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Managing Change is about implementing health care reforms, policies and programs into everyday practices. The book explores organizational change in health care as influenced by contemporary policy and management concepts, and presents and applies theoretical perspectives.





This book is about managing change in healthcare settings. The book draws upon the presentations and discussions at the 9th International Organisational Behaviour in Healthcare Conference (OBHC), which took place in Copenhagen in April 2014, hosted by Copenhagen Business School. The conference theme was ‘When health policy meets every day practices’. The conference was international, receiving papers from scholars in countries worldwide, including Denmark, Sweden, Norway, the United Kingdom, Ireland, Germany, the Netherlands, Belgium, Italy, the United States, Canada and Australia. To date, Palgrave Macmillan has published eight editions in a series linked to the OBHC conferences organized by the Society for Studies in Organising Healthcare (SHOC).
Susanne Boch Waldorff, Anne Reff Pedersen, Louise Fitzgerald, Ewan Ferlie

Designing Change Processes


1. The Ideas and Implementation of Public Health Policies: The Norwegian Case

In Denmark, Norway and Sweden, the municipal and regional administrative levels are in charge of implementing public health policies and measures on behalf of the state. In fact, both in Denmark (Waldorff, 2010; Vrangbæk and Sørensen, 2013) and in Norway (Report to the Storting no. 47, 2008–2009; Rommetveit et al., 2014; Torjesen and Vabo, 2014), recent reforms have emphasized the role of the municipalities in carrying out public health policies. In this chapter, we investigate the challenges of managing organizational change processes, in order to create changes in practices within the field of public health in the case of Norway. We study the relationship between changes in national policies and legislation and implementation at the municipal level. Our main question concerns how national public health policies are put into local practice. To answer this, we need to (1) investigate which ideas about the government of public health are articulated in national policies, (2) study how these policies are received and acted upon locally and (3) explain local choices regarding public health practices. Furthermore, in this chapter we present a theoretical framework focusing on major ideas on public health management and on the relation between ideas and practice in a neo-institutional perspective. This is followed by a brief presentation of the material and methods, as well as an explanation on how the empirical data are analysed. Then the analysis of the empirical data is presented, concluding the chapter with a discussion.
Charlotte Kiland, Gro Kvåle, Dag Olaf Torjesen

2. The Path from Policy to Practice: Resilience of Everyday Work in Acute Settings

Implementation of policy in terms of detailed rigid protocols and procedures is perennially at odds with how everyday work is enacted in healthcare. This is especially evident when the needs of patients cannot be met by following guidance as written and can manifest as disconnects and misunderstandings between policymakers and clinicians. Healthcare is a complex adaptive system that does not lend itself to linear processes and ‘one-size-fits-all’ solutions, or standardization. This chapter provides a critique of policy implementation processes and presents an alternate perspective of policy implementation translated in terms of intent rather than inflexible directives. Several examples from acute care settings are provided to illustrate this perspective. Allowing for flexible interpretation of policy to meet the needs of patient care can result in a more resilient — and potentially safer — healthcare system.
Robyn Clay-Williams, Julie K. Johnson, Deborah Debono, Jeffrey Braithwaite

3. Dealing with the Challenges of Healthcare Reform: American Hospital Systems Strive to Improve Access and Value through Retail Clinics

The passage of new legislation in a certain healthcare system can spark significant change processes in healthcare organizations, where local interpretations, sense making and inherent challenges affect what specific change practices are implemented. The Patient Protection and Affordable Care Act (PPACA), signed by President Barrack Obama on March 23, 2010, is the most significant piece of legislation in the history of American healthcare. Never before has a healthcare-related policy been so fiercely debated, widely beloved and vehemently opposed. The provisions of the act aim to expand coverage, control healthcare costs and improve the healthcare delivery system and therefore have many substantial implications on the way hospital systems provide healthcare services and the way they get paid for those services.
Amer Kaissi

4. Institutional Logics and Micro-processes in Organizations: A Multi-actor Perspective on Sickness Absence Management in Three Dutch Hospitals

Since healthcare organizations often have significant problems with the recruitment and retention of staff (McKee et al., 2008), preventing sickness absence and improving return-to-work processes are highly relevant for hospitals in order to deliver adequate services and ensure the quality and quantity of healthcare (Boselie et al., 2003). A high turnover of employees increases costs (e.g. recruitment and training) and potentially decreases patient care. Turnover can seriously affect both patients and other employees through higher error rates and increased workloads. In this chapter, we examine the implementation of new legislation aimed at preventing sickness absence and solving obstacles towards the return to work for sick-listed employees. We selected three hospitals in the Netherlands to study how national legislation for sickness absence management is understood and enacted locally by the involved actors.
Nicolette van Gestel, Daniel Nyberg, Emmie Vossen

