Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work

To sustain costs while also improving care quality, scholars and policymakers alike have highlighted the need for the reorganization of hospital care delivery, with increased emphasis on implementing new models of financing and restructuring care delivery processes. However, despite a wide range of scholarship, how best to organize hospital care in order to improve care delivery processes remains an open question. The restructuring of secondary care continues to face many challenges, and many proposed solutions prove difficult to translate from theory to practice, indicating a potential mismatch between the two. With this thesis, I attempt to bridge this divide by offering a micro-level view into the challenges, effects, and complexities of organizing secondary care delivery. Three in-depth case studies were conducted in hospital organizations that recently underwent a structural change. Each study focuses centrally on how to organize hospital based medical specialists and brings forward the often-overlooked perspective of clinicians themselves. The empirical results reveal the relational and cultural barriers that are often overlooked, but play a crucial role in determining the outcome of reform efforts. In Chapter 2 and 3 we examine how physicians respond to proposed employment reform. Our findings indicate that while physicians recognize the need to be accountable for costs and care quality, they may view the move to employment as a threat to their core professional values. In Chapter 4 we unveil importance structural, interpersonal, and cultural barriers that undermine integration efforts and disrupt processes of care in the emergency care chain.