Hospital management teams – reflections on organizational and medical specialization cultures

h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 ORIGINAL ARTICLE Hospi al managemen eams – e lec ions on o ganiza ional and medical specializa ion cul u es Elina Vii anen∗1, Lau i Kokkinen2, Hannu Puolijoki3 1School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland 2Finnish Ins i u e o Occupa ional Heal h, Tampe e, Finland 3E elä-Pohjanmaa Hospi al Dis ich , Seinäjoki, Finland Recei ed: Sep embe 15, 2015 Accep ed: No embe 19, 2015 Online Published: Decembe 1, 2015 DOI: 10.5430/jha. 5n1p90 URL: h p://dx.doi.o g/10.5430/jha. 5n1p90 ABSTRACT Al hough hospi al managemen is s udied in se e al b anches o science, sca ci y o s udies in es iga ing managemen eam wo k in hospi als exis . The pu pose o his pape was o s udy manage s’ unde s anding conce ning he ole o managemen eam wo k in specialized heal h ca e, as well as managemen eam wo k me hods wi hin he di e en ac i i y a eas in a hospi al and in he ope a ional uni s wi hin hei domain. A o al o 54 in e iews o ac i i y a ea manage s and ope a ional uni manage s in one Finnish hospi al dis ic in 2007-2008 was analyzed using da a-d i en con en analysis. Wo k o all managemen eams ocused on inancial and ope a i e issues. Howe e , di e en managemen eams used di e en wo king me hods, which implica es he exis ence o medical specializa ion-speci ic wo k subcul u es wi hin a sha ed o ganiza ional cul u e. The psychia ic ac i i y a ea appea ed he mos ac i e and he mos u u e-o ien ed, whe eas he ac i i y a ea o ope a i e specializa ions seemed he mos de ensi e, and he ac i i y a ea o conse a i e specializa ions was businesslike and un ocused as ega ds he u u e. These di e ences we e po ayed in he eams’ inne dynamics and in e ac ion p ac ices. Ac i i y a ea wo k me hods did no di ec ly ans e o hose o he uni -le el managemen eams. We conclude ha managemen eams may no be op imally used as a o um o s a egic issues o inno a ion h oughou hospi al o ganiza ions and mo e esea ch is needed in o de o be e unde s and he connec ions be ween managemen eam wo k, o ganiza ional cul u e and medical specializa ion cul u e. Key Wo ds: Managemen eams, Specialized heal h ca e, Specialis ields, Hospi al ac i i y a eas, Ope a ional uni s 1. INTRODUCTION In e na ional managemen li e a u e deems la ge hospi als complex, di icul - o-manage o ganiza ions, [1–3] which can- no be o ganized wi hou conside a ion o he wide heal h ca e con ex .[4] In addi ion o i s o mal ju idical and adminis a i e o gani- za ion, a hospi al is also un by a no ma i e o ganiza ional s uc u e, in which he ins i u ionalized ules and me hods o ope a ion o he hospi al come in o play. [5] Typically, hospi als ha e a mul i- ie hie a chy o managemen le els, as well as highly specialized wo k uni s buil a ound s ong p o essional expe s. [6] Va ying o ien a ions be ween di - e en p o essions may cause communica ion p oblems and ic ion.[7–9] Medical specializa ions g ea ly de e mine he s uc u e o la ge hospi al o ganiza ions. Specializa ions unc ion as he basis o he ope a ional o ganiza ion and he di e en ac i - i y a eas. Ope a ional uni s a e usually g ouped by hese med- ical specializa ions. Hospi al manage s discuss specializa- ions wi hou making he dis inc ion be ween o ganiza ional s uc u es and medical e ms. Fo examples “gas oen e ol- ogy” may e e o ei he a medical specializa ion o s uc u al ∗Co espondence: Elina Vii anen; Email: [email p o ec ed]; Add ess: School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland. 90 ISSN 1927-6990 E-ISSN 1927-7008 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 uni wi hin he hospi al o ganiza ion.[10] Hospi als a e also pa h-dependen on hei his o y. They a e in a cons an s a e o dynamic e olu ion and hei his o y pa ially de ines hei cu en ope a ion and ope a ional cul- u e. [11] Cul u ally, hospi als can be b oken down in o se e al subcul u es. [12] O ganiza ional cul u e ela es o he assump- ions, alues, a i udes and belie s ha a e sha ed among signi ican g oups wi hin an o ganiza ion. [13,14] Cul u e con- ce ns he common, accep ed ways o doing hings wi hin an o ganiza ion, as well as he sha ed, indi idual ways o each o i s membe s o making sense o he o ganiza ion. O gani- za ional cul u e a ies ac oss he hospi al o ganiza ion and some o his a ia ion is a ibu able o he a ie y o o gani- za ional cha ac e is ics and measu es o pe o mance. [15] In a hospi al, subcul u es may be ound in, o example, specialis ields and managemen eam ope a ions.