Report Of Research Project (10,000 Words) assignment

iPoor Working Relationship betweenDoctors and Hospital Managers– A Systematic ReviewA Dissertation submitted in part fulfilment of the requirementsfor the degree of Master of Business Administration (MBA) inHealthcare Management of the Anglia Ruskin University, UKDate: January 2020Word Count: 9,428iABSTRACTBackground: At a time when healthcare organisations worldwide including the UnitedKingdom’s (UK) National Health Service (NHS) are faced with limited financialresources, changes in patients’ demographics, rising aging population and rapidtechnological advancement, the need for doctors and hospital managers to workeffectively together for the successful running of the organisation has become vitalnow, more than ever. Previous studies have drawn attention to the poor workingrelationship between doctors and hospital managers on the quality of healthcare theyprovide, however, despite the significance of the problems, there is limited systematicreview in this area.Objectives: This study is a systematic review, investigating the organisational factorscontributing to the poor working relationship between doctors and hospital managerswith a view to recommend potential solutions to address them.Methods: A comprehensive search was undertaken of AMED, MEDLINE, CINAHLPlus with Full Text, SportDiscus and EBSCO Ebooks from January 2000 to July 2019and updated in November 2019. Mixed methods, qualitative studies and quantitativestudies that explored doctors and managers working relationship in hospital orhealthcare services were included in this review. The settings of the included studieswere hospitals or healthcare service centers. Studies that were published in Englishlanguage in peer reviewed journals between January 2000 and December 2016 wereincluded. Study selection, data extraction and appraisal of study were undertaken bythe researcher (PO). Quality criteria were selected using CASP (Critical AppraisaliiSkills Programme, 2013), which is a Qualitative Research Checklist comprising 10questions, used in assessing the rigor and quality of the selected papers.Results: A total of 49,340 citations were retrieved and screened for eligibility, 41articles were assessed as full text and 15 met the inclusion criteria. They include 2mixed method studies, 8 qualitative studies, and 5 quantitative studies. The studieswere analysed qualitatively as meta-analysis of these multiple studies was notpossible.Conclusion: This study found that poor collaboration and effective communication,cultural issues, power and autonomy, finance and resources issues, as well aseducational differences were among the organisational and professional factors thatcontributed to poor working relationship between physicians and hospitaladministrators. This study recommends that healthcare policy makers, administratorsand funding providers should create and implement strategic plans such as aconsensual agreement that is flexible and includes frequent dialogue and greaterorganisational transparency in decision making to improve doctor-managerrelationships – which ultimately could lead to improved quality of care, better workperformance and job satisfaction.Key Words: Doctors, physicians, hospital managers, administrators, poor relations,poor working relationship.iiiTABLE OF CONTENTS ABSTRACT ………………………………………………………………………………………………….. iCHAPTER 1 INTRODUCTION ……………………………………………………………………… 11.1 Introduction ……………………………………………………………………………………. 11.2 Purpose of the Study ………………………………………………………………………. 91.3 Research Question …………………………………………………………………………. 91.4 Chapter Summary …………………………………………………………………………. 101.5 Introduction to Chapters Two to five ………………………………………………. 10CHAPTER 2 METHODS ……………………………………………………………………………. 112.1 Introduction ………………………………………………………………………………….. 112.2 Data Source and Search Strategy …………………………………………………… 122.3 Inclusion and Exclusion Criteria …………………………………………………….. 162.3.1 Inclusion Criteria …………………………………………………………………….. 162.3.2 Exclusion Criteria ……………………………………………………………………. 162.4 Search Strategy and Search Outcome ……………………………………………. 172.5 Quality Appraisal …………………………………………………………………………… 192.6 Data Extraction and Synthesis ……………………………………………………….. 202.7 Chapter Summary …………………………………………………………………………. 20CHAPTER 3 RESULTS ……………………………………………………………………………… 213.1 Organisational Causes of Poor Doctor-Manager Working Relationships ……………………………………………………………………………………..303.1.1 Theme 1: Poor Collaboration and Communication…………………….. 303.1.2 Theme 2: Cultural Issues …………………………………………………………. 313.1.3 Theme 3: Power and Autonomy ……………………………………………….. 333.1.4 Theme 4: Finance and Resources Issues ………………………………….. 353.1.5 Theme 5: Education Differences/Challenges …………………………….. 373.1.6 Chapter Summary ……………………………………………………………………. 38CHAPTER 4 DISCUSSION ………………………………………………………………………… 394.1 Chapter Summary …………………………………………………………………………. 47CHAPTER 5 CONCLUSION ………………………………………………………………………. 48REFERENCES …………………………………………………………………………………………… 51APPENDICES: …………………………………………………………………………………………… 61Appendix 1: Critical Appraisal Skills Programme (2013) Qualitative Research Checklist ……………………………………………………………………………………………………. 61Appendix 2: Summary of Main and Subthemes of Included Studies …………………… 67ivLISTS OF TABLES Table 1: Qualitative Search – Combined Results of Electronic Database Searches of AMED, CINAHL, CINAHL Plus with Full Text, eBook Collection (EBSCOhost), MEDLINE, SPORTDiscus ……………………………………………………………………………. 15 Table 2: Inclusion and Exclusion Criteria ……………………………………………………….. 17 Table 3: Summary of the Included Studies ……………………………………………………… 23 Table 4: Summary of Thematic Analysis: Organisational Factors Causing Poor Doctor-Manager Relationships ……………………………………………………………………… 28 List of FIGURES Figure 1: Proposed PRISMA Flow Diagram ……………………………………………………. 181CHAPTER 1 INTRODUCTION1.1 IntroductionThe problem of poor relationship between doctors and hospital managers is a commonfeature of many healthcare systems worldwide, including the United Kingdom’s (UK)National Health Service (NHS) (Edwards, 2003, Drife and Johnston, 1995). Accordingto Powell and Davies, (2016), good working relationship between physicians andhospital executive are essential ingredients for the effect performance, improvedpatients’ wellbeing and quality of the NHS care (Powell and Davis, 2016). Therefore,a poor working relationship could have a significant impact on the quality of healthcare,as it could lead to higher mortality rates, near misses, low staff performance as wellas low patient satisfaction (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).Several authors (Powell and Davis, 2016 and Rundall and Kaiser, 2004), havesuggested that the lack of understanding and agreement between managers anddoctors in the management of hospital services is not only common but that they havenegative impact on healthcare services. They have also suggested that the problemis likely to deteriorate in the coming years. Furthermore, despite the significant impactpoor working relationship between doctors and managers could have on quality ofcare, staff performance and patient experience, there is limited systematic review inthis area (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998). This is one of mymotivations for this study.Previous healthcare models involved government appointment of hospital board ofadministrators with members not necessarily working in the hospital for example,2former military officers or politicians with a level of experience as public servants(Vlastarakos and Nikolopoulos, 2007). However, one of the criticisms of thesepractices is that it was not effective because it lacked competent technocratic leaderswho have the requisite knowledge and experiences of long-term planning and bettermanagement of hospital systems (Vlastarakos and Nikolopoulos, 2007). Furthermore,with the growth of healthcare management and the emergence of healthcareprofessionals in hospital administration, the acceptance of these models amonghospital professionals have been limited, more so that they lacked multidisciplinarycollaboration and cooperation (Vlastarakos and Nikolopoulos, 2007, Spurgeon, 2001).However, according to Spurgeon (2001), growth in healthcare and involvement ofmanagers who are empowered to enforce government policy and the role of hospitalprofessionals such as doctors in hospital administration have led to tensions or poorworking relationships between the two groups.A study on doctor-manager relationships in the United States (US) and the UnitedKingdom (UK), found that both groups agreed that relations between them were poor.In the UK study, both the hospital administrators and clinical executive were optimisticabout the state of their relationships (Rundall and Kaiser, 2004). About 76% of hospitalexecutives rated the quality of current relationships between the two groups as verygood, compared with just 37% clinical directors. Furthermore, 78% of chief executivesbelieved the communication and interactions between doctors and hospital managerswould improve over the coming year, compared with just 28% of clinical directors(Rundall and Kaiser, 2004). Similarly, in the US study, managers were perceived morefavourable regarding their relationships with the doctors (Rundall and Kaiser, 2004).The researchers also observed that 26% of clinical directors and 29% physician3executives were of the view that the relationship between them and their chiefexecutive counterparts would likely deteriorate over time. Despite the obviousdifferences between the US and the UK system of healthcare delivery, the surveyrevealed how doctors in both countries were more pessimistic than managers aboutthe state of their working relationships. A strength of this study is that a significantpercentage of doctors and managers (24% to 44%) were unhappy with the time,resources and energy committed to developing effective relationships locally (Rundalland Kaiser, 2004).Similarly, a recent UK research by Nuffield Trust (Powell and Davies, 2016), foundthat 72% of chief executives were more optimistic about their relationship comparedwith only 50% of clinical directors. Although 80% of hospital executives believe that inthe coming year, progress would be made, only about 35% of clinical directors held asimilar viewpoint. Surprisingly, more than half of the clinical directors (51%) and only18% of chief executives were of the view that physician-hospital manager relationshipswere likely to decline in the coming year. Although both the clinical directors and chiefexecutives were dissatisfied about the relationship between the two groups, thenumber was higher in the clinical director group.Although both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studiesused a questionnaire survey method for data collection, the former utilised a face toface interviews and focus groups for data collection. While questionnaires are a veryuseful survey tool for gathering information from a large cohort with relative ease, theyrequire extensive planning, time and effort (Jones, et al., 2013). A strength of thePowell and Davis, (2016) study is that it involved a larger cohort (472 respondents)4compared to the study by Rundall and Kaiser (2004), which had only 117 respondents.It is also worthy to note that in the study by Powell and Davis (2016), the inclusion offace to face interviews and focus group as additional methods of data collectionimproved the trustworthiness of their research findings.Both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studies havehighlighted the need to further investigate the poor working relationships betweendoctors and managers because it is likely to deteriorate over the coming years. Thisis one of motivations for this study. Furthermore, despite the significant impact thispoor relationship could have on the quality of care, there is limited research in thisarea (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).Globally, the role doctors and hospital managers’ play in the administration ofhealthcare service has more than ever before, continued to be in the spotlight of boththe general public and