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The Translation of Hospital Management Models in European Health Systems: A Framework for Comparison

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British Journal of Management, Vol. 24, S48–S61 (2013)
DOI: 10.1111/1467-8551.12030

The Translation of Hospital Management
Models in European Health Systems:
A Framework for Comparison
Ian Kirkpatrick, Bernadette Bullinger,1 Federico Lega2 and Mike Dent3
University of Leeds, UK, 1University of Innsbruck, Universitätsstraße 15, 6020 Innsbruck, Austria,
2
Bocconi University, Italy, and 3Staffordshire University, UK
Corresponding author email: bernadette.bullinger@uibk.ac.at
In this paper we develop a framework for comparing changes in the management of
public hospitals across different national health systems, drawing on insights from
institutional theory. Using a range of secondary sources we show how one particular
form of hospital management, pioneered originally at the Johns Hopkins Hospital in
Baltimore, has been translated differently in four health systems: England, Denmark,
Italy and France. This analysis builds on the notion of editing rules, which derive from
the institutional context, and illustrates how these rules broaden our understanding of
variable translations of global templates for hospital management. The paper concludes

by highlighting wider implications for theory and policy.

In health systems around the world there has been
a common focus on strengthening the management capabilities of hospitals following the model
of private corporations (McKee and Healy, 2002).
However, while there are strong indications that
healthcare management has become an international trend there are risks of overstating convergence. Existing comparative research highlights
similar priorities that are driving reforms, but also
‘distinctive national or regional variants’ (Dent,
2006, p. 624). A handful of studies, for example,
have noted differences in the implementation of
diagnostic related groups (DRGs), clinical governance regimes (Burau and Vrangbæk, 2008) and
in the responses of clinical professionals to
budgets and leadership education (Jacobs, 2005;
Kurunmäki, 2004).
However, while this work suggests ‘alternative
change pathways’ in health reform (Jacobs, 2005,
p. 158), with some exceptions (Dorgan et al.,
2010; Eeckloo, Delesie and Vleugels, 2007), less
attention has been paid to how this might apply
to the management of hospitals. Although there
are strong indications that private sector man-

agement ideas and templates with a global profile have been interpreted differently, we know
very little about the details of this process. There
are also deficiencies in our understanding of
why variations might occur between health systems and the factors that influence this process.
Much of the available comparative research
has drawn loosely on notions of path dependence
(Burau and Vrangbæk, 2008; Dent, 2003;
Kirkpatrick et al., 2009), which, although useful,
provide only a general starting point for drawing
attention to different national outcomes of health
management reforms.
In this paper we address the question of how
similar management ideas and models have been
implemented differently across health systems and
how one might explain varying outcomes. To do so
we draw on recent advances in institutional theory
and in particular the notion of ‘translation’


(Boxenbaum, 2006; Morris and Lancaster, 2006),
which shows how actors engage in modifying templates such as universal models of management.
Specifically we use ideas from Scandinavian institutionalism (Boxenbaum and Pedersen, 2009) and

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management. Published by John Wiley & Sons Ltd,
9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA, 02148, USA.


Translation of Hospital Management Models
comparative literature on new public management
(NPM) reforms to develop the concept of editing
rules for cross-national comparisons. Actors
involved in translations implicitly follow editing
rules, which, we argue, are derived from the institutional context (Sahlin-Andersson, 1996).
Applying these ideas, we focus on the translation of a particular model of organization, pioneered in the USA in the 1970s at the Johns
Hopkins Hospital (JHH) in Baltimore but which
later served as a template for how any hospital,
including the public or non-profit sectors, might
enhance their performance. Specifically, it emphasized the need to strengthen the corporate governance of hospitals and sub-divide them into
business units (or ‘clinical directorates’) to maximize efficiency. Focusing on this particular template in the context of four health systems – the
English National Health Service (NHS),
Denmark, France and Italy − we pursue two main
objectives. First, we explore the translation
process of the JHH model and whether this
resulted in different interpretations and practices
across national systems. Second, using the
concept of editing rules, we explore how differences in the wider institutional and regulative
context might help to explain variations in the
translation of the JHH model. A key contribution
of the paper is to advance understandings of comparative hospital management reforms and also,
drawing on concepts from institutional theory,
develop our knowledge of how these processes
might be theorized and explained.

Translation as a model for
disseminating institutional templates
In many ways the notion of translation represents
a departure from institutional theory’s early focus
on isomorphism and conformity in organizational
fields. More emphasis is given to the way templates such as lean management or diversity management – often available on a global scale – are
legitimated and enacted in local settings. A
number of scholars have highlighted the modifications which actors introduce to make institutional templates ‘fit’ in a local context. Taking
into account the localized origin of templates, the
‘travel of ideas’ concept, for example, illustrates
how they can be translated into global ideas. This
implies dis-embedding templates from their local

