Challenges in Hybrid Management in Healthcare: A Study of the Interplay between Divisional Managers and Clinical Directors in a Decentralized Healthcare Organization in Sweden

Challenges in Hybrid Management in Healthcare: A Study of the Interplay between Divisional Managers and Clinical Directors in a Decentralized Healthcare Organization in Sweden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges in Hybrid Management in Healthcare: A Study of the Interplay between Divisional Managers and Clinical Directors in a Decentralized Healthcare Organization in Sweden Mikael Ohrling This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7107551/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Health Services Research → Version 1 posted 11 You are reading this latest preprint version Abstract Background: The integration of medical professionals into management—so-called hybrid management—has emerged as a key strategy in public healthcare reforms. Clinical directorates (CDs) are often seen as vehicles for this integration. While prior studies have explored hybrid management roles and decentralization, less is known about how multiple hybrid-managerial levels interact within one organization. This study examines the perceptions of clinical directors in a large decentralized healthcare provider in Sweden, following the introduction of a divisional hybrid-managerial level intended to enhance efficiency and coordination. Methods: A mixed-methods approach was used, combining two web-based surveys (2018 and 2019) sent to all clinical directors (n = 95). The responses were analyzed quantitatively via nonparametric tests (Mann‒Whitney exact test, Fisher’s exact test) and indices (polarity, intensity, uncertainty). The open-ended responses were analyzed via directed content analysis to deepen the interpretation of the quantitative trends. Results: Response rates were high (84% in 2018; 97% in 2019). The introduction of a divisional hybrid-managerial level yielded mixed results. Some improvements in coordination and leadership support, particularly in mental health care services, have been reported. However, many clinical directors—especially in primary care—perceived increased administrative burden, unclear roles, and confusion over responsibilities. Statistical analysis confirmed significant changes in perceived time for patient care and administrative burden but not in central support. The qualitative data revealed that while some directors appreciated improved strategic dialog, others cited increased complexity and ineffective support systems. Conclusions: Introducing a divisional hybrid-managerial level in a decentralized healthcare setting can improve coordination but risks adding bureaucratic complexity without clear role definitions and adequate support. The study underscores the importance of clarifying authority and responsibilities when layering hybrid roles. Effective hybrid management requires more than professional alignment—it demands robust systems, clear communication, and a culture that reconciles managerial and professional logics. These findings offer insights for health systems pursuing hybrid governance models and contribute to theory on decentralized management in complex service organizations. Hybrid Management Clinical Directorates Decentralization Healthcare Governance Organizational Change Figures Figure 1 Figure 2 1. INTRODUCTION The incorporation of medical professionals into management can be considered a multifaceted strategy [ 1 – 4 ]. Initially, financial management was in focus when a traditional command-and-control model with a managing administrative body as budget holders separated from clinical operations and medical professionals was changed into new organisational forms [ 5 ]. New public management (NPM) principles, as drivers, called for more solid managerial knowledge in clinical operations for key decisions in contracting and performance management [ 2 , 6 ]. These changes from dual management resulted in hybrid management roles, defined as professionals engaged in contracting and resource allocation [ 7 ]. After the fallacy of the NPM reforms, hybrid roles were considered more to integrate managerial and professional dimensions for improvement than just control [ 8 – 10 ]. Clinical directorates (CDs) are a common organizational configuration for involving medical professionals in management [ 5 , 10 ]. The model has been developed to encompass performance and improved service delivery in a broader sense [ 3 , 11 , 12 ]. CDs have been studied mainly in hospital settings [ 2 , 5 , 13 ] but have also been investigated in primary and community healthcare organizations [ 12 , 14 ]. There is evidence that hospitals managed by doctors do better than other hospitals do [ 15 , 16 ]. A positive association has also been shown between medical professionals at the board level and quality improvement [ 3 , 17 ]. However, CDs can be defined at different levels in an organization [ 5 ]. Thus, hybrid roles as managers can be found at the corporate, divisional, departmental and clinical levels within the same organization, thereby creating a potentially challenging hierarchical chain of “hybrid commands”. Despite the substantial literature on improving healthcare services by introducing hybrid management and CDs, there is a knowledge gap around the interplay between hybrid-managerial levels within an organization. Correia and Denis [13, p 74] stress the importance of understanding the “microlevel processes of role configuration and relations among hybrids and their medical peers ”. This paper aims to address these concerns by focusing on the experiences of a large public primary and community healthcare service delivery organization with a history of two decades of decentralization in Sweden and how the introduction of a divisional hybrid-managerial level to increase efficiency was perceived by clinical directors in the CDs. Earlier in-depth studies of the management model in the same organization are considered advantageous for understanding the objectives of this study. In the first study, the program theory of the management model is outlined [ 12 ]. In the second study, the clinical directors’ perceptions of the model are analyzed [ 14 ]. This article is structured as follows. First, the setting and the theoretical frameworks will be presented to understand hybrid management in relation to organisational structures and processes in the study setting. Then, empirical data from two surveys are used to illustrate how the introduction of a hybrid-managerial divisional level to increase efficiency is perceived by clinical directors. Finally, these findings will be discussed in relation to clinical directorates, hybrid management, and decentralization. 1.1 Study setting The regional public health provider in Stockholm, Sweden, manages its hospitals and services as separate entities, but in 2004, all public primary, community and mental healthcare services were integrated into one healthcare provider organization. This healthcare service serves 2.4 million inhabitants with responsibility for all tax-financed regional public services in the capital county. The organization is structured in 122 decentralized CDs divided into 700 centers or units, as shown in Table 1 [ 18 ]. Private providers are also contracted by the regional Commissioner in the mixed public and private service delivery healthcare system [ 19 ]. However, private providers are accountable for their contracts and governed by their owners. The public healthcare services have a professional board appointed by the general assembly of the region and are contracted as well by the Commissioner. Table 1 Facts on the healthcare services organization Services PHC MHCS GASE HA RD* Total Revenue 2018 (million Euro) 320 480 130 150 32 1 112 No of employees 3 600 5 500 1 050 960 360 11 470 No of outpatient visits 3 776 272 1 208 931 502 810 157 108 - 5 645 121 No of beds - 875 246 - - 1 21 No of clinical directorates 95 9 7 6 5 122 No of clinical directors 68 9 7 6 5 95 PHC = Primary healthcare; MHCS = Mental healthcare services; GASE = Geriatrics, Advanced palliative home care, Somatic specialist care, Emergency centers; HA = Habilitation and assistive technology; RD = Research and development; *) from 1 Oct 2017 The organization is a typical line-management, a public professional bureaucracy with value- and trust-based governance with approximately 650 managers in total [ 12 ]. The organization is one of the largest and most decentralized public health care service delivery organisations in Sweden. This provides a unique opportunity to study the interplay between managerial levels when introducing a divisional level within a decentralized organization structured in CDs. Each department or healthcare center is defined as a CD with a clinical director, with the responsibility of one or more CDs, given a large degree of delegated authority that matches their accountability. The organisational configuration was flat at two levels: the chief executive officer (CEO) with coordinators and the other with CDs with the clinical director and staff. The program theory has been presented in an earlier study and can be schematically described as in Fig. 1 [ 12 ]. After a decade with a large decision latitude given to the clinical directors in CDs, an urge for increased boundary spanning effectiveness and flexibility, as well as a need to reduce local administration, was identified in workshops held with the clinical directors. To support consolidation and coordination to better use resources, a new managerial division level was introduced in 2016. The CDs were grouped into four divisions. Managers with medical backgrounds and experience as clinical directors were appointed division managers by the CEO. However, the authority delegated to clinical directors for staff, budget, and quality did not change. The assignment of the divisional hybrid managers, appointed by the CEO, was to appoint clinical directors and work with them to coordinate, consolidate and increase efficiency in the divisions. The clinical directors reported to the divisional managers. In October 2017, the research centers were collected in a fifth division for research and development. Three objectives were formulated for the new organization. First, free-up time at the clinical level (CD) is needed to obtain more time for patients, collaboratives, and quality improvement. Second, increasing efficiency and reducing the administrative burden at the CD level, and third, increasing competence in administrative central support by consolidation. 1.2 Study objectives To address these knowledge gaps, the objectives of this study were to 1) describe and understand the interplay between managerial hybrid levels within a decentralized organization structured in CDs grouped in divisions, 2) inform health care systems and managers that are considering implementing clinical managerial levels, and 3) contribute to theory by discussing these findings in relation to hybrid management, clinical directorates, and decentralization. 1.3 Theoretical background Clinical directorate (CD) structures have been introduced to involve health professionals by incorporating them in managerial responsibilities [ 2 – 4 , 10 ]. The model originates from the introduction of functional units at the specialty level, primarily to control cost, at Johns Hopkins, USA, in 1973 [ 20 ]. Since then, the model has spread globally but has translated differently in relation to contextual factors [ 13 ]. These structures have been described as “move from a professional bureaucracy to a divisionalised form” [ 21 ]. However, the introduction of CDs by hybrid managers should enhance resource allocation [ 22 ] and improve efficiency [ 23 ]. Hybrid managers are professionals managing resources and staff in professional work framed by both professional and managerial logics [ 6 ]. Professionals are experts in self-regulating areas who are not available without qualifications, training, and socialization and who claim autonomy [ 24 – 26 ]. Historically, professionals have been described as opponents of change that challenges autonomy [ 21 , 27 – 29 ]. Hybrid managers with a combination of clinical and managerial expertise [ 30 ] and a focus on patients [ 31 ] are assumed to overcome the gap between the rivaltry between the managerial and medical professional logics [ 32 , 33 ]. The decentralization of decision-making from the central to the lower level has been proposed to increase the response to local needs [ 34 , 35 ]. The introduction of CDs with hybrid managers given a delegated authority is supposed to enhance decentralized decision-making [ 36 ]. In a previously published scoping review [ 37 ], management decentralization was conceptualized in a framework developed from Bossert’s original decision space model [ 38 ] to fit healthcare service delivery organisations and the daily challenges faced by managers in healthcare. The framework illustrates the interaction between authority delegated to managers, accountability and capacity at both the individual and organizational levels (Fig. 2 ). 2. METHODS 2.1 Study Design A mixed methods design with both quantitative and qualitative analyses of the findings of two surveys was used to examine the interplay between managerial hybrid levels within a decentralized organization [ 39 ]. This approach enabled statistical analysis for quantification and comparisons over time, whereas the open-ended questions were analyzed with directed content analysis to refine and explain those results in greater depth [ 39 , 40 ]. 2.2 Survey instrument The survey instrument was designed as a questionnaire to evaluate the introduction of the divisional level. An ad hoc questionnaire [ 41 , 42 ] was developed through a stepwise process: 1) the objectives of the organisational change were formulated as three questions; 2) a workshop to validate the instrument was performed with the management team; and finally, 3) a group of experienced clinical directors were consulted to check for feasibility, reliability and validity, whether they considered the questions assessed the objectives, and could be used for evaluation [ 43 ]. The three questions in the survey were formulated as statements, and the responses were given on Likert scales [ 44 ], ranging from one (strongly disagree) to four (strongly agree), with a neutral alternative. Free-text boxes enabled participants to provide detailed open-ended answers. In the second survey in 2019, more questions related to actuality were added. 2.3 Participants All ninety-five (20% male, 80% female) clinical directors of the organization received the survey. This sampling strategy ensured the participation of the whole organization across all different facility types and sizes of CDs and the professional background and experience of the hybrid managers. All clinical directors, as decision-makers responsible for translating organisational policies into operational practices, were captured in this way. They all had the same delegated authority and accountability as managers for their CDs, regardless of their professional clinical background, healthcare division, or size of services. They all, to various extents, worked as clinicians and had a detailed understanding of daily operations and the issues involved for all clinical and administrative staff. At the time of the first survey, research centers were separate entities but a research and development division was under formation. 2.3 Data collection The survey data were collected anonymously online twice via the Webropol survey (webropol.com), first in May 2018 and second in November 2019. Each time, ten days were given a reply, and a reminder was sent out to everyone after five days. The survey instrument is available in Supplementary File 1. 2.4 Data analysis The analysis was both quantitative and qualitative. Several statistical methods have been used to analyze and compare the results from 2018 and 2019 concerning the three main objectives across the whole organization (Total) and across each division to compare the four divisions: primary healthcare (PHC), mental healthcare services (MHCS), geriatrics and advanced palliative home care, somatic care and local emergency centers (GASE), and habilitation and assistive technology (HA). Both nonparametric tests, such as the Mann‒Whitney exact test and Fisher's exact test, which are chi-square (χ²)-based tests, are used to compare groups, whereas various indices (polarity, intensity, and uncertainty) are employed to understand the distribution of responses and uncertainty in the data [ 4 , 45 ]. Open-ended survey responses were systematically analyzed via directed content analysis [ 46 , 47 ], guided by the three main objectives of the change, which are sorted according to advantages or disadvantages identified by the clinical directors, to supplement the quantitative findings. This contributes to understanding and triangulation to enhance the validity of the results. 2.5 Ethical considerations The study was performed as a part of a larger project on management decentralization, the research plan of which has been evaluated and endorsed by the Stockholm Regional Research Ethics Board (DNr 2018/98-31/5) which is a part of The Swedish Ethical Review Authority”. The surveys were performed as a part of ordinary operations. All methods were performed in accordance with relevant guidelines and regulations, including informed consent to participate in the study from all the participants. 