Abstract
How are accountability measures used by actors in the administrative field? Consequently, which are the associated effects on workers in the health sector?Research in control has shown that the French hospital has undergone profound changes, notably through the introduction of accountability. Compliance with institutional pressure drives organizations to move towards new tools and principles that reinforce their external legitimacy (Power, 2003). The same literature has shown that accountability infiltrates the medical sphere and that a new phenomenon occurs: doctors adopt hybridization role in hospital. This hybridization creates doctors who are aware of financial constraints (Kurunmäki, 1999). The administrative sphere is no exception and is also subject to coercive pressure. The aim of our thesis is to contribute to this literature by analyzing the intra-organizational effects and roles of accountability on the medical logic in the French public hospital sector. To analyze these effects, we focus on accountability mechanisms such as information reporting (i.e. financial audit, budget practice). To answer this problematic, we use semi-structured interviews into French hospitals and we adopt an ethnographic approach of one large university hospital. Firstly, from a series of exploratory interviews with 19 financial administrative directors (in 19 public hospitals), we show that accountability through financial audit leads to organizational changes and also use to “give account” not only to external stakeholders (Regional Health Agency, banks) but also internal hospital organizations. Our results show that the financial audit reinforces the legitimacy of the administrative sphere towards the medical sphere. Secondly, we identify with an ethnographic approach (non-participant observation and interviews) in a UHC of specific administrative actors called “Medical coders” (i.e. actors serving as vectors for the infiltration of accountability in the medical sphere). These administrative members have a key role in hybridization of health professionals to management skills, and sensitize them to financial logics. Through the reporting of their medical activity, our results highlight an attenuation of the traditional cleavage observed in the literature between administrative members and the medical profession.Moreover, we show that the infiltration of accountability by others specialized administrative agents tends to sensitize doctors to the reduction of surplus, and the slack in the care of patients. It turns out that, the hospital organization favors support systems to make physicians integrate efficiency in their health role. Our result show that physicians are now trying to find a balance in order to articulate medical logic and managerial logic. For this, our study highlights a modification of care protocols as well as the reasoning and values of health professionals who reconcile and promote medico-economic logic. This thesis argues that the introduction of accountability within the French public hospital sector has intra-organizational effects on both the administrative and medical spheres and emphasizes that on the basis of the reduction of the organizational slack, the conflicts between medical and managerial logic are lessened.