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context in order to travel to other institutional
settings, where re-embedding efforts are necessary
to translate the global idea into practices
(Czarniawska and Joerges, 1996). These multiple
translations depend on institutional actors like
organization members, but also policy makers
and professional bodies, who are no longer perceived as passive adopters but as actively modifying ideas as well as being modified by them. This
idea of translation helps to explain ‘how apparently isomorphic organizational forms become
heterogeneous when implemented in practice in
different organizational contexts’ (Boxenbaum
and Pedersen, 2009, p. 191). They are transformed
both in verbal accounts and actual practices
(Boxenbaum, 2006; Morris and Lancaster, 2006).
While there is broad agreement within and
between Scandinavian and North American
institutionalism that actors modify spreading
institutional templates, there is some disagreement concerning the degree of agency in this
process. As Boxenbaum and Pedersen (2009)
suggest, the ‘strategizing’ approach places most
emphasis on the strategic intentions of actors in
the translation to promote their own interests. By
contrast, the ‘embeddedness’ approach focuses
more on implicit and pragmatic dimensions of
actors’ translations, which are unconscious
efforts to make sense of and adopt templates in
local contexts.
Following the embeddedness approach,
Sahlin-Andersson (1996) stresses the importance
of the institutional context for translation outcomes. She found that actors do not arbitrarily
modify or ‘edit’ practices. Rather, their translations are governed by non-formalized ‘editing
rules’ which influence this process and may even be
taken for granted by the actors themselves. Thus,
the outcomes of translation are not arbitrary constructions but are linked to the way ‘different contexts provide different editing rules’ (Sahlin and
Wedlin, 2008, p. 226). Implied here is that local
history, traditions and institutions form the background for how actors in a given setting engage
with new templates. More specifically, editing rules
which arise from the local context enable and
restrict how actors modify templates, how they
translate them and make them fit. However, it is
important to note that editing rules cannot be
conceptualized as prescriptive ‘rules to follow’ but
rather they are implicit ‘rules which have been
followed’ (Sahlin-Andersson, 1996, p. 85).

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


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I. Kirkpatrick et al.

To illustrate this idea Sahlin-Andersson (1996)
talks about editing rules concerning logic which
refer to reasons given for the introduction of a
template. Stories about successful implementation of new practices such as, for instance, corporate codes of ethics in multinationals (Helin and
Sandström, 2010) often have a rationalistic plot
or logic, which presents the template as solving
clearly defined problems in line with models of
rational decision making. Editing rules might also
concern the formulation, labelling or packaging
of new organizational templates, providing
attention-attracting rationales and moral justifications for change (Sahlin-Andersson, 1996). An
example would be rules actors implicitly followed
to promote lean management in the UK building
industry (Morris and Lancaster, 2006). These
practices were dramatized as morally superior to
the ‘outmoded’ wasteful forms of management
that existed previously and thus lean management
was labelled a modern management technique. In
addition to this Sahlin-Andersson (1996, p. 86)
refers to editing rules concerning the context and
claims that ‘the history of the local setting may
restrict the translating’. Here the focus is not just
on how new templates are framed and articulated
in rhetorical terms, but also on how new practices
get implemented that shape the strategies and
behaviour of actors as they engage with these
changes.
An embeddedness approach therefore requires
a detailed understanding of the national context
in which translation occurs. However, to date
this insight has not been fully developed in the
translation literature. Most studies have only
looked at two institutional contexts: the context
of origin of a template (often the USA) and the
context of ‘destination’. Boxenbaum (2006), for
instance, studied the translation of diversity management from the USA for the Danish context.
Morris and Lancester (2006) studied originally
Japanese lean management ideas being translated
for the UK construction industry, while Helin
and Sandström (2010) explored the travel of a
corporate code of ethics from the US parent to
its Swedish subsidiary. While providing rich
descriptions of the inquired cases on organizational or field level, these studies have tended
to understate editing rules stemming from
the specific national context and how these
shape a varying potential for agency on different
levels.

Given these limitations a fruitful line of enquiry
for understanding the role played by national contexts are other branches of institutional theory,
such as the varieties of capitalism and business
systems literature (Tempel and Walgenbach,
2007), which have tended to place more emphasis
on exploring the national institutional conditions
that shape the reception of ideas. With regard to
our own specific focus on hospital management,
ideas from the comparative literature on NPM
reforms are also helpful (Dent, 2003; Hood, 1995).
Pollitt and Boukaert (2011), for example, note that
while socioeconomic forces and political pressures
lie behind the spread of management reforms
globally, crucially important at the national level
are the perceptions of elite decision-makers both
of what is desirable and what is feasible. The latter
relates to what is considered possible given
available resources, existing structures and likely
obstacles such as ‘conservative forces which
resist change’ (Pollitt and Boukaert, 2011, p. 25).
Perceptions of what is desirable are influenced
by political ideologies and cultural perceptions of
the kinds of reform that are important and valuable. From these perceptions emerge editing rules
that are more or less prescriptive in guiding how
actors adopt global templates in each national
context.
Hence, to understand these particular national
idiosyncrasies and their influence on the translation process, we argue that editing rules need to
be extended from a merely symbolic and linguistic level of analysis to the level of structural implications and material practices. As such our
approach is not to focus on editing rules concerning logic and formulation, which refer to the
symbolic level of editing stories, but rather to
emphasize editing rules concerning the context
(Sahlin-Andersson, 1996). Drawing on Pollitt and
Boukaert’s cross-national focus, we specify such
rules by looking for national differences in the
perception (by elite actors) of the desirability and
feasibility of a particular model of hospital
management.

