Power from what? A reexamination of its relationships with structural conditions

Administrative Science Quarterly,  June, 1989  by Ran Lachman

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METHOD

Setting

Studied here were nine healthcare clinics that are part of a publicly owned network organization of 30 clinics in the southern region of Israel. These are community out-patient clinics that handle regular ambulatory medical services, provide preventive health care, and, when necessary, refer patients to specialized or nonambulatory medical services. All 30 clinics provide the same health service, which is highly regulated and controlled by the parent organization as well as by the Israeli Ministry of Health.

The clinics are small interactive systems (with an average staff of 14), internally divided into three major subunits: the medical subunit (average staff of five doctors), the paramedical subunit (average staff of six nurses), and the administrative subunit (average staff of three). Each subunit has only one authority position, that of the subunit head, and the three subunit heads constitute the top echelon of the clinic. There is no single chief executive officer in the clinic. The administrative subunit handles functions like setting appointments, checking eligibility for services, arranging for specialist or hospital care, and keeping records. The paramedical subunit provides independent services such as taking tests, giving injections, and treating minor injuries, as well as preparatory and supplementary services to the medical subunit. Some of the larger clinics also provide pharmacy and laboratory services, but since these services are provided in only a very few clinics and on a very small scale (one or two employees), they were not included in the study. In most cases two or all three subunits participate in the treatment of each patient, but the workflow among them does not follow any particular sequence. The workflow is determined by the needs of each particular case and the interaction among service providers or between them and the recipient of the service. Work dependence among subunits can therefore be described as reciprocal.

Sample

The 30 clinics in the network are very similar in structure, and differences between them stem mostly from their different locations and the need to serve different communities. Nine clinics were included in the study to represent the different environments of the 30 in the network: five (56 percent) were located in small, semirural towns, three (33 percent) in urban settings, and one (11 percent) in a Bedouin (nomadic Arab) center. This distribution is similar to the actual distribution (49, 40, and 11 percent, respectively) of the 30 clinics in the region ([chi].sup.2 = 0.7, n.s.). All the clinics contacted agreed to participate in the study. Thus, 27 subunits were examined here.

Data Collection

Data were collected on the same clinics twice, two years apart, thus allowing for both contemporaneous and intertemporal analyses. Almost all the staff of the nine clinics (an average of 80 percent across clinics) and a majority of the staff in any one subunit who participated at the first stage also participated at the second. A multimethod approach was used: interviews, questionnaires, observations, and content analysis of organizational records were employed in collecting data. Each variable was assessed by at least two different methods.