GENERAL PRACTICE MANAGEMENT
There is a way, but is there a will?
Master thesis, Msc Human Resource Management
University of Groningen, Faculty of Economics and Business
Abstract
To reduce the increasing workload of general practitioners (GPs), the function of general practice manager (GPM) was introduced. In this study the effects of the division of medical and management tasks between GP and GPM on perceived accountability, domain autonomy and role ambiguity were investigated. In addition the effects of these factors on job satisfaction and the effects of the division of tasks on perceived quality of general practice management were investigated.
This paper contains results of a pre-study (N = 39) and a follow-up interview study (N = 8). The practices differed in the division of medical and management tasks between GP and GPM. These differences related to perceived accountability, quality of general practice management and to domain autonomy in GPMs and were not related to role ambiguity.
Table of contents 1. Introduction 2. Theory
2.1 The effect of the division of medical and management tasks between the GP and GPM on their perceived accountability, domain autonomy and role ambiguity 2.2 The effect of accountability, domain autonomy and role ambiguity on job
satisfaction
2.3 The effect of the division of medical and management tasks between the GP and GPM on their perceived quality of general practice management
3. Methods
3.1 Pre-study 3.2 Main research
4. Results
4.1 The effect of the division of medical and management tasks between the GP and GPM on their perceived accountability, domain autonomy and role ambiguity 4.2 The effect of accountability, domain autonomy and role ambiguity on job
satisfaction
4.3 The effect of the division of medical and management tasks between the GP and GPM on their perceived quality of general practice management
4.4 Overview of results
5. Discussion
5.1 Conclusion
5.2 Suggestions for implementation in general practice 5.3 Possible flaws of this study
5.4 Suggestions for further research
1. Introduction
General practitioners (GPs) face a tremendous increase in workload, particularly as a consequence of more administrative tasks (Bex et al., 2008). A reason contributing to this extension is the growing demand from governments and insurance companies worldwide for transparency (Laughlin et al, 1992, Stoffels, 2008). Based on the large amount of government money spent on health care, governments argue that they need to have more insight in the costs and expenses of this sector. In turn, this demand for transparency leads to more administrative tasks and higher overall workload (Winthereik et al., 2007).
Obviously, high workload is a source of unhappiness of GPs (Edwards et al., 2002). To reduce the workload, a new function in the general practice was introduced: the function of general practice manager (GPM). With the introduction of this GPM, management and administrative tasks could shift from the GP to the manager 1.
these domains are non-medical tasks, however, to some tasks, medical knowledge can be helpful. For example concerning the quality and safety tasks: in case a GPM has the task to develop and implement a quality system, knowledge about how this system will interfere with the daily tasks of the GP can help to improve the applicability of the system.
autonomy refers to the knowledge domain about which a professional possesses expertise and skills which is acknowledged by relevant others as that domain in which the professional has exclusive rights to make decisions and to act (based on Stoffels, 2008). Based on the tasks of a GPM, the knowledge of a GPM can interfere with the knowledge of a GP. The domain autonomy of both the GPM and the GP can be influenced by the way of dividing management tasks.
The practical relevance of this study derives from the novelty of this function. As this function is still in the making, for GPs and GPMs it is useful to know what effect the division of tasks has on job satisfaction, influenced by a change in accountability, domain autonomy and role ambiguity. In addition, it is convenient to know how GPs and GPMs should divide medical and management tasks to create the optimal situation concerning both job satisfaction and the quality of general practice management.
Many GPs do not want to have a manager in the practice because of their fear of losing their job satisfaction due to a change in domain autonomy and accountability. Also an increase in role ambiguity can influence job satisfaction (Noe et al., 2006). So it is important to find out whether the division of tasks between the GP and GPM will actually influence job satisfaction as a result of changing accountability, domain autonomy and role ambiguity.
Therefore, the main question of this paper is:
What effect has the division of medical and management tasks between a general practitioner (GP) and general practice manager (GPM) on their perceived accountability, domain autonomy, and role ambiguity; how does this affect their job satisfaction and how does the division of tasks affect their perceived quality of general practice management?
This question can be presented as follows:
Division of medical and
management tasks Domain Autonomy
The following sub-questions derive from the conceptual model:
1. What effect has the division of medical and management tasks between the GP and GPM on their perceived accountability?
2. What effect has the division of medical and management tasks between the GP and GPM on their perceived domain autonomy?
3. What effect has the division of medical and management tasks between the GP and GPM on their perceived role ambiguity?
2. Theory
2.1 The effect of the division of medical and management tasks between the GP and GPM on their perceived accountability, domain autonomy and role ambiguity
2.1.1 The effect of the division of tasks on accountability
Accountability can be described as the degree in which the GP and GPM have to justify their decisions they have made, or are intending to make, to each other (based on Molleman et al., 2010; Frink & Klimoski, 1988).
The division of management tasks in the practice can have implications for the accountability of the GP and GPM. In case both the GP and GPM have a combination of medical and management tasks, they will have to justify their actions to each other more often. The reason for this justification is to assure continuity in the execution of both medical and management tasks, as two different professionals work on the same domain. In case the tasks of the GP and GPM are highly specialized, which means that the GP can focus on medical tasks and the GPM can focus on management tasks, the professionals have to justify their actions to each other less often, because their work areas are strictly divided and they are not involved in each others domain. Thus it can be expected that the more the GP and GPM have a combination of both medical and management tasks, the more they will have to justify their actions or intended actions to each other.
2.1.2 The effect of the division of tasks on domain autonomy
administrative tasks on his own, having to deliberate on these issues with the GP can be experienced as a constraint to his domain autonomy. When the GP and GPM have mixed tasks, they both have knowledge about the two areas. This decreases the amount of unique skills and knowledge and in addition reducing the domain in which they have exclusive rights to make decisions, thus decreasing the level of domain autonomy. When the GP and GPM have solely medical and management tasks respectively, this can lead to a higher domain autonomy because both professionals have their own knowledge domain. In such a situation the GP has the exclusive right to make decisions and to act concerning medical tasks, while the GPM has the exclusive right to make decisions and to act in the management domain. That is why it is expected that a combination of medical and management tasks for both GP and GPM will lead to lower domain autonomy, compared to the situation in which the GP has solely medical tasks and the GPM has solely management tasks.
