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21 May 2021
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How do medical directors improve care? Through ‘translation work’, ‘diplomatic work’, and ‘repair work’

Lorelei Jones is an Anthropologist and Lecturer in Healthcare Organisation and Governance at Bangor University

Naomi Fulop is Professor of Healthcare Organisation and Management at UCL

In recent years healthcare policy has given medical leaders a prominent role, both within healthcare organisations, and in the broader health and social care system. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. We compared the day-to-day activities of Medical Directors in organisations with different levels of quality improvement maturity. We asked, ‘what do Medical Directors do?’ and ‘how does this contribute to healthcare improvement?’ Fieldwork included shadowing a Medical Director in an organisation with a ‘high’ quality improvement maturity. To preserve anonymity, we refer to him here as ‘Stephen’.

Translation work

In high performing organisations medical directors are important ‘boundary spanners’, translating between different domains and forms of knowledge. For example, they translate data for other members of the senior management team, both in written narratives at the beginning of reports, and verbally during meetings. Drawing on their medical training, or on additional training in quality improvement undertaken as part of continuing professional development, they draw attention to any significant trends. From their experience of front-line clinical work, and their communication with clinical staff on the wards, they contribute additional analysis, identifying causes and consequences, and suggesting remedial courses of action. For example, during one board meeting Stephen presented a report of a mortality review. He explained to the board the technical practice of risk adjustment and gave guidance on how to interpret the data. Medical Directors also translate findings from recent research; developments in national healthcare policy; and the activities of various external agencies, distilling the implications for the organisation and for the work of front-line staff.

In contrast, in organisations with a ‘low’ quality improvement maturity, this translation work was often missing, as when there was no Medical Director in post, or withheld. For example, in one organisation the Medical Director appeared during board meetings to be primarily concerned with verbal sparring with the chair, and putting a positive spin on data that related to a service development programme he was overseeing in the organisation. Another Medical Director provided graphs with no explanation of how to interpret them, and appeared hostile and uncommunicative during meetings, both in verbal and non-verbal forms of communication.

Diplomatic work

Diplomatic work involves tactful dealings with doctors at different levels of the organisation informed by knowledge of professional norms, cultural differences between specialties and professional groups, and routine working practices. Being a doctor helped Stephen to engage clinicians who had previous experience of multiple initiatives that had been abandoned and, as a result, had become cynical or wary of becoming involved in further change programmes. As Stephen explained during an interview:

What the urgent care doctor was saying is ‘this is the sixth time in two years where I’ve been pulled out of the actual work to come to focus groups to put ‘post its’ on [mimes sticking a ‘post it note’ onto the wall]’ ... So some of it is just getting people to just hope, if you know what I mean, because they’re wary, they’ve been let down before.

In organisations with a ‘high’ quality improvement maturity, the work of medical directors was embedded in long-standing relationships and social networks across the region. Good relationships were an important antecedent for inter-organisational collaboration and cooperation, fostering trust and reducing conflict. A good relationship with the commissioner had also enabled Stephen to negotiate dedicated funding for quality improvement in the organisation.

Medical Directors are heavily involved in the politics of regional healthcare planning, working on both the ‘front stage’ and ‘back stage’. While planning on the ‘front stage’ emphasises the values of rationality, objectivity, efficiency and participation, planning on the ‘back stage’ recognises the political dimensions of planning, the real-world constraints, and the strategies and tactics of different actors.

Repair work

Stephen spent a lot of time repairing relationships, between rank and file doctors and the hospital management, and between different organisations in the region. An important part of service development was acknowledging previous trauma and rebuilding trust. He described the meetings he had with senior doctors within the organisation as ‘mainly a therapy session’.

Stephen also spent large amounts of time repairing relationships with external organisations that had been damaged by previous government reforms, such as the introduction of provider competition, and structural reorganisations of clinical services. In one instance Stephen had spent ‘two or three years’ having meetings with another hospital in an effort to repair the relationship so that he could develop a region-wide network for surgery.  

The ‘translation work’, ‘diplomatic work’ and ‘repair work’ of Medical Directors improves the quality of services by enhancing the absorptive capacity of the organisation. Absorptive capacity describes an organisation’s ability to identify, assimilate, and exploit knowledge from the environment. Establishing and maintaining relationships enables Medical Directors to identify innovations in external networks, while their knowledge of the cultures and routines within their organisation enable them to translate these into practice.

 Our study highlights the fact that top-down changes to clinical services can leave a long emotional shadow. Much of the research on organisational change in healthcare has tended to focus on clinical outcomes, or adopt technical models of implementation that neglect the social and emotional consequences. Our study therefore complements existing studies of organisational change in healthcare by foregrounding the experiences of loss and change, and the work of attending to emotions such as anger.

 ‘Disruption’ often has a positive valence in policy debate. Our study contributes to the evidence for the potential negative effects of repeated cycles of structural change, on service development, patient care, and outcomes. Our findings also provide for a more nuanced understanding of professional ‘resistance’ to organisational change, showing how this may stem not just from vested interests, but from initiative fatigue and distrust borne from previous experience of change initiatives that were abandoned or replaced by ‘the next thing’.

Note: the above draws on the author’s published work in Social Science and Medicine

We thank the staff who generously gave their time to participate in the study.

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