Why and how practitioners in the mental healthcare
perceive and react towards Management Control systems?
A case study at PsyQ
MScBa Thesis
Version 1
23-‐06-‐2014
Stijn Hofman
S1726455
Why and how practitioners in the mental healthcare
perceive and react towards Management Control
systems? : A case study at PsyQ
University of Groningen Faculty Economics and Business
& PsyQ
Master Thesis Organizational Management & Control Groningen, June 23, 2014
First Supervisor: Dr. B. Crom Co-‐assessor: Drs. D.P. Tavenier Supervisor at PsyQ: Drs. R.M. Kist
Stijn Hofman Lutkenieuwstraat 2b 9712 AX Groningen Student number: S1726455 s.hofman.3@student.rug.nl
Abstract
Why and how practitioners in the mental healthcare perceive and react towards Management Control systems? This research examines the above question while making use of the framework of enabling and coercive control. Data is collected in a case study performed at a mental healthcare facility (PsyQ) to perform an exploratory research. The management control systems that are being researched are Routine Outcome Measurement (ROM) and protocols. Findings show that practitioners are likely to perceive MCS’s as being enabling and positive when these facilitate their actions without unnecessarily constraining them. This is because the calling of practitioners, influences the perceiving of the MCS’s.
Key words: Management Control Systems, Mental Healthcare, Case study, PsyQ, mental healthcare
Preface
This thesis is the last milestone of my business master “organizational management and control”. I have enjoyed working on this thesis mainly because close relatives are also active is this sector. The writing and researching during this research gave me the opportunity to learn more about the world of healthcare. First of all I want to thank my supervisors Ben Crom and Robin Kist. Without them the writing of this paper would have taken a lot more time. This, due to the otherwise lack of great feedback and advice. Also my family has been of great importance in supporting me. Especially in showing me different perspectives and telling me real live cases. Second I want to thank al the respondents who made interviews possible. Without all of them it would not have been possible to gain the information that was needed for this case study.
Table of Content
1
Introduction ... 5
2.
Literature review... 7
2.1
Management Control Systems (MCS’s) ...7
2.1.1
Clinical protocols. ... 10
2.1.2
Routine Outcome Monitoring (ROM)... 11
2.2
Perceiving of MCS’s... 12
2.2.1
Enabling and coercive. ... 12
2.3
Calling of The Mental Healthcare Practitioner... 14
2.4
Reaction towards MCS’s ... 15
2.5
Theoretical framework ... 16
3.
Methodology... 17
3.1 Research Design ... 17
3.2
Case Organization “PsyQ” ... 20
3.2.1
Procedure of a treatment... 20
4
Results ... 21
4.1
Perceiving ... 21
4.1.1
Characteristics... 21
4.1.2
Aspects and calling. ... 25
4.2
Reaction ... 28
4.3
Conclusion from the results... 29
5
Discussion and Conclusion... 29
7
Reference... 31
1
Introduction
The Dutch healthcare sector has experienced some major changes since 2004. These changes where initiated because of four issues presented by Perrot (2008) that where threatening the future sustainability of the health care system. The following issues were rising expenditures, quality of care, people unable to self-‐fund insurance and too many insurers.
In response to overcome the upcoming issues, the Dutch government decided to initiate a transition from the budgeted system to a regulated market system. This regulated market system, is a system that is controlled by market forces. However the government has the ability to intervene, therefore ‘regulated’. The Dutch government imposed to the insurance companies and healthcare providers to follow the new system. Now the insurance companies were taken responsible for carrying out the cost reduction that was imposed by the government. From this point numerous of control measures have been used by the insurance companies to gain insight in the costs which healthcare providers produce. Because of the buying powers and the information gained by insurance companies they are now able to create a fierce pressure on the healthcare providers.
