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En undersøgelse af styringskompleksiteten i det kommunale sundhedsvæsen efter strukturreformen

Thomsen, Lone; Gehlert, Helle Wagner (Frederiksberg, 2011)

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Abstract:

Taking off from a profound curiosity of the management complexity of the Danish public sector and the way public sector leaders handle this complexity, we chose local community healthcare as the empirical field we would look into. In connection with the structural reform of the whole public sector of Denmark, also structures, objects and means of the health care sector were changed. The development towards further specializing of the hospitals and, at the same time, building new competencies in local community health care was strengthened. Especially rehabilitation and preventive care were given to local health care as new assignments. After identifying the two management paradigms New Public Management (NPM) and New Public Governance (NPG) as our main analytical framing of the thesis, our main question was articulated: What new complexity relating to different management paradigms has occurred in local community healthcare after the Danish structural reform, and how is this complexity dealt with from a leadership point of view? To be able to answer this question, we put forward the following four sub questions, touching on several analytical strategic moves and choices: 1. Which management forms seem to be prominent today in local community healthcare, and what tensions in management do they create? The purpose being to make the management complexity more concrete by pointing to existing management challenges here and now. On this issue, we used Osborne’s schematic presentation of elements relating to the three paradigms Public Administration (PA), New Public Management (NPM) and New Public Governance (NPG) to identify signs of the paradigms in specific management forms relating to local community healthcare 2. How do the new economic incentive structures work, after the structural reform has given part of the financial responsibility for the hospitals to local community health authorities? The purpose being to illustrate the management complexity that follows with the introduction of economic incentive structures, characteristic of the NPM-paradigm. On this issue, we used the Principal-Agent perspective and, in particular, we used ‘moral hazard’ as an important concept for analyzing the way these specific incentives were built and to what effect 3. How do preventive care and rehabilitation imply the citizen’s self-responsibility and self-management? The purpose being to illustrate the management complexity that follows the increasing demands for management of the citizen’s self-conditions and with that the citizen’s active participation in the welfare production, a problem relating primarily to the NPG management paradigm. On this issue, we used Foucault’s notion of power technologies and self technologies for analyzing the way in which new technologies set both citizens and employees in new ways, also including discursive displacements and changing professional identities in the analysis 4. How is this management complexity dealt with in practice? The purpose partly being to illustrate relevant management strategies for dealing with the cross pressure and partly being to understand the differences existing among local healthcare authorities. On this issue, we used Luhmann’s concept of couplings to analyze how leaders put together different rationales, agents and decision contexts in the effort of creating overall and coherent healthcare solutions Despite of limited empirical material, consisting mainly of written official documents and five fully transcribed interviews with top leaders of the local community healthcare authorities, our analysis pointed to the following central findings:  We did see traces of different and sometimes conflicting management paradigms, even within the same management forms, resulting in tensions in the management reality experienced by leaders. This analytical result confirms that the management paradigms do not supersede one another but, in contrast, co-exist in what has been termed archeological layers  With the P-A perspective, we showed how the incentive structure built to give local healthcare authorities financial responsibility for the hospitals, presented some serious problems and challenges: Preventing hospitalization of citizens is not always possible or even desired and general practitioners as independent agents are not part of the incentive structure. And even when prevention is possible, the effort might be too big compared to the possible gain. On another level though, the main challenge of the NPM-management form turned out to be a lack of support of entirety and coherence  Turning against rehabilitation as an empirical prominent NPG-management form, the analysis demonstrated how rehabilitation controls citizens and employees at the same time by demanding new mentalities and creating new relations, using among other things conversational technologies. Finally, the chapter picked up on the three management paradigms from the first analysis and pointed to the challenge of setting free citizens and employees (as part of the competition and free selection of the NPM-paradigm) and, at the same time, controlling that freedom in a specific direction of employees activating citizens and citizens undertaking an active citizenship (as part of the NPG-management form)  Stepping on the challenge of the division between management and self-management and looking into leaders’ strategic way of handling these specific conditions in practice, we found that efforts to couple agents, decision contexts and rationalities from different paradigms are indeed made, but in different ways in the two case-municipalities, linking one primarily with a management way of thinking and the other in the midst between a management and governance way of thinking. Either way, we still saw signs of lack of entirety and coherence Summing up, the thesis has shown how new dynamics between the different paradigms of PA, NPM and NPG should be invented in order to embrace the numerous demands on public healthcare in Denmark, thereby creating a future that meets citizen’s public security, society’s optimal use of its resources and a whole and coherent performance all in all.

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http://hdl.handle.net/10417/1907

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lone_thomsen_og_helle_wagner_gehlert.pdf (1.237Mb)

Mening i spil

Om meningsskabelse og ledelse i strukturreformens tegn

Bager, Michael Hansen; Frølich, Torben (Frederiksberg, 2009)

