Writing in the 1970s, Peter Drucker, one of the most highly regarded pioneers of management stated, "Management is tasks. Management is a discipline. But management is also people." Indeed, management is both complicated and stressful, hospital management even more so. Hospital managers' decisions impact patients, meaning higher stakes and more responsibility. Instead of a typical market they rely on public funds and they are also responsible for managing different independent professional groups (doctors, nurses etc). It is their job to create a tool that these groups can use to perform their duties but the hospital manager is not a direct authority. But what qualifications and experience are required before assuming this position? Are there legal requirements? Does the level of experience vary between countries in Europe? And also, what qualifications and training programmes are available? We decided to ask our correspondents and associate members from EAHM to enlighten us on the subject and answer these questions.
We began our research by searching for relevant management courses and it has to be said there is certainly no shortage of business and management courses in Europe. Searching for hospital management courses however, is not as easy as it seems. You will come across a plethora of healthcare management courses but these are not specifically designed for hospital managers. Of course, general healthcare management issues are important; hospitals are embedded in this system and managers need to know what is happening on this macro-level. But hospital management is much more specific with the most important focus being on a micro-level.
The Changing Environment of Hospitals
The organisation of hospitals is under constant evolution. Recent demographic and financial changes have lead to significant changes in hospitals. This has also affected the management. Instead of the allencompassing power of the CEO, hospital management is changing in favour of management teams. This team is made up of representatives from the different professions within the hospital: doctors, nurses, engineers, finance, IT etc.
This has lead to a broader dimension of hospital management. The power of the hospital CEO has not lessened but the role has changed. Now the CEO is the coordinator of all approaches, he assumes the general responsibility of the hospital. He has gone from a one player to a team player.
We have witnessed this change in Denmark in the last 25 years. Before it was common practice that the administrative responsible for the management of the hospital consisted of only one person (and never an educated physician or nurse). Now it is normal for the top management to consist of several leaders including a chief doctor and head nurse. For the purpose of this article we are investigating training for CEOs and not the wider departmental management for which there are many courses available.
We have tried to get a European overview of training and education for hospital managers using our correspondents, national associations and associate members, including universities proposing studies for hospital managers. It is in no way a complete overview of the situation in Europe, indeed, it can be better described as a starting point for a dialogue on training. We wish to continue this discussion every year, and will feature it in one issue of (E)Hospital per year.
The information used comes from the answers to our questionnaire and is not a definitive guide to training programmes. We would apreciate your input to complete our study (please contact us via [email protected]).
The interest is not to discuss whether hospital managers should be or can be a medical doctor or not. This is about the practice in different countries and the legal and practical requirements. We asked correspondents a set of questions regarding legal requirements, experience and they types of qualifications available in their countries.
Educational Requirements: Legal and Practical
Let us take the requirements first. For a doctor, nurse, lawyer or accountant there are professional bodies regulating who can practice this particular profession. The same simply does not exist for hospital managers. From the responses to our questionnaire it is apparent that in many European countries there are no formal legal requirements for becoming a hospital manager, instead requirements are set up by the hospitals themselves. This is certainly the case in the Netherlands, Belgium, UK and Austria. Most commonly, hospital managers will have a Bachelor's degree and probably a Master's and significant management experience.
In Austria for example, the hospital system is by principle regulated by the Austrian government while the specific details are left to the governments of the nine provinces. Austrian law simply states, "For each hospital a suitable person should be appointed as director/manager of the economic, administrative and technical affairs... For the education and training of the staff in the hospital administration and management measures must be taken." In the provinces there are usually more detailed regulations, but there are no uniform rules in Austria.
Like most European countries, Finland places importance on education requirements. For higher supervisory positions, like hospital managers, a higher academic degree is required as is sufficient experience in supervisory and administration tasks. Notably, in Finland there is another dimension: language. Hospital managers must have good language skills in both Finnish and Swedish. In Ireland, as in Germany and the UK, most hospital managers have Master's degrees (but the subject area is not important) and of course extensive experience in a management position.
In Italy there appear to be more formal regulations. In fact, a reform of current regulations is being discussed in Parliament at the minute. At the present moment the director of public hospital is required by law to have a degree and at least five years experience as a manager in a hospital, local healthcare enterprise, private hospital or public or private (not healthcare) company. This experience must also include managing their own budget and human, technical and financial resources. There is also a compulsory course on the public healthcare sector and healthcare management, which must be followed within six months of appointment. Different regions can also have further requirements.