This change from a budgeted system to a more performance based, regulated market system thus has led to a need for change for the healthcare institutions. For they must now act more market focused. Becoming more market focused implicitly means that in this “new world” the way of doing business (business case) has to change to match the new environmental settings. New business cases are now being developed for these healthcare institutions are willing to survive. In doing so, healthcare institutions have a difficult task to resolve, because of the great amount of factors to take into account when developing a new business case. One important factor to be aware of, are the human recourses of the healthcare institutions, especially the practitioner. The practitioner is performing the core activities of the institution. Their performance is thus the reason why these institutions exist in the first place. Changing management control can therefore have a major impact on the job processes of the practitioner. Thereby it creates resistance. In the mental healthcare facility “PsyQ” which is located in the Netherlands, this changing is also still happening. However, some steps are already taken. These steps are: the implementation of a routine outcome measurement system (ROM) and the use of protocols. Which are both MCS’s. Because it is unclear from the perspective of literature and because this is a new situation for PsyQ, The management wants to have insights in the perception and reaction of their mental healthcare practitioners towards the recent implemented MCS’s. Special in the case of behavioral studies towards MCS’s in the field of (mental) healthcare is the presence of practitioners to view their jobs as a “calling” (robin, 2002; Duffy et all., 2012). This shift from work, once done “for love” to being done “for the money” can be seen as a representation of a moral contamination of the workplace for many practitioners. This can have an effect on the reaction towards MCS’s that other professions do not have. Mauritsen (1994) found in a survey:
“Most research on public sector organizations actually points out that the immediate visible
accounting technologies are not implemented, do not work or are merely a waste of time” (1994, p.203).
The existence of the calling can be an explanation for the findings of Mauristen (1994). Even today it is expected to be still the same. Also in the literature there is an awareness of the limited research done in the interpretive field (Hopper et al, 1985). Charpentier (1996) noticed the above and performed a research in the Swedish health care to look at the underlying causes that make the practitioners behave the way they do. However in the literature it is mentioned that how people perceive and react towards MCS’s is bound in time (Jordan & Messner, 2012). The Dutch mental health care sector has undergone a major change since 2004 going from a budgeted based financial system to a performance based financial system. This has led to changes for the mental health care practitioners form PsyQ. These changes have not yet been fully developed and are still further crystallizing. Examples of these changes are the introduction of a Routine Outcome Measurement (ROM) and the use of evidence based clinical protocols. It is thus a great possibility that practitioners in the Netherlands perceive and react differently towards MCS’s than a couple of years ago. Therefore the aim of this research is to increase our knowledge on how and why the MCS’s are perceived by practitioners of PsyQ. With the new gained knowledge this research tries to create insights and to come up with a direction for improvement (if necessary) for the case organization (PsyQ) to further implement their MCS.
With this new knowledge we contribute to the existing Management control literature. This is done by adding insights about whether or not MCS’s conflicts with the calling of employees. It will also show how people react to these possible conflicts. This can raise future questions about the effectiveness of MCS’s. These findings are interesting because there is a great amount of people working in the mental healthcare sector as a practitioner. Therefore new insights can have a great impact on a part of the society. Also knowledge on how practitioners respond to MCS’s is of importance. Because with this knowledge future MCS’s can be modified to create a better fit between the MCS’s and their outcome.
The main research question of this research is thus the following: “Why and how practitioners in the mental
healthcare perceive and react towards Management Control systems?”. To answer the main question, it is
useful to look at two underlying questions. They help answering the main research question and give an advise for PsyQ to improve their MCS. First, how the MCS’s affect psychologists’ perceiving towards MCS’s as being positive or negative? Second why and how psychologists react towards these MCS’s?
To do so, this research makes use of a qualitative case study that is held at PsyQ. Here the data is collected through a series of open and semi-‐structured interviews conducted at the mental healthcare practitioners working at PsyQ. This research is explorative in nature because there is little known about the field of interest. However, it sometimes makes use of the literature developed in fields that have a purpose of exploring other professions than mental healthcare practitioners. These other fields are related in a sense that they are also looking at the reactions of employees. This exploratory research thus makes use of these findings to find out whether or not they are applicable for the field of the mental healthcare.
towards the MCS’s and the mental healthcare practitioners and their moral perception towards their job. Second, the research methodology is presented, explaining why this research makes use of a case study and how this study is performed. Also the case facility ‘PsyQ’ is further elaborated on. Third, the results gained from the data collection are analyzed on the basis of interview statements and existing inter-‐organizational documents. Fourth, this is the discussion and conclusion part. Here the main findings are discussed in the context of academic knowledge found in the theoretical section. Also the main findings, limitations and future research directions are presented in this section.
