Table 3.

Hospital governance and organization in 7 OECD countries

Country	Hospital governance	Middle tier	Management authority	Development of non-clinical management
Czech Republic [27]	Hospital governance varies depending on the type of hospital. State hospitals usually have simple organisational structures headed by a director controlled by a given state department. Municipal hospitals are governed by boards of directors consisting of between six and ten employees (mainly medical doctors). Privately owned hospitals have top-down traditional pyramid ownership structures, where a board of directors consists of company managers and a supervisory board represents owners and operate under standard profit oriented business principles.	At department level, chiefs of ward/clinic are the important medical management roles.	Interests of board members are usually quite distinct from each other and therefore corporate performance is not always regarded as the most important objective. Accordingly, disputes among the different in-groups result in higher autonomy of management at the expense of owners.	Approximately half of the hospitals have now a senior manager with a non- medical qualification.
France [28]	The governance of hospitals is characterised by a tripartite structure comprising 1) an executive council (including the General Director and President of the Medical Council); 2) an administrative (or supervisory) council representing external stakeholders, and 3) a medical council (or commission) representing medical doctors.	After 2007 hospitals are organised into clinical and non-clinical activity poles run by a triumvirate of director, administrative manager and nurse manager. All poles also have a council with strong representation from medical heads of clinics. In theory activity poles operate as semi-independent businesses contracted by the hospital.	Despite efforts to streamline management, authority at hospital and activity pole level remains fragmented, characterised by internal checks and balances.	Public hospitals employ non-clinical managers both centrally and, increasingly, within at activity pole centres. A large proportion of these ‘managers’ are also civil servants (with legal or political science backgrounds) with statutory roles.
Germany [29]	Hospitals have an executive committee and sometimes an advisory committee composed of senior medical doctors. Traditionally the executive committee is composed of a ‘troika’ consisting of as a medical director, the top representative of nurses, and the head of the hospital’s administration.	At the level of departments doctors may design clinical management filling in a regulatory gap that results from the absence of a comprehensive troika structure. New modes of performance management are established, but accountability structures are not adequately adapted. This creates space for strategic action of medical doctors as the most powerful group in hospital governance.	Hospital authority remains varied, with a lot of discretion given to owners and boards. Today’s hospitals may either organize their medical departments as self-dependent hospitals “sub-enterprises,” with a head doctor (clinical director) holding a more encompassing budget responsibility, or maintain head physicians as mere medical experts and directors of a more centrally controlled medical department.	In the hospitals CEO positions above the troika are established and often fulfilled by a non-clinical manager.
Poland [30]	Most hospitals are public owned by local governments and universities. Around 30 per cent of them have been transformed into “non-public” entities, operating under the same legal framework as commercial companies. Hospitals have an executive board composed of a CEO and a medical director.	At department level, chiefs of ward/clinic are the important medical management roles. The post is held by a senior doctor, reporting to a medical director, who is responsible for all ward operations. Some, but not all, chiefs also have responsibility for the financial standing of the unit.	At departmental level the structure lacks coherence. Centralised managerial controls increasingly intervene in medical budgets, thus reducing medical power, while organisational controls are weaker and flexibility of doctors higher in the area of quality and safety management.	The CEO role is increasingly held by non-medical professionals.
Portugal [31, 32]	Troika structure at top level with some flexibility. Managers are in the lead of the board of directors. The administration board consists of medical doctors and nurses.	The Board appoints a director for each medical area (service or department) from among the most qualified doctors in the professional career.	In a situation of poorly established accountability structures, the ability of doctors to use management strategically is increasing on the level of departments and in the area of quality management.	Non-medical managers, who are now in control of the hospital board of directors, are expected to play a crucial role in hospital governance.
Spain	Troika structure relevant at all levels; but double structure of general & ‘doctors only’ boards assures flexibility & medical power.	Medicine is expanding into management and this is driven by both departmentalisation and the establishment of clinical management with doctors utilising control bottom-up.	Top-down with some bottom-up controls; troika structure expanding, but quality mainly managed by medical doctors; weak coordination & flexibility.	There are non-medical managers in the system.
Turkey [33, 34]	The management of public hospitals is under government control.	At the departmental level medical doctors have to work as managers in a strong top down hierarchy.	Strong hierarchy with integration of medical power.	There are few qualified health managers who took part in a management course.
	The chief medical doctor is the manager of the hospital and is assisted by hospital managers responsible for administrative, financial and technical issues and by chief nurses responsible for nursing services. Under the ‘pilot hospital autonomy law’ (2007) the traditional centralised governance structure is replaced by a ‘public-enterprise’ model whereby hospitals joining the pilot project would be managed by boards, while remaining affiliated to the Ministry of Health.