Understanding the difficulties of implementing management delegation in hospitals: a reading through the concept of organised anarchy

The French public hospital system is in the midst of a restructuring around the questions of the quality of the supply of care and medico-economic efficiency. We mainly make reference to the organisational change known as New Governance, which leads to the setting-up of " poles " of medical activity, in which several care services are brought together. In this context of change, some responsibilities have been devolved to the poles, and thus to the doctors who act as pole leaders, with a view to bringing decision-making down to the clinical level for the sake of efficiency. While studies do indeed identify modifications in the organisation of care activity, decisions remain centralised at the level of the General Directorate. Our aim therefore is to study the effects of the new governance on the devolution of management and therefore of decision-making within the poles, and the factors that act as brakes on the setting-up of a real delegation of management. To do so we mobilise the work of Cohen, March and Olsen (1972). We shall make reference to organised anarchies, a particular model of organisation that makes it possible to understand organisational behaviours. By demonstrating whether the hospital is an organised anarchy, we aim to better understand the decision processes at work in this organisation and so shed light on the brakes on devolution. The research hypothesis is that the new governance accentuates the three characteristics of organised anarchy: ill-defined preferences, unclear technology and fluid participation. Our research was conducted in a large teaching hospital. To carry out this analysis we focus on three activity poles. To understand the decision-making mechanisms, we analyse two specific management processes: staff management and bed management. The data were collected through semi-structured interviews, non-participant observation and document analyses between September 2013 and November 2014. A new phase of fieldwork will start in the first quarter of 2016.