2.1.3 The effect of the division of tasks on role ambiguity
Role ambiguity is the level of uncertainty about what employees expect from each other in terms of what to do or how to do it (Noe et al., 2006). Within a practice it is important to have clear agreements about how to divide tasks and functions between the different employees and how to fulfill these tasks and functions. This kind of information is needed to perform a job adequately. When this information is uncertain, the employee will experience a feeling of ambiguity. So role ambiguity arises when required information is not available to a given organizational position (Kahn et al., 1964). According to these authors, complexity and rapid changes in work and work environment can contribute to role ambiguity.
In case of a mix between medical and management tasks for both professionals, it can be difficult to divide time properly between the domains and it can be unclear when it is required to consult the other professional for things concerning medical and/or management tasks. Confusion will be less in case management tasks belong to the GPM and medical tasks belong to the GP.
2.2 The effect of accountability, domain autonomy and role ambiguity on job satisfaction
Job satisfaction can be defined as a pleasurable feeling that results from the perception that one’s job fulfils or allows for the fulfilment of one’s important job values. A value, in this case, is something that a person consciously or unconsciously desires to obtain. (Noe et al, 2006). A general practitioners job is linked to a high level of job satisfaction (Edwards et al. 2002). This high level of job satisfaction is a result of the autonomy and freedom in this job (Cooper et al., 1989). Particularly in England, job satisfaction was influenced negatively in the 90’s of the last century mainly due to GPs being contracted by the government. These contracts were viewed as an attack on their independence and professional autonomy. In the same period the workload concerning the administrative tasks increased (Sibbald et al., 2000).
The specific division of the medical and management tasks between the GP and GPM can have influence on job satisfaction, mediated by accountability, domain autonomy and role ambiguity. It is expected that these variables will be influenced by the division of medical and management tasks between the GP and GPM, and these factors, in turn, will influence job satisfaction. Therefore, the effects of these factors on job satisfaction will be investigated in the current study. A research by Thoms et al. (2002) demonstrated a positive relationship between accountability and job satisfaction. However, whether this positive relationship will be found in the situation concerning the GP and GPM can be questioned. With the introduction of a GPM in general practice, it is the first time that someone other than the GP is informed about the ins and outs of the practice to such an extent. To be able to understand everything in the practice, the GPM has to be involved in many processes in the practice, which holds that the GP has, to a certain extent, to justify and explain his actions to the GPM. Justification of decisions and (intended) actions can be experienced as threatening by the GP.
The relation between autonomy and job satisfaction has been studied many times before and it can be concluded that general autonomy is positively related to job satisfaction (Noe et al., 2006; Breaugh, 1999). The same relationship is expected to be true for domain autonomy specifically. Therefore, high domain autonomy of the GP or GPM is expected to lead to higher job satisfaction. If this domain autonomy is restricted, it will result in lower job satisfaction.
Role ambiguity is often associated directly with different aspects of strain, like depression and burnout (Lyons, 1971; Lang et al., 2007). Vice versa, the opposite of role ambiguity, role clarity, is linked to high job satisfaction (Lang et al., 2007). Role ambiguity influences the individual as well as the organization. In case of high role ambiguity, individuals will perceive a loss in job satisfaction and with it the performance of the whole organization will decrease (Breaugh & Colihan, 1994). Therefore, it is important to create clarity around roles and functions of employees in an organization. Job satisfaction is most influenced by ambiguity around performance criteria. When it is unclear for employees how they will be evaluated on the job, job satisfaction will suffer (Breaugh & Colihan, 1994). Yet, the division of management and medical tasks between the GP and GPM can create uncertainty about the tasks and roles of the professionals. Subsequently, this can lead to uncertainty on how they will be judged, which, in turn, will lead to lower job satisfaction.
A negative relation between role ambiguity and job satisfaction is therefore expected to be found, which means that high role ambiguity will lead to a decrease in job satisfaction and low role ambiguity will lead to an increase in job satisfaction.
2.3 The effect of the division of medical and management tasks between the GP and GPM on their perceived quality of general practice management
3. Methods
3.1 Pre-study
Due to the lack of information concerning general practice management in The Netherlands, a explorative pre-study was necessary to provide the information needed to set a focus for the main research. Besides, this pre-study was needed to get a clear view of the function of the GPM in the practice and the consequences of this function for the role of the GP. Based on a questionnaire, a better understanding of the average role, tasks, and responsibilities of the GPM was created. Furthermore, the intensity and usage of this function in the practice and the division of medical and management tasks in the job of GPM was investigated.
3.1.1 Setting, variables and measures of pre-study
In the Netherlands, the function of general practice manager is still in the making. There are no lists available of registered GPMs or figures concerning the numbers of GPMs. Some of the Dutch GPMs are united in an association (network of practice managers), yet, in this network, also other types of practice managers are associated, like veterinary and dental practice managers. Because of a lack of figures concerning the number and location of GPMs in Dutch practices, GPMS had to be looked for on the internet. The search engine Google was used to find GPMs. Key terms used were: ‘medewerker’ (employer), ‘praktijkmanager’ (practice manager) and ‘huisarts’ (general practitioner)’. Based on these three key terms, 46 GPMs were found being mentioned on the employee list on websites of practices. Sometimes, it was stated on the website that the management function was combined with being a GP or practice assistant.
To achieve as many participants as possible, the questionnaire was distributed by email to all 46 GPMs who were found during the search on internet. The email sent to the managers included a short explanation of the context of the questionnaire and a clear instruction was added on how to fill out the questionnaire and how to send it back by email. Within one week, 26 completed questionnaires were returned. One week after the first distribution, a reminder was sent to the non-responders. This resulted in ten more respondents.
completed questionnaire. Overall, 39 of the 49 distributed questionnaires were filled out and sent back by email. The response rate of this questionnaire was 80%.
It can be questioned whether the respondents are representative for all GPMs in The Netherlands as their selection might be biased based on availability on the internet.
