bs_bs_banner British Journal of Management, Vol 24, S48–S61 (2013) DOI: 10.1111/1467-8551.12030 The Translation of Hospital Management Models in European Health Systems: A Framework for Comparison Ian Kirkpatrick, Bernadette Bullinger,1 Federico Lega2 and Mike Dent3 University of Leeds, UK, 1University of Innsbruck, Universitätsstraße 15, 6020 Innsbruck, Austria, Bocconi University, Italy, and 3Staffordshire University, UK Corresponding author email: bernadette.bullinger@uibk.ac.at In this paper we develop a framework for comparing changes in the management of public hospitals across different national health systems, drawing on insights from institutional theory Using a range of secondary sources we show how one particular form of hospital management, pioneered originally at the Johns Hopkins Hospital in Baltimore, has been translated differently in four health systems: England, Denmark, Italy and France This analysis builds on the notion of editing rules, which derive from the institutional context, and illustrates how these rules broaden our understanding of variable translations of global templates for hospital management The paper concludes by highlighting wider implications for theory and policy In health systems around the world there has been a common focus on strengthening the management capabilities of hospitals following the model of private corporations (McKee and Healy, 2002) However, while there are strong indications that healthcare management has become an international trend there are risks of overstating convergence Existing comparative research highlights similar priorities that are driving reforms, but also ‘distinctive national or regional variants’ (Dent, 2006, p 624) A handful of studies, for example, have noted differences in the implementation of diagnostic related groups (DRGs), clinical governance regimes (Burau and Vrangbæk, 2008) and in the responses of clinical professionals to budgets and leadership education (Jacobs, 2005; Kurunmäki, 2004) However, while this work suggests ‘alternative change pathways’ in health reform (Jacobs, 2005, p 158), with some exceptions (Dorgan et al., 2010; Eeckloo, Delesie and Vleugels, 2007), less attention has been paid to how this might apply to the management of hospitals Although there are strong indications that private sector man- agement ideas and templates with a global profile have been interpreted differently, we know very little about the details of this process There are also deficiencies in our understanding of why variations might occur between health systems and the factors that influence this process Much of the available comparative research has drawn loosely on notions of path dependence (Burau and Vrangbæk, 2008; Dent, 2003; Kirkpatrick et al., 2009), which, although useful, provide only a general starting point for drawing attention to different national outcomes of health management reforms In this paper we address the question of how similar management ideas and models have been implemented differently across health systems and how one might explain varying outcomes To so we draw on recent advances in institutional theory and in particular the notion of ‘translation’ (Boxenbaum, 2006; Morris and Lancaster, 2006), which shows how actors engage in modifying templates such as universal models of management Specifically we use ideas from Scandinavian institutionalism (Boxenbaum and Pedersen, 2009) and © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA, 02148, USA Translation of Hospital Management Models comparative literature on new public management (NPM) reforms to develop the concept of editing rules for cross-national comparisons Actors involved in translations implicitly follow editing rules, which, we argue, are derived from the institutional context (Sahlin-Andersson, 1996) Applying these ideas, we focus on the translation of a particular model of organization, pioneered in the USA in the 1970s at the Johns Hopkins Hospital (JHH) in Baltimore but which later served as a template for how any hospital, including the public or non-profit sectors, might enhance their performance Specifically, it emphasized the need to strengthen the corporate governance of hospitals and sub-divide them into business units (or ‘clinical directorates’) to maximize efficiency Focusing on this particular template in the context of four health systems – the English National Health Service (NHS), Denmark, France and Italy − we pursue two main objectives First, we explore the translation process of the JHH model and whether this resulted in different interpretations and practices across national systems Second, using the concept of editing rules, we explore how differences in the wider institutional and regulative context might help to explain variations in the translation of the JHH model A key contribution of the paper is to advance understandings of comparative hospital management reforms and also, drawing on concepts from institutional theory, develop our knowledge of how these processes might be theorized and explained Translation as a model for disseminating institutional templates In many ways the notion of translation represents a departure from institutional theory’s early focus on isomorphism and conformity in organizational fields More emphasis is given to the way templates such as lean management or diversity management – often available on a global scale – are legitimated and enacted in local settings A number of scholars have highlighted the modifications which actors introduce to make institutional templates ‘fit’ in a local context Taking into account the localized origin of templates, the ‘travel of ideas’ concept, for example, illustrates how they can be translated into global ideas This implies dis-embedding templates from their local S49 context in order to travel to other institutional settings, where re-embedding efforts are necessary to translate the global idea into practices (Czarniawska and Joerges, 1996) These multiple translations depend on institutional actors like organization members, but also policy makers and professional bodies, who are no longer perceived as passive adopters but as actively modifying ideas as well as being modified by them This idea