3. RESULTS 3.1 Sample characteristics Eighty (84%) clinical directors completed the first survey in May 2018, and 92 (97%) completed the second survey in November 2019, of which 62% were completed by the same clinical director as in the first survey. The study sample characteristics based on the response rates of the two surveys are shown in Table 2. CDs in primary care represented 74% and 69%, respectively, of the responses. They are mainly smaller entities with fewer than 50 employees, whereas the other services are larger CDs with up to approximately 1 000 employees, which indicates that the number of subordinate managers ranges from none to 35, with a median of 27 in the larger CDs (MHCS and HA). Regardless of this or professional and clinical background, the clinical directors have the same delegated authority. However, 46% and 65%, respectively, of the responders had less than two years of experience as clinical directors. Table 2. Characteristics of the study samples, surveys 1 and 2 Characteristics Response rate (n of total 95 in %) Survey 1 May 2018 n=80 (84%) Survey 2 November 2019 n=92 (97%) Divisional affiliation Primary healthcare (PHC) Mental healthcare services (MHCS) Geriatric and somatic care (GASE) Habilitation and Assistive technology (HA) Research and Development (RD) * 59 (74%) 10 (12%) 7 (9%) 4 (5%) Under formation 63 (69%) 10 (11%) 9 (10%) 5 (5%) 5 (5%) Experience as clinical director ≤2 years 3-10 years 11-15 years ≥16 years 37 (46%) 27 (34%) 9 (11%) 7 (9%) 60 (65%) 24 (26%) 1 (1%) 6 (8%) Span of control 201 employees 4 (5%) 37 (46%) 28 (35%) 11 (14%) 8 (9%) 35 (38%) 34 (38%) 14 (15%) Subordinate managers in CDs None Yes Range [1-35] Median PHC/GASE/RD 6; MHCS/HA 27 17 (21%) 63 (79%) 19 (21%) 73 (79%) PHC=Primary healthcare; MHCS=Mental healthcare services; GASE=Geriatrics, Advanced palliative home care, Somatic specialist care, Emergency centers; HA=Habilitation and assistive technology; RD=Research and development; *) from 1 Oct 2017 3.2 Objective 1: Free-up time for patient care and development at CD The survey in May 2018 revealed that a majority (72%) disagreed or strongly disagreed, and 6% agreed with the statement that the new divisional organization had freed up more time for patient care and development at the CD level. In November 2019, 47% of the respondents disagreed or strongly disagreed, whereas 24% agreed. However, 22% and 28% answered “Don’t know”. All the data are presented in Supplement File 2. The most notable change between 2018 and 2019 was an increase in the proportion of respondents who "strongly agree" (from 6% to 24%). The percentage of those who "strongly disagree" decreased from 43% to 14%, indicating positive development in how respondents perceive the new organization's impact on freeing up time for care and organisational development. Fifty-two (23 and 29) open-ended comments were gathered in the two surveys. Most of the advantages mentioned relate to improved communication, more effective leadership, and, in some cases, more time for care through joint organisational development. One clinical in MHCS expressed that the collaboratives have been better, but there was no time freed up at the CD level: “In several ways, joint collaboratives have been better, but no time is freed up in my daily operations”. These improvements suggest that some aspects of the new organizational level function to elevate important issues to higher levels and provide better support for operations. One clinical director commented, "There is a clear improvement in leadership and prioritization from the new division managers, who are doctors with good knowledge of the task." The main disadvantages revolve around too many meetings and confusion about responsibility. Several expressed concerns that governance had become more detailed and thus an obstacle than support: “I have noticed an increase in detail, which makes my work more difficult”. These negative effects suggest that the new organisational level has not managed to free up time as intended. Instead, it seems that new processes and requirements have created more work for employees. One of the clinical directors in PHC expressed this: "It feels like the organiz ation hasn’t truly settled yet, and there’s still a lot to work on." Another clinical director in the MHCS commented, "Organiz ational development within the CD has been stimulated by the new organiz ation, but time has not been freed up. ". 3.3 Objective 2: Reduced administrative burden at the CD level In May 2018, 74% of the clinical directors disagreed or strongly disagreed, and only 10% agreed with the statement that the administrative burden was reduced at the CD level. The November 2019 results revealed that 57% disagreed or strongly disagreed, whereas 15% agreed and 2% strongly agreed with the statement. The percentages of “don’t know” were 15% and 24%, respectively, in the two surveys. In 2019, there was a decrease in those who "strongly disagree" (from 44% to 25%). There was an increase in those who "agreed" from 10% to 15%. Those who answered "Don’t know" increased, which may indicate that respondents became more uncertain about the effects of the new organization in terms of coordination and reduced local administration. Fifty-eight (29 in each survey) comments were made in response to this statement. The advantages described were improved coordination, especially in the context of shared plans (e.g., patient safety plans) and management processes. Some respondents noted that administrative tasks have been simplified in specific areas, such as plans that are now shared and simplified. Several clinical directors commented on increased trust: "I think communication has improved, trust has increased, which has led to unnecessary administration being avoided." However, disadvantages are described as increased administrative burden, often due to a lack of coordination between support units and a lack of digitalization with outdated paper-based procedures slowing down work. Some respondents highlight the fragmented nature of some of the divisions, which makes coordination challenging, limiting the effectiveness of the reorganization. One clinical director in the GASE division expressed, “Our needs are so diverse, so the new organization contributes rather to more administration.” Several respondents across divisions expressed doubt that the reorganisation has had a substantial impact, with some feeling that they see no real difference compared with before: "There are many question marks and ambiguities about which level should handle different issues. This increases the risk of contradictory decisions." One clinical director expressed concern that the delegated authority had been limited: “The new organization makes me confused? What is my authority and responsibility? It has become unclear”. 3.4 Objective 3: The new Divisional level has strengthened central administrative support The statement refers to increased expertise in administrative support and faster service to CDs due to consolidation at the new divisional level. There were relatively small changes between 2018 and 2019. Forty-nine percent disagreed or strongly disagreed with the statement in May 2018, and 37% disagreed in November 2019. Twenty-five percent agreed, and 8% strongly agreed in May 2018, 35% and 7%, respectively, in November 2019. A noticeable proportion of respondents (22% in 2019) answered "Don’t know," which may indicate that uncertainty about the effects of central operational support was greater in 2019. Sixty-three (28 and 35) open-ended comments were given. There is recognition of greater competence at higher levels of the organization, particularly in areas such as human resources (HR) and patient safety, especially in MHCS. Positive comments regarding specific support functions, such as IT-helpdesk, finance, and documentation. Improved continuity in HR and economic support, as well as more involvement from the chief medical officer, were mentioned. There is appreciation for competent division hybrid managers and experts for complicated matters: "It is valuable to have 'second-line competence' in complicated matters concerning patient safety and HR." Several clinical directors have common concerns about increased administrative workload due to the increased involvement of CDs. Many respondents expressed frustration with inconsistent support, particularly when the quality of help depends on the specific person, they interact with rather than the support system itself. Another concern was the lack of understanding of different operational needs within the organization and the effort that comes with local involvement: "More ambitious work, but it requires more effort from each CD. The new organization works more with various types of issues at a higher level, and CDs are more involved in these matters than before." 3.4 Comparison of Perceptions between the Divisions The findings in the open-ended comments from the clinical directors in the different divisions show that PHC expressed significant frustration with the increased administrative burden and the inefficiency of support functions, although IT-helpdesk was a notable exception. In MHCS, improvements in coordination and support for complex cases were identified, but administrative work and confusion about responsibilities were still major concerns. HA highlighted inconsistent support and the absence of central HR representation as key issues, with some areas performing well but others lacking attention. The GASE indicated potential for development, especially in the continuity of HR and finance functions, but administrative issues and the need for systematic changes were still challenges. The RD was under development as a division at the time of the first survey in May 2018. They were a part of their clinical division until reorganization. In November 2019, RD clinical directors perceived a better strategic focus when the research affairs were held together. However, concerns were noted from the clinical directors in the clinical divisions that there was a risk when research centers were in another division than the clinical activities, which could be counterproductive. One of the clinical directors in the RD division expressed another opinion, “The collaboration has never been better than it is now. My feeling is that this is largely due to the new organiz ation”. 3.5 Comparison of Perceptions b etween May 2018 and November 2019 Over time, the open-ended comments revealed some improvements in coordination and strategic focus, particularly in PHC and MHCS. However, all divisions still faced increased administrative workloads. MHCS and GASE reported some improvement in leadership involvement but continued to struggle with bureaucracy and administrative overload. HA noticed minor improvements, but inconsistent support remained an ongoing challenge. Overall, some divisions showed positive shifts in terms of support and competence, but administrative challenges and unclear roles continued to hamper full success. 3.6 Statistical analysis The statistical analysis conducted via the Mann‒Whitney exact test (M-W) and Fisher's exact test (Chi2) provides insights into the distribution and trends of responses between 2018 and 2019 for various groups (total, PHC, MHCS, GASE, HA). Below is an analysis of the results and an interpretation of the significance. A p value < 0.05 indicates that the change is significant. All the statistical comparisons between 2018 and 2019 and their corresponding significance levels are summarized in Table 4. Table 4. Significance levels for the three objectives total and per division Objective 1: Free up time Objective 2: Reduce admin Objective 3: Central support M-W p value Chi2 p value M-W p value Chi2 p value M-W p value Chi2 p value Total 0.0001 0.0001 0.0046 0.056 0.1348 0.4766 PHC 0.0003 0.0009 0.0311 0.1771 0.0203 0.1708 MHCS 0.0105 0.0555 0.3276 0.809 0.5382 0.7613 GASE 0.7336 0.8238 0.7308 1 0.4261 0.5668 HA 1 1 0.3016 0.1905 1 0.5714 The results for the total group from the Mann‒Whitney and Fisher’s exact tests reveal significant changes in the perception of whether the new organization freed up time for care and development (objective 1) from 2018--2019. The total group experienced a significant decrease in agreement with the statement in 2019. The Mann‒Whitney p value of 0.0001 and the chi2 p value of 0.0001 confirm the statistical significance of this change. Other statistical measures (likelihood ratio chi-square and Mantel‒Haenszel chi-square) also indicate that the differences between 2018 and 2019 are statistically significant, indicating that the changes are not due to chance. The analysis for the total group indicated a slight improvement in the reduction in local administrative tasks (objective 2) in 2019, with a significant Mann‒Whitney p value of 0.0046, whereas the chi-square p value of 0.056 was borderline, suggesting that although a shift was statistically significant, its practical relevance may be small. The likelihood ratio chi-square test and other tests support this interpretation. No significant changes were observed in the strengthening of central support (objective 3) across the total group from 2018--2019. The Mann‒Whitney p value of 0.1348 and the chi2 p value of 0.4766 suggest that perceptions regarding the competence and speed of central support remained largely unchanged. The likelihood ratio chi-square test and other tests support this result since the changes are not large enough to be considered a real effect. In the groupwise breakdown, a significant reduction in agreement was observed in PHC and MHCS, indicating decreased confidence in the new organization’s ability to free up time for care and development (objective 1). GASE and HA did not significantly change. PHC reported a slight improvement in the reduction in the administrative burden at the CD level (objective 2), but no significant changes were observed in MHCS, GASE, or HA. PHC experienced a significant decrease in the perceived improvement in central support (objective 3), whereas other areas, such as MHCS, GASE, and HA, experienced no significant changes in central operational support. The data provided for the three objectives show changes in the polarity index (PI), intensity index (II), and uncertainty index (UI), as shown in Table 5. The indices measure the distribution of responses, the intensity of opinions, and the level of uncertainty among respondents. Across the divisions, there was a general trend toward more evenly distributed responses in 2019, reflecting a shift from extreme to moderate opinions. The increase in PI from 2018--2019 suggests that a more balanced distribution of opinions emerged. The overall decrease in II for most divisions indicates a move from strong polarization to more moderate views, with MHCS showing the largest decrease, highlighting a shift toward less extreme opinions. There was an increase in uncertainty in PHC, MHCS, and GASE, with MHCS experiencing the most drastic shift toward uncertainty, whether the new organization had freed up time and reduced administration. In conclusion, these shifts in PI, II, and UI suggest that the organizational changes introduced in 2019 led to greater balance in opinions across most divisions, although uncertainty persisted in certain areas. This may reflect an evolving understanding of the new structures and roles, with some divisions experiencing more moderate and decisive opinions and others facing greater uncertainty. Table 5. Polarity (PI), intensity (II) and uncertainty (UI) indices Division PI_2018 PI_2019 II_2018 II_2019 UI_2018 UI_2019 Total *0.08/0.67/0.32 0.53/0.88/0.54 43/23/44 15/16/21 22/18/4 28/21/14 PHC 0.12/0.53/0.4 0.56/0.7/0.6 48/21/37 18/16/18 21/19/5 25/22/15 MHCS 0/0.5/0 0.75/0.6/0.11 40/30/80 10/10/20 10/10/0 30/20/0 GASE 0/1/0.39 0/0.16/0.77 29/14/57 22/11/34 14/14/0 33/22/22 HA 0/0.5/0 0.33/0/0.5 0/50/50 0/0/20 50/25/0 20/40/40 RD - 1/0.67/0 - 0/40/20 - 60/0/0 *) Indices in frames corresponding to objective 1/objective 2/objective 3. 4. DISCUSSION This study offers valuable insights into the perceptions of clinical directors regarding the interplay between hybrid-managerial levels when a division level is introduced within a large public healthcare organization decentralized in CDs. Despite the default intended benefits of more time for patients and increased efficiency, a reduced administrative burden, and improved central support, the results of the study highlight several observations and outcomes. In this section, the findings are discussed in relation to existing research on clinical directorates (CDs), hybrid management, and decentralization addressing the complexities of integrating clinical and managerial roles within a decentralized healthcare service delivery organization. 4.1 Freeing Up Time for Patient Care and Development The results of this study indicate that the new divisional hybrid-managerial level did not significantly free up time for patient care and organizational development, particularly in PHC and MHCS, as intended. This outcome aligns with findings from previous research on clinical directorates, which emphasize the difficulties inherent in balancing managerial and clinical responsibilities [ 2 , 13 ]. According to Braithwaite and Westbrook [ 1 ], while the introduction of hybrid roles can theoretically lead to more efficient management, in practice, these roles often face challenges related to maintaining clinical autonomy while simultaneously adopting managerial tasks. The interplay will be even more complicated when there is hybrid management at both divisional and CD levels, which this study explores. Hybrid managers may experience role ambiguity, leading to resistance from both clinical staff and administrative personnel [ 21 ]. Moreover, some clinical directors expressed frustration with the increased number of meetings and the complexity introduced by the new structure, which, rather than freeing up time for patient care, contributed to further administrative burdens. These findings are consistent with Christensen and Laegreid [ 8 ], who noted that while hybrid models aim to foster integration between clinical and managerial roles, they often fail to reduce the administrative workload, especially in decentralized organizations. These outcomes also resonate with those of Packwood et al. [ 22 ], who reported that hybrid managerial roles frequently encounter tensions that limit their ability to streamline operations. However, in this study, the improvement in joint collaborations is facilitated by the divisional organization in the MHCS with a professional hybrid manager who enables the clinical directors to contribute to joint quality and process improvement. This is supported by the findings of a recent scoping review on the importance of identifying and understanding how hybridity can be enabled to benefit core processes [ 48 ]. In relation to previous research on decentralization and the importance of clear roles and responsibilities within a decentralized organization, the results of this study highlight both the potential and challenges of decentralization [ 49 , 50 ]. The proper implementation of decentralization can lead to more responsive management structures that can address local needs and improve overall organizational efficiency. However, for decentralization to be effective, it is crucial that roles, delegated authority, responsibilities, and structural and individual capacity are clearly defined, ensuring that managers at different levels have the authority and accountability required to make decisions effectively [ 37 , 38 ]. In this study, although the introduction of the divisional hybrid managerial level was intended to free up time for patient care and reduce the administrative burden at the CD level, many clinical directors reported increased complexity and confusion regarding their roles and responsibilities in relation to the division hybrid manager. This is consistent with findings that decentralization can lead to ambiguity if the delineation of authority and responsibility is unclear [ 51 , 52 ]. The lack of clarity about responsibilities, particularly in areas such as administrative tasks, was a recurrent theme in the comments of the clinical directors, undermining the intended outcomes of the reorganization. In previous research, decentralized decision-making stresses that while local autonomy can increase responsiveness and adaptability, it also requires a balance between authority and accountability to ensure effective decision-making [ 3 , 14 ]. In the case of this study, the hybrid-managerial roles on the divisional level, while intended to enhance coordination and reduce administrative workload at the CD level, seem to have blurred the lines between authority and responsibility, resulting in role confusion. This is evident in the 2019 survey results, where a significant portion of respondents indicated uncertainty about their authority within the new structure, particularly in the wake of the introduction of the divisional managerial level. These findings suggest that the decentralization process may have been impeded by the lack of clear communication regarding the roles of hybrid managers at the different organizational levels and their delegation of authority, thus limiting the potential benefits of decentralization. However, several clinical directors, especially in MHCS and PHC, noted that collaboratives and joint quality improvement work were enhanced by the divisional hybrid managers thanks to their clinical background, which is consistent with findings from a survey conducted by Prenestini et al. in an Italian context [ 4 ]. Furthermore, the delegated authority must be matched with adequate capacity and support at the local level to achieve the desired outcomes of decentralization [ 38 , 53 ]. The study findings, particularly those from the clinical directors in PHC, suggest that although the intention was to reduce local administrative burdens and increase managerial support, the increased span of control and lack of clear support systems led to the opposite effect. This finding indicates that while decentralization might have theoretically empowered clinical directors with greater autonomy, the practical implementation of this structure when introducing the divisional level, with its unclear role and additional administrative complexity, led to confusion and inefficiency at the CD level. This finding aligns with Wong’s [ 54 ] argument that a wider control span, especially in complex healthcare settings, can overwhelm managers with too many responsibilities, leading to inefficiencies and confusion. The increase in administrative workload and confusion about roles, particularly within PHC and MHCS highlights how the span of control may have expanded in a way that made governance more difficult rather than being more streamlined or that the streamlining has confused the clinical directors instead of being clear. In summary, the results of this study support the assertion that decentralization can be an effective strategy for improving healthcare management, but only when roles, responsibilities, and authority are clearly communicated and well supported at all levels. The findings indicate that the lack of clarity in the new divisional structure and the blurred boundaries between roles undermined the positive effects of decentralization, leading to increased administrative burden and confusion rather than the expected efficiency improvements. This finding reinforces the importance of clear delegation of responsibilities and authority at all organizational levels and how they interplay as central to the success of decentralization in healthcare organizations [ 50 , 51 ]. 