2.
Literature review
In the literature a lot is written about management control systems (MCS’s) and their effect on the perceived behavioral impact by the ones influenced by the MCS’s (Hopper & Powel, 1985). This study tries to add up to this literature by showing how mental healthcare practitioners react when being controlled by the management through a MCS. There is however little known on how the healthcare practitioners perceive these MCS’s and how they react to these systems (not all reactions are known and/or visible). This is interesting to know, because it seems that healthcare practitioners have a different perspective towards their jobs than non-‐ healthcare practitioners. This is seen as a “calling” (Duffy et al, 2012) which entails that MCS’s will possibly have different outcomes when applied to healthcare practitioners than when applied to non-‐healthcare practitioners. Because, of the moral conflicts that can arise when healthcare practitioners have to life up to the requirement from the MCS. We assume this Calling is also applicable for the mental healthcare practitioners at PsyQ. Before drawing any conclusions in relation with the calling, this research first looks at the definition of MCS’s and the two systems that are in place at PsyQ. Second, how people perceive MCS’s is then explained using the enabling and coercive framework. Third, the reactions towards MCS’s shall be further elaborated on. Finally in the fourth section of this literature review calling is explained.
2.1 Management Control Systems (MCS’s)
Before studying the MCS’s it is best to know what is meant by these systems and to know what Management Control is itself. Management Control is related to the Management Accounting, which refers to “a collection of practices such as budgeting or product costing”. However the systematic use of Management Accounting (to achieve organizational goals) is referred to Management Accounting Systems (Chenhall, 2003). According to Chenhall (2003), “MCS’s is a broader term that encompasses Management Accounting Systems and also includes other controls such as personal or clan controls”. Management control was defined by Anthony (2007) as ‘‘the process by which managers ensure that resources are obtained and used effectively and efficiently in the accomplishment of the organization’s objectives.’’
commonly studied contingency factors may imply different things for different types of accounting systems and controls. Therefore Malmi and Brown (2008) come up with a definition of MCS’s to prevent the above, which is stated:
“Management controls systems include all the devices and systems managers use to ensure that the behaviors and decisions of their employees are consistent with the organization’s objectives and strategies, but exclude pure decision-‐support systems.”
The above definition clearly mentions that to be a proper MCS, one should have an influence on both the behaviors and decision making of the employees.
For classifying the MCS’s, Malmi and Brown (2008) present a framework for this purpose (see fig. 1). This framework shows five main MCS’s namely Cultural controls, Planning controls, Cybernetic controls, Reward and compensation controls and Administrative controls. The following part, till the beginning of 2.1.1. is strongly related to the article of Malmi and Brown (2008).
Fig. 1 (malmi & Brown (2008))
explicit set of organizational definitions that senior managers communicate formally and reinforce systematically to provide basic values, purpose, and direction for the organization”. Organizational definitions are the “values and direction that senior managers want subordinates to adopt” (Simon, 1994). Belief systems are for example mission statements and vision statements because these express these values.
Symbol-‐based controls can be seen present when organizations create visible expressions to create a certain type of culture (schein, 1997). This can be done through, for example, the design of buildings/workspace, dress codes and through cars which employees drive.
Second, Planning controls set out goals formulated by the organization, thereby directing effort and behavior. With this they try to control the activities of individuals and groups to make sure they are in line with desired organizational outcomes. There are two approaches toward planning controls. Action planning that is short term focused and thus tactical. Long range planning, which have a long-‐term focus and therefore is defined as being strategic. An example of planning controls can be the development of projects, or producing task lists. Whether it is called tactical or strategically depends on the time span for completion of the plan. A plan is seen tactical focused if shorter than 12 months, and strategically if longer than 12 months.