the media due to the increasing demands for improve qualityof life, quality of healthcare and cost effectiveness (Vlastarakos and Nikolopoulos,2007). These difficulties may be attributed to the modern expensive high-technologicalmedicine, to the growing demands and awareness of patient’s rights and to theincreasing financial constraints facing hospital administrators, which include bothdoctors and managers (Stadhouders, et al., 2018, Vlastarakos and Nikolopoulos,2007, and Pollitt, 1996). Furthermore, with the introduction of the market into thehealthcare industry, increasing the drive for efficiency, there is a well-established shiftin public sector management for improved quality of healthcare, better clinicaloutcomes and improved patient satisfaction (Degelin, et al., 2003). In order to meetthese growing demands facing healthcare services, which is not only unique to the5National Health Services (NHS), both hospital doctors and managers must collaborateand work in harmony. However, differences in opinion between doctors and managershave not only led to poor working relationships between the two groups, but alsoaffected their ability to meet these healthcare demands.A study by Gallup found that physicians who were fully engaged with hospitaladministration were 26% more productive than physicians who were dissatisfied(Burger and Giger, 2014). This increase equates to an average of $460,000 in patientrevenue per physician per year’ (Burger and Giger, 2014). The study also found thatwhen physicians are fully engaged with hospital administration, the outpatient andinpatient referrals increased on average by 3% and 51% respectively. One particularstrength of this study is that it highlights the benefits of physician involvement withhospital administration in the delivery of healthcare services. Conversely, lack ofphysician-manager engagements could not only lead to decrease in hospital revenuefrom low physician productivity, but it could also ultimately affect the quality of patientcare.Besides, with the current unsustainable growth in the UK NHS healthcare expenditurethat is characterised by higher scarcity of resources, fiercer competition with amonumental shift towards public-private partnerships and strict cost-containmentpolicies, managers and physicians must work collaboratively to achieve betteroutcomes for the healthcare industry, members of the public and funding providers(Stadhouders, et al., 2018, Powell and Davis, 2016 and Kaissi, 2005). This partnershipbetween doctors and managers together could be under a conjoint responsibility or ashared authority (Kaissi, 2005). According to the Guardian publication by William6(2017), “with an army of more than 1.5 million NHS staff, a £11 billion budget andmillions of patients and service users to look after, it is very important that the NHS iswell managed by doctors and managers”Although the success of healthcare services in efficiently and effectively achievingthese outcomes is theoretically pursued by all involved in hospital function, differencesin understanding between doctors and managers may jeopardise this objective(Kaissi, 2005). Several factors have been argued to be associated with poor workingrelationship between doctors and managers such as cultural and behaviouraldifferences, as well as differences on philosophy of managing care strategies (Kim, etal., 2017, Kaissi, 2005, Drife and Johnston, 1995).Powell and Davies, (2016), suggested that financial constraints in the NHS wereassociated with poor working relationship between managerial and clinic staff such asdoctors; and that the situation is likely to continue to deteriorate if nothing is done toprevent it. These economic challenges are associated with the challenges inhealthcare delivery arising from economic liberalisation policies such as privatisation,deregulation, and cuts in government spending in order to increase competition inpublic services such as the NHS (Powell and Davies, 2016, Schultz, 2004). It has beenargued that there are fundamental differences between the mentality of doctors andnon-medically educated managers who are often responsible for hospitalmanagement (Freidson, 1972). Another source of tension between doctors andmanagers as noted by Freidson (1972) is the huge gap between the mentality ofphysicians (doctors) and that of non-medically educated managers who often areresponsible for oversight functions of the doctors. It has been argued that doctors hold7this clinical mentality as they believe that their fundamental role or allegiance is to theirpatients. On the other hand, managers typically have a managerial mentality as theybelieve their primary duty is to the organisation and they are responsible for thefinancial management and organisational strategy (Freidson, 1972).The traditional roles of physicians and hospital administrators are similar, however,the root causes of poor working relationships between these two groups and themanner in which this issue is manifested may vary from one country to anotherdepending on the specific arrangements for financing, organising, and deliveringhealthcare services (Rundall and Kaiser, 2004). For instance, in the US, there aresome states where hospitals are prohibited from hiring doctors as employees due tocorporate practice of medicine laws in those states. In those instances, doctors remainin private practice, but they are permitted by hospital staff to refer patients to thehospital (Rundall and Kaiser, 2004). The doctor who referred the patient to thehospital, manages the hospital care of the patient as the “visiting medical doctor”(Rundall and Kaiser, 2004). The services provided by the private doctor arereimbursed by the hospital depending on their health insurance policy (Rundall andKaiser, 2004). In this example, the doctors are independent from corporate control andthey exercise the autonomy of being able to admit patients to any hospital where theyhave credentialing privileges (Rundall and Kaiser, 2004). This is in contrast to the UK,where most hospitals are managed by the NHS Trusts, patients who are referred tothe hospital by their general practitioner (referring physician), are overseen andmanaged by hospital-based doctors employed by the hospital or under contract withthe NHS, and the care provided is free of charge to patients (Rundall and Kaiser,2004).8These differences in the management systems, professional relationships andfinancial responsibilities between the U.S. and UK healthcare models are likely toaffect the way doctors and managers interact. In 2003, a U.S. study by the GovernanceInstitute (2003) involving 60 hospital managers, revealed that competition betweenhospitals and doctors for outpatient services and physicians covering on-call dutieswithout compensation were two significant factors that affected the workingrelationships of these two groups. The study found that because of the poor manager-doctor relationships, some of the doctors who were displeased with the hospitaladministration thought of referring patients elsewhere, while some attempted tocompete with the hospital (The Governance Institute, 2003). In the UK, a study (Davieset al, 2003) found that the rejection of the NHS medical consultant contract in Englandand Wales by the doctors was partly due to doctor’s mistrust of managers and fearthat might lose their autonomy. In both countries therefore, doctor-managerinteractions have consequences not only for policy and funding providers but also forthe efficiency of local patient care processes (Rundall and Kaiser, 2004).Previous studies (Powell and Davis, 2016 and Rundall and Kaiser, 2004) havehighlighted the need to investigate the lack of cooperation between doctors andmanagers further because of the impact on healthcare provision. Furthermore, despitethe significant impact that a poor working relationship between the two groups couldhave on quality of care, there is limited systematic review in this area (Schultz, 2004,Edwards, 2003 and Aiken et al, 2003). The problem does not only persist, but it islikely to deteriorate with the growing risks of doctors disengaging from management.Therefore, further research is necessary to investigate organisational factors, whichcontribute to the poor working relationship between doctors and managers with a view9of recommending potential solutions to address them. This is my main motivation forundertaking this study.1.2 Purpose of the StudyThe purpose of this study is to undertake a systematic review of literature on theevidence regarding poor working relationships between doctors and managers inhospitals with a view to identify possible root causes of the problem and suggest waysto overcome them. The expectation is that this study will add to the body of knowledgerequired to help improve doctor-manager relations, which in turn could potentially leadto better outcomes for patients and their families, healthcare services, policy makersand funding providers.In order to address the gap in the current knowledge regarding poor workingrelationships between doctors and hospital managers, a main research question wasformulated which is: “what are the organisational factors which contribute to the poorworking relationship between doctors and hospital managers?”1.3 Research Question1. What are the organisational factors that contribute to poor workingrelationship between doctors and hospital managers?101.4 Chapter SummaryChapter 1 has introduced the research topic and presented why poor workingrelationships between doctors and managers is a problem. It discussed the backgroundliterature on this issue, highlighted some of the causes and consequences of theproblem on healthcare services, the knowledge gap and the purpose of this currentstudy. This chapter also stated the research question. The remainder of the study isorganised into four chapters.1.5 Introduction to Chapters Two to fiveChapter 2 presents a systematic review of the literature on poor working relationshipsbetween doctors and managers in hospitals. Chapter 3 presents the results of peer-reviewed journal articles that were included in this systematic review including thesummary of the included studies and the identified key themes. In Chapter 4 thediscussion on the findings of the systematic review are presented. Chapter 5 containsthe conclusion, the limitations of the study, and recommendations for further research.11CHAPTER 2 METHODS2.1 IntroductionThis chapter deals with the study design, which is a qualitative systematic review, thedata source and search strategy, the inclusion and exclusion criteria, as well as thesearch outcome. It includes quality appraisal of the included studies, data extractionand synthesis.Research designs are different, and they include a single observational case study, acohort or case-controlled design, non-randomised and randomised controlled trials(RCTs), qualitative studies and systematic reviews. Each method has its ownadvantages and disadvantages. The choice of which method to adopt is dependenton factors such as the research question, ethical issues, sample size and funding(Hicks 1999). Therefore, the choice of this research methodology, which is asystematic review was because this is a secondary research – that is a review ofprevious studies, as well as a result of the research question. According to Higginsand Green, (2011), “a systematic review is a secondary research (study of studies)that seeks to gather all primary studies that fit prespecified eligibility criteria in order toaddress a specific research question, aiming to minimize bias by using anddocumenting explicit, systematic methods” (Higgins and Green, 2011).To undertake a systematic review, the researcher usually develops a protocol, whichguides the whole process of the review. This is to ensure that the findings of the revieware of a high-quality evidence (Butler, et al., 2016). Therefore, the qualitativesystematic review defined by Ring and her colleagues (2010) and the York Centre for12Reviews and Dissemination (2019) guided the methodological protocol for this study.It also ensures that both the inclusion and exclusion criteria