Hospital management: integrating the dual hierarchy?

Traditionally, hospitals are seen as dual hierarchies: in addition to the formal administrative pyramid, the professional medical system forms a second line of authority. Equally traditional, this poses substantial problems for hospital management. The present study reported in this article took place as part of a larger research project on Industrial Democracy in Europe (IDE-2), aimed at studying changes in industrial relations and internal relations in metal and insurance companies. In the Netherlands, this project was enlarged to include hospitals. A number of significant changes have taken place in the past decade in Dutch general hospitals. As a reaction to environmental changes, e.g. in legislation, planning and financing, organizational structures have shown interesting developments. Examples are an increased hospital size due to mergers, the emergence of mid-level management, divisionalization (inpatient vs outpatient wards), and integration of medical specialists in the organization. As a result, several changes in power positions have occurred, mainly at the strategic decision level: middle and top management have gained while the medical profession has lost some influence. The Works Council has established its position, and made a significant gain in influence on strategic decision making.