Third, Cybernetic controls have five characteristics as formulated by Malmi and Brown (2008) “ First, there are measures that enable quantification of an underlying phenomenon, activity or system. Second, there are standards of performance or targets to be met. Third, there is a feedback process that enables comparison of the outcome of the activities with the standard. This variance analysis arising from the feedback is the fourth aspect of cybernetic control systems. Fifth is the ability to modify the system’s behavior or underlying activities”. The four basic cybernetic systems are budgets, financial measures (for example Return On Investments), non-‐financial measures (for example Total Quality Management) and hybrids that are mixtures of financial and non-‐financial measures (for example Balanced Score Card).
Fourth, Reward and Compensation is concerned with the way of motivating the employees as well intrinsic and external. Intrinsic motivation can be seen as motivation that is driven by a positive feeling gained in performing the job itself. For example, helping other people. This feeling lies within the individual rather than relying on external motivation. External motivation is gained by an organization when creating a pressure or making use of a monetary incentive (Richard et al, 2000).
Fifth, Administrative Controls Systems are those that direct employee behavior through the organizing of individuals (organization design and structure), the monitoring of behavior and who employees are made accountable to for their behavior (governance); and through the process of specifying how tasks or behaviors are to be performed or not performed (policies and procedures), (Simons, 1987).
Now that it is clear what MCS’s actually are and what they try to achieve, this research will focus on the two MCS’s functioning at PsyQ. These are, the use of clinical protocols (medical guidelines) and Routine Outcome Monitoring (ROM). Above MCS’s are of interest for this research because they are specifically put in place to support the change in the mental healthcare sector. This situation is also the case for PsyQ.
2.1.1 Clinical protocols.
As in 1994 Cicchetti already mentioned, “Clinicians are often faced with the critical challenge of choosing the most appropriate available test instrument for a given psychological assessment”. For the above reason and because some external pressure from the healthcare insurance companies, the field of mental healthcare has developed these protocols. Often also called “Medical guidelines”. During the years there are a lot of protocols developed that are standardized and can be tested by norms set for these protocols.
Allocating protocols to the framework (fig. 3) of Malmi and Brown (2008), protocols can be classified as two kinds of MCS namely an administrative and planning control system. First, protocols are policies and procedures that are to be followed. A protocol is nothing more than a description of how to handle in a certain situation. However protocols are more than only a decision-‐support system, because the behavior is also controlled (Krishnaiah et al, 2013), therefore Protocols can be seen as a proper MCS. Second, the protocol selected also has an influence on the short term planning. When selecting a certain protocol, the practitioner immediately commits to a given treatment schedule set by the protocol, which affect the behavior and decision making of the psychologist.
Protocols are formulated according to evidence-‐based research, which has been described as “ . . . the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-‐based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al, 1996).
Therefore this is sometimes also called a “cookery book” (Daalen and Hondius, 1995) were the practitioner can select the right treatment. The use of protocols that are evidence-‐based are expected to have some potential benefits according to Woolf et al (1999) these can be divided into three groups to whom the benefits relate. First, the patients who benefit from the protocols. Because protocols can ensure that all practitioners handle patients in a same manner. This way a patient is less dependent on the interpretation of the practitioner and can expect a certain standard of quality of the treatment. Also protocols inform patients about the treatments that are available and what their practitioner should do. Thus it makes the treatments more transparent for the patient. Second, the practitioner can also benefit from the use of protocols. Practitioners are alerted what kind of treatments can be ineffective, wasteful and maybe even dangerous. Using evidence-‐based protocols thus gives the psychologist a better position in legal discussions. Next gaps in the medical treatment are identified while doing performing research activities for the development of evidence-‐based treatments. Third, the healthcare system itself can benefit because protocols can improve efficiency and thus creating a better value for the money (Shapiro, 1993).