In 2009, a questionnaire was developed by ‘Medisch Ondernemen’ (medical entrepreneurship), an information platform for first line health care entrepreneurs which aims to investigate the position of practice managers in first line care practices. This questionnaire was distributed among members of the network of practice managers. Due to the fact that veterinary and dental practice managers were also included in this research, the results of this questionnaire could not be used for this pre-study, which focuses on general practice managers solely. Yet, many questions of the questionnaire of Medisch Ondernemen could be used for this study. Therefore, partly based on their questionnaire, a questionnaire for this pre-study was developed to make an inventory of the gender, average age, educational background, duration of the function, hours employed, division of hours between GPM tasks and medical tasks, task allocation, presence at the GP’s meeting, involvement in long term decisions and the most important tasks of the GPM. The questionnaire for exploration practice management can be found in Appendix I.
3.1.2 Outcomes of the pre-study
A small overview of the most important results of the pre-study will be discussed here. A complete overview of the results is presented in Appendix II.
Finally, all tasks being mentioned in the questionnaire (such as staff matters, financial issues, computerization and long term decision making) were experienced as being part of GPM tasks by almost all respondents. However, only 46,2% of the GPMs indicated tax issues as part of their function.
3.1.3 Sampling procedure main research
Based on this questionnaire, one of the most salient results was the number of medically educated GPMs (71,8%), though only 38,5% of the GPMs currently had medical tasks. In line with this question, two groups of GPMs can be distinguished: GPMs with solely management tasks and GPMs with both management and medical tasks. Based on the information on the websites of the general practices, it appeared that some of the respondents were both GP and GPM at the same time. In addition, based on the questions concerning the tasks of the GPMs, not all GPMs are involved in all tasks. Yet, as these tasks have to be fulfilled in the practice, it can be argued that some of the management tasks have to be fulfilled by the GPs. Therefore, the medical and management tasks can both be divided between the GP and GPM. Management tasks and medical tasks are both explained by Engels et al (2006) where management tasks are described as all non-medical, supporting tasks and medical tasks are explained as patient care and research tasks.
Figure 2, division of medical and management tasks between GPM and GP
The choice for GPMs to be approached to participate in the main research was first based on the GPM having medical tasks or not. Secondly, due to geographical differences in population, the choice for the practices was restricted to the northern part of The Netherlands: Groningen, Friesland, Drenthe, Overijssel and Flevoland. All 17 GPMs of the pre-study located in the northern part of The Netherlands were approached to participate in the interview for the main research. Of all approached practices, only eight of them had enough time to participate. Based on their answers on the pre-study questionnaire, it seemed that of these eight practices, four GPMs did have and four of them did not have medical tasks in addition to the management tasks. Even though most of the GPMs in the questionnaire did not have medical tasks, it was intended to approach the same amount of GPMs with and without medical tasks to gather as much information as possible on both situations. However, during the interviews it turned out that one GPM actually did not have medical tasks whereas he indicated that he did. It is not clear how this misunderstanding could have happened. Consequently, of the eight participating practices, three GPMs had both medical and management tasks and five GPMs had solely management tasks. In this way, the number of participants was more representative for the GPM population as found in the pre-study, because most of these GPMs appeared to have solely management tasks.
Due to the fact that only GPMs were approached in the pre-study phase, information on the division of medical and management tasks solely in the function of the GPM was gathered. Whether the GP was involved in both management and medical tasks in these practices, or if the
Management tasks
(all non-medical, supporting tasks)
Medical tasks
(patient care and research tasks) GPM GPM GPM GPM GP(s) I II III IV GP(s) GP(s) GP(s) GPM with medical tasks GP with management tasks Both combination of tasks
GP solely medical and GPM solely
GP has solely medical tasks was unknown. That is why it was not clear upfront in which types the participating practices could be placed.
It was unknown whether the selected group for the main research was representative for all general practices in the northern part of The Netherlands where GPMs are associated, given that there are no figures available concerning the arrangements of management tasks in Dutch general practices.
3.2 Main research
3.2.1 Sample
During the interview, the GPs and GPMs had to indicate which type, as depicted in Figure 2, was applicable to their situation. At first, in only four practices, the GP and GPM indicated the same type to their situation. Remarkably, in the other four cases the GP and GPM assigned different types. Yet, based on the answers given during the interviews, it was still possible to adjust a situation type to three of the four practices. In one of the practices, the answers given by the GP and GPM differed that much that it was impossible to come to an accordance. Of the seven remaining practices, one practice indicated type II, in which the GP had solely medical tasks and the GPM had both medical and management tasks. Four practices indicated type III, in which the GP had both medical and management tasks and the GPM had solely management tasks. Two practices indicated type IV, both GP and GPM had a combination of medical and management tasks.
Type II The practice in type II is a singlehanded practice. The GP and GPM are husband and wife and the GPM was medically educated during his function as GPM to be able to fulfill the tasks of practice assistant as well.
Type III These four practices consisted of a mix of singlehanded practices and co operations between different GPs. Some of the GPMs had a background as practice assistant and some of them did not. Two of these practices were run by a married couple.
Type IV Both GPMs in this situation were of course medically educated. They were both involved in the practice concerning medical tasks before they became involved in management tasks as well. Both situations concern an association of practices.
3.2.2 Procedure
At every practice, a meeting was scheduled with the GPM and with one of the GPs of the same practice. During those meetings, a semi structured interview of approximately 45 minutes was conducted with each of the professionals separately. Their privacy was guaranteed and they were asked whether they agreed with recording the interview. The interview (see Appendix III) started with an introduction followed by a description of the type of their practice concerning the division of medical and management tasks between the GP and GPM. Both the GP and the GPM had to point out which of the four types as presented in Figure 2 was most applicable in their practice. Further, the other variables, domain autonomy, accountability, role ambiguity, job satisfaction and the quality of general practice management were discussed. The order of the interviews differed; in some practices, the GPM was the first one being interviewed and in other practices, the GP started.
3.2.3 Variables
The variables studied in this phase can be divided in three categories: Independent variables, mediators, and dependent variables (see Figure 1).
domain autonomy and role clarity. These three items were studied as mediators between the division of medical and management tasks and job satisfaction.