follow logically from thereview question. It has been suggested that an important step in the development ofa qualitative systematic review is to have a research question (Bettany-Saltikov, 2012).The framework for developing a research question in qualitative studies that wassuggested by Stern, et al., (2014) was adopted by this review and it involves thePopulation, Exposure, Outcome (PEO) framework, which is readily used by qualitativestudies.2.2 Data Source and Search StrategyThe aim of the search strategy was to maximally retrieve relevant papers that wereappropriate to the research question, as well as reduce retrieval of papers that are notrelevant (Higgins & Green 2006). To achieve this objective, several widely accepteddatabases were searched. These include:I. A search for papers was conducted through the search engine of the AngliaRuskin University Ebscohost, using AMED (Allied and ComplimentaryMedicine), MEDLINE (Medical Literature Analysis and Retrieval System),CINAHL (Cumulative Index to Nursing & Allied Health Literature) Plus with FullText, SportDiscus and EBSCO Ebooks from January 2000 to July 2019 andupdated in November 2019.II. Reference Lists: These were searched from the relevant primary and reviewstudiesIII. Grey Literature: The following was searched via –a. SIGIE (System for Information on Grey Literature in Europe)IV. Conference Proceedings: These were searched via:13a. ZETOCb. ISI (Institute for Scientific Information) web of scienceV. Cochrane LibraryVI. The Internet: The following were searcheda. Department of Health (http://www.dh.gov.uk)b. Google Scholar (http://www.scholar.google.co.uk)c. Google (http://www.google.co.uk)In addition to the above, relevant healthcare management textbooks were consultedfor information on manager-doctor relations.The search was limited to studies published in English language. Non-Englishlanguage studies for example, French and Chinese were not included because of theconstraints of translation into English language such as time and money. According toBettany-Saltikov., (2012), an electronic search strategy should in general have threesets of terms. These include terms to search for –1. The population of interest – Doctors and managers2. The exposure – Working relationships in hospital or healthcare service3. The types of study design to be included – Mixed methods, qualitative studiesand quantitative studiesThe search strategy began with the use of key words and multiple terms that describethe population such as doctors, managers and physicians. The Boolean operator “OR”was used to link these terms in order to retrieve articles that contained at least one ofthe search terms. The same process was repeated for a second and a third set ofterms related to the exposure (working relationships in hospital or healthcare service)14and the study design (Mixed methods, qualitative studies and quantitative studied)respectively. These three sets of terms were then combined with the Boolean operator“AND”. This allows for the retrieval of articles that are relevant to the study design, andaddress both the population of interest and the research question.The following lines: S5, S15, S26 and S27 of the updated search through the AngliaRuskin University Ebscohost were used respectively to identify records related to thepopulation (doctors and managers) and exposure (working relationships in hospital orhealthcare service) and studies of the appropriate design. See Table 1 below fordetailed description.15Table 1: Qualitative Search – Combined Results of Electronic Database Searches of AMED, CINAHL, CINAHL Plus with Full Text, eBook Collection (EBSCOhost), MEDLINE, SPORTDiscus# Search Terms Combined Results from above Database SearchesS1 Doctors 499.000 S2 Physicians 1,546,371 S3 Physicians or doctors or clinicians 2,214,757 S4 Medical doctors or practitioners 1,406,777 S5 S1 OR S2 OR S3 OR S4 2,634,181 S6 Manager or managers 318,119 S7 Manager or leadership 561,491 S8 Manager or leader or executive oradministrator 881,949S9 Hospital manager or managers 318,119 S10 Hospital management or administration 4,526,489 S11 Hospital directors 2,162 S12 Trust management 319 S13 Trust administrators 18 S14 Trust managers 321 S15 S6 OR S7 OR S8 OR S9 OR S10 OR S11 ORS12 OR S13 OR S14 5,246,569S16 Poor relations or relationships 2,776,115 S17 Conflict 300,258 S18 Differences in opinion 3,600 S19 Dispute 120,739 S20 Disagreement or argument or conflict 492,086 S21 S16 OR S17 OR S18 OR S19 OR S20 3,134,782 S22 Mixed method 55,689 S23 Qualitative method 38,649 S24 Quantitative method 24,596 S25 Mixed or qualitative or quantitative 1,821,590 S26 S22 OR S23 OR S24 OR S25 1,821,590 S27 S5 AND S15 AND S21 AND S26 49,340162.3 Inclusion and Exclusion CriteriaA properly formulated inclusion and exclusion criteria provides the researcher withclearly defined boundaries for a review, which helps in determining the studies that willbe potentially included or those to be excluded (Stern, et al., 2014). Furthermore, aproperly formulated selection criterion removes possible selection bias that thereviewer may have thus ensuring that the studies that are selected are mainly on thebasis of predefined, justified standards excluding the personal interest of theresearcher (Aromataris and Pearson, 2014).2.3.1 Inclusion CriteriaMixed methods, qualitative studies and quantitative studies that explored doctorsand managers working relationships in hospital or healthcare service were includedin this review. The settings of the included studies were hospital or healthcareservices. Studies that were published in English language in peer reviewed journalsbetween January 2000 and July 2019 were included. See Table 2 for details.2.3.2 Exclusion CriteriaStudies were excluded if the target populations were not doctors (physicians) andmanagers (hospital administrators, executives, directors), who were working inhospital or healthcare settings. Studies that were not focussed on doctors-managerrelationships were excluded from this review. Studies that were not published inEnglish language before January 2000 were also excluded. See Table 2 below fordetails.17Table 2: Inclusion and Exclusion CriteriaInclusion Criteria Exclusion CriteriaPopulation Doctors and managers Not doctors and managersExposure Doctors and managers workingin hospital or healthcare serviceNot doctors and manager working inhospital or healthcare settingsOutcome Studies on doctors andmanagers working relationshipsin hospital or healthcare serviceStudies not centred on doctors andmanagers working relationships inhospital or healthcare serviceType of studies  Mixed methods, studies,qualitative studies that arepublished appropriately Full texts of Studies Research studies in EnglishLanguage or translation toEnglish from other languages Studies with clear EthicalApproval Abstracts or summaries Commentaries Studies not in English Language Studies without ethical approvalwill not be included2.4 Search Strategy and Search OutcomeA total of 49, 340 citations were initially identified and retrieved from the Ebscohostelectronic databases and additional 15 papers were also found from the reference listsand grey literature. There were 29,126 citations after removal of 20,229 duplicates.After careful evaluation of the titles and/or abstracts, a total of 29,085 articles that werenot related to the study design were excluded from the 29,126 citations and 41 articleswere left. Full texts of the 41 potentially eligible articles were reviewed. Upon full textreview, 21 studies were excluded with the following reason: they were exploratorystudies that described the relationships between doctors and nurses. 20 full textarticles that were possibly relevant to this study were identified and reviewed for quality18appraisal and five articles that were commentaries were excluded. (See Figure 1below for details).Figure 1: Proposed PRISMA Flow DiagramE ligib ilityId enti fica tio nScr een ingIn clu de dAdditional Studies identified through other sources n = 1520,229 duplicates removed from the combined searches (n = 49,35529,126 potential relevant studies screenedCitations excluded at title or abstract with reasons n = 29, 08521 full text articles excluded with reasons: Not population and exposure of interest = 2141 Full text studies retrieved for detailed assessment for eligibility15 studies included as part of the quality appraisal and synthesis5 Commentaries excluded20 Full text studies reviewed for quality appraisal49,340 Citations identified through database searching:a. CINAHL Plus with Full Text (45,075)b. eBook Collection (EBSCOhost) (118)c. CINAHL (1,917) d. MEDLINE (2,177) e. SPORTDiscus (38)1915 studies were included as part of the quality appraisal and synthesis. Titles andabstracts of these remaining articles were then hand searched for studies thatinvestigated poor working relationships between doctors and managers in hospital orhealthcare services.2.5 Quality AppraisalAlthough it has been argued that quality assessment is not a major requirement forqualitative systematic review, however, it is recommended that studies that areretrieved should not have methodological issues (Butler, et al., 2016). The qualityappraisal of the studies that were included in this review were conducted using theCritical Appraisal Skills Programme (2013) Qualitative Research Checklist (seeAppendix 1 for details), which is a tool that has been developed and commonly usedby researchers for checking the trustworthiness and rigor of qualitative research. Thetool enables the assessment of a qualitative study’s aim, methodology, samplingprocess, data collection and analysis, ethics and findings. The tool contains 10questions and each question was categorised as either ‘yes’, ‘can’t tell’ or ‘no’. If onequestion was scored ‘yes’, it was counted as 1 point. If all questions were assessedas ‘yes’, the total quality score for a study was maximum of 10 points. If the questionwas assessed, as ‘can’t tell’ or ‘no’ it was counted as 0. Since this current study is partof an MBA degree programme, the researcher conducted the quality appraisal withguidance of the programme supervisor (SF). This is to ensure that all the studiesincluded in this review had adequate methodological rigor. After the qualityassessment, all the 15 studies selected for full review have a quality score of 8 pointsor more.202.6 Data Extraction and SynthesisA data extraction form by Bethany-Saltikov, (2012) was used as a data registry and asa guide for identification studies on poor working relationships between doctors andmanagers. Details of the author, year of publication, country, aim of study, studypopulation, study design, quality appraisal, methods of data collection/data analysisand key findings were included in the data extraction form.After extraction, data analysis and synthesis began. This qualitative systematic reviewadopted the thematic synthesis of qualitative findings. According to Ring, et al., (2010)thematic synthesis involves identifying and coding recurring concepts from theselected studies’ textual findings, synthesising the codes into themes, and generatinghigher level themes. The concept of the framework not only enabled the researcher togain an overview and make sense of the data, but to also manage, synthesise andinterpret the data in a structured and systematic manner using descriptive andillustrative accounts. See Table 4 for details of codes and synthesised themes.2.7 Chapter SummaryThis chapter discussed the study design, which is a qualitative systematic review, thedata source and search strategy, the inclusion and exclusion criteria, as well as thesearch outcome. It also included quality appraisal of the included studies, the processof data extraction and synthesis.The next chapter presents the results of the studies included in this review. It alsoincludes the key themes that were identified.21CHAPTER 3 RESULTSFifteen peer-reviewed journal articles were included in this systematic review. Sixstudies discussed factors affecting doctor-manager working relationships (Berenson,et al., 2006, Klopper-Kes, et al, 2010, Knorring, et