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This Masters thesis analyzes sensemaking within extreme circumstances in the Danish public sector, represented through a case analysis of the merger between the two municipalities Vaerloese and Farum into The municipality of Furesoe. As an introduction we motivate this field of interest by describing different views on the meaning or lack of meaning in The Structural Reform that was used as an occasion for merging the two municipalities. Thereafter we present a theoretical framework on meaning and sensemaking, where Karl E. Weick constitutes the overall frame for our theoretical approach. We follow his ideas of exploring closer, the substance of sensemaking, by linking his concept of ‘minimal structures’. We do that by prolonging two of his six minimal structures Third-order control and Stories to a more operational approach, than Weicks rather abstract theories of sensemaking. Third-order control is prolonged with a radical perspective on how social technologies (e.g. Value based management) influence upon the organization and its sensemaking. Stories are (naturally) prolonged with a narrative perspective, showing plots and genres. This framework is constructed to analyze tensions between the results of the intended sensemaking and the local sensemaking in the municipality of Furesoe. The intended sensemaking is constructed through an analysis in three parts: Service strategies as a governmental or central intent to guide action in municipalities, the Service Strategy in The Municipality of Furesoe and finally the narrative from the executive manager of the merger between the two former municipalities of Farum and Vaerloese – now Furesoe. Whereas the local sensemaking is analyzed through a primarily narrative approach, asking the questions: is there one or more genre present, how is time perceived in relation to the merger, is fore-shadowing and side-shadowing present, to which extent is the sensemaking process retrospective and finally what is the local sensemaking of the Service Strategy and other organizational technologies? We sum up the differences or mismatch between the two areas of sensemaking in order to describe the tensions between the two areas of sensemaking. We describe the tensions between the two areas of sensemaking as separate parts of a puzzle which is not compatible, nor complete. These tensions constitute a field of tension in which management and sensemaking is to be performed. Thus we conclude our analysis by giving recommendations on how management can be performed under these circumstances and how to build an organization that is resistant to the collapse of meaning. These conclusions reflect the discovery that Danish municipalities are robust to changes, that the ability to make sense locally is both strong and creative and hence very productive.

URI:

http://hdl.handle.net/10417/558

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Meningsskabelse blandt medarbejdere i skolens forandringsproces

En komparativ analyse i et prøveår på Gilbjergskolen

Grønvaldt, Mette (Frederiksberg, 2013)

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Abstract:

This master thesis sets out to explore sensemaking on a Danish public, primary school during an important and radical transformation. The school, Gilbjergskolen, is currently reorganizing and developing new common learning practises65 in vertical66 teams with multiple professions (teachers and pedagogues). The exploration and analysis in this thesis is based on the hypotheses that on comparison sensemaking will differ from one group of employees to another. And the differences will depend on a number of variables for example: origin of the transformation, management, professional norms and culture, team structure and isomorphic influences. I use three different theoretical perspectives to describe and analyze my findings. Firstly I take a rational approach to transformations provided by H.J. Leavitt and J.P. Kotter. As my second perspective I take K.E. Weicks more systemic view on changes and sensemaking in to account. Finally I examine whether the transformations shows any signs of isomorphic pressure as suggested by Di Maggio & Powell. I expect to identify indicators from all of the three theories upon analyzing my data with regards to the different variables. From data it is evident, that differences do exist between the different professions, sections and teams as expected. A typical example is a noticeable difference in perception and interpretation of the present results and impact with regards to the children. The difference is most significant on comparing teachers and pedagogues but also on comparing two parallel and structural similar sections of the school, that have just recently merged. Findings like these suggest, that the differences primarily emerge from social constructions like norm and culture in the different groups, professions and teams rather that rational reasons such as objective, plan, structure end deployment. Thus not said that rational and cognitive factors don’t contribute to sensemaking; they do partially. A good example of this is the fact, that a huge majority of all employees find it sensible and necessary to transform the school. So the objective is clear, if the objective in it self is to transform. But when asking why the transformation is necessary, the answers vary a lot. In a similar fashion both teachers and pedagogues are concerned with establishing a structure, which supports and endorses the transformation and development of a common learning practise. But they do not agree on which structure does in fact serve that purpose. This leads me to conclude, that the differences in sensemaking primarily arise from differences in norms and culture as mentioned. Currently these norms are still being confirmed and verified in the dialogues within each of the two professions in stead of being renegotiated and reinterpreted in the team dialogues between teachers and pedagogues. This finding confirms that several of Weicks seven features of sensemaking are present on Gilbjergskolen, and that these features influence the transformation process and early results. As headmaster of Gilbjergskolen I find it crucial for the progress of the transformation that we succeed in developing a true common language and practise with one common objective: to increase the children’s learning and capacity. This inspires me to find further ways to establish and develop dialogues and reflections on learning and thus also sensemaking as close to the learning practise and children as possible. We need to help the professionals to identify the small steps and positive results, which will take them and their practise to the next level. To do so we might need to repeat, revitalise and highlight our mutual objective and narrative for Gilbjergskolen so that they drown some of the dominant norms and culture that currently inhibit part of our transformation.

URI:

http://hdl.handle.net/10417/4284

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mette_groenvaldt.pdf (414.7Kb)

Meningsskabelse i en reformtid

Enevoldsen, Jette (Frederiksberg, 2016)

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The aim of this master’s thesis is to analyse and elucidate how a control technology such as the purchaser/ supplier model has affected Sensemaking among employees at the Danish Communication Center in Hillerød, and how an understanding of this Sensemaking can be utilised in a managerial sense going forward. With the 2007 structural reform, the Danish Communication Center was taken over by Hillerød municipality, and the purchaser/supplier model was introduced in 2008. This control technology is market inspired and separates the purchaser and supplier function in that the referral competence is transferred to the municipalities, meaning that only the supplier function is still placed with the Danish Communication Center. Implementation of the model at the Center entailed the introduction of new terms such as service catalogue, rates and time recording. In a phenomenologically inspired approach, I apply Karl E. Weick’s theory on Sensemaking (Weick, 1995), which can be used to develop an understanding of how employees attempt to make sense of changes with which they are faced. Weick presents seven characteristics that are central to Sensemaking: 1) grounded in identity construction, 2) retrospective, 3) enactive of sensible environments, 4) social, 5) ongoing, 6) focused on and by extracted cues and 7) driven by plausibility rather than accuracy. These seven characteristics are used as inspiration for the creation of a question guide and analysis of the collected data. The survey, focus group interviews and interview with the head of the Center provided a good basis for the analyses. Karl E. Weick’s future of Sensemaking practice has been incorporated into the analysis, which shows which areas the management team should focus on. As a supporting theory, I have chosen Leon Lerborg’s theory on control paradigms, which is used to map thought patterns that must be taken into account in the two competing control paradigms - the professional and New Public Management market. The main conclusions are as follows: - The time recording task still remains a challenge for some employees. - New identities have now been attached to the professional identity. - Employees want more professional coaching and training.Finally, I can conclude that Sensemaking theory has helped me gain a better understanding of how employees at the Danish Communication Center have experienced the implementation of the purchaser/supplier model, and what still affects them greatly. It is now up to the management team to review these findings and act on them.