3.2.4 Measures
During the interview the respondents were asked to what extent they experienced the different variables: division of tasks, domain autonomy, accountability, role ambiguity, job satisfaction and quality of general practice management.
Division of tasks First, Figure 2 was shown to them and the meaning of the picture was explained. Further, they were asked to indicate which type of situation they experienced in their practice concerning the division of medical and management tasks between the GP and GPM. In addition, they also indicated: whether they were satisfied with this division; what effect a different division of tasks (i.e. a different type) would have on the clarity of the division of tasks; the level to which they could discuss their tasks; their job satisfaction; and the quality of the tasks.
Domain autonomy The participants were asked to explain the division of the tasks based on the responsibility the GP and GPM had for different tasks. They were asked whether this division of tasks was clear for all parties in the office and whether there were discussions concerning the division. In addition, they could explain more about these discussions. Further, it was discussed whether the GP or GPM did interfere with tasks which did not belong to that professional and whether that professional took over tasks of the other or vice versa. If this was the case, they were asked to explain more about this experience, which tasks they took over and how it affected job satisfaction and the quality of general practice management.
Accountability The respondents were asked to tell whether they received feedback or questions concerning the tasks for which they were responsible and whether they had to justify these actions. Also, they indicated on which things they had to justify their actions, to whom they had to make this justification; and how they experienced this. Further, they were asked whether they also had to justify for things for which they were not responsible.
whether it was clear for them on which items their functioning was evaluated; by who; and how this evaluation was arranged.
Job satisfaction The participants were asked whether they were currently satisfied with their job and what contributed to this level of job satisfaction. Also, their satisfaction concerning general practice management in their practice was discussed and they indicated what could be improved. To conclude the interview, the interviewees were able to indicate topics that they missed during the interview and what aspects should be discussed in the light of this topic. Quality of management The quality of general practice management was explained by an indication of items in daily practice in which the GPM has the highest added value. The different domains, as explained by Engels et al. (2006) (infrastructure, personnel, information, finance and quality & safety tasks), were discussed and the respondents indicated to what extent the GPM was involved in these domains. In addition, they were asked whether the GPM could expand his added value on one of these domains.
3.2.5 Analysis
The recorded interviews were worked out and were analyzed with help of Kwalitan 5. In this program, fragments and citations concerning a specific factor were labeled. When all interviews were processed, all text fragments of the different interviews concerning one variable were collected and grouped per type of division of tasks as depicted in Figure 2. This created a clear overview of the things said by different practices about the variables.
4. Results
4.1 The effect of the division of medical and management tasks between the GP and GPM on their perceived accountability, domain autonomy and role ambiguity
4.1.1 The effect of the division of tasks on accountability
Based on literature it was expected that when the GP and GPM both have a combination of medical and management tasks, they have to justify their actions or intended actions to each other more often than in a situation in which the GP and GPM have solely medical and management tasks respectively.
Of all fourteen participating GPs and GPMs, eleven interviewees justify their actions to the other professional frequently. Only type II GPs and GPMs justify their actions rarely. GPs and GPMs have to justify to each other because they want to know what the other is doing and why he does it in order to understand these actions and to be kept updated. One type IV manager did not experience a need for justification for him or the GP, though, he argues that the GP has to explain his way of working to the GPM so the last can continue to execute related tasks in the same way.
„The GPs do not have to account for their actions, yet they have to explain certain duties they pass on to me. So I can continue it in the same way‟ (GPM, type IV)
Two of the type III and IV GPs expect that in case they have solely medical tasks and the GPM has solely management tasks, their role as GP and owner of the practice will change from a control role to a consulting role, i.e. the GPM can consult the GP for issues.
„I think that once the role of the manager will come more into use, my duties of practice owner will only have to be informative and regulative, acting as a sounding board‟ (GP type IV)
Thus, the expected relation is supported by the interview: the more the GP and GPM focus solely on medical and management tasks respectively, the less they justify their (intended) actions to each other.
4.1.2 The effect of the division of tasks on domain autonomy
It was expected that when the GP and GPM both have a combination of medical and management tasks, domain autonomy of both professionals would decrease as the experienced amount of unique knowledge and skills would be lower and the domain in which they have exclusive rights to make decisions would be smaller.
Regardless of the situation type, all of the participating GPs indicate that they experience a high level of domain autonomy. However, four of the seven type III and IV GPs are afraid of losing domain autonomy by handing over management tasks to the GPM completely. Therefore, these GPs do not want to hand over all of their management tasks, i.e. approaching type I or II situation. Yet, the GP of type II, who has handed over all management tasks to the GPM, indicates that he has no problems with losing his management tasks and he still experiences a high level of domain autonomy, solely based on his medical domain.
Thus, although the GPs of type III and type IV are afraid of losing domain autonomy if they approach type I or II, it seems that the actual domain autonomy of type II GP is not affected by the current division of the medical and management tasks between the GP and GPM.
Five of the six GPMs in situation III and IV report that they experience a restricted domain autonomy as their GPs can not hand over their management tasks completely. Their GPs want to stay involved in management issue. One of these GPMs feels that he is restricted in his decision making in the job.
„I suggested to create a new policy (…) but it was not supported by the GPs. They wanted to keep everything the same‟ (GPM type IV)
Therefore, in situation type III and IV, in which both GP and GPM are involved in management tasks, domain autonomy of the GPM decreases. The GPM of type II, where the GP is not involved in management tasks, has a high domain autonomy.
domain autonomy. However, domain autonomy of GPMs is influenced negatively in case the GP and GPM both have a combination of medical and management tasks.
4.1.3. The effect of the division of tasks on role ambiguity
A combination of medical and management tasks for both professionals (type IV) was expected to lead to higher role ambiguity compared to a situation in which the GP can focus on medical tasks solely and the GPM can focus on management tasks solely (type I).
Six of the seven GPs of type II, III and IV point out that their role is clear, they experience a low degree of role ambiguity. This clarity was mainly based on years of experience on the job.
„After 25 years, I know what is expected of me at work‟(GP type III)
Just one type IV GP indicates that he does not know what is expected of him because he does not know the expectations of patients. Yet, this has no direct link to the role of the GPM in the practice.
