공공의료전문직의 혁신과 동기부여 (Health Policy, 2007)

공공의료전문직의 혁신과 동기부여 (Health Policy, 2007)

Innovation and motivation in public health professionals

Manuel Garc´ıa-Go˜ni a,∗, Andr´es Maroto b, Luis Rubalcaba c

a Manuel Garc´ıa-Go˜ni, Universidad Complutense de Madrid, Departamento de Econom´ıa Aplicada II,

Campus de Somosaguas, 28223 Pozuelo de Alarc´on, Madrid, Spain

b Universidad de Alcal´a and SERVILAB, Spain

c Universidad de Alcal´a, SERVILAB and RESER, Spain

1. 도입

1. Introduction

공공보건에서 혁신 프로세스의 효과에 대한 연구가 많이 됨.

The effect of innovation processes has been greatly explored in the public health literature under different perspectives, as its diffusion [1],

연구자들과 공공보건 정책개발자들 사이에서 헬스서비스 제공에 대한 혁신프로세스의 도입이 population의 health status를 높여준다는 합의가 있다.

In fact, there is a general consensus among researchers and public health policy makers in the statement that the adoption of innovative processes (either technological or organ- isational) in the provision of health services promotes an increase in the health status of the population or in their quality of life [4–6].

일부 연구는 구체적인 의료기구나 치료 혁신의 효과를 보기도 한다. 이들은 대부분의 신약 (심장마비, 백내장, 우울증 등) 치료에서 productivity의 향상을 보여준다.

Some of the studies in the literature [7,8] examine the productiv- ity of specific health innovations in medical equipment or treatments. Those studies find an increase in pro- ductivity for most new treatments, such as for heart attacks, cataracts, and depression.

그러나 일반적인 연구에서도 productivity가 높아진다. 신약 개발에서도 그렇다.

However, general studies [9] find that innovations lead to increased productivity in health care. Also, related to innovations in the drug industry [10], the same conclusion is obtained with a signifi- cant positive effect of new drug launches on average lifespan.

두 가지 효과가 있다: 치료대체효과와 치료확장효과(the treatment substitution effect and the treatment expansion effect). 치료대체효과는 과거의 기술을 새로운 기술로 대체하는 것이다.

There are two different effects derived from innovation that need to be taken into account: the treatment substitution effect and the treatment expansion effect [8]. Treatment sub- stitution consists of the substitution of the “old” by the “new” technology or way of organising resources.

그러나 한계비용이 감소하더라도, 총 비용이 증가하기도 한다. 이는 치료확장효과 때문인데, availability가 생기면서, 새로운 테크놀로지가 효과를 보기 시작하면 demand가 늘어나는 것이다. 따라서 technical innovation은 보건지출의 중요한 driver가 된다.

However, even when marginal cost decreases, after the process of adoption of health innovations total cost often increase. The reason is pro- vided by the treatment expansion effect, explained by the fact that given its availability, the new technology is applied to other treatments and health services and once they become more effective, the demand of health services increases [11]. Hence, technical innovations in health are thought by some to be an important driver behind increasing in health expenditures [12–14].

따라서 헬스서비스 공급 측면에서 혁신의 긍정적 효과가 있더라도 연구자들과 정책개발자들은 기술적/조직적 혁신 프로세스를 이해하는 것이 중요하고, 그것이 health productivity의 관점에서 어떤 결과를 낳는지를 알아야 하고, socially beneficial medical intervention을 제공해야 한다.

Therefore, being positive the effect of innovation in the provisionof healthservices, it is a major concernfor researchers and public policy makers to understand the drivers of both technological and organisational inno- vative processes in the provision of health services, its consequences in terms of health productivity [9], and providing incentives for the development of socially beneficial medical interventions [16].

근무환경에서의 동기부여는 'the individ- ual’s degree of willingness to exert and maintain an effort towards organisational goals'와 같이 정의되곤 한다. 헬스서비스 제공은 의료전문직의 motivation에 매우 의존적인데, 이 motivation은 financial incentive만큼이나 non-financial incentive에 의해서 영향을 받는다.

Motivation in the work context has been defined [19] as the individ- ual’s degree of willingness to exert and maintain an effort towards organisational goals. The performance in the provision of health services is highly depen- dent on the motivation of health professionals [20,21], and this motivation might be affected by non-financial incentives (

• the feeling of having the work under con- trol,

• the perception of how much salary depends on effort, or

• the communication system used

) as much as by financial incentives [22–24].

full time과 part time의 비율에 따라서도 motivation이 달라진다.

Different moti- vation is also evidenced in the literature through the different proportion of full-time or part-time contracts by types of health professionals [27,28].

 

두 가지 유형의 분석이 가능하다.

There are two different types of analysis that can be developed with respect to the different behaviour and motivation of professionals in the health care provi- sion.

• 수평적 관점에서, 서로 다른 기관에 종사하는 동일한 의료전문직 사이의 행동 비교분석
  The first one, froma horizontal perspective, would analyse the differences in the behaviour of the same type of health professionals at distinct types of insti- tutions (public versus private), while

• 수직적 관점에서, 동일한 기관에 종사하는 서로 다른 의료전문직 사이의 행동 비교분석
  the second, from a vertical perspective, would analyse the differences in the behaviour of different types of health profes- sionals (managers versus front-line employees) at the same type of institutions.

