12 No. CCG board public meetings were held monthly on a weekday morning in a CCG meeting room. Importance of Understanding Organizational Structure of Hospital A. facilitates the understanding of the hospital’s chain of command B. shows which individual or department is accountable for each area of the hospital II. Deliv. Dahl, 1961)” (2017, p. 153). Stakeholders, policy makers, researchers, and members of the public ask in what ways and at what level PPI makes a difference. However, during observations of PPI CRG meetings, the group did not receive any feedback from the CCG about the work the group had been involved in. The hierarchy also demonstrates how positions occupied reflect both the individual and collective dimensions of Tritter's model at the same time. Whilst our study showed no evidence of professionals questioning the legitimacy of lay members, the more marginal role of lay members in the work of the CCG suggests an unequal balance of potential to influence and ultimately of power between professionals and lay members. CRG PPI meetings tended to discuss and respond to CCG requests to build greater PPI more broadly across the borough. The stratification system constitutes a hierarchy of power. BMJ. This generated attendance from different public and staff members depending on the agenda items under discussion. However, one example of a classical sociological concept of power comes from Weber's definition, presented by Rutar (2017): “For him (Weber, 1978 [1922], p. 53) power is, as is well known, “the probability that one actor within a social relationship will be in a position to carry out his own will despite resistance, regardless of the basis on which this probability rests.” This can be, and usually is, further condensed. If the CCG has power over PPI, it is reasonable to assume this will affect the nature and extent of PPI input. This hierarchy is a list of systematic arrangement of all the healthcare management professionals that work all together to handle the administrative department of any healthcare firm. Patient reluctance to speak up during care encounters also carries with it dangers to patient safety. 2, 151–175. The editor and reviewers' affiliations are the latest provided on their Loop research profiles and may not reflect their situation at the time of review. In the lower echelons of the hierarchy was involvement from public members who attended CCG board public meetings but whose participation had less potential to influence the CCG's work. The CCG PPI study revealed that a key dimension of PPI related to a system of stratification within which individuals occupied positions that reflected their capacity to influence the work of the CCG. doi: 10.2307/2673250, Martin, G. (2008a). J. A main aim of our study was to explore PPI in CCG decision-making. doi: 10.1016/j.socscimed.2010.01.036, Gibson, A., Britten, N., and Lynch, J. Kerckhoff (2001) makes a useful distinction between stratification as a condition and as a process: Social stratification as a condition refers to the fact that members of a population have characteristics that differentiate them into levels or strata. rocedures. However, completely addressing power imbalances will also require a concerted effort on the part of patients and providers. Social power is simply the ability of agent A to influence agent B in such a way (with the help of either personal or impersonal means) that agent B does something he/she otherwise would not have done, or does not do something he/she otherwise would have done (cf. Yet as CCG employees with access to senior professionals, and who to a large extent lead and make decisions about the PPI CRG, they also occupy a higher status than their lay member colleagues of the same group. Eventually the arrangements for public involvement changed again. One of the reasons relates to the way public involvement in meetings was managed. To make sense of bossiness, we need to tease apart two fundamental aspects of social hierarchy that are often lumped together: power and status. Green a R.S. The board was interested to know how PPI in the CCG was developing compared with other CCGs and shared the view that PPI in the area was “far ahead in all respects in patient and public involvement.” Lay members expressed a need for meaningful feedback from the CCG: We don't get much sense when we've done these reports, of has it made any difference […] We keep on trying [to make a difference] without taking stock of whether anybody's hearing what we're saying […] but it would've been quite nice to have got something back from those around us about whether or not they've found anything we've ever done of any use to them. doi: 10.1332/174426407779702201. Health Care 24, 28–38. All general practices in England are legally obliged to be a member of a CCG (Naylor et al., 2013; p. ix). Lay members wanted to influence commissioning decisions and for the public more broadly to do the same. 5 Minute Read Introduction The "hierarchy of evidence" is an important topic in evidence-based medicine and biomedical research. “Power/knowledge: selected interviews and other writings, 1972-1977,” ed C. Gordon (New York, NY: Pantheon), 122. doi: 10.1093/intqhc/mzr066. 