Multilevel translation: a local focus, but a national work process
As part of implementing the National Health and Hospital Plan, all health authorities have had to create their own development plans. This section examines how government intentions are translated and operationalized through various government guidelines within Norwegian specialist healthcare.  theoretical concepts of connectivity and contingency are used to analyze decision communication regarding development plans in what we call a multilevel translation process. Figure 1 presents the guidelines used and illustrates how they are translated vertically in the Norwegian specialist healthcare system. In this process, different health authorities try to ensure their decisions’ connectivity and limit the contingencies by implementing the various guidelines.
Figure 1 (to be placed here)
The overall national goal is to facilitate good future-oriented patient treatment, as well as the rational prioritization of resources at every level of Norwegian specialist healthcare (see no. 1, Fig. 1). Guidelines (see no. 2, Fig. 1) on how to manage development plans were sent by the Ministry of Health and Care Services to the five regional health authorities. According to the Ministry, the national guidelines for development plans should help navigating the practical work. The political goal of the guidelines is to achieve collectively binding decisions through the development plan formulated by the various authorities, clinics, and hospitals. The guidelines present a recommended thematic structure for the development plans, whose main components are to be historical background, current situation, contextual change, desired situation, and strategic choices. The guidelines also emphasize transparency and stakeholder involvement. All documentation connected to the development plan process are therefore published, and at all levels there should be broad involvement of users, patient organizations, professionals, unions, municipalities, and private actors. The emphasis on involvement and transparency can be understood as a way of legitimizing the political system’s function of achieving collective binding decisions regarding healthcare strategy.
The regional health authorities then translated the national guidelines according to their mandate (no. 3, Fig. 1), serving as a premise for the work on local development plans. In this case, the regional health authorities stated that local development plans must follow national and regional instructions issued through various parliamentary reports and reforms. This includes guidance from the National Health and Hospital Plan  and the Coordination Reform . The regional instructions concentrate on how local health services can be adapted to improve regional economic conditions, efficiency, capacity, and competence. They also emphasize how to improve internal coordination and collaboration with other health regions. Through the regional mandate (no. 3, Fig. 1), the health authorities try to ensure connectivity to both the National Health and Hospital Plan and previous reforms. At the same time, translation is done through a shift in focus from a national and political context to a regional and economic context. The goal of the development plan is no longer merely to create binding decisions regarding strategy but to create binding decisions regarding strategy based on regional economic conditions. In light of systems theory, the regional mandates entail incorporating the economic code into development plan work.
Based on their mandates (see no. 3, Fig. 1), the local health authorities created their own guidelines (see no. 4, Fig. 1), which ensure connectivity by stating that the local development plans must follow the thematic structure recommended in the national guidelines (see no. 2, Fig. 1). The local guidelines (see no. 4, Fig. 1) also state that local development plans must include three types of perspectives: local health service, coordination, and clinic perspectives. The local health service perspective should take account the various clinic perspectives, and the coordination perspective is to be developed by a working group consisting of representatives from various clinics and municipalities. This differentiation into perspectives allows space for contingency because there is no longer any integration between decisions regarding the different perspectives. This means that the clinic perspectives do not have to connect themselves to those of the local health authorities or the coordination function.
At the last level, the various clinics, who had responsibility for the clinic perspective, makes their own notes (no. 5, Fig. 1) on how the work process should be structured in their own organizations. These notes state that the plan should be based on previous strategy work, and on regional and national guidelines. Neither the National Health and Hospital Plan nor the Coordination Reform is mentioned in the note (no. 5, Fig. 1).
This section has analyzed the development plan from a top - down perspective. It shows that intentions and rationalities from the national government level are translated through the government system. The translation process has strong connectivity, enhancing the top-down control element. The process also contains room for contingency in the form of local interpretations, highlighting the autonomy of the different subsystems. After finalization at the clinical level, the development plans are sent to the upper organizational level; these plans are then used as a foundation for the local and regional development plans (see nos. 7–9, Fig. 1). This process is not covered in this article.
A development plan in a clinic under construction
The following section presents the work with the development plan at a clinic for mental health and drug addiction. This organizational level was selected for a in depth study since it holds most tension between control and autonomy. The section is divided into three parts: 1) presentation of the development plan and of the clinic’s reactions to the requirement of making a plan, and it’s interpretations of the process; 2) how the clinic organized the plan work and 3) mangers managing reactions on the finalization of the plan.