of translation helps to explain ‘how apparently isomorphic organizational forms become heterogeneous when implemented in practice in different organizational contexts’ (Boxenbaum and Pedersen, 2009, p 191) They are transformed both in verbal accounts and actual practices (Boxenbaum, 2006; Morris and Lancaster, 2006) While there is broad agreement within and between Scandinavian and North American institutionalism that actors modify spreading institutional templates, there is some disagreement concerning the degree of agency in this process As Boxenbaum and Pedersen (2009) suggest, the ‘strategizing’ approach places most emphasis on the strategic intentions of actors in the translation to promote their own interests By contrast, the ‘embeddedness’ approach focuses more on implicit and pragmatic dimensions of actors’ translations, which are unconscious efforts to make sense of and adopt templates in local contexts Following the embeddedness approach, Sahlin-Andersson (1996) stresses the importance of the institutional context for translation outcomes She found that actors not arbitrarily modify or ‘edit’ practices Rather, their translations are governed by non-formalized ‘editing rules’ which influence this process and may even be taken for granted by the actors themselves Thus, the outcomes of translation are not arbitrary constructions but are linked to the way ‘different contexts provide different editing rules’ (Sahlin and Wedlin, 2008, p 226) Implied here is that local history, traditions and institutions form the background for how actors in a given setting engage with new templates More specifically, editing rules which arise from the local context enable and restrict how actors modify templates, how they translate them and make them fit However, it is important to note that editing rules cannot be conceptualized as prescriptive ‘rules to follow’ but rather they are implicit ‘rules which have been followed’ (Sahlin-Andersson, 1996, p 85) © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management S50 I Kirkpatrick et al To illustrate this idea Sahlin-Andersson (1996) talks about editing rules concerning logic which refer to reasons given for the introduction of a template Stories about successful implementation of new practices such as, for instance, corporate codes of ethics in multinationals (Helin and Sandström, 2010) often have a rationalistic plot or logic, which presents the template as solving clearly defined problems in line with models of rational decision making Editing rules might also concern the formulation, labelling or packaging of new organizational templates, providing attention-attracting rationales and moral justifications for change (Sahlin-Andersson, 1996) An example would be rules actors implicitly followed to promote lean management in the UK building industry (Morris and Lancaster, 2006) These practices were dramatized as morally superior to the ‘outmoded’ wasteful forms of management that existed previously and thus lean management was labelled a modern management technique In addition to this Sahlin-Andersson (1996, p 86) refers to editing rules concerning the context and claims that ‘the history of the local setting may restrict the translating’ Here the focus is not just on how new templates are framed and articulated in rhetorical terms, but also on how new practices get implemented that shape the strategies and behaviour of actors as they engage with these changes An embeddedness approach therefore requires a detailed understanding of the national context in which translation occurs However, to date this insight has not been fully developed in the translation literature Most studies have only looked at two institutional contexts: the context of origin of a template (often the USA) and the context of ‘destination’ Boxenbaum (2006), for instance, studied the translation of diversity management from the USA for the Danish context Morris and Lancester (2006) studied originally Japanese lean management ideas being translated for the UK construction industry, while Helin and Sandström (2010) explored the travel of a corporate code of ethics from the US parent to its Swedish subsidiary While providing rich descriptions of the inquired cases on organizational or field level, these studies have tended to understate editing rules stemming from the specific national context and how these shape a varying potential for agency on different levels Given these limitations a fruitful line of enquiry for understanding the role played by national contexts are other branches of institutional theory, such as the varieties of capitalism and business systems literature (Tempel and Walgenbach, 2007), which have tended to place more emphasis on exploring the national institutional conditions that shape the reception of ideas With regard to our own specific focus on hospital management, ideas from the comparative literature on NPM reforms are also helpful (Dent, 2003; Hood, 1995) Pollitt and Boukaert (2011), for example, note that while socioeconomic forces and political pressures lie behind the spread of management reforms globally, crucially important at the national level are the perceptions of elite decision-makers both of what is desirable and what is feasible The latter relates to what is considered possible given available resources, existing structures and likely obstacles such as ‘conservative forces which resist change’ (Pollitt and Boukaert, 2011, p 25) Perceptions of what is desirable are influenced by political ideologies and cultural perceptions of the kinds of reform that are important and valuable From these perceptions emerge editing rules that are more or less prescriptive in guiding how actors adopt global templates in each national context Hence, to understand these particular national idiosyncrasies and their influence on the translation process, we argue that editing rules need to be extended from a merely symbolic and linguistic level of analysis to the level of structural implications and material practices As such our approach is not to focus on editing rules concerning logic and formulation, which refer to the symbolic level of editing stories, but rather to emphasize editing rules concerning the context (Sahlin-Andersson, 1996) Drawing on Pollitt and Boukaert’s cross-national focus, we specify such rules by looking for national differences in the perception (by elite actors) of the desirability and feasibility of a particular model of hospital management Methods To address the question of how global templates of hospital management were translated we focused on the experiences of reform in four European health systems: the English NHS, © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Translation of Hospital Management Models S51 Table Hospital sector characteristics Proportion of health expenditure accounted for by hospital sector (%) Percentage of total acute care beds in publicly owned hospitals (%) UK 40 96 Denmark 45 97.7 Italy France 52 35 81.5 66 Hospital payment system (public) Autonomy of hospitals to recruit medical and other health professionals Autonomy of hospitals to decide the remuneration of other health professionals Per case/DRG (70%) and global budget (30%) Global budget (80%) and per case/DRG (20%) Per case/DRG Per case/DRG Yes Yes Yes Yes No No No No Sources: Healthcare expenditure, 2008; Paris, Devaux and Wei, 2010 Denmark, Italy and France This comparison is both meaningful and theoretically interesting On the one hand all four represent health systems that are heavily state regulated, with central governments being key actors in the top-down initiation of management reforms In this respect, they differ from more decentralized health systems such as Germany where the diffusion of new management ideas has been less centrally directed On the other hand our sample of cases is also illustrative of different contexts that might shape the process and outcomes of reform Hence, while the UK and Denmark are unambiguously national health systems with hospitals largely owned and managed by the state, Italy and France both operate more hybrid funding and provision regimes, with a large proportion of hospital care located in the private sector (see Table for details) These cases also illustrate the variable timing of reforms, with France being a relatively late starter To conduct this analysis we drew on a range of secondary data sources from the healthcare management, policy and sociology literatures A key source was work already conducted by ourselves, both on country-specific developments in health management (Lega, 2008) and comparatively (Dent, 2003; Kirkpatrick et al., 2009) A systematic literature review was also conducted in two stages First, we used published summaries of hospital management reforms to construct a general narrative for each country Second, we carried out a more focused search of the available academic research – mainly published in English − relating directly to changes in hospital management This initially focused on peer reviewed journal articles, manually reviewing titles for relevance to the topic of hospital management Following a snow- ball approach, the review was then extended to include book chapters and reports Lastly, we drew on available comparative research on hospital management (e.g Dorgan et al., 2010) and information published by transnational agencies such as the Organization for Economic Cooperation and Development (OECD) and Eurostat Our analysis of these data involved two main stages First we sought to identify differences in the translation of the JHH model across our four case study health systems As we shall see, variation occurred along two key dimensions: the nature of the authority structure of hospitals and development of non-clinical management functions Second, we analysed the data on the actual process of reform, noting how change was influenced by perceptions of elite actors of desirability and feasibility and inputting from this different editing rules The results of this analysis are presented below, although prior to that it is important to describe briefly the nature and emergence of the JHH model itself Hospital management reforms: a case study of translation The origin of an institutional template As noted earlier, the drive to reform the management of healthcare has been present in many developed economies since the mid-1970s Hospitals in particular became a target for these reforms given the high proportion of resources they absorbed and the apparent difficulty of coordinating different priorities of care, cure and administration (Glouberman and Mintzberg, 2001) In this context an alternative model emerged for how © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management S52 I Kirkpatrick et al hospitals might be run to maximize efficiency, originating from the JHH, a teaching hospital in Baltimore in 1972 (Chantler, 1984; Heyssel, Gainter and Kues, 1984) In its original form this model moves away from the practice of governing hospitals through parallel hierarchies, with doctors represented by a senior medical committee, sometimes with powers to veto management decisions Instead, the focus is on all clinical staff (doctors and nurses) reporting through a single, unitary chain of command to a clinical director who in turn is accountable to the chief executive or general manager of a hospital Closely related to this were changes to the governance arrangements of hospitals, moving away from an exclusively trusteeship logic, with boards focusing on conformance and external accountability to a management logic with a stronger performance orientation (Eecklo, Delesie and Vleugels, 2007) In organizational terms, the JHH model involved a break from the traditional functional structure (with medicine, nursing and other functions organized separately) with the hospital representing a kind of ‘holding company’ of semiautonomous divisions (based around product/ service lines or clusters of activities) (Braithwaite and Westbrook, 2004, p 142) At the middle tier this meant grouping resources, with specialties and doctors aggregated in clinical units, each managed by a team (or triumvirate) headed by a medical chief, supported by a lead nurse and administrator Each group (or, later, directorate) was given responsibility for budgets and made accountable for direct costs, and the operational performance of their units, delivery against targets and human resource management Proponents