URI:

http://hdl.handle.net/10417/6065

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Metaforer vi leder efter

Et felteksperiment om agency i primær sundhedstjeneste

Bovin, Jakob (Frederiksberg, 2016)

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Abstract:

Aim and scope: The production of welfare has transformed itself from the production of service to a production of participatory possibilities. This transformation produces new forms of organisational tension and paradox that may surface in several shapes. In the present thesis, tension and paradox are addressed as and through narratives. According to cognitive linguistics, we live largely by metaphors and the metaphor is consider-ed especially potent in the construction, preservation and reconstruction of narratives. The aim and scope of the present thesis is therefore to explore the potential of deliberate metaphoric leadership as a means for developing agency in the present day tension and paradox of public management. The thesis is further narrowed down to the empirical field of primary health care with the strategic manager as observation point. Three strategic managers of primary health care have been involved as both study objects and co-researchers in designing, conducting and documenting experiments with metaphoric intervention during a period of one month. The theoretical focal point has been Klaus Majgaard’s division of management into simple, reflected and transformative management combined with a scope of theoretical frames of reference for understanding the effects, the embeddedness, the life and the narrative potential of metaphor. The main research question is: How can deliberate metaphorics catalyse a development of agency in primary health care? The main findings are: Three Danish strategic health care managers have conducted each a metapho-ric intervention. One re-frames a management dialogue on coordination, in order to achieve a higher level of functional efficiency, in a context that was otherwise bureaucratically paralysed. Another re-frames rehabilitation to enhance a sense of professional coherence over simple linear efficiency. The third re-frames welfare technology with intentions of establishing both a positive attitude and an orientation towards cross-organisational collaboration. All three metaphoric interventions entail elements of both simple-, reflected and transformative rationality. A metaphor is an instrument of representation. In the perspective of three strategic managers, metaphors can produce visibility, overcome organisational distance and establish remote control. It does so by means of simplification, displacement and fixation of complexities. The original tension or paradox is thus not dispersed but transformed into new tension or paradox. In the case of the managers involved, this has been a productive process in itself, but the process of strategic re-configuration is not brought to an end. Metaphors are easily communicated when they tap in to existing metaphorically structured schemata. In the three experiments providing the empirical foundation of the thesis this seems to have the advantage of efficiency in communicating complexity in a simple way. Thus it seems that metaphors that are highly ‘metaphorically true’, prior to an intervention, is a suitable means of simple management. But this kind of communication is efficient at the expense of entangling the communication in the very same foundations of the pre-established schemata that one would sometimes like to renew. A metaphor has a life circle. If a new metaphor is well chosen, the experiments suggest that it can be brought to life by a creative and/or persistent pedagogic effort. It can thereafter live out a re-organising potential in a period of vitality. There are some empirical indications that such an innova-tive metaphor will tend to progress towards becoming a truism and thus in time also progress towards its own death. A dead metaphor is a metaphor that is no longer seen as a metaphor, but instead as a more or less literal expression. The birth and the initial nurturing of a metaphor seems to be an example of reflective leadership and the vitality of a living metaphor an indicator of organisational transformativity. In the present study there are examples of both effective simple management by metaphor, reflective production of self-awareness of managers, and transformative facilitation of practical implementations – all catalysed by metaphoric framing. Metaphors can carry meaning, but to some extent the meaning must also be carried by a broader communicative context. Innovative metaphoric intervention is therefore seen as an element amongst others in a complex process of organisational re-narration. For instance a strong metaphor can help distill a desirable component in an existing narrative of the past from an undesirable component. In such a case the metaphor functions as a catalyst for the establishment of plots by intertwining future, past and present in strategic ways. A new story of the future can be told by metaphoric reframing of the past in a metaphoric effort in the present. In conclusion a metaphor can be seen as a powerful catalytic instrument of agency in primary health care. It can be so (1) in a relevant degree; (2) in ways, that produces both simple-, reflective-, transfor-mative- and integrated agency depending on context and approach; (3) the developed agency addres-ses both spatial and temporal tension and (4) metaphoric intervention can be seen as an always tem-porary and intermediary remedy, -but (therefore) also as a relevant and productive catalytic of agency. One of the outcomes is, that public managers who are aware of the life cycles of metaphors might strengthen the capacity for embracing, designing and potentialising the organisation respon-sibly in the image of futures of the future.

URI:

http://hdl.handle.net/10417/5881

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Moderniseringsreformer og incitamenter i det danske sygehusvæsen

Langbakke, Bjørn; Lornsen, Karin (Frederiksberg, 2009)

