title: Medicine and management: looking inside the box of changing hospital governance.
abstract: Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing 'hybridization' of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study.
  
  
  
  We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the 'managed' and the 'managing' doctors in an organization.
  
  
  
  Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial-professional coordination at the micro-level of the organization.
  
  
  
  This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management.
authors.affiliation: Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden. ellen.kuhlmann@ki.se.|Institute of Economics, Labour and Culture, Goethe-University Frankfurt, Frankfurt, Germany. ellen.kuhlmann@ki.se.
authors.forename: Ellen
authors.initials: E
authors.lastname: Kuhlmann
authors.affiliation: Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ylva
authors.initials: Y
authors.lastname: Rangnitt
authors.affiliation: Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden.|Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Mia
authors.initials: M
authors.lastname: von Knorring
mesh_terms: D054976:Clinical Governance; D015510:Clinical Medicine / Q000592:standards*; D003695:Delivery of Health Care / Q000592:standards*; D006291:Health Policy; D006779:Hospitals, Public / Q000592:standards*; D006801:Humans; D007400:Interprofessional Relations; D010820:Physicians; D011216:Practice Management, Medical / Q000592:standards*; D024382:Professional Role; D013548:Sweden
keywords: Actor-centred healthcare governance; Doctors in management; Hybrid hospital governance; Medical management; Multi-level governance; Needs of managed and managing doctors; Sweden