al., 2010, Morana, 2014, Rundalland Kaiser, 2004, and Samadi-niya, 2015). Four studies explored perceptions ofphysicians-managers’ relationships and discussed their different viewpoints (Davies,et al., 2003, Klopper-Kes, et al., 2009, Powell and Davis, 2016, Spaulding, et al.,2014). One study focussed on the involvement of clinical professionals (physicians)with hospital administrators in hospital management (Dalmus, 2012). Two studiesfocussed on work-related conflicts between physicians and managers’ relationships(Tengilimoglu and Kisa, 2005, Viastarakos and Nikolopoulos, 2007). One studyinvestigated the role of educational qualifications between medically educated andmanagerially educated senior manager relationships (Waldman, 2006). One studyexplored the cultural dynamics between physicians and hospital administrators (Keller,et al., 2019). Two studies were conducted in the UK, five in the US, one study wasconducted in both the UK and the US, two studies were from the Netherlands, onestudy each in Malta, Sweden, Norway, Turkey and Greece. Four studies werequantitative, seven were qualitative and four used mixed methods.See Table 3 below, which summarises all the studies included in this review. Thestudies’ details, design, samples, data collection, data analysis and key findings weresummarised in the Table 3.22Five key themes were identified from the data analysis (see Appendix 2 for details ofthe process for data extraction using thematic approach) and they are related toorganisational factors that caused poor doctor-manager relationships (see Table 4).These key themes and sub-themes are discussed in the next session below.23Table 3: Summary of the Included StudiesAuthor (year), countryPurpose of study Study Population Study DesignQuality AppraisalMethods of Data Collection/Data AnalysisKey FindingsBerenson et al, 2006, Washington, U.S.To examine hospital and physician relations in terms of changes in financial, organisational and healthcare delivery296 respondents – Hospital CEOs, chief medical officers, single and multispecialty medical group CEOs and medical directorsQualitative study8 Semi-structured interviews in persons and by telephoneThe study showed that increasing expectations on healthcare system such as market forces and finance were organisational factors that affected physicians and hospital administrators’ collaboration and ability to work together.Dalmus, 2012, Valletta, MaltaTo investigate the role of clinicians in hospital management16 professionals – eight medical/clinical professionals and eight – hospital management or departmentQualitative method/88 Convenience sampling method, Unstructured in- depth interviews/groun ded theory approachThe study showed that although medical doctors have complete autonomy on all decisions related their patient care, however they do not have such control over financial and human resources. This issue affected doctor-manager relationships. All participants acknowledge that more involvement of clinicians in the strategic, decision-making and resource allocation processes of hospital management will improve collaboration.Davies et al, 2003, London, UKTo understand the current perceptions of doctor-manager relationship by examining areas of agreement and disagreement of views among the two groups in the NHS103 chief executives, 168 medical directors, 445 clinical directors, and 376 non-medical directorate managersMixed method/99 A postal questionnaire survey method and interview methodDoctors were dissatisfied with their relationship with managers because of issues of professional autonomy, bureaucracy and lack of trust. However, senior managers and non-physician managers were more positive about the relationship than staff at directorate level and medical managers. Clinical directors were easily the most disaffected, with many holding negative opinions about managers’ capabilities. They also believe that the respective balance of power and influence between managers and clinicians affected their working relationships.24Author (year), countryPurpose of study Study Population Study DesignQuality AppraisalMethods of Data Collection/Data AnalysisKey findingsKeller et al, 2019, Chicago, U.S.To efficiently characterise the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement40 participants – 20 physicians and 20 healthcare administratorsA qualitative mixed method9 Purposive sampling/qualita tive mixed method analysisA professional cultural disconnect between managers and physicians was undermining efforts to improve physician engagement. This disconnect was further complicated by the minority (10%) who did not believe that the issue existed.Klopper-Kes et al, 2009, Enschede, NetherlandsTo understand the complex relationships between hospital managers and doctors166 respondents – 109 physicians and 59 managersA quantitative mixed method8 Quantitative questionnaire and interview methodsThe data showed three variables – professional status, power and goals, responsible for the differences between physician and managers relationships. Hospital administrators consider doctors as higher in professional status and power and having different goals. Physicians on the other hand, think hospital administrators have higher power, lower status, and different goals.Klopper-Kes, et al 2010, Dutch, NetherlandsTo provide practical tools to improve cooperation between manager and physicians in order to enhance hospital performance1239 participants – 929 physicians and 310 managersQuantitative design method9 Questionnaire method/Paired sample T-tests and ANOVA were used to determine significant differences between physicians and doctors’ responsesThere were statistically significant differences between physicians and managers’ relationship (ANOVA, p-value < 0.05) in three categories. Differences between current safety concerns, quality of care and professional autonomy were some of the issues that caused tensions between doctors and managers. Physicians were more satisfied about the current safety and quality of patient care than managers. While managers, preferred computer-based registration of patients, physicians on the other hand, prefer more informal consultations. Professional autonomy and collegiality among physicians also contributed to discontent in the relationships between doctors and managers.25Author (year), countryPurpose of study Study Population Study DesignQuality AppraisalMethods of Data Collection/Data AnalysisKey findingsKnorring et al, 2010, Stockholm, SwedenTo understand how the top managers in Swedish healthcare regard management of physicians in their organisations and what this implies for the management role in relation to the medical profession18 Chief executive officers – seven physicians and 11 other professional background.Qualitative semi- structured interview method9 Semi-structured individual interviews/groun ded theory approachIn this study, managers identified three key issues that affected their working relationship with doctors. Managers believe that doctors had very high opinion of themselves, but they lacked knowledge of the system and they do what they want in the organisation. Therefore, the differences in opinion in perceptions of daily practice and value of professional autonomy between doctors and managers affected their relationships.Morana, 2014 To investigate the working relationship among physicians and their practice administratorsN = 15 – physicians Qualitative phenomenol ogical study/10Interview methodPhysicians reported that open and honest communication, dependability, trust, honesty, collaboration and knowledge were factors that affected their relationship with practice administrators.Powell and Davis, 2016, UKTo investigate current perceptions of the working relationships between hospital chief executives who are non-clinical and clinical directors and the factors affecting their ability to work together, and to assess if and in what ways these perceptions have changed since the 2002 UK survey.A total of 472 respondents – 59 Chief executives, Medical directors, 132 Directorate managers and 150 Clinical directorsA mixed method designs/10Online and postal survey, telephone and face to face interviews and focus groupThe study showed that financial issues, professional autonomy, lack of trust and lack of training were detrimental to effective working and to developing and nurturing sound relationships between physicians and hospital executives for the medium and long term. Surprisingly, more than half of the clinical directors (51%) and 18% of chief executives were of the view that doctor- manager relationships were like to deteriorate over the next year.26Author (year), countryPurpose of study Study Population Study DesignQuality AppraisalMethods of Data Collection/Data AnalysisKey findingsRundall and Kaiser, 2004, US and UKTo investigate manager-physician relationships looking at the data collected in both US and UK surveys for possible similar factors affecting the relationships and those specific to each country’s health servicesIn US – 65 Senior managers and 52 Physician executives, in UK – 103 Chief executives, 168 Medical directors, 445 Clinical directors, 376 Nonmedical directorate managersQuantitative design method8 67 item postal questionnaires using a four- point Likert scale. Data analysis using Chi-square tests were used to determine the statistical significance of differences between across all sampled groups.This study concluded that power and autonomy, and cost cutting measures were some of the organisational factors that affected manager- physician relationships. The study also found that physicians were more pessimistic than hospital managers regarding their relationships.Samadi-niya, 2015To investigate the effects of interprofessional doctor-manager relationships on patient care qualityN = 137 (Physicians and hospital administratorsQuantitative study9 Multivariable correlational studyThis study showed organisational factors such as relative power, lack of resources, financial issues, differences in role capability, communication and clinical priority, affected the relationships between doctors and managers. Consequently, this could impact on the quality of patient care.Spaulding, et al., 2014, Florida, U.S.To identify perspectives regarding physician-manager engagementHealth system administrators and physician administratorsA qualitative interview8 Open-ended interviewsThe lack of open dialogue, transparency, communication and lack of collaboration created a huge gap in the physician-manager engagement. The study recommended that the identification of success factors such as effective communication was critical to improving physician and management relationships.27Author (year), countryPurpose of study Study Population Study DesignQuality AppraisalMethods of Data Collection/Data AnalysisKey findingsTengilimoglu and Kisa, 2005, TurkeyTo outline the key features of conflict in a large modern hospital that can be targets for successful management204 Hospital staff completed the questionnaire – 30.9% were physicians and 12.5% were administrators; 61.5% were female and 38.5% were male.Quantitative design method8 A questionnaire method. A convenience sampling method. Statistical analysis was by Chi-square and P-values.Educational differences among physicians and administrators were a major barrier to good communication and relationship between the groups. Another source of conflict was that resource allocation was considered unfair across departments. A lack of career development was mentioned by 52% of the respondents as source of conflict. 