Clinicians and accounting: A systematic review and research directions

• Author: Emidia Vagnoni,Cristina Campanale,Chiara Oppi,Lino Cinquini
• Date: 01 August 2019
• Published date: 01 August 2019
• DOI: http://doi.org/10.1111/faam.12195

Received: 18 September 2017 Revised: 24 May2018 Accepted: 5 September 2018

DOI: 10.1111/faam.12195

ORIGINAL ARTICLE

Clinicians and accounting: A systematic review

and research directions

Chiara Oppi1Cristina Campanale1Lino Cinquini1

Emidia Vagnoni2

1Institute of Management, Sant’ Anna School of

Advanced Studies, Pisa, Italy

2Department of Economics and Management,

University o f Ferrara, Ferrara, Ital y

Correspondence

ChiaraOppi, Institute of Management, Sant’ Anna

Schoolof Advanced Studies, Piazza Martiri della

Libertà24, 56127 Pisa, Italy.

Email:chiara.oppi@santannapisa.it

Abstract

This paper provides a review of the literature concerning clinicians’

approach to accounting information systems (AISs) in healthcare

organizations. The paper examineshighly rated accounting and man-

agement literature since 1980. Articles are categorized according to

their research topics, settings, and methodologies, then findings are

analyzed.

Results show that clinicians’ resistance to accounting is the con-

sequence of the inadequacy of AISs, which are designed according

to reforms inspired by a managerial orientation. This suggests that

future research should focus on AISs design, investigating patterns

of implementation of AISs that can increase clinicians’ commitment

to and use of accounting for decision making.

KEYWORDS

accounting information system, clinician, controller, healthcare, sys-

tematic literature review

1INTRODUCTION

Since the 1980s, healthcare organizations (HCOs) worldwide have been subject to a series of managerial reforms,

which emphasized economic results, disseminated a market culture and private sector practices (Hood, 1995), and

proposed a managerial approach centered on planning and budgeting (Adinolfi, 2014). Reforms aimed to reduce costs

and improveefficiency (Hill, 2000). Those reforms were undertaken in a context in which HCOs experienced economic

concerns related to the increasing costs of their health services (France, Taroni, & Donatini, 2005; Negrini, Kettle,

Sheppard, Mills, & Edbrooke, 2004). As a consequence of the reform process, HCOs started to introduce accounting

techniques to control expenditures and to maximize both service quality and efficiency (Adinolfi, 2014; Hellström &

Hallberg, 2001; Marcon & Panozzo, 1998).

In order to cope with this changing environment and to address reforms, HCOs changed the way in which account-

ing information systems (AISs) were shaped; the new AISs were designed to provide information directed at cost

reduction and at supporting benchmarking (Guven Uslu & Conrad, 2008; Järvinen, 2009; Lehtonen, 2007). Clinicians

have a significant impact on costs (Abernethy & Stoelwinder, 1995). Therefore, hospitals committed clinicians to a

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OPPI ET AL.291

strategicrole in resources and staff management to fulfill reforms’ aims (Fitzgerald & Sturt, 1992) and turned the role of

clinicians into a management role. Clinicians became accountable to management in terms of costs, performance, and

clinical outputs (Jacobs, 1995, Nyland & Pettersen, 2004; Scarparo, 2006). Further,the role of clinical manager (senior

clinicians who have assumed managerial responsibilities and are in charge of managing a health unit while retaining

a clinical role) was introduced to act as a bridge in the communication between clinicians and controllers (Llewellyn,

2001).

Since the enactment of national reforms over time and the change in AISs, the management accounting literature

has widely investigated clinicians’ responses to their new role, such as their approach to managerial activities and to

the use of AISs. This allowed researchers to increase their understanding of the usefulness of accounting for decision

making in HCOs and investigate the features associated with the role of AISs from different approaches (Abernethy,

Chua, Grafton, & Mahama, 2006). Forinstance, several positivistic studies investigated the contribution of AISs to the

provision of accurate, timely, and reliable information, considering AIS a tool that reduces uncertainty and supports

decisions and control behaviorswhen conflicting objectives between individuals occur. In this sense, research has high-

lighted the role of AISs in the provision of information to facilitate clinicians’ decisions or allow managerial control over

their activities (Abernethy & Stoelwinder, 1990; Abernethy & Vagnoni,2004; Eldenburg, Soderstrom, Willis, & Wu,

2010; Jones & Dewing, 1997).

Other studies adopted a critical approach and explored how AISs and the contexts in which they operate inter-

sect and influence each other (Abernethy et al., 2006). These studies investigatedaccounting changes in the organiza-

tions following managerial reforms, and the patterns of power distribution giventhe increasing influence of controllers

overclinicians’ activities. The critical approach also reported that clinicians questioned accounting and resisted change

when their space for action was reduced; clinicians adapted AISs to their own culture (Coombs, 1987; Doolin, 1999;

Kurunmaki, 2004). These studies demonstrated the challenges of AIS implementation, where AISs are directed at sat-

isfying multiple and opposing interests, contributing to social and political change (Abernethy et al., 2006).

Furthermore, interpretative research investigated how individual differences and cultural orientation influenced

accounting change and decision making (Pettersen, 1999, 2004). In this sense, the interpretation of accounting role in

the organization relies upon actors’ beliefs and experiencesthat guide their behaviors and their interpretative scheme

of reality (Broadbent & Laughlin, 1997). Interpretative studies also highlighted the differences between clinicians and

controllers that arise from their different cultures, which challenged accounting change in HCOs (Pettersen, 1999).

Interpretative studies in healthcare focused on clinicians’ reaction to their new managerial duties and to increasing

pressures over their activities, exploring the elements guiding their decisional processes in the light of accounting

implementation,and the reasons that limited AISs success (Jacobs, Marcon, & Witt, 2004; Nyland and Pettersen, 2004).

The aim of this paper is to investigatethe reasons of the failure of AISs, namely the reasons for clinicians’ resistance

to AISs, which may have threatened the capability of AISs to increase efficiency as required by reforms. In particular,

this paper investigatesthe organizational factors that support the use of AISs by clinicians or exacerbate the resistance

of clinicians over AISs in HCOs. Organizational factors are: clinicians’ education and training, the patterns of collabo-

ration between clinicians and controllers, and the features of AISs implemented in HCOs.

In particular,this paper explores how and if the above mentioned factors can exacerbate or increase clinicians’ resis-

tance to AISs. Through a narrow focus on the organizational factors, this paper also aims to provide suggestions to

decision makers in HCOs for increasing clinicians’ involvement in management and enhancing the relevance of AISs

in clinical activity. Forthis reason, factors related to the external contexts, such as characteristics of reforms and the

cultural and historical settings in which the reforms took place, havenot been considered.

Toachieve this aim, this research conducted a systematic literature review of highly rated journals.

Despite the large volume of research, in the accounting literature few articles have provided a comprehensive

overview of the organizational factors that can increase or reduce the use of AISs by clinicians. This paper differs from

earlier research in its focus on the organizational factors that can affect clinicians’ approach to AISs. In this sense, this

paper adopts a narrow perspective which investigates the factors within HCOs that can support or reduce clinicians’

resistance, and influence the design and implementation of AISs.