Ledelsesfortællinger om regulering af kvalitet: Er lederne helte eller skurke?

Karin Højgaard Jeppesen, Lisbeth Lund Pedersen & Gitte Bachmann Therming

Student thesis: Master executive thesis


This Masters thesis takes its origin in our own thoughts on the question, how middle managers in hospital departments translate and make sense of the top down regulation of quality in National Health Care in Denmark, as well as how they legitimate their actions in the translation process. As starting point of the thesis we frame our thoughts in the context in which the question is embedded and as an example of regulation of quality, the idea of accreditation is outlined. The research question is: How do middle managers in two hospital departments translate and make sense of regulation of quality by storytelling and how do they legitimate the translations? The aim of the thesis is to obtain insight into the above and to use the knowledge gained to understand how these managers make sense of the regulation of quality, despite the fact that standards for quality are centrally determined and the lack of evidence that efforts and resources commensurate with the returns. In order to clarify the phases in which translation of ideas occur and give raise to organizational changes, Czarniawska and Joerges’ (1996) “Travels of Ideas” is presented as a theoretical framework, as well as a model of the translation process according to their interpretation. The three phases are: 1) When an idea is objectified, 2) when the idea is translated into action and 3) - if the idea is successful - the translation into an institution. However, this framework is vague in its description of how people translate. Therefore a structural narrative theory and poetic modes in the interpretation of Gabriel (2000) is presented, in order to outline in which way middle managers use storytelling to make sense of regulation of quality. Finally, legitimation strategies by Vaara (2006) are outlined in order to understand in which way middle managers legitimate their action in the translation process. The study design has an inductive approach. Data were collected by using documentary style and narrative interviews. The material consisted of quality policies and interviews with eight middle managers from a hospital in Region Hovedstaden. The managers are nurses and physicians at two managerial levels in hospital departments. The analysis is structured using the three phases of translations as an overarching framework. In phase one we look into how the idea of accreditation is translated in policy documents in Region Hovedstaden and at one specific hospital in this region, and we analyze in which way the translations are legitimized as well. Phase two analyzes three prominent events in the narratives of the managers: a) regulation of quality as a compulsory task, b) managers verbalizing accreditation and c) managers by-passing the regulation. The analysis shows which poetic modes the managers prefer when trying to make sense of the three events and how they legitimate their translation into action. Finally the characters in the narratives are analyzed, that is in which way two groups of professionals, physicians and nurses, are presenting themselves and each other as heroes, villains or victims when it comes to interdisciplinary and managerial collaboration on quality work. Differences and similarities in translation are examined, as well as how the managers legitimate their translation into action. Phase three analyzes to what extent the idea of accreditation has become as an institution in the two hospital departments. From the analysis it can be concluded, that the managers are telling epic stories as far as accreditation makes sense and when it does not, they are telling a sad and tragic story. They compensate for the tragedies by telling epic stories about conquers and quests when they translate accreditation into their own words and academic discipline. If that does not work either, they by-pass the rules of regulation and concentrate on their clinical practice: The nurses regretting that they cannot follow the rules and the physicians are as a whole still presenting themselves as heroes despite breaking or bending the rules. When it comes to interdisciplinary and managerial collaboration on quality work, the nurses present the physicians as villains due to their lack of participation and presence. Contrary, the physicians are proclaiming the nurses as heroes due to their skills in implementing accreditation in the department. This point is especially significant at the lowest managerial level in the departments examined and one can say that these counter-stories make managerial collaboration troublesome. It is difficult to become a hero if the part is already occupied by the nurses, but it could also be of convenience performing a role as the one and only, who is able to save patient lives in the chaos of documentation demands. On the other hand, it could also be of some sort of convenience for the nurses not letting the physicians into the managerial office – they can keep control. Finally, the thesis concludes that it might be difficult to close the “knowing-doing-gap” concerning best practice of equal patient treatment, because of a lack of dialogue between middle managers and their superiors, when accreditation does not make sense in the local departments. This lack has implications for managerial practice, because it forces middle managers in hospital departments to decide on their own how to prioritize what is important in order to fulfil the accreditation standards and it is doubtful that they will make equal prioritizations.

EducationsMaster of Health Management, (Executive Master Programme) Final Thesis
Publication date2010
Number of pages81
SupervisorsAnne Reff Pedersen