4.2 Reduction in administrative burden While some improvement in the reduction of administrative burdens was noted, particularly within PHC, the overall reduction was minimal. The study revealed that administrative tasks remained a persistent challenge across divisions, even though some respondents reported improved coordination and communication. This reflects earlier findings by Exworthy et al. [ 35 ], who reported that decentralization and the introduction of hybrid management often fail to significantly reduce the administrative workload, as anticipated by healthcare policymakers. The introduction of hybrid managerial roles at a new organizational level in this study did not lead to widespread reductions in administrative tasks, and in some cases, clinical directors reported that the new structure increased bureaucracy. Lega and Sartirana [ 3 ] also reported that hybrid management roles tend to face challenges when tasked with reducing administrative workloads in healthcare organizations. The introduction of new administrative levels and hierarchical structures often leads to greater complexity, as power dynamics shift, and coordination challenges arise. The negative experiences expressed by clinical directors regarding administrative overload further support the conclusions drawn by Fitzgerald and Ferlie [ 6 ], who argued that the administrative burden in hybrid management systems often outweighs the intended benefits of decentralization. Furthermore, while there were reports of improved coordination in some areas, particularly related to shared patient safety plans, these positive changes were not universally experienced across all divisions. This variability in outcomes could be attributed to the heterogeneous nature of the divisions themselves, which, as noted by Braithwaite and Westbrook [ 1 ], may create challenges for hybrid managers when attempting to implement standardized processes across different clinical settings. 4.3 Strengthening of Central Administrative Support With respect to the strengthening of central administrative support, the results suggest that there was little significant change in central support from 2018–2019. While there were some improvements in the competency of support functions, particularly in areas such as HR and patient safety, many respondents indicated that the support remained inconsistent and was often dependent on individual staff members rather than systematic improvements. This mirrors findings by Hickie [ 30 ] and Lathrop et al. [ 31 ], who highlighted the challenges faced by hybrid managers in securing reliable, competent support across all aspects of administrative functions. Additionally, Reay and Hinings [ 32 ] suggested that hybrid managers are frequently caught between competing demands from both the professional and the managerial sides of the organization, which can undermine their ability to leverage centralized support effectively. This is particularly evident in this study, where clinical directors reported frustration with inconsistent support and confusion about responsibility allocation. One of the positive aspects reported by the clinical directors was the increased competence in specific support areas, such as human resources and patient safety, which aligns with the findings of Montgomery [ 16 ], who suggested that when hybrid management models are effectively implemented, they can improve central administrative services. However, as noted by Christensen and Laegreid [ 8 ], these improvements are often tempered by a broader organizational culture that resists change and undermines the effectiveness of hybrid roles. In our case, the power shift that occurred when the new divisional level was introduced, and the interplay between the two hybrid-managerial levels, were major cultural challenges. 4.4 Organizational Culture and Resistance to Change A common theme that emerged across the divisions was ongoing resistance to structural changes, particularly in the form of unclear roles and responsibilities, which echoes the findings of Jamous and Peloille [ 24 ] and Abbott [ 25 ] regarding professional resistance to managerial oversight. The clinical directors expressed concerns that the new divisional management level created ambiguity in the division of responsibilities between clinical and managerial roles. This uncertainty is particularly problematic in hybrid models where managers are expected to straddle both professional and managerial identities, often leading to role conflict and resistance from staff, who feel that their autonomy is being compromised [ 21 , 27 ]. Furthermore, Packwood et al. [ 22 ] suggested that the introduction of hybrid roles can lead to a clash between the professional culture of healthcare and the managerial logic imposed by hybrid managers, which may result in inefficiencies and dissatisfaction among staff. The findings of this study underscore these concerns, as clinical directors reported challenges in navigating the new governance structures, particularly in areas where responsibilities were not clearly defined. Olakivi and Niska's [ 33 ] concept of competing logics, in which the professional focused on clinical expertise and autonomy versus the managerial on efficiency and resource control, shed light on the struggles within hybrid management. When balanced, these conflicts undermine the success of hybrid roles. In this study, several clinical directors expressed frustration with the increased administrative burden and lack of clarity in responsibilities following the introduction of hybrid managerial roles. These challenges point to a clash between professional autonomy and managerial oversight, where professional logics may resist managerial controls or feel compromised by them, even though the divisional level is hybrid managers with professional backgrounds there is a power shift in the organization. This is particularly evident in the responses from clinical directors in MHCS and PHC, where despite a perceived improvement in leadership and coordination, confusion about roles and responsibilities persisted. Olakivi and Niska [ 33 ] suggested that this conflict between competing logics can lead to dissatisfaction and inefficiency, which is echoed in the results of this study, where the intended reduction in administrative workload and increased efficiency did not materialize as expected. Therefore, the struggles with role clarity and the perceived increase in bureaucracy can be seen as manifestations of the tensions between the managerial and professional logics described by Olakivi and Niska. However, this balance is even more challenging, as seen in the results from this study, when hybrid managers have the same professional background at the higher, divisional level as do clinical directors at the CD level, which can be assumed to be expressed in terms of role ambiguity and confusion in authority. This emphasizes the importance of understanding the power shift when introducing a new organizational level. It is crucial to identify the enablers that enhance different capacities on the different levels and training hybrid managers in their twofold role. This is discussed in a scoping review by Sartirana and Giacomelli [ 48 ] and supported by a study of the importance in training hybrid managers in decision-making [ 10 ]. 4.5 Implications for Healthcare Management This study has several implications for healthcare management, particularly for organizations considering the introduction of hybrid managerial roles and divisional structures. First, the results suggest that while hybrid management roles can improve certain aspects of coordination and leadership on divisional level, they may not automatically lead to reduced administrative burdens or increased time for patient care at the CD level. As such, organizations should carefully consider the broader impact of these structural changes on staff workload and operational efficiency, as the introduction of new managerial levels may inadvertently increase complexity. Second, the findings highlight the need for clearer role definitions on the different organizational levels and more effective coordination across divisions. Hybrid managers, particularly in decentralized systems, require strong support structures to ensure that they can effectively navigate both managerial and clinical responsibilities. This is consistent with the conclusions of Packwood et al. [ 22 ], who argued that successful hybrid management requires a balance between professional autonomy and managerial authority, which can be difficult to achieve without careful consideration of the organizational context and training [ 10 ]. Finally, the study suggests that healthcare organizations must address resistance to change by fostering a culture that values both professional and managerial perspectives. As Reay and Hinings [ 29 ] noted, successful hybrid management relies on creating an environment where both professional autonomy and managerial efficiency are valued and where hybrid managers are provided with tools and support, they need to succeed. Identifying enablers that enhance these capacities and train for them have been shown in other studies [ 10 , 48 ]. Furthermore, as suggested by Correia and Denis [ 13 ], future research should explore the microlevel processes that influence the success of hybrid roles within healthcare organizations. Understanding the nuances of the interplay how hybrid managers interact with their medical peers and navigate organizational structures is essential for improving the effectiveness of these roles in practice. 4.6 Limitations and challenges This study has several limitations that should be considered when interpreting the results. First, the surveys were conducted at only two time points (2018 and 2019), which limits the ability to draw conclusions about long-term trends. Additionally, the sample size, while large, is still limited to one healthcare provider in Sweden, which may affect the generalizability of the findings to other healthcare systems. Further studies with longer follow-up periods and across multiple organizations would provide more comprehensive insights into the long-term effects of hybrid-management reforms. Another limitation is the reliance on self-reported data from clinical directors, which may be influenced by personal biases or a desire to align responses with organizational expectations The use of both quantitative and qualitative data helps mitigate this issue, but the potential for response bias remains. The use of the Mann‒Whitney exact test, Fisher’s exact test, and indices for polarity, intensity, and uncertainty provide valuable insights into the data, particularly in the context of small sample sizes and ordinal data. However, each method has strengths and weaknesses. While the Mann‒Whitney and Fisher’s exact tests allow for robust comparisons in the context of small sample sizes and nonnormally distributed data, the interpretation of the polarity, intensity, and uncertainty indices requires a careful, context-dependent approach. These methods, when used together, offer a comprehensive view of the data. Future studies could benefit from larger sample sizes to increase the power of the tests and reduce the influence of small sample size limitations. 5. CONCLUSION This study contributes to our understanding of the interplay between hybrid management at different levels in healthcare organizations by exploring the experiences of clinical directors, when a new organizational level is introduced, within a large decentralized public healthcare provider in Sweden. The introduction of a divisional hybrid-managerial level had mixed outcomes, with some improvements in coordination and leadership but limited success in reducing administrative burdens or freeing up time for patient care. The findings highlight the challenges in power shifts and balancing clinical autonomy with managerial responsibility and underscore the importance of clear role definitions, effective coordination, and organizational support in hybrid management systems, which become more complicated when professional hybrid management is present at different levels. Abbreviations CD Clinical Directorate CEO Chief Executive Officer NPM New Public Management HR Human Resources PHC Primary healthcare MHCS Mental healthcare services GASE Geriatrics, Advanced Palliative Home Care, Somatic Specialist Care, Emergency centers HA Habilitation and Assistive technology RD Research and Development M-W Mann‒Whitney Exact test PI Polarity Index II Intensity Index UI Uncertainty Index Declarations Ethical approval The study was performed as a part of a larger project on management decentralization, the research plan of which has been evaluated and endorsed by the Stockholm Regional Research Ethics Board (DNr 2018/98‐31/5) which is a part of The Swedish Ethical Review Authority. The surveys were performed as a part of ordinary operations. All methods were performed in accordance with relevant guidelines and regulations, including informed consent to participate in the study from all participants. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study, data associated, and surveys are available from the corresponding author upon reasonable request. Competing interests MO was at the time the manager of the organization studied. However, the survey was administered, and the results were compiled by persons without relations with the respondents. The analysis, including statistics, was openly and transparently discussed by the research team. Funding This study was conducted as a part of ordinary operations. Author contributions MO designed the study. The surveys were distributed, collected, and compiled by administrative specialists without any personal relations with the respondents. MO wrote the manuscript. Acknowledgments The contributions of the following individuals are gratefully acknowledged: Mr. Robert Zetterlind for the administration of the surveys and compilation of the results; MSc Per Tynelius; a senior statistician at the Center for Epidemiology and Social Medicine at Region Stockholm for excellent support with the statistics; and the research team at the Medical Management Center, Karolinska Institutet, for discussion and validation of the results. References Braithwaite J, Westbrook MT. Organisational change in healthcare: A review of the evidence. J Health Organ Manag. 2005;19(3):205–16. Lega F. The rise and fall(acy) of clinical directorates in Italy. Health Policy. 2008;85(2):252–62. 10.1016/j.healthpol.2007.07.010 . Lega F, Sartirana M. Hybrid management models in healthcare: Theory and practice. Health Policy. 2016;120(10):1191–7. Prenestini A, Sartirana M, Lega F. Involving clinicians in management: assessing views of doctors and nurses on hybrid professionalism in clinical directorates. BMC Health Serv Res. 2021;21(1):350. 10.1186/s12913-021-06352-0 . Dunnion M, Dunne E. Clinical directorates: stakeholders’ knowledge and expectations. Br J Health Care Manag. 2004;10(1):10–7. Fitzgerald L, Ferlie E. The integration of managerial and clinical roles in the NHS: A critical review. Public Adm. 2000;78(2):345–64. McGivern G, Currie G, Ferlie E, Fitzgerald L, Waring J. Hybrid manager-professionals’ identity work: The maintenance and hybridization of medical professionalism in managerial contexts. Public Adm. 2015;93(2):412–32. 10.1111/padm.12119 . Christensen T, Laegreid P. New public management reforms: An analysis of implementation in the public sector. Public Adm Rev. 2012;72(4):526–37. Byrkjeflot H, Kragh Jespersen P. Three conceptualizations of hybrid management in hospitals. Int J Public Sect Manag. 2014;27(5):441–58. 10.1108/IJPSM-12-2012-0162 . Giacomelli G, Ferré F, Furlan M, Nuti S. Involving hybrid professionals in top management decision-making: How managerial training can make the difference. Health Serv Manage Res. 2019;32(4):168–79. 10.1177/0951484819844778 . Epub 2019 May 6. PMID: 31060388; PMCID: PMC7324121. Gupta R, Vaidya A, Campbell R. Analyzing the clinical directorate system. Br J Health Care Manag. 2008;14(9):382–9. 10.12968/bjhc.2008.14.9.30833 . Ohrling M, Tolf S, Solberg Carlsson K, Brommels M. That’s how it should work: The perceptions of senior management on the value of decentralization in a service delivery organization. J Health Organ Manag. 2021;35(5):596–613. 10.1108/JHOM-12-2020-0474 . Correia T, Denis JL. Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal. BMC Health Serv Res. 2016;16(S2):161. 10.1186/s12913-016-1398-2 . Ohrling M, Tolf S, Solberg-Carlsson K, Brommels M. Managers do it their way: How managers act in a decentralized healthcare services provider organization – a mixed methods study. Health Serv Manag Res. 2022;35(4):215–28. 10.1177/09514848211065467 . Hoff TJ. Exploring Dual Commitment among Physician Executives in Managed Care. J Healthc Manag. 2001;46(2):91–111. Montgomery K. Physician executives: the evolution and impact of a hybrid profession. Adv Health Care Manag. 2001;2:215–41. Weiner BJ, Shortell SM, Alexander J. Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership. Health Serv Res. 1997;32:491–510. Stockholms läns. sjukvårdsområde, Region Stockholm, Årsrapport 2018. Ludvigsson JF, Bergman D, Lundgren CI, Sundquist K, Geijerstam JL af, Glenngård AH, Lindh M, Sundström J, Kaarme J, Yao J. The healthcare system in Sweden. Eur J Epidemiol. 2025;40(5):563–79. 10.1007/s10654-025-01226-9 Heyssel R, et al. Decentralized management in a teaching hospital. N Engl J Med. 1984;310(22):1477–80. Mintzberg H. The Structuring of Organizations: A Synthesis of the Research. Prentice-Hall; 1989. Packwood T, et al. The role of clinical directors in the management of healthcare organizations. Int J Health Serv. 1992;22(3):425–41. Ruffner JK. Product line management: how six healthcare institutions make it work. Healthc Forum. 1986;29(5):11–4. Jamous H, Peloille B. Professions or self-perpetuating systems? Changes in the French university-hospital system. In: Jackson JA, editor. Professions and Professionalization. Cambridge: Cambridge University Press; 1970. pp. 111–52. Abbott P. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press; 1988. Freidson E. Professionalism Reborn: Theory, Prophecy and Policy. Cambridge: Polity; 1994. Harrison S, Ahmad A. The Changing Role of Doctors in Health Service Management: Decentralization and the Hybridization of Healthcare Roles. J Health Organ Manag. 2000;14(4):183–95. Harrison S, Ahmad WIU. Medical Autonomy and the UK State 1975 to 2025. Sociol (Oxford). 2000;34(1):129–46. 10.1177/S0038038500000092 . Reay T, Hinings B. Managing professional identities: Organizational change and the restructuring of professional work. J Organ Behav. 2009;30(1):1–15. Hickie S. Hybrid roles in health care: Bridging the gap between clinical and managerial expertise. J Manag Med. 1994;8(3):58–65. Lathrop AH, et al. Managing change in healthcare systems: A critical review of hybrid management roles. J Health Soc Behav. 1991;32(4):374–9. Reay T, Hinings CR. Managing the rivalry of competing institutional logics. Organ Stud. 2009;30(6):629–52. 10.1177/0170840609104803 . Olakivi A, Niska M. Rethinking managerialism in professional work: from competing logics to overlapping discourses. J Prof Organ. 2017. 10.1093/jpo/jow007 . Saltman RB, Bankauskaite V, Vrangbaek K. Decentralization in health care. Berkshire, England: European Observatory on Health Systems and Policies; 2007. Exworthy M, Frosini F, Jones L, Peckham S, Powell M, Greener I, Anand P, Holloway J. Decentralization and Performance: Autonomy and Incentives in Local Health Economies. Research Report. National Institute of Health Research; 2010. Sang H. Decentralization in Health Care Systems: A Comparative Study of Decision-Making in Health Organizations. Soc Sci Med. 1993;37(7):957–69. Ohrling M, Ovretveit J, Brommels M. Can management decentralization resolve challenges faced by healthcare service delivery organisations? Findings for managers and researchers from a scoping review. Int J Health Plann Manag. 2021;36:30–41. Bossert TJ. An Analytical Framework for Decentralization in Health Systems. Health Policy Plann. 1998;13(2):75–84. Creswell JW. Research design: Qualitative, quantitative, and mixed methods approaches. 2nd ed. Thousand Oaks, CA: Sage; 2003. Tashakkori A, Teddlie C. Mixed methodology: Combining qualitative and quantitative approaches. Sage Publications, Inc.; 1998. United Nations. Recommendations for the Preparation of Sample Survey Reports (Provisional Issue). Statistical Papers Series C, No. 1, Rev 2. Department of Economic and Social Affairs, Statistical Office of the United Nations; 1964. Krosnick JA. Questionnaire Design. In: Vannette D, Krosnick J, editors. The Palgrave Handbook of Survey Research. Cham: Palgrave Macmillan; 2018. 10.1007/978-3-319-54395-6_53 . Jesús García de Yébenes, Prous M, Salvanés FR, Ortells LC. Validation of questionnaires. Reumatol Clin (Barc). 2009;5(4):171–7. Nemoto T, Beglar D. Developing Likert-scale questionnaires. In: Sonda N, Krause A, editors. JALT2013 Conference Proceedings. Tokyo: JALT; 2014. Braithwaite J, Westbrook MT. A survey of staff attitudes and comparative managerial and nonmanagerial views in a clinical directorate. Health Serv Manage Res. 2004;17(3):141–66. 10.1258/0951484041485629 . PMID: 15285824. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. 10.1177/1049732305276687 . Assarroudi A, et al. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;42–55. 10.1177/1744987117741667 . Sartirana M, Giacomelli G. Hybridity enabled: A research synthesis of the enabling conditions for hybrid professionalism in healthcare. Health Serv Manag Res. 2024;37(1):2–15. 10.1177/09514848231151829 . Vrangbæk K. Decentralization in Scandinavian Health Systems: From a Single Model to Different Approaches. Health Policy. 2007;80(3):310–21. Exworthy M, Frosini F, Decentralization. Decision-Making, and Public Services: A Comparative Analysis. Public Adm Rev. 2015;75(1):100–8. Exworthy M, Halford S. Organizational Change and Public Services: The Impact of Decentralization in the UK. Public Adm. 1999;77(4):553–77. Harrison S, Ahmad A. Professionalism and managerialism: The challenges of hybrid roles. Soc Sci Med. 2000;50(7–8):1145–55. Saltman RB, Ferroussier-Davis J. The Concept of Decentralization in Health Systems: A Critical Review of the Literature. Health Policy. 2004;70(3):1–16. Wong CA, Elliott-Miller P, Laschinger H, Cuddihy M, Meyer RM, Keatings M, Burnett C, Szudy N. Examining the relationships between span of control and manager job and unit performance outcomes. J Nurs Manag. 2015;23(2):156–68. 10.1111/jonm.12107 . Additional Declarations Competing interest reported. MO was at the time the manager of the organization studied. However, the survey was administered, and the results were compiled by persons without relations with the respondents. The analysis, including statistics, was openly and transparently discussed by the research team. Supplementary Files SupplementaryFile1.docx SupplementaryFile2.docx Cite Share Download PDF Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 06 Nov, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 29 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviews received at journal 19 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers invited by journal 29 Jul, 2025 Editor assigned by journal 24 Jul, 2025 Editor invited by journal 17 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7107551","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492970649,"identity":"ac1ec8c3-6cdb-4f9a-8ad8-c7c096494478","order_by":0,"name":"Mikael Ohrling","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABQUlEQVRIie2QP2vCQBTAXxDS5cKtVwL5BoVXDixCaL6Kh+Ak1LHjBSFdgl3N3C+QyTlyYJdYV8FF8QtYukh7Qy9asaZK10Lz4/68u3c/Hu8AKir+IjXbLF0AhJrMAHxzsuQuRQjA4pyCxbAKpb1XcKc0T5X5pphI7a/PK1cPtlivEbwbdxSq7vv0jtKncNXV2qPxZLQQHQjosVJXtrocIPBGX0iV9OeNZLDs8SRCzib9FoohiESWlAvpEgSR5pZUTjxHnI0i15EoUkrqzChNzMpK70MflBcMCoXogxIEZcUeu7BXyCZDpKFRbKM48Vax0h+9tBsxMo7bKrKFbGb1uBNxzvKcm16YGJSqTMd8trn3Pcxr6o3oW6SPz8sV0Z75sc714nXoB/S4/S/YbrOiIm6eSp1Fm0mzXx5VVFRU/Dc+Ae6Yd0qRPZI6AAAAAElFTkSuQmCC","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":true,"prefix":"","firstName":"Mikael","middleName":"","lastName":"Ohrling","suffix":""}],"badges":[],"createdAt":"2025-07-12 10:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7107551/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7107551/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13977-y","type":"published","date":"2026-01-12T16:31:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88100919,"identity":"d555d502-89bd-462d-9cf2-6ea5a0c1a0fe","added_by":"auto","created_at":"2025-08-01 11:25:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":297450,"visible":true,"origin":"","legend":"\u003cp\u003eProgramme theory is based on a continuous and iterative organisational process with perpetual interactions between structure, culture and outcomes.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7107551/v1/a5468dad49ae431f46fd8db7.jpeg"},{"id":88099686,"identity":"a579640f-3ccf-49c2-9897-e9d3df748446","added_by":"auto","created_at":"2025-08-01 11:17:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":518360,"visible":true,"origin":"","legend":"\u003cp\u003eThe interaction between delegated authority, accountability, and capacity (both individual and organisational) in CDs [37].\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7107551/v1/562dbbf98c5e4bed9bd690e7.png"},{"id":100616255,"identity":"fe63acfc-fb3f-43e9-86f8-6b5a7927f21b","added_by":"auto","created_at":"2026-01-19 17:41:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1879415,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7107551/v1/b641ec40-dbe1-4646-9093-2bc8cf5f5c93.pdf"},{"id":88098440,"identity":"9082ae18-177b-480f-b82d-dd8436db34b0","added_by":"auto","created_at":"2025-08-01 11:09:17","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15219,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7107551/v1/63c951b61fee35bfe5f9cb98.docx"},{"id":88099688,"identity":"39c55057-78ac-4bee-9d4c-50f5ccecf74d","added_by":"auto","created_at":"2025-08-01 11:17:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16064,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7107551/v1/ed8fc3306d3f3d0ead9b9265.docx"}],"financialInterests":"Competing interest reported. MO was at the time the manager of the organization studied. However, the survey was administered, and the results were compiled by persons without relations with the respondents. The analysis, including statistics, was openly and transparently discussed by the research team.","formattedTitle":"Challenges in Hybrid Management in Healthcare: A Study of the Interplay between Divisional Managers and Clinical Directors in a Decentralized Healthcare Organization in Sweden","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eThe incorporation of medical professionals into management can be considered a multifaceted strategy [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Initially, financial management was in focus when a traditional command-and-control model with a managing administrative body as budget holders separated from clinical operations and medical professionals was changed into new organisational forms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNew public management (NPM) principles, as drivers, called for more solid managerial knowledge in clinical operations for key decisions in contracting and performance management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These changes from dual management resulted in hybrid management roles, defined as professionals engaged in contracting and resource allocation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. After the fallacy of the NPM reforms, hybrid roles were considered more to integrate managerial and professional dimensions for improvement than just control [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eClinical directorates (CDs) are a common organizational configuration for involving medical professionals in management [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The model has been developed to encompass performance and improved service delivery in a broader sense [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. CDs have been studied mainly in hospital settings [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] but have also been investigated in primary and community healthcare organizations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. There is evidence that hospitals managed by doctors do better than other hospitals do [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A positive association has also been shown between medical professionals at the board level and quality improvement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, CDs can be defined at different levels in an organization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, hybrid roles as managers can be found at the corporate, divisional, departmental and clinical levels within the same organization, thereby creating a potentially challenging hierarchical chain of \u0026ldquo;hybrid commands\u0026rdquo;.\u003c/p\u003e\u003cp\u003eDespite the substantial literature on improving healthcare services by introducing hybrid management and CDs, there is a knowledge gap around the interplay between hybrid-managerial levels within an organization. Correia and Denis [13, p 74] stress the importance \u003cem\u003eof understanding the \u0026ldquo;microlevel processes of role configuration and relations among hybrids and their medical peers\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThis paper aims to address these concerns by focusing on the experiences of a large public primary and community healthcare service delivery organization with a history of two decades of decentralization in Sweden and how the introduction of a divisional hybrid-managerial level to increase efficiency was perceived by clinical directors in the CDs. Earlier in-depth studies of the management model in the same organization are considered advantageous for understanding the objectives of this study. In the first study, the program theory of the management model is outlined [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the second study, the clinical directors\u0026rsquo; perceptions of the model are analyzed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis article is structured as follows. First, the setting and the theoretical frameworks will be presented to understand hybrid management in relation to organisational structures and processes in the study setting. Then, empirical data from two surveys are used to illustrate how the introduction of a hybrid-managerial divisional level to increase efficiency is perceived by clinical directors. Finally, these findings will be discussed in relation to clinical directorates, hybrid management, and decentralization.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Study setting\u003c/h2\u003e\u003cp\u003eThe regional public health provider in Stockholm, Sweden, manages its hospitals and services as separate entities, but in 2004, all public primary, community and mental healthcare services were integrated into one healthcare provider organization. This healthcare service serves 2.4\u0026nbsp;million inhabitants with responsibility for all tax-financed regional public services in the capital county. The organization is structured in 122 decentralized CDs divided into 700 centers or units, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Private providers are also contracted by the regional Commissioner in the mixed public and private service delivery healthcare system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, private providers are accountable for their contracts and governed by their owners. The public healthcare services have a professional board appointed by the general assembly of the region and are contracted as well by the Commissioner.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFacts on the healthcare services organization\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eServices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePHC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMHCS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGASE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRD*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRevenue 2018 (million Euro)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e480\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo of employees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026nbsp;500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 050\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e360\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11 470\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo of outpatient visits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u0026nbsp;776 272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026nbsp;208 931\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e502 810\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e157 108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u0026nbsp;645 121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo of beds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e875\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1 21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo of clinical directorates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo of clinical directors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003ePHC\u0026thinsp;=\u0026thinsp;Primary healthcare; MHCS\u0026thinsp;=\u0026thinsp;Mental healthcare services; GASE\u0026thinsp;=\u0026thinsp;Geriatrics, Advanced palliative home care, Somatic specialist care, Emergency centers; HA\u0026thinsp;=\u0026thinsp;Habilitation and assistive technology; RD\u0026thinsp;=\u0026thinsp;Research and development; *) from 1 Oct 2017\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe organization is a typical line-management, a public professional bureaucracy with value- and trust-based governance with approximately 650 managers in total [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The organization is one of the largest and most decentralized public health care service delivery organisations in Sweden. This provides a unique opportunity to study the interplay between managerial levels when introducing a divisional level within a decentralized organization structured in CDs. Each department or healthcare center is defined as a CD with a clinical director, with the responsibility of one or more CDs, given a large degree of delegated authority that matches their accountability. The organisational configuration was flat at two levels: the chief executive officer (CEO) with coordinators and the other with CDs with the clinical director and staff. The program theory has been presented in an earlier study and can be schematically described as in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAfter a decade with a large decision latitude given to the clinical directors in CDs, an urge for increased boundary spanning effectiveness and flexibility, as well as a need to reduce local administration, was identified in workshops held with the clinical directors. To support consolidation and coordination to better use resources, a new managerial division level was introduced in 2016. The CDs were grouped into four divisions. Managers with medical backgrounds and experience as clinical directors were appointed division managers by the CEO. However, the authority delegated to clinical directors for staff, budget, and quality did not change. The assignment of the divisional hybrid managers, appointed by the CEO, was to appoint clinical directors and work with them to coordinate, consolidate and increase efficiency in the divisions. The clinical directors reported to the divisional managers. In October 2017, the research centers were collected in a fifth division for research and development.