Introducing the work with a development plan at clinic level
The first time the clinic manager presented the idea of making a development plan was at a leaders’ meeting in June 2017 at which various managers and union representatives were present. The clinic manager began by informing the participants that the clinic needed to address strategy and development. He then presented his view of the development plan, which he called “a political requirement,” the aim of which was to obtain an overview of how the various health organizations organize their work at the national, regional, and local levels. The clinic manager noted the three perspectives from the regional mandate (see no. 3, Fig. 1) and highlighted the thematic structure in the national guidelines (see no. 2, Fig. 1). He specifically highlighted the clinic and the local health authority’s economic conditions and proclaimed that “a key question when working on the development plan is how we can get as much health for the patient given the economic constraints that we work under. There have to be strategic prioritizations” (Observation 1).
The clinic manager’s presentation illustrates how the various guidelines have ensured connectivity. The main translations at the different levels of the health authorities, shown in the previous section, were all covered in the presentation. By calling the development plan a political requirement, the clinic manager activated the political system, placing the contingency of further decisions within the context of a concrete decision premise, namely, the political guidelines. The clinic manager’s emphasis on economic conditions also implies that the economic code should be activated when working on the development plan.
During and after the presentation, there were many reactions from both the union representatives and various managers. There were negative reactions related to the political establishment of guidelines through a top-down process lacking professional involvement. For example, one section manager asked why politicians, instead of their own healthcare professionals, were allowed to formulate guidelines for the clinic’s development plan. Another section manager argued that “decisions on the future direction of the clinic can’t be made only at the top of the system, as the professionals working with the patients must be involved in the process.” These reactions were connected to the strong use of the political code when presenting the development plan. The way the clinic managers set the contingency of decisions within the context of the politically defined guidelines also resembled a top-down process. By emphasizing the role of healthcare professionals within the organization, the reactions were intended to place decisions regarding the plan inside the organization itself, in this way activating and reinforcing the functional system of health in the ongoing process.
Based on observations of the presentation of the development plan (Observation 1), there was clearly a gap between the organization’s top management (e.g., clinic and unit managers) on one hand, and the section managers and union representatives on the other hand. Top management was more comfortable with political rhetoric and working to achieve political and economic goals set at the national and regional levels. Using  concepts attaching their communication to the political and economical function system. Section managers and union representatives on the other hand was more link to functional system of health. Discussion in the meeting addressed the fact that the organization had not yet decided how to manage the contingency of decisions connected to the development plan, or chosen the functional system through which the decisions should be made.
This section presents the “hands-on work” of the development plan, constructing the content of the plan and attempting to engage healthcare professionals. In this section, systems theory will be complemented with the theoretical concepts of “broker” and inclusive management to analyze the managers’ role in facilitating participation and involvement when formulating a development plan.
Four weeks after the development plan work was first presented, a new meeting was held, led by the clinic manager and a clinical adviser, who were responsible for writing and coordinating the clinic’s development plan. The clinical adviser started the meeting by stating that it was important that the development plan was based on a mutual understanding of how it can be used in the clinic. The work process must be driven from within the clinic, and the local context must be in focus. He also emphasized that the work must end up with something more than merely a political document (Observation 2). Here, the clinical adviser was alluding to inclusive management  and attempting to translate the development work from a political requirement to an internal collaborative practice. To reach this goal, he had to translate and coordinate the political and economic aspects of the various guidelines into a language with which the various organizational actors could relate. In the interviews, performed after the meeting, the clinical adviser followed up on his role and reflected on the process of making the development plan:
For me it was very important that our plan reflect our organization and the professional work done throughout our organization. I was concerned that this was not happening. Several times I tried to make the point that it had to be our process. Our process of actually figuring out what our patients’ needs would be in the future, and how we should meet them. I felt in the meeting, and several times afterwards, that this point wasn’t getting through. (Clinical adviser)
At the meeting, the clinic manager stressed the importance of having a development plan by pointing out that the clinic lacked a clear purpose and direction and often had to make reactive and rash decisions instead of being in front of situations as they arose. The clinic manager argued that the development plan could be a tool for turning around this dynamic. In addition, the clinic manager wanted the development plan work to be a collaborative practice and emphasized the importance of involving the whole organization. He stated that it was a personal choice to become involved, but that the managers should try to facilitate discussion about where the focus should be regarding local challenges and areas of improvement. He also pointed out that the management group (clinic manager and unit managers) could not make a good product by themselves (Observation 2).