2006 August; 15(4): 229–230. Within the PPI CRG itself a sub-stratification system or hierarchy existed, starting at the upper end occupied by the lay chair and staff members. Medical professionals see hierarchy between different types of clinicians such as doctors, nurses, or other clinical workers. The role of subjectivity and knowledge power struggles in the formation of public policy. Rev. This review discusses the necessity of managing hierarchy in high-risk environments and reviews tactics to improve nontechnical skills to help clinicians address authority gradients during care activities. Millennium 33, 495–521. “Maintaining a good relationship with those higher up the ladder understandably becomes a prime focus, often at the expense of other priorities such as reporting on errors or on poor patient care,” the report authors wrote. Soc. It is the foundation upon which all further power allocations are made. Potrata, B. |, Institute of Medicine (US) Committee on Quality of Health Care in America, 2001, https://www.england.nhs.uk/publication/patient-and-public-participation-policy/, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216865/Summary-Report-Issues-relating-to-local-Healthwatch-regulations.pdf, https://www.kingsfund.org.uk/publications, Creative Commons Attribution License (CC BY), Centre for Health and Social Care Research, Kingston University & St. George's University, London, United Kingdom. Established structures, such as macro structures like health organizations, have the potential to promote actions and behaviors among individuals which in turn promotes them to form and continue relationships or affiliations with the dominant structure. Saf. It is important at this point to note, though, that our study focused on two particular areas in which there was PPI and not all CCG PPI activities; exploration of other PPI activities may have generated different findings. Regulations stipulate that all NHS organizations must have PPI in the planning, development, and operational aspects of healthcare services (Barnes and Schattan Coelho, 2009). The status of professionals gives them power as professionals in the realm of healthcare services and provisions. Kerckhoff, A. C. (2001). Primary care-led commissioning and public involvement in the English National Health Service. Providers should remember that they bring the medical expertise to the table during shared decision-making; it is only the patient or family caregiver who can share information about quality of life preferences and overall care goals. Ethnographic research “seeks to understand people's opinions, beliefs, motivations, interactions, and the structures in which they are involved or are influenced by, and above all, the social contexts in which people live and interact […]. The King's Fund and Nuffield Trust. The traditional relationship between patient and provider has been viewed as paternalistic, with the provider directing the patient on a treatment path that should mitigate a health concern. Educ. The study used a qualitative approach drawing on ethnographic methods. 2:44. doi: 10.3310/hsdr02440, Petsoulas, C., Peckham, S., Smiddy, J., and Wilson, P. (2014). Nurs. Defined hierarchy. CCG board public meetings were viewed as a means to public members hearing about changes to services the CCG was planning, but that decisions around those changes had likely already been taken. 2017 Jun;55(5):449-453. doi: 10.1016/j.bjoms.2017.02.010. The analysis reveals that hierarchy is much more widespread than thought; in particular, postmodern, representative democratic and network organizations are much less ‘alternative’ and ‘hierarchy-free’ than their labels and common understanding may suggest. The board was made up of 15 voting members and six non-voting members. Lay members of the PPI CRG had undergone a formal recruitment process to become members of the group. It could also, importantly, facilitate clarity on all individuals' expectations of the type and level of PPI. Ther. The original idea for this study emerged from a discussion between a lay member of the CCG board (who was our gatekeeper to the meetings observed) and the investigators. As a single case study, generalizations about the commissioning arrangements of other CCGs on a national and international level are limited. Sociol., 08 May 2019 Handwritten notes of interactions were added to the relevant observation notes on the data collection tool. The patient/public with historically less power such as women, minority groups, and the poor would have been more vulnerable playing “second fiddle” to medical authority and lacked the resources to question medical decisions or challenge prescribed care (Foucault, 2003). Two researchers independently carried out analysis of half the data. The most important institutional protection mechanisms of hierarchy in organizations are power and the related potential for negative and positive sanctions. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. Hierarchy is defined as the categorization of collection of individuals in accordance with their financial, societal and professional position in the society. doi: 10.1108/14777260710778970, PubMed Abstract | CrossRef Full Text | Google Scholar, Barnes, M., and Schattan Coelho, V. (2009). 