\u003c/p\u003e\u003cp\u003eThree objectives were formulated for the new organization. First, free-up time at the clinical level (CD) is needed to obtain more time for patients, collaboratives, and quality improvement. Second, increasing efficiency and reducing the administrative burden at the CD level, and third, increasing competence in administrative central support by consolidation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Study objectives\u003c/h2\u003e\u003cp\u003eTo address these knowledge gaps, the objectives of this study were to 1) describe and understand the interplay between managerial hybrid levels within a decentralized organization structured in CDs grouped in divisions, 2) inform health care systems and managers that are considering implementing clinical managerial levels, and 3) contribute to theory by discussing these findings in relation to hybrid management, clinical directorates, and decentralization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Theoretical background\u003c/h2\u003e\u003cp\u003eClinical directorate (CD) structures have been introduced to involve health professionals by incorporating them in managerial responsibilities [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The model originates from the introduction of functional units at the specialty level, primarily to control cost, at Johns Hopkins, USA, in 1973 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Since then, the model has spread globally but has translated differently in relation to contextual factors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These structures have been described as \u0026ldquo;move from a professional bureaucracy to a divisionalised form\u0026rdquo; [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, the introduction of CDs by hybrid managers should enhance resource allocation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and improve efficiency [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHybrid managers are professionals managing resources and staff in professional work framed by both professional and managerial logics [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Professionals are experts in self-regulating areas who are not available without qualifications, training, and socialization and who claim autonomy [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Historically, professionals have been described as opponents of change that challenges autonomy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Hybrid managers with a combination of clinical and managerial expertise [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and a focus on patients [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] are assumed to overcome the gap between the rivaltry between the managerial and medical professional logics [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe decentralization of decision-making from the central to the lower level has been proposed to increase the response to local needs [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The introduction of CDs with hybrid managers given a delegated authority is supposed to enhance decentralized decision-making [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In a previously published scoping review [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], management decentralization was conceptualized in a framework developed from Bossert\u0026rsquo;s original decision space model [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] to fit healthcare service delivery organisations and the daily challenges faced by managers in healthcare. The framework illustrates the interaction between authority delegated to managers, accountability and capacity at both the individual and organizational levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eA mixed methods design with both quantitative and qualitative analyses of the findings of two surveys was used to examine the interplay between managerial hybrid levels within a decentralized organization [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This approach enabled statistical analysis for quantification and comparisons over time, whereas the open-ended questions were analyzed with directed content analysis to refine and explain those results in greater depth [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Survey instrument\u003c/h2\u003e\u003cp\u003eThe survey instrument was designed as a questionnaire to evaluate the introduction of the divisional level. An ad hoc questionnaire [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] was developed through a stepwise process: 1) the objectives of the organisational change were formulated as three questions; 2) a workshop to validate the instrument was performed with the management team; and finally, 3) a group of experienced clinical directors were consulted to check for feasibility, reliability and validity, whether they considered the questions assessed the objectives, and could be used for evaluation [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The three questions in the survey were formulated as statements, and the responses were given on Likert scales [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], ranging from one (strongly disagree) to four (strongly agree), with a neutral alternative. Free-text boxes enabled participants to provide detailed open-ended answers. In the second survey in 2019, more questions related to actuality were added.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Participants\u003c/h2\u003e\u003cp\u003eAll ninety-five (20% male, 80% female) clinical directors of the organization received the survey. This sampling strategy ensured the participation of the whole organization across all different facility types and sizes of CDs and the professional background and experience of the hybrid managers. All clinical directors, as decision-makers responsible for translating organisational policies into operational practices, were captured in this way. They all had the same delegated authority and accountability as managers for their CDs, regardless of their professional clinical background, healthcare division, or size of services. They all, to various extents, worked as clinicians and had a detailed understanding of daily operations and the issues involved for all clinical and administrative staff. At the time of the first survey, research centers were separate entities but a research and development division was under formation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data collection\u003c/h2\u003e\u003cp\u003eThe survey data were collected anonymously online twice via the Webropol survey (webropol.com), first in May 2018 and second in November 2019. Each time, ten days were given a reply, and a reminder was sent out to everyone after five days. The survey instrument is available in Supplementary File 1.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data analysis\u003c/h2\u003e\u003cp\u003eThe analysis was both quantitative and qualitative. Several statistical methods have been used to analyze and compare the results from 2018 and 2019 concerning the three main objectives across the whole organization (Total) and across each division to compare the four divisions: primary healthcare (PHC), mental healthcare services (MHCS), geriatrics and advanced palliative home care, somatic care and local emergency centers (GASE), and habilitation and assistive technology (HA). Both nonparametric tests, such as the Mann‒Whitney exact test and Fisher's exact test, which are chi-square (χ\u0026sup2;)-based tests, are used to compare groups, whereas various indices (polarity, intensity, and uncertainty) are employed to understand the distribution of responses and uncertainty in the data [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOpen-ended survey responses were systematically analyzed via directed content analysis [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], guided by the three main objectives of the change, which are sorted according to advantages or disadvantages identified by the clinical directors, to supplement the quantitative findings. This contributes to understanding and triangulation to enhance the validity of the results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethical considerations\u003c/h2\u003e\u003cp\u003eThe study was performed as a part of a larger project on management decentralization, the research plan of which has been evaluated and endorsed by the Stockholm Regional Research Ethics Board (DNr 2018/98-31/5) which is a part of The Swedish Ethical Review Authority\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThe surveys were performed as a part of ordinary operations. All methods were performed in accordance with relevant guidelines and regulations, including informed consent to participate in the study from all the participants.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e\u003cstrong\u003e3.1 Sample characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEighty (84%) clinical directors completed the first survey in May 2018, and 92 (97%) completed the second survey in November 2019, of which 62% were completed by the same clinical director as in the first survey. The study sample characteristics based on the response rates of the two surveys are shown in Table 2. CDs in primary care represented 74% and 69%, respectively, of the responses. They are mainly smaller entities with fewer than 50 employees, whereas the other services are larger CDs with up to approximately 1 000 employees, which indicates that the number of subordinate managers ranges from none to 35, with a median of 27 in the larger CDs (MHCS and HA). Regardless of this or professional and clinical background, the clinical directors have the same delegated authority. However, 46% and 65%, respectively, of the responders had less than two years of experience as clinical directors.\u003c/p\u003e\n\u003cp\u003eTable 2. Characteristics of the study samples, surveys 1 and 2\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"93%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eResponse rate (n of total 95 in %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMay 2018\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=80\u0026nbsp;\u003c/strong\u003e(84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNovember 2019\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=92\u0026nbsp;\u003c/strong\u003e(97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eDivisional affiliation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Primary healthcare (PHC)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mental healthcare services (MHCS)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Geriatric and somatic care (GASE)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Habilitation and Assistive technology (HA)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Research and Development (RD)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59\u0026nbsp;(74%)\u003c/p\u003e\n \u003cp\u003e10 (12%)\u003c/p\u003e\n \u003cp\u003e7 (9%)\u003c/p\u003e\n \u003cp\u003e4 (5%)\u003c/p\u003e\n \u003cp\u003eUnder formation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63 (69%)\u003c/p\u003e\n \u003cp\u003e10 (11%)\u003c/p\u003e\n \u003cp\u003e9 (10%)\u003c/p\u003e\n \u003cp\u003e5 (5%)\u003c/p\u003e\n \u003cp\u003e5 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eExperience as clinical director\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026le;2 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;3-10 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;11-15 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge;16 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (46%)\u003c/p\u003e\n \u003cp\u003e27 (34%)\u003c/p\u003e\n \u003cp\u003e9 (11%)\u003c/p\u003e\n \u003cp\u003e7 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60 (65%)\u003c/p\u003e\n \u003cp\u003e24 (26%)\u003c/p\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003cp\u003e6 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eSpan of control\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;20 employees\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;21-50 employees\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 51-200 employees\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026gt;201 employees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (5%)\u003c/p\u003e\n \u003cp\u003e37 (46%)\u003c/p\u003e\n \u003cp\u003e28 (35%)\u003c/p\u003e\n \u003cp\u003e11 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (9%)\u003c/p\u003e\n \u003cp\u003e35 (38%)\u003c/p\u003e\n \u003cp\u003e34 (38%)\u003c/p\u003e\n \u003cp\u003e14 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eSubordinate managers in CDs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;None\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Range [1-35]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Median PHC/GASE/RD 6; MHCS/HA 27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (21%)\u003c/p\u003e\n \u003cp\u003e63 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (21%)\u003c/p\u003e\n \u003cp\u003e73 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePHC=Primary healthcare; MHCS=Mental healthcare services; GASE=Geriatrics, Advanced palliative home care, Somatic specialist care, Emergency centers; HA=Habilitation and assistive technology; RD=Research and development; *) from 1 Oct 2017\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Objective 1: Free-up time for patient care and development at CD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey in May 2018 revealed that a majority (72%) disagreed or strongly disagreed, and 6% agreed with the statement that the new divisional organization had freed up more time for patient care and development at the CD level. In November 2019, 47% of the respondents disagreed or strongly disagreed, whereas 24% agreed. However, 22% and 28% answered \u0026ldquo;Don\u0026rsquo;t know\u0026rdquo;. All the data are presented in Supplement File 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most notable change between 2018 and 2019 was an increase in the proportion of respondents who \u0026quot;strongly agree\u0026quot; (from 6% to 24%). The percentage of those who \u0026quot;strongly disagree\u0026quot; decreased from 43% to 14%, indicating positive development in how respondents perceive the new organization\u0026apos;s impact on freeing up time for care and organisational development.\u003c/p\u003e\n\u003cp\u003eFifty-two (23 and 29) open-ended comments were gathered in the two surveys. Most of the advantages mentioned relate to improved communication, more effective leadership, and, in some cases, more time for care through joint organisational development. One clinical in MHCS expressed that the collaboratives have been better, but there was no time freed up at the CD level: \u003cem\u003e\u0026ldquo;In several ways, joint collaboratives have been better, but no time is freed up in my daily operations\u0026rdquo;.\u003c/em\u003e These improvements suggest that some aspects of the new organizational level function to elevate important issues to higher levels and provide better support for operations. One clinical director commented, \u003cem\u003e\u0026quot;There is a clear improvement in leadership and prioritization from the new division managers, who are doctors with good knowledge of the task.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe main disadvantages revolve around too many meetings and confusion about responsibility. Several expressed concerns that governance had become more detailed and thus an obstacle than support: \u003cem\u003e\u0026ldquo;I have noticed an increase in detail, which makes my work more difficult\u0026rdquo;.\u003c/em\u003e These negative effects suggest that the new organisational level has not managed to free up time as intended. Instead, it seems that new processes and requirements have created more work for employees. One of the clinical directors in PHC expressed this: \u003cem\u003e\u0026quot;It feels like the organiz\u003c/em\u003e\u003cem\u003eation hasn\u0026rsquo;t truly settled yet, and there\u0026rsquo;s still a lot to work on.\u0026quot;\u0026nbsp;\u003c/em\u003eAnother clinical director in the MHCS commented, \u003cem\u003e\u0026quot;Organiz\u003c/em\u003e\u003cem\u003eational development within the CD\u003c/em\u003e\u003cem\u003e\u0026nbsp;has been stimulated by the new\u0026nbsp;\u003c/em\u003e\u003cem\u003eorganiz\u003c/em\u003e\u003cem\u003eation, but time has not been freed up. \u0026quot;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Objective 2: Reduced administrative burden at the CD level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn May 2018, 74% of the clinical directors disagreed or strongly disagreed, and only 10% agreed with the statement that the administrative burden was reduced at the CD level. The November 2019 results revealed that 57% disagreed or strongly disagreed, whereas 15% agreed and 2% strongly agreed with the statement. The percentages of \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; were 15% and 24%, respectively, in the two surveys.\u003c/p\u003e\n\u003cp\u003eIn 2019, there was a decrease in those who \u0026quot;strongly disagree\u0026quot; (from 44% to 25%). There was an increase in those who \u0026quot;agreed\u0026quot; from 10% to 15%. Those who answered \u0026quot;Don\u0026rsquo;t know\u0026quot; increased, which may indicate that respondents became more uncertain about the effects of the new organization in terms of coordination and reduced local administration.\u003c/p\u003e\n\u003cp\u003eFifty-eight (29 in each survey) comments were made in response to this statement. The advantages described were improved coordination, especially in the context of shared plans (e.g., patient safety plans) and management processes. Some respondents noted that administrative tasks have been simplified in specific areas, such as plans that are now shared and simplified. Several clinical directors commented on increased trust: \u003cem\u003e\u0026quot;I think communication has improved, trust has increased, which has led to unnecessary administration being avoided.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, disadvantages are described as increased administrative burden, often due to a lack of coordination between support units and a lack of digitalization with outdated paper-based procedures slowing down work. Some respondents highlight the fragmented nature of some of the divisions, which makes coordination challenging, limiting the effectiveness of the reorganization. One clinical director in the GASE division expressed, \u003cem\u003e\u0026ldquo;Our needs are so diverse, so the new organization contributes rather to more administration.