by regional authorities, and Legislative Decree 502/1992 assigned the task of developing clinicians’ managerial skills to Regional Authorities. The big differences between models led us to expect big differences between the development of managerial skills of health professionals in the two regions (see P3), and the fact that no such difference was found can probably be explained in two ways: (1) The complex national system proves to have greater influence than regulations introduced by individual Italian Regions, and (2) Health professionals themselves, in both Emilia-Romagna and Lombardy, know what competences are required to obtain a higher level of organizational efficacy.

Conclusion

Since the early 1980s, all western countries have given priority to reforming health service management. Such reforms have led to the co-optation of health professionals into the management of services, transforming doctors and nurses into managers.⁵ However, a general perception of inadequacy by healthcare professionals in their managerial skills prevailed for many years.^3,13,47

Our study highlighted that healthcare professionals in Italy today feel more ready to play their role as managers, but at the same time require greater effort to be made in developing these skills on the part of their employing organizations.

The analysis highlights that organizational models do not directly influence the self-perception of managerial competences by health professionals. This conclusion is useful for Italian Regional Authorities in identifying where professionals feel a lack of preparation, and promoting training programs and policies. Our findings therefore provide important indications to healthcare organizations on areas where it is necessary to invest more in the future to meet the needs of professionals.

The literature finds that the general management of resources in complex organizations is often the responsibility of health professionals.⁴⁸ Financial management however remains the managerial skill where professionals self-assess weakest competence. Our suggestion to regional policy-makers and health organizations is to try to make health professionals more aware and better informed about their function as managers of economic resources, as the sustainability of the national service depends on their ability to optimize the use of resources and save costs.

Furthermore, this study clearly shows that health professionals identify themselves as generally prepared on the competences domains identified. However, at the same time, they demand their organization invest in more trainings. This evidence can be appreciated in all categories of subjects identified, although it seems to be more evident in doctors than other health professionals. This may appear contradictory but possible explanations for this phenomenon can vary. However, an hypothesis to be further investigated in future research may be that doctors are very self-serving compared to other professional figures, ⁴⁹ as they believe to be competent enough but also believe that the environment they work in does not have the same level of competences.

The study is not without limitations. First, although the sample is large, it is taken from only two regions of Italy. Future research could investigate whether and how the results vary when the investigation is extended to other Italian regions or to other countries. The second limitation is that gender, age, study path, and years of service are all elements that can influence the professional’s response but which have not been taken into consideration. Third, it would be interesting to investigate possible links between the perception of managerial skills with the financial performance or quality outcome of healthcare organizations. Finally results of this research may be subject to bias due to the single source bias and the fact that the self-assessment competency levels may be higher thank their factual competences.

Supplemental Material

sj-pdf-1-hsm-10.1177_09514848211010264 - Supplemental material for Managing healthcare services: Are professionals ready to play the role of manager?

Supplemental material, sj-pdf-1-hsm-10.1177_09514848211010264 for Managing healthcare services: Are professionals ready to play the role of manager? by Simone Fanelli, Lorenzo Pratici and Antonello Zangrandi in Health Services Management Research

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lorenzo Pratici

References

Kaissi

“Learning” from other industries: lessons and challenges for health care organizations. Health Care Manag (Frederick) 2012; 31: 65–74.

Mintzberg

Power in and around organizations. Vol. 142. Englewood Cliffs, NJ: Prentice-Hall, 1983.

Correia

Denis

JL.

Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal. BMC Health Serv Res 2016; 16: 161.

Aini

Management skill and leadership: a case study from hospital managers of charity business in health. J Soc Sci Res 2018; 4: 478–482.

Kippist

Fitzgerald

Organisational professional conflict and hybrid clinician managers: the effects of dual roles in Australian health care organisations. J Health Organ Manag 2009; 23: 642–655.

Day

Klein

Two views on the Griffiths report. The mobilisation of consent versus the management of conflict: decoding the Griffiths report. Br Med J (Clin Res Ed) 1983; 287: 1813–1816.

Kirkpatrick

Jespersen

Dent

, et al. Medicine and management in a comparative perspective: the case of Denmark and England. Sociol Health Illn 2009; 31: 642–658.

Flynn

Remodelling hospitals and health professions in Europe. Sociol Health Illn 2004; 26: 1037–1040.

Bode

Dent

Maerker

Management in medicine or medics in management? The changing role of doctors in German hospitals. Int J Public Sector Manag 2014; 27: 395–405.

10.

Kak

Burkhalter

Cooper

MA.

Measuring the competence of healthcare providers. Oper Res Issue Paper 2001; 2: 1–28.

11.

Berkenbosch

Bax

Scherpbier

, et al. How Dutch medical specialists perceive the competences and training needs of medical residents in healthcare management. Med Teach 2013; 35: E1090–E1102.

12.

Freidson

Professionalism, the third logic: on the practice of knowledge. Chicago: University of Chicago Press, 2001.

13.

Plochg

Klazinga

NS.

Talking towards excellence: a theoretical underpinning of the dialogue between doctors and managers. Clin Governance 2005; 10: 41–48.

14.

Groene

Botje

Suñol

, et al. A systematic review of instruments that assess the implementation of hospital quality management systems. Int J Qual Health Care 2013; 25: 525–541.

15.

Spyridonidis

Hendy

Barlow

Understanding hybrid roles: the role of identity processes amongst physicians. Public Admin 2015; 93: 395–411.

16.

