Management control levers in hospitals: the influence of accreditation on other management control systems/Niveles de control de gestion en hospitales: la influencia de la acreditacion en otros sistemas de control de gestion/Niveis de controle gerencial em hospitais: a influencia da acreditacao em outros sistemas de controle gerencial.
| Autor | da Silva, Marcia-Zanievicz |
| Cargo | Research article texto en ingles |
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Introduction
Hospitals face managerial challenges that raise concerns regarding management quality and the improvement of their management processes (Oliveira & Matsuda, 2016; Chopra & Kondapalli, 2015; Manzo, Brito, & dos Reis Correa, 2012). Inefficiency in these processes, inflation in the health costs and the increasing patient dissatisfaction with the services provided make it necessary to reduce costs and improve on those services (Araujo, Figueiredo, & Figueiredo, 2015). One of the strategies adopted by health organizations to improve quality and productivity is the creation of hospital accreditation programs (Francois & Pomey, 2005).
Hospital accreditation is an external evaluation methodology, contracted voluntarily by health organizations. According to Portela and Schmidt (2008) and Jaafaripooyan, Agrizzi and Akbari-haghighi (2011) the objective of accreditation is to improve the service delivery quality of health organizations. Accreditation allows the continuous improvement of healthcare, and guarantees effectiveness of care in all organizations providing health services.
Alonso, Droval, Ferneda and Emidio (2014) emphasize that hospital accreditation seeks to evaluate and validate the quality of care provided, by describing the practice developed and the use of accepted care standards. Bomfin, Trivellato and Hastenreiter (2013) show that the process cannot be disassociated from organizational change, a necessary condition for receiving certification. El-Jardali, Jamal, Dimassi, Ammar and Tchaghchaghian (2008) emphasize that the adaptation to quality standards advocated by accreditation obliges the hospital to review its working methods and institutional controls.
These controls, when deployed, are able to soften or eliminate bottlenecks that impede the achievement of strategic objectives (Imoniana & Nohara, 2005). For Tuomela (2005) and Canonico and Soderlund (2010) the joint use of controls from the perspective of levers of control, as proposed by Simons (1995), can minimize possible difficulties and managerial problems, contributing to the improvement of management quality and increased commitment to institutional goals and strategies.
For Kruis, Spekle and Widener (2016), the impact of levers of control (LOC) in accounting literature is relevant. The existing literature recognises the use of management control systems in implementing organisational strategies and to promote organisational change (Akroyd, Biswas, & Chuang, 2016; Wijethilake, Munir, & Appuhami, 2017). Our study therefore sheds light on one of the key concepts in the scope of control levers and their balanced use (Songini, Morelli, & Vola, 2018).
In the search for an understanding of how management control systems contribute to the improvement of performance, allied to strategy, Contingency Theory is used, among other theories (Chenhall, 2003). In Contingency Theory, the improvement of a structure depends on factors internal to the organization, which in turn are influenced by the environment (Donaldson, 2007).
In this context, and considering that hospital accreditation is a management tool used by health organizations to improve the quality of their internal processes and patient care (Jaafaripooyan et al., 2011; Alkhenizan & Shaw, 2011; Rooney & Van Ostenberg, 1999), it is assumed that accreditation is a management control tool that, when implemented, generates dynamic tensions between the other existing controls (Kruis et al., 2016; Alkhenizan & Shaw, 2011; Tuomela, 2005). In order to improve the quality of hospital accreditation, it is assumed that hospitals adopting accreditation modify the use of other management tools with the intention of adjusting their control levers in search of balanced use of LOC (Mundy, 2010). In this way, the research aims to identify the influence of accreditation on management control systems (MCS) before and after its implementation.
Francois and Pomey (2005) analyzed whether accreditation plays an important role in institutionalizing processes in hospital entities. In general, previous studies have contributed to the management control of health organizations (Viana & Fonseca, 2016). However, this study contributed to understanding the changes, especially the use of MCSs, after the implementation of the National Accreditation Organization (ONA) and Joint Commission International (JCI).