\u0026rdquo;\u0026nbsp;\u003c/em\u003eSeveral respondents across divisions expressed doubt that the reorganisation has had a substantial impact, with some feeling that they see no real difference compared with before: \u003cem\u003e\u0026quot;There are many question marks and ambiguities about which level should handle different issues. This increases the risk of contradictory decisions.\u0026quot;\u0026nbsp;\u003c/em\u003eOne clinical director expressed concern that the delegated authority had been limited:\u003cem\u003e\u0026nbsp;\u0026ldquo;The new organization makes me confused? What is my authority and responsibility? It has become unclear\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Objective 3:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe new Divisional level has strengthened central administrative support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statement refers to increased expertise in administrative support and faster service to CDs due to consolidation at the new divisional level. There were relatively small changes between 2018 and 2019. Forty-nine percent disagreed or strongly disagreed with the statement in May 2018, and 37% disagreed in November 2019. Twenty-five percent agreed, and 8% strongly agreed in May 2018, 35% and 7%, respectively, in November 2019. A noticeable proportion of respondents (22% in 2019) answered \u0026quot;Don\u0026rsquo;t know,\u0026quot; which may indicate that uncertainty about the effects of central operational support was greater in 2019.\u003c/p\u003e\n\u003cp\u003eSixty-three (28 and 35) open-ended comments were given. There is recognition of greater competence at higher levels of the organization, particularly in areas such as human resources (HR) and patient safety, especially in MHCS. Positive comments regarding specific support functions, such as IT-helpdesk, finance, and documentation. Improved continuity in HR and economic support, as well as more involvement from the chief medical officer, were mentioned. There is appreciation for competent division hybrid managers and experts for complicated matters: \u003cem\u003e\u0026quot;It is valuable to have \u0026apos;second-line competence\u0026apos; in complicated matters concerning patient safety and HR.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral clinical directors have common concerns about increased administrative workload due to the increased involvement of CDs. Many respondents expressed frustration with inconsistent support, particularly when the quality of help depends on the specific person, they interact with rather than the support system itself. Another concern was the lack of understanding of different operational needs within the organization and the effort that comes with local involvement: \u003cem\u003e\u0026quot;More ambitious work, but it requires more effort from each CD. The new organization works more with various types of issues at a higher level, and CDs are more involved in these matters than before.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Comparison of Perceptions between the Divisions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings in the open-ended comments from the clinical directors in the different divisions show that PHC expressed significant frustration with the increased administrative burden and the inefficiency of support functions, although IT-helpdesk was a notable exception. In MHCS, improvements in coordination and support for complex cases were identified, but administrative work and confusion about responsibilities were still major concerns. HA highlighted inconsistent support and the absence of central HR representation as key issues, with some areas performing well but others lacking attention. The GASE indicated potential for development, especially in the continuity of HR and finance functions, but administrative issues and the need for systematic changes were still challenges.\u003c/p\u003e\n\u003cp\u003eThe RD was under development as a division at the time of the first survey in May 2018. They were a part of their clinical division until reorganization. In November 2019, RD clinical directors perceived a better strategic focus when the research affairs were held together. However, concerns were noted from the clinical directors in the clinical divisions that there was a risk when research centers were in another division than the clinical activities, which could be counterproductive. One of the clinical directors in the RD division expressed another opinion, \u003cem\u003e\u0026ldquo;The collaboration\u0026nbsp;\u003c/em\u003e\u003cem\u003ehas never been better than it is now. My feeling is that this is largely due to the new\u003c/em\u003e\u003cem\u003e\u0026nbsp;organiz\u003c/em\u003e\u003cem\u003eation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5\u0026nbsp;Comparison of Perceptions b\u003c/strong\u003e\u003cstrong\u003eetween May 2018 and November 2019\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver time, the open-ended comments revealed some improvements in coordination and strategic focus, particularly in PHC and MHCS. However, all divisions still faced increased administrative workloads. MHCS and GASE reported some improvement in leadership involvement but continued to struggle with bureaucracy and administrative overload. HA noticed minor improvements, but inconsistent support remained an ongoing challenge. Overall, some divisions showed positive shifts in terms of support and competence, but administrative challenges and unclear roles continued to hamper full success.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analysis conducted via the Mann‒Whitney exact test (M-W) and Fisher\u0026apos;s exact test (Chi2) provides insights into the distribution and trends of responses between 2018 and 2019 for various groups (total, PHC, MHCS, GASE, HA). Below is an analysis of the results and an interpretation of the significance. A p value \u0026lt; 0.05 indicates that the change is significant. All the statistical comparisons between 2018 and 2019 and their corresponding significance levels are summarized in Table 4.\u003c/p\u003e\n\u003cp\u003eTable 4. Significance levels for the three objectives total and per division\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObjective 1: Free up time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObjective 2: Reduce admin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObjective 3: Central support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eM-W p value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eChi2 p value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eM-W p value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eChi2 p value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eM-W p value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eChi2 p value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.0046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.1348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e0.4766\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.0311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.1771\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.0203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e0.1708\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.3276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.809\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.5382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e0.7613\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.7336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.8238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.7308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.4261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e0.5668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.3016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.1905\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e0.5714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe results for the total group from the Mann‒Whitney and Fisher\u0026rsquo;s exact tests reveal significant changes in the perception of whether the new organization freed up time for care and development (objective 1) from 2018--2019. The total group experienced a significant decrease in agreement with the statement in 2019. The Mann‒Whitney p value of 0.0001 and the chi2 p value of 0.0001 confirm the statistical significance of this change. Other statistical measures (likelihood ratio chi-square and Mantel‒Haenszel chi-square) also indicate that the differences between 2018 and 2019 are statistically significant, indicating that the changes are not due to chance.\u003c/p\u003e\n\u003cp\u003eThe analysis for the total group indicated a slight improvement in the reduction in local administrative tasks (objective 2) in 2019, with a significant Mann‒Whitney p value of 0.0046, whereas the chi-square p value of 0.056 was borderline, suggesting that although a shift was statistically significant, its practical relevance may be small. The likelihood ratio chi-square test and other tests support this interpretation.\u003c/p\u003e\n\u003cp\u003eNo significant changes were observed in the strengthening of central support (objective 3) across the total group from 2018--2019. The Mann‒Whitney p value of 0.1348 and the chi2 p value of 0.4766 suggest that perceptions regarding the competence and speed of central support remained largely unchanged. The likelihood ratio chi-square test and other tests support this result since the changes are not large enough to be considered a real effect.\u003c/p\u003e\n\u003cp\u003eIn the groupwise breakdown, a significant reduction in agreement was observed in PHC and MHCS, indicating decreased confidence in the new organization\u0026rsquo;s ability to free up time for care and development (objective 1). GASE and HA did not significantly change. PHC reported a slight improvement in the reduction in the administrative burden at the CD level (objective 2), but no significant changes were observed in MHCS, GASE, or HA. PHC experienced a significant decrease in the perceived improvement in central support (objective 3), whereas other areas, such as MHCS, GASE, and HA, experienced no significant changes in central operational support.\u003c/p\u003e\n\u003cp\u003eThe data provided for the three objectives show changes in the polarity index (PI), intensity index (II), and uncertainty index (UI), as shown in Table 5. The indices measure the distribution of responses, the intensity of opinions, and the level of uncertainty among respondents. Across the divisions, there was a general trend toward more evenly distributed responses in 2019, reflecting a shift from extreme to moderate opinions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe increase in PI from 2018--2019 suggests that a more balanced distribution of opinions emerged. The overall decrease in II for most divisions indicates a move from strong polarization to more moderate views, with MHCS showing the largest decrease, highlighting a shift toward less extreme opinions. There was an increase in uncertainty in PHC, MHCS, and GASE, with MHCS experiencing the most drastic shift toward uncertainty, whether the new organization had freed up time and reduced administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, these shifts in PI, II, and UI suggest that the organizational changes introduced in 2019 led to greater balance in opinions across most divisions, although uncertainty persisted in certain areas. This may reflect an evolving understanding of the new structures and roles, with some divisions experiencing more moderate and decisive opinions and others facing greater uncertainty.\u003c/p\u003e\n\u003cp\u003eTable 5. Polarity (PI), intensity (II) and uncertainty (UI) indices\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDivision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePI_2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePI_2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eII_2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eII_2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUI_2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUI_2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e*0.08/0.67/0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.53/0.88/0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e43/23/44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e15/16/21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e22/18/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e28/21/14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.12/0.53/0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.56/0.7/0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e48/21/37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e18/16/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e21/19/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e25/22/15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0/0.5/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.75/0.6/0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e40/30/80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10/10/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e10/10/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e30/20/0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0/1/0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0/0.16/0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e29/14/57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e22/11/34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e14/14/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e33/22/22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0/0.5/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.33/0/0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0/50/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0/0/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e50/25/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e20/40/40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1/0.67/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0/40/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e60/0/0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*) Indices in frames corresponding to objective 1/objective 2/objective 3.\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThis study offers valuable insights into the perceptions of clinical directors regarding the interplay between hybrid-managerial levels when a division level is introduced within a large public healthcare organization decentralized in CDs. Despite the default intended benefits of more time for patients and increased efficiency, a reduced administrative burden, and improved central support, the results of the study highlight several observations and outcomes. In this section, the findings are discussed in relation to existing research on clinical directorates (CDs), hybrid management, and decentralization addressing the complexities of integrating clinical and managerial roles within a decentralized healthcare service delivery organization.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Freeing Up Time for Patient Care and Development\u003c/h2\u003e\u003cp\u003eThe results of this study indicate that the new divisional hybrid-managerial level did not significantly free up time for patient care and organizational development, particularly in PHC and MHCS, as intended. This outcome aligns with findings from previous research on clinical directorates, which emphasize the difficulties inherent in balancing managerial and clinical responsibilities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. According to Braithwaite and Westbrook [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], while the introduction of hybrid roles can theoretically lead to more efficient management, in practice, these roles often face challenges related to maintaining clinical autonomy while simultaneously adopting managerial tasks. The interplay will be even more complicated when there is hybrid management at both divisional and CD levels, which this study explores. Hybrid managers may experience role ambiguity, leading to resistance from both clinical staff and administrative personnel [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, some clinical directors expressed frustration with the increased number of meetings and the complexity introduced by the new structure, which, rather than freeing up time for patient care, contributed to further administrative burdens. These findings are consistent with Christensen and Laegreid [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], who noted that while hybrid models aim to foster integration between clinical and managerial roles, they often fail to reduce the administrative workload, especially in decentralized organizations. These outcomes also resonate with those of Packwood et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], who reported that hybrid managerial roles frequently encounter tensions that limit their ability to streamline operations. However, in this study, the improvement in joint collaborations is facilitated by the divisional organization in the MHCS with a professional hybrid manager who enables the clinical directors to contribute to joint quality and process improvement. This is supported by the findings of a recent scoping review on the importance of identifying and understanding how hybridity can be enabled to benefit core processes [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn relation to previous research on decentralization and the importance of clear roles and responsibilities within a decentralized organization, the results of this study highlight both the potential and challenges of decentralization [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The proper implementation of decentralization can lead to more responsive management structures that can address local needs and improve overall organizational efficiency. However, for decentralization to be effective, it is crucial that roles, delegated authority, responsibilities, and structural and individual capacity are clearly defined, ensuring that managers at different levels have the authority and accountability required to make decisions effectively [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, although the introduction of the divisional hybrid managerial level was intended to free up time for patient care and reduce the administrative burden at the CD level, many clinical directors reported increased complexity and confusion regarding their roles and responsibilities in relation to the division hybrid manager. This is consistent with findings that decentralization can lead to ambiguity if the delineation of authority and responsibility is unclear [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The lack of clarity about responsibilities, particularly in areas such as administrative tasks, was a recurrent theme in the comments of the clinical directors, undermining the intended outcomes of the reorganization.