Inflexibility exists when there is no possibility for the practitioner to make some modifications to the protocols to create a better fit for the treatment. When protocols are made, researchers sometimes choose a certain situation in which the problem exists. This can lead to oversimplification of the situation for which the protocols are developed. In practice the complexity of the patients problem can make the protocols useless. Disagreement with evidence interpretation is not necessarily arrogance of the practitioner. There are drawn different conclusions coming from research. This makes the conclusions and thus the interpretation doubtful. Besides, over the years gained experience of the practitioner certainly has an influence on what they think (know) works best. This can create a conflict in the perspective of the interpretation of evidence.
This part thus shows the positive and negative aspects that could influence the practitioner way of perceiving the protocols. In the following part 2.1.2. Routine Outcome Monitoring (ROM) is discussed.
2.1.2 Routine Outcome Monitoring (ROM).
Routine outcome monitoring (ROM) is a method often applied in the mental healthcare in which measurements are done regularly for evaluating and if necessary to make adjustments in the treatment applied (Buwalda et al, 2011). The ROM as applied at PsyQ is a questionnaire. This questionnaire has to be filled in by the patient at two moments. Before the first treatment and when the treatment is finished. This data is then comparable in a lot of different ways. The way ROM collects its data, is best done by using measurements from the start of the treatment and afterwards when the treatment is finished, this data is then compared and analyzed (Nugter and Buwalda 2012). This is thus the same way as PsyQ applies the ROM.
The ROM is implemented for fulfilling the need set by the insurance companies to make the healthcare provided more comparable and to give insights into the quality of the care given (Laane and Luijk 2012). There are more benefits for using the ROM. However not all researchers are consistent in defining the benefits. This is because ROM is a relatively new method applied in the mental healthcare. If even the researchers find it hard to define the benefits, then is logical to assume that mental healthcare practitioners also not per se perceive the benefits the same. The practitioners and how they perceive the ROM is actually one of the main focuses of this research.
does (Seligman 1995). Whether or not these goals evoke positive or negative feelings towards the ROM is hard to say. It depends on the situation the practitioner is in. This is further explained in part 2.2.
Allocating ROM to the framework (fig. 3) of Malmi and Brown (2008), ROM can be classified as two kinds of MCS namely a cybernetic control system and a reward and compensation control system. The former is applicable because ROM makes use of a feedback process, however the data collected by ROM is non-‐financial and thus a non-‐financial measurement system. The latter is because the feedback process also shows information about a specific practitioner. This information thus can be used for performance-‐based payments. ROM is actually also used as a performance measurement in the case for PsyQ. Healthcare insurance companies make agreements with PsyQ on the outcomes of the ROM. If these agreements are not met, for example not enough patients filled in the ROM, then the fees towards PsyQ are reduces.
One can expect that the responsibility for making sure that the patient fills in the ROM lie on the shoulders of the practitioners at PsyQ. This can be seen as a downside of the ROM to the practitioners.
Above possible positive and negative aspects of both protocols and ROM are discussed in part 2.1.1. and 2.1.2. These can influence the way “how” practitioners perceive Protocols and ROM. However they are assumed to be incomplete. This is because every situation in which the practitioner is present can create different positive or negative aspects towards protocols and ROM from the point of the practitioner (Jordan & Messner, 2012). The positive and negative aspects of the protocols and ROM should therefore be seen as a first direction for this research in which effects on perceiving can be found. However there are thus more aspects possible available. In this research also these other possible aspects are tried to be found when conducting the semi-‐ open interviews. During these interviews there is also shed light on the characteristics that make a MCS to be perceived as being enabling or coercive. This is further explained in the next part 2.2.
2.2 Perceiving of MCS’s
When employees (psychologists) are confronted with MCS’s (explained in part 2.1), they can perceive this as being enabling or coercive. This part further elaborates on the perceiving of MCS’s to be enabling or coercive. Also the moral contract, equity and the interference of MCS’s with the profession, which are of influence in the enabling or coercive perception of the MCS, is further discussed.
