Professional Autonomy and Service Performance in Dual Agency Physician－Patient Relationship：Contextual Effects and Mediation of Physician's Affective States
| Autor: | Hsiu-Ling Wang, 汪秀玲 |
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| Rok vydání: | 2009 |
| Druh dokumentu: | 學位論文 ; thesis |
| Popis: | 97 Based on studies of incentive control of agency theory, strategy change, medical professionalism and alienation theory, we examined the contextual effects of outcome-based incentives (OBI) on physician and hospital service performance after the implementation of Hospital Global Budgeting (HGB) in Taiwan. This study identifies dual mediating processes, namely physician detachment and clinical empathy, that are activated by the infringing of professional autonomy during the implementation of hospital strategic changes that emphasize cost containment and revenue enhancement. This article will offer a theoretical and empirical approach for isolating the performance decrements that occur during changes. This was a retrospective, cross-sectional study. We selected 1,260 physicians employed at 84 general hospitals in Taiwan. A structured questionnaire was mailed to chief executive officers and physicians of the study hospitals. Secondary data was provided by the Bureau of National Health Insurance (BNHI) and Department of Health (DOH), Executive Yuan. A total of 441 usable questionnaires from 51 hospitals were returned. Our model was tested with the use of structural equations modeling (SEM) using LISREL 8.7 software. To examine the contextual effects along with hierarchical linear modeling, HLM 6.0 software was applied. We draw conclusions in the following areas. 1. Direct effect of service performance by OBI policy. (1) At the organizational level, the hospitals using OBI did not significantly effect productivity of the out-patient department (OPD) or the inpatient department (IPD). When comparing accreditation levels and ownership type of hospitals, the productivity of IPDs in medical centers was higher than in regional hospitals. Productivity of OPDs and IPDs in public hospitals was lower than in private ones. (2) At the individual level, at higher levels of OBI, physicians gained better service quality along with better performance in OPD and IPD. 2. Antecedents of physician''s perceptions on professional autonomy. Implementation of hospital strategic changes on cost containment positively impacted physicians'' recognition of "Administrative supervision". However, a strategy of revenue enhancement disclosed positive influence on perceptions of "Physician''s control over his/her work" and "Status in hospital". These findings suggest that an increasing emphasis on revenue generation reduces physicians'' perceptions of professional autonomy infringement, whereas increasing emphasis on cost containment enhances their beliefs in a breach of autonomy. Also, a hospital''s rank had an independent effect on "Physician''s control over his/her work" and "Work load". By medical specialization, surgeons experienced a greater sense of "Administrative supervision" when compared to internists. 3. Direct effects of professional autonomy on affective state. Our results showed the perceptions of "Administrative supervision" and "Status in hospital" separately have a positive and negative influence on detachment. In addition, the perceptions of "Administrative supervision" had a positive influence on three components of clinical empathy, namely "Perspective taking", "Compassionate care" and "Standing in patient’s shoes". In sum, physician detachment is associated with a breach of autonomy; however, physicians do not decrease their empathy for the patient. 4. Direct effects of professional autonomy on service performance. There is positive influence of "Administrative supervision" perceptions on quality and productivity. However, the "Status in hospital" perceptions were negatively related to quality performance as well as positively related to physician productivity. 5. Direct effects of detachment on service performance. Detachment had a negative influence on quality performance but did not effect productivity in OPD and IPD. 6. Direct effects of clinical empathy on service performance. The three dimensions of clinical empathy, namely "Perspective taking", "Compassionate care", and "Standing in patient''s shoes", all had a positive influence on quality performance; "Compassionate care" was also positively related to productivity in OPD and IPD. 7. Performance loss mechanism: the mediating effect of affective state. The perceptions of "Administrative supervision" and "Status in hospital" had a negative influence on detachment, and detachment had a negative influence on quality performance. The perceptions of "Administrative supervision" had a positive relationship with quality performance and the effect was mediated by three dimensions of empathy-"Perspective taking", "Compassionate care", and "Standing in patient''s shoes". The perceptions of "Administrative supervision" had a positive influence on productivity and the effect was mediated by "Compassionate care". Our results show that the OBI system did not have a significant influence on the productivity and quality in hospitals, but did have a direct impact on physician''s service performance. Strategic changes of revenue enhancement and cost containment respectively promote or curb professional autonomy, which can subsequently produce positive or negative effects on the performance. Because productivity performance is more easily measured and monitored than quality performance, physicians will try to maintain their productivity to expected levels. Our study also confirms that "Affect-event theory (AET)" plays an important role in performance outcome; and separating out physicians as dual agents responsible towards hospitals and patients is important in gauging response to changing practices. The study''s findings provide evidence that different strategic emphases (cost containment vs. revenue enhancement) translate into qualitatively different (negative vs. positive) effects on physicians'' perceptions of professional autonomy and insights into mechanisms of performance loss that include positive pathways in hospitals. We posit that empathy can reduce loss in quality performance and physician''s detachment curbs the loss of quality performance due to a decrease in physicians'' professional autonomy. We further suggest that detachment produces overall negative effects on physicians'' performance while empathetic processes produce gains. Managerially, it is thus important to attend to the perceptions of physicians while altering incentive controls and strategic change processes in organizations. |
| Databáze: | Networked Digital Library of Theses & Dissertations |
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