\u003c/p\u003e\u003cp\u003eIn previous research, decentralized decision-making stresses that while local autonomy can increase responsiveness and adaptability, it also requires a balance between authority and accountability to ensure effective decision-making [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the case of this study, the hybrid-managerial roles on the divisional level, while intended to enhance coordination and reduce administrative workload at the CD level, seem to have blurred the lines between authority and responsibility, resulting in role confusion. This is evident in the 2019 survey results, where a significant portion of respondents indicated uncertainty about their authority within the new structure, particularly in the wake of the introduction of the divisional managerial level. These findings suggest that the decentralization process may have been impeded by the lack of clear communication regarding the roles of hybrid managers at the different organizational levels and their delegation of authority, thus limiting the potential benefits of decentralization. However, several clinical directors, especially in MHCS and PHC, noted that collaboratives and joint quality improvement work were enhanced by the divisional hybrid managers thanks to their clinical background, which is consistent with findings from a survey conducted by Prenestini et al. in an Italian context [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, the delegated authority must be matched with adequate capacity and support at the local level to achieve the desired outcomes of decentralization [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The study findings, particularly those from the clinical directors in PHC, suggest that although the intention was to reduce local administrative burdens and increase managerial support, the increased span of control and lack of clear support systems led to the opposite effect. This finding indicates that while decentralization might have theoretically empowered clinical directors with greater autonomy, the practical implementation of this structure when introducing the divisional level, with its unclear role and additional administrative complexity, led to confusion and inefficiency at the CD level. This finding aligns with Wong\u0026rsquo;s [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] argument that a wider control span, especially in complex healthcare settings, can overwhelm managers with too many responsibilities, leading to inefficiencies and confusion. The increase in administrative workload and confusion about roles, particularly within PHC and MHCS highlights how the span of control may have expanded in a way that made governance more difficult rather than being more streamlined or that the streamlining has confused the clinical directors instead of being clear.\u003c/p\u003e\u003cp\u003eIn summary, the results of this study support the assertion that decentralization can be an effective strategy for improving healthcare management, but only when roles, responsibilities, and authority are clearly communicated and well supported at all levels. The findings indicate that the lack of clarity in the new divisional structure and the blurred boundaries between roles undermined the positive effects of decentralization, leading to increased administrative burden and confusion rather than the expected efficiency improvements. This finding reinforces the importance of clear delegation of responsibilities and authority at all organizational levels and how they interplay as central to the success of decentralization in healthcare organizations [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Reduction in administrative burden\u003c/h2\u003e\u003cp\u003eWhile some improvement in the reduction of administrative burdens was noted, particularly within PHC, the overall reduction was minimal. The study revealed that administrative tasks remained a persistent challenge across divisions, even though some respondents reported improved coordination and communication. This reflects earlier findings by Exworthy et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], who reported that decentralization and the introduction of hybrid management often fail to significantly reduce the administrative workload, as anticipated by healthcare policymakers. The introduction of hybrid managerial roles at a new organizational level in this study did not lead to widespread reductions in administrative tasks, and in some cases, clinical directors reported that the new structure increased bureaucracy.\u003c/p\u003e\u003cp\u003eLega and Sartirana [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] also reported that hybrid management roles tend to face challenges when tasked with reducing administrative workloads in healthcare organizations. The introduction of new administrative levels and hierarchical structures often leads to greater complexity, as power dynamics shift, and coordination challenges arise. The negative experiences expressed by clinical directors regarding administrative overload further support the conclusions drawn by Fitzgerald and Ferlie [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], who argued that the administrative burden in hybrid management systems often outweighs the intended benefits of decentralization.\u003c/p\u003e\u003cp\u003eFurthermore, while there were reports of improved coordination in some areas, particularly related to shared patient safety plans, these positive changes were not universally experienced across all divisions. This variability in outcomes could be attributed to the heterogeneous nature of the divisions themselves, which, as noted by Braithwaite and Westbrook [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], may create challenges for hybrid managers when attempting to implement standardized processes across different clinical settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Strengthening of Central Administrative Support\u003c/h2\u003e\u003cp\u003eWith respect to the strengthening of central administrative support, the results suggest that there was little significant change in central support from 2018\u0026ndash;2019. While there were some improvements in the competency of support functions, particularly in areas such as HR and patient safety, many respondents indicated that the support remained inconsistent and was often dependent on individual staff members rather than systematic improvements. This mirrors findings by Hickie [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and Lathrop et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], who highlighted the challenges faced by hybrid managers in securing reliable, competent support across all aspects of administrative functions.\u003c/p\u003e\u003cp\u003eAdditionally, Reay and Hinings [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] suggested that hybrid managers are frequently caught between competing demands from both the professional and the managerial sides of the organization, which can undermine their ability to leverage centralized support effectively. This is particularly evident in this study, where clinical directors reported frustration with inconsistent support and confusion about responsibility allocation.\u003c/p\u003e\u003cp\u003eOne of the positive aspects reported by the clinical directors was the increased competence in specific support areas, such as human resources and patient safety, which aligns with the findings of Montgomery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], who suggested that when hybrid management models are effectively implemented, they can improve central administrative services. However, as noted by Christensen and Laegreid [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], these improvements are often tempered by a broader organizational culture that resists change and undermines the effectiveness of hybrid roles. In our case, the power shift that occurred when the new divisional level was introduced, and the interplay between the two hybrid-managerial levels, were major cultural challenges.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Organizational Culture and Resistance to Change\u003c/h2\u003e\u003cp\u003eA common theme that emerged across the divisions was ongoing resistance to structural changes, particularly in the form of unclear roles and responsibilities, which echoes the findings of Jamous and Peloille [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and Abbott [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] regarding professional resistance to managerial oversight. The clinical directors expressed concerns that the new divisional management level created ambiguity in the division of responsibilities between clinical and managerial roles. This uncertainty is particularly problematic in hybrid models where managers are expected to straddle both professional and managerial identities, often leading to role conflict and resistance from staff, who feel that their autonomy is being compromised [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, Packwood et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] suggested that the introduction of hybrid roles can lead to a clash between the professional culture of healthcare and the managerial logic imposed by hybrid managers, which may result in inefficiencies and dissatisfaction among staff. The findings of this study underscore these concerns, as clinical directors reported challenges in navigating the new governance structures, particularly in areas where responsibilities were not clearly defined.\u003c/p\u003e\u003cp\u003eOlakivi and Niska's [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] concept of competing logics, in which the professional focused on clinical expertise and autonomy versus the managerial on efficiency and resource control, shed light on the struggles within hybrid management. When balanced, these conflicts undermine the success of hybrid roles. In this study, several clinical directors expressed frustration with the increased administrative burden and lack of clarity in responsibilities following the introduction of hybrid managerial roles. These challenges point to a clash between professional autonomy and managerial oversight, where professional logics may resist managerial controls or feel compromised by them, even though the divisional level is hybrid managers with professional backgrounds there is a power shift in the organization. This is particularly evident in the responses from clinical directors in MHCS and PHC, where despite a perceived improvement in leadership and coordination, confusion about roles and responsibilities persisted.\u003c/p\u003e\u003cp\u003eOlakivi and Niska [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] suggested that this conflict between competing logics can lead to dissatisfaction and inefficiency, which is echoed in the results of this study, where the intended reduction in administrative workload and increased efficiency did not materialize as expected. Therefore, the struggles with role clarity and the perceived increase in bureaucracy can be seen as manifestations of the tensions between the managerial and professional logics described by Olakivi and Niska.\u003c/p\u003e\u003cp\u003eHowever, this balance is even more challenging, as seen in the results from this study, when hybrid managers have the same professional background at the higher, divisional level as do clinical directors at the CD level, which can be assumed to be expressed in terms of role ambiguity and confusion in authority. This emphasizes the importance of understanding the power shift when introducing a new organizational level. It is crucial to identify the enablers that enhance different capacities on the different levels and training hybrid managers in their twofold role. This is discussed in a scoping review by Sartirana and Giacomelli [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and supported by a study of the importance in training hybrid managers in decision-making [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Implications for Healthcare Management\u003c/h2\u003e\u003cp\u003eThis study has several implications for healthcare management, particularly for organizations considering the introduction of hybrid managerial roles and divisional structures. First, the results suggest that while hybrid management roles can improve certain aspects of coordination and leadership on divisional level, they may not automatically lead to reduced administrative burdens or increased time for patient care at the CD level. As such, organizations should carefully consider the broader impact of these structural changes on staff workload and operational efficiency, as the introduction of new managerial levels may inadvertently increase complexity.\u003c/p\u003e\u003cp\u003eSecond, the findings highlight the need for clearer role definitions on the different organizational levels and more effective coordination across divisions. Hybrid managers, particularly in decentralized systems, require strong support structures to ensure that they can effectively navigate both managerial and clinical responsibilities. This is consistent with the conclusions of Packwood et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], who argued that successful hybrid management requires a balance between professional autonomy and managerial authority, which can be difficult to achieve without careful consideration of the organizational context and training [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, the study suggests that healthcare organizations must address resistance to change by fostering a culture that values both professional and managerial perspectives. As Reay and Hinings [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] noted, successful hybrid management relies on creating an environment where both professional autonomy and managerial efficiency are valued and where hybrid managers are provided with tools and support, they need to succeed. Identifying enablers that enhance these capacities and train for them have been shown in other studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, as suggested by Correia and Denis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], future research should explore the microlevel processes that influence the success of hybrid roles within healthcare organizations. Understanding the nuances of the interplay how hybrid managers interact with their medical peers and navigate organizational structures is essential for improving the effectiveness of these roles in practice.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Limitations and challenges\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be considered when interpreting the results. First, the surveys were conducted at only two time points (2018 and 2019), which limits the ability to draw conclusions about long-term trends. Additionally, the sample size, while large, is still limited to one healthcare provider in Sweden, which may affect the generalizability of the findings to other healthcare systems. Further studies with longer follow-up periods and across multiple organizations would provide more comprehensive insights into the long-term effects of hybrid-management reforms.\u003c/p\u003e\u003cp\u003eAnother limitation is the reliance on self-reported data from clinical directors, which may be influenced by personal biases or a desire to align responses with organizational expectations The use of both quantitative and qualitative data helps mitigate this issue, but the potential for response bias remains.\u003c/p\u003e\u003cp\u003eThe use of the Mann‒Whitney exact test, Fisher\u0026rsquo;s exact test, and indices for polarity, intensity, and uncertainty provide valuable insights into the data, particularly in the context of small sample sizes and ordinal data. However, each method has strengths and weaknesses. While the Mann‒Whitney and Fisher\u0026rsquo;s exact tests allow for robust comparisons in the context of small sample sizes and nonnormally distributed data, the interpretation of the polarity, intensity, and uncertainty indices requires a careful, context-dependent approach. These methods, when used together, offer a comprehensive view of the data. Future studies could benefit from larger sample sizes to increase the power of the tests and reduce the influence of small sample size limitations.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eThis study contributes to our understanding of the interplay between hybrid management at different levels in healthcare organizations by exploring the experiences of clinical directors, when a new organizational level is introduced, within a large decentralized public healthcare provider in Sweden. The introduction of a divisional hybrid-managerial level had mixed outcomes, with some improvements in coordination and leadership but limited success in reducing administrative burdens or freeing up time for patient care. The findings highlight the challenges in power shifts and balancing clinical autonomy with managerial responsibility and underscore the importance of clear role definitions, effective coordination, and organizational support in hybrid management systems, which become more complicated when professional hybrid management is present at different levels.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eClinical Directorate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCEO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChief Executive Officer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNPM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNew Public Management\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Resources\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary healthcare\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMHCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMental healthcare services\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGASE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeriatrics, Advanced Palliative Home Care, Somatic Specialist Care, Emergency centers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHabilitation and Assistive technology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch and Development\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eM-W\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMann‒Whitney Exact test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolarity Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eII\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensity Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUncertainty Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed as a part of a larger project on management decentralization, the research plan of which has been evaluated and endorsed by the Stockholm Regional Research Ethics Board (DNr 2018/98‐31/5) which is a part of The Swedish Ethical Review Authority. The surveys were performed as a part of ordinary operations. All methods were performed in accordance with relevant guidelines and regulations, including informed consent to participate in the study from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study, data associated, and surveys\u003c/p\u003e\n\u003cp\u003eare available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMO was at the time the manager of the organization studied. However, the survey was administered, and the results were compiled by persons without relations with the respondents. The analysis, including statistics, was openly and transparently discussed by the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as a part of ordinary operations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMO designed the study. The surveys were distributed, collected, and compiled by administrative specialists without any personal relations with the respondents. MO wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe contributions of the following individuals are gratefully acknowledged: Mr. Robert Zetterlind for the administration of the surveys and compilation of the results; MSc Per Tynelius; a senior statistician at the Center for Epidemiology and Social Medicine at Region Stockholm for excellent support with the statistics; and the research team at the Medical Management Center, Karolinska Institutet, for discussion and validation of the results.