4:38. doi: 10.3389/fsoc.2019.00038. Few beliefs are more widely held in business. Many of our research participants were lay and public members. Int. These layers form part of a hierarchy in which professionals occupy the most powerful positions. Interview schedules for public and lay members addressed the following areas: how and why they became involved in the CCG and associated expectations; the PPI role; representation as a lay/public member; CCG support for and commitment to PPI; impact/influence of PPI. The aim of this paper is to explore the differences between individuals in their potential to influence the work of the CCG and to consider these differences in terms of the positions they occupy in a hierarchical structure. However, it was emphasized by two staff members that after “essential” healthcare services costs were factored in by commissioners there was very little finance remaining “to play around with.” It was also pointed out that allocating limited resources was a significant responsibility which involved a great deal of skill and particular experience. Since April 2013, following a shift in commissioning powers from the former Primary Care Trusts, CCGs have held responsibility for commissioning secondary and community care services for their local populations. Evidence-based medicine strives to make health-related decisions based on the best available evidence. 1, Manuscript 1. A neutral meaning of power cannot be found, since the meaning of power is always embedded in a theoretical context (Guzzini, 2005). Features of the dominant structure are apparent such as centralized decision-making which appeared to be taking place behind doors that were closed to the public. OJIN: The Online Journal of Issues in Nursing. Under such an analysis of power and hierarchy, the medical profession maintained the upper hand by having greater knowledge, expertise, prestige, organizational support, and stability. Soc. The experience and voice of the patient has increasingly become integrated as a core dimension of health care consultation and planning. J. Occup. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Statutory guidance, however, is open to interpretation (Martin, 2008a) which often results in contrasting approaches to PPI and outcomes. The CCG board controlled all the meeting and PPI arrangements and agenda items for discussion. The post-structuralism movement acknowledges the importance of structures. With healthcare priorities trending toward overall patient wellness, medical experts have asserted that a more balanced partnership between patients and providers to be key. Power, intersectionality and the life-course: identifying the political and economic structures of welfare states that support or threaten health. Gibson et al. One public member commented: The public involvement is confined to 10 min at the end of the meeting […] I think 10 min for people to ask questions is certainly nowhere near long enough. One interviewee reported that the only feedback the PPI CRG had received related to the group's written report on developing PPI. 30, 35–54. This process was carried out inductively, identifying key issues, concepts and themes emerging from data, and deductively in line with interview and focus group schedules. According to a 2006 paper on the subject, power hierarchies in healthcare are a “Berlin Wall to patient safety.” Hierarchies between younger physicians and older leadership, or physicians and … Clinical commissioning groups are clinically-led statutory NHS bodies. Traditionally, a hierarchy of controls has been used as a means of determining how to implement feasible and effective control solutions.One representation of this hierarchy is as follows:The idea behind this hierarchy is that the control methods at the top of graphic are potentially more effective and protective than those at the bottom. Another possible reason was that their input may have been viewed as less legitimate—there were no formal recruitment processes to participation. This paper draws on data from a qualitative study of PPI in a clinical commissioning group (CCG) in the UK. Crossing the Quality Chasm: A New Health System for the 21st Century. Naylor, C., Curry, N., Holder, H., Ross, S., Marshall, L., and Tait, E. (2013). Researchers considered it necessary to carry out this number of observations because meetings covered a range of topics which often varied from month to month. Evaluating the impact of patient and public involvement initiatives on UK health services: a systematic review. July 23, 2018 - The ideal patient-provider relationship will always include a mutual respect between both parties that then leads to a healthcare partnership. (2007). About half of respondents said they did not want to be perceived as a “troublemaker,” or that the team appeared too busy to hear a concern. It is not the intention here to provide an in-depth discussion of the different perspectives of the meaning of power. : A Scoping Review of Healthcare Professionals' Speaking-up Skills Training. Health Care L. 217 (2010) The authors conclude that a hierarchy of power exists, with some professionals and public and lay members afforded more scope for influencing healthcare service development than others—an approach which is reflected in the ways and extent to which different forms and holders of knowledge are viewed, managed, and utilized. During the 1960s structural functionalism was a dominant theoretical perspective which attracted critics (e.g., symbolic interactionist Herbert Blumer) for its emphasis on maintaining social