[10] One B i ish s udy ocused on he NHS’s 189 acu e hospi al us s and he nea ly 900 manage s unning hem. Desc ibing senio managemen eam cul u e, mo e han hal o he us s we e iden i ied as dominan clan cul u e ypes, whe eas 29 pe cen we e dominan a ional, 11 pe cen we e de elop- men al, and only 6 pe cen we e hie a chical in hei cul- u e. [15] A hospi al may be conside ed a complex, dynamic and adap i e sys em, in which no one is ully able o con ol he sys em o o e ell he ou comes o decisions. [16,17] Hospi- als ep esen cul u ally and s uc u ally di ided ope a ional ields, and a e e y challenging o manage as a whole. To be e manage such an en i y, one may ake ad an age o a enas ha b ing oge he people om di e en sub-g oups. In a hospi al, hese include managemen eams on di e en hie a chical le els. Concep ual amewo k In his s udy, a managemen eam deno ed a g oup o peo- ple om a gi en o ganiza ion, and was composed o man- age s, expe s, human esou ce (HR) and o he in e es g oup ep esen a i es, b ough oge he by a manage o egula planned mee ings, o discuss ma e s conce ning he hos- pi al’s ope a ions. A managemen eam’s main ole is o suppo he manage in his/he wo k, o which he/she is pe sonally esponsible. Managemen eams a e con inuous in hei ope a ions and a e no o med o ca y ou only a single p ojec . Recen esea ch on op managemen eams (TMT) has demons a ed ha hey can ha e a p o ound impac on he s a egic di ec ion and pe o mance o hei o ganiza ions. The majo i y o TMT esea ch has b ough he impo ance o managemen eam composi ion o ligh , and has employed a ious e sions o demog aphy heo y. [18] Demog aphy he- o y sugges s ha he composi ion o TMTs, wi h ega ds o a ious demog aphic cha ac e is ics (e.g. age, enu e, unc ional and educa ional backg ound), may explain he collec i e beha io o managemen eams. [19–21] Recen s ud- ies on TMTs ha e also demons a ed ha he managemen eam cul u e s ongly in luences he beha io s, a i udes and alues o he indi iduals o an o ganiza ion [22] and impac s he o ganiza ion’s pe o mance.[23] A i s bes , managemen eam wo k helps b oaden he pa ici- pan s’ pe spec i e on he o ganiza ion’s ope a ions and helps hem unde s and he signi icance o decisions ela ing o hei own ield as ega ds he o ganiza ion’s main ask and he inancial success o he business. [24–26] A unc ional manage- men eam ac i ely pa icipa es in ca ying ou and moni o - ing he o ganiza ion’s s a egy. [27,28] A well- unc ioning man- agemen eam is also a s ong decision-making body [29–31] and inc eases he o ganiza ion’s inno a i eness.[32–34] In a hospi al, managemen eam membe ship is mainly based on he pe son’s hie a chical o p o essional posi ion wi hin he o ganiza ion, and no , o ins ance, on pe sonal quali ies, o an analysis o he alen o knowhow he managemen eam lacks, o he ideal combina ion o demog aphic ac o s. Managemen eams a e composed wi h e e ence o ep esen- a ion. [35] They a y g ea ly in how hey ope a e. The mos dis inc i e a e he p o essional and execu i e managemen eams and hei ways o ealizing he o ganiza ion’s s a egy di e conside ably om hose o o he s.[27,36] The aim o his s udy is o add o he unde s anding o he ole ha managemen eam wo k plays in hospi al manage- men . The s udy ocuses on ac i i y a eas and ope a ional uni managemen eams’ asks as a pa o unning a hospi- al, as well as on managemen eam p ac ices. Ou esea ch ques ions a e he ollowing: 1) How do managemen eam membe s pe cei e he ope a ion o hei managemen eam? 2) How do managemen eam p ac ices in di e en ac i i y a eas and ope a ional uni s di e om each o he ? 2. METHOD 2.1 Da a collec ion The Specialized Medical Ca e Ac (1062/1989) equi es ha Finnish municipali ies p o ide specialized heal h ca e o hei esiden s. Fo his pu pose, each municipali y is asso- cia ed wi h one o 20 hospi al dis ic s, which each ha e a cen al hospi al. Hospi al dis ic s collec a clien ee, bu he majo i y o he se ices a e paid o by he municipali ies, ha is, hey a e ax- unded. The highes decision-making powe in hospi al dis ic s lays wi h a poli ical o gan. The p esen s udy is based on semi-open in e iews o man- age s who a e membe s o managemen eams. The in e - Published by Sciedu P ess 91 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 iews we e abou managemen eam ope a ions. The da a we e collec ed om he ac i i y a eas (conse a i e, ope a- i e, psychia ic) o one hospi al dis ic and he ope a ional uni s subo dina e o hem, and conce ned he subjec o hei managemen eams. The conse a i e ac i i y a ea included he ope a ional uni s o in e nal medicine, neu ol- ogy, lung diseases, physia y and ehabili a