Methods
To address the question of how global templates
of hospital management were translated we
focused on the experiences of reform in four
European health systems: the English NHS,

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Translation of Hospital Management Models

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Table 1. Hospital sector characteristics
Proportion of health
expenditure
accounted for by
hospital sector (%)

Percentage of total
acute care beds in
publicly owned
hospitals (%)

UK

40

96

Denmark

45

97.7

Italy
France

52
35

81.5
66

Hospital payment system
(public)

Autonomy of
hospitals to recruit
medical and other
health professionals

Autonomy of
hospitals to decide
the remuneration of
other health
professionals

Per case/DRG (70%) and
global budget (30%)
Global budget (80%) and per
case/DRG (20%)
Per case/DRG
Per case/DRG

Yes

Yes

Yes

Yes

No
No

No
No

Sources: Healthcare expenditure, 2008; Paris, Devaux and Wei, 2010.

Denmark, Italy and France. This comparison is
both meaningful and theoretically interesting. On
the one hand all four represent health systems that
are heavily state regulated, with central governments being key actors in the top-down initiation
of management reforms. In this respect, they
differ from more decentralized health systems
such as Germany where the diffusion of new management ideas has been less centrally directed. On
the other hand our sample of cases is also illustrative of different contexts that might shape the
process and outcomes of reform. Hence, while the
UK and Denmark are unambiguously national
health systems with hospitals largely owned and
managed by the state, Italy and France both
operate more hybrid funding and provision
regimes, with a large proportion of hospital care
located in the private sector (see Table 1 for
details). These cases also illustrate the variable
timing of reforms, with France being a relatively
late starter.
To conduct this analysis we drew on a range of
secondary data sources from the healthcare management, policy and sociology literatures. A key
source was work already conducted by ourselves,
both on country-specific developments in health
management (Lega, 2008) and comparatively
(Dent, 2003; Kirkpatrick et al., 2009). A systematic literature review was also conducted in two
stages. First, we used published summaries of hospital management reforms to construct a general
narrative for each country. Second, we carried out
a more focused search of the available academic
research – mainly published in English − relating
directly to changes in hospital management. This
initially focused on peer reviewed journal articles,
manually reviewing titles for relevance to the
topic of hospital management. Following a snow-

ball approach, the review was then extended
to include book chapters and reports. Lastly, we
drew on available comparative research on
hospital management (e.g. Dorgan et al., 2010)
and information published by transnational
agencies such as the Organization for Economic
Cooperation and Development (OECD) and
Eurostat.
Our analysis of these data involved two main
stages. First we sought to identify differences in
the translation of the JHH model across our four
case study health systems. As we shall see, variation occurred along two key dimensions: the
nature of the authority structure of hospitals and
development of non-clinical management functions. Second, we analysed the data on the actual
process of reform, noting how change was influenced by perceptions of elite actors of desirability
and feasibility and inputting from this different
editing rules. The results of this analysis are presented below, although prior to that it is important to describe briefly the nature and emergence
of the JHH model itself.

Hospital management reforms: a case
study of translation
The origin of an institutional template
As noted earlier, the drive to reform the management of healthcare has been present in many
developed economies since the mid-1970s. Hospitals in particular became a target for these reforms
given the high proportion of resources they
absorbed and the apparent difficulty of coordinating different priorities of care, cure and administration (Glouberman and Mintzberg, 2001). In
this context an alternative model emerged for how

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


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I. Kirkpatrick et al.

hospitals might be run to maximize efficiency,
originating from the JHH, a teaching hospital in
Baltimore in 1972 (Chantler, 1984; Heyssel,
Gainter and Kues, 1984).
In its original form this model moves away
from the practice of governing hospitals through
parallel hierarchies, with doctors represented by a
senior medical committee, sometimes with powers
to veto management decisions. Instead, the focus
is on all clinical staff (doctors and nurses) reporting through a single, unitary chain of command to
a clinical director who in turn is accountable to
the chief executive or general manager of a hospital. Closely related to this were changes to the
governance arrangements of hospitals, moving
away from an exclusively trusteeship logic,
with boards focusing on conformance and external accountability to a management logic with a
stronger performance orientation (Eecklo,
Delesie and Vleugels, 2007).
In organizational terms, the JHH model
involved a break from the traditional functional
structure (with medicine, nursing and other functions organized separately) with the hospital representing a kind of ‘holding company’ of semiautonomous divisions (based around product/
service lines or clusters of activities) (Braithwaite
and Westbrook, 2004, p. 142). At the middle tier
this meant grouping resources, with specialties
and doctors aggregated in clinical units, each
managed by a team (or triumvirate) headed by a
medical chief, supported by a lead nurse and
administrator. Each group (or, later, directorate)
was given responsibility for budgets and made
accountable for direct costs, and the operational
performance of their units, delivery against
targets and human resource management.
Proponents of this change in hospital organization have highlighted a number of advantages. At
JHH an explicit goal was to mimic practices in the
corporate sector to drive down the costs of inpatient care (Heyssel, Gainter and Kues, 1984). By
merging clinical specialities into larger directorates and sharing other costs associated with
administration, nursing and ancillary staff, the
model offered potential for economies of scale
and scope, as well as better integrated services.
These changes also represented a way of streamlining lines of accountability and strengthening
the authority of managers to make decisions.
Lastly, an added advantage might be to co-opt
clinicians (especially doctors) themselves more

