Abstract: Healthcare managers must introspect today to create high functioning teams to deliver value based care. The providers must adopt management techniques and teachings to deliver inter professional care. This review is grounded in management of healthcare literature on principles of Fayol and Mintzberg to provide an insight to develop strategies and shared decision making in multi-disciplinary team management of modern healthcare organisations.
It offers healthcare managers the clairvoyance to promote change implementation and initiate patient centered care delivery to make a significant and positive impact on equity and social justice. The key lies in comprehending the gist of both Fayol and Mintzberg’s doctrines to give a coordinated hypothetical structure to direct both healthcare management and managerial behaviour. Health care does not need superior and domineering managers neither imperious professionals, what it desires is ethos, logos and pathos.
Management is a broad term and has been interpreted by many theorists in different perspectives. In simple terms, it is an art of getting work done through people in a most efficient and effective manner. Strategic management includes conceptualization, execution and initiatives undertaken by a company in light of different externalities and due diligence of the situations in which the organization works (Whittington, 1996). In practice, it is very difficult to separate conception analysis, formulation and execution process.
Fayol and Mintzberg theories are like two sides of the same coin. Whereas Fayol viewed the system as closed, Mintzberg observed that in real world it is more of an open system involving multiple dynamics and interactions. However today the arguments should not be critiqued as ‘Fayol vs Mintzberg’ but as ‘Fayol and Mintzberg’ to gain valuable lessons to be put in perspective and practice. Fayol’s bureaucratic approach need Mintzberg’s flexibility to handle modern day contingencies faced by organizations today.
Henri Fayol was a mining engineer and worked in an organization which required proper planning and coordination in unifying and harmonizing collective efforts to function which still holds true in a way, for many modern organizations. His observations in the mining industry led him to describe management as functions, whereas Mintzberg, an academician with degrees in mechanical engineering and management believes that management is ‘what a manager encounters’ on the job.
Henri Fayol argued managers needed specific roles to manage work and workers while Mintzberg has a systematic framework approach as opposed to the orthodox doctrines. He demonstrates that management is much more than these five capacities and includes inter personal relationship and open dialogue with workers and clients.
Fayol argued that division of work, based on different skills and level of specialization in distinguished knowledge areas, supports personal and professional development. It promotes efficiency, diversification and accuracy of care delivery both at technical and managerial level. He believed that discipline, authority and responsibility with traceability are much needed to establish hierarchy and smooth workflow in any organization much like mining industry.
The unity of command avoids potential conflict of individual interest and leads to unity of direction. Teamwork which is oriented towards a common goal and planned activities, work cohesively towards same objectives. He emphasized that ethics lead to subordination of individual interests with focus on organizational objectives. According to him productivity and motivation are directly linked to both non-monetary and monetary compensation.
Reputation, hierarchy, job satisfaction is just as important as are financial rewards. Fayol proposed to strive a healthy balance in the decision-making process amongst different levels of management.
He further proposed that hierarchy establishes a clear chain of command in effective decision making and addressing concerns on social order. Balance of safety, clean environment with a mix of right resources at disposal are pre-requisites to function efficiently. He reiterates that all employees should be treated with dignity and offered equal opportunities along with a supervision process which should be fair and impartial. He was of the view that liberty of expression of new ideas and experimentation adds to the strength of an organization and leads to innovation.
On the other hand, Henry Mintzberg elaborates on manager’s diverse roles which need not be limited by any defined function and advocates for practical training of managers in different real-world experiences. He emphasizes not on specific functions but a complex interplay between various roles a manager has to play. His hypothesis incorporates isolating work environment association, roles and administrative obligations to cultivate an unmistakable comprehension of these complex concepts. He advocates the ten roles of a manager and along these lines segregates them into three distinct classes, Interpersonal, Informational and Decisional (Henry Mintzberg).
Relevance to healthcare today
Applying these theories to healthcare industry, where I work, present a good opportunity today to understand these applications in light of the contingencies and demands of the sector. Healthcare today is under tremendous pressure and review by various agencies. Modern managers are trying their best to find a ‘fix’. There is no doubt that it is being managed adversely with consequences to population at large.
The issue stems from distorted interpretations of ‘management’ both in terms of generic and technocratic detachment at the expense of human engagement. Healthcare has become fragmented with many diversified specializations and under division of labor in contrast with Fayol arguments due to lack of coordination and effective communication amongst different divisions disrupting continuity of care.
Scientific advances and technological breakthroughs in the last two decades have increased the expenditure making success in cure the very reason of its structural failure as an organization.Fortunately, we can learn a lot from the basic theories advocated by both Henry Fayol and Mintzberg to adapt and incorporate a change in the failing model.
Organizational complexity according to Mintzberg, depends on horizontal differentiation (the number and size of units or departments) and vertical differentiation (hierarchical levels) as both require increased level of coordination and information processing costs. (Mintzberg, 1979; Obel and Burton, 1998). Healthcare managers develop and maintain a professional team with inherent team spirit, ensuring division of labor and aim to achieve team results in terms of efficiency and equity.