 

수평적 분석에서 보건경제학은 (어느 일정정도까지는) private sector가 public sector보다 high technology medical equipment 를 더 빠르게 수용함을 보여주었다. 한 가지 이유는 private sector에 비해서 인센티브나 동기부여가 적기 때문일 수 있다. public institution은 지역 수준의 문제만 해결하면 되고, 외부의 문제는 인식조차 못하기도 한다.

With respect to the horizon- tal analysis, the health economics literature has shown how, at least at some extent, private sector health insti- tutions are quicker to adopt high technology medical equipment than public sector institutions [29]. One possible reason is the lack of incentives or motiva- tion for increasing efficiency While for-profit private sector institutions must be efficient in order to survive, and need to generate profits that satisfy their stakeholders [30] public insti- tutions invariably deal with local/regional problems, sometimes unaware of outside problems.

또한 보건시장의 구조, 즉 private과 public 의 상대적 비율이 혁신의 전파에 영향을 준다. 혁신의 전파는 미국과 같이 병원이 높은 수준의 autonomy를 유지하고 있고 private sector가 significant한 곳에서보다, 캐나다와 스웨덴과 같이 보건시스템이 publicly owned한 국가에서 더 느리다. 이러한 차이는 incom-plete contracts and the definition of property rights 에 대한 연구에 의해 이론적 기반을 설명할 수 있다.

 Also, it is sug-gested that the structure of the health market, i.e. the relative proportion of private and public sector institu-tions that make up the sector, affects the diffusion of health innovations. Thus, the diffusion of innovations is slower in countries such as Canada or Sweden, in which the health system is publicly owned and organ-ised centrally, than in countries such as the US, where hospitals have a high degree of autonomy and there isa significant private sector component [31]. Theoreti-cal basis in one of the main differences between public and private sector can be adapted by the study of incom-plete contracts and the definition of property rights [32] 

 

property rights 에 따른 인센티브의 차이가 혁신 프로세스에 영향을 준다. 공공기관의 (manager와 front-line employee의) property rights 이 없는 곳에서, public sector (의 혁신이) 더 disadvantage를 받는다.

Also, the literature [33] has shown how dif- ferences in incentives due to the property rights lead to different frequencies and magnitudes of the innovation processes. Therefore, the absence of property rights (in managers and front-line employees) in public institu- tions supposes a disadvantage existing in the public sector relative to the private sector.

보건의료전문직의 motivation이 혁신행동을 이끄는 주된 driver의 차이로 지적되어 왔지만, 같은 기관 내에서 서로 다른 보건의료전문직 사이의 차이는 더 연구될 필요가 있다(수직적 관점). Property right은 매니저든 현장직원이든 차이가 없지만, 매니저의 책무성(혹은 목소리)는 더 크기 때문이다.

Although motivation in health professionals has usually been pointed out as the main driver of the differences in innovating behaviour in public versus private institutions [30,34–36], it remains unexplored the differences in the behaviour of different health professionals at the same type of institution. Under this vertical perspective, there are no differences in the incentives to innovate due to the property rights because neither managers nor front-line employees par- ticipate of the benefits or are stakeholders, although the accountability (and voice) of managers is considered an important dimension of organisational reforms in health institutions like hospitals [37].

In this paper we explore and test the existence of differences in the attitude towards innovation between managers and front-line employees at public health institutions. Those differences might be supported by the different role in the adoption of innovations. While

• managers act as “innovation entrepreneurs” with a higher responsibility and involvement in the process and have a better knowledge of the benefits of the innovation,

• front-line employees usually present more resistancetochanges, includinghostileor sceptical atti- tudes and difficulty maintaining the enthusiasm [38].

2. 자료, 방법

2. Materials and methods

설문지

The original questionnaire in English is provided in Appendix A.

93개 문항

It consisted on 93 questions covering dif- ferent topics related to the

• communication system in the health institution and the channels of generating and disseminating information;

• the overall performance of the institution in its daily activity and specifically in adopting innovations;

• the health professionals attitude towards the institution and towards innovative processes, evaluating creativity or innovativeness from both the individual and institution perspective;

• the level of connectedness and centralisation in the decision taking process at the health institution; the learning processes, or their level of satisfaction at work; besides

• other socio-demographic questions as gender, age, or level of studies.

 

The original components of innovativeness in the survey are summarised into different major blocks:

• market orientation – information generation and dissemination, and

• responsiveness – openness, risk taking, future orientation, creativity and pro-activeness, team spirit and connectedness, and expected outcomes of organisational innovativeness

• (at the individual level: commitment and work satisfaction; and

• at the organisational level: innovation performance, organisational performance and organisational learning). 

Health professionals are divided in the survey into managers and front-line employees attending to their role at the health institutions instead of to their capa- bilities. Thus, while health professionals as

• nurses, auxiliary workers or administrative staff are consid- ered front-line employees because they work directly with patients without any management task;

• doctors or physicians managing a team of front-line employees and the head of the institutions are considered man- agers.