Noordegraaf

Risky business: how professionals and professional fields (must) deal with organizational issues. Organ Stud 2011; 32: 1349–1371.

17.

Ireri

Walshe

Benson

, et al. A comparison of experiences, competences and development needs of doctor managers in Kenya and the United Kingdom (UK). Int J Health Plann Manage 2017; 32: 509–539.

18.

Fanelli

Lanza

Enna

, et al. Managerial competences in public organisations: the healthcare professionals’ perspective. BMC Health Serv Res 2020; 20: 1–9.

19.

Williams

SJ.

What skills do physician leaders need now and in the future?

Phys Exec 2001; 27: 46–48.

20.

Guo

KL.

An assessment tool for developing healthcare managerial skills and roles. J Healthcare Manag 2003; 48: 367–376.

21.

Stoller

JK.

Developing physician-leaders: key competencies and available programs. J Health Adm Educ 2008; 25: 307–328.

22.

Gunawan

Aungsuroch

Managerial competence of first‐line nurse managers: a concept analysis. Int J Nurs Pract 2017; 23: e12502.

23.

Li-Min

Ing-Chung

, et al. Management development: a study of nurse managerial activities and skills. J Healthcare Manag 2007; 52: 156–168.

24.

Peres

Ezeagu

TNM

Sade

PMC

, et al. Mapping competencies: identifying gaps in managerial nursing training. Texto Contexto-Enfermagem 2017; 26.

25.

Hudak

Brooke

Jr Finstuen

, et al. Health care administration in the year 2000: practitioners. J Healthcare Manag 1993; 38: 181–195.

26.

Jones

Dewing

IP.

The attitudes of NHS clinicians and medical managers towards changes in accounting controls. Financ Acc Man 1997; 13: 261–280.

27.

Quinn

Perelli

First and foremost, physicians: the clinical versus leadership identities of physician leaders. J Health Organ Manag 2016; 30: 711–728.

28.

Liu

Bartram

Casimir

, et al. The link between participation in management decision-making and quality of patient care as perceived by Chinese doctors. Public Manag Rev 2015; 17: 1425–1443.

29.

Bailey

Mankin

Kelliher

, et al. Strategic human resource management. Oxford: Oxford University Press, 2018.

30.

Longest

Jr and Rohrer

WM.

Communication between public health agencies and their external stakeholders. J Health Hum Serv Admin 2005; 2: 189–217.

31.

Karuppan

Waldrum

Dunlap

NE.

Operations management in healthcare: strategy and practice. New York: Springer Publishing Company, 2016.

32.

WHO. Quality of care: a process for making strategic choices in health systems. Geneva: WHO, 2006.

33.

Trybou

Gemmel

Van Vaerenbergh

, et al. Hospital-physician relations: the relative importance of economic, relational and professional attributes to organizational attractiveness. BMC Health Serv Res 2014; 14: 232.

34.

Lyles

Joiner

Supervision in health care organizations. Albany: Delmar Publishers Inc., 1986.

35.

Osborne

SP.

The new public governance?

Public Manag Rev 2006; 8: 377–387.

36.

Inamdar

Kaplan

Reynolds

Applying the balanced scorecard in healthcare provider organizations/practitioner's response. J Healthcare Manag 2002; 47: 179.

37.

Sperry

Mobbing and bullying. The influence of individual, work group and organizational dynamics on abusive workplace behaviour. Consulting Psychol J 2009; 61: 190–201.

38.

Salvatore

Numerato

Fattore

Physicians’ professional autonomy and their organizational identification with their hospital. BMC Health Serv Res 2018; 18: 775.

39.

Baluch

Salge

Piening

EP.

Untangling the relationship between HRM and hospital performance: the mediating role of attitudinal and behavioural HR outcomes. Int J Hum Resour Manag 2013; 24: 3038–3061.

40.

Townsend

Lawrence

Wilkinson

The role of hospitals’ HRM in shaping clinical performance: a holistic approach. Int J Hum Resour Manag 2013; 24: 3062–3085.

41.

Fanelli

Lanza

Zangrandi

Competences management for improving performance in health organizations. Int J Health Care Qual Assur 2018; 31: 337–349.

42.

Wawrzenczyk-Kulik

Transversal managerial competence: in search of new methods of education. In: Managing intellectual capital and innovation for sustainable and inclusive society: managing intellectual capital and innovation; Proceedings of the MakeLearn and TIIM joint international conference 2015, 2015, pp.1205–1210. UK: ToKnowPress.

43.

Taherdoost

What is the best response scale for survey and questionnaire design; review of different lengths of rating scale/attitude scale/Likert scale. Amsterdam, 2019, pp.1–10.

44.

Preston

Colman

AM.

Optimal number of response categories in rating scales: reliability, validity, discriminating power, and respondent preferences. Acta Psychol (Amst) 2000; 104: 1–15.

45.

Baker

Denis

JL.

Medical leadership in health care systems: from professional authority to organizational leadership. Public Money Manag 2011; 31: 355–362.

46.

Ashmos

Duchon

Mcdaniel

RR.

Physicians and decisions: a simple rule for increasing connections in hospitals. Health Care Manage Rev 2000; 25: 109–115.

47.

Lorber

Skela Savič

Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian hospitals. Croat Med J 2012; 53: 263–270.

48.

Berwick

Nolan

Whittington

The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27: 759–769.

49.

Doolin

Doctors as managers-new public management in a New Zealand hospital. Public Manag Rev 2001; 3: 231–254.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.17 MB