fully into the ‘world’ of management (Eecklo,
Delesie and Vleugels, 2007).
This model of hospital management, or at least
various translations of it, has subsequently been
adopted in health systems around the world.
According to Braithwaite and Westbrook (2004,
p. 142): ‘The clinical director (CD) concept dispersed relatively rapidly, in ways that innovation
diffusion theorists would find predictable of an
attractive idea’, such that ‘every large hospital
now has some form of CD structure as a key
component of its governance arrangements’. This
process began in the USA and Canada (Fitzgerald
and Dufour, 1998) but quickly spread to Australia and Europe (Neogy and Kirkpatrick, 2009).
This rapid dissemination of the JHH model was
aided partly by the existing strength of international professional networks in the health sector.
In England, for example, the model was championed by Professor (later Sir) Cyril Chantler of the
United Medical and Dental Schools of Guy’s and
St Thomas’ Hospitals, who had previously been a
visiting Professor at Johns Hopkins (Chantler,
2012). Also important was the status of JHH
itself, one of the elite university hospitals in the
USA, and the publicity which leading clinicians
gained by publicizing their experiences in the
highly prestigious and widely read New England
Journal of Medicine.
Translation process and outcomes in four
health systems
Focusing on our exemplar countries it can be seen
that versions of the JHH model have been implemented in public hospitals in all four cases. The
timing of this process varied between countries. In
the English NHS, a version of the JHH model was
introduced following legislation in 1991 (NHS
Community Care Act), which also led to the
establishment of semi-autonomous foundation
trusts with corporate style boards (Harrison and
Pollitt, 1994). In Denmark, major changes to hospital governance were first introduced following
legislation in 1984, with a second hospital commission promoting the model of clinical directorates based on ‘unambiguous management’ in
1997 (Kragh Jespersen and Wrede, 2009). In Italy
regulatory pressures were also important. Here a
key piece of legislation in 1992 allowed some
public hospitals the opportunity to convert to
semi-independent enterprises (Aziende Ospe-

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Translation of Hospital Management Models
daliere) with a chief executive officer (CEO) and
board structure and actively promoted clinical
directorates, although these only became mandatory in 1999 (Lega, 2008). In France, although the
idea of strengthening management in hospitals
had been attempted in 1983, it was not until 2002
that a sustained push in this direction began with
the introduction of the ‘Hospital 2007’ plan. An
ordinance of 2005 established a new governance
structure for hospitals, establishing management
boards. Hospitals were also encouraged to rearrange clinical units into larger ‘activity centres’ (or
Poles) with delegated budgets, very similar (on
paper at least) to the English model (Dent, 2003;
Or and de Pourourville, 2006).
Hence, while there have been differences in the
timing of reforms, versions of the JHH model
have been adopted in the public hospital systems
of all four countries. As indicated in Table 1, this
has also been associated with some move towards
variable funding per case (based on DRGs), away
from global budgets for hospitals. It has also
manifested itself in new hospital governance
arrangements − formalizing the role of chief
executive officers or equivalent − and the establishment of a middle tier of management around
departments (or directorates) with devolved
responsibilities (see Table 2). However, the available evidence suggests that the degree of convergence should not be exaggerated and the JHH
model has been translated by actors operating
both at the national (policy) level of each country
and locally, within hospital organizations.
This is most obviously the case if we look at the
degree to which reforms in each country have
been formally implemented. In Italy, for example,
Lega (2008, p. 255) reports that, even in 2004,
only 66% of hospitals had fully adopted clinical
directorates. Perhaps unsurprisingly, studies also
point to wide variations in the size of clinical
directorates (measured by staff, beds or turnover)
and in the level of authority clinical managers
might exercise over budgets (Bellanger, 2007;
Cantù and Lega, 2002; Kragh Jespersen and
Wrede, 2009). Clinical directorates are even configured in different ways according to their size or
differing logics with respect to the size of hospitals
(Braithwaite and Westbrook, 2004).
In addition to this are variations in translation
outcomes between countries, most obviously with
regard to nomenclature. In the English NHS a
corporate language of CDs, boards and CEOs has