of this change in hospital organization have highlighted a number of advantages At JHH an explicit goal was to mimic practices in the corporate sector to drive down the costs of inpatient care (Heyssel, Gainter and Kues, 1984) By merging clinical specialities into larger directorates and sharing other costs associated with administration, nursing and ancillary staff, the model offered potential for economies of scale and scope, as well as better integrated services These changes also represented a way of streamlining lines of accountability and strengthening the authority of managers to make decisions Lastly, an added advantage might be to co-opt clinicians (especially doctors) themselves more fully into the ‘world’ of management (Eecklo, Delesie and Vleugels, 2007) This model of hospital management, or at least various translations of it, has subsequently been adopted in health systems around the world According to Braithwaite and Westbrook (2004, p 142): ‘The clinical director (CD) concept dispersed relatively rapidly, in ways that innovation diffusion theorists would find predictable of an attractive idea’, such that ‘every large hospital now has some form of CD structure as a key component of its governance arrangements’ This process began in the USA and Canada (Fitzgerald and Dufour, 1998) but quickly spread to Australia and Europe (Neogy and Kirkpatrick, 2009) This rapid dissemination of the JHH model was aided partly by the existing strength of international professional networks in the health sector In England, for example, the model was championed by Professor (later Sir) Cyril Chantler of the United Medical and Dental Schools of Guy’s and St Thomas’ Hospitals, who had previously been a visiting Professor at Johns Hopkins (Chantler, 2012) Also important was the status of JHH itself, one of the elite university hospitals in the USA, and the publicity which leading clinicians gained by publicizing their experiences in the highly prestigious and widely read New England Journal of Medicine Translation process and outcomes in four health systems Focusing on our exemplar countries it can be seen that versions of the JHH model have been implemented in public hospitals in all four cases The timing of this process varied between countries In the English NHS, a version of the JHH model was introduced following legislation in 1991 (NHS Community Care Act), which also led to the establishment of semi-autonomous foundation trusts with corporate style boards (Harrison and Pollitt, 1994) In Denmark, major changes to hospital governance were first introduced following legislation in 1984, with a second hospital commission promoting the model of clinical directorates based on ‘unambiguous management’ in 1997 (Kragh Jespersen and Wrede, 2009) In Italy regulatory pressures were also important Here a key piece of legislation in 1992 allowed some public hospitals the opportunity to convert to semi-independent enterprises (Aziende Ospe- © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Translation of Hospital Management Models daliere) with a chief executive officer (CEO) and board structure and actively promoted clinical directorates, although these only became mandatory in 1999 (Lega, 2008) In France, although the idea of strengthening management in hospitals had been attempted in 1983, it was not until 2002 that a sustained push in this direction began with the introduction of the ‘Hospital 2007’ plan An ordinance of 2005 established a new governance structure for hospitals, establishing management boards Hospitals were also encouraged to rearrange clinical units into larger ‘activity centres’ (or Poles) with delegated budgets, very similar (on paper at least) to the English model (Dent, 2003; Or and de Pourourville, 2006) Hence, while there have been differences in the timing of reforms, versions of the JHH model have been adopted in the public hospital systems of all four countries As indicated in Table 1, this has also been associated with some move towards variable funding per case (based on DRGs), away from global budgets for hospitals It has also manifested itself in new hospital governance arrangements − formalizing the role of chief executive officers or equivalent − and the establishment of a middle tier of management around departments (or directorates) with devolved responsibilities (see Table 2) However, the available evidence suggests that the degree of convergence should not be exaggerated and the JHH model has been translated by actors operating both at the national (policy) level of each country and locally, within hospital organizations This is most obviously the case if we look at the degree to which reforms in each country have been formally implemented In Italy, for example, Lega (2008, p 255) reports that, even in 2004, only 66% of hospitals had fully adopted clinical directorates Perhaps unsurprisingly, studies also point to wide variations in the size of clinical directorates (measured by staff, beds or turnover) and in the level of authority clinical managers might exercise over budgets (Bellanger, 2007; Cantù and Lega, 2002; Kragh Jespersen and Wrede, 2009) Clinical directorates are even configured in different ways according to their size or differing logics with respect to the size of hospitals (Braithwaite and Westbrook, 2004) In addition to this are variations in translation outcomes between countries, most obviously with regard to nomenclature In the English NHS a corporate language of CDs, boards and CEOs has S53 been adopted quite explicitly By contrast, in other countries the terms used to describe new roles suggest much greater continuity with professional norms and pre-existing models of hospital organization Hence, ‘clinical directors’ are formally heads of centres in Denmark, of activity centres (or Chefs de Pole) in France and, in Italy, chairs of departments (Cantù and Lega, 2002) Table outlines further differences in translation looking at four key areas: strategic (governance), middle management, the nature of authority structures and development of nonclinical management roles Concerning the former in England, the decision was made to establish a unitary governance arrangement both at board and clinical directorate