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBraithwaite J, Westbrook MT. Organisational change in healthcare: A review of the evidence. J Health Organ Manag. 2005;19(3):205\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLega F. The rise and fall(acy) of clinical directorates in Italy. Health Policy. 2008;85(2):252\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.healthpol.2007.07.010\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2007.07.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLega F, Sartirana M. Hybrid management models in healthcare: Theory and practice. Health Policy. 2016;120(10):1191\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrenestini A, Sartirana M, Lega F. Involving clinicians in management: assessing views of doctors and nurses on hybrid professionalism in clinical directorates. BMC Health Serv Res. 2021;21(1):350. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-021-06352-0\u003c/span\u003e\u003cspan address=\"10.1186/s12913-021-06352-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDunnion M, Dunne E. Clinical directorates: stakeholders\u0026rsquo; knowledge and expectations. Br J Health Care Manag. 2004;10(1):10\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFitzgerald L, Ferlie E. The integration of managerial and clinical roles in the NHS: A critical review. Public Adm. 2000;78(2):345\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGivern G, Currie G, Ferlie E, Fitzgerald L, Waring J. Hybrid manager-professionals\u0026rsquo; identity work: The maintenance and hybridization of medical professionalism in managerial contexts. Public Adm. 2015;93(2):412\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/padm.12119\u003c/span\u003e\u003cspan address=\"10.1111/padm.12119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChristensen T, Laegreid P. New public management reforms: An analysis of implementation in the public sector. Public Adm Rev. 2012;72(4):526\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eByrkjeflot H, Kragh Jespersen P. Three conceptualizations of hybrid management in hospitals. Int J Public Sect Manag. 2014;27(5):441\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/IJPSM-12-2012-0162\u003c/span\u003e\u003cspan address=\"10.1108/IJPSM-12-2012-0162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiacomelli G, Ferr\u0026eacute; F, Furlan M, Nuti S. Involving hybrid professionals in top management decision-making: How managerial training can make the difference. Health Serv Manage Res. 2019;32(4):168\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0951484819844778\u003c/span\u003e\u003cspan address=\"10.1177/0951484819844778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 May 6. PMID: 31060388; PMCID: PMC7324121.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta R, Vaidya A, Campbell R. Analyzing the clinical directorate system. Br J Health Care Manag. 2008;14(9):382\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12968/bjhc.2008.14.9.30833\u003c/span\u003e\u003cspan address=\"10.12968/bjhc.2008.14.9.30833\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOhrling M, Tolf S, Solberg Carlsson K, Brommels M. That\u0026rsquo;s how it should work: The perceptions of senior management on the value of decentralization in a service delivery organization. J Health Organ Manag. 2021;35(5):596\u0026ndash;613. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/JHOM-12-2020-0474\u003c/span\u003e\u003cspan address=\"10.1108/JHOM-12-2020-0474\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorreia T, Denis JL. Hybrid management, organizational configuration, and medical professionalism: evidence from the establishment of a clinical directorate in Portugal. BMC Health Serv Res. 2016;16(S2):161. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-016-1398-2\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1398-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOhrling M, Tolf S, Solberg-Carlsson K, Brommels M. Managers do it their way: How managers act in a decentralized healthcare services provider organization \u0026ndash; a mixed methods study. Health Serv Manag Res. 2022;35(4):215\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/09514848211065467\u003c/span\u003e\u003cspan address=\"10.1177/09514848211065467\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoff TJ. Exploring Dual Commitment among Physician Executives in Managed Care. J Healthc Manag. 2001;46(2):91\u0026ndash;111.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMontgomery K. Physician executives: the evolution and impact of a hybrid profession. Adv Health Care Manag. 2001;2:215\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiner BJ, Shortell SM, Alexander J. Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership. Health Serv Res. 1997;32:491\u0026ndash;510.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStockholms l\u0026auml;ns. sjukv\u0026aring;rdsomr\u0026aring;de, Region Stockholm, \u0026Aring;rsrapport 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLudvigsson JF, Bergman D, Lundgren CI, Sundquist K, Geijerstam JL af, Glenng\u0026aring;rd AH, Lindh M, Sundstr\u0026ouml;m J, Kaarme J, Yao J. The healthcare system in Sweden. Eur J Epidemiol. 2025;40(5):563\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10654-025-01226-9\u003c/span\u003e\u003cspan address=\"10.1007/s10654-025-01226-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeyssel R, et al. Decentralized management in a teaching hospital. N Engl J Med. 1984;310(22):1477\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMintzberg H. The Structuring of Organizations: A Synthesis of the Research. Prentice-Hall; 1989.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePackwood T, et al. The role of clinical directors in the management of healthcare organizations. Int J Health Serv. 1992;22(3):425\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRuffner JK. Product line management: how six healthcare institutions make it work. Healthc Forum. 1986;29(5):11\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJamous H, Peloille B. Professions or self-perpetuating systems? Changes in the French university-hospital system. In: Jackson JA, editor. Professions and Professionalization. Cambridge: Cambridge University Press; 1970. pp. 111\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbbott P. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press; 1988.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreidson E. Professionalism Reborn: Theory, Prophecy and Policy. Cambridge: Polity; 1994.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarrison S, Ahmad A. The Changing Role of Doctors in Health Service Management: Decentralization and the Hybridization of Healthcare Roles. J Health Organ Manag. 2000;14(4):183\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarrison S, Ahmad WIU. Medical Autonomy and the UK State 1975 to 2025. Sociol (Oxford). 2000;34(1):129\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/S0038038500000092\u003c/span\u003e\u003cspan address=\"10.1177/S0038038500000092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReay T, Hinings B. Managing professional identities: Organizational change and the restructuring of professional work. J Organ Behav. 2009;30(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHickie S. Hybrid roles in health care: Bridging the gap between clinical and managerial expertise. J Manag Med. 1994;8(3):58\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLathrop AH, et al. Managing change in healthcare systems: A critical review of hybrid management roles. J Health Soc Behav. 1991;32(4):374\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReay T, Hinings CR. Managing the rivalry of competing institutional logics. Organ Stud. 2009;30(6):629\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0170840609104803\u003c/span\u003e\u003cspan address=\"10.1177/0170840609104803\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlakivi A, Niska M. Rethinking managerialism in professional work: from competing logics to overlapping discourses. J Prof Organ. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jpo/jow007\u003c/span\u003e\u003cspan address=\"10.1093/jpo/jow007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaltman RB, Bankauskaite V, Vrangbaek K. Decentralization in health care. Berkshire, England: European Observatory on Health Systems and Policies; 2007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eExworthy M, Frosini F, Jones L, Peckham S, Powell M, Greener I, Anand P, Holloway J. Decentralization and Performance: Autonomy and Incentives in Local Health Economies. Research Report. National Institute of Health Research; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSang H. Decentralization in Health Care Systems: A Comparative Study of Decision-Making in Health Organizations. Soc Sci Med. 1993;37(7):957\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOhrling M, Ovretveit J, Brommels M. Can management decentralization resolve challenges faced by healthcare service delivery organisations? Findings for managers and researchers from a scoping review. Int J Health Plann Manag. 2021;36:30\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBossert TJ. An Analytical Framework for Decentralization in Health Systems. Health Policy Plann. 1998;13(2):75\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW. Research design: Qualitative, quantitative, and mixed methods approaches. 2nd ed. Thousand Oaks, CA: Sage; 2003.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTashakkori A, Teddlie C. Mixed methodology: Combining qualitative and quantitative approaches. Sage Publications, Inc.; 1998.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnited Nations. Recommendations for the Preparation of Sample Survey Reports (Provisional Issue). Statistical Papers Series C, No. 1, Rev 2. Department of Economic and Social Affairs, Statistical Office of the United Nations; 1964.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrosnick JA. Questionnaire Design. In: Vannette D, Krosnick J, editors. The Palgrave Handbook of Survey Research. Cham: Palgrave Macmillan; 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-319-54395-6_53\u003c/span\u003e\u003cspan address=\"10.1007/978-3-319-54395-6_53\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJes\u0026uacute;s Garc\u0026iacute;a de Y\u0026eacute;benes, Prous M, Salvan\u0026eacute;s FR, Ortells LC. Validation of questionnaires. Reumatol Clin (Barc). 2009;5(4):171\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNemoto T, Beglar D. Developing Likert-scale questionnaires. In: Sonda N, Krause A, editors. JALT2013 Conference Proceedings. Tokyo: JALT; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraithwaite J, Westbrook MT. A survey of staff attitudes and comparative managerial and nonmanagerial views in a clinical directorate. Health Serv Manage Res. 2004;17(3):141\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1258/0951484041485629\u003c/span\u003e\u003cspan address=\"10.1258/0951484041485629\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 15285824.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049732305276687\u003c/span\u003e\u003cspan address=\"10.1177/1049732305276687\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAssarroudi A, et al. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;42\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1744987117741667\u003c/span\u003e\u003cspan address=\"10.1177/1744987117741667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSartirana M, Giacomelli G. Hybridity enabled: A research synthesis of the enabling conditions for hybrid professionalism in healthcare. Health Serv Manag Res. 2024;37(1):2\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/09514848231151829\u003c/span\u003e\u003cspan address=\"10.1177/09514848231151829\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVrangb\u0026aelig;k K. Decentralization in Scandinavian Health Systems: From a Single Model to Different Approaches. Health Policy. 2007;80(3):310\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eExworthy M, Frosini F, Decentralization. Decision-Making, and Public Services: A Comparative Analysis. Public Adm Rev. 2015;75(1):100\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eExworthy M, Halford S. Organizational Change and Public Services: The Impact of Decentralization in the UK. Public Adm. 1999;77(4):553\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarrison S, Ahmad A. Professionalism and managerialism: The challenges of hybrid roles. Soc Sci Med. 2000;50(7\u0026ndash;8):1145\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaltman RB, Ferroussier-Davis J. The Concept of Decentralization in Health Systems: A Critical Review of the Literature. Health Policy. 2004;70(3):1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong CA, Elliott-Miller P, Laschinger H, Cuddihy M, Meyer RM, Keatings M, Burnett C, Szudy N. Examining the relationships between span of control and manager job and unit performance outcomes. J Nurs Manag. 2015;23(2):156\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jonm.12107\u003c/span\u003e\u003cspan address=\"10.1111/jonm.12107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hybrid Management, Clinical Directorates, Decentralization, Healthcare Governance, Organizational Change","lastPublishedDoi":"10.21203/rs.3.rs-7107551/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7107551/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eThe integration of medical professionals into management\u0026mdash;so-called hybrid management\u0026mdash;has emerged as a key strategy in public healthcare reforms. Clinical directorates (CDs) are often seen as vehicles for this integration. While prior studies have explored hybrid management roles and decentralization, less is known about how multiple hybrid-managerial levels interact within one organization. This study examines the perceptions of clinical directors in a large decentralized healthcare provider in Sweden, following the introduction of a divisional hybrid-managerial level intended to enhance efficiency and coordination.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA mixed-methods approach was used, combining two web-based surveys (2018 and 2019) sent to all clinical directors (n\u0026thinsp;=\u0026thinsp;95). The responses were analyzed quantitatively via nonparametric tests (Mann‒Whitney exact test, Fisher\u0026rsquo;s exact test) and indices (polarity, intensity, uncertainty). The open-ended responses were analyzed via directed content analysis to deepen the interpretation of the quantitative trends.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eResponse rates were high (84% in 2018; 97% in 2019). The introduction of a divisional hybrid-managerial level yielded mixed results. Some improvements in coordination and leadership support, particularly in mental health care services, have been reported. However, many clinical directors\u0026mdash;especially in primary care\u0026mdash;perceived increased administrative burden, unclear roles, and confusion over responsibilities. Statistical analysis confirmed significant changes in perceived time for patient care and administrative burden but not in central support. The qualitative data revealed that while some directors appreciated improved strategic dialog, others cited increased complexity and ineffective support systems.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eIntroducing a divisional hybrid-managerial level in a decentralized healthcare setting can improve coordination but risks adding bureaucratic complexity without clear role definitions and adequate support. The study underscores the importance of clarifying authority and responsibilities when layering hybrid roles. Effective hybrid management requires more than professional alignment\u0026mdash;it demands robust systems, clear communication, and a culture that reconciles managerial and professional logics. These findings offer insights for health systems pursuing hybrid governance models and contribute to theory on decentralized management in complex service organizations.\u003c/p\u003e","manuscriptTitle":"Challenges in Hybrid Management in Healthcare: A Study of the Interplay between Divisional Managers and Clinical Directors in a Decentralized Healthcare Organization in Sweden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 11:09:12","doi":"10.21203/rs.3.rs-7107551/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-07T02:41:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T08:56:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275120555720124951976233253685808985759","date":"2025-09-29T04:16:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39888866623393053867628705467302005323","date":"2025-09-27T20:39:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T11:50:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210105367819921220288469430482339045441","date":"2025-08-03T23:31:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T19:11:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-24T17:08:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T03:04:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T23:27:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-07-17T22:48:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe69b944-997d-4193-995c-860c197a2283","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:07:19+00:00","versionOfRecord":{"articleIdentity":"rs-7107551","link":"https://doi.org/10.1186/s12913-025-13977-y","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-01-12 16:31:01","publishedOnDateReadable":"January 12th, 2026"},"versionCreatedAt":"2025-08-01 11:09:12","video":"","vorDoi":"10.1186/s12913-025-13977-y","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13977-y","workflowStages":[]},"version":"v1","identity":"rs-7107551","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7107551","identity":"rs-7107551","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}