48.4% felt that bureaucracy was a source of conflict because their performance was less than optimal due to presence of multiple supervisors.Vlastarakos and Nikolopoulos, 2007, GreeceTo access health practitioner’s views on the issue of hospital administration and explore possible conflicts124 Doctors and 15 hospital managersQualitative method8 Questionnaire- based multi- stage cluster sampling techniqueDifferences in the educational qualification of hospital administrators and doctors, lack of flexibility and collaboration were factors that affected their relationships. The perception of doctors was that hospital administration by the managers was ineffective, because they lacked the necessary educational qualification to manage. The interdisciplinary model, with a manager having both health sciences and economics degrees and exercising the role with flexibility and collaboration with physicians were suggested as ways of improving doctor-manager relationships.Waldman, 2006, New Mexico, U.S.To establish common ground between Chief executive officers and physicians670 hospital and health system Chief executive officersA qualitative survey8 Survey methodThe system-wide dysfunction that affected relationships of physicians and hospital executives were reimbursement/cost issues (77%) and shortages of critical personnel (66%), both of which reflected imbalance between resources and commitments, contradictory obligations and ineffective systems. The study suggests that effective alliance of managers and care providers could turn their diversity of talents and experience into a powerful tool for solving health care problems.28Table 4: Summary of Thematic Analysis: Organisational Factors Causing Poor Doctor-Manager RelationshipsMain Themes Code in the texts Poor collaboration between managers and doctorsLack of open dialogue, transparency, communication in physician-manager relationships (Powell and Davis, 2016, Spaulding, et al., 2014) Competition as a potential source of disagreement between managers and doctors (Berenson et al, 2006) There needs to be more partnering and more physician driven models (Spaulding, et al., 2014) Without involving the physicians in defining that positive environment, the organisation runs the risk of developing wrong model (Spaulding, et al., 2014) Management structures, which focus on the patient rather than on professional hierarchies (Dalmas, 2012) Disconnection between the board and divisional or doctorate level (Powell and Davis, 2016) Lack of development initiatives for cross-professional collaboration (Dalmas, 2012) Communication issues (Davis, et al., 2003, Morana, 2014, Spaulding, et al., 2014) Engagement survey (Keller, et al., 2019) Trust, respect and shared values and objectives (Dalmas, 2012, Morana, 2014) Bureaucracy- presence of multiple supervisors (Tengilimoglu and Kisa, 2005)Finance and resource issues Competition over services between doctors and managers (Berenson, et al., 2006) Increased public expectation for improved patient safety and quality of care (Berenson et al, 2006, Dalmus, 2012) Physicians are asked to do more for less pay (Samadi-niya, 2015) The use of hospitalists rather than physicians and specialists (Berenson et al, 2006) Management is more focused on financial than clinical priorities (Powell and Davis, 2016, Rundall and Kaiser, 2004, Tengilimoglu and Kisa, 2005, Samadi-niya, 2015) Financial arrangement of hospitals and physicians with payers (contract) (Samadi-niya, 2015) Adequacy of resources (Waldman, 2006 and Samadi-niya, 2015)Power and autonomy Physicians think hospital manager are pushing the limits by trying to go as far as possible (Klopper-Kes, et al.,2009) The influence of the trust board (Powell and Davis, 2016) Physicians see hospital managers as threat to their status and power, and vise versa (Klopper-Kes, 2009) Hospital managers think physicians ruthless and try to stay in power as long as they are the biggest and strongest (Klopper-Kes, et al., 2009) Lack of proper and clear definition of roles and responsibilities (Dalmas, 2012) Doctor-manager differences in value of professional autonomy (Davis, et al., 2003, Klopper-Kes, et al, 2010)29Disagreement on the relative power and influence between management and physicians (Rundall and Kaiser, 2004, Samadi-niya, 2015) Management exert pressure on physicians to discharge or transfer patients early (Rundall and Kaiser, 2004) CEO’s thought physicians were reluctant to abide by rules, avoid participating in group meetings (Von Knorring, et al., 2010) “Half of administrators and physicians oriented themselves as bosses and islands” (Keller, et al., 2019) Non-medical managers were perceived to hold all of the power (Powell and Davis, 2016)Cultural issues Culture of medicine versus culture of management (Samadi-niya, 2015, Keller, et al., 2019) Cultural views of managers are business and profit oriented, while doctors’ views are clinical and patient focussed (Morana, 2014, Samadi-niya, 2015) Both managers and doctors showed differences in perceptions of daily practice (Klopper-Kes, et al, 2010) Differences in physicians’ and administrators’ professional backgrounds, values and thought processes (Keller, et al., 2019) Differences between physicians and hospital managers with regards to loyalty to organisation and profession (Keller, et al., 2019)Educational differences/challenges Differences in educational qualification of doctors and managers (Tengilimoglu and Kisa, 2005, Vlastarakos and Nikolopoulos, 2007) Impact of training on relationships between senior clinicians and management (Powell and Davis, 2016) Educational differences led to communication problems between different professionals (Tengilimoglu and Kisa, 2005) Lack of development initiatives for cross-professional collaboration (Dalmas, 2012) Training in management skills (Dalmas, 2012) Lack of opportunity for career development (Tengilimoglu and Kisa, 2005) Physicians lack knowledge of the system (Von Knorring, et al., 2010) Physicians do not respect opinion of managers with education in history or geography (Samadi-niya, 2015)303.1 Organisational Causes of Poor Doctor-Manager Working Relationships3.1.1 Theme 1: Poor Collaboration and CommunicationTo ensure that the core values of healthcare, which include quality of patient care,patient satisfaction and prevention of adverse effects, are achieved, interprofessionalrelationships between physicians and hospital administrators should be collaborative.The notion of professional permeability and the spread of ideas by osmosis betweenthe two groups will foster mutual understanding and agreement on core hospital values(Mascie-Taylor, 2003, Wilson and Sweeney, 2003).Nine studies reviewed, reported lack of collaboration and communication asorganisational factors affecting the relationships between physicians and hospitalmanagers (Berenson, et al, 2006, Dalmus, 2012, Davis, et al., 2003, Keller, et al.,2019, Morana, 2014, Powell and Davis, 2016, Samadi-niya, 2015, Spaulding, et al.,2014 and Tengilimoglu and Kisa, 2005). Furthermore, three studies (Morana, 2014,Powell and Davis, 2016, Spaulding, et al., 2014) found that lack of open dialogue,transparency, communication resulted in a ‘we versus them’ type of relationshipbetween the two groups. In the study by Powell and Davis, (2016), many doctors feltthey had a distant relationship with the hospital trust board because the board did notinclude them in decision making. Similarly, in the study by Spaulding, et al., (2014),one of the managers interviewed stated “the physicians have to feel that they arepartners within the group and valued participants…you treat them inappropriately andseparately, then you are not going to have a great success” (p.69). In the same study,the connection between communication and staff engagement, was noted in the wordsof one of the hospital administrators: “I think we need to do a better job of listening toour physicians…not just listening to them, but really hearing them…what their core31values are, and engaging with them” (Spaulding, et al., 2014, p.69). Equally, Samadi-niya (2015) found that lack of teamwork and communication has significant impact oninterprofessional relationships between the two groups.One study found that bureaucratic involvement of multiple supervisors was a sourceof conflict between physicians and hospital administrators leading to poor workperformance (Tengilimoglu and Kisa, 2005). Lack of development initiatives for cross-professional collaboration, trust, respect and shared values and objectives wereidentified as some of the barriers to physician-administrator rapport (Dalmas, 2012,Morana, 2014). This point was re-echoed by Weiner, et al., (1997), stating that lack ofcollaboration does not only have a negative effect on interprofessional relationsbetween the two groups, it also hinders the improvement in the quality of patient care.To reduce this problem, some researchers have suggested the development ofstrategic communication and collaboration plans (Baker, et al., 2004 and Powell andDavis, 2006).3.1.2 Theme 2: Cultural IssuesOrganisational culture is centred on the values, views and aspirations that membersof an organisation share (Hirayama and Fernando, 2018). Therefore, organisationalculture within the healthcare service has the potential to influence the pattern ofbehaviour of healthcare professionals such as physicians and hospitaladministrators/managers working within the organisation (Morgan and Ogbonna,2008). This view resonates with the statement by Taylor and Benton, (2008), advising“that all the problems that exist in interprofessional relationships between physiciansand administrators are cultural barriers to effective healthcare”.32Three other studies described cultural issues as barriers to the relationship betweendoctors and managers’ (Keller, et al., 2019, Klopper-Kes, et al., 2010, Morana, 2014and Samadi-niya, 2015). Keller, et al., (2019), reported that physicians’ andadministrators’ professional backgrounds, values and beliefs differed considerably.Furthermore, the researchers reported that the differences in their professionalbackgrounds, values and beliefs affected their working relationships. For example,while administrators believe that excellent patient care can be achieved by promotingthe organisation and its brand, physicians on the other hand were of the view thatexcellence in patient care was attainable by advancing profession/specialty througheducation and research (Keller, et al., 2019).Another key cultural difference that affected the relationships between the two groupswas their different approaches to decision making. The physicians’ viewpoint was thatpatient care occurred in high acuity, with short clinical decision-making time, andwhere a lot of information were shared in a single best course of action (Keller, et al.,2019). On the other hand, administrators follow a lot of bureaucratic process withregards to organisational care, and this takes much longer time and involves multiplechannels (Keller, et al., 2019). These views compared favourably with Bujak, (2003)who reported that “physicians have an expert culture and administrators have anaffiliative culture”.According to Samadi-niya, (2015), the cultural views of managers are businessoriented, rooted on profitability and having the big picture in view. In contrast,physicians have dissimilar cultural views, which are clinical, and patient focused(Samadi-niya, 2015).333.1.3 Theme 3: Power and AutonomyNine studies cited the complexity of power and autonomy as a barrier to doctor-manager relationships (Dalmus, 2012, Davis, et al., 2003, Keller, et al., 2019, Klopper-Kes, et al., 2009, Klopper-Kes, et al., 2010, Von Knorring, et al., 2010, Powell andDavis, 2016, Samadi-niya, 2015, Rundall and Kaiser, 2004). Physicians saw hospitaladministrators as having powers while hospital administrators saw doctors as havinggreater powers (Klopper-Kes, et al., 2009). This implies both doctors and managersfelt relatively “powerless” in the same organisation and the practical implication of thisis that there could be lack of proper and clear definition of roles and responsibilities inachieving organisational goals such as improved quality of patient care and staffperformance (Dalmas, 2012, Davis, 2003 and Klopper-Kes, et al., 2009). In one of thestudies, a hospital administrator was quoted saying, “if they understand what I amcapable of doing and how useful I could be, our relationship and cooperation wouldnot be such a problem” (Klopper-Kes, et al., 2009, p.221).Doctor-manager differences in value of professional autonomy was another