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been adopted quite explicitly. By contrast, in
other countries the terms used to describe new
roles suggest much greater continuity with professional norms and pre-existing models of hospital
organization. Hence, ‘clinical directors’ are formally heads of centres in Denmark, of activity
centres (or Chefs de Pole) in France and, in Italy,
chairs of departments (Cantù and Lega, 2002).
Table 2 outlines further differences in translation looking at four key areas: strategic (governance), middle management, the nature of
authority structures and development of nonclinical management roles. Concerning the former
in England, the decision was made to establish a
unitary governance arrangement both at board
and clinical directorate levels (Harrison and
Pollitt, 1994; Shortland and Gatrell, 2005). A
similar situation applied to Denmark, especially
after 1997 (Kirkpatrick et al., 2009). By contrast,
in France and Italy, notwithstanding the rhetoric
of reform, the management authority of CEOs (or
equivalent) is far less clear-cut. In both cases the
translation of the JHH model has resulted in tripartite decision-making structures involving both
external and internal (notably medical) stakeholders. In France, for example, while supervisory and
medical committees are formally consultative,
they have powers to nominate Chefs de Pole and
in many cases are locked in to relationships of
‘collective bargaining’ with the director (Laouer,
2011; Vinot, 2012). As Bellanger (2007) notes,
while ‘both General Director and Hospital Directors do manage physicians’, this is primarily ‘by
influence’ such that ‘the decisional process is generally based on consensus’.
Similar differences are apparent when one turns
to the changes at middle management (clinical
directorate) level. While in England and Denmark
the focus has been on developing clinical directorates based on a single line of management
accountability, this has been less obvious in
France and Italy. In the latter, the decision was
made to establish executive committees within
each department (or directorate) made up of the
chiefs of clinical units with powers to nominate
the chair and veto key decisions (Tousijn and
Giorgino, 2009).
These differences in the way hospitals have
reorganized management also have implications
for the nature of authority. While in England
establishing a unitary chain of command in hospitals was a central plank of the reforms

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Clinical directorate structures are well
established in NHS trusts (by law),
with ‘clinical directors’ and
departments having their own
management teams and autonomy
over budgets

Unitary (unambiguous) authority
structure at hospital and CD levels

This is highly developed in the NHS
since the Griffiths report (1983).
General managers (often with private
sector expertise) make up the
majority. All trusts employ specialist
managers in core functions (finance,
human resources, procurement) and at
CD level

Management
authority
structure

Development of
non-clinical
management

Trusts have a unitary board structure,
headed by a CEO with executive and
non-executive members, although
some changes are under way with the
establishment of foundation trusts

Middle tier

Hospital
governance

England

Table 2. Hospital governance and organization

Following the second hospital
commission in 1997 public hospitals
implemented ‘unambiguous
management’ with a unitary authority
structure at hospital and CD levels
Non-clinical management specialists are
employed, mainly in functional
departments serving the whole
hospital. Some of the larger teaching
hospitals also employ managers at
centre level, although not in large
numbers

Public hospitals are structured into
centres (Centerledelsen) and
wards/clinics (afdelinger) with
separate management teams
(consisting mainly of doctors and
nurses) with degrees of autonomy
over budgets

The governance of public hospitals
(Hospitalsledelsen) consists of a
‘troika’ made up of a CEO and
Medical and Nurse Directors

Denmark

Ambiguous authority structures at both
hospital and CD levels with parallel
hierarchies and internal checks and
balances on the executive power of
managers
Italian hospitals, notably AOs, employ
specialist managers in functional
support roles. Jacobs (2005, p. 157)
notes the ‘absence of a manager/
accountant at the unit level’, although
this may have changed recently in
some of the larger teaching hospitals

Italian public hospitals are typically run
by a team consisting of a General
Manager (Direttore Generale),
Clinical Director (Direttore Sanitario)
and Administrative Director
(Direttore Amministrativo). This team
is supported by two committees with
supervisory functions: an (elected)
Health Council (Consiglio dei
Sanitari) and Management Board
(Collegio di Direzioni)
Aziende Ospedaliere (AO) hospitals are
typically structured into
‘Departments’ headed by a Chair of
Department (always a doctor) with
nominal control over budgets.
However, Departments also have
executive committees, which
represent the interests of chiefs of
medical units/clinics

Italy

After 2007 French hospitals are
typically organized into clinical and
non-clinical activity Poles run by a
triumvirate of Director, administrative
manager and nurse manager. All
Poles also have a ‘Pole Council’ with
strong representation from medical
heads of clinics (Chefs de Service). In
theory activity Poles operate as
semi-independent businesses
contracted by the hospital
Despite efforts to streamline
management, authority at hospital
and CD (activity pole) level remains
fragmented, characterized by internal
checks and balances
French public hospitals employ
managers both centrally and,
increasingly, within activity centres.
However, a large proportion of
‘managers’ are also civil servants
(with legal or political science
backgrounds)

The governance of French University
Hospitals is characterized by a
tripartite structure comprising an
executive council (including the
General Director and President of the
Medical Council), an administrative
(or supervisory) council representing
external stakeholders and a medical
council (or commission) representing
doctors