ion, cance , skin diseases and ge ia ics, and co e ed al oge he 390 employ- ees. The ope a i e ac i i y a ea included he ope a ional uni s o su ge y, o hopedics, gynecology, anes hesia, in ensi e ca e, pedia ics, oph halmology, o o hinola yngology and o al diseases, co e ing al oge he 660 employees. The hi d ac i i y a ea, psychia ics, included he ope a ional uni s o adul and elde ly psychia y, child and adolescen psychia- y and collabo a i e psychia ic ou pa ien clinics, co e ing al oge he 370 employees. In e iew pa icipa ion was olun a y. The in e iews we e hemed, and hey add essed, o example, managemen eam s uc u e, wo k me hods, in e ac ion, ime managemen , he ole o he chai pe son, and managemen eam decision- making. A he end o he in e iews, he in e iewees ook ime o hink abou how hey could imp o e hei manage- men eam. The da a included 54 manage in e iews, which we e con- duc ed indi idually. The in e iews a ge ed a managemen eam chai pe son and eam membe s in i e ac i i y a eas and in i e ope a ional uni s. They we e conduc ed du ing he all o 2007 and he sp ing o 2008, and las ed app oxima ely 45-60 minu es. All in e iews we e eco ded and ansc ibed as 15-25 yped pages. The in e iewees we e 23 head physicians, 6 head nu ses, 7 us ees, 9 nu se manage s, and 9 pe sonnel membe s. O hose in e iewed, 21 we e men and 33 we e women. The in e iews and he analysis we e conduc ed by he same wo esea che s h oughou he s udy. Because managemen eam membe ship was connec ed o he pe son’s o mal posi ion in he o ganiza ion, he ep esen a i eness o managemen eams u ned ou o be qui e la ge. The size o managemen eams a ied om 8 o 15 pa icipan s. 2.2 Da a analysis Fo he i s esea ch ques ion, we u ilized all 54 in e iews, and o he second esea ch ques ion, we used he in e iews o he managemen eam membe s om he conse a i e, ope a i e and psychia ic ac i i y a eas and he managemen eam membe in e iews o he ou ope a ional uni s subo - dina e o he a o emen ioned ac i i y a eas. These in e iews amoun ed o 44. App oxima ely hal o he membe s in each managemen eam we e in e iewed, aking in o conside a- ion he ep esen a i eness o he g oups. We applied da a-d i en con en analysis o he esea ch ques- ions. [37] Fi s , he da a was ead h ough se e al imes o ob ain a gene al iew. The i s s age conce ned looking o subjec -ma e ela ing o managemen eam ope a ions. The analysis uni was a sen ence o a comple e hough . The o iginal quo es we e chosen wo d o wo d, a e which hey we e pa aph ased, g ouped and labeled wi h wo ds desc ip- i e o con en . Du ing he g ouping phase, we looked o simila i ies and di e ences. Exp essions wi h simila con- en we e g ouped in o sub-ca ego ies, and u he , h ough abs ac ion, in o umb ella ca ego ies and uni ing ca ego ies. The ca ego ies we e named acco ding o hei con en . [37,38] 3. RESULTS The managemen eams deal wi h a la ge a ie y o di e en subjec s. Some o hese we e on he agenda each ime, some ollowed an annual schedule, and some we e si ua ional. The majo i y o he subjec s a hand we e in o ma i e, ou ine and ecu en in na u e. The a mosphe e a he mee ings was, acco ding o he in e iewees, mainly posi i e and dia- logic. New managemen eam membe s we e no b ie ed on managemen eam wo k be o ehand. The e we e no known common goals o he managemen eam’s wo k, no did eam membe s come oge he o assess he success o hei wo k. The manage s in e iewed we e membe s o one o mo e managemen eams and some o hem we e chai pe - sons in hei own specialis ield’s managemen eam. 3.1 Managemen eam asks The da a showed ha hospi al managemen eams had se - e al di e en asks. A summa y o hese asks is p esen ed in Table 1. Table 1. Managemen eam asks • Sha ing in o ma ion • Inc easing in e ac ion • Fo ming a common consensus • Di ision o asks and du ies ela ing o ope a i e managemen • Assis ing and coo dina ing u u e-planning • Making Decisions • Inc easing commi men o o ganiza ion • O e ing de elopmen oppo uni ies o manage s As in o ma ion channels, he managemen eams wo ked bo h e ically and ho izon ally. The chai pe son was able o use he managemen eam o dis ibu e in o ma ion and he membe s we e able o ecei e i . The managemen eam mee ing ac ed as a o um o aising issues. In addi ion, managemen eam membe s ecei ed in o ma ion om o he sub-uni s in hei own ope a ional uni . 