The Reality Dysfunction: 1 (The Night's Dawn trilogy, 1)

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The second contextual limitation is a set of specific market failures in public hospitals, which limit the scope of the standard financial incentives and reform measures. These mechanisms are also often in conflict with the role of professional medical authority (which has been already discussed above as the second structural limitation in hospitals). Brown SL, Eisenhardt KM. The art of continuous change: Linking complexity theory and time-paced evolution in relentlessly shifting organizations. Adm Sci Q. 1997;42(1):1–34.

The media gets its share of blame these days for the nation's polarized politics. Brown doesn’t call the news media “the enemy of the people,” as Trump is wont to do, but he sees the press as deeply irresponsible. At the president’s news conference after the Xi meeting, a reporter asked if he still believed Xi to be a “dictator,” a term Biden used earlier in the year. “Well, look, he is,” Biden replied, an answer that appeared to elicit a wince from Secretary of State Antony Blinken. Schwarzenegger sees democracy as more resilient than Brown does. When he first moved to the U.S. in 1968, the nation was roiled by political assassinations, he said. Then came Watergate. But democracy persevered, as he expects it will do again. This complex response from public hospitals is not always inappropriate or misguided [ 31]. Many of the characteristics of successful organizations and professional and managerial practice can easily tip over into behaviors that thwart change. This poses questions which are a core governance issue for both policy and management in public hospitals: when does the positive and necessary need for day-to-day organizational stability decay into a negative and obstructive form of organizational stasis? Domberger S, Jenson P. Contracting out by the Public Sector: Theory, evidence, prospects. Oxf Rev Econ Policy. 1997;13(4):67–78. Moreover, all of these analytic frameworks may have different (usually implicit) assumptions about the nature of human behavior and motivation. For example, readings of how far policymakers view staff and managers as ‘knights’ or ‘knaves,’ to use Le Grand’s typology [ 40]. In other words, the extent to which it is possible to rely on intrinsic motivation, professionalism and good intentions (‘knightly’ behaviors) rather than having to use a variety of incentives, sanctions, inspection and other methods to control self-interest and less noble motives. Three structural sources of public hospital resistance to changethe conflict between expanding curative and primary care coverage areas as against staying within financial and budgetary limitations

All of these measures have had at least some effect on hospital behavior and institutional outcomes [ 27, 28]. This has been generally positive but the effect has often been less powerful than expected and not necessarily what was intended [ 29]. However, most evoked reaction from the forces of institutional status quo, and nearly all have had a relatively short half-life in generating effective organizational change [ 30]. Further, these three structural dimensions come together in an institutional environment shaped by a set of three external contextual factors that further constrain effective management and reform of public hospitals. America, he said needs "fresh blood in there." He insisted he was not singling out Biden. But there's no denying the obvious: Biden has held elective office for most of the last half-century. Rumbold BE, Smith JA, Hurst J, Charlesworth A, Clarke A. Improving productive efficiency in hospitals: findings from a review of the international evidence. Health Econ Policy Law. 2015;10(1):21–43. Throughout this period, turning away from public sector control by creating semi-autonomous public hospital management [ 21], private sector contract management for public hospitals [ 15, 22], privately built and managed but publicly paid new public hospitals [ 23, 24], and also full privatization of existing public hospitals [ 25, 26] have all been suggested and, in a number of countries in different circumstances and with a wide range of limitations, introduced. Simultaneously, in tax-funded health systems like England, a panoply of new regulatory bodies were established (National Institute for Clinical Excellence (NICE); Commission on Health Improvement (CHI); Monitor; Care Quality Commission; etc.) to try to rein in poor quality and/or inefficient managerial practices in individual institutions.Schwarzenegger said he understood that his role was to represent all Californians — not just Republicans and not just loyalists.

Who makes these decisions, and what type of response is possible? In privately owned hospitals, responsibility rests with senior management, and their jobs may well depend on how rapidly and effectively they respond. But how does this major institutional process play out in public hospitals? This paper’s approach

Iles V. Managing People. In: Walshe K, Smith J, editors. Healthcare Management. 2nd ed. Berkshire: Open University Press/McGraw-Hill Education; 2011. p. 470–87. Degeling P. Mediating the cultural boundaries between medicine, nursing and management – the central challenge in hospital reform. Health Serv Manage Res. 2001;14:36–48.