Both the clinical adviser and the clinic manager emphasized the importance of translating the development plan work from the political to the local context. They also pointed out that all managers were responsible for encouraging involvement in and enthusiasm for the plan process throughout the organization. This meant that all managers (unit and section managers) in the organization were encouraged to assume the role of “brokers” . This role was also highlighted through the method by which the clinic organized the work process of making the development plan. To involve the whole organization, it was decided that the work process should follow the “line principle.” The goal was to use the existing organization and areanas within the organization to develop the development plan. This meant that all unit managers were to use their hierarchical lines of authority to produce a description of their current situation, possible challenges, and future goals, and to ensure broad involvement. In this work process, the unit managers had to involve their section managers, who would then involve their healthcare professionals through various staff and union meetings.
Top-down or bottom-up?
Despite the management’s goal of involving the healthcare professionals in constructing the development plan, this did not quite work out. The line principle did not have a positive impact on involvement, and the managers did not succeed in their job as brokers. Based on the interviews and observations, it seems that the line principle enhanced the opinion that the plan work was a top-down process. In the interviews, the section managers responsible for involving the healthcare professionals said that it was difficult to get any feedback and enthusiasm from them:
There has been little talk of the mission plan in our section. The goal of the work process was that it should be bottom-up. Yes, it was, and there has been a lot about that goal and I think many are tired of the whole thing. Especially those at the bottom. I found it hard to get any feedback or engagement. (Section manager 2)
For the development plan, everybody was supposed to be involved, and our clinic has over 1000 employees … There are guidelines from the Ministry of Health and Care Services about what we are to deliver, and from Central Health Norway through the mandates. This quickly met with skepticism and indifference. For the employees and many of the managers, the work feels like a duty, and then people lose their commitment and enthusiasm. This has been top-down, not bottom-up at all. We are invited in, but too late and everything is already been defined. (Section manager 3)
The ambivalence evident at the meeting was due to the fact that the development plan was part of the larger political health policy project while being an essential part of the clinic’s strategic development. In response to criticism that too much planning and too many processes were happening at the same time, the clinic manager argued that a new process must not displace old processes. There is a political demand that the clinic must deliver on, and it should be integrated into the clinic’s strategy work. The clinic manager noted that the work can also be used to get a full picture of the main challenges and collective goals to address (Observation 2).
Here the challenge of translating the political requirements into local strategy work is obvious. The clinic manager attempted to stress the importance of the development plan, but he also called it a political demand that they might as well try to use positively. The clinical adviser also noted the contradiction between a top-down demand and a bottom-up strategy process, feeling that this had made it difficult to foster involvement and commitment from the professionals:
Another element of this is that the plan is part of a bigger political order. Everybody knows that our plan will be almost invisible in the local and regional plans. Maybe we will be able to find traces of it, but its essence will disappear. This makes it more difficult to get commitment from the professionals. But it doesn’t change the fact that we need this kind of plan for ourselves. So for me, the process in the clinic of working on such a development plan may be more important than the document that we will send to the local health authorities. (Clinical adviser)
Achieving a shared mission in a functionally differentiated organization
The last phase was to finalize the development plan. As in previous phases, to obtain broad input and legitimize the content, the finalization of the development plan was discussed at a managers’ meeting. At this meeting, all the managers and union members representing the various professions were present. The objective was to present and discuss the feedback on the development plan work process, and to discuss which areas should be prioritized in the final version of the statement.
The meeting started with a presentation by the clinic manager. He stated that the development plan had been introduced as part of a governing process for professional and organizational development in clinics all over the country. This meant that decisions regarding professional and organizational change must be reflected in the development plan before they could proceed. The development plan should, therefore, be the basis for future decisions. This illustrates how the governing bodies and healthcare authorities want to use development plans to ensure connectivity in decisions concerning organizational and professional development. For the clinic manager, it was therefore important that certain key areas in the organization be prioritized. The clinic manager argued that the work that had been done so far did not constitute a good basis for assessing what professional and organizational changes were needed for the future. He stated that to make this assessment, the professionals must be more involved in the ongoing development work (Clinic Manager 2, Observation 3).