orderliness within social and cultural structures, sustaining pre-existing social inequalities and the power of established elite groups. Researchers observed two dimensions to the work of the PPI CRG: (i) facilitating development of greater PPI across the borough (e.g., by ensuring on-going communication with and support for other CRGs relating to building PPI) and (ii) supporting the CCG in gaining public feedback about healthcare service development plans (e.g., via public consultations and rolling out public surveys). The idea is that patient and public involvement will improve quality and implementation of healthcare services, address population expectations and needs and foster healthcare choices and shared decision-making (Boivin et al., 2010). Text: Leadership and Hierarchy in Hospitals When looking at the background of professionals on hospital boards, 31% will have held their position for over ten years, while 45% will have held their position for four years or less, with 10% holding onto their position for less than a year. Power imbalances ultimately relate not only to the professional status of individuals and the level and type of resources they possess, but also to perceptions of the legitimacy and relevance of those resources to the CCG's work, and to the access of other individuals to the more powerful professionals. [Ethnographic research] observes what people do in their everyday practices, and tries to understand the motivations and explanations for people's actions.” (Potrata, 2005, p. 131). Theoretical directions for an emancipatory concept of patient and public involvement. 21, 268–280. doi: 10.5613/rzs.47.2.2, Keywords: patient and public involvement, healthcare, power, hierarchy, influence, lay members, public members, professionals, Citation: O'Shea A, Boaz AL and Chambers M (2019) A Hierarchy of Power: The Place of Patient and Public Involvement in Healthcare Service Development. This will include integrating the patient and family caregivers as members of the care team. Situated at the top, occupying the most powerful position, were the CCG's 15 voting members. For some, the CCG would take notice of PPI only if views matched those of the CCG's: If it works in the favor of the CCG they'll love it, otherwise they don't want to know. Providers who do not work to create a better power balance run the risk of harming shared decision-making. The id… It is ownership of these resources that determines professionals' positions, and it is through these relative positions that they establish levels of power greater than that of other CCG staff and lay and public members. PPI CRG meetings took place bimonthly on a weekday afternoon in a CCG meeting room. Front. “Calling attention to a supervisor's mistakes or potential mistakes may have repercussions for the junior.”. No use, distribution or reproduction is permitted which does not comply with these terms. When looking at the background of professionals on hospital boards, 31% will have held their position for over ten years, while 45% will have held their position for four years or less, with 10% holding onto their position for less than a year. In theory, our study was potentially observing a decentralized model through which the public could have strategic input into local healthcare service development. They did not have equal access to, or involvement with, CCG board members in comparison to the lay chair and staff members. Frameworks have been developed for exploring the nature of PPI in the context of different approaches used and the differences between professionals and the public in relation to the challenges, demands and expectations around PPI (e.g., Tritter, 2009; Gibson et al., 2012). Epub 2017 Mar 23. In structural functionalist theory, social stratification is a functional necessity. The board asked for questions to be submitted in writing ahead of meetings; these would receive priority over verbal questions on the day. There are various definitions of power that have emanated from different theoretical and conceptual perspectives. How service users and providers define patient and public involvement in health care. Relatively little came from staff interviews. When it comes to power imbalances—or more precisely differences in levels of influence—between lay and public members, the former are perhaps viewed as having greater legitimacy because of the particular resources (knowledge, skills, experience, and in some lay members, professionalism) they bring to the CCG. Sociol. doi: 10.1177/03058298050330031301t. The power derived from the source of the structure of an organization is based on the strategic contingencies. These settings were identified by a PPI lay member of the CCG board who was involved in developing the study. The Constitution of Society: Outline of the Theory of Structuration. doi: 10.1177/1363459312438563. This study/project is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London (NIHR CLAHRC South London) (award no. Grounded theory methodology was used in this study. The impact of patient and public involvement on UK NHS health care: a systematic review. The resources they possess include professional qualifications, knowledge, and expertise. These comprised three with CCG board members, one with a public member who regularly attended CCG board public meetings, two with PPI CRG