France

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© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Translation of Hospital Management Models
(Harrison and Pollitt, 1994), this has been less
true for both Italy and France. According to Lega
(2008, p. 260) in Italian public hospitals many
chairs of departments still lack formal authority
over chiefs of clinical units and consequently
behave more like ‘project managers, responsible
for special projects . . .’. Indeed, it is suggested
that ‘change following the introduction of CDs
was more formal than real’ (2008, p. 255).
Similarly, in France, while Chefs de Pole have
‘hierarchical authority over medical, nurse,
administrative teams’ they have ‘no decision concerning the nomination of doctors or the quality
of their clinical activity’ (Vinot, 2012, p. 6).
Lastly, one can note differences in development
of non-clinical management roles in areas such as
finance, procurement and human resource management within hospitals. In the USA, both
private and non-profit hospitals tend to invest
heavily in these areas, with non-clinical ‘administration’ making up a significant part of the health
labour force: 27% according to one estimate
(Woolhandler, Campbell and Himmelstein,
2003). In our own cases the picture is quite different with ‘administration’ accounting for a much
lower proportion of the workforce and expenditure. However, as can be seen from Table 2, this
does not rule out some quite marked differences
between countries. At one extreme, in England,
specialist managers are employed in large
numbers within clinical directorates (Jacobs,
2005; King’s Fund, 2011) and make up a majority
of board members (over 70% according to one
calculation (Veronesi, Kirkpatrick and Vallascas,
2012)). At the other are Italy and Denmark where
hospital governance is dominated by clinicians
with very few specialists employed at lower levels
(Barbetta, Turati and Zago, 2007; Jacobs, 2005;
Kirkpatrick et al., 2009; Lega, 2008).
These conclusions are supported by other
comparative research. Dorgan et al. (2010)
for example note that non-clinically qualified
managers/administrators make up approximately
42% of all managers in the hospital system of the
UK, 36% in France and only 10% in Italy. This
study also assigns a composite ‘management practice score’ (rating capabilities in the management
of operations, performance and talent) on a fivepoint scale, with the UK scoring 2.82, coming
ahead of both Italy (2.48) and France (2.4) (US
hospitals in the sample scored 3.0). In this
research no figures are provided for Denmark,

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Figure 1. Translation outcomes

although Eurostat data suggest that the Danish
health system operates with administrative overheads of only 1.2% of total expenditure, which is
low by international standards.
Hence, while ideas originating from the JHH
model have clearly influenced health policy in the
four countries, leading to a broadly convergent
move to restructure hospitals along corporate
lines, there are also differences in the outcomes of
this translation. This process in turn, we suggest,
has resulted in pathways of change that vary
along two key dimensions, as depicted in
Figure 1: (a) the extent to which management
authority within hospitals has been streamlined
(or left ambiguous); and (b) the extent to which
management work itself is performed either by
clinicians or non-clinical specialists. Viewed in
this way it can be argued that the English NHS
comes closest to the original corporate model of
the JHH, while in both France and Italy significant compromises have been made which essentially preserve key elements of professional
bureaucracy and consensus administration within
hospitals. By contrast Denmark represents a
hybrid case in which management authority structures have been streamlined but without large
investments in non-clinical managers.

Accounting for comparative differences
in the context of translation for
the clinical directorate model
In this section we turn to our second question of
how one might account for variable translation
outcomes. When discussing this topic it is first

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


S56

I. Kirkpatrick et al.

important to note how different actors were
involved in the translation process. In some cases
change followed initiatives that were taken locally
by managers and clinical professionals who had
been influenced by the model. In England, for
example, Guy’s Teaching Hospital in London
first experimented with clinical directorates in
1984, with other hospitals also copying this model
before legislation was introduced (Harrison
and Pollitt, 1994). However, a more important
driver for change has been top-down regulatory
demands from governments responsible for the
bulk of hospital funding. Indeed, one can identify
almost coercive institutional pressures linked to a
broader agenda of reforming the management of
public services more generally (Pollitt and
Boukaert, 2011). A key question, though, is how
these reform agendas and their interpretations
were shaped in ways that led to the different
translation outcomes described in Table 2 and
Figure 1.
To address this question we return to the notion
of editing rules described earlier and to the work
of Pollitt and Boukaert (2011) on the importance
of elite actors (dominant coalitions of decisionmakers) in each country mediating economic,
political and ideational pressures for reform. Specifically we argue that the nature of rules in a
given context – how much leeway they leave for
local interpretations and deviations from the template − will depend upon elite perceptions of the
desirability and feasibility of reforms. With regard
to desirability, it is often noted that the level of
commitment of policy makers in different countries to the restructuring of public services has
been highly variable. Hood (1995), for example,
differentiates between ‘high’ and ‘low’ NPM
groups of countries depending on how forcefully
they have sought reforms. Others note differences
in the objectives of reform and how far these have
been influenced by neo-liberal ideas emphasizing
the risks of public monopoly and the need to
weaken professional ‘provider power’ (Greener,
2002).
Concerning editing rules relating to feasibility,
perceptions of elite actors of the likely obstacles to
radically changing the existing health management system by introducing ‘foreign’ templates
are important. In some contexts these may be considerable depending on a number of factors, such
as the ‘countervailing power’ (Light, 1995) of
clinical professionals, the nature of administrative

cultures and the wider political governance of
public services (including health). Where professionals are concerned Light (1995) compares
systems along a continuum of professional or
state dominance. In the former, the medical profession ‘controls not only its own work but also a
range of related institutions, services, privileges
and finances’ (Light, 1995, p. 30) arguably making
it harder for governments to impose radical
change without consent. Thus, in contexts with
professional dominance professional actors will
engage in a significant editing and modifying of
government-introduced templates. Closely related
to this are the ‘administrative cultures’ of public
services, which have particular consequences for
the status of clinical professionals, either as salaried employees (or contractors) of the state or
(under what Pollitt and Boukaert (2011) term the
Rechtstaat model) tenured civil servants. The
wider governance of health systems may also have
consequences for the feasibility of reforms, especially when, as is the case of many federal states,
hospitals are technically owned and managed by
regions that possibly have differing political
agendas (Reay and Hinings, 2009).
These considerations, we argue, have direct
implications for editing rules that apply in different contexts and which shape not only the content
of reforms (e.g. whether all aspects of the JHH
model are adopted or more loosely translated) but
also their timing and pace. Indeed, one might even
place national health systems along a continuum
ranging from those in which radical reforms are
considered to be both desirable and feasible and
those at the opposite extreme. In the former,
editing rules will be far more prescriptive in specifying new management models for hospitals,
offering actors at the policy and local level far less
room for interpretation and translation. By contrast, in the latter, perceptions of limited desirability and feasibility will result in editing rules that
emphasize elements of the national context and
thus require translations that considerably deviate
from global templates. As a result, policy makers
have been more selective in how they adopt
models of hospital management, and reforms
show more continuity with established practices
and structures.
Turning to our own cases, it is possible to argue
that the English NHS sits at the high desirability/
feasibility end of this continuum, with editing
rules that are generally more prescriptive and thus