All of the participating GPMs say that they know what is expected of them in their function. They experience a clear division of tasks between the GP and GPM, and some of the GPMs were able to design their function from the start. During the last years it seemed possible to add tasks to their function or remove tasks.
„I know what is expected of me at work because our duties are clearly divided‟ (GPM type III)
„Since 1999 I have defined myself and to explore myself over and over again‟ (GPM type II)
Role ambiguity does not seem to be linked to the kind of division of tasks (see Figure 2), but rather to the consensus the different GPs and the GPMs have about this division. For example, consensus among the different GPs in the practice contributes to clarity of the role of the GPM in the practice. An important condition for preventing role ambiguity is that GPs consider consciously which tasks they want to hand over to the GPM.
In contrary to the expected relationship, even if both professionals have a mix of medical and management tasks (type IV), a low degree of role ambiguity is experienced due to the clarity of task division..
„One GP performs ICT duties, another financial duties, another is responsible for the maintenance of the building and another is concerned with staff matters. When I have a question, I know exactly who to turn to‟ (GPM type IV)
However, two of the three type II and type IV GPs argue that a combination of medical and management tasks for the GPM might create vagueness. One of the type IV GPMs supported this idea of the GPs.
„Since I performed medical duties next to my management duties, I was wearing two hats. This was hard for both me and the GP‟ (GPM type IV)
This GPM explained that the GPs did not always know whether they had to approach him as an practice assistant or as a manager. In addition, he explained that due to his medical background he approached the GPs more carefully than he should do as a GPM. Yet, still this GPM experienced a low level of role ambiguity.
Two type III GPs expect that medical interference of the GPM will lead to a complicated situation.
„In case a manager also interferes in medical decisions, I think it will be very difficult who does what‟ (GP type III)
This type III GP was afraid that the different jobs would interfere with each other.
Thus, there is no relationship found between the division of the tasks and role ambiguity. The participants argue that a combination of medical and management tasks for both professionals might create vagueness, yet, they do not experience vagueness themselves.
4.2 The effect of accountability, domain autonomy and role ambiguity on job satisfaction
Overall, the participating GPs and GPMs are satisfied with their jobs. With no exception, all of the GPMs indicated that they are (very) satisfied. Six of the seven participating GPs said the same, though, the remaining GP can not say that he is completely satisfied with his job.
„I think that you choose a job as manager because you like to justify your actions and that you find pleasure in it‟ (GPM type III)
The requirement to be able to justify one’s actions is seen as a positive thing: it attributes to an open atmosphere in the practice and it should be stimulated to keep employees focused.
For GPs, accountability is accepted and does not reduce job satisfaction as long as these GPs do have to justify for their actions concerning management tasks solely. GPs do not want to justify for their medical actions or for management-related decisions concerning the execution of their medical tasks, like the duration of a consult. They want to have the space to decide on what they want and how they want to do things, without any restrictions from other employees in the practice.
I do not have to justify for the duration of a consult for example, thank God! (GP type II)
In conclusion: the effect of accountability on job satisfaction is positive, but, in case of the GP, only as long as it concerns management tasks.
Domain autonomy was expected to be related positively to job satisfaction.
GPs state that they do not mind losing some of their domain autonomy concerning management tasks, but for type III and IV GPs it appears to be difficult to actually hand over all management tasks. In addition, four of the six these GPs say they want to get rid of management tasks, but actually they do not do so.
„Many people really want to give up these duties, really get rid of them, (…) in order to feel some sense of relief‟ (GP type IV)
They say they only want to hand over management tasks if they are sure these tasks will be executed well. If the GPs discover that GPMs can fulfill management tasks to the same standards and execute them in the same way, they are willing to hand over these tasks.
„At first you tend to control everything, but at a particular moment I realized that the manager had more knowledge about it, so why should I still check on him?‟ (GP type IV)
In fact, as soon as GPs notice that things are in good hands at the GPM, they are willing to hand over (almost) all of their management tasks.
„Actually, the manager is too careful: he does not take over duties from me, which he might do more often‟ (GP type III)
When the GPs have made the step to sacrifice their management tasks, their job satisfaction increases. Though, it can be questioned whether domain autonomy is linked directly to job satisfaction or whether the relationship between domain autonomy and job satisfaction is mediated by a decline in workload and administrative tasks. Giving up management tasks can have implications for domain autonomy of the GP. Yet, when the GP can focus on medical tasks solely, he experiences a lower role overload which was theoretically expected to lead to higher job satisfaction.
„I do not mind being restricted in my domain autonomy, as long as I do not have to perform these stupid financial duties anymore. In that case I would be more satisfied‟ (GP type III)
Difficulties concerning domain autonomy influences job satisfaction of the GPMs as well. They say it was hard to conquer a place in the group, which is also confirmed by the GPs.
„One of the other GPs treated the manager as a clerk‟ (GP type IV)
Especially in situations concerning a cooperation of former singlehanded practices it is difficult for GPMs to get a good position within the practice. In the singlehanded practice situation, as it was before the cooperation, the GP and practice assistant consulted each other easily. Conversely, now the communication between the GP and the assistant is mediated by the GPM. According to a type III GPM it is the task of the GP to refer to the GPM before he deliberates with the assistant. Although the GPs of this practice know what they should do in this situation, it is difficult for them to rebuff the practice assistant when they address the GPs directly. Consequently, when a GP indeed talks to the practice assistant about issues which should be discussed with the GPM, the domain autonomy of the GPM is influenced negatively and it subsequently influences job satisfaction negatively.
Thus, domain autonomy is indeed positively related to job satisfaction for GPs and GPMs. GPMs argue that they are more satisfied when they are able to fulfill their tasks without interference of the GP. Yet, in case of the GP, this positive effect between domain autonomy and job satisfaction might be mediated by a decline in workload and administrative tasks.
As expected, all types of GPs and GPMs point out that clarity about their role contributes to higher job satisfaction.
„I like to know what is expected from me‟ (GPM type IV)
„It is not restricting or boring, since working conditions are known, daily duties vary but you know what you have to do‟ (GP type III)
They say that when their role ambiguity would be higher, they would be less satisfied about their jobs.
