Control modes in care delivery organisations

Three different, overlapping management and control systems co-exist in healthcare delivery organisations: in order of their legibility, they are a Weberian bureaucracy (the formal hospital organization); a feudal system (the medical staff); and an informal, peer-based network of senior nurses roughly analogous to networks of noncommissioned officers in the military. The co-existence of these three modes of control leads to areas of conflict, confusion, and cooperation. The paper discusses the benefits and problems associated with this complexity and draws on insights from the engineering of polycentric control architectures involving heterogeneous agents to suggest ways to beneficially influence such organisations.