ANASTASIA BALASOPOULOU, MSC, NATIONAL SCHOOL OF PUBLIC HEALTH EHMA CONGRESS, ATHENS, JUNE 2008 THE POWER GAME IN DECISION MAKING PROCESS IN THE PUBLIC GREEK HOSPITAL

The research questions There is a need for major changes within the Greek hospitals, but a number of interventions designed and a lot of attempts for improvement have failed. The main question set is: why all these failures? The usual accuses of the middle level managers’ capability or of the high political orientation, seem rather general opinions than interpretation? What is the real decision making context that influences the results? Who are the players? Is there a power game? The Power Game is an important issue; its interpretation might be useful for a further and deeper understanding of the potential to enhance the decision making process

What is Power? Power is a locus of will  Held by people  Measured by response  Influenced by values Key conceptions: Agency Interests Intention Authority Accountability Knowledge Culture Power is the possibility that a man has to be in the position to influence a social relation up to the degree to adopt his/her own will for action, despite the resistance (Max Weber)

The decision making context The decision making in a hospital organisation is a very complex process, due to the size and aim, to the different levels of rules, to the formal and informal hierarchy, to the strong interests. The status of power among the different groups is an essential part of this context, as it is the expression of conflicting interests, the exercise of regulations, the balance to external factors that either build barriers or facilitate processes. The public hospital is close to both direct and indirect political influence regarding the aims, the legislation framework, the hierarchy and the interests.

Hierarchy Structure  Clear Political orientation and Legitimate Authority for the Top Management  INCLUDING the Employees’ Representative as a member of the Board,  ALSO the Nursing Director as a member of the Board BUT  The Administrative Director as well as the Medical Director are not members of the Board APART OF THESE  The managers’ election can’t guarantee the knowledge and the character required to play their formal role CEO Medicine Directorate Administration Directorate (*) Nursing Directorate Board Dpt. Economic Sub-D. Administrative Sub-D. Vice CEO Politically appointed Career managers Chosen after MDs proposal PSL * Technical Service D.

The players and their power characteristics CEO Med. DFameDEconMAdm.DNursDTechDUnion Political Orientation no Agency Authority legitimate no Account ability no Technical Expertise ? Interests, Intention The degree of characteristics’ expression may differ depending on the personality 2.“Organized unaccountability” developed, as a symptom of the organizational context

The Three Dimensions Model of Power (Luke) Key elements1 st dimension Episodic Agency 2 nd dimension Power Intention 3 rd dimension Real Interests Objects of analysis Indicators Fields of analysis Study the Behaviour, that is defeated the agency’s choice Concrete Decisions Issues Overt conflict Express policy preferences based on political involvement Interpretive understanding of Intentional actions Non- decisions Potential Issues Covert conflict Express policy preferences embodied in sub- political grievances Evaluative estimations of real interests in action Political agenda Issues, potential issues Latent conflict Relation between expressed policy preferences and real interests

Players’ Strengthnesses and Weaknesses All the players run the 1 st dimension of the episodic agency The more mature players (in terms of expertise or clearer interests) run in addition the 2 nd dimension of the Intention to power The formal structure supports, in a way and up to a degree, the agencies The Doctors and the Union, as well as the Economic Managers have the characteristics to interpret the intentions and the covert conflicts as well as to deal with the political factor in a sub-political way The Directors have a degree of knowledge and the accountability to deal with the power, as well as their authority to build on, but these characteristics are rather latent, as well as their conflicts These latent characteristics do not seem to have the intention or to know the process to build a strong position in this power game or even consensus

Politics in Decision Making The politics could be both the political involvement and the agencies’ strategies The political orientation of the hospital organizations is based mainly on the high interest for the politicians, due to their size, compared to others The absence of rules and control lead to higher dependence on politics The structure supports agencies and, accompanied by the political influence, lead to a power game, with poor-level gains for the player The criterion of accountability of decision makers is not stressed enough, as a factor able to link the process to the rationality The easy decisions, which fail, is the result of the episodic agency phase, and the politically connected agencies can build on these The non-decision is a status preferable by the mature players, may be for repositioning or even as a type of resistance, or both The expertise and knowledge is not an issue to be developed, as a criterion of less importance The consensus needs will, discipline, knowledge

Culture and Resistance The interests, expressed by groups or by persons: are not always based on clear professional or economic issues, but are also based on the perception for personal development and wide acceptance The Resistance is a usual expression in the power game and its volume depends on both interests and culture. The culture, both the personal and the organizational, is very important and basic aspect to build the future on. The Culture has a close relation, conceptual and active, to the Resistance. This is based on the Dominant Ideology been developed in the person, the society and the organizational life. In the whole Europe Marxism and sociology have played a dominant role on people’s will to change, to adopt or to resist, at least for a long time (Abercrombie et al. 1980). Specifically the Greek organizational and social life, due to historical reasons, has developed a “Say No” Culture, expressed with resistance or at least suspicion to any decision Thus the non-decision is accepted and the personal strategies are stronger

The circuits of Power Social relations Agencies Standing conditions Means Resources control Outcomes Rules fixing relations of meaning, membership Obligatory passage points Innovation in techniques of discipline, production Exogenous contingencies Fix/ re-fix Reproduce/ transform Control/ contest Empower/ disempower Facilitate/ restrict Level of circuitType of power agencycausal Social integration dispositional System integration facilitative The circuits are responsive to the Three Dimensions model, in the meaning that they present a process, leading from the 1 st to the 3 rd, from the episodic agency to integration – based on consensus, using the rules and the production discipline

Power reformation to enhance decisions The players will stay in this power game but they can pass from the 2 nd dimension to the 3 rd, in which the real interests can be supported to be formulated and developed The production discipline (as 3 rd circuit) links the outcome to the process needed to reformulate the power game Hospitals are “first line” organizations, thus the production and service methods are of high importance and respect The knowledge and, even more the expertise, is a power itself and that should be used under this meaning There is no evidence that politics are stronger than expertise The managers, who are more stable in the organization, must undertake to develop their knowledge latent power

Decision Making cycles and Principles The membership and participation in DM should be an issue of respect, apart of a play: Roles for decision makers Rules for the process Responsibility of all Responsiveness to the real problematic situation Results close to the aim The rational Decision Making cycles, towards the organization’s aims Board M.D. A.D. T.D. E. sD. Syndicate Informal hierarchy Patients groups Stakeholders Internal N.D. Committees

Conclusions A leader or manager, of each level, has to accept that: Politics is a part of life, with their own rationality and faces, and the only solution is to deal with The bad situations are not somebody else’s fault Also must realize the power itself of: Knowledge for the production and service system Analytical techniques for the conflicts and the context Finally: Invest in the long run