France also requires a special mention. As you will see from our interview with Antoine Flahault, the Dean of EHESP School of Public Health (pg.16), 90 percent of public hospital managers are trained at the school. The 27 month training programme only available after first being hired by the government, is extensive involving a two degrees and 11 months of internship in various hospital positions. From our questionnaire we can conclude that for most European countries there are no formal regulations set out for the appointment of hospital managers. That being said, there is a general consensus that the role can only be appointed to someone with a degree and significant management experience. Further conditions depend on countries, regions and even hospitals.
Changing to Meet New Demands
Recent developments including the economic and financial crisis, demographic change and the increased mobility of patients and healthcare workers have all put increasing pressure on hospitals and therefore hospital managers. With this in mind, one of our key questions was whether or not hospital management qualifications and training programmes have been adapted to take into account these new situations and offer hospital managers specific, tailored guidance.
As you can see from our interviews with representatives from management schools across Europe, most programmes have indeed been adapted along with recent changes in the hospital environment. In Germany, Prof. von Eiff highlights that their programme is a living programme updated in line with legal reforms implemented twice a year. While in France, course adaptation and changes are monitored by the board of education and a special committee with the help of various stakeholders including alumni and employees.
In light of the difficult financial situation in Ireland, all training and development is being reviewed in terms of deliverables in the current setting. Training and education is capitalising on modern technology and e-learning is being utilised more and more. In Belgium, the University of Leuven ensures its students learn about cross-border care and hospital care in Europe. There is a specific course on healthcare systems studying and comparing systems in various countries.
Continuous Professional Development
So far we have discussed the educational requirements for becoming a hospital manager, but what about training for hospital managers already in their post? This is where continuous professional development (CPD) comes in. Few can dispute the advantages of CPD; it is an essential element of effective management practice. Both the British and Irish health management institutes promote and even require CPD from their members.
The UK Institute of Healthcare Management (IHM) defines CPD as "A process that enables managers to acquire, maintain and enhance their knowledge, skills and attitude to optimise individual and organisational performance." Each member of the IHM must abide by the Healthcare Management Code, which stipulates managers must ensure their skills and competences are up to date.
A similar situation in Ireland, the Health Management Institute of Ireland (HMI) is "dedicated to the education and continuing Professional Development of all its members. Education, training and related activities play a central role in ensuring that members have the skills and know-how to apply best management practices in their work." In association with their education partner SHRC, HMI deliver practical management training that combines theory, peer learning, networking and action learning principles.
Many of the national associations offer or recommend further training for their members. These range from extended programmes to one-day seminars. In Austria, the national association of hospital managers (BUKO, Bundeskonferenz der Krankenhaus-Manager Österreichs) has led the ÖIK (Austrian Institute of Hospital Management Sciences) for over 20 years. ÖIK organises an appropriate, practical training for senior hospital management with a special focus on commercial activity on a nonprofit basis.
Specifically tailored to the Austrian health system, these training courses provide the business knowledge necessary for modern hospital management. There is a clear focus on the importance of highly skilled commercial management, improving economics to combat the current financial situation.
Although there are no legal requirements of specific qualifications to become a hospital manager in Austria, their MBA programme is so well established it is considered by many hospitals in Austria as a qualification requirement for senior management roles. Topics include quality management, planning, performance management, benchmarking, supply management and HR. They also run basic business seminars with the aim of ensuring employees meet the growing demands of the hospital as a service provider and focus on efficiency.
It is clear that training and education is an important issue for hospital management and something that our member associations take seriously. While there are no fixed European regulations or standards for hospital management training it is evident that many countries in Europe expect the same level of training and education teamed with significant management experience.
Although there might not be so many hospital management courses in comparison to healthcare management, we can see from our questionnaire and interviews that there are many options out there for both Bachelor's and Master's degrees and professional training programmes for hospital management. Another key point is how these programmes and courses are being adapted to meet the current changes in our hospitals providing hospital managers with the correct tools they need to manage successfully.
As we said before, this is not an exhaustive study of management training and education. It is merely a starting point. We would love to continue the discussion and learn about your experiences, programmes and opinions.