4.3 The effect of the division of medical and management tasks between the GP and GPM on their perceived quality of general practice management
Theoretically, it was expected that the more the GP and GPM can solely focus on medical and management tasks respectively, the higher the quality of general practice management would be. During the interviews, participants were asked on which domain in daily practice the GPM contributed the most. The variety in answers was high. GPs appreciate the GPM for taking care of organizational tasks and sometimes financial tasks as well. As a result, everything in the practice runs more smoothly, like it should without interference of the GP. Additionally, GPs indicate that they have more spare time.
Four of the six GPs of type III and IV argue that the GPM could expand his tasks, like communicating with contractors and insurance companies.
Irrespective to the kind of division of tasks, ten of the participating GPs and GPMs expect that when the GP can solely focus on medical tasks and the GPM solely on management tasks (type I, Figure 2), the quality of general practice management will increase.
A type IV GP argues that it is possible for GPMs to have a combination of both medical and management tasks however this is only possible if the GPM is able to arrange both areas in a good way simultaneously.
„I think that it would be possible if the manager has medical tasks as well, however, I haven‟t met that Jack-of-all-trades yet ‟(GP type IV)
The type II GPM indicates that in case the GP will interfere with the decision making concerning management tasks, it will negatively influence the quality.
„When the GP should interfere more with management, I would be less able to fulfill my duties‟ (GPM type II )
It was argued by five of all fourteen GPs and GPMs that a medical background is an advantage for GPMs to function optimally.
„A medical background is an advantage, (…) since you are able to understand why patients react in a particular way and what the assistants are talking about‟ (GPM type III)
Thus, actually type I is seen as the optimal solution for high quality of general practice management, in which the GPM does not have medical tasks. Yet, medically educated GPMs are expected to be more able to fulfill their management tasks optimally.
While type I (see Figure 2) seems to be the optimal division, type II and IV GPMs, who have medical and management tasks, indicate that they enjoy the combination of both tasks very much. It can be questioned whether their job satisfaction will remain at the same level when they will solely focus on management tasks. In turn, a decline in job satisfaction can lead to lower quality of general practice management.
The different types of GPs and GPMs indicate that a focus on medical and management tasks respectively would possibly lower workload and consequently increase job satisfaction. However, although type I is indicated as the optimal division of tasks, this type was not realized in any of the participating practices.
4.4 Overview of results
Relation Expected Results
Division of tasks – accountability
The more the GP and GPM focus on medical and management tasks respectively, the less they have to justify their actions to each other
The more the GP and GPM focus on medical and management tasks respectively, the less they justify their actions to each other
Division of tasks – domain autonomy
The more the GP and GPM focus on medical and management tasks respectively, the higher domain autonomy will be
No relationship was found between the division of the tasks between the GP and GPM on domain autonomy of the GP. In case of the GPM: The
more the GP and GPM focus on
medical and management tasks respectively, the higher the domain autonomy of the GPM
Division of tasks – role ambiguity
The more the GP and GPM focus on medical and management tasks respectively, the lower role ambiguity will be
No relationship found
Accountability – job satisfaction
The more the GP and GPM have to justify their actions to each other, the lower job satisfaction will be
The more the GP and GPM justify their actions to each other, the higher their job satisfaction (as long as it concerns management tasks in case of the GP)
Domain autonomy – job satisfaction
The higher domain autonomy of the GP and GPM, the higher job satisfaction will be
The higher domain autonomy of the GP and GPM, the higher their job satisfaction, yet, in case of the GP, this effect might mediated by a
decline in workload and
administrative tasks Role ambiguity – job
satisfaction
The lower role ambiguity of the GP
and GPM, the higher job
satisfaction will be satisfaction Division of tasks –
quality of GP
management
The more the GP and GPM can focus on medical and management tasks respectively, the higher the quality of general practice management
The more the GP and GPM focus on medical and management tasks respectively, the higher the quality of GP management
Division of medical and
management tasks Domain Autonomy
Role Ambiguity Job Satisfaction Quality of general practice management Accountability 5. Discussion 5.1 Conclusion
In this study, the effect of the division of medical and management tasks between the GP and GPM on their perceived quality of general practice management and on job satisfaction, mediated by accountability, domain autonomy and role ambiguity was investigated. The studied relations were depicted in the conceptual model.
Figure 1, conceptual model
The information derived from the interviews supported the expected relationship between the division of tasks and accountability: the more the GP and GPM focus solely on medical and management tasks respectively, the less they justify their actions to each other.
The effect of the division of medical and management tasks between the GP and GPM on their perceived domain autonomy and role ambiguity were found to be different than expected based on the literature.
the professional has exclusive rights to make decisions and to act. The domain in which the GP has exclusive right to make decisions is actually smaller when GPs and GPMs are both involved in medical and management tasks. Yet, these different levels of domain autonomy are not experienced by the different GPs.
It was expected that the more the GP and GPM can solely focus on medical and management tasks respectively, role ambiguity would be lower. This relation was not supported by the interviews. Different types of GPs and GPMs all experienced a low level of role ambiguity. When GPMs sometimes did experienced some vagueness around their tasks, it was caused by disagreements between GPs about which tasks they want to hand over to the GPM.
Accountability was expected to be negatively related to job satisfaction: the more the GPs and GPMs have to justify their actions, the lower their job satisfaction was expected to be, yet, information derived from the interviews shows the opposite effect. The more GPs and GPMs justify their actions, the higher their job satisfaction. This effect between accountability and job satisfaction supports the outcomes of a study of Thoms et al. (2002), which also indicated a positive relation between these variables. However, accountability has a positive influence on a GP’s job satisfaction as long as it concerns management tasks. Therefore, it seems that there might be a mediating effect between accountability and a GP’s job satisfaction.
The effect of domain autonomy and role ambiguity on job satisfaction found in literature was supported by the interviews. Domain autonomy relates positively to job satisfaction, which supports the theory of Breaugh (1999) and Noe et al. (2006). However, especially for GPs this effect might be mediated by a decline in (administrative) workload. To get a clear view on this relation, further investigation should focus on this underlying effect.
Role ambiguity was indeed found to relate negatively to job satisfaction as stated by Lang et al. (2007) and Breaugh & Colihan (1994).