The Role of Professions in Change Processes


5. The Persistence of Professional Boundaries in Healthcare: A Re-examination Using a Theory of Foundational Values

In this chapter, we draw on a theory of ‘modest foundationalism’ (Little et al., 2011, 2012; Little, 2014) as a means of shedding fresh light on the persistence of strict boundaries between the medical profession and other occupations, including other healthcare occupations such as nursing and allied health.
Kathleen Montgomery, Wendy Lipworth, Louise Fitzgerald

6. Medical Doctors and Health System Improvement: Synthesis Results and Propositions for Further Research

Many efforts in different countries provide useful examples of new care models and broad strategies for improving population health, quality of care and patients’ experiences while controlling costs (Baker et al., 2008). The successful strategies in these examples of health system improvement have relied on developing medical engagement and leadership as a critical element of transformative change (Baker et al., 2008; Baker and Denis, 2011; Ham, 2014). Recent policy initiatives in different jurisdictions also emphasize effective medical leadership and engagement. These include recent National Health System (NHS) reforms in the United Kingdom (Department of Health, 2010) and US efforts to develop accountable care organizations (Singer and Shortell, 2011). Yet, although the need to engage doctors seems to affect policy reforms and organizational change efforts, the issue of physician leadership and engagement has drawn only limited empirical attention.
Jean-Louis Denis, G. Ross Baker

7. The Role of the Quality Coordinator: Articulation Work in Quality Development

Quality development in healthcare has undergone a movement from processes led by the medical professions to processes increasingly regulated by nationally formulated frameworks that consist of increased systematics, transparency and data-driven quality development (Power, 1997; Wiener, 2000; Timmermans and Berg, 2003; Knudsen et al., 2008; Knudsen, 2011). As part of this change, quality development has become a consolidated and permanent part of healthcare, with its own institutions, organizations and practices. In that respect, it has become a distinct, formalized field and a part of the hospital organization in its own right, occupying a considerable space in the hospitals in terms of tasks, methods, technologies and assigned employees. As part of this development, organizational positions in the hospital are changing and new organizational positions have been introduced in order to address the increasing demands for quality development (Kirkpatrick et al., 2009, 2011).
Marie Henriette Madsen

8. The Role of Outside Consultants in Shaping Hospital Organizational Change

Achieving strategic change in hospitals, similar to other types of organizations, involves reorienting employees’ interpretative frameworks — shared assumptions, narratives or cognitive schema that give meaning to organization members’ experiences (Currie and Brown, 2003; Balogun and Johnson, 2004; Lockett et al., 2014; Nigam et al., 2014). Recent studies have begun to consider the social position of actors engaged in interpretative change activities (Battilana et al., 2009). For example, Lockett et al. (2014) show how actors’ social positions in the National Health Service in England — as physicians or nurses and as staff in research-oriented tertiary care centres or in clinical care-oriented secondary care centres — shape their ability to envision strategic change. Prior research on social position and interpretive change focuses on the social positions of diverse insiders. Although external consultants often play a critical role in the change process in all types of organizations, including hospitals, our knowledge how they are able to bring about interpretive change remains unclear (Bartunek et al., 2011).
Amit Nigam, Esther Sackett, Brian Golden

Leadership and Organizational Change


9. NHS Managers: From Administrators to Entrepreneurs?

Health service managers have long been involved in organizational restructuring, notably in the apparent ‘transition’ narrative from public administration to ‘new public management’ (NPM). More recently, debates have focused on entrepreneurialism.
Mark Exworthy, Fraser Macfarlane, Micky Willmott

10. Opportunity Does Matter: Supporting Doctors-in-Management in Hospitals

The introduction of professional-manager ‘hybrid’ roles has been seen as a solution to ‘bridge the gap’ between the two competing worlds of medicine and management (Freidson, 2001; Noordegraaf, 2007) at the organizational level. In particular, in a number of Western countries we observe doctors being involved in management as head of clinical directorates, which have become a popular object of analysis for management scholars (Fitzgerald and Dufour, 1998; Kitchener, 2000; Marnoch et al., 2000; Llewellyn, 2001; Kirkpatrick et al., 2009; Witman et al., 2011; McGivern et al., 2015). Clinical directorates are intermediate management units formed around either a broad medical specialty or a support service grouping a number of smaller specialties. They were introduced in order to increase the governance of clinical services, pool resources, favour inter-specialty integration and support the top management in the strategy making (Chantler, 1993; Kirkpatrick et al., 2013).
Marco Sartirana