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The choice of subject for our dissertation is based on observations of social trends with regard to the Danish health service, where an increase in the degree of privatization is apparent. The Danish public health service is under increasing pressure at present and has to meet a series of challenges in the form of increasing population age with a consequent increase in the need for treatment and a shortage of personnel resources. We experience a struggle for these resources be-tween the public and private hospitals service. In 2007 the government passed a law on patients` rights to extended free choice of hospital, which guaranteed patients free hospital treatment within four weeks in either a public or private hospital. By passing this law the government made clear its intention to increase efficiency in the public health service by encouraging private enterprise in an effort order to ensure real competition. With a clear political desire to maintain free access to health services, ensure freedom of choice and maintain a moratorium on taxes, the health sector, along with other services in the public sector, has undergone several modernization reforms with a view to increasing efficiency in the health service. This series of reforms and initiatives is referred to by the term New Public Management (NPM). With these views taken into consideration our focus of enquiry (problem description) aims at inves-tigating and understanding the consequences, which may be directly attributed to this health policy agenda: What consequences has NPM had, as a modernizing reform, on the Danish health service? The following subsidiary questions will also be addressed: • What consequences can be seen in relation to the use fixed charge financial control in the Danish health service, including the advantages and disadvantages of fixed charge financ-ing, consequences in relation to quality and increased activity and productivity in public hospitals? • Does the present DRG accounting system encourage price competition between public and private hospitals, and if this is not the case, what conditions are required to achieve price competition? • What consequences does the government’s privatization policy have for the hospital service, concerning, amongst other things, objectives for high quality of treatment and allocative and technical efficiency? The chosen problem areas will be investigated and analyzed using NPM, economic theory and in-terviews with leaders of two neuro-surgical clinics from the private and public sector, respectively. The conclusion of the dissertation is that the modernization reforms have had a marked effect on both management and financial control in the health service, which now appears as a mixture of public and private sector. Experience with fixed charge financial control has led to a greater degree of transparency in areas such as production costs and activity, but does not seem to have lead to a significant increase in activity. Furthermore, we conclude that under the law on extended free hospital choice, contracts with pri-vate hospitals did not seem to have lead to increased price competition but rather to competition concerning waiting lists. It was only after the law had been suspended and tenders were invited for surgical services, that one can speak of true competition between private and public health service providers being achieved, with a subsequent real drop in prices. Regarding the question of efficiency, it would seem that both the allocative and technical efficiency were affected in a negative direction by the law. This was mainly because of a lack of transparency with regards to the costs of production and included higher salaries and the possibility of skimming patients by the private sector. Finally, it is concluded that there was no real competition regarding quality between public and pri-vate hospital services, as the contracts made with the private hospitals did not address the question of quality objectives. The question remains, whether the government’s guarantees about waiting lists achieve the greatest amount of health in relation to resource expenditure, or whether it would be better to prioritize ser-vices, so that guarantees are differentiated with regard to individual treatments.

URI:

http://hdl.handle.net/10417/559

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bjorn_langbakke_og_karin_lornsen.pdf (2.097Mb)

Motivation og opgaveflytning

Hvad motiverer personale, som er involveret i opgaveflytning - og hvilken betydning har det for ledelsen?

Lohmann-Olsen, Allan; Krogager, Gitte (Frederiksberg, 2014)

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Abstract:

In the Mental Health Services, Capital Region of Denmark (RHP), like in the rest of the health care system, a number of initiatives that aim to move tasks from one profession to another is launched, and several initiatives indicate a continued shift in tasks location across the health care system. This projects aim is to examine: What motivates employees involved in task shifting – and what are the managerial consequences? The question will be examined through three approaches, which will form the basis for the selection of theory, empirical and analytical approach: The individual motivation, leadership and goals and the role of the professions. The project is confined to assessing motivation among nurses and physicians in the Central Visitation (CVI) in RHP and nurses training to become nursing specialists in psychiatric centers in RHP. The project takes on a semi-inductive approach to the use of theories. The theories are serving as prisms that allow different observations of the empirical material. The use of theories will force the analysis to take certain directions, but the analysis will not attempt to prove or falsify the theories. At the same time the project wished to be able to identify other motivation factors not embraced by the chosen theories. The theories used as inspiration were: • Management of Prima Donnas • Theories of Public Service Motivation • Goal Setting Theory • Theory of Professionalization The empirical data comprises eight interviews: with one doctor employed by CVI, three doctors working in CVI on an hourly basis, two nurses from CVI and two nurses training to become nursing specialists from two psychiatric centers. In analyzing the empirical data, the project used the program NVivo, which provides the opportunity to compare coding amongst authors, between the interviews or between coding categories. The data was coded with a combination of closed and open coding; the closed coding was inspired by the theories and the open coding by other motivational issues that seemed important to the participants. The project finds that the mark of the individual motivation is the dissimilarities in the group. Commonalities were also identified, but the most common feature is that participants are motivated in different ways. The ideal leader must be able to distinguish his or hers leadership in relation to each individual motivation profile. A part from this, every participant calls for a visible, clear, inclusive and open management. An inductive analysis across individual profiles furthermore showed that all had two needs in common; time enough and to do their job properly. Four respondents had a story of always having wanted to be in the profession. This may indicate, that people who report always having wanted to join a certain field, are people who experience a vocation. Such narrative may be used as an indicator of the presence of vocation of an employee. In a management context, this is interesting, since the presence of vocation according to Hein is strongest in the archetype of the prima donna. Respondents would like to have clear goals that make sense. Most participants felt that a number of the current goals of the company are meaningless. Whether goals would actually motivate the employees if they were developed with involvement, is not to be answered within this project. In between the professions there are disputes in relation to task shifting. The nurses understand if doctors feel that something is taking from them - but at the same time, they want new tasks that lead to development. Doctors generally experience that nurses are good at what they are doing, but not at diagnostics, and an assignment in this area is associated with risks for both patients and the profession. Both doctors and nurses have clear and consistent ideas about the core values of the profession. Nurses refer to “good nursing”, seeing the human being, and focus on the problems/symptoms the individual. Caring and compassion are the core values . For doctors, the diagnosis and treatment are the key tasks, and both must rely on evidence based facts. The overall conclusion is that nurses and doctors are motivated by a combination of the above. What perhaps dominate the motivation about task shifting is that the nurses are motivated by opportunity of developing professional skills and experiencing new professional challenges, while the doctors are motivated by retaining the core of the professional field, to maintain the monopoly. Both the nurses and doctors motivations are characterized by their profession and the values within it. On the other hand, a profession is also characterized by the individuals constituting it. In a managerial context it is important to consider that there is a relationship between the individual and the profession's motivation, meaning doctors and nurses are motivated differently. Managers therefore have to take into account both the profession and the particular employee's motivation profile. Finally, which appears to be important for all, is getting enough time to complete tasks properly. There are managerial challenges in how "enough time" should be understood, and what will it take to do the job "properly". The manager needs to explore the company's understanding of "enough time" and "properly" and compare it with the individual's understanding of what "enough time" and "properly" means. The application of knowledge about what motivate professions may guide, but it is the individual motivation that holds the essential potential.