2.2.1 Enabling and coercive.
Employees in organizations in the case of this research “the psychologist” can have positive or negative reactions towards a MCS. For explaining this reaction the framework of enabling and coercive formalization, as suggested by Adler and Borys (1996) is used. This part 2.2.1 is strongly related to and based on the article of Jordan and Messner (2012). Adler and Borys (1996) say that MCS have are perceived/experienced positive when these are enabling, thus helping the employee to do his/her work better and/or more easily. The opposite is when a MCS is perceived as being negative, this is when employees have a feeling they are being
and coercive control perceived in different situations (e.g. Chapman & Kihn, 2009; Jørgensen & Messner, 2009; Wouters & Wilderom, 2008; Jordan & Messner, 2012). Following Adler and Borys (1996), these studies suggest that whether a control system is enabling or coercive depends on how the control system is designed and on how the design and implementation process is organized. Regarding the design features, Adler and Borys (1996) argue that enabling systems have four key characteristics. First, they allow users to repair the formal system in case of a breakdown or problem. In the case of a control system, this can mean, for example, that practitioners have the permission and ability to modify the definition and measurement of performance indicators used in the ROM, if deemed appropriate (Wouters & Wilderom, 2008). Second, enabling systems exhibit internal transparency in the sense that practitioners are able to see through and understand the logic of the system. For example, in order for an MCS to be transparent, target values for performance need to be communicated to the practitioners (Ahrens & Chapman, 2004). This communication of target values can be done beforehand through organizing meetings with the management and practitioners. The third feature of an enabling system is global transparency. This denotes the extent to which practitioners understand the up-‐ and downstream implications of their work. For example, global transparency is achieved when the MCS increases practitioners’ understanding of the firm’s strategy and operations (Chapman & Kihn, 2009). Finally, MCS’s enable practitioners to better manage their work if they allow for some flexibility in terms of how they are used. This is the case, for instance, if a protocol for treatment specifies guidelines that can be adjusted in order to suit the individual patient (Jørgensen & Messner, 2009).
MCS’s are also more likely to be perceived favorably if the development process of such systems is organized in an enabling way. According to Adler and Borys (1996), this is the case if such systems are designed with user involvement. Rather than exclusively by outside experts if the system is made to fit the organization. For the case of MCS’s, Wouters and Wilderom (2008) suggest that a MCS can be rendered more enabling if the practitioners who are to be controlled by the MCS are involved in developing the system. The practitioners should have a learning-‐centred and professional attitude, be able to capitalize on their local knowledge, and willingly to experiment with the control system design.
the very introduction of a particular MCS, but also with the help of symbolic practices through which the role and relevance of the control system are communicated. Evaluation processes are thereby of particular relevance. They form part of the signals that top management sends and which, once interpreted by practitioners, can make MCS’s appear as a more or less enabling (or coercive) control tool.
The possible positive and negative aspects that could effect whether or not protocols or ROM is perceived as being enabling or coercive are presented in 2.1.1. and 2.1.2. However it is possible that there are other aspects also of influence, then this research will identify those.
The enabling and coercive framework thus finds out if the MCS is being enabling or coercive. This is done by examining the characteristics as described above. Adding these findings from the characteristics up with the possible positive or negative aspects as described in part 2.1.1. and 2.1.2. this research tries to create an image about the perceiving of the practitioner towards the MCS’s. This image should represent the overall perception towards the MCS’s. As well the smaller aspects that come to this overall perception.
Normally now one could make an expectation about how one thinks a practitioner would react. Off course based on the way practitioner perceive the MCS’s. If a practitioner reacts overall positive, than it is assumable that the practitioner executes the MCS’s as ordered. However. When someone has a negative perception towards the mentioned aspects, or a coercive feeling towards the characteristics, then it is assumable someone would resist the MCS’s.
Before we come to this point something has to be taken aware of. This is the “calling”. The calling has an influence on the practitioner way of doing his work and thus his possible perception towards perceiving the MCS’s. This point of interest is discussed in the next part 2.3. After this part the actual reaction is discussed in part 2.4.
