Högskolan i Skövde

Previously, improvement work in healthcare has mainly been medically related and driven by medical research, but NPM implies that management-initiated improvement work targeting organizing, productivity, efficiency, work flow etc. has become more and more common. Management-initiated improvement work has a high failure rate, and in general it seems difficult to motivate co-workers to actively participate. In all processes of organizational change, trust in the initiator of a change project is an important prerequisite to enable change take place. In this article, our purpose is to investigate how trust in management influences management-initiated improvement work. In a qualitative study we investigate improvement work at three Swedish hospitals. Our theoretical framework is based on a view of management as being both the people who manage and the system of management. This distinction is important since we can trust people and we can have confidence in a system, but these processes are different. Consequently, it is possible to trust individual managers, but as long as we do not trust management as a system, management-initiated improvement work will face considerable problems.  To analyze trust we use a model that identifies three important antecedents for one person (the trustor) to consider another person (the trustee) as trustworthy: ability, benevolence and integrity. Using social system theory, we extend this model to on the one hand describe trust in specific persons (specific managers), and on the other hand describe confidence in a system (management in general, which the system-specific managers are parts of). The results indicate that there in general is a lack of trust between healthcare personnel and healthcare management.

We were able to find certain managers who were found trustworthy by the personnel, but despite these trust-relations the personnel did still not have confidence in management as a system. To the contrary, these managers were perceived as exceptions, and did not change the perception of management in general. The consequences for management-initiated improvement work were that most personnel at best were ignorant to it, and at worst resisted it openly. However, there were examples when trusted enthusiastic managers succeeded in initiating improvement work, but then the continuation and success was directly connected to this person, and if s/he left, the improvement work stopped. Furthermore, some work groups seemed to very clearly separate “real” improvement work, which they initiated themselves, from “phony” improvement work initiated by management, which only stole time from more important tasks.