URI:

http://hdl.handle.net/10417/4415

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Motivation og styring på sundhedsområdet

Varder, Søren Frejo (Frederiksberg, 2013)

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The Danish healthcare system is confronted by two challenges: There is a strong pressure for better performance on quality and efficiency, due to indications of quality problems and regional differences in results, limited future funding and a growing demand. And there is a cross-pressure in governance, where on the one hand demands for high quality across hospitals and regions would legitimize a strong central control and adherence to fixed standards, and where on the other hand current discourse on public governance speaks for increased local freedom and room for innovation as a preample for an effective public service. Both challenges lead back to the design of governance in health care – and how this design secures maximum performance from the clinical staff. This thesis seeks to address the issue of motivation in this regard. The point of departure for the thesis is the assumption that the support of motivation is an important factor in securing performance in health care. Is present governance in healthcare rightly constructed as to secure motivation and maximum performance from the clinical staff – or are there grounds for adjustment, where governance instruments with more emphasis on motivation is brought into play. The form is triangulation, where I assess what rational theory and social constructivist theory say on the effect on motivation from the different governance instruments in Danish health care. As motivation in health care is not very thoroughly handled in the literature, the approach is to a large extent hermeneutic with attempts to present different understandings from the results of the analysis. The thesis and analysis falls in two parts: Part I (chapters 3-5) consists of descriptive and characterising analysis, where the present governance paradigms are mapped, where the possible conflict of interests and values between state and local levels is assessed, where rational theory and social constructivist theory is outlined as to what supports motivation, where the perspectives of systemic evaluation governance as a possible third way is considered, and where health care is analysed as to its readiness for the use of new public management inspired instruments. Part II (chapter 6) consist of an analysis of what motivates doctors, how do they respond to the different types of current governance instruments in health care – and what does this imply in regard to motivation seen from a rational perspective and a social constructive perspective. The basis is a survey conducted in three Danish hospitals (Odense, Køge og Hvidovre), consisting of 41 questions on motivation and attitude towards the current governance instruments, testing my hypothesis derived from the theories in chapter two. Chapters 7 forms the conclusions. The descriptive analysis indicates that governance in the health sector today is characterized by instruments from the rational and pragmatic perspective, with a very clear dominance of the bureaucratic paradigm and NPM-market/contract. The analysis of motivation confirms a significant public service motivation in clinical staff. Doctors have a very high motivation from the job itself – as the motivation, however, first and foremost is about personal gratification, while the more altruistic and victim-derived public service motivation comes a little less clear through. The analysis cannot confirm though a theory that the current management instruments (accreditation, financial incentives, free choice and benchmarking), which are all to a greater or lesser extent are rounded from rational thought, are perceived as very controlling or as an expression of distrust. The analysis confirms a (negative) correlation between the extrinsic management tools and the intrinsic motivation. But the overall picture is that the instruments are not seen as controlling. It is not the same as the instruments are perceived as directly supportive of it professional. Here is the image is, that accreditation and benchmarking is experienced as supportive, while this does not apply to economic incentives and free choice. This gives rise to a conclusion that the rational management tools in the area of health care today to some extent seem accepted by doctors, regardless of their high intrinsic motivation. At the same time, the professional identity seems so strong that the instruments that are not directly experienced to support quality, do not seem to be absorbed in the daily practice. This could support a supposition that doctors, rounded from natural science, and as opposed to other major public sector staff-groups, has a certain understanding of the rationally derived paradigms. With even more caution, the image can support a more rational derived supposition that doctors are to some extent driven by self-interest, why the extrinsic instruments in principle should be justified. The results do not indicate that the instruments degrades the motivation, and therefore in isolation do not give rise to fundamental changes in the current steering. The analyses also shows that health have characteristics that support the use of rational derived instruments: generally seen good standardization options and easy to measure output – all though measuring outcome still has development potential. The political focus and the serious consequences of failure shows less basis though for NPM in its more pure form – with market solutions and encapsulation in contract- driven companies on arms length from the political level. That the professional values with doctors are strong indicates a need for a reinforced effort to ensure that the governance instruments applied to health care can be coupled with quality, and seen as such by the doctors. The analysis also points out that there seems to be an absence of clear leadership at the hospitals. Knowledge of the department’s central goals is highly variable. Involvement in the setting of these goals is very limited. And new management tools and reforms are not accompanied by clear managerial framework of implementation. A partial finding is that women doctors seem to be more perceptive on management – and the absence hereof. The analysis suggests further that doctors are sensible to outside views, which indicates that doctors are in accordance with the sensemaking-thinking. The result therefore indicates, that a precondition to act rationally and in accordance with central goals in the form of clear leadership is missing. And that from a social constructivist perspective the leadership which represents translates outside expectations in a form that makes sense, and which facilitates the common narrative, is equally missing. The analysis also shows a significant potential to support a steering concept Systemic evaluation governance, which is rounded from rationalist thinking with a focus on benchmarking and continuous evaluation, but which also have roots in the professional (what works) and articulates the need for innovation for the clinical staff. The analysis shows a high degree of support for benchmarking – also when it comes to benchmarking of other than the professional results, e.g. economy. Support for benchmarking does also not disappear, if publication is wide as opposed to clinical staff only. Chapter 8 frames perspectives from the findings, part lessons for central and local management, part perspectives in regard to the present discourse on public governance.

