AuthorBarsbay, Mehtap Cakmak
  1. Introduction

    Hospital organizations are considered complex adaptive systems by relying on interdisciplinary interactions among healthcare professionals; the overall performance in a healthcare organization depends on the interdependent work of highly specialized clinicians and the vision of managers (Vainieri et al., 2019). To address the emerging issues and challenging trends facing clinicians and healthcare managers, two broad recommendations have been prominently proposed: professionalization of health management and leadership, and employing physicians in management positions. Professionalization of health management and leadership is a key component of health policy development, health system strengthening, and performance management in health systems (Op de Beeck and Hondeghem, 2010, p. 21; Tudor Car, Kyaw and Atun, 2018; Horton, 2000). The International Hospital Federation (IHF) (2015) highlights professionalization of health management and leadership for efficient and resilient health systems as one of its capacity-building initiatives in developing countries. Another possible solution for better-performing health systems is employing physicians in management positions in healthcare organizations (Degeling et al., 2003; Rivers, Woodard and Munchus, 1997). This is particularly relevant because they differentiate from their counterparts with a nonmedical background on healthcare quality and clinical processes (Clay-Williams et al, 2017; LeTourneau and Wesley, 1997). Although many developed countries still push physicians into executive management positions, most countries have spurned this recommendation (Modi, Gupta and Singh, 2015; Loh, 2013; Ireri et al., 2017). For example, in the US, hospitals with physician managers decreased from 35% in 1935 to 3.6% in 2008 (Gunderman and Kanter, 2009). It was due to physician managers having considerable competency gaps and difficulty at balancing their medical and managerial roles and responsibilities (McConnell, 2002). In particular, physicians face challenges regarding financial management, negotiating and teamwork skills, and health management terminology (Kumpusalo et al., 2003). Despite the numerous examples of effective interprofessional education programs (Grace, 2020), the business aspects and interprofessional collaboration can be limited in medical schools, as they receive relatively little attention compared with clinical aspects of medicine (McAlearney, 2006).

    Although a growing body of literature on professionalization of health management and leadership can be traced back to the US and the UK, it is an emerging field in developing countries (Horton, 2000; Wallick, 2002; Walsh, Harrington and Hines, 2020). Previous studies have not shed sufficient light on current cases in developing countries that still follow traditional approaches in employing and dismissing executive managers. Executive managers in healthcare organizations have a pivotal role in overcoming current and emerging challenges in healthcare delivery. However, very little is known about the characteristics of executive managers and their skills, capabilities, roles and responsibilities in healthcare organizations in developing countries.

    1.1. The situation in Turkey

    Turkey is a developing country between Europe, Asia and the Middle East, and has recently been characterized by remarkable and incremental improvements in the healthcare sector (Atun et al, 2013). The Health Transformation Program (HTP) gave rise to a reorganization of healthcare providers, a purchaser-provider split in the healthcare system, redesigning service delivery, and developing capacity. As a result of this reorganization, public hospitals hold a 61% share of the total 217,771 beds; 52% of physicians and 82% of registered nurses are employed in the healthcare organizations affiliated to the Ministry of Health (The Ministry of Health, 2019). In addition, decentralization and performance measurement in these organizations have gained importance in eliminating performance problems and developing administrative capacity in hospitals (Akdag, 2018). For example, two-thirds of state-run hospitals in Turkey operate inefficiently and have excessive expenditures for medical devices and medicinal products, and inappropriate bed use (Cakmak, Oktem and Omurgonulsen, 2009), which is a piece of data-driven evidence for the lack of administrative capacity in hospital organizations. This is an indication for professionalization of management and leadership in hospitals and the healthcare system.

    The government is mainly concerned with health management and leadership competency, as Turkey's healthcare system comprises large and publicly funded healthcare providers. Despite evident policy actions, management and leadership in public healthcare organizations in Turkey remains unclear. Governmental policies influence the competency-based human resource system and selection of managers in the health system and top-level managers of healthcare facilities. Moreover, 'health professions education in Turkey is based on old and traditional paternalistic values of professionalism' (Domac and Anderson, 2012, p. 83). In addition, Ministry of Health centrally supervises selecting and appointing executive managers in public health organizations. In this context, professionalization of health management and leadership in Turkey is extremely valuable.

    1.2. Theoretical and conceptual background

    This study applied the lens of domain theory of Kouzes and Mico (1979) to examine top-level managerial competencies and roles in hospital management. It may be a good fit for public hospitals that are run by state, perform under governmental regulations and are sensitive to political interventions (Cakmak, 2019). Top managers in hospitals ought to fulfill expectations of different stakeholders within and outside the organization. First, they meet the needs and expectations of elected politicians by developing policies. Second, they ought to allocate scarce resources efficiently and achieve organizational goals. Third, they must satisfy the patients enhancing healthcare quality. According to this theory, each domain develops relevant mechanisms to legitimize their locus. It also assumes that interactions between policy, management and service domains can result in discordance and conflict (Kouzes and Mico, 1979). However, it says a little about integrating these domains and specific competencies for collaboration and interprofessional aspects.

    Despite having distinct sub-cultures with defensive professional borders, healthcare workers continue to coexist in silos in healthcare organizations (Bate, 2000). Therefore, considerable efforts have been devoted to strengthen relationships among health professions. Over the past two decades, publications have concentrated on interprofessional education to prepare the health workforce of the future to strengthen their teamwork skills. Graduate and undergraduate health programs have incorporated interprofessional collaboration into their curricula and this has expanded to other countries. In particular, many governments have recommended that all undergraduate health professions programs ought to include a common set of core curricula that consists of ethics, communication and collaboration, scientific theory and methods (Almas and Barr, 2008). Furthermore, the World Health Organization (WHO) has also outlined a broad category for interprofessional learning outcomes such as 'teamwork and collaboration; roles and responsibilities; communication, reflection and learning; patients; and ethics'. Similarly, a very recent study on teamwork performance in healthcare management has specifically involved these core skills in their research (Banks and Toy, 2020).

    A great deal of previous research has been carried out on core competencies that are strategic and powerful assets for managerial positions in healthcare. Professional organizations and researchers have developed several tools to assess competency levels of managers at different management levels. One of the most popular instruments for assessing the self-efficacy of people in management positions in healthcare was developed by the Healthcare Leadership Alliance (HLA). This is a list of competencies designed to evaluate relevant tasks typically performed by healthcare managers. The HLA designed this framework based on five key dimensions such as 'communication and relationship management, professionalism, knowledge of healthcare environment, and business skills and knowledge' (Stefl, 2008, p. 364). The International Hospital Federation (2015) revised this framework for further country-specific frameworks. The US National Centre for Healthcare Leadership also used research-based competency modelling delineating 26 competencies organized into the 'categories of transformation, execution, and people' (Herd et al., 2016, p. 218). A very recent systematic review identified management competences in hospitals (Walsh, Harrington and Hines, 2020). The authors compiled nine competency subdomains organized into three categories: communication skills, conflict management, professionalism, professional development, ethics and social responsibility, time management, strategic thinking, effective planning, and scheduling of tasks and activities. However, these competency frameworks are not limited to top-level executives, but include nursing managers, medical specialists, educators, athletic trainers, graduate students, mid-level managers and hospital managers at all hierarchical levels (Walsh, Harrington and Hines, 2020). However, many have criticized these competency-based frameworks, which may 'oversimplify management by fragmenting rather than integrating' (Spehar, Frich and Kjekshus, 2012, p. 9). Despite the variety of competency frameworks for healthcare managers, there remains a lack of agreement about key competencies required for top-level executive managers...

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