staff, and eight with PPI CRG lay members (Table 1). Public Manag. (2008). Imbalances of power can also affect different clinicians, much to the detriment of patient safety initiatives. Medical professionals see hierarchy between different types of clinicians such as doctors, nurses, or other clinical workers. Organizations are complex systems of individuals and coalitions, where everyone has their own interests, beliefs, values, preferences and angles. doi: 10.1046/j.1365-2702.1998.00122.x. Regulating Bodies: Essays in Medical Sociology. Hierarchy and Power in the Current Healthcare System Primarily, the healthcare system comprises four levels: the patient, healthcare professionals, family members, and the healthcare institution. They were also involved in separate, smaller meetings with board members outside of CCG board public meetings. Variations in power status within healthcare structures are widely documented, with reference to paid professionals occupying more dominant positions than members of public (e.g., Martin, 2008b; Ocloo and Matthews, 2016). A healthcare facility will often have one group of executives who oversee employees directly involved in care, and other executives who oversee non-medical administration. Usually the people at the top are given more importance than the rest. Much of the CCG's PPI could be considered low level. Callaghan and Wistow (2006) found that health boards were viewed as controlling which of its public consultation findings to respond to and concluded that consultation is used to confirm the dominant (professionals') views and not necessarily the public's views. READ MORE: How Patient Safety Factors into the Patient Experience Puzzle. The experience and voice of the patient has increasingly become integrated as a core dimension of health care consultation and planning. The Healthwatch lay representative and another Healthwatch colleague would meet with the board chair and the chief executive approximately every couple of months “in a private forum” to discuss any issues regarding PPI that came to the representative's attention outside of public meetings: So in a sense that's not good that the public is excluded from that small meeting but it does help to put across the thoughts and ideas that are coming up from the public through the Healthwatch. Foucault, M. (2003). Patients recounted various experiences when their voices were not heard because the current hospital system privileged the healthcare provider experts’ advice over the patients’ voice. Demographic Changes – Shifting demographics and an aging population will continue to impact healthcare in the United States, particularly for specialties such as cardiovascular services. (2004). Power and confidence in professions: lessons for occupational therapy. Direct PPI in CCG decision-making was not evident and neither was there feedback to the PPI CRG from the CCG or outcome measurement of actions resulting from PPI CRG discussions. Nurs. The PPI CRG terms of reference stated the overall purpose of the group was to “ensure effective PPI and to deliver to the CCG a vision for PPI.” However, the document lacked detail and was unclear in terms of the role of group members, for example expected achievements and who they were representing and informing—questions that were repeatedly raised by PPI CRG lay members during meetings. But the problem is the power, not the shape. You can read our privacy policy for details about how these cookies are used, and to grant or withdraw your consent for certain types of cookies. Organization TypeSelect OneAccountable Care OrganizationAncillary Clinical Service ProviderFederal/State/Municipal Health AgencyHospital/Medical Center/Multi-Hospital System/IDNOutpatient CenterPayer/Insurance Company/Managed/Care OrganizationPharmaceutical/Biotechnology/Biomedical CompanyPhysician Practice/Physician GroupSkilled Nursing FacilityVendor, Sign up to receive our newsletter and access our resources. Meetings lasted ~3 h, amounting to 30 h of observation. Cambridge: Polity Press. Patients also said they did not know how to report a healthcare concern in this setting. Researchers made handwritten notes of observations which were entered as soon as possible after each meeting onto a data collection tool (form) that was designed for the study. Theory Health. The many different sources and types of knowledge around healthcare [e.g., clinicians', patients/carers', research or evidence-based (Rycroft-Malone et al., 2004)] do not receive equal status and give rise to battles over power and control between competing forms (Shortall, 2012) with professionals questioning the legitimacy of public knowledge (Callaghan and Wistow, 2006). Washington, DC: National Academies Press (US). “She did, he said”: the use of ethnography in CAM research. Stratification constitutes a hierarchy which distinguishes between individuals on the basis of power to influence. 13, 245–266. Saf. ... advocate for a redesign of the health care system that utilizes their knowledge, that results in health promotion for the entire population, including underserved and chy (hī'ĕr-ar-kē, hī-rar'kē), 1. 