URI:

http://hdl.handle.net/10417/4283

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Multi-Criteria Decision Analysis

En analyse af de ledelsesmæssige muligheder i en beslutningsmodel

Juhl, René (Frederiksberg, 2013)

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URI: http://hdl.handle.net/10417/4172

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Når man sidder bedst mellem to stole

Om bureaukrati, responsivitet og legitimitet hos Borgerrådgiveren i Københavns Kommune

Busse, Johan Brandgård (Frederiksberg, 2015)

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Abstract:

What happens to the legitimacy of an organization when the organization changes its methods, procedures and routines and thereby departs from the traditions that prevail? That is the question of this thesis, which examines the standards, values and preconceptions that exist among lawyers and politicians in a field of public complaint boards and supervision. Specifically the study considers The Citizens Advice Bureau in the City of Copenhagen (a municipal ombudsman) with a special focus on how the professions perceive changes in working methods, procedures and routines. The thesis seeks to answer what the consequences are for the legitimacy of the Citizens Advice Bureau when introducing a new method for solving complaints, which is partially unchained from legal traditions and more responsive towards the needs and expectations of the citizens. In short it is the case of a classic showdown between bureaucracy (rule of law) and responsiveness. The question is important because it determines the possibilities for further developing the Citizens Advice Bureau. The study is based on interviews and documents and is based neoinstitutional theory from the late 1970s until today. The thesis includes concepts of rationality and looks at the importance of individual intentionality. The study identifies standards, values and preconceptions that, in the form of rationalized myths, are affecting the actions and support for the Citizens Advice Bureau. These rationalized myths are examined to get closer to assess how these myths affect the legitimacy of the Citizens Advice Bureau. Finally, the paper considers how conditions can influence the existing institutional myths towards change for a greater acceptance of responsiveness. The study shows a risk that the legitimacy of the Citizens Advice Bureau is unfavourably affected by perceptions of the profession regarding resolution of conflicts and proper methods of appeals when a new method is applied. These perceptions comes in the form of social structures on conflict resolution, the rule of law, justice, etc., which are embedded in the lawyers' perception of reality as something they deem appropriate, socially binding or simply take for granted. Others may also be affected by the perceptions of the professions, but the study indicates that this effect is less extensive and more flexible towards other values, for example regarding responsiveness. However the survey also shows that the professions could be affected by external pressure on the organization, personal involvement in developing the new methods and socialization in a way that may make them open to absorb competing institutional myths on responsiveness. This seems to be applicable at least to the extent that the alternative method may co-exist with the perceptions of the profession. The study shows that profession perceptions are not static, but to some extent sensitive to other perceptions and that it is possible to introduce new methods even if they are not based on professional recognized standards. The analysis confirms that a profession is a source of establishing social meaning, but the case shows that the professions' conservative influence can be exaggerated. The survey points out that organizations should be aware of the preconceptions of the professions when innovations are introduced and provides suggestions as to which managerial strategies that could be applied to prevent resistance from the professions and so maintain their support.

URI:

http://hdl.handle.net/10417/5392

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johan_brandgaard_busse.pdf (806.1Kb)

National sambeskatning

Udfordringer i forbindelse med koncernskifte

Bille, Heidi (Frederiksberg, 2015)

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Abstract:

This dissertation explores the challenges associated with ownership changes within a group in rela-tion to the Danish rules on national joint taxation. Current law on the definition of a group under the Corporation Tax Act is accounted for. Under these rules, a group exists when a parent entity exercises control over a subsidiary's financial and operational decisions. This usually applies in situations where the parent entity has direct or indi-rect ownership of more than 50% of the voting rights in the subsidiary. Even if the parent entity does not own more than 50% of the voting rights, it may still have control if, by other means, it disposes of the majority of the votes or has been given control per specified agreement. If changes to the group occur during an accounting period, an interim income statement must be prepared in order to attribute the income to the right joint taxation consolidation. The dissertation shows that the preparation of an interim income statement can be very resource-demanding. During an ownership change within the group, any tax losses in the transferred subsidiary prior to the transfer cannot be used by the other subsidiaries in the joint taxation, just as these subsidiaries' losses from income years prior to the transfer cannot be used by the transferred subsidiary. All subsidiaries in joint taxation must use the same income year as the administration enterprise, for which reason current law on changing income years is accounted for. The dissertation considers the national joint taxation provision on liability, under which the admin-istration enterprise and fully-owned subsidiaries are jointly and severally liable for the payment of income tax etc. Subsidiaries not fully-owned by the ultimate parent entity have only secondary and limited liability. If the income is corrected later, a previous joint taxation consolidation may be lia-ble to pay taxes concerning a divested enterprise. It is subsequently examined whether the admin-istration enterprise of the previous group has a right of complaint regarding the income assessment. It is concluded that the administration enterprise does not have any right of complaint based on ex-isting practices.

