5: What We Should Take Into Consideration: Perspectives, Expectations and Advice From Top Hospital Managers

Top managers cooperate within a strategic framework composed of five dimensions (Khan & Lega, 2021): playmaking, enabling, aligning, compromising and equivocality. Playmaking refers to the ability to guide the system while building consensus about their decisions. Enabling regards setting the conditions for middle managers and leading healthcare professionals to operate in a single direction, a common scope, with continuity and at the lowest level of stress as possible. Aligning is fundamental to share a common vision promoted by top managers in their ability to identify room for strategy – frequently but not explicitly – defined by politicians. It is often performed together with the involvement of leading clinicians who represent the voice of patients and influential stakeholders, given their networking ability. For this reason, engaging leading clinicians in managerial practice and aligning their interests with organisational interests is a critical factor for an organisation's success. Compromising is essential – as in every political framework albeit with a greater degree of complexity in the healthcare sector – to balance potential conflicting perspectives, interests and positions. Finally, equivocality is a constant because politicians frequently set unattainable goals that burden organisational strategy and result in the so-called political isomorphism phenomenon. Politicians and top managers know how to distinguish between expected and promised outcomes, and they accept this gamesmanship in a sort of tacit agreement.