reasoncited as a barrier to a harmonious working relationship between the two groups (Davis,2003, Klopper-Kes, et al., 2009, Von Knorring, et al., 2010). For example, hospitaladministrators described how doctors were reluctant to abide by rules, avoidingparticipating in group meetings with them, and in many respects, choosing to followtheir own agendas (Von Knorring, et al., 2010). This type of “do-what-you-want”mentality was perceived by the administrators as “strong” and not limited to clinicalmatters. One respondent put it directly:“They very much guard how they exercise their own professional practice. That theyhave the professional right of interpretation, that it is not the deliverer of care, from34some holistic picture, who has the preferential right of interpretation, but rather it is theindividual physician who has that in all situations, not only in the direct consultationwith the patient where you make an assessment, but in all matter” (Von Knorring, etal., 2010, p.5)Similarly, Keller, et al., (2019) reported that half of the administrators intervieweddescribed their relationship with physicians as living in isolated “islands’ with doctorsworking in ‘silos’ and acting as ‘bosses’. This implies that there was increasingcommunication gap and lack of engagement between both parties. In the study byPowell and Davis (2016), hospital administrators were perceived by physicians ashaving too much authority. However, hospital managers thought doctors are ruthlessand try to stay in power for as long as possible since they are the largest and strongestgroup within the hospital (Klopper-Kes, et al., 2009). On the contrary, in the study byRundall and Kaiser, (2004), physicians felt management exerted too much pressureon them to discharge or transfer patients early. Furthermore, the physicians believethat hospital managers are pushing the limits by trying to go as far as possible byinstructing them on what to do (Klopper-Kes, et al., 2009). The practical implication isthat since the above-mentioned challenges constitutes major barriers to physician-hospital administrator relationships, it is important therefore, to find ways of resolvingthem so that patient experience, clinical outcomes and hospital performance are notadversely affected.353.1.4 Theme 4: Finance and Resources IssuesIn seven studies, financial and resource challenges were reported as barriers torelationships between doctors and managers (Berenson, et al., 2006, Dalmus, 2012,Powell and Davis, 2016, Rundall and Kaiser, 2004, Samadi-niya, 2015, Tengilimogluand Kisa, 2005 and Waldman, 2006). A directorate manager in the study done byPowell and Davis, (2016) cited the negative impact of financial and resourceconstraints on relations between the two groups, stating that “the rising financialpressures and increasing expectations of patients on the service are affecting theirrelationships with doctors” (p.25). It was noted that both the physicians and hospitaladministrators agreed that the bond between them is negatively affected by the natureof financial targets set by the funding providers. For example, Powell and Davis, (2016)stated:“The punitive financial nature of targets set by, for example, the clinical commissiongroup has a negative impact on all NHS establishments. It leads to a deepening of thedivide between management and clinicians as NHS trusts strive to maintain financialbalance. Whilst all targets should be based on good clinical practice they are inevitablyinterpreted as being financially driven and this disengages clinicians whichexacerbates the manager clinician interface” (p.25).Four studies (Powell and Davis, 2016, Rundall and Kaiser, 2004, Tengilimoglu andKisa, 2005 and Samadi-niya, 2015) found that part of the conflict and disengagementbetween the two groups was because doctors felt management was driven more byfinancial gain rather than clinical priorities. Increased public expectation for improvedpatient safety and quality of care in the face of financial scarcity was identified asanother source of tension between the two groups (Berenson et al, 2006 and Dalmus,362012). The disparity between managers and physicians in terms of hospital resourceand patients demand, were factors, which inevitably created conflict and disagreementbetween the two groups (Powell and Davis, 2016, p.25).Several services that are performed in acute hospitals such as management ofdiabetes, hypertension and chronic obstructive pulmonary disease can safely andconveniently be performed in ambulatory settings such as community health centers,urgent care centers, and physician offices (Berenson, et al., 2006, Powell and Davis,2016, Waldman, 2006. Competition between the hospital administrators andphysicians over such services that had once been managed within the sphere of thehospital, caused a strain in their relationship (Berenson, et al., 2006, Powell and Davis,2016, Waldman, 2006. Although the expectation is that such health system challengewill lead hospital managers and physicians to collaborate more, in many instances thewillingness and ability for the two groups to work together is actually declining(Berenson, et al., 2006). For example, one hospital executive was noted saying “weare in competition with our own physicians”. Whilst a physician stated “everyone ……is opening an ambulatory surgery or diagnostic centre today, there is more and moremovement of services from acute hospital control to non-medical physicians’ control”.Furthermore, there is growing tension between non-medical physicians and medicalphysicians because of the growing reluctance of medical physicians to take onemergency department duties, and the consequence is that hospital administratorsare hiring non-medical physicians instead of medical physicians to cater for theirinpatients.373.1.5 Theme 5: Education Differences/ChallengesFour studies cited differences in educational qualifications of doctors and managersas a source of tension and lack of engagement between the two groups (Dalmus,2012, Von Knorring, et al., 2010, Tengilimoglu and Kisa, 2005, Vlastarakos andNikolopoulos, 2007).According to Powell and Davis, (2016) lack of management training for doctors andexecutive coaching on leadership style could hamper the relationship between doctorsand managers. Hence, the presence of joint training events for the groups have beenshown to improve their collaboration (Powell and Davis, 2016). For example, one ChiefExecutive (CEO) said that the individual executive coaching on leadership style thatwas organised by management for both senior physicians and hospital administratorshad a positive effect on their relationship (Powell and Davis, 2016).In the study by Vlastarakos and Nikolopoulos, (2007), 61% of the doctors working inthe hospitals being reviewed ignored the basic degree of the hospital manager, while71% of the doctors felt the degrees were inadequate for the efficient management ofthe hospital. Furthermore, Tengilimoglu and Kisa, (2005), concluded that educationaldifferences between physicians and administrators were a major barrier to effectivecollaboration and integration between the groups. Similarly, it has been stated thatthrough professional training, regulation, medical licensing and certification,physicians have this communal type relationship within the hospital, which Kaissi,(2005) termed “occupational community”. This occupational community relationshipamong doctors influence their interaction with hospital managers who on the otherhand are not viewed as part of that community because they are individuals from38various educational backgrounds such as business, public administration andaccounting (Kaissi, 2005).3.1.6 Chapter SummaryThis chapter presents the findings of the studies included in this review. It describedthe different studies, their details, design, methods of data collection/data analysis andimportant findings including the five key themes that were identified from the dataanalysis.The next chapter is centred on the discussion of the findings of the included studies inthis review, which are the barriers to doctor-manager working relationships.39CHAPTER 4 DISCUSSIONThis qualitative systematic study found considerable evidence of organisationalfactors that contributes to poor working relationships between doctors and managers.This review identified five major themes from the studies that were reviewed. The firstwas poor communication and collaboration amongst physicians and hospitaladministrators. Several authors have reported that there are well known challenges inthe communication and group work between hospital executives and doctors (Davies,et al., 2003, Edwards, 2003, Kaissi, 2005, and Shortell, et al., 2005). In this review,respondents highlighted lack of open dialogue, transparency, communication asfactors that created a rift in the relationship between doctors and hospitaladministrators. Doctors felt that their inability to access hospital executives created a“we versus them” adversarial type relationship (Chhetri, 2017, Powell and Davis,2016). Doctors also felt they were not being listened to by the hospital executives(Powell and Davis, 2016).Previous research in healthcare settings (Degeling and Maxwell, 2004, Bartunek,2011, Kaissi, 2014) suggested that if there is concentrated effort and resources increating and maintaining effective working relationships between different groups suchas doctors and managers working within healthcare services, communication andcollaboration between them is likely to improve. Furthermore, it would also fosterdevelopment of initiatives for cross-professional collaboration, development ofsystems and processes that will function well for both groups and improve mutual trust,respect and shared values and objectives (Degeling and Maxwell, 2004, Bartunek,2011, Kaissi, 2014, Dalmas, 2012 and Morana, 2014). However, insufficient time and40resources was cited as challenges to nurturing physician-hospital administrator’srelationship (Powell and Davis, 2016). Nevertheless, if health services such the NHSare mainly depending on doctors and managers to make this crucial relationship towork, then it is important that specific attention, effort and resources including timeincentives should be committed to specifically nurturing the relationship, as this willenhance staff performance and provide better quality of care (Powell and Davis, 2016).This is consistent with the assertion by Baker, et al., (2004) who in a study ofhealthcare leaders from various professional groups suggested a governance planthat puts collaboration among medical staff, senior leadership teams and boards atthe heart of doing healthcare business, necessary to improving the quality of patientcare. The practical implication of such a strategic plan is that, not only will there beagreement on key issues that bothers on service provision but there will also beenhanced cooperation and collaboration in achieving set objectives (Klopper-Kes, etal., 2009).Cultural issues were the second theme cited by majority of the studies included in thisreview. It has been reported that cooperation and communication between physiciansand managers are affected by differences in their professional and organisationalcultures (Klopper-Kes, et al., 2010 and Kaissi, 2005). Furthermore, differences inorganisational values, views and aspirations between physicians and hospitaladministrators were reported as obstacles for successful relationships between thegroups. Although both doctors and managers agree on guaranteeing the safety ofpatients and improving their quality of care, they disagree on the level of involvementin the implementation (Klopper-Kes, et al., 2010). This disagreement is based on41differences in meaning, values, and behavioural norms which are generally notcomparable by the same standards (Kaissi, 2005). For instance, in current review,physicians’ primary loyalty was to their patients, while managers had strong allegianceto the organisation they serve.The different socialisation and training that managers and physicians receive resultsin varied worldviews, value orientation and expectations, which can