levels (Harrison and Pollitt, 1994; Shortland and Gatrell, 2005) A similar situation applied to Denmark, especially after 1997 (Kirkpatrick et al., 2009) By contrast, in France and Italy, notwithstanding the rhetoric of reform, the management authority of CEOs (or equivalent) is far less clear-cut In both cases the translation of the JHH model has resulted in tripartite decision-making structures involving both external and internal (notably medical) stakeholders In France, for example, while supervisory and medical committees are formally consultative, they have powers to nominate Chefs de Pole and in many cases are locked in to relationships of ‘collective bargaining’ with the director (Laouer, 2011; Vinot, 2012) As Bellanger (2007) notes, while ‘both General Director and Hospital Directors manage physicians’, this is primarily ‘by influence’ such that ‘the decisional process is generally based on consensus’ Similar differences are apparent when one turns to the changes at middle management (clinical directorate) level While in England and Denmark the focus has been on developing clinical directorates based on a single line of management accountability, this has been less obvious in France and Italy In the latter, the decision was made to establish executive committees within each department (or directorate) made up of the chiefs of clinical units with powers to nominate the chair and veto key decisions (Tousijn and Giorgino, 2009) These differences in the way hospitals have reorganized management also have implications for the nature of authority While in England establishing a unitary chain of command in hospitals was a central plank of the reforms © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Clinical directorate structures are well established in NHS trusts (by law), with ‘clinical directors’ and departments having their own management teams and autonomy over budgets Unitary (unambiguous) authority structure at hospital and CD levels This is highly developed in the NHS since the Griffiths report (1983) General managers (often with private sector expertise) make up the majority All trusts employ specialist managers in core functions (finance, human resources, procurement) and at CD level Management authority structure Development of non-clinical management Trusts have a unitary board structure, headed by a CEO with executive and non-executive members, although some changes are under way with the establishment of foundation trusts Middle tier Hospital governance England Table Hospital governance and organization Following the second hospital commission in 1997 public hospitals implemented ‘unambiguous management’ with a unitary authority structure at hospital and CD levels Non-clinical management specialists are employed, mainly in functional departments serving the whole hospital Some of the larger teaching hospitals also employ managers at centre level, although not in large numbers Public hospitals are structured into centres (Centerledelsen) and wards/clinics (afdelinger) with separate management teams (consisting mainly of doctors and nurses) with degrees of autonomy over budgets The governance of public hospitals (Hospitalsledelsen) consists of a ‘troika’ made up of a CEO and Medical and Nurse Directors Denmark Ambiguous authority structures at both hospital and CD levels with parallel hierarchies and internal checks and balances on the executive power of managers Italian hospitals, notably AOs, employ specialist managers in functional support roles Jacobs (2005, p 157) notes the ‘absence of a manager/ accountant at the unit level’, although this may have changed recently in some of the larger teaching hospitals Italian public hospitals are typically run by a team consisting of a General Manager (Direttore Generale), Clinical Director (Direttore Sanitario) and Administrative Director (Direttore Amministrativo) This team is supported by two committees with supervisory functions: an (elected) Health Council (Consiglio dei Sanitari) and Management Board (Collegio di Direzioni) Aziende Ospedaliere (AO) hospitals are typically structured into ‘Departments’ headed by a Chair of Department (always a doctor) with nominal control over budgets However, Departments also have executive committees, which represent the interests of chiefs of medical units/clinics Italy After 2007 French hospitals are typically organized into clinical and non-clinical activity Poles run by a triumvirate of Director, administrative manager and nurse manager All Poles also have a ‘Pole Council’ with strong representation from medical heads of clinics (Chefs de Service) In theory activity Poles operate as semi-independent businesses contracted by the hospital Despite efforts to streamline management, authority at hospital and CD (activity pole) level remains fragmented, characterized by internal checks and balances French public hospitals employ managers both centrally and, increasingly, within activity centres However, a large proportion of ‘managers’ are also civil servants (with legal or political science backgrounds) The governance of French University Hospitals is characterized by a tripartite structure comprising an executive council (including the General Director and President of the Medical Council), an administrative (or supervisory) council representing external stakeholders and a medical council (or commission) representing doctors France S54 I Kirkpatrick et al © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Translation of Hospital Management Models (Harrison and Pollitt, 1994), this has been less true for both Italy and France According to Lega (2008, p 260) in Italian public hospitals many chairs of departments still lack formal authority over chiefs of clinical units and consequently behave more like ‘project managers, responsible for special projects ’ Indeed, it is suggested that ‘change following the introduction of CDs was more formal than real’ (2008, p 255) Similarly, in France, while Chefs de Pole have ‘hierarchical authority over medical, nurse, administrative teams’ they have ‘no decision concerning the nomination of doctors or the quality of their clinical activity’ (Vinot, 2012, p 6) Lastly, one can note differences in development