When Power Shapes Decisions: Lessons from a French Hospital

A case study on how departments protect thier turf, and how change initiatives get quietly rewritten.

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Management theory tells us that clearer metrics, more accountability and more “evidence-based” management leads to better decisions.  This is true when all parties to the decision process engage in good faith, however psychological and power dynamics can corrupt this process. When power is unevenly distributed, the decision-making process can become less about outcomes and more about protecting autonomy, status, and resources. 

Risk frameworks are often oblivious to power dynamics, instead focusing on the robustness of the decision-making methodology and its application. This can undermine the effectiveness of risk assessments, particularly with respect to change initiatives where the impact of power dynamics is often elevated.

A case study of a change programme at a French hospital[i] illustrates how corruption of the descision-making process can happen, with well-intentioned change programmes getting bent out of shape.

French Hospital Case Study

Background

A French hospital attempted to introduce a new methodology to the Surgery and Cardiology departments to guide how patients were selected and treated, with the goal of improving patient outcomes. 

Hospital strategy had historically been dominated Surgery, the most powerful department. Surgery's ongoing success and reputation was widely understood as being fundamental to the hospital's regional identity, and central to its financial performance.  In practice, other departments were subordinate to Surgery, and it was widely accepted that if the Surgery department struggled, so would the hospital.

Department #1: Surgery—powerful enough to ignore the plan

Surgery understood the leverage their power and reputation within the hospital gave them. They pushed back on management’s attempt to standardise decision-making by emphasising how complex and specialised surgical work was. They perceived themselves as experts who were highly trained to deal with a sophisticated practice, and other hospital departments had accepted this view.

Surgery prioritised protecting their autonomy and status at the expense of shaping a new methodology that might have improved both patient outcomes and their own day-to-day experience. If you’ve worked in a company where one function controls an outsized share of revenue, margin, or “mission-critical” delivery, this may feel familiar: improvement initiatives can be quietly blocked through the non-engagement of those with the most organisational power.

Department #2: Cardiology—less power, different incentives

Cardiology had significantly less organisational power than Surgey, which gave them a strong incentive to engage with management’s initiative: working with the new case mix methodology created an opportunity to influence processes they normally wouldn’t get to touch.

But less power didn’t translate into more altruism. The researchers found that the cardiologists did not embrace the logic or purpose of the initiative. Instead they sought to redesign it to achieve their own goal of funding a chronic heart failure unit that would have allowed for the provision of complete patient handing without the involvement of Surgery.

In practice, Cardiology sought to use the change in methodology to increase their organisational power by creating pathways to remove surgeons from key aspects of the decision-making process. Cardiology presented themselves as a successful example of how the management initiative could be used to improve patient outcomes.  However, what was hidden from this analysis was that the “improvement” was achieved by diverting more complex patients to another sub-group, allowing the cardiologists to focus on less costly patients and so increase their measured performance.  This meant that the hospital didn’t reduce costs, it largely shifted them elsewhere.

What this shows: change tools get politicised

In this study, both departments subverted the decision-making process to preserve their own interests.  Surgery attempted to use its organisational power to undermine the hospital management’s legitimacy and resist standardisation. Cardiology engaged with the change programme, but co-opted it to advance its own priorities, even when that conflicted with hospital-level outcomes. As the researchers put it, “in such complex settings, in order to survive and preserve some autonomy, actors tend to take a manipulative stance towards those very tools that they are supposed to comply with… [which] eventually undercut the accountability and effectiveness they purport to target.” 

What this can mean for change programmes more generally

If you don’t understand the organisation’s existing power dynamics, it can be hard to design change programmes that fulfil their original intent.  Whilst power dynamics will not corrupt every change programme, research suggests that this phenomenon is sufficiently widespread that risk analysis that ignores power dynamics will inevitably fail at some point.

This risk analysis needs to take into account how power dynamics could be affected: who benefits, who loses autonomy, and who gets to control scarce or desirable resources. It also needs senior leadership buy-in to be accepted as part of a formal risk opinion. This is because it confronts an uncomfortable truth: people don’t always act in line with organisational interests, but no one wants to be accused of this, especially before they have even done so. 

What power does to behaviour (even in “good” organisations)

The above case study considers how groups of individuals can put their team's needs and priorities ahead of the wider organisation.  However, risk analysis also needs to take into account for power dynamics to influence the behaviour of individuals.[ii]

People aren’t automatons, so you can’t reliably predict how any one individual will behave when their formal or informal power increases. But at a population level, increased power has been found to change how people behave, regardless of personality type.  Increased organisational power tends to come with a shift in attention: people become more focused on their own needs and wants (and less focused on others), and they are more likely to break or reinterpret organisational norms.

Power can also inflate confidence. Many managers overstate how much they understand about the organisation simply because they sit near the centre of it. This is the fallacy of centrality: the assumption that a central position automatically confers the knowledge required for effective leadership. Decision processes can unintentionally amplify this bias, unless business culture, risk teams and governance processes deliberately build in mechanisms that test assumptions and reward curiosity.

Dissent can be managed or manipulated

When management teams tolerate dissent, they can unintentionally shift power and increase future transactional costs (as we saw with the Cardiologists). There’s a reason governments monitor protest movements closely!

Selectively allowing dissent that reinforces existing power dynamics may increase organisational stability, but it can also reduce diversity of thought and reward people who simply echo the dominant view. Rewarding the surgeons’ undermining of the change initiative would likely have had this effect.

Selectively allowing dissent that furthers one faction’s interests over another can create the illusion of openness while reducing real scrutiny. Risk teams should watch for “engineered dissent” - where disagreement is encouraged only when it helps those already in power, or prioritises one world view, rather than embracing a genuinely diverse array of opinions.

Getting the right balance for dissent is difficult.  Risk teams can help organisations mitigate the risk of getting it wrong by reviewing the scope, intent and methodology of decision-making in the context of power dynamics. 

In order for this to be effective, risk teams need to be granted sufficient social license to consider power dynamics as part of their challenge process. They can achieve this through both top-down sponsorship, and by demonstrating a comprehensive understanding of power dyanamics to stakeholders.

Practical takeaways

• Map incentives before you launch. Identify who could lose autonomy, gain control, or quietly veto adoption.

• Design for gaming. If metrics can be improved by shifting cost or risk elsewhere, it is likely that someone eventually will.

• Validate “expert” objections. Complexity can be real, but it can also be a shield for preserving autonomy.

• Counter the fallacy of centrality. Build in structured challenge, data visibility, and mechanisms that reward decision-makers for updating their beliefs.

• Review how dissent is curated. If disagreement only shows up when it benefits the status quo or a specific faction, you don’t have psychological safety, you have choreography.

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I hope this blog sparks ideas and discussion. If you found it interesting, please share or connect with me on LinkedIn to contribute or provide feedback! 

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[i] Kern, A., Laguecir, A., & Leca, B. (2018). Behind Smoke and Mirrors: A Political Approach to Decoupling. Organization Studies, 39(4), 543-564. https://doi.org/10.1177/0170840617693268

[ii] How to be a good boss in a bad economy, Harvard Business Review, June 2009, Robert I Sutton