hinder harmoniousrelationships between them (Kaissi, 2005, Klopper-Kes, et al., 2010). However, ifthese differences in perceptions are recognised and harnessed, they can become averitable tool in enhancing their relationship, more so that subsistence in the currenthealth care environment requires a diversity of skills, orientations and thoughtprocesses (Kaissi, 2005).This is consistent with the suggestion by Brockschmidt (1994), advising thatorganisations should adopt a corporate culture that allows both physicians andhospital managers to play important roles in solving conflicts of views, values andbehavioural beliefs between them. However, it has been argued that if doctors are tobe involved in such process, a “cultural change” may be necessary (Kaissi, 2005).According to Spurgeon (2001), “the cultural change” should recognise, involve andaccept that doctors are part of a managed healthcare community and thatmanagement is a valued and important process”. One of the strengths of hissuggestion is that the cultural divide between doctors and managers regardingbusiness profitability and patient centred care could be a potential source fordiscussion and corporate engagement between the two groups. More so, the42continuity of an effective patient centred care and quality improvement are hinged ona formidable and successful business continuity plan (Spurgeon, 2001).The third theme identified was power and autonomy. In the studies under review,physicians viewed administrators as superiors with higher administrative powers,while managers perceived doctors as being higher with clinical decision-makingpowers. These perceived differences in professional autonomy and power does notonly create tensions that can sometimes be counterproductive to the attainment ofshared objectives but can also negatively affect the relationship between the twogroups (William, 2007). According to Klopper-Kes, et al., (2009), if hospitaladministrators and physicians understand clearly each other’s roles andresponsibilities in achieving organisational goals such as improved quality patient careand staff engagement, any perceived differences between the two groups couldbecome key strengths in their relationship.This review highlighted the fact that physicians, compared to hospital administratorswere more focussed on clinical autonomy – that is taking independent decisions onpatient care, whereas hospital administrators were more concerned aboutorganisational bureaucracy and accountability. While physicians are patient-oriented,practicing their specialty well and treating more patients, they are easily frustrated byorganisational bureaucracy (Edwards, 2003, Porter 2007 and William, 2007). On theother hand, hospital managers are mindful of managing the organisation, balancingthe needs of specialty areas and physicians against each other, in the face of decliningrevenues (Edwards, 2003 and William, 2007). These differences create tensions intheir working relationships.43Furthermore, increasing competition, rising consumer expectations and the growingcosts of healthcare means that the decisions of physicians have come under scrutinywith increasing attempts by hospital administrators to control it (Edwards, 2003 andWilliam, 2007). Another significant challenge to physicians’ autonomy is the increasingpressure from governments and hospital executives for them to be transparent andsystematic in aspects of their clinical work such as scheduling, follow-up andcommunication (Edwards, 2003 and William, 2007). This is consistent with thesuggestion by Davies and Harrison, (2003), that there should be a paradigm shift fromdoctor’s basic understanding of medicine and work pattern to a model that is evidencebased in which the emphasis is on how to reduce cost and improve patient andorganisational outcomes. It is in view of this that Edwards (2003) recommended thatboth physicians and hospital administrators should develop guidelines, protocols anddevelop the use of information to feedback utilisation data, cost effectiveness andclinical outcomes.In addition, it has been suggested that mutual respect for physician-hospital managerdifferences, responsible autonomy between the two groups, avoiding personal attacksand keeping to the principles of shared decision making – particularly in difficult areassuch as resource control and accountability, could potentially improve relationsbetween the two groups (Succi, et al., 1998, Degeling, et al., 2003, Edwards, 2003and Spaulding, et al., 2014). However, more research is required on the relativeeffectiveness of strategies involving physicians in shared decision making in areas ofresource control and accountability.44The fourth theme identified in this qualitative systematic review was related to financeand resource challenges. Doctors and hospital managers/directors do not only facesignificant financial challenges, they also struggle to align behaviours to achieve costand quality goals in today’s healthcare environment (William, 2007). Several authorshave cited the role of administrators in the management of hospital resources asfinancial bookkeepers (Nash, 2003, Edwards, et al., 2003 and Rundall, et al., 2004).However, this role may affect physician-administrator relationships as doctors do notaccept the accounting mind-set of managers, as this may suggest critical evaluationof their practice (Nash, 2003, Edwards, et al., 2003 and Rundall, et al., 2004,Vlastarakos and Nikolopoulos, 2007). Multicentre studies both in the UK and USAdemonstrated that doctors are sceptical about hospital administrators in handlinghospital resources because they believe that the resources provided are insufficientfor effective hospital function (Davis, et al., 2003 and Rundall, et al., 2004. This impliesthat for hospital administrators to achieve efficiency in the services provided bydoctors, they need to adopt a management style that is flexible, which takes intoaccount the widest consent of all healthcare professionals such as medical doctors(Edwards and Marshall, 2003 and Marshall, et al., 2003). It is for similar reasons thatRundall, et al., (2004), recommended that managers can implement severalstrategies to improving their relationships, including greater organisationaltransparency in decision making; frequent dialogue between managers anddoctors; and more physician involvement in decision making, especially with regardto important resource-related decisions, and in organisational governance.45Competition between doctors and managers over services that were usuallyperformed in hospitals was reported as one of the reasons for poor working relationsbetween them. This notwithstanding, competition could be a potential source ofcooperation, as some physicians thought that using hospital-physician joint ventureswhere both physicians and managers had similar interest and stake was a way toavoid risky head-on competition between them and the hospital (Berenson, et al.,2006). Hospital employment and involvement of physicians to have greater role andcontrol on service provision and marketing of services that are of mutual interests andbenefits is also another avenue that competition could be used as a potential sourceof cooperation and collaboration between them (Berenson, et al., 2006 and Dalmas,2012).The final theme identified by this review was educational differences/challengesbetween doctors and hospital executives/managers. This systematic review found thatmajority of doctors felt that the hospital administration is ineffective because thehospital managers do not have a health sciences degree. Their point of view is thatmanagers should have some sort of health sciences degree and where possiblecombined with a post graduate studies in healthcare economics (Vlastarakos andNikolopoulos, 2007). In contrast, majority of the administrators consider economics asthe best basic degree for hospital management, however, they agree on thecombination of both health and economic sciences (Vlastarakos and Nikolopoulos,2007). By way of resolving these issues some researchers have recommended acombination of medical doctor/master’s degrees in business administration trainingprogrammes or a post graduate training programme in healthcare administration for46healthcare professionals such as physicians and hospital executives (Atun, 2003 andNash, 2003).This suggestion resonates well with the statement made by Kaissi’s, (2005) on themanager-physician relationships from an organisational perspective. The researchernoted that more and more physicians are taking business courses and acquiringmaster’s in business administration (MBA) degrees in order to become a physicianexecutive, however once they attain this role, their loyalties shift from their colleaguesto that of the organisation. This shift in loyalty by the physician-administrator negativelyaffects their relationship with other practicing physicians (Kaiser, 2005). Conversely,Chhetri, (2017) argues that because doctors share a common educational andprofessional background, they naturally respect and trust other physicians includingthose in administrative positions, compared with non-clinical hospital executives withdifferent educational and professional experiences. These differences betweenpractising doctors and non-physician managers creates a great difficulty in reachingmutual understanding regarding the process of healthcare delivery and qualityimprovement (Chhetri, 2017). Thus, communication breaks down, suspicion heightensand the cultural gulf that is formed between the two groups becomes a difficult bridge(Chhetri, 2017). This suggests that hospital administrators need to pay enoughattention to a mutual but different viable educational and career development path forboth doctors and hospital managers. Some researchers stressed that the training ofdoctors in multidisciplinary management education early in their careers is necessaryto appreciate key managerial and organisational issues that may impact on physician-administrator relationships, affecting patient care (Mitchell, 1998, Simpson, 2000 andAtun, 2003).47Lack of management training for doctors and executive coaching on leadership stylefor hospital administrators have been cited as factors that not only limited the smoothworking relationship between them but were also a major barrier to effectiveengagement between the groups. However, this review also found that if bothphysicians and hospital managers are properly trained on leadership skills that it wouldenhance the communication, collaboration and agreement between them. (Powell andDavis, 2016). Furthermore, future researches are needed to investigate the effects ofthese trainings on the physician-administrator relationships. This systematic reviewwas only focused on organisational factors, which contributed to the poor workingrelationship between the two groups.4.1 Chapter SummaryThis chapter provided in-depth discussion on the key organisational barriers tophysician and hospital administrators working relationship such as poor collaborationand effective communication, cultural, finance and resource issues. It also includeddiscussions on some recommendations to resolve these challenges.The next chapter is the conclusion of this systematic review including some of its shortcomings and future recommendations.48CHAPTER 5 CONCLUSIONThis qualitative systematic review sets out to investigate the evidence in relation topoor working relationships between doctors and managers in hospital settings, with aview of identifying possible root causes of the problem as well as suggesting ways ofovercoming them.In summary, this study found that poor collaboration and effective communication,cultural issues, power and autonomy, finance and resource allocation, as well aseducational differences were among the organisational and professional factors thatcontributed to poor working relationships between the two groups. However, despiteprevious studies on the topic highlighting problems in the relations between the pair,no solutions on how to resolve the problems were proposed, which is disappointingconsidering the fact that poor working