5.2 Suggestions for implementation in general practices
As many GPs are afraid of losing domain autonomy, job satisfaction and control over their practice as they approach a situation in which the GPM has and is fully responsible for management tasks, it appears that GPs in such a situation still experience a high level of domain autonomy and are still very satisfied with their job. Because most of the GPs and GPMs indicate that type I situations, in which the GP and GPM have solely medical and management tasks respectively, will have a positive influence on the quality, this type seems to be the optimal solution to arrange the division of tasks between the GP and GPM. So the medical and management tasks between the GP and GPM should be divided in such a way that the GP has solely medical tasks and the GPM has solely management tasks.
5.3 Possible flaws of this study
In the analysis of the qualitative data, it was striking that four of eight participating practices could not agree on the type of situation in their practice, concerning the division of tasks. Finally, based on their other answers three practices still could be placed in one situation, yet, the answers of a GP and GPM of one practice were so different that this practice could not be placed in one situation. The cause of this lack of agreement concerning the division of tasks definitely needs further investigation, because lack of a clear vision can harm all variables as investigated in this study and will damage the quality of general practice management.
Some of the participating GPs and GPMs were husband and wife. In this study, no attention has been paid to the private situation between the GP and GPM while it might influence their perception of different aspects in their job.
5.4 Suggestions for further research
Based on the outcomes of this study, an additional relationship between the variables in this study was discovered which should be further investigated. It appears that the level of role ambiguity can influence the division of the tasks between the GP and GPM. When the GPM knows what is expected from him, he can fulfill his tasks in a better way (which indicated that there is also a direct relation between role ambiguity and quality of general practice management), and if the GPs discover the value of the GPM, they are willing to hand over more management tasks to the GPM.
References
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Appendix I Questionnaire pre-study
Vragenlijst verkenning praktijkmanagement
Invulinstructie: Het invullen van deze vragenlijst neemt maximaal 5 minuten in beslag. Bij meerkeuzevragen kunt u het hokje aankruisen door deze met de muis aan te klikken. Indien u een hokje heeft aangekruist maar dit kruisje weg wilt halen, klik dan nogmaals op het hokje,
daarmee verdwijnt het kruisje. Bij de open vragen kunt u uw antwoord in de grijze vakken typen, klik voor het typen met de muis het grijze vak aan. Onderaan de vragenlijst is ruimte voor overige opmerkingen.
U kunt de ingevulde vragenlijst opslaan en als bijlage terugmailen naar
n.w.boendermaker@med.umcg.nl (uiterste inleverdatum: 23 april 2010).
Gegevens Praktijk: Praktijknaam:
Naam praktijkmanager: Postadres: Telefoonnummer: Emailadres: Website: 1. Geslacht: Man Vrouw 2. Leeftijd: < 25 jaar 25 t/m 34 jaar 35 t/m 44 jaar 45 t/m 54 jaar 55 t/m 64 jaar 65 jaar of ouder
3. Wat is uw hoogst genoten opleiding (afgerond): Mavo Havo VWO MBO HBO WO Anders, nl.:
4. Heeft u in het verleden een medische opleiding afgerond? (Bijvoorbeeld opleiding tot doktersassistente, huisarts, fysiotherapeut of verpleegkundige)
Ja Nee
2 tot 4 jaar 4 tot 6 jaar Meer dan 6 jaar
6. Hoeveel uren per week omvat uw totale aanstelling? 0-8 uur
9-16 uur 17-24 uur 25-32 uur 33-40 uur
7. Hoeveel uur per week besteedt u gemiddeld aan de taken van praktijkmanager? 0-8 uur
9-16 uur 17-24 uur 25-32 uur 33-40 uur
8. Verricht u daarnaast ook medische taken? Ja (ga door naar vraag 9) Nee (ga door naar vraag 10)
9. Hoeveel uur per week besteedt u gemiddeld aan medische taken? 0-8 uur
9-16 uur 17-24 uur 25-32 uur 32-40 uur
10. Wie is uw leidinggevende met betrekking tot de praktijkmanagementtaken? Individuele huisarts
Groep huisartsen / maatschap / Hagro Doktersassistente(s)
Ik ben zelf leidinggevende / ik maak zelf deel uit van de maatschap Anders, nl.:
11. Van wie krijgt u uw praktijkmanagementtaken toegewezen? Individuele huisarts
Groep huisartsen / maatschap / Hagro Doktersassistente(s)
Ik bepaal zelf mijn taken Anders, nl.:
Nee (ga door naar vraag 14)
Er is geen huisartsenoverleg (ga door naar vraag 14) 13. Op het verzoek van wie bent u aanwezig bij het huisartsenoverleg?
Op verzoek van de individuele huisarts
Op verzoek van de groep huisartsen / maatschap / Hagro Op mijn eigen verzoek
Op verzoek van meerdere partijen
14. Bent u betrokken bij lange termijn beslissingen? (Lange termijn is 3-5 jaar) Ja
Nee
15. Welke van de volgende taken horen bij uw functie als praktijkmanager in uw huidige werksituatie? (meerdere antwoorden mogelijk)
Personeelszaken (werving/selectie) Personeelsplanning
Strategisch beleid (lange termijn beleid, 3-5 jaar) Inkoop van kantoorartikelen
Inkoop van medisch apparatuur Fiscale zaken
Financiën Huisvesting
Onderhoud van apparatuur Automatisering
PR activiteiten / marketing Overig, nl.:
16. Aan welke drie van de volgende taken besteedt u gemiddeld per week de meeste tijd? (drie antwoorden aankruisen s.v.p.)
