Heinz Brock, Marlies Garbsch, and Doris Wilhelmer


This chapter first argues that leaders of health-care organizations have to cover the requirement of shaping intermediary coordination and negotiation processes between conflicting expectations represented within different subsystems of the organization. Second, it outlines a new approach of leadership learning, combining personal leadership learning of managers with organizational learning. In-house programs as integrated setups for management learning combine both dimensions of learning by using specific setups for steering, learning and organizational change. Thereby, the transformation of an organization can be speeded up in a new mode. Furthermore, this combination offers the opportunity that leadership-role learning immediately results in new leadership behavior through learning on the job as internal change managers in organizations development (OD) projects about negotiation and intermediary coordination. Third, a case study in a health-care organization illustrates this new approach.


How Does Austria Organize Public Health?

Like most industrialized countries, Austria is confronted with permanently rising health expenses. In 2007, Austria invested 10.3% of GDP in the health-care system and was third place in the EU comparison (Habl, Bachner, Klinser, & Ladurner, 2010). Approximately 76% of the expenditures on health care in Austria are obtained from the Federation's public funds, the municipalities and the social insurance carriers. The rest is financed by private households and private insurance companies.

The majority of the investments in health care is dedicated to in-patients (ca. 33%) whereas the holding for out-patients seems relatively low in comparison (18.2%). Austria has a high rate of hospitals, beds and doctors. In 2007, Austria was at the peak in the EU comparison, having about 28 hospital in-patient stays per 100 inhabitants (average length of stay 5.7 days; Habl et al., 2010). In addition to contract physicians, roughly 800 out-patient clinics mainly take care of out-patients.

The tasks of public health care in Austria are split among the Federation, the states and the municipalities. Even though there are numerous initiatives to improve the coordination and cooperation in health care (e.g., nationwide and regional structural plans), division in competencies complicates fundamental reforms. That is evident interalia in the closing of public hospitals, which is hardly enforceable politically.

Public and private hospitals as well as other organizations which provide medical and care services (such as outpatient clinics and diagnostic centers) are under high competitive and changing pressure due to increasing life expectancy, high supply density and economizations in the public sector. In numerous states and municipalities, public hospitals have been hived off into individual companies. Even if a spin-off is successful, it still underlies political influence due to the ownership structures and the committees' occupations (e.g., of the supervisory boards).

These changes in the health sector result in new requirements for leading health-care organizations as well as an urgent demand for new leadership roles and leadership learning.

Health-Care Organizations in an Area of Tension Between Conflicting Expectations

Viewing health organizations systemically requires their description from a stakeholder perspective: As expert organizations they are permanently confronted with conflicting expectations of action and performance based on their environment: politics, economy, science and citizens as patients. Understanding the intrinsic logic of these four subsystems of society becomes a central condition for the planning and implementation of change processes in health-care organizations (Luhmann 1982, 1984; Willke 1982, 2001).

Relevant environments of health-care organizations.

Figure 21.1. Relevant environments of health-care organizations.

(A) Politics (see Figure 21.1)

In democratic systems, the political sector (nation, states and municipalities) obtains the competencies to legitimately exercise power (Willke 1982, 2001). It administrates and spreads taxes among functional subsystems such as education, science and health care while providing them with money and rights, so they can comprehensively fulfill their public order. In Austria, politics aims to provide health care as a public good by giving access to the best treatment to everyone (at the lowest costs). The exertion of influence by the political sector mainly happens through legislation (e.g., the law for the financing of hospitals) and goal setting. For health care to be fundable, suitable legal general conditions—and, as a result, functional public infrastructure (e.g., public hospitals)—have to be established to assert legal claims and/or fundamental political decisions.

(B) Economy (see Figure 21.1)

The economic perspective is represented by financiers and carriers of health organizations (private and public funding, insurance companies); they expect effective management of resources in international comparison. Owners primarily control via standards such as key performance indicators and budgets deriving from them. Those health-care organizations which do not meet the expectations lose money.

In the implementation, the owner's and financier's initiatives often fail because of the logic of the other subsystems. Though controlling instruments (such as Balanced Score Card and Quality Management) have been introduced, it is difficult to embed guidelines in practical routines of health organizations. Public institutions are required to ensure comprehensive infrastructures which may not be economical for private institutions.

The current cutbacks in public funds aggravate the dilemma of political ownership in its dual role representing economy and politics: Political owners must, on the one hand, manage health organizations in an economically efficient manner and, on the other hand, ensure a comprehensive health care coverage.

(C) Patients/Relatives (see Figure 21.1)

Citizens as informed, undeceived patients and their relatives expect professional and trust-based care. They want to be treated as individuals and have their fears as well as needs for time and attention respected. Furthermore, depending on educational background and motive, they want to be included in decisions concerning their health. Their needs for exclusivity often collide with economic demands such as cost reduction through "patient-cycle times".

(D) Science (see Figure 21.1)

Scientific-standard communities serve as guidelines for doctors, nurses and medical-technical staff (MTs) in their roles as experts for core processes concerning survival and healing. These communities form the primary reference system for career choice and profession. Academic education (i.e., medical schools, schools for MTs and nurses) and mentor systems (i.e.. residency, internships) socialize the trainees in the particular field of competence and, after their formal graduation, delegate to them responsibility for taking professional care of patients' lives and welfare. After the professional imprinting phase, learning primarily takes place in expert peer groups without hierarchy and outside of the market (e.g., at congresses, Balint 2001, according to Janes 2010). Motivators for medical experts are the discovery of new treatment processes, scientific reputation among experts and the wish for extraordinary healing success. Experts need free space from health organizations for research to develop new treatment methods and to translate them into practical routines without economic pressure.

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