One section manager questioned the clinic manager’s thoughts on involvement when it came to decisions on prioritizing:
The national government has given us an order. We cannot prioritize 19 areas. It is a managerial responsibility to decide what is to be prioritized. We cannot have a democratic process on this ... There are so many different motives and wishes in the clinic, that it must be up to the leaders to decide what our focus should be. At the same time, there are quite clear [political] guidelines about what we really should prioritize. (Section manager 2)
This discussion was concerned with how the clinic should manage the decision contingencies connected to the development plan. The section manager made the point that without displacing the paradox or handling the contingency , there will be no decisions: the various subsystems are not motivated to understand one another and are therefore incapable of reaching an agreement on what should be prioritized in the organization. In the interviews after the meeting, the section managers criticized the work process, calling it “skin-deep democracy”:
I think the process is being contaminated by “skin-deep democracy,” when it should have been [a matter for] good strategic management. The belief in democracy and involvement is “in the time,” but not all administrative decisions should be made bottom-up. Administrative changes and organizational goals should be decided at the top. It could be unpleasant, but you cannot make good strategic decisions if you expect everybody to be involved. (Section manager 2)
The clinic manager responded:
I have to follow the assignment given to me. If I don’t, I have to find another job, but it is also important to get the process right. I can’t and won’t decide everything alone. That’s why I think it’s important to involve the whole clinic. When the time comes, everyone should have had the opportunity to get involved, and I will make a decision. (Clinic manager 2)
At the meeting, the clinic manager opened up a discussion of how the organization should follow up on the development work. He asked whether there was any real desire to get involved, and what was needed to get the healthcare professionals involved. These questions started a discussion of how the clinic should proceed to ensure the engagement of the healthcare professionals in the future process (Observation 3).
Several union representatives expressed their views on how to involve the healthcare professionals. One union representative stated that they found it difficult to get involved in the process because they could not relate to the general matter of clinic strategy. Another union representative added that there was no shortage of commitment from the professionals in regards to working with patients, but that it could be difficult to get them involved in general organizational matters (Observation 3). This feedback shows that the managers did not succeed in their brokering role . In the previous meeting, it had been stated that it was the managers’ responsibility to translate the “general” aspects addressed by the various guidelines into more concrete elements concerning the professionals’ local context and practices.
A unit manager then pointed out that the clinic has many areas in which to facilitate broad and open processes and asked how these could be better used to achieve broader involvement in finalizing the development plan. Another union representative agreed, believing that it would be easier to involve the healthcare professionals in strategy and development questions if they had areas in which they could discuss them, rather than simply being told to get involved in something by the management (see Observation 3). It was also pointed out that the healthcare professionals cannot be seen as a homogeneous group. For example, one section manager stated that it was important to involve the professionals, but did not believe that meetings between the various specialists would lead to any unity or mutual understanding because there was too much professional disagreement in the organization. One unit manager responded by stating that it would be unfortunate to gather the different specialist groups separately, as this would only reinforce the differences between them (see Observation 3).
The point being discussed here concerns the functional differentiation in the clinic and how this challenge the goal of having a “mutual” mission and development plan. A mission statement should define an organization’s unique and enduring purpose . The problem for the clinic was that the various subsystems represented by the organization’s sections and professional disciplines operated according to different purposes and understandings based on their functions in the clinic. This theoretical point was exemplified in the interviews when two of the unit managers reflected on the heterogeneous group of professionals working in the clinic:
To achieve good collaboration in the clinic, we have to break down the professional boundaries between drug addiction, psychiatry, and rehabilitation and the geographical boundaries between north and south. (Unit manager)
The problem is that our focus is on ourselves and not on the clinic as a whole. Everyone looks at the clinic based on their own sections and unions. The goal must be to achieve a shared understanding... Or that we should at least relate to the clinic as a whole. The goal must be to bring about a common culture with the patient in the center. (Unit manager 2)
Both quotes show that the mental health and drug addiction functions consist of different subsystems, both organizationally and professionally. These different subsystems operate according to different understandings and cultures, making it difficult to achieve uniform understanding and consensus when it comes to describing the organization’s challenges and long-term goals. Elements that are essential for developing a strategic plan .