This is achieved by planning, organizing, coordinating and leading the team. Monitoring and control are essential and important in any organizational structure to achieve its goals. Health care management is defined as “the profession that provides leadership and direction to organizations that deliver personal health services and to divisions, departments, units, or services within those organizations” (Sharon et al).
Foresight, vision and contingency plans allow for implementation of policies on how to adapt and strategize decision making to deal with exposure and as what should be done to complete that choice. Fundamentals of management skills come in handy but require amalgamation of different views and an opportunistic approach to make better business decisions in healthcare set up for improved safety, efficiency and performance enhancement along with the minimization of disruption of service delivery.
Innovation and Adaptability
To illustrate by example, I would highlight a recent strategical exercise undertaken in our hospital to tackle patient appointment issues. This exercise though structured on Fayol’s managerial functions also exemplified Mintzberg’s managerial roles of leadership, networking and liaison, dissemination, resource allocation and monitoring, highlighting the need to innovate conceptual thinking in different contexts individually.
Our hospital system was overburdened and to an extent saturated with patient appointments leading to a long list and wait periods. Sometimes a patient had to wait as long as 4 to 5 weeks to see his physician. To address this, we rebuilt our strategy and focused on key healthcare issues, accessibility and capacity building.
The model we created required implementation of fundamentals of management which we realized were long lost in the hierarchy of command and technological advances in our establishment. An ‘action plan’ was developed for specific steps required to deal with this change implementation as each step was crucial for effective adaptation and accommodation of varying practice habits of different departments with an overarching goal of empowering both hospital staff and patients to enable smooth and earlier physician appointments.
To begin with we made sure every voice was heard and requested all the hospital staff to email in their concerns and suggestions, thus making them active participants in the change implementation process. Patients were asked to fill in a questionnaire at each clinic visit for a month. Then we calibrated our reception and call centre. We analysed the patient visit times and their preferred time slots for visits and noticed a clear dip in demand during midday with a clear patient preference for early mornings and late during the day.
We also took note of the ‘no shows’ or cancelled appointments mostly for follow up patients. In our old model when a physician started his clinic for the day all his slots were completely booked. The emergency visits were piled on top and squeezed in between leading to chaos and complaints and cancelled staff break times. We developed our contingency plan for the different load periods scattered throughout the day by dividing straight day’s work into morning and evening shifts.
Utilizing the spared noon time to be oriented towards inpatient care and academic activities. We then went ahead and centralized our hospital booking centre.
For any day only 80% of the slots were booked in advance leaving 20% slots open for any direct walk in patient during the day at physician’s reception, to maximize same day visits. This lead to same day appointments for all cross referrals and no piling up. We also established a dedicated nurse station to answer queries for chronic illness patients. By maximizing same day physician visits and dedicated access to nurse, all unnecessary follow up visits were reduced.
A sense of order and control was soon restored in all the clinics. The appropriate scheduling made staff more coherent and efficient. The energy spent on handling complaints and managing chaos was now being spent towards revenue generating patient care. The very fact that one could visit his physician the same day was reassuring to many; patient anxiety was decreased and the mad rush for overbooking and no shows gradually stabilized. The physician visits became richer and more satisfying to both the physician and patient with increased patient education and practice management.
Learn and Implement
What we learn from our own example mentioned above is that health care organizations are effective but also complicated. By adopting novel patient appointment schedules, we demonstrated an organizational trade off in two dimensions, applying innovation and increasing proficiency against standardized practice norms. For any organization to accomplish their objectives and targets, the managers contribute by governing, superintendence and harmonizing the efforts of employees because organizations don’t succeed by individual singularity.
They must ensure that all resources are tapped and adequately utilized. Health care managers must demonstrate expertise to develop the organization by settling on vital choices in the areas of estimation, arrangements, superintendence, synchronization, innovation, technology acquisitions, and prudent allocation for augmenting efficiency. Health care managers should not simply concentrate on choices that will enable patients to get quality services but additionally to quantify and contrast their executive decisions with alternatives, in light of the fact how various options impact the accomplishment of the organisation.
Fayol’s observations led him to specify managerial roles and what they should do to achieve efficiency. Based on his observations we might believe that mangers are contemplative and methodical planners but this hardly is a universal rule. In real-world, managers adapt to their role and their behaviour represents condensation, heterogeneity and disruption oriented to action in a specific context.
They do contemplate and have a vision but are flexible to change according to the need of the hour, which is what Mintzberg postulates, the conditioning to the job. Accordingly, Fayol’s descriptive functions exist but only as a guide which are amenable to different stimuli and situations. Fayol prescribed management as a science and gave specific professional definitions which he believed are to be enacted in a systematically determined fashion whereas Mintzberg describes it more as an art, by virtue of figurehead where information is processed and disseminated after a mix of due diligence and intuition.
