In the Eye of The Storm: When a new Horizontal Management Position meets hospital reality

The new organization of the hospitals can be regarded as a sort of matrix structure combining a vertical integration of clinical departments with a horizontal integration of patient flows. This structure has elements of both interprofessional and interorganizational integration. A strong focus on team-work, meetings and information exchange is combined with elements of co-location and horizontal management.


Introduction:
In 2013 the 'Region of North-Jutland' in Denmark started a major reorganization of their hospitals. In order to improve the quality of care for their patients, the reorganization was focusing on the coordination of patient flows through the hospitals and also between the hospitals and the primary sector.
The new organization of the hospitals can be regarded as a sort of matrix structure combining a vertical integration of clinical departments with a horizontal integration of patient flows. This structure has elements of both interprofessional and interorganizational integration. A strong focus on team-work, meetings and information exchange is combined with elements of co-location and horizontal management.
In short there are three main innovations. The first innovation is a new clinical structure with a creative combination of interdependent medical specialties in order to facilitate the patient flows. In each clinical department there is a management "troika" consisting of a clinical director (primarily physicians), a deputy clinical manager responsible for human resources (nurses) and a new horizontal management position accountable for patient flows (nurses and a few physicians).
The second innovation is the appointment of this latter and third member of the "troika": a new horizontal management position. They are accountable for horizontal integration strategies and development of patient flows within their own clinics, across the boundaries of the different clinics and across the boundaries of the hospital and the primary sector.
The third innovation is the strong focus on teamwork to support the patient flows of the hospital. Among others the "troika" is working as a management team, where the new horizontal management position plays an important role.
The aim of the article is to describe and analyze the role of the new horizontal management position in the reorganization of the hospital (in the following and to facilitate the written communication this role will be named the new managers). The paper maps these new managers' efforts to shape their role in the management processes and to gain legitimacy.
Theory and methods: The reorganization process which is still going on is followed by a group of organizational researchers. They are conducting a qualitative case study of Aalborg University Hospital, based on a number of individual and focus group interviews with professionals and managers on different organizational levels. The interview data are combined with data from observations of meetings and documentary materials including strategy and planning documents, annual reports, as well as five Master Theses about the reorganization. The analysis is guided by a broad theoretical framework, focusing on the development of horizontal processes in a professional organization.
Results: The results show that the new managers started with a lot of uncertainty regarding their responsibilities. There was also a lot of resistance to the reorganization, which the new managers came to personify. Throughout the change process, the educational background of the new managers had been discussed a lot. The physicians had emphasized that, according to the law, they are responsible for the treatment of patients, and therefore the new managers with a nursing background could not be responsible for patient flows.
Because of the critical views of the physicians, the new managers began their work with a positive, humble and cautious, exploratory approach. It seemed that they played the role of a facilitator or coordinator rather than being a negotiator or giving instructions. Another role that was not so prominent among the new managers was to monitor the coordination of the patient flows. It would require the involvement of many different actors, which was not possible during the first year.
There were also some positive results, achieved by the new managers, but on the whole they felt that the expectations placed on them had been unrealistic.
Discussion: Having followed the first two years of the change process the opportunities for the new managers to act as horizontal change agents and deal with key barriers to change will be discussed. The main barriers consisted of a number of structural, cultural, financial and strategic barriers influencing the change process.
Conclusion: The study sheds new light on integrated care as a concept that can be used also in a hospital, since integrated patient flows through horizontal management was of major importance in the reorganization. The new managers have faced major challenges trying to implement top management visions concerning integrated patient flows through horizontal management. It seems obvious to characterize this new role as placed right in the eye of the storm.
Keywords: integrated care in a hospital; implementing integrated care; patient flow; horizontal management; interorganizational integration