Between Patients, Professions and Politics: Managerial Agency in Health Care Reform Ann Langley, HEC Montréal SHOC-OBHC May 6, 2020
Acknowledgements (but no blame!) � 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.
How do managers engage with and contribute to the enactment of mandated health care reforms? Managers as Politicians “institutional Reform in Theory workers” Shadow of past Reform in institutionalized Management Practice arrangements Team Reforming Professionals Patients/ Public Organization
Original source of ideas: Longitudinal CONCEPTUALLY AMBIGUOUS : study of health care reform in Quebec “And that [population responsibility], nobody… had STRUCTURALLY COMPLEX: seen it. It was like a UFO – we Merger of up to 17 formerly talked about it but we didn’t independent organizations know what it was, what it New “population-based” New integrated + development of alliances would mean.” concept of care organizational structure: HSSC with others Servi vice-bas based Pop opulation on-bas based HSSC approa oach approa oach Respon onsibility Individuals who use Population of local services territory (users or not) Obje Objectiv ives Care for the person Improve the health of who requests service the population Servi vices of offered Focus on diagnosis Continuum: prevention and curative care –– cure – rehabilitation Actor ors invol olved Health care Health care system + professionals and (schools, municipalities, managers social economy, etc.) Organization on Structured by type of Structured by program service offered. around population needs
Research design: 4 newly created organizations followed over 3 years Region 1 Region 2 Samples organizations Data (urban) (semi-urban) � 136 interviews; Without hospital HSSC1 HSSC2 - 3 organizations -2 organizations � 324 meeting observations - 7 sites - 5 sites - c. 2000 - < 1000 employees � Documents no hospital employees - � Quantitative survey of - no hospital managers, With hospital HSSC4 HSSC3 professionals and network partners at -6 organizations -6 organizations end of study -11 sites -17 sites -c. 3500 -c. 4000 employees employees -includes hospital -includes hospital
A model of forms of institutional work in the enactment of policy reform.
STRUCTURAL WORK: Managerial efforts to establish formalized roles, rules, and resource allocation that support a new policy framework. PRECURSIVE STRUCTURAL WORK “Logically, it would be nice Shadow of if the structure followed the past from the clinical plan. But that takes too long. It creates instability” RECURSIVE DISRUPTIVE “One of the Board’s wishes “Just putting the structure in was that in the top team, place – that takes two there would be room for all, years. All our energies are so the CEO asked people taken up with that” where they wanted to go”
Structural work: Data from a case study of the implementation of health system alliance in US Time allocated to topics in top management meetings by month after merger 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.
CONCEPTUAL WORK: Managerial efforts to establish new belief systems, norms, and interpretive schemes consistent with the new policy. Push to the new, SPECIALIZED but hard to “The project, was very, very connect to conceptual and there were action on the only certain elites here that ground carried that science” Claiming moral legitimacy REPETITIVE DETACHED “It’ll take time… marketing “All these professionals, the campaigns, where we CONCEPTUAL employees have been repeat the same message WORK trained to treat a person, 10 times in the same day. not a population” It’s not obvious.”
OPERATIONAL WORK: Managerial efforts to implement concrete actions affecting the everyday behaviors of frontline professionals linked with the new policy. Negotiating TRANSACTIONAL with the old to “When we present a achieve the new change, we must always think of what advantages it Tied to pragmatic gives to the the doctors legitimacy that we can highlight.” FRAGMENTED CONTENTIOUS “In principal, and in spirit, it “That hospital tends to refer is an important reform. But everything to primary care. OPERATIONAL in practice, we have What’s the point of having WORK difficulty: the levers are an emergency room if they more or less nonexistent” behave like that?.”
RELATIONAL WORK: Managerial efforts aimed at building linkages, trust, and collaboration between people involved in enacting reform Structural work RELATIONAL WORK It took a full year to get to know each other (on the top team) Stop looking at nice This requires documents, making links, We have to to develop go and mutual trust explain stuff to people Underpins and supports Operational all others forms of Conceptual work institutional work work
Managers as institutional workers in enacting reform Type of Work Sources of DILUTION RECURSIVE: Structural Impregnated with work remnants of old structures Conceptual DETACHED: Hard to link work with operations TRANSACTIONAL: Operational Results in negotiated work settlements Relational Smoothes over the work edges
The DILUTION dilemma: Purity Between purity and pragmatism Pragmatism PURITY PRAGMATISM He was someone with an incredible Things have been achieved in the last year. (…) But it was difficult because [the mind… the CEO… who would have done partners] are people who negotiate. If well to set aside the conceptual and they get their conditions, then they put philosophical aspect of the approach to things in place. Otherwise they don’t take go and weave some linkages with people risks. on the ground… with middle managers and employees in particular, taking into account the hospital context. DILUTION BY CONTENTION & REJECTION DILUTION BY RECURSION & NEGOTIATION EMPHASIS ON MORAL LEGITIMACY EMPHASIS ON PRAGMATIC LEGITIMACY
Conclusions & Implications � 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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