92 ISSN 1927-6990 E-ISSN 1927-7008 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 Managemen eam mee ings had a ying le els o success as in e ac ion o ums. The chai -pe son’s ole was seen as highly impo an in achie ing success ul in e ac ion. Mem- be s epo ed ha managemen eams we e “ he image o hei chai pe son”. All membe s had he oppo uni y o speak bu no e e yone el he need o do so. Manage s (mos ly doc o s) spoke, and depu ies (mos ly nu ses) emained quie , al hough hey we e amilia wi h he subjec s a hand. HR ep esen a i es did no speak unless spoken o. Pa icipan in- e es was mainly ocused on he subjec ha hey hemsel es ep esen ed. In ac i i y a ea managemen eam mee ings in pa icula , membe s we e mainly only in e es ed in ma e s conce ning hei own specialis a ea o specialis a eas close o hei own. Managemen eam mee ings we e used o o ming a com- mon consensus and ag eemen on how o de s om highe up, di ec ions, o some ask o he wise deemed impo an , would be ca ied ou in p ac ice. Managemen eam mee ings laid ounda ions and discussed coo dina ion o u u e plans, alked abou pa ien queues o he need o s and-ins and assigned indi idual planning assignmen s o membe s o he managemen eams. S a e- gic planning had li le p ominence in managemen eams’ ou ine ope a ions. Pe sonnel issues came up in managemen eam in e iews as small snippe s o discussion conce ning employee well- being a wo k, appoin men s, applica ions o u he aining, wo k o ce su iciency, and ec ui men . No sha ed o planned HR managemen iews we e b ough up in managemen eam in e iews. The in e iews depic ed he managemen eam’s ole as a decision-making body as somewha ambiguous in e ms o ac ual decisions being made in he mee ings and whose de- cisions hese we e. In e iewees mainly spoke o decisions made by he managemen eam, bu o mos o hem - hough no o e e yone - i was clea ha he ope a ional uni man- age was esponsible o he decisions. The decision-making p ocess was e y much po ayed as a sea ch o consensus. Open dispu es we e a e. Chai pe sons in pa icula empha- sized he p esen uni y and good a mosphe e o hei own managemen eams. Consensus was sough h ough con e - sa ions in which e e y oice coun ed and comp omises we e made. Mee ings in which no consensus was eached we e a e. Once a decision was join ly made, e e yone commi - ed o i , especially in op- ie managemen eams, in spi e o possible di e ing pe sonal opinions. Managemen eam wo k was seen o possess a quali y o commi ing a pe son o join decisions. 3.2 Managemen eam’s signi icance o manage ial wo k Table 2 p esen s he mos signi ican ma e s ha he man- age s b ough up in he in e iews when discussing he man- agemen eams’ signi icance o hei own wo k. Table 2. Managemen eams’ signi icance o manage ial wo k Ac i i y a ea managemen eams Ope a ional uni managemen eams • Fo ming a gene al iew o e ac i i y a eas • Fo ming a gene al iew o e ope a ional uni s • Recei ing in o ma ion • Recei ing in o ma ion • Commi ing o he ac i i y a ea subcul u e • Achie ing join ag eemen • Inc easing he unde s anding o o he special ields • Inc easing he in e ac ion be ween manage s • Inc easing he unde s anding o o he s' wo k • Commi ing a manage o he leade ship ole • Suppo ing pe sonnel managemen • Cla i ying ones own manage ial ole Membe s o ac i i y a ea managemen eams who we e man- age s s essed he impo ance o in o ma ion low, as well as ha ing a bigge pic u e o he ac i i y a ea and he specialis a eas ope a ing wi hin hem. In ope a ional uni managemen eam in e iews, he manage s emphasized ea u es ha sup- po ed hei own manage ial wo k and i s imp o emen . Join ac i i ies and pee suppo we e also deemed impo an . 3.3 Ac i i y a ea managemen eam p ac ices The manage s in he managemen eams o all h ee ac i i y a eas we e o he opinion ha ep esen a ion was key o in- o ma ion sha ing. All eams ecei ed he same in o ma ion a he same ime. All h ee managemen eams conside ed hei chai pe son o be communica i e and esponsi e o he managemen eam. The e we e ce ain dis inc ions in he way managemen eams ope a ed. These we e mainly isible in he manage s’ de- sc ip ions o g oup a mosphe e, in e ac ion wi hin he g oup, he manage ’s a i ude owa d managemen eam membe s, inclina ion owa ds de elopmen , and join ac i i ies. Ta- ble 3 con ains desc ip ions o he di e en wo k cul u es dis inc i e o di e en ac i i y a eas’ managemen eams. The psychia ic ac i i y a ea clea ly s ood ou om he o he Published by Sciedu P ess 93 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 wo by i ue o i s own s ong emi s a egy, cla i y o decision-making, inclina ion o change and openness, and i s dialogic wo king me hod. The managemen eam s o e o de elopmen and inno a ion wi h an eye on he u u e. The e was less ocus on esul s o inancing han in he con- se a i e and ope a i e ac i i y a eas. In bo h o hese wo ac i i y a eas, he