2.3 Calling of The Mental Healthcare Practitioner
As already mentioned in the introduction: mental healthcare practitioners experienced their work around a sense of altruism or mission (Robins 2001). A “calling” can be seen as being a mission or a sense of altruism. You can say that if one perceives his/her work as being a calling that they view their work differently than those who simply believe their work is a good fit for their skill and interests (Dik & Duffy, 2009; Wrzesniewski, 2010). A definition is given about “a calling” by Dik and Duffy (2009) and is as following:
A transcendent summons, experienced as originating beyond the self, to approach a particular life role (in this case work) in a manner oriented toward demonstrating or deriving a sense of purpose or meaningfulness and that holds other-‐oriented values and goals as primary sources of motivation.
(p.427)
This definition strengthens the concept of a calling and shows that a calling can also be applied to work related issues. Schneider (1969) acknowledge the above by arguing in his research that people conceptualize separate moral spheres, see Figure 2, Moral spheres.
Figure 2, Moral spheres.
Care giving is normally been seen as a task that is symbolically situated within the domain of love (Robins, 2001) The domain ‘Love’ (left sphere), is in contrast with the domain ‘money’ (right sphere) as Schneider (1969) claims. This shift from work once done “for love” to being done “for the money” in the public mental health care is increasing its emphasis on financial issues can be seen as a representation of a moral contamination of the workplace for many individuals. Duffy et al. (2012) noticed that psychologists see their ‘calling’ as “to help or serve others”.
The question arises how the MCS’s affect the behavior of people when such as a calling is involved? Because as already mentioned in the previous literature about MCS’s, these MCS’s try to influence the behavior of employees to produce the wanted outcomes. What if these outcomes do not line up with the calling? Then there will be some kind of conflict between the purpose of the MCS applied and the calling perceived by the practitioner. This conflict can arise as Schneider (1969) mentions, when going from one moral sphere to another is seen as inappropriate and polluting. These shifts from one sphere to another happen when a healthcare facility moves to a more explicit financial orientation (Robin, 2002). This is similar to what is happening in the Dutch healthcare sector right now. As the goal in the mental healthcare is to strive for service effectiveness and cost-‐efficiency Robin (2001) also suggest that this strategy could backfire as the focus shifts from the quality to the quantity of the service. Therefore this research focuses on how the MCS’s, implemented in our case facility, enables or disables the possibility for practitioners to perform their calling. The calling will be measured by using a ten point Likert scale. This research contributes to the existing literature in taking the calling into account for the way practitioners perceive the MCS’s. This knowledge is usable for improving MCS’s, especially for the healthcare sector.
2.4 Reaction towards MCS’s
Charpentier et al. (1996) found that the area of negative reactions is large when a system functions both as a product classification system and sets fixed prices. In their case there was an acceptance by the majority of the system, however in general people were using a wait-‐and-‐see policy. They mention that as long as people who were affected by the system (healthcare participants) felt they are the winners, the system will be accepted. This is in line with the enabling and coercive presented in 2.1. When healthcare participants felt they would not win in the long run then they would resist against the system. This resistance took several forms of dysfunctional use of the system namely: Gaming, creeping and dumping (Charpentier et al, 1996). These forms of resistance are reflected on the case of PsyQ:
Gaming can be considered as an under-‐treatment of the patient when for instance a practitioner discharges
the patient to soon or when he/she skip treatments in order to finish the treatment sooner. Also possible is the use of less effective treatments. Over-‐treatment is the opposite of under-‐treatment in which the practitioner is using more treatments then necessary. This way he/she is able to get more treatments out of one patient and thus create a filled schedule, also making sure you are in the next treatment time block, which gives a higher payout, is a way of over-‐treatment. Creeping is letting the insurer pay for a treatment that is not performed by the practitioner. This can be seen as an illegal procedure. The practitioner selects a treatment for the patient but claims a treatment that has a higher payoff. This is especially interesting to do when being in financial crisis.