URI:

http://hdl.handle.net/10417/5093

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heidi_bille.pdf (592.4Kb)

Nedsættelse af gaveafgiften ved generationsskifte af erhvervsvirksomheder

Due Rasmussen, Finn (Frederiksberg, 2018)

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Abstract:

This master thesis examines the reduction of tax expenses when business companies are handed over to family members. June 2nd 2017 the Danish parliament introduced law no. L 183 (2016/2017). The purpose of the law was to reduce the tax levels progressively from 15% in 2015 to 5% in 2020. The reduction of the gift tax includes both the transfer of equities and personally owned business companies to family members. For family members to have their taxes reduced, the fulfilment of three demands are required: the succession requirement, the ownership requirement and the participant requirement. These three conditions will be examined and categorised into three main subjects; 1. What personally owned business companies and capital companies have in common, 2. What concerns only the personally owned companies, and 3. What concerns only the capital companies? As the three requirements can be subcategorised into three main subjects, this master thesis investigates whether the new legislation results in different tax levels depending on whether the company is handed over as a personally owned company or as a capital company. Those business assets that may result in different calculations of the gift tax when companies are transferred, as either personally owned or capital companies will be examined. Regarding the personally owned companies the tax expenses will be less if the involved parties make use of tax counselling prior to the change in ownership. The counselling may involve planning and/or important dispositions prior to or during the transfer. The thesis involves a case study (an agricultural company) in order to calculate and compare the tax levels for the different types of company. Two calculations are made – one where the company is handed over as a personally owned company and one where the company is handed over as a capital company. The result of the calculation is that the tax expenses are considerably less if the company is transferred as a capital company. The reason behind these findings is that the reduced gift tax for personally owned companies only encompasses the business part of the buildings, whereas the capital company may include up to 49 percent passive capitalization. Hence, it is possible to include more assets in the calculations of the tax reduction in the case of a capital company than in the case of a personally owned company – thus resulting in a larger reduction.

URI:

http://hdl.handle.net/10417/6281

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Finn Due Rasmussen.pdf (1.182Mb)

New public management

forandring og fornyelse af den specialiserede indsats

Wøssner Hansen, Ole (Frederiksberg, 2015)

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Abstract:

This thesis deals with the management of specialised social services – based on in-house activities and own organisation – where in-house activities and the new Danish social supervision (Socialtilsyn) will be used as case studies to both analyse the areas where the New Public Management (NPM) has changed the public management and also the areas where the NPM has not managed to make an impact with its original material. NPM made its entrance in the social services In Denmark trough the structural and municipal reform in 2007. That was a major and fundamental reform, which was introduced to simplify and streamline the public sector, and through interviews with my colleagues (managers of residential NPM – forandring og fornyelse af den specialiserede sociale indsats 49 49 Masterafhandling – Ole Wøssner efterår 2014 and vocational services) I show how competition and market forces have gained ground in the management of social institutions in Denmark. But in a previous study in last semester, I recognized that there also were some areas where NPM's original material has not succeeded in changing the management. I am continuing with this premise to look at what happened to the management and how especially the Danish theories on the paradigmatic management in the public sector can explain the development and the new forms of management. In many ways this is reminiscent of the earlier classical paradigms, such as the professional and bureaucratic, but they are mixing different logics and management technologies in a new way and in this way transcend the old paradigms and become neo-forms - a synthesis or hybrid form, which contains much of the original material from NPM, including that which did not make an impact. It has returned in a renewed and changed form, in which the hardest control technologies, such as targets, competitive contracts, costs and impact evaluation have been softened by renewed professional and qualitative management elements, such as confidence, core service, priorities, ownership, etc. My claim is that NPM as logic and management tools has changed the management of specialised effort, but it has not done so in one go, and that there has also been an NPM 02 and NPM 03 and that the content of the NPM material has changed over time, but a crucial fundamental idea of NPM, namely that simplifying and efficient management with citizens in mind still has potential, which we will see bear fruit in the future. This will not happen within the same paradigmatic framework that has characterised the last 10-15 years of management discourse, but management will be transcended and assume neo-forms, from which some new combinations of management technologies and tools shall be created. And maybe we are moving towards a new paradigm, a neo-form of NPM, which I have chosen to call Post Public Management, since it will redefine some key areas of the original NPM in which the market shall become the public market and management organised thereafter.

URI:

http://hdl.handle.net/10417/5107

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ole_wossner_hansen.pdf (7.492Mb)

No Problem is a Problem

Gram Henneberg Pedersen, Solvejg (Frederiksberg, 2017)

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Abstract:

