The Nature of Internal Mediator and The Nature of Internal Mediator and Moderator Influences in a Health Care Moderator Influences in a Health Care

System in TransitionSystem in Transition

EHMA – Barcelona, June 2005EHMA – Barcelona, June 2005

Stiofán deBúrca Ph.DStiofán deBúrca Ph.D..Health Service Executive, Ireland Health Service Executive, Ireland

and University of Limerickand University of Limerick

BackgroundBackground::

Embedded levels in a change context.Embedded levels in a change context.Inherited internal influences e.g., culture, style, strategy, Inherited internal influences e.g., culture, style, strategy, structure, previous change/innovation.structure, previous change/innovation.

Literature: Policy, Systems, Theoretical Perspectives e.g.,Literature: Policy, Systems, Theoretical Perspectives e.g.,

Leadership approaches and change models.Leadership approaches and change models.Domains in tension, professional and managerial Domains in tension, professional and managerial bureaucracies. bureaucracies.

Methodology/Methods: Case Study – Grounded TheoryMethodology/Methods: Case Study – Grounded Theory

Pluralist – methods, participants, settings.Pluralist – methods, participants, settings.Analytic Text – categories and paradigm analysisAnalytic Text – categories and paradigm analysis

Mediators and Moderators:Mediators and Moderators:

MediatorsMediators

Inclusive concepts which encompass agents, agency, artifacts, ideas Inclusive concepts which encompass agents, agency, artifacts, ideas and social influence processes.and social influence processes.

(i) Influences: purpose, roles, leadership.(i) Influences: purpose, roles, leadership.

(ii) People: relationships, ownership, capability, capacity.(ii) People: relationships, ownership, capability, capacity.

(iii) Operational System: structure, service management (iii) Operational System: structure, service management practices. practices.

Define relationships which connect the organisation and people to Define relationships which connect the organisation and people to the overall objective of activity.the overall objective of activity.

ModeratorsModerators

Moderators, as intervening and situational variables, modify and Moderators, as intervening and situational variables, modify and affect mediators/mediation.affect mediators/mediation.

Moderators as systemic and/or substantive or intrinsic factors which Moderators as systemic and/or substantive or intrinsic factors which affect mediator influence e.g., limitations, variations, substitutes affect mediator influence e.g., limitations, variations, substitutes and environments.and environments.

Potential and Experiential Change - IllustrationPotential and Experiential Change - Illustration

Mediator Influence:Mediator Influence:

Purpose of Change:Purpose of Change:(i) (i) PropensityPropensity: dependent on a shared purpose and enabling : dependent on a shared purpose and enabling

objectivesobjectives (a) Population dimension – corporate.(a) Population dimension – corporate.

(b) Quality of care – managers and (b) Quality of care – managers and professionals. professionals.

(ii) (ii) ActualActual: (a) Not tangible in Corporate roles: (a) Not tangible in Corporate roles (b) Explicit in roles of (b) Explicit in roles of

ManagersManagers – system, process. – system, process.ProfessionalsProfessionals – practice – practice. .

Leadership:Leadership:

(i) (i) PropensityPropensity : a shared objective linked to new ideology : a shared objective linked to new ideology ManagersManagers- transparent, accountable organisation.- transparent, accountable organisation.Professionals Professionals - corporate exemplars and leadership- corporate exemplars and leadership skills. skills.

* Concept as: corporate accountability, clinical * Concept as: corporate accountability, clinical responsibility and professional influence on responsibility and professional influence on

morale and practice.morale and practice.* Prototypes: Managers – leadership and change. * Prototypes: Managers – leadership and change.

Professionals – attractor/influencer. Professionals – attractor/influencer.

(ii) (ii) ActualActual: senior managers and change leadership : senior managers and change leadership Professional and domain leadership. Professional and domain leadership.

Style:Style:

(i) Propensity: (i) Propensity: Corporate level variety Corporate level variety ++ (ii) Actual: (ii) Actual: Positive and empowering +Positive and empowering +

Autocratic -Autocratic -

Mediating Change Through PeopleMediating Change Through People

Relationships:Relationships:

(i) (i) PropensityPropensity:: ManagersManagers - wanted quality linkages and - wanted quality linkages and leaders with strong relational attributes. leaders with strong relational attributes.

Professionals Professionals - wanted credible engaging - wanted credible engaging leaders and relationships based on trust and leaders and relationships based on trust and mutual obligation.mutual obligation.

(ii) (ii) ActualActual: : ManagersManagers - problems in linkages and - problems in linkages and mutual mutual understanding! understanding!

ProfessionalsProfessionals - relationship with - relationship with management and inter/intra disciplinary management and inter/intra disciplinary tensions.tensions.

Outcome: Positive indications through managers and ositive indications through managers and professionals reciprocal engagement and,professionals reciprocal engagement and,stakeholder participation and professional stakeholder participation and professional involvement. Positive relationships in involvement. Positive relationships in smaller hospitals, MHS and Elderly Caresmaller hospitals, MHS and Elderly Care..

Mediating Change Through the Operational System.Mediating Change Through the Operational System.Structure:Structure:

(i)(i) PropensityPropensity: : too hierarchical in acute or too loose in hierarchical in acute or too loose in community care. MHS – flat and integrated with community care. MHS – flat and integrated with MDTs.MDTs.

Managers – separate strategic and Managers – separate strategic and operational. operational.

Professional – wanted clear lines of Professional – wanted clear lines of accountability for others. accountability for others.

(ii) Actual: managers restructured the organisation with professionals’ input.Outcome:Outcome: Managers Managers – care group management and – care group management and

decentralised line and decentralised line and functional functional management. management. Professionals Professionals – good awareness, participation – good awareness, participation

and integrated management. and integrated management.

External External ++

ContextsContexts

Internal Internal

Inherited Inherited ++

InterventionsInterventions OutcomesOutcomes

MediatorsMediators influencesinfluences

MediationMediation

PeoplePeople OperationalOperational systemsystem

ChangeChange

IndicatorsIndicators

IssuesIssues

ResponsesResponses

Actions Actions

ReactionsReactions

OutcomesOutcomes

ModeratorsModerators

Intervening,Intervening,

Situational.Situational.

AntecedentsAntecedents

An Emergent Model of Internal Mediators and ModeratorsAn Emergent Model of Internal Mediators and Moderators