of non-clinical management roles in areas such as finance, procurement and human resource management within hospitals In the USA, both private and non-profit hospitals tend to invest heavily in these areas, with non-clinical ‘administration’ making up a significant part of the health labour force: 27% according to one estimate (Woolhandler, Campbell and Himmelstein, 2003) In our own cases the picture is quite different with ‘administration’ accounting for a much lower proportion of the workforce and expenditure However, as can be seen from Table 2, this does not rule out some quite marked differences between countries At one extreme, in England, specialist managers are employed in large numbers within clinical directorates (Jacobs, 2005; King’s Fund, 2011) and make up a majority of board members (over 70% according to one calculation (Veronesi, Kirkpatrick and Vallascas, 2012)) At the other are Italy and Denmark where hospital governance is dominated by clinicians with very few specialists employed at lower levels (Barbetta, Turati and Zago, 2007; Jacobs, 2005; Kirkpatrick et al., 2009; Lega, 2008) These conclusions are supported by other comparative research Dorgan et al (2010) for example note that non-clinically qualified managers/administrators make up approximately 42% of all managers in the hospital system of the UK, 36% in France and only 10% in Italy This study also assigns a composite ‘management practice score’ (rating capabilities in the management of operations, performance and talent) on a fivepoint scale, with the UK scoring 2.82, coming ahead of both Italy (2.48) and France (2.4) (US hospitals in the sample scored 3.0) In this research no figures are provided for Denmark, S55 Figure Translation outcomes although Eurostat data suggest that the Danish health system operates with administrative overheads of only 1.2% of total expenditure, which is low by international standards Hence, while ideas originating from the JHH model have clearly influenced health policy in the four countries, leading to a broadly convergent move to restructure hospitals along corporate lines, there are also differences in the outcomes of this translation This process in turn, we suggest, has resulted in pathways of change that vary along two key dimensions, as depicted in Figure 1: (a) the extent to which management authority within hospitals has been streamlined (or left ambiguous); and (b) the extent to which management work itself is performed either by clinicians or non-clinical specialists Viewed in this way it can be argued that the English NHS comes closest to the original corporate model of the JHH, while in both France and Italy significant compromises have been made which essentially preserve key elements of professional bureaucracy and consensus administration within hospitals By contrast Denmark represents a hybrid case in which management authority structures have been streamlined but without large investments in non-clinical managers Accounting for comparative differences in the context of translation for the clinical directorate model In this section we turn to our second question of how one might account for variable translation outcomes When discussing this topic it is first © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management S56 I Kirkpatrick et al important to note how different actors were involved in the translation process In some cases change followed initiatives that were taken locally by managers and clinical professionals who had been influenced by the model In England, for example, Guy’s Teaching Hospital in London first experimented with clinical directorates in 1984, with other hospitals also copying this model before legislation was introduced (Harrison and Pollitt, 1994) However, a more important driver for change has been top-down regulatory demands from governments responsible for the bulk of hospital funding Indeed, one can identify almost coercive institutional pressures linked to a broader agenda of reforming the management of public services more generally (Pollitt and Boukaert, 2011) A key question, though, is how these reform agendas and their interpretations were shaped in ways that led to the different translation outcomes described in Table and Figure To address this question we return to the notion of editing rules described earlier and to the work of Pollitt and Boukaert (2011) on the importance of elite actors (dominant coalitions of decisionmakers) in each country mediating economic, political and ideational pressures for reform Specifically we argue that the nature of rules in a given context – how much leeway they leave for local interpretations and deviations from the template − will depend upon elite perceptions of the desirability and feasibility of reforms With regard to desirability, it is often noted that the level of commitment of policy makers in different countries to the restructuring of public services has been highly variable Hood (1995), for example, differentiates between ‘high’ and ‘low’ NPM groups of countries depending on how forcefully they have sought reforms Others note differences in the objectives of reform and how far these have been influenced by neo-liberal ideas emphasizing the risks of public monopoly and the need to weaken professional ‘provider power’ (Greener, 2002) Concerning editing rules relating to feasibility, perceptions of elite actors of the likely obstacles to radically changing the existing health management system by introducing ‘foreign’ templates are important In some contexts these may be considerable depending on a number of factors, such as the ‘countervailing power’ (Light, 1995) of clinical professionals, the nature of administrative cultures and the wider political governance of public services (including health) Where professionals are concerned Light (1995) compares systems along a continuum of professional or state dominance In the former, the medical profession ‘controls not only its own work but also a range of related institutions, services, privileges and finances’ (Light, 1995, p 30) arguably making it harder for governments to impose radical change without consent Thus, in contexts with professional dominance professional actors will