To this end, 276 questionnaires were sent to ONA and JCI accreditation officers in Brazilian hospitals. Of these 92 answered the survey instrument. To achieve the research objective, we used a t-test, assessing the impact of accreditation on management control systems (MCS) post-implementation. The research results demonstrate that accreditation has a significant effect on Simons' (1995) control levers, and belief, diagnostic, boundary and interactive control systems used by Brazilian hospital entities are positively altered after accreditation.
The contribution of the study derives from its focus on health institutions, essential for people's quality of life. By analyzing the balanced use of MCS's, one can contribute to better service delivery and maximize organizational resources, often scarce, in response to the growing demands of the health sector. It is also hoped that the study may guide hospital managers who are in the process of implementing accreditation, in view of the fact that, aware of the dynamic tensions that accreditation generates in other MCS's, they act proactively to ensure the adequate rearrangement of the tools and maximize the benefits generated by them.
With reference to the existing literature, the study expands on the findings of Mundy (2010) and Kruis et al. (2016) regarding the creation of dynamic tensions and the balanced use of MCS. It also builds on the work of authors such as Francois and Pomey (2005) and El-Jardali et al. (2008), dedicated to the understanding of the hospital accreditation process, its importance and associated organizational impacts.
Finally, it is important to analyze the implications of accreditation in hospital entities; according to Mendes & Mirandola (2015), more studies are needed to evaluate the real contribution of accreditation in the improvement of hospital organizations. The present study contributes by demonstrating the benefits of management controls after accreditation, demonstrating to managers, investors and researchers the importance of accreditation for hospital entities.
The paper is structured in the following way: section 2 consists of a literature review, section 3 contains the methodology used, section 4 comprises the analysis of results and section 5 presents the conclusions.
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Literature review
2.1. Management control systems
The first studies on managerial control were based on Anthony (1965), who presented it as a way to guarantee that the objectives of the organization are fulfilled. More recently, authors such as Anthony and Govidarajan (2008) have added that managerial control systems are defined as processes of influence exerted by managers, in order to implement organizational strategy and to verify how available resources can be maximized so that targets are achieved.
Organizations face challenges on a daily basis and for these to be overcome, they require differentiated and effective control by managers (Spekle, 2001). Differentiated controls contribute to generating information that makes managers' choices more assertive, and are usually provided by management control systems (MCS).
In this context, Simons (1995) proposes a methodology for strategic control and organizational practices, which meets the company's evolving requirements. Simons (1995) outlines core values, risks to be avoided, strategic uncertainties and critical aspects of performance, giving rise to four systems called control levers: belief systems, boundaries, diagnostics and interactive control.
Belief systems for Simons (1995, p.34) are "the explicit set of organizational definitions that senior managers communicate formally and reinforce systematically to provide basic values, purpose, and direction for the organisation". Belief systems communicate core values of the company (Tessier & Otley, 2012) and aim at innovation and guided creativity (Simons, 1995). Widener (2007) describes them as the interlocutor of essential values, stimulating and encouraging employees to investigate and innovate.
The boundary system delineates the region possible for organizational activities (Simons, 1995). This lever defines the actions to be avoided by workers. It establishes limits, based on fixed risks and the search for opportunities (Simons, 1995).
The diagnostic system is designed to guarantee the achievement of organizational objectives (Simons, 1995). It is the formal information system, which is used by those responsible for the measurement of outputs, monitoring of results and possibility of correcting deviations. Diagnostic controls guide and motivate employees in their roles and behaviors, so that they are in accordance with the organization's goals (Widener, 2007). For Widener (2007) this lever reports critical information on performance, allowing managers to better monitor the company's strategy.
The interactive system is the essence of managerial control because it focuses the tension between creativity and the achievement of organizational goals (Simons, 1995) providing for the emergence of new strategies...
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