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Translation of Hospital Management Models
result in translations that do not deviate considerably from global templates. Since the early
1980s there has been a strong push by governments, both Conservative and New Labour, to
adopt the practices of private firms, with clinical
professionals often viewed as ‘part of the problem
rather than the solution’ (Greener, 2002). Linked
to this has been a drive to recruitment of nonclinical specialists with commercial expertise
(Veronesi and Keasey, 2012). The command and
control structure of the NHS (with professionals
directly employed) has also made it easier for governments to legislate and enforce these changes,
most recently through the use of targets and performance management techniques (King’s Fund,
2011). As a consequence, in the English case,
editing rules have been highly supportive of a
more literal translation of the JHH model than
elsewhere.
This situation is in stark contrast with the
French and Italian cases. Here, although politicians have paid lip service to the NPM, the goals
of policy have often been ambiguous. This is
notably true in France, which according to
Bellanger and Mossé (2005, p. 119) has adopted
‘one of the least market-oriented models for
reforming its health care system’. Despite the fact
that a stated rationale for reform was to drive up
efficiency, ‘Ironically the word “competition” was
hardly ever mentioned’ (Or and de Pourourville,
2006, p. 22). Similarly, in Italy, although attempts
to implement NPM reforms including quasi
markets are more long-standing, here too there
has been considerable ambiguity about objectives.
Competition was immediately discouraged
through the arrangement of funding caps for individual hospitals. Under the close scrutiny of local
politicians CEOs were required to focus on
improving weak areas of their hospitals, rather
than incentivizing their competitive advantages
(Tousijn and Giorgino, 2009). Indeed, at one
point in 2003 the Minister of Health, himself a
doctor coming from the largest teaching hospital
in Milan, explicitly linked quality problems in the
Italian NHS to the introduction of too many
managers (Anonymous, 2003).
This mixed commitment to reform in the
French and Italian cases has been further exaggerated by the existence of certain barriers to
radical change. In both countries, medical professionals have considerable ‘countervailing powers’
and make up a higher proportion of the clinical

S57
workforce than in either England or Denmark
(OECD, 2008). In Italy doctors have also laid a
claim to the general administration of hospitals,
with a sub-specialization in ‘Hospital hygiene and
organization’ dating back to 1938. Over the years,
this category of physicians (referred to as ‘hygienists’) emerged as an independent medical specialization, taking care of hospital hygiene, hospital
organization, medical archives and epidemiological analysis (Cantù and Lega, 2002). A related
point is that in both France and Italy doctors are
effectively state functionaries (or civil servants),
their contracts held centrally, with no direct
employment relationship with hospitals (see
Table 1). Lastly, while the French public health
system is relatively centralized (theoretically
allowing for the top-down imposition of new
management models), this is not the case in Italy
where regional governments also play a significant role in negotiating policy. Indeed, as Mattei
(2007) suggests, it was largely to avoid a head-on
clash with these regional governments (worried
about the loss of control over hospitals) that key
aspects of the JHH model, strengthening the
executive authority of hospital directors, were
deliberately watered down in the 1990s.
From these conditions we impute editing rules
in France and Italy that have been less prescriptive and placed more emphasis on crafting
reforms in ways that ensure conformity with the
local institutional context and thus play down key
aspects of the original corporate model. Indeed,
one might argue that the JHH template was
adopted as a ‘label’, which was loosely combined
with existing practices. Influenced by the editing
rules in these two health systems, actors
de-emphasized the initial idea of market orientation and management authority in favour of traditionally legitimate forms of (professional)
organization of hospitals.
Finally, using this framework it is possible to
argue that the Danish case lies somewhere
between these two extremes. Since the mid-1980s
governments have supported the objectives of
NPM reforms, increasingly so after 1997 (Kirkpatrick, Kragh Jespersen and Dent, 2011). A
command and control healthcare system, broadly
similar to the English NHS, also makes it less
problematic to implement changes. However, in
Denmark, long-standing political traditions that
emphasize decentralization and partnership with
key stakeholders (notably the clinical professions)

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


S58

I. Kirkpatrick et al.

have generated a different set of rules and associated choices (Ham and Dickinson, 2008; Kragh
Jespersen and Wrede, 2009).