He portrays it as an integration of knowledge, insight and understanding in response to the job contingencies involved. For organizations to be successful they need to adopt structures which are pertinent to different possibilities that influence necessity, capacity and functions of the organisation. Best practice then mandates that each contingency be assessed exclusively to best suit the circumstance (Patricia Flinsch).
While clinicians today have been energized and bolstered by adoption of evidence based clinical practice, it might not hold true for healthcare managers for various reasons. “Healthcare research has been esoteric and does not always address practical management issues” (Axelsson, 1998).
‘Numerous healthcare managers are neither trained nor competent in practicing evidence based best healthcare practices’ (Kovner et al., 2000). Modern clinicians benefit from emphatically proficient and standardised programs, while supervisors have varied ideologies studying different expert foundations and their thought process are often quite divergent as compared to clinicians. Failure stems from a wide range of components, say lack of vision and engagement, restricted integration with clinical process, frameworks and ludicrous design or arrangements.
Health sector employs large numbers of professionals and varying level of specialists in different areas and tends not to perform well when it becomes overly bureaucratic. Abnormal amounts of centralization, hierarchy and bureaucracy in an organization makes it less adaptable to change by losing flexibility and ‘less inclined to engage’ staff. Health sector herein will not be able to extract full potential of employees by laying restrictions and limiting their scope.
It is a good idea to be interactive and incorporate clinicians in the process of transformation by harnessing their experience in advancing change implementation process. Health sector reforms must involve incremental participation of their professionals in decision making exercises regarding improvements on existing capabilities to serve as a steady guide to the leaders driving the change.
Creating unambiguous work environment for health care professionals requires changes in the design, structure and culture of the organization as to how it comprehends and authorizes administration. The practice should incorporate (1) fine balance between efficiency, productivity and vulnerability, (2) establishing and preserving trust, (3) Incremental staff participation and shared decision making, (4) administering unfolding of change, (5) ongoing communication, which increases health professionals commitment towards organization, (6) continuous training, (7) mechanisms for feedback, measurement, and redesign,(8) using knowledge and theories advocated by Fayol to develop “learning organizations” along with improving managerial skills through Mintzberg’s empirical observations and, (9) encouraging motivation to fortify and encourage information uptake.
To summarize, Fayol implies bureaucracy and Mintzberg argues for flexible onsite dynamic interactions. It is imperative to note here that bureaucracy incorporates adeptness, a pecking order and almost a ceremonialistic process to go about things with experts in all serviceable areas and tends to be rigid and slow to change adaptations with reliance on top down control adding layers both to cost and decision making.
Healthcare organizations need to be flexible and adaptable to provide value based services and scientific management has shown improvements in healthcare operations. Having said that I would however agree that both Fayol’s and Mintzberg’s theories are different sides of the same coin and must coexist to satisfy acclimation in the thought process with changing paradigms of modern healthcare practice and service delivery.
Healthcare management reforms today are possible by translation of our theoretical understanding towards pragmatism or implementation of managerial functions on healthcare services delivery model. The key is to comprehend the gist of both Fayol and Mintzberg’s doctrines to give a coordinated hypothetical structure to direct both management and managerial behaviour. Health care does not need superior and domineering managers neither imperious professionals, what it desires is ethos, logos and pathos.
About Dr Manish Barman
MBBS, MD – Internal Medicine, FRCP (Edin. UK),FESC (EU), FAHA (USA)
Fellow, Royal College of Physicians, Edinburgh, UK
Fellow, American Heart Association, USA
Fellow, European Society of Cardiology, France
MSc – Health Economics- Outcomes and Management. London School of Economics (UK)
Dr Barman, with more than 17 years of diverse leadership experience in healthcare industry is currently engaged with the Medicare group in Qatar, He is an MD from Delhi University and is a distinguished ‘Fellow’ of Royal College of Physicians, Edinburgh (UK), European Society of Cardiology and American Heart Association. His dedication towards public health lured him to study Health Economics (outcomes and management) from the reputed Social Policy department of London School of Economics and political science, UK. He also holds a dual Masters in Healthcare administration and Risk Insurance management.
He is credited with significant accomplishments in developing managed care services, integrating delivery systems, improving quality and utilization, management programs and coaching medical staff on healthcare business and practice issues. He specializes in creating strategic alliances with health care providers to effectively align with and support key business initiatives. A Physician at heart he builds consensus and promotes teamwork to manage healthcare costs and establish strategic, mutually beneficial partnerships and relationships with users, vendors and service providers by coordinating multidisciplinary care, organizing community outreach programs and community education. Dr Barman builds high performance teams by developing and motivating skilled professionals committed to cost-effective management of resources and quality performance.
Work- Department of Cardiology, Al Ahli Hospital, PO Box- 6401, Doha, Qatar.
Affiliation – London School of Economics and Political Science, London, UK.
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