engage in a significant editing and modifying of government-introduced templates Closely related to this are the ‘administrative cultures’ of public services, which have particular consequences for the status of clinical professionals, either as salaried employees (or contractors) of the state or (under what Pollitt and Boukaert (2011) term the Rechtstaat model) tenured civil servants The wider governance of health systems may also have consequences for the feasibility of reforms, especially when, as is the case of many federal states, hospitals are technically owned and managed by regions that possibly have differing political agendas (Reay and Hinings, 2009) These considerations, we argue, have direct implications for editing rules that apply in different contexts and which shape not only the content of reforms (e.g whether all aspects of the JHH model are adopted or more loosely translated) but also their timing and pace Indeed, one might even place national health systems along a continuum ranging from those in which radical reforms are considered to be both desirable and feasible and those at the opposite extreme In the former, editing rules will be far more prescriptive in specifying new management models for hospitals, offering actors at the policy and local level far less room for interpretation and translation By contrast, in the latter, perceptions of limited desirability and feasibility will result in editing rules that emphasize elements of the national context and thus require translations that considerably deviate from global templates As a result, policy makers have been more selective in how they adopt models of hospital management, and reforms show more continuity with established practices and structures Turning to our own cases, it is possible to argue that the English NHS sits at the high desirability/ feasibility end of this continuum, with editing rules that are generally more prescriptive and thus © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Translation of Hospital Management Models result in translations that not deviate considerably from global templates Since the early 1980s there has been a strong push by governments, both Conservative and New Labour, to adopt the practices of private firms, with clinical professionals often viewed as ‘part of the problem rather than the solution’ (Greener, 2002) Linked to this has been a drive to recruitment of nonclinical specialists with commercial expertise (Veronesi and Keasey, 2012) The command and control structure of the NHS (with professionals directly employed) has also made it easier for governments to legislate and enforce these changes, most recently through the use of targets and performance management techniques (King’s Fund, 2011) As a consequence, in the English case, editing rules have been highly supportive of a more literal translation of the JHH model than elsewhere This situation is in stark contrast with the French and Italian cases Here, although politicians have paid lip service to the NPM, the goals of policy have often been ambiguous This is notably true in France, which according to Bellanger and Mossé (2005, p 119) has adopted ‘one of the least market-oriented models for reforming its health care system’ Despite the fact that a stated rationale for reform was to drive up efficiency, ‘Ironically the word “competition” was hardly ever mentioned’ (Or and de Pourourville, 2006, p 22) Similarly, in Italy, although attempts to implement NPM reforms including quasi markets are more long-standing, here too there has been considerable ambiguity about objectives Competition was immediately discouraged through the arrangement of funding caps for individual hospitals Under the close scrutiny of local politicians CEOs were required to focus on improving weak areas of their hospitals, rather than incentivizing their competitive advantages (Tousijn and Giorgino, 2009) Indeed, at one point in 2003 the Minister of Health, himself a doctor coming from the largest teaching hospital in Milan, explicitly linked quality problems in the Italian NHS to the introduction of too many managers (Anonymous, 2003) This mixed commitment to reform in the French and Italian cases has been further exaggerated by the existence of certain barriers to radical change In both countries, medical professionals have considerable ‘countervailing powers’ and make up a higher proportion of the clinical S57 workforce than in either England or Denmark (OECD, 2008) In Italy doctors have also laid a claim to the general administration of hospitals, with a sub-specialization in ‘Hospital hygiene and organization’ dating back to 1938 Over the years, this category of physicians (referred to as ‘hygienists’) emerged as an independent medical specialization, taking care of hospital hygiene, hospital organization, medical archives and epidemiological analysis (Cantù and Lega, 2002) A related point is that in both France and Italy doctors are effectively state functionaries (or civil servants), their contracts held centrally, with no direct employment relationship with hospitals (see Table 1) Lastly, while the French public health system is relatively centralized (theoretically allowing for the top-down imposition of new management models), this is not the case in Italy where regional governments also play a significant role in negotiating policy Indeed, as Mattei (2007) suggests, it was largely to avoid a head-on clash with these regional governments (worried about the loss of control over hospitals) that key aspects of the JHH model, strengthening the executive authority of hospital directors, were deliberately watered down in the 1990s From these conditions we impute editing rules in France and Italy that have been less prescriptive and placed more emphasis on crafting reforms in ways that ensure conformity with the local institutional context and thus play down key aspects of the original corporate model Indeed, one might argue that the JHH template was adopted as a ‘label’, which was loosely combined with existing practices Influenced by the editing rules in these two health systems, actors de-emphasized the initial idea of market orientation and management authority in favour of traditionally legitimate