Concluding discussion
The main contribution of this paper is to build on
and strengthen existing accounts of management
reform across different national health systems
(Dent, 2006; Jacobs, 2005; Neogy and
Kirkpatrick, 2009). Around the world it is noted
that governments are promoting very similar
models of management and organization.
However, at the same time, the available research
points to variations in how these models are
implemented in situ. Focusing on one highly influential model of hospital organization (the JHH),
which emerged in the USA in the 1970s, we
suggest that this convergence and divergence in
practice can be usefully explained using the lens of
institutional theory and in particular the notion of
translation. This approach draws attention to
ways in which aspects of a management template
become dis-embedded from their original context
and re-embedded in the context of adoption. In
our own cases this resulted in quite different
translation outcomes, ranging from a more literal,
corporate version of the model in the English
NHS to essentially more professionally mediated
approaches in France and Italy.
A further strength of this approach is to further
develop the notion of editing rules. While this idea
has been used extensively to understand the way
templates have been re-embedded on a symbolic
and linguistic level, for instance in success stories
(Sahlin-Andersson, 1996), less attention has been
paid to the rules that refer to the local context and
its regulatory and political structures and thus
shape ‘material’ translations of templates. Nor
have many studies explored this dimension in a
comparative perspective, looking at how national
institutions may influence translation outcomes.
In this regard the framework presented here
breaks new ground. Drawing on ideas from
comparative public management (Pollitt and
Boukaert, 2011), we argue that elite actors’ perceptions of reform (in terms of desirability and
feasibility) may be important in defining the
nature of editing rules in a given country. Specifically we show that, where elite actors have been
both supportive of reform and less concerned

about the obstacles to changing the existing hospital management models, editing rules are far
more prescriptive allowing less scope to veer away
from a literal adoption of the JHH template. As
such this paper contributes not only to debates
about comparative health reform, offering new
frameworks for comparison, but also to translation theory itself, showing how the concept of
editing rules may be further extended and applied.
Of course, when drawing these conclusions it is
necessary to bear in mind a number of caveats and
identify areas for further work. Clearly, the
mapping exercise of translation processes and
institutional factors influencing translations that
we have conducted represents only a first step
with empirical research needed to fully develop
the approach described here. Several themes also
need to be explored in more detail, in particular
the longer-term development and evolution of
hospital management regimes. This longitudinal
perspective is especially important given the variable timing of health management reforms in each
country, with France being a late starter in our
own sample. More work would also be useful to
explore national differences in the way management roles are enacted by, for example, clinical
professionals. The available evidence suggests
that these responses might vary along national
lines (Kurunmäki, 2004), but clearly more
research is needed. Looking at differences in
engagement with new management practices
(such as the JHH model) also raises the question
of how far these have become fully institutionalized. Even in the English case there is evidence to
suggest that, while the formal governance structures of trust hospitals might have changed, professional cultures remain deeply embedded and in
many ways still shape the practice of management
(Kirkpatrick et al., 2009). Lastly there is clearly
scope to extend this framework to understand the
implementation of other kinds of management
templates that have been disseminated globally,
e.g. new organizational models for primary care
or funding regimes such as DRGs.
Notwithstanding these caveats and limitations,
this paper makes an important contribution to
our understanding of comparative health management reforms, illustrating for the first time the
usefulness of notions of translation for researching and explaining these changes. As suggested
earlier, we also contribute to translation theory
extending the notion of editing rules from its pre-

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


Translation of Hospital Management Models
vailing focus on symbolic and linguistic aspects to
incorporate structural and practice changes. In
addition to this our analysis has relevance to
cross-national policy making and learning.
Saltman (1997) notes that international comparisons are ‘both seductive and deceptive’: seductive
because the potential value of identifying ‘best
practice’ is so high and deceptive because these
practices are often hard to transfer from one
context to another. The findings reported here
advance this kind of understanding, directing
policy makers to think more carefully about the
feasibility of management templates and whether,
given national institutional conditions, it is possible to implement them in ways that were originally intended.

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Translation of Hospital Management Models

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Ian Kirkpatrick is Professor in Work and Organisation at Leeds University Business School. His
research interests include management change in professional organizations and the restructuring of
public services. He currently serves as Director of the Leeds Social Science Institute and is a member
of the editorial management team of the British Sociological Association journal, Work Employment
and Society.
Bernadette Bullinger, PhD, is Assistant Professor in Human Resource Management at the University
of Innsbruck. She has a strong interest in social and organization theory, specifically in institutional
and French convention theory. Her research interests also include the translation of management and
human resource management concepts and questions of corporations’ and professions’ legitimacy,
especially in the context of the employment relationship.
Federico Lega, PhD, is Professor of Healthcare and Public Management at Bocconi University,
Milan, Italy. He leads the executive education segment for the healthcare sector at SDA Bocconi
School of Management and is a senior researcher at CERGAS. He sits on the board and scientific
advisory committee of the European Health Management Association (EHMA) and works as
advisor for national and international institutions on health policy and management issues.
Mike Dent is an organizational sociologist and a Professor of Health Care Organisation at Staffordshire University. He has been researching into the medical and nursing professions for a number of
years and has published widely in that area. His book Remodelling Hospitals and Health Professions
in Europe: Medicine, Nursing and the State came out in 2003.

© 2013 The Author(s)
British Journal of Management © 2013 British Academy of Management.


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