Between Patients, Professions and Politics: Managerial Agency in - - PowerPoint PPT Presentation
Between Patients, Professions and Politics: Managerial Agency in Health Care Reform Ann Langley, HEC Montral SHOC-OBHC May 6, 2020 Acknowledgements (but no blame!) Charlotte Cloutier Jean- Louis Denis Lise Lamothe Inspiration:
Ann Langley, HEC Montréal SHOC-OBHC May 6, 2020
Charlotte Cloutier Jean- Louis Denis Lise Lamothe
Inspiration: Cloutier, C., Denis, J.-L., Langley, A. & Lamothe, L. 2016. Agency at the managerial interface: Public sector reform as institutional work. Journal of Public Administration Research and Theory, 26(2): 259-276.
Politicians Reform in Theory Reforming Organization Professionals Patients/ Public Management Team Reform in Practice Shadow of past institutionalized arrangements
Managers as “institutional workers”
New integrated
New “population-based” concept of care
HSSC
Servi vice-bas based approa
Pop
based approa
Respon
Individuals who use services Population of local territory (users or not)
Obje Objectiv ives
Care for the person who requests service Improve the health of the population
Servi vices of
Focus on diagnosis and curative care Continuum: prevention –– cure – rehabilitation
Actor
Health care professionals and managers Health care system + (schools, municipalities, social economy, etc.)
Organization
Structured by type of service offered. Structured by program around population needs
CONCEPTUALLY AMBIGUOUS: “And that [population responsibility], nobody… had seen it. It was like a UFO – we talked about it but we didn’t know what it was, what it would mean.” STRUCTURALLY COMPLEX: Merger of up to 17 formerly independent organizations + development of alliances with others
Samples organizations Data
136 interviews; 324 meeting
Documents Quantitative survey of managers, professionals and network partners at end of study Region 1 (urban) Region 2 (semi-urban)
Without hospital HSSC1
employees
HSSC2
With hospital HSSC4
employees
HSSC3
employees
A model of forms of institutional work in the enactment of policy reform.
DISRUPTIVE “Just putting the structure in place – that takes two
taken up with that” PRECURSIVE “Logically, it would be nice if the structure followed from the clinical plan. But that takes too long. It creates instability” RECURSIVE “One of the Board’s wishes was that in the top team, there would be room for all, so the CEO asked people where they wanted to go” STRUCTURAL WORK Shadow of the past
Yu, J., Engleman, R. M., & Van de Ven, A. H. (2005). The integration journey: An attention-based view of the merger and acquisition integration process. Organization Studies, 26(10), 1501-1528. Time allocated to topics in top management meetings by month after merger
DETACHED “All these professionals, the employees have been trained to treat a person, not a population” SPECIALIZED “The project, was very, very conceptual and there were
carried that science” REPETITIVE “It’ll take time… marketing campaigns, where we repeat the same message 10 times in the same day. It’s not obvious.” CONCEPTUAL WORK Push to the new, but hard to connect to action on the ground Claiming moral legitimacy
FRAGMENTED “In principal, and in spirit, it is an important reform. But in practice, we have difficulty: the levers are more or less nonexistent” TRANSACTIONAL “When we present a change, we must always think of what advantages it gives to the the doctors that we can highlight.” CONTENTIOUS “That hospital tends to refer everything to primary care. What’s the point of having an emergency room if they behave like that?.” OPERATIONAL WORK Negotiating with the old to achieve the new Tied to pragmatic legitimacy
RELATIONAL WORK Structural work Operational work Conceptual work Underpins and supports all others forms of institutional work
Stop looking at nice documents, We have to go and explain stuff to people It took a full year to get to know each other (on the top team) This requires making links, to develop mutual trust
Type of Work Sources of DILUTION Structural work RECURSIVE: Impregnated with remnants of old structures Conceptual work DETACHED: Hard to link with operations Operational work TRANSACTIONAL: Results in negotiated settlements Relational work Smoothes over the edges
He was someone with an incredible mind… the CEO… who would have done well to set aside the conceptual and philosophical aspect of the approach to go and weave some linkages with people
and employees in particular, taking into account the hospital context. DILUTION BY CONTENTION & REJECTION EMPHASIS ON MORAL LEGITIMACY
Things have been achieved in the last
partners] are people who negotiate. If they get their conditions, then they put things in place. Otherwise they don’t take risks. DILUTION BY RECURSION & NEGOTIATION EMPHASIS ON PRAGMATIC LEGITIMACY
Purity Pragmatism
Managers are key institutional workers (with others) in enactment of reform. Structural work: Greatly underestimated; Highly critical; Hugely time and energy consuming; Raises critical questions: Is reform worth the cost? Conceptual work: Purism vs. pragmatism – need for skilful translation; Role of patient participation in building moral AND pragmatic legitimacy? Operational work: Reform on ground is transactional and depends on the incentives in place. Managers need autonomy to offer incentives locally. Relational work: Clear need for managers to master relational skills… relational work will contribute to getting stuff done, but partly by smoothing the edges.
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