forms of (professional) organization of hospitals Finally, using this framework it is possible to argue that the Danish case lies somewhere between these two extremes Since the mid-1980s governments have supported the objectives of NPM reforms, increasingly so after 1997 (Kirkpatrick, Kragh Jespersen and Dent, 2011) A command and control healthcare system, broadly similar to the English NHS, also makes it less problematic to implement changes However, in Denmark, long-standing political traditions that emphasize decentralization and partnership with key stakeholders (notably the clinical professions) © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management S58 I Kirkpatrick et al have generated a different set of rules and associated choices (Ham and Dickinson, 2008; Kragh Jespersen and Wrede, 2009) Concluding discussion The main contribution of this paper is to build on and strengthen existing accounts of management reform across different national health systems (Dent, 2006; Jacobs, 2005; Neogy and Kirkpatrick, 2009) Around the world it is noted that governments are promoting very similar models of management and organization However, at the same time, the available research points to variations in how these models are implemented in situ Focusing on one highly influential model of hospital organization (the JHH), which emerged in the USA in the 1970s, we suggest that this convergence and divergence in practice can be usefully explained using the lens of institutional theory and in particular the notion of translation This approach draws attention to ways in which aspects of a management template become dis-embedded from their original context and re-embedded in the context of adoption In our own cases this resulted in quite different translation outcomes, ranging from a more literal, corporate version of the model in the English NHS to essentially more professionally mediated approaches in France and Italy A further strength of this approach is to further develop the notion of editing rules While this idea has been used extensively to understand the way templates have been re-embedded on a symbolic and linguistic level, for instance in success stories (Sahlin-Andersson, 1996), less attention has been paid to the rules that refer to the local context and its regulatory and political structures and thus shape ‘material’ translations of templates Nor have many studies explored this dimension in a comparative perspective, looking at how national institutions may influence translation outcomes In this regard the framework presented here breaks new ground Drawing on ideas from comparative public management (Pollitt and Boukaert, 2011), we argue that elite actors’ perceptions of reform (in terms of desirability and feasibility) may be important in defining the nature of editing rules in a given country Specifically we show that, where elite actors have been both supportive of reform and less concerned about the obstacles to changing the existing hospital management models, editing rules are far more prescriptive allowing less scope to veer away from a literal adoption of the JHH template As such this paper contributes not only to debates about comparative health reform, offering new frameworks for comparison, but also to translation theory itself, showing how the concept of editing rules may be further extended and applied Of course, when drawing these conclusions it is necessary to bear in mind a number of caveats and identify areas for further work Clearly, the mapping exercise of translation processes and institutional factors influencing translations that we have conducted represents only a first step with empirical research needed to fully develop the approach described here Several themes also need to be explored in more detail, in particular the longer-term development and evolution of hospital management regimes This longitudinal perspective is especially important given the variable timing of health management reforms in each country, with France being a late starter in our own sample More work would also be useful to explore national differences in the way management roles are enacted by, for example, clinical professionals The available evidence suggests that these responses might vary along national lines (Kurunmäki, 2004), but clearly more research is needed Looking at differences in engagement with new management practices (such as the JHH model) also raises the question of how far these have become fully institutionalized Even in the English case there is evidence to suggest that, while the formal governance structures of trust hospitals might have changed, professional cultures remain deeply embedded and in many ways still shape the practice of management (Kirkpatrick et al., 2009) Lastly there is clearly scope to extend this framework to understand the implementation of other kinds of management templates that have been disseminated globally, e.g new organizational models for primary care or funding regimes such as DRGs Notwithstanding these caveats and limitations, this paper makes an important contribution to our understanding of comparative health management reforms, illustrating for the first time the usefulness of notions of translation for researching and explaining these changes As suggested earlier, we also contribute to translation theory extending the notion of editing rules from its pre- © 2013 The Author(s) British Journal of Management © 2013 British Academy of Management Translation of Hospital Management Models vailing focus on symbolic and linguistic 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Promotion of Health, 127, pp 78−86 Fitzgerald, L and Y Dufour (1998) ‘Clinical management as boundary management: A comparative analysis of Canadian and UK health- care institutions’, Journal of Management. .. hospitals In the USA, both private and non-profit hospitals tend to invest heavily in these areas, with non-clinical ‘administration’ making up a significant part of the health labour force: 27% according... Giorgino, 2009) These differences in the way hospitals have reorganized management also have implications for the nature of authority While in England establishing a unitary chain of command in hospitals