Decision-making in hospital management

A total of 71 expert interviews were conducted and transcribed, including with the administrative management, the managing director, the nursing management and the medical management of the various hospitals as well as with the head physicians of an internal medicine department and a surgical department. In some hospitals, it was possible to conduct participatory observations in the management meetings. In view of the results to date, it can be stated globally for all hospitals that they are under varying degrees of stress with regard to their current environmental relationships. The existential economic pressure resulting from the incentive structure of the DRG system in combination with the global political requirements appears to be of primary importance.

Accordingly, this is precisely where management attempts to intervene in a controlling manner. The following prominent points of attack should be mentioned in this context: New strategic positioning via new service offerings and specialisations, expansion of case numbers via targeted referral management, attempts to retain patients, but also profiling in fields that appear lucrative in the future (e.g. as a gerontological specialist hospital). In addition, there are also attempts to undermine competition with other hospitals through agreements, monopolisation and cooperation with the outpatient sector. In particular, (state) politics and health insurance companies tend to appear more as opponents than as partners, who have to be outwitted accordingly - also with the help of legal subtleties.

With regard to the internal conditions of the hospital, the overarching challenge is to cope with the highly concentrated work under conditions of scarcity (such as reduced nursing staff), as well as to motivate staff to actively support the processes and strategies deemed necessary by management for economic reasons. For example, chief physicians and senior physicians are asked to intensify and/or maintain their contacts with outpatient referring physicians, and nursing staff are required to be willing to familiarise themselves with other areas after departments have been merged.

Although the aforementioned "internal and external tensions" (Rohde 1974) can be found in all the hospitals in our sample, there are different ways in which management deals with them. Typologically, there are particular differences in the motivational structure, the way in which the various professional groups are integrated into management and the form of the organisation's strategic positioning.