s a egy seemed unclea . The e we e di e - ences be ween he wo managemen eams’ wo king me hods. In he ope a i e ac i i y a ea, he emphasis was on he pa ic- ipan s s anding up o hei own subspecialis a eas, headed by la ge specialis ields such as su ge y and o hopedics. The conse a i e ac i i y a ea’s in e nal wo king me hods we e cha ac e ized by s icking o ac s, he impo ance o in o ma ion sha ing, he managemen eam’s aci u ni y, and es ablished wo king me hods. 3.4 Ope a ional uni managemen eam p ac ices Table 4 p esen s he wo k cul u es o he ou ope a ional uni s’ managemen eams. Two o he uni s belonged o he ope a i e ac i i y a ea, one o he conse a i e and one o he psychia ic. The same p ac ices appea ed o be la gely in use in he ope a- ional uni s, as in he ac i i y a ea managemen eams abo e hem. Obse ing inances and p o i abili y was emphasized. In all he ope a ional uni s, as well as in he ac i i y a eas abo e hem, he p inciple o he managemen eam’s unc- ion appea ed unclea . The e was also some con usion abou decision-making in all bu wo ope a ional uni s. Ma e s conce ning he whole hospi al dis ic we e no discussed in uni -le el managemen eam mee ings and we e mainly only epo ed. Each ope a ional uni managemen eam had i s own in e nal in e ac ion p ac ices which gene ally did no ollow hose o he ac i i y a ea managemen eams. The managemen eams ha sha ed he la ges amoun o managemen eam p ac ices we e he su ge y ac i i y a ea and uni -le el managemen eams, which emphasized a simila specialis e i o ial ide- ology o ha o he ope a i e ac i i y a ea managemen eam. The lung diseases uni , which is a pa o he conse a i e ac i i y a ea, appea ed he mos ac i e and open o change. The child psychia y uni had a d i e o change in i s com- munica i e p ac ices and was inno a i e and dialogic, and was in his way simila o he psychia ic ac i i y a ea, bu disjoin ed and chao ic in i s o he p ac ices. Table 3. Ac i i y a ea managemen eam wo k cul u es Conse a i e ac i i y a ea • The managemen eam is o mal and uncommunica i e. The chai -pe son p epa es he mee ings and o he pa icipan s do no b ing issues o he agenda. • Finding consensus is always he main goal. • The mee ings ocus on medical issues and he nu ses' p esence is a nuisance. The doc o s do no speak o hei own p oblems and no pee -suppo is expec ed o he managemen eam. • Fa - eaching issues a e no discussed. • Discussions abou pe sonnel a e a e. • Chai -pe son is conside ed businesslike, p ecise, conside a e and mode a e, wi h a ouch o an expe ienced clinician. Ope a i e ac i i y a ea • The a mosphe e is open and con iden ial in he managemen eam mee ings. • The eam ecognizes i s own po en ial and is open o change. • The ocus is on he head doc o s and nu sing- ela ed ma e s a e le o o he o ums. • Head doc o s de end hei own special ields and a e unin e es ed in o he s. The eam is no used o pee -suppo . • The mee ings a e domina ed by a he o ic o inance and e ec i eness. • Decision-making is unclea , consensus is sough . • Chai -pe son is deemed as someone who sha es esponsibili ies and se s he one o he mee ings. Pshycia ic ac i i y a ea • The a mosphe e is elaxed, egali a ian and da ing in he managemen eam mee ings. • Di e en opinions a e well ole a ed and he eam is open o new ideas, con iden ial and suppo i e. • The managemen eam aises discussion on he ac i i y a ea's ocus and u u e-plans. • In he discussions, inance is no dominan . Pe sonnel's abili ies a e deemed as impo an discussion- opics. • Di e en p o essions de end hei posi ions, bu head nu ses ake ca e o he g ass- oo s le el and ha e no ime o a end managemen eam mee ings. • Chai -pe son is deemed as adap i e and as someone who se s he one o he mee ings. 94 ISSN 1927-6990 E-ISSN 1927-7008 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 Table 4. Ope a ional uni managemen eam wo k cul u es Ope a ional uni o Lung diseases (in Conse a i e ac i i y a ea) • The a mosphe e is con iden ial and open in he managemen eam mee ings. • Chai -pe son keeps e e yone in o med abou ma e s conce ning he en i e o ganiza ion. O he pa icipan s also aise issues o he agenda. • Focus is on inancial ma e s, and on HR ma e s, such as pe sonnel well-being, ec ui men and educa ion. • Common consensus is sough and decisions a e made. • Chai -pe son has emula ed managemen eam p ac ises om he ac i i y a ea-le el managemen eam he pa icipa es in. Chai -pe son is deemed as inspi ing and able o c ea e a good a mosphe e. Ope a ional uni o Su ge y (in Ope a i e ac i i y a ea) • The managemen eam is businesslike, ou ined and open o de