The aim of this thesis is to investigate, whether my physician colleagues are correct, when they state that in reality Lean is New Public Management. The first part of the thesis investigated the roots of Lean, in order to define what authentic Lean is. This literary analysis included establishing a time line for the evolvement of Lean, determining that Lean was coined as a term describing the Toyota Production System (TPS). The article (Krafcik 1988) coining the term Lean concluded, that Lean was a specific Toyota attribute, not a generic Japanese effect. However, as TPS was introduced in USA, small changes were added, due to a number of books on the Japanese miracle, based on a different methods used by Japanese manufacturers. The quintessential book on Lean: Lean thinking (Womack and Jones 2003) is a collection of case studies on implementing Lean, and these cases included a number of techniques related to American management techniques. Since then the terms Fake TPS and Fake Lean have been coined. This thesis proposes, that the leadership model of Lean can described as Curling Leadership. The next part of the thesis was a comparison of Lean to the big models of reform in the Western World: New Public Management (NPM), New Public Governance (NPG) and New Weberian state (NWS), the modernized form of the classic Weberian state as described by Pollitt & Bouckaert (Pollitt and Bouckaert 2011). The comparison found some shared values and tools between Lean and all three models, and no more similarity between NPM and Lean than with the other two models. A further analysis found fundamental and not reconcilable differences between NPM and Lean, such as focus on long-term relationships with employees as well as suppliers in Lean versus contracts in NPM; and trust versus control. Empiric data from the health care system in Zeeland, Denmark included the budget agreements from Region Zeeland from 2010-2017, The Key Performance Indicators of a Lean Board in a medical department, and interviews with three elite informants placed in central positions in the healthcare system. The analysis used Pollitt & Bouckart’s model for comparative analysis of public reform, viewing the big models as menus with different dishes. Tools may be used by more than one model, but in different ways, as a main dish or side dish, thus determining whether the menu is one or another. Furthermore, the analysis used Patton’s model for Developmental Evaluation to determine attributes of evaluation on the Lean boards. The analysis found a mix of different tools and menus in the Health care system, except for NPG. In the budget agreements the biggest clash seemed to be between NPM and NWS, leading to management by incentives being stopped in 2016, as it had not been possible to slow down the effect of this type of management. The NPM tool of incentives had been too effective. Lean was in the early years a part of the region’s management philosophy and in recent years has been mentioned less and less. The current management philosophy is value-based management. The interviews showed a clear adherence to the Lean model presented by Womack & Jones (Womack and Jones 2003). The aim of implementing Lean was as much to increase the well-being of the workers, increase satisfaction from the patient by assuring less waiting time, as getting more health for the money. An important tool in the Lean model was Management by Objectives (MBO), and the analysis elucidated that MBO in principle are contradictory to TPS, as MBO has a defined goal, and when this is achieved, you have reached your goal, whereas TPS has a focus of constant improvement, and you can always do better. It also highlighted a possible confusion, when introducing MBO and measuring in a NWS organization such as a Public Danish hospital setting, where an objective a priori will be seen as an order. An objective can also be seen as an ideal end stage or as a method to monitor progress to motivate to keep going or as visual management of processes to pinpoint changes in processes. In addition, an important feature are the usage of the measuring: is the aim to punish/push or is it to identify problems in order to help solve them. An important feature of Lean is seeing problems as a source of learning, so far as to say that an organization, that believes it has no problem, has a problem indeed. Thus, it is an obligation of workers to notice and tell of problems. The final part of the empirical analysis investigated the KPI on the Lean board, and found that ‘a problem is a problem’, the goal of the KPI being either achieved (green) or failed (red). Using Patton’s distinction between traditional evaluation and developmental evaluation, the evaluation happening at the Lean board were a Traditional Evaluation with Fear of Failure, rather than a Developmental Evaluation with a focus on Hunger for Learning. As Hunger for Learning is fully compatible with Lean, and Fear of Failure is in opposition to lean, reaching the full potential of Lean is precluded. To conclude, the analysis showed a mix of different tools and menus with NPM being somewhat eclipsed by NWS and further that the full potential of Lean was eclipsed by NPM methods. The Trust necessary for Lean was eclipsed by the control part of NPM, and fear of failure overcame hunger for learning. The co-creation aspect of Lean was not achieved. In order to gain the full benefits of Lean it is therefore necessary to be careful to use the two types of menus separately. Lean appears to be the ideal management system in the healthcare system with the focus on the patient-customer, on quality and of trust and respect for workers driven by public service motivation.

URI:

http://hdl.handle.net/10417/6263

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Solvejg Gram Henneberg Pedersen.pdf (2.019Mb)

Nordsjællands park og vej

et paragraf 60 fællesskab fra idé til praksis

Koefoed, Niels Christian (Frederiksberg, 2015)

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URI: http://hdl.handle.net/10417/5686

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Ny Nordisk Skole

Uddannelsesrevolution eller varm luft?

Nielsen, Nina; Hunsdahl, Mette (Frederiksberg, 2012)

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Abstract:

This master asks the question whether New Nordic School is an indication on that there is a new management paradigm on the way to the public school? New Nordic School is a two-year development project which is developed and launched by the Child and Education Minister Christine Antorini in the spring of 2012. The Minis-ter's starting point has been that too few young people complete a youth (upper sec-ondary) education in Denmark, and her suggestion for a solution to the problem is de-scribed in New Nordic School, which focuses on children and youth’s learning from 0-18 years. The project identifies the professional teachers and educators as agents of change. The Minister expresses that the school can only be changed from within, and she invites all professionals to join the project. It is voluntarily to join the project, but there is a re-quirement that the individual institution is in consensus about the connection, and the requirement of working in networks across institutions. The study is based on data material downloaded from the website of the Ministry of Youth and Education and is also based on interviews with key people in the project. Our study is divided into three sub-analyzes: The first sub-analysis deals with hedging New Nordic School as a phenomenon. Here we show how New Nordic Schools draw on both the Nordic and the Danish school tradition, but also how it draws on inspiration from Ontario in Canada. At the same time, we try to identify what is the "new" in New Nordic School. The conclusion of this part can be summarized as follows: New Nordic School lacks concretization, and the consequence is that right now that the project has many meanings added to it. The described sources of inspiration are several places only used in extracts, in which they are taken out of con-text and reused in another in order to create legitimacy for the project, but with the possible outcome that the chosen approaches do not lead to the desired target. The second sub-analysis is dealing with New Nordic School in a paradigm context. Based in Leon Lerborgs paradigm theory, it is here shown how New Nordic School can be un-derstood in a paradigm context. The conclusion of this part says that New Nordic School is a new management approach in primary and lower secondary school, but also that this new approach leans against a professional paradigm. At the same time coupled with new management approaches, where the clear focus on achieving the common objectives are inspired by NPM, but also foster new innovative approaches in the elementary school. The third sub-analysis is dealing with the management task of extending the connection to New Nordic School. We show that the project does not contain a real management point of view, but the respondent leaders perceive New Nordic School as an opportunity and a legitimization of new approaches in management. We conclude, that New Nordic School will require new management approaches and that the project do not contain adequately focus on management efforts, but also that in the municipal management context marked by NPM-control measures, can be strengthened by the cross-pressures that leaders must make within New Nordic School . The Master concludes that New Nordic School cannot currently be taken as an indication that a new management paradigm is on its way. But it can be perceived as something qualitatively new, where we see both a rearticulating of a professional management paradigm but also a qualitative change, which adds a common focus on goal setting and an approach to innovation. The Master describes this movement as a shift of the known paradigms, and in this way concludes that New Nordic School pushes the dominant management paradigms in the school area.

URI:

http://hdl.handle.net/10417/3527

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nina_nielsen_og_mette_hunsdahl.pdf (1.157Mb)

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