11. A New Approach to Hybrid Leadership Development

The strategic importance of involving professionals in the leadership of healthcare systems is noted globally (Degeling et al., 2006; Clark, 2012). In particular, leadership development amongst mid-level managers from clinical backgrounds (hybrids) is seen as a pivotal influence on enhanced patient care, organizational effectiveness and innovation (Ferlie et al., 2005; Martinussen and Magnussen, 2011; McGivern et al., 2015). The influence of hybrids stems from their potential ability to move between managerial and professional realms, viewing organizational issues through ‘two-way windows’ (Llewellyn, 2001) and encouraging professional groups to work collaboratively with managerial colleagues (Ackroyd et al., 2007; Fitzgerald et al., 2013). However, healthcare organizations are characterized by managerially driven priorities and professional hierarchies (Exworthy et al., 1999), which shape the organizational context and may influence hybrid leadership development (Fitzgerald et al., 2013; Croft et al., 2014; McGivern et al., 2015). If hybrid leadership development is undermined by organizational context, the strategic potential of hybrids is lost, as their influence as boundary spanners between professional and managerial jurisdictions will be limited (Croft et al., 2015).
Charlotte Croft

Change Programmes: Content and Performance


12. Scotland ‘Bold and Brave’? Conditions for Creating a Coherent National Healthcare Quality Strategy

Healthcare quality is an enduring and global concern, evidenced via supranational responses, such as those of the United Nation’s World Health Organization (Ovreveit, 2003, 2005, 2013), the OECD (Arah et al., 2003) and the European Union (Vollaard et al., 2013), as well as the policy responses of individual countries (Arah et al., 2003) and devolved regions (such as the Scottish example considered in this chapter1). The Institute of Medicine’s seminal report (IOM, 2001; Kohn et al., 2001) led to increasing recognition of the need for a systems focus in managing healthcare quality. However, a European Union (EU)-oriented analysis (Vollaard et al., 2013: 229) notes, ‘There is much variation [in national quality and safety strategies] between and within Member States and that therefore there is a large potential to learn from each other.’ In this chapter, we follow Ovreveit and Staines (2007) in purposively analysing an established system-wide approach to quality improvement. We consider the evolution of the policy process in Scotland — rather than evaluating its impact — and ensuing lessons for other contexts.
Aoife M. McDermott, David R. Steel, Lorna McKee, Lauren Hamel, Patrick C. Flood

13. The Social Spaces of Accountability in Hybridized Healthcare Organizations

UK healthcare organizations are undergoing progressive changes to become more flexible and cost-effective (Kernaghan, 2000). Recently, the government’s latest incarnation of New Public Management, ‘open public services’ (Cabinet Office, 2012), has articulated a shift from traditional organizational forms to a more indeterminate organizational landscape of shifting social and spatial relations (James and Manning, 1996; McNulty and Ferlie, 2004; Dunleavy et al., 2005). As a result, formulation and execution of public health policy occurs increasingly in complex networks featuring multiple, overlapping coordination between government, third sector organizations and the citizen/service user, so that ‘accountability… gets lost in the cracks of horizontal and hybrid governance’ (Ferlie et al., 2007: 240; also see Frolich, 2011). It is to an interrogation of accountability within such increasingly hybridized healthcare organizations that we address ourselves in this chapter.
Aris Komporozos-Athanasiou, Mark Thompson

14. Culture Shock and the NHS Diaspora: Coping with Cultural Difference in Public-Private Partnerships

Public-private partnerships (PPPs) are a prominent feature of contemporary healthcare reform associated with global trends towards the marketization of public healthcare (Collyer and White, 2011; Barlow et al., 2013). In general, PPPs involve a formal collaboration between public agencies and private businesses premised on the idea that distinct resources from each sector can be brought together to share risks, foster innovation and co-produce service (Hodge and Greve, 2007). For the private partner, benefits are accrued from access to new markets and return on investment, whilst the public partner benefits from access to private finance and business expertise. PPPs are commonly portrayed as a pragmatic solution to the economic dilemmas of public service renewal and a shift towards progressive era governance (Osborne, 2000), whilst more critical commentators argue they transfer responsibilities for public healthcare from state to market.
Justin Waring, Amanda Crompton

15. Organizational Healthcare Innovation Performed by Contextual Sense Making

Organizational change occurs when innovative ideas are implemented and translated into the everyday life of healthcare organizations and concerns the involvement of local healthcare professionals. A number of studies describe the resistance professionals can exhibit during organizational change processes (Bloom, 1998; Sehested, 2002). One way of gaining an understanding of this resistance is by investigating the meanings healthcare professionals derive from the implementation process and by examining how meanings can become a driver for involvement in the implementation process, but also by looking at how losses of meanings can become a barrier to involvement. This chapter investigates the contextual meanings of healthcare professionals in healthcare innovation processes. The term ‘meaning’ refers to the storyteller’s creation of meanings from narrative knowledge and narrative practice (Bruner, 1986; Humle and Pedersen, 2014).
Anne Reff Pedersen


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