elopmen . • Te i o ial hinking is s ongly p esen , bu he eam seeks o sha ed unde s anding. • Wi hin di e en special ields he pa icipan s seek pee -suppo om ou side o hei own p o ession. • Discussion concen a es on pa ien -ques and pe sonnel well-being and ec ui men . • Common consensus is sough ou , decision-making is unclea . • Chai -pe son is deemed as dynamic and a ional. Ope a ional uni o Pedia ics (in Ope a i e ac i i y a ea) • The managemen eam is undiscou si e and has i s own mee ing p ac ice wi h no agenda. • Team-wo k is deemed equal, wi h no clea doc o -nu se jux aposi ion p esen . • Dispu es be ween special ields, which esul s in in ense discussions. • Mee ing- opics include pe sonnel cos s, ec ui men and well-being, bu a ely inance. • Pa icipan s do no eel hey ecei e pee -suppo . • Chai -pe son is deemed ai o all. Ope a ional uni o Child and adolescen pshychia y (in Psychia ic ac i i y a ea) • The managemen eam is deemed a sa e place whe e e e yone can b ing up hei opinions. • People wi h s ong pe sonali ies con ol he mee ings. Nu sing pe sonnel is less ocal han doc o s. • Se e e ensions be ween di e en special ields exis . • Mee ings ocus on pe sonnel coping and appoin men s. Finance is also a dominan opic. • Decisions a e a ely made and hings a e o en le un inished. • Chai -pe son is deemed meande ing and inexpe ienced in leading he magagemen eam mee ings. 4. DISCUSSION The aim o he s udy was o obse e managemen eam wo k in specialized heal h ca e, and o de e mine he di e ences in he ways di e en managemen eams wo k. Table 5 p esen s he summa y o ou indings. The managemen eams we s udied we e qui e la ge. La ge g oups may no be ideal o in o ma ion p ocessing o inno- a ion, bu hey do inc ease he likelihood o he managemen g oup’s he e ogenei y. On he o he hand, he e ogenei y may dec ease he g oup’s p oduc i i y i he g oup is unable o each a sa is ac o y le el o consensus. [39] The mos c ucial pa is he in e ac ion be ween eam membe s and he shape ha his akes. [40,41] Hospi als ypically ha e a consensus- seeking wo k cul u e, which also became e iden du ing his s udy. In addi ion o a posi i e ou look, i may also lead o he selec ion o neu al opics o he managemen eam’s pe usal which do no lead o open, p og essi e discussion. The esul s indica e ha no new ideas o de elopmen p ojec s we e ha ched in he managemen eams. This may be a esul o hei a o e-men ioned la ge size. The lack o b ains o ming dec eases in o ma ion p ocessing and in- o ma ion use and inally a ec s he hospi al’s openness o de elopmen . [19,42] Acco ding o p e ious li e a u e, he bes - unc ioning managemen eams ha e membe s wi h di e en le els o expe ience, skills and pe sonal ou looks, and hei powe is une enly dis ibu ed. Managemen eams such as Published by Sciedu P ess 95 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 his a e be e equipped o p omo e s a egic change in hos- pi als and o imp o e ce ain igu es depic ing pa ien -ca e e iciency.[27,43] I has also been s a ed ha mul i- alen ed managemen eams a e openly mo i a ed o lea n new hings (such as inancial ad- minis a ion da a sys ems and da a adminis a ion) ela ed o he de elopmen o a hospi al’s s a egic de elopmen . [44,45] Acco ding o c i e ia based on expe ience and p o ession, all he managemen eams in his s udy had equal oppo uni y o ac i ely pa icipa e in de eloping he hospi al’s ope a ion. Table 5. Summa y o indings • Membe s o ac i i y a ea managemen eams s essed he impo ance o in o ma ion low, as well as ha ing a bigge pic u e o he ac i i y a eas ope a ing wi hin hem. In ope a ional uni managemen eams he membe s emphasized ea u es ha suppo ed hei own manage ial wo k and i s imp o emen . • The e we e ce ain dis inc ions in he way ac i i y a ea managemen eams ope a ed. The psychia ic ac i i y a ea clea ly s ood ou om he o he wo by i ue o i s own s ong emi s a egy, cla i y o decision-making, inclina ion o change and openness, and i s dialogic wo king me hod. In conse a i e and ope a i e ac i i y a eas he s a egy seemed unclea . In he ope a i e ac i i y a ea, he emphasis was on he pa icipan s s anding up o hei own subspecialis a eas, headed by la ge specialis ields such as su ge y and o hopedics. The conse a i e ac i i y a ea’s in e nal wo king me hods we e cha ac e ized by s icking o ac s, he impo ance o in o ma ion sha ing, he managemen eam’s aci u ni y, and es ablished wo king me hods. • The same p ac ices appea ed o be la gely in use in he ope a ional uni s, as in he ac i i y a ea managemen eams abo e hem. Howe e , each ope a ional uni managemen eam had i s own