relationship between physicians and hospitaladministrators is an important issue currently in healthcare organisations worldwideincluding the UK’s National Health Service. In addition, some of the included studieslacked sufficient details on the consequences of poor working relationships betweenphysicians and hospital managers on the quality of service they provide, clinical andbusiness outcomes.Furthermore, the studies did not use any theoretical framework to conceptualise thepsychosocial factors of intergroup relationships such as those involving doctors andhospital managers. It is assumed that a theoretical model that considers the social andpsychological aspects of inter-communication between doctors and managers couldhave helped to understand the problems better. Therefore, future research should49consider these aspects because solutions could be easier when the problems areinvestigated through a theoretical lens.It is worthy to note that no previous study has systematically explored organisationalfactors affecting doctor-manager relationships. To my knowledge, this systematicreview is the first qualitative synthesis study to explore organisational barriers tocordial working relationship between doctors and managers. Based on the challengesidentified in the studies under review, it was recommended that a hospital governanceplan that involves both doctors and managers in the decision-making processregarding the quality of patient care, could potentially enhance the relationshipsbetween the two groups as it would build trust between them. It was alsorecommended that recognising and harnessing the differences such as diversity ofskills, orientations and thought processes that exist between the two groups and usingthem as a viable tool in improving their relationship. In addition, the use of shareddeveloped guidelines, protocols and information to feedback utilisation data, costeffectiveness and clinical outcomes were recommended to enhance consensus andimprove relationships between physicians and hospital administrators regardingresource control and accountability.A consensual agreement that is flexible and includes frequent dialogue and greaterorganisational transparency in decision making was also regarded as an importantmeans of improving physicians and hospital administrators’ relationships. Anotherrecommendation is that management training for doctors and executive coaching onleadership style for hospital administrators would enhance the working relationship ofboth parties. It is anticipated that if these recommendations are adopted by healthcare50policy makers, funding providers and hospital administrators, the relationship betweenthe two groups could potentially improve – ultimately leading to improved quality ofcare, better outcomes for patients, better work performance and job satisfaction.However, future studies are required to further examine the effectiveness of theserecommendations on physician-hospital administrator relationships. In addition, it isrecommended that further research is carried out to explore the consequences thatpoor working doctors-managers’ relationships could have on the quality of care,patient safety, patient experience and staff performance.Finally, there are some limitations to this study; one of the limitations is that there arefew primary UK studies on poor working relationship between doctors and hospitalmanagers, therefore this review looked at this issue from a global perspective.Furthermore, to reduce the risk of bias, systematic reviews are carried out by two ormore researchers, however, in this case, this study was carried out by a lone studentunder the guidance of the course supervisor, as part of a final dissertation researchproject in partial fulfilment of a Master’s Degree programme.51REFERENCESAiken, L. H, Sloane, D. M and Sochalski J., 1998. Hospital organisation and outcomes.Qual Heal Care, 7: 222–226.Aromataris, E., and Riitano, D. 2014. 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(Accessed 11thNovember 2019).60Wilson T, Sweeney K. 2003. Doctors and managers. “You just don’t understand”.British Medical Journal. 22, 326 (7390): 656.York (UK), 2019. Systematic Reviews: Centre for Reviews and Dissemination’s(CRD’s) guidance for undertaking systematic reviews. Available online athttps://www.york.ac.uk/media/crd/Systematic_Reviews.pdf (Accessed 11thNovember 2019).61APPENDICES:Appendix 1: Critical Appraisal Skills Programme (2013) Qualitative ResearchChecklist626364656667Appendix 2: Summary of Main and Subthemes of Included StudiesStudy Main Themes Subthemes Berenson et al, 2006 Hospitals perceptions of relations with physicians Service line strategyPurchasers’ expectations Physician-hospital competitionCompetition over services Emergency department call Hospitalist programs Competition as a potential source of cooperation Hospital-physician joint venturesHospital employment of physicians Dalmas, 2012 Recognition of the fact that key decisions are typically taken at two levels –corporate and departmental – and that the hospital management process must aim to build effective linkages and flows between the two rolesLevels of decision-makingDecentralisation of services and delegation of authority to the lowest appropriate level, i.e. at or near the point of delivery of careDecentralisation of servicesManagement structures, which focus on the patient rather than on professional hierarchiesFocus on the patientRecognition that clinical involvement will come from doctors, nurses, allied health professionals and others, in partnership to serve patientsIn partnership to serveAvailability of good quality, accurate and timely information as a basis for informed dialogue and decision-makingManagement informationTrust and respect on both sides between clinicians and managers, and common focus on shared values, goals and organisational objectivesTrust, respect and shared values and objectivesProper and clear definition of roles and responsibilities, both of individuals and of groups within the hospitalDefinition of roles and responsibilitiesIntegration of the executive management of the hospital’s business with the clinical/medical management of servicesExecutive management’s involvement in the management of clinical servicesEffective training and development plans for staff involved in taking on new managerial and resource management responsibilitiesTraining in management skillsComprehensive team-building and organizational development exercises to improve cross professional collaboration between staffDevelopment initiatives for cross-professional collaboration68Study Main Themes Subthemes Davies, et al., 2003 Issues of relative power Perceptions of staff calibre Views on goals, decision making and team working Communication issues Resource issues ***Keller, et al., 2019 Organisational growth pains Perceived issuesCompensation plan Centralised call centre Support staff Engagement survey Physician lounge Maternity leaveObserved cultural differences Virtues/values Background Identify Goals Time horizon Problem-solving Professional successConflicting connotations Interventions Klopper-Kes, et al., 2009 Perceptions Professional statusPower Overall goals: delivery of care Subgoals ScopeKlopper-Kes, et al., 2010 Cultural gaps Collegiality Information emphasis Quality emphasis Management style Cohesiveness Business emphasis Organisational trust Innovativeness Autonomy69Study Main Themes Subthemes Von Von Knorring, et al., 2010Descriptions of physicians’ behaviour by CEOs Physicians have high status and expertise Physicians lack knowledge of the system Physicians can do what they wantStrategies to manage physicians  General management strategies Physician-specific strategies Implications for the manager roleManagement control Motivational strategies Line management Organisational separation Nagging and arguing Compensation Relying on physician role General management strategiesMorana, 2014 Open and honest communication Dependability Trust Honesty Collaboration KnowledgePowell and Davis, 2016 Differences in doctor-manager relationships between trusts and within individual trustsThe influence of the trust board Disconnection between the board and divisional or doctorate levelHow medical managers and managers perceive each other Are there common goals between doctors and managers? General managers: serving two masters? Recognition of additional challenges for non-medical managersThe status of medical management among doctors Increasing status of medical directors and some chief executives Clinical directors: continuing challenges with the role Improving services as a key motivator for medical managersThe impact of the external context on doctor-manager relationships Tension between financial and quality of care targets External regulation Lack of unified medical leadership bodies The impact of external reports70Study Main Themes Subthemes Public esteem of doctors and managers Local initiatives to support doctor-manager relationships The trajectory in doctor-manager relationships since the 2002 survey Rundall and Kaiser, 2004 Perspectives on hospital resourcingManagement organises the structures and procedures need to support cost effectiveness (UK) The hospital provides the needed structure and resources to support cost-effective care (U.S.) Are there an adequate number of consultants to provide quality of patient care? (UK) The hospital provides the personnel needed to support quality care (U.S.) Within this organisation there are generally sufficient clinical resources (UK) There is adequate availability of beds (U.S.) There is adequate number of nurses to provide quality patient care (U.S.) Management provides the information technology need to support quality carePerspectives on teamwork and communication Doctors and managers work well together as a team Hospital managers and doctors are largely in agreement on the overall goals of the institution There is good communication between hospital management and clinical leaders Doctors are adequately involved in hospital management and clinical leadership Doctors are adequately involved in hospital management activitiesPerspectives on role capacity Medical staff in this hospital are consistently of high quality Managers have confidence in clinical leadership capabilities Management encourages clinician leadership development Doctors have confidence in management leadership capabilities71Study Main Themes Subthemes Perception on issues of relative power Managers allow doctors sufficient autonomy topractice medicine effectively Management exerts pressure to not use certain tests or services Manager exert pressure to discharge or transfer patients early The relative power and influence between management and medical staff is about right Doctors view the management decision-making process to be fairPerspectives on financial versus clinical priorities Management is driven more by financial than clinical priorities (UK)Barriers to improved doctor-manager relationships The hospital is more interested in financial survival than clinical quality (U.S.)Samadi-niya, 2015 *****Culture of medicine versus culture of management Relative power Adequacy of resources Role capability: leadership Teamwork and communication Financial drivers versus clinical priority Healthcare technology: information technology (IT) Financial arrangement of hospitals and physicians with payers (contract)Spaulding, et al., 2014 Relationships and communication Providing positive experience Integration Accountability and qualityTengilimoglu and Kisa, 2005Participants’ concerns about the factors causing conflict Participants’ concerns about organisational factors Participants’ concerns about group factors in conflictEducational differences Resource control Lack of career development BureaucracyVlastarakos and Nikolopoulos, 2007Differences in educational qualification of healthcare professional – doctors and managersWaldman, et al., 2006 Personal reasons for becoming CEO Prior job positions Critical issues facing medical careApplied Sciences
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