3. Results

Principal components (PC)는 아래와 같음

Table 1 provides the results and the relationship between the principal components and the different topics covered in the question- naire.

• 조직 퍼포먼스 The first PC, explaining most of the data, is clearly related to organisational performance, includ- ing some components of the innovativeness such as

• creativity and pro-activeness,

• team spirit and con- nectedness, and

• the individual behavioural variables such as commitment and work satisfaction.

• 변화 지향적 태도 The sec- ond PC links the pro-change aptitude and learning of the organisation –

• organisational openness,

• risk taking and future orientation – and

• the participa- tion of front-line employees, managers and external agents—promotion of innovation and internal learning processes.

• 환경과 시장 지향성 The third PC is related to environment and market orientation—

• generation and dissemination of information, and

• responsiveness to agents’ needs and environmental changes.

• 조직의 혁신 퍼포먼스 Finally, the fourth PC is related to innovation performance of the organisation, relative to

• planned, and to

• the political, and

• perceived users’ and advocacy groups’ expectations.

 

 

 

 

managers 의 인식은 FLE의 인식보다 더 복잡했다.

The perception of managers with respect to organisational innovation is more complex than the perception of front-line employees.

4개의 component가 61.3%의 variance를 설명함. 가장 중요한 PC는 overall performance이고 나머지 component들이 그 뒤를 이음

We found four components which explained61.3% of the variance of data. The first and most important PC (explaining 41.6%) is related to organ-isational overall performance, while the remaining components are related to pro-change aptitude and learning, environment and market orientation, and innovation performance, following the trend observed in the total sample.

 

 

 

 

Table 2 Differences between managers and employees about innovation (ANOVA results)

PC1과 PC3이 가장 consistent한 관계를 보여줌(manager와 FLE 모두에 해당됨)

PC4는 FLE에서는 유의하나 Manager에서는 그렇지 않음.

With respect to the separate analysis for managers and front-line employees, we obtain that principal components related to innovative profile of the organisation (PC1) and overall organi- sational performance (PC3) present the strongest and most consistent relationship with the motivation in health professionals, across both managers and front- line employees, and the total database. While the second principal component, related to environment and information spread (PC2), presented also a con- sistent relationship between the two sub-samples, the fourth principal component, related to pro-change apti- tude (PC4) is significant in the analysis corresponding to front-line employees, but not for managers.

 

 

 

 

 

Table 3 General non-linear model results (multinomial ordered probit)

4. Discussion

공공의료기관에서 혁신에 대한 태도가 manager와 FLE사이에 다르며, manager가 더 동기부여가 되어있다. 동기부여의 차이가 어느정도는 혁신의 도입에 관련이 될 것이며, 그러한 차이를 줄이기 위한 정책이 필요하고, low-involved 한 사람을 위한 동기부여 등이 필요하다.

As a conclusion, this paper provides evidence that different types of health professionals at public health institutions present different attitude towards innova- tions and are differently motivated, being managers better motivated than front-line employees. Because motivation is important in the health performance and the adoption of innovations, the gap in the motivation between different types of health professionals is, at least at some extent, responsible for the delay in the adoption of innovations in public health institutions, and policy measures should be undertaken in order to reduce such a gap, increasing the motivation for low involved health professionals and the interaction and co-production of innovative activities between man- agers and front-line employees.

Appendix A. Questionnaire distributed to managers and front-line employees at public health institutions

 

 

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Health Policy. 2007 Dec;84(2-3):344-58. Epub 2007 Jul 6.

Innovation and motivation in public health professionals.

García-Goñi M1, Maroto A, Rubalcaba L.

Author information

• 1Manuel García-Goñi, Universidad Complutense de Madrid, Departamento de Economía Aplicada II, Campus de Somosaguas, 28223 Pozuelo de Alarcón, Madrid, Spain. mggoni@ccee.ucm.es

Abstract

OBJECTIVES:

Innovations in public health services promote increases in the health status of the population. Therefore, it is a major concern for health policy makers to understand the drivers of innovation processes. This paper focuses on the differences in behaviour of managers and front-line employees in the pro-innovative provision of public health services.

METHODS:

We utilize a survey conducted on front-line employees and managers in public health institutions across six European countries. The survey covers topics related to satisfaction, or attitude towards innovation or their institution. We undertake principal components analysis and analysis of variance, and estimate a multinomial ordered probit model to analyse the existence of different behaviour in managers and front-line employees with respect to innovation.

RESULTS:

Perception of innovation is different for managers and front-line employees in public health institutions. While front-line employees' attitude depends mostly on the overall performance of the institution, managers feel more involved and motivated, and their behaviour depends more on individual and organisational innovative profiles.

CONCLUSION:

It becomes crucial to make both managers and front-line employees at public health institutions feel participative and motivated in order to maximise the benefits of technical or organisational innovative process in the health services provision.

PMID:

 

17618010

 

DOI:

 

10.1016/j.healthpol.2007.05.006

[PubMed - indexed for MEDLINE]