in e nal in e ac ion p ac ices which gene ally did no ollow hose o he ac i i y a ea managemen eams. The da a showed se e al asks assigned o he managemen eams. They o med an excellen channel o he ickling up o down o in o ma ion. Regula mee ings b ough me h- ods o manage ial wo k. Managemen eam membe ship inc eased commi men o he decisions al eady made and o he “subcul u e” o managemen . Middle-manage s in pa icula saw he managemen eams o hei espec i e op- e a ional uni s as he mos impo an manage ial ool a hei disposal. The managemen eam di ec ly abo e a manage ’s own ope a ional uni was no deemed impo an . The e is a con adic ion he e, in ha he manage s la gely deal wi h ma e s in hei own le el’s managemen eam mee ings, which hey we e in o med o and asked wi h in uppe -le el managemen eam mee ings. In addi ion, he esul s indi- ca e ha chai pe sons modeled hei own ac ions on hose o hei p edecesso s and he chai pe sons in uppe -le el man- agemen eams. P ac ices such as his ha e been p e iously s a ed o s em om he adi ion o p o essional manage- men .[10] The esul s show ha managemen eams se ed he ope - a i e managemen and coo dina ion o e e yday unc ions o a hospi al, which consis ed o mul iple hie a chal le - els and se e al highly specialized uni s. Ce ain signi ican managemen a eas, such as s a egic emi managemen , HR managemen and o e all u u e-o ien a ion, we e a ely ad- d essed in managemen eam mee ings. The s udy aises he ques ion o whe e exac ly hese managemen a eas ma e ial- ize in hospi als, and whe he hey ma e ialize enough a all. The hospi al dis ic ’s sha ed s a egy emained seconda y in all managemen eams and he s a egy conce ning he eam’s own ield appea ed unclea in he ope a i e and conse a i e ac i i y a ea. Al hough managemen eam wo k is a common p ac ice in public hospi als, he eams’ asks and goals appea ed la gely unclea . This may be pa ly due o he ac ha new eam membe s a e no gi en any o ien a ion owa ds he esponsi- bili ies and liabili ies hey ha e as eam-membe s. Simila ly, he hospi al’s s a egy, along wi h i s ou lined issues and goals, quickly anished on he way down in managemen eams along he hospi al hie a chy. Uni -le el managemen eam asks appea ed o consis o o ganizing daily manage- men and sol ing e e yday issues. E en i he signi icance o managemen eam wo k o man- aging a hospi al emained weak, as he esul s indica e, we mus acknowledge he impo ance ha he eams had o single soli a y manage s’ wo k and o imp o ing hei own leade ship. Managemen eam wo k se ed o b oaden ho i- zons and o help see one’s own wo k as pa o a la ge whole. Managemen eams unc ioned as a enas o ou lining a common ision wi hin a uni and o ou lining he asks and esponsibili ies o ope a i e managemen . Managemen eams had di e en ways o ope a ing acco d- ing o emi . The mos clea ly pe cei able we e he di e - ences in in e nal g oup dynamic and in e ac ion p ac ices. Some o he managemen eams’ p ac ices may ha e di e ed 96 ISSN 1927-6990 E-ISSN 1927-7008 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 due o he eam membe s’ backg ounds in specialized heal h ca e, specialis ields, and hei subcul u es.[15] In a s udy by Vi anen, di e en specialized heal h ca e man- age s no ed ha people wi h p o essional backg ounds in a ce ain medical specializa ion and who wo ked in he o - ganiza ional uni adjacen o ha specializa ion had ce ain common ai s unique o hei specializa ion backg ound, and ha hey migh di e g ea ly om people wi h o he medical specializa ion backg ounds. The di e ence was appa en in beha io and i was clea ly pe cei able among doc o s; less so among nu ses. Conce ning su geons, he image was one o s aigh o wa d, some imes exube an , people wi h an app ecia ion o hemsel es and o p ac ical su gical ex- pe ience. O in e ns, he image was one o slow-mo ing, ho oughly analy ical people who made decisions and ac ed in a calm and elaxed manne , all he while e aining hei own opinions. A an equal dis ance om bo h hese g oups we e he psychia is s, who we e conside ed o be “di e en ” and impossible o de ine using he same c i e ia.[10] These di e ences we e also appa en in managemen eam in- e ac ion and in e nal dynamics. The ope a i e managemen ac i i y a ea’s managemen eam had di e en subspecializa- ion manage s who jealously gua ded hei own e i o y, and manage s who had a dis inc p e e ence o p ocedu es, [8,9] whe eas he conse a i e ac i i y a ea managemen eam membe s could be desc ibed as composed, businesslike, and con empla i e. Membe s o psychia ic managemen eams o en b ough o he eam’s discussion an open and mul i al- ued discou se conce ning nea ly e e y hing ha happened wi hin he eam’s emi . The mee ings we e meande ing in na u e, bu o en he open in e ac ion and e e yone being hea d p oduced a good a mosphe e; one in which inno a ion was also possible.