Dumping is also sometimes referred as cherry picking, here the less profitable patients or difficult patients are
avoided. Thus referring the patient to another mental healthcare facility or simply refusing the patient. There are off course more possible negative reactions towards MCS’s these will be searched for in this research. Besides the negative reactions towards MCS’s there are also positive reactions. Because negative reactions are not in line with the purposes of the MCS’s, positive reactions are expected to be in line with the purpose of the MCS’s. We therefore assume these reactions are in favor of the MCS’s however there is not much written about the positive reactions people perform when they perceive a MCS’s as being enabling and beneficial, but one can think about positive initiatives that enhance the MCS’s for example.
2.5 Theoretical framework
This theoretical framework as presented in fig.3 gives an overview of the relations expected according to the theory presented in the literature review. As MCS’s influence the job fulfillment of practitioners, it is expected that the practitioner who is influenced by the MCS’s have a certain perceiving towards these MCS’s. This perceiving is believed to be positive or negative. How the practitioner perceives the MCS, is according to the literature dependent on the characteristics and the aspects of this system.
However, practitioners also are believed to have a calling. The calling can influence the perceiving of the practitioners. This because having a calling makes the practitioner see the patient as most important. So it is expected that the practitioner will not act in behalf of him/herself or the facility.
Fig. 3 Theoretical Framework.
3.
Methodology
The following will be presented in this chapter. First, the methodology applied for generating data and useable information is being covered. It shows how and why certain methods are chosen and why some are rejected and it expresses why this research will come up with valid and reliable information. Second, the case organization is elaborated on, to give a contextual view and the situation in which this case study is done. Also the management control systems (MCS’s) that are being studied at the case organization are further defined.
3.1 Research Design
In order to answer the main question “Why and how practitioners in the mental healthcare perceive and react
towards Management Control systems” this research focuses on two sub questions. First, how the MCS’s affect
this specific situation. Outcome of this research is thus focused in depth and on theory developing (Eisenhart, 1989). The theory developed can be interesting for future research. Beside the fact that a quantitative research is not suitable for these complex questions, qualitative research also has the strength of going deeper into the topic because by using interviews the researcher can recognize irritations, anger and other emotions that could lead to discovering new insights (Flick, 2006). Therefore this research builds upon a qualitative case study conducted at the mental health care facility called “PsyQ”.
Opting for a case study is appropriate for certain types of problems in which the boundaries between context and phenomenon are not well defined, as is the case in this research (Yin, 2003, p.13). Those in which research and theory are at their early, formative stages (Roethilisberger, 1972) and as Bonoma (1983) states “sticky, practice based problems where the experiences of the actors are important and the context of action is critical”. Also, this research looks at the subjective side of the management accounting literature, because this research gives insights into the perspective from the practitioner towards the MCS’s rather than an objective functional view, which mainly focuses on the perceived behavioral outcomes (Hopper & Powell, 1985). Chenhall (2003) mentions that this subjective side of the management accounting literature is underdeveloped. Mason et al. (2010) suggest that for these kinds of situations, in which there is a new research theme or when addressing an existing issue from a new perspective, an exploratory research is well suited.
The case of this research can be described as the mental healthcare organization ‘PsyQ’. PsyQ has 31 facilities located nationally. In this case the focus lies on the relation between MCS’s and the practitioners (respondents). These are the main subjects to be interviewed in this case study. Therefore the case study design is a single case study as Ying (1984) suggests because the case is the organization PsyQ itself. This form is appropriate when it is a revelatory case i.e., it is a situation previously inaccessible to scientific investigation. The respondents must be selected at facilities inside the case organization because the problem as formulated is initiated at this mental healthcare organization. The respondents are interviewed at different facilities of PsyQ this because they use a franchise formula which makes the facilities almost identical, therefore the findings are generalizable for the 31 facilities of PsyQ. Whether these findings are also generalizable for other mental healthcare organizations is hard to say because of the existence of a different organizational context and maybe even a different environment. Further elaboration about the case organization is done in part 3.2. More research has to be done to test whether the theory developed is also applicable for other MCS’s and different professional disciplines than working as a psychologist.