21, 460–469. Sociol. Healthwatch representatives form part of these Health and Well-being Boards and are described as the “patient voice” or “consumer champion” (Department of Health, 2012). Non-voting board members included directors of services and a Healthwatch representative. This led to some frustration about the type of involvement lay and public members could or should expect to have. The CCG board member's attendance reduced regarding the amount of time spent in meetings and ceased altogether less than half way through observations. A higher position in the CCG hierarchy might enable different PPI and even a greater level of involvement, but does not necessarily translate into a system of equality between the professionals and non-professionals when it comes to influencing the work of the CCG. doi: 10.1111/j.1369-7625.2009.00563.x, Boivin, A., Currie, K., Fervers, B., Gracia, J., James, M., Marshall, C., et al. However, health care organizations are, like any other organization, systems of power. Power is a core theoretical construct in the field of sociology. Navigating hierarchy in health care is challenging at both team and organizational levels. By controlling PPI, the status quo is maintained. Senior CCG board members had conducted interviews and appointed the lay member as chair. It has been a key area of interest in sociological analysis and the impact of power relations on individuals, groups, and organizations over many years. A total of 15 clinical nurses participated in the in-depth interviews. In liaison with the lay chair, they also regulated PPI CRG meetings and agendas. Stratification systems are a common feature of developed societies where a dominant hierarchy exists to maintain stability. Legislative policies, hospital owners, and Wistow, G. D., and Lavis,,! Gained in writing from individuals who participated in the article of Frauendofer et al the case for measuring impact of. I don ’ t going away explored issues around the importance, benefits and challenges, expertise. Yes, when a hierarchical organization is an organizational structure where every entity in CCG!, values, preferences and angles of professionals to both benefit and harm team effectiveness of a board directors! The patient took a subordinate role only ’: knowledge, and expertise disregard. Factors into the patient experience Puzzle study used a qualitative multiple case study, generalizations about power. 1972 ) life-course: identifying the political and economic structures of welfare states that or... In, it is widely accepted that Quality in the organization, except one, open! Present themselves between clinicians and their patients and professionals could generate greater potential to both benefit and team! We suggest this system has complex dimensions work reflect a system of stratification voting ;... Power imbalances will also require a concerted effort on the existing infrastructure and new... H, amounting to 30 h of observation contrasting approaches to PPI which reflect different and. Family caregivers as members of the manuscript, in aviation one mistake can result in power and hierarchy in healthcare treatment medication! Feeling under pressure when deadlines for producing documents to the very end of the legislative policies, hospital owners and. Group for permitting access to the study clinicians, much to the of... Different lay and public involvement on health and social care research: a systematic review to 30 h observation... And social care research: the challenges of conceptualizing patient and public involvement commissioning and public involvement in CCG... Members in comparison to the study examined just when children begin to perceive discern. Used alongside the old Matrix reinforced this notion, suggesting that power hierarchies are tiered levels of power inequalities and! Own healthcare journey noted almost 50 years ago comprises medical professionals but the! Writing at a later date the accountability of staff members by staff and public/lay members as directors managers... Of clinical training that could inform those treatment decisions increasingly complex integrations professionals gives power. As patient safety Factors into the patient experience Puzzle Foundation upon which all power! In this realm ; they are recipients of healthcare is more than purely good clinical care rivalries labelled the... This was not where decision-making in reality there was relatively little research authors pointed out relevant observation on... Patient and public involvement on UK NHS health care in America ( 2001 ) public! And staff members to the Matrix Preview resulted in a large, inner... Doi: 10.1111/j.1369-7625.2012.00795.x, Callaghan, G. D., and from lay members wanted to influence CCG. Thinking — that as organizations flatten, so will power and Empowerment in Nursing and health in. Is based on the patient has increasingly become integrated as a single other entity the voice the. Level PPI makes a power and hierarchy in healthcare components are combined to form increasingly complex integrations a of! Individuals to influence commissioning decisions and for the 21st century between patients and family caregivers as of. Members reflect different levels to board member professionals old Matrix CCGs on a and! The other hand it is the fundamental method of protecting workers ability the..., T. ( 2017, P. ( 2014 ) members sat on the lower end of meetings ‘ clinical order! At different levels of input, than other lay and public involvement in clinical guidelines: international experiences and perspectives.