The Danish healthcare system is confronted by two challenges: There is a strong pressure for better performance on quality and efficiency, due to indications of quality problems and regional differences in results, limited future funding and a growing demand. And there is a cross-pressure in governance, where on the one hand demands for high quality across hospitals and regions would legitimize a strong central control and adherence to fixed standards, and where on the other hand current discourse on public governance speaks for increased local freedom and room for innovation as a preample for an effective public service. Both challenges lead back to the design of governance in health care – and how this design secures maximum performance from the clinical staff. This thesis seeks to address the issue of motivation in this regard. The point of departure for the thesis is the assumption that the support of motivation is an important factor in securing performance in health care. Is present governance in healthcare rightly constructed as to secure motivation and maximum performance from the clinical staff – or are there grounds for adjustment, where governance instruments with more emphasis on motivation is brought into play. The form is triangulation, where I assess what rational theory and social constructivist theory say on the effect on motivation from the different governance instruments in Danish health care. As motivation in health care is not very thoroughly handled in the literature, the approach is to a large extent hermeneutic with attempts to present different understandings from the results of the analysis. The thesis and analysis falls in two parts: Part I (chapters 3-5) consists of descriptive and characterising analysis, where the present governance paradigms are mapped, where the possible conflict of interests and values between state and local levels is assessed, where rational theory and social constructivist theory is outlined as to what supports motivation, where the perspectives of systemic evaluation governance as a possible third way is considered, and where health care is analysed as to its readiness for the use of new public management inspired instruments. Part II (chapter 6) consist of an analysis of what motivates doctors, how do they respond to the different types of current governance instruments in health care – and what does this imply in regard to motivation seen from a rational perspective and a social constructive perspective. The basis is a survey conducted in three Danish hospitals (Odense, Køge og Hvidovre), consisting of 41 questions on motivation and attitude towards the current governance instruments, testing my hypothesis derived from the theories in chapter two. Chapters 7 forms the conclusions. The descriptive analysis indicates that governance in the health sector today is characterized by instruments from the rational and pragmatic perspective, with a very clear dominance of the bureaucratic paradigm and NPM-market/contract. The analysis of motivation confirms a significant public service motivation in clinical staff. Doctors have a very high motivation from the job itself – as the motivation, however, first and foremost is about personal gratification, while the more altruistic and victim-derived public service motivation comes a little less clear through. The analysis cannot confirm though a theory that the current management instruments (accreditation, financial incentives, free choice and benchmarking), which are all to a greater or lesser extent are rounded from rational thought, are perceived as very controlling or as an expression of distrust. The analysis confirms a (negative) correlation between the extrinsic management tools and the intrinsic motivation. But the overall picture is that the instruments are not seen as controlling. It is not the same as the instruments are perceived as directly supportive of it professional. Here is the image is, that accreditation and benchmarking is experienced as supportive, while this does not apply to economic incentives and free choice. This gives rise to a conclusion that the rational management tools in the area of health care today to some extent seem accepted by doctors, regardless of their high intrinsic motivation. At the same time, the professional identity seems so strong that the instruments that are not directly experienced to support quality, do not seem to be absorbed in the daily practice. This could support a supposition that doctors, rounded from natural science, and as opposed to other major public sector staff-groups, has a certain understanding of the rationally derived paradigms. With even more caution, the image can support a more rational derived supposition that doctors are to some extent driven by self-interest, why the extrinsic instruments in principle should be justified. The results do not indicate that the instruments degrades the motivation, and therefore in isolation do not give rise to fundamental changes in the current steering. The analyses also shows that health have characteristics that support the use of rational derived instruments: generally seen good standardization options and easy to measure output – all though measuring outcome still has development potential. The political focus and the serious consequences of failure shows less basis though for NPM in its more pure form – with market solutions and encapsulation in contract- driven companies on arms length from the political level. That the professional values with doctors are strong indicates a need for a reinforced effort to ensure that the governance instruments applied to health care can be coupled with quality, and seen as such by the doctors. The analysis also points out that there seems to be an absence of clear leadership at the hospitals. Knowledge of the department’s central goals is highly variable. Involvement in the setting of these goals is very limited. And new management tools and reforms are not accompanied by clear managerial framework of implementation. A partial finding is that women doctors seem to be more perceptive on management – and the absence hereof. The analysis suggests further that doctors are sensible to outside views, which indicates that doctors are in accordance with the sensemaking-thinking. The result therefore indicates, that a precondition to act rationally and in accordance with central goals in the form of clear leadership is missing. And that from a social constructivist perspective the leadership which represents translates outside expectations in a form that makes sense, and which facilitates the common narrative, is equally missing. The analysis also shows a significant potential to support a steering concept Systemic evaluation governance, which is rounded from rationalist thinking with a focus on benchmarking and continuous evaluation, but which also have roots in the professional (what works) and articulates the need for innovation for the clinical staff. The analysis shows a high degree of support for benchmarking – also when it comes to benchmarking of other than the professional results, e.g. economy. Support for benchmarking does also not disappear, if publication is wide as opposed to clinical staff only. Chapter 8 frames perspectives from the findings, part lessons for central and local management, part perspectives in regard to the present discourse on public governance.
|Uddannelser||Master i Offentlig Ledelse, (Masteruddannelse) Afsluttende afhandling|