[31] In he ligh o his s udy, i would appea ha he su gical specialis s and hei ep esen a i es had a s onge endency o ans e hei own wo k me hods o managemen eam wo k han he o he specialis s and hei ep esen a i es. The su gical uni was go e ned by he same e i o ial men ali y and he igh o one’s own ield ound in non-su gical uni s, and in he ac i i y a ea abo e i . In u u e s udies, i would be pe inen o pay mo e a en ion o he ans e o wo k me hods om uppe o lowe managemen le els, because he wo k cul u e a managemen eam adop s has been ound o a ec heal h ca e o ganiza ion e ec i eness in hospi als, as well as in p ima y heal h ca e.[15,46,47] Li e a u e on hospi al managemen eam ope a ion om a medical specializa ion pe spec i e is sca ce, so i is di icul o say how s ong he subcul u es ound ac ually a e and whe he o no hey ha e cha ac e is ics which, in he long un, could ei he hinde o p omo e managemen eam wo k. In his s udy, we only looked a ou di e en ope a ional uni s and o make a conclusi e judgmen , da a om addi- ional uni s om di e en ac i i y a eas would ha e been necessa y. The esea ch was ca ied ou in one hospi al and he esul s a e no di ec ly applicable mo e gene ally. This would e- qui e addi ional da a o compa ison om o he hospi als and he wo k o hei managemen eams. Also, as ce ain aspec s o o ganiza ional cul u e and p o essional cul u e may by highly embedded in ce ain na ional con ex , [48] he s udy needs o be eplica ed ou side i s No dic con ex . How- e e , as ecen leade ship esea ch has demons a ed, s udies conduc ed in se e al Wes e n coun ies ha e been highly con- sis en wi h esea ch ou comes om China and o he Asian coun ies, [48–50] indica ing he impo ance o o ganiza ional and p o essional cul u es on he global scale. Also, as such, he one-on-one in e iews o 54 manage s om di e en specialis ields o e a b oad iew o managemen eams’ oles in hospi als, and he pa allel analysis ca ied ou by wo esea che s imp o es he eliabili y o he s udy. F om a hospi al managemen pe spec i e, we should pay mo e a en ion o managemen eam ope a ion, hei asks, and he way in which a hospi al’s op managemen di ec s i s managemen eams. As managemen eam wo k me hods mani es di e en ea u es o specialized heal h ca e, he managemen eams do no necessa ily ope a e in he same way. Manage s a di e en o ganiza ional le els ha e di e - en pe sonal and o ganiza ional goals and needs.[17] Managing di e si y in managemen eam wo k is a challenge o he hospi al managemen . Quinn e al. [51] s a e ha man- age s mus simul aneously ackle mul iple di e en oles and e en ho izons, which hey need o unde s and and accep . Managemen eam chai pe sons would be ha d p essed o u ilize he di e en wo k cul u es ound in di e en g oups while e lec ing on imp o ing hei own managemen eams’ wo k. Managemen eam wo k could be imp o ed by cla i ying ope a ional goals and in o ming e e yone in he o ganiza ion abou hem, as well as by e ining managemen eam dy- namics by consciously dissol ing ou inized wo k me hods, a oiding unnecessa ily ou ine handling o ma e s, enhanc- ing mee ing echniques, and by adding u u e o ien a ion o he eams’ wo k. Managemen eam leade ship and decision- making could also be imp o ed by applying di e en models o eam wo k.[52] Published by Sciedu P ess 97 h p://www.sciedup ess.com/jha Jou nal o Hospi al Adminis a ion 2016, Vol. 5, No. 1 REFERENCES [1] Begun J, Zimme man B, Dooley K. Heal h Ca e O ganiza ions as Complex Adap i e Sys ems. In S. Mick and M. Wy enbach (Ed.), Ad ances in Heal h Ca e O ganiza ion Theo y. San F ansisco, CA: Jossey-Bass; 2003. 253-288. [2] Sweeney K. Eme gence, complexi y and o ganiza ional de elop- men . In E. Peck (Ed.), O ganiza ional De elopmen in Heal hca e. App oaches, inno a ions, achie emen s. Abing on, UK: Radcli e Publishing L d; 2005. 143-166. [3] Da idson D, Peck E. O ganiza ional de elopmen and o ganiza ional design. In K. Walshe and J. Smi h (Ed.), Heal hca e Managemen . New Yo k, NY: Two Pen Plaza; 2006. 343-363. [4] Sho ell SM, Kalunzny A. O ganiza ion Theo y and Heal h Se ices Managemen . In S.M. Sho ell and A.D. 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Does Top managemen eam di e si y p o- mo e o hampe o eign expansion? S a egic Managemen Jou nal. 2007; 28(2): 663-680. h p://dx.doi.o g/10.1002/smj.604 98 ISSN 1927-6990 E-ISSN 1927-7008