Personeelszaken (werving/selectie) Personeelsplanning
Strategisch beleid (lange termijn beleid, 3-5 jaar) Inkoop van kantoorartikelen
Inkoop van medisch apparatuur Fiscale zaken
Financiën Huisvesting
Onderhoud van apparatuur Automatisering
PR activiteiten / marketing Overig, nl.:
Overige opmerkingen:
Appendix II Outcomes pre-study General characteristics Gender Age Male 17,9% 25 – 34 10,3% Female 82,1% 35 – 44 25,6% 45 – 54 46,2% 55 – 65 15,4% 65 or older 2,6% Education
Education level Medical education
MAVO 2,6% Yes 71,8% HAVO 2,6% No 28,2% MBO 10,3 HBO 56,4% WO 23,1% Function Duration of function Hours employed
Less than 2 years 13,2% 0-8 hours 2,6%
2 – 4 years 28,2% 9-16 hours 15,8%
4 – 6 years 25,6% 17-24 hours 42,1%
More than 6 years 30,8% 25-32 hours 23,7%
33-40 hours 18,4% Medical tasks in the job Hours spent on management tasks Hours spent on medical tasks
17-24 hours 33,3% 17-24 hours 13,3%
25-32 hours 17,9% 25-32 hours 20,0%
33-40 hours 5,1% 33-40 hours 6,7%
Supervisor and tasks allocation
Who is supervisor Who allocates tasks
GP(s) 69,2% GP(s) 28,9% GPM part of partnership and own supervisor 17,9% GPM determines tasks himself 26,3% Another person (not indentified) 12,9% GPM and GP together 34,2%
Another person (not identified) 10,3% GP’s meeting Participant in GP‟s meeting On request of who Yes 42,1% GP(s)’s request 46,4% Sometimes 34,2% GPM’s request 3,6%
No, never 21,1% Both GP and
GPM’s request
50%
Tasks of GPM
Tasks Yes No
Long term decision making 74,4% 25,6%
Staff matters 89,7% 10,3%
Staff planning 87,2% 12,8%
Strategic policy 61,5% 38,5%
Purchase of medical equipment 61,5% 38,5%
Appendix III Structure of interview Introductie
Introduceren van mijzelf en context van onderzoek kort toelichten Hebt u vragen vooraf?
Alle antwoorden worden vertrouwelijk behandeld. Alles wat u mij nu vertelt zal niet met uw collega besproken worden.
Vindt u het goed als het gesprek wordt opgenomen? Ja/nee
Opname starten, datum en tijd noemen
Als ik het onderzoek heb afgerond dan kan ik u een terugkoppeling sturen als u dat op
prijs stelt. Wilt u dat graag? Ja/nee
Overal waar in de vraagstelling huisarts wordt gebruikt, kunt u ook huisartsengroep opvatten
Algemene vragen:
- Hoelang is de praktijkmanager werkzaam in de praktijk?
- Wat was de aanleiding om een praktijkmanager in dienst te nemen?
In geval van doktersassistente: Vanaf wanneer zijn uw taken uitgebreid en wat was hiervoor de reden?
Verdeling taken:
Op basis van het figuur (Figuur uitleggen!!)
- Welke situatie is op uw praktijk het meest van toepassing? o Bent u tevreden over deze verdeling? Waarom?
- Zou een andere verdeling van de taken, zoals in het figuur weergegeven, een positieve of negatieve uitwerking hebben op:
o De helderheid in taakverdeling? (domeinautonomie) o De mate waarin u met elkaar kunt discussiëren over taken? o De samenwerking? Welke situatie zou welke uitwerking hebben?
o Uw tevredenheid met uw werk? Welke situatie zou welke uitwerking hebben? Domein autonomie:
- Welke taken vallen duidelijk onder de verantwoordelijkheid van de manager? - Welke taken vallen duidelijk onder de verantwoordelijkheid van de huisarts? - Is de verdeling van de taken duidelijk?
o Zijn hier wel eens discussies over? o Over welke taken gaan die discussies?
o Hoe worden onduidelijkheden over de verdeling van de taken opgelost? o Bent u daar tevreden mee?
- Bemoeit de manager/huisarts zich wel eens met dingen die volgens u niet onder zijn verantwoordelijkheid vallen?
- Hebt u wel eens het idee dat de manager/ huisarts taken van u overneemt? o Wat voor taken zijn dat bijvoorbeeld?
o Hoe gaat u daar mee om?
o Beïnvloedt dit alles uw tevredenheid met uw werk? Accountability:
- Krijgt u wel eens een reactie op dingen waar u verantwoordelijk voor bent en beslissingen die u neemt en moet u zich daarvoor verantwoorden?
o Om welke dingen gaat dat?
o Door wie wordt u daar op aangesproken?
o Hoe vindt u dat u aangesproken kunt worden voor uw verantwoordelijkheden en wie zou dat volgens u mogen/moeten doen?
- Wordt u wel eens op beslissingen aangesproken die volgens u niet onder uw verantwoordelijkheid vallen?
o Om welke zaken gaat dat?
o Is dat bespreekbaar? Hoe lost u dat op? Rol (on)helderheid:
- Hebt u het idee dat u precies weet wat er van u verwacht wordt in uw werk? o Hoe komt dit?
o Hoe ervaart u dit? o Is dit bespreekbaar?
- Door wie wordt uw functioneren beoordeeld?
o Is dit de meest logische persoon hiervoor? Waarom?
- Hoe wordt uw functioneren beoordeeld (bijvoorbeeld tijdens een functioneringsgesprek)? - Weet u op basis waarvan uw functioneren wordt beoordeeld?
o Is dit ergens vastgelegd? o Vindt u dit prettig? Waarom? Kwaliteit van management:
- Op welke punten in de dagelijkse praktijkvoering heeft de manager een duidelijke toegevoegde waarde?
o Waar blijkt die toegevoegde waarde uit?
- Wat is de bijdrage van de praktijkmanager op het terrein van o Infrastructuur (gebouw, inventaris, toegankelijkheid)
o Werknemers (contracten, teamproces, opleiding/training, arbeidstevredenheid) o Informatie (omgang patiëntgegevens, computersystemen, automatisering) o Financiën (financieel plan, jaarverslag)
o Kwaliteit en veiligheid (infectiepreventie, patiënttevredenheid, evaluaties) - Waar blijkt die toegevoegde waarde uit?
- En zijn er nog mogelijkheden om de toegevoegde waarde op dit terrein te vergroten?
Afsluitende vragen:
- Bent u tevreden over uw werk op dit moment? o Wat is daarop het meest van invloed?
- Wat zou er verbeterd mogen worden? o Waarom?
- Zijn er nog andere dingen van belang die nog niet aan de orde zijn geweest tot nu toe?
