Activities and Episodes of Work
One of my key themes in analyzing what managers do is the usefulness of the concepts of activities and episodes of managerial work. Strauss et al. have written about the organization of medical work for patients with chronic illness and its impact on those who do the work. The authors describe the contingencies that workers cannot control (in part because the patient is part of the work process) and the difficulties of managing chronic illness, including the longer-than-usual care trajectory and the importance of care rather than disease management.
In managing chronic care, practitioners shape rather than control the work, which they experience emotionally. In diagnosing problems, the providers of care estimate the potential course of the illness without medical intervention. Then they map what the interventions might be, what might happen if the interventions are effective, what resources are required to make the interventions, and the patient's location along the course of the disease, which is a judgment call.
In organizing therapeutic action, providers generate a search for options of treatment, because many chronically ill patients are defined as "problematic." Unexpected contingencies occur. Operational decisions are made to get the trajectory into the best manageable order. It is not always a simple matter to say who is in charge. Specialists share in the shaping of the work. There are debates over trajectory. Clusters and sequences of tasks constitute the details of trajectory work.
There are many implications for managing large health care organizations. The work involves dealing with contingencies that managers cannot control, managing others who are part of the management process itself, and episodes or projects that take a long time to accomplish meaningful results. Managers estimate early on what would happen without management intervention. Operational changes must be made midcourse in order to adjust work flow. It is not always a simple matter to say who is in charge. Specialists share in the shaping of the work to be done. There are debates over what should be done and how. Clusters and sequences of tasks constitute the details of managerial work.
Managerial Choice
Brown writes about the organizational cost to health maintenance organizations (HMOs) of their mission of comprehensiveness and responsibility (1983). Management of HMOs demands coordination of highly diverse substantive tasks with different technologies; the HMO combines in one structure a collegiums of professionals-highly trained scientists delivering intimate human services-and a business that is competitive, entrepreneurial, and preoccupied with the bottom line. Conflicts arise easily and are difficult to resolve. There is great organizational fragility Managers must constantly make trade-offs all across the economic and political spheres and between short-term and long-term benefits.
Brown argues that managers must design the optimum size and location of facilities and number and specialty mix of staff in light of actual, expected, or desired membership. It is difficult to find managers who have specialized skills, knowledge of local conditions and attitudes, and negotiating ability in addition to an ability to get along well with employees and other contributors. Management skills and experience must change as an HMO grows larger and more complex, and the early, valued images of organizational character may get in the way of dynamic growth.
Implications of Brown's analysis are that managers in large health care organizations are constantly making choices, not so much regarding policy as use of their time, given the overwhelming abundance of stimuli and the complexity of the managerial field. Although a large part of the CEO's job may be making policy decisions, it is in the formulation and implementation of such decisions that managers make daily and strategic choices.
The Leadership Challenge
Kotter writes that diversity and interdependence are characteristic of large modern organizations (Kotter 1985). There are differences among workers with respect to goals, values, stakes, assumptions, and perceptions. Interdependence exists among parties who have power over each other because they are to some degree dependent on each other. Managers must get others to help and cooperate, but they often do not have control over those others. More and more jobs in large organizations have a built-in gap between the power one needs to get the job done well and the power that automatically comes with the job.
Managerial power is derived from information or knowledge, good working relationships, personal skills, intelligent agendas for action, resource networks (through which agendas are implemented), and good track records in managing. Skilful managers develop the power sources they need to create effective agendas and networks. This is not easy: It requires time, effort, and constant attention (Kotter 1985).
Large health care organizations, in particular, suffer from these built-in gaps between responsibility and authority. They are characterized by so much diversity and interdependence that perhaps more of them should be reorganized into smaller entities with some centralized control but without centralized management. How do health care managers build appropriate agendas and develop resource networks? What does this mean for the structuring of the CEO position in large health care organizations? These are subjects about which little has been written.
Specifying Objectives
Hales defines effectiveness as the extent to which what managers actually do matches what they are supposed to do (1986). He summarizes what is known about managerial work as follows:
- It combines a specialist-professional element and a general managerial element
- The substantive elements involve essentially liaison, human-management, and responsibility for a work process
- The character of work elements varies by duration, time span, recurrence, unexpectedness, and source
- Much time is spent in day-to-day trouble-shooting and ad hoc problems of organization and regulation
- Much managerial activity consists of asking or persuading others to do things, involving the manager in face-to-face verbal communication of limited duration
- Patterns of communication vary in terms of what the communication is about and with whom the communication is made
- Little time is spent on any one activity, particularly on the conscious, systematic formulation of plans
- Managers spend a lot of time accounting for and explaining what they do, in informal relationships and in politicking
- Managerial activities are driven by contradiction, cross pressures, and conflicts; much managerial work involves coping with and reconciling social and technical conflicts
- There is considerable choice of what is done; part of managerial work is setting the boundaries of and negotiating the work itself.
