Centre Formation Processes in Hospitals
A grounded theory research exploring centre formations in hospitals, and the contribution of
guiding coalitions to this change success.
Master Thesis, MSc BA, Change Management
University of Groningen, Faculty of Economics and Business
September 2013
JOHAN DOUMA
Student number: 1788981
De Sitterstraat 1
9721ET Groningen
(+31) 623573988
Doumajs@gmail.com
Supervisors/ University
Dr. C. Reezigt
Dr. J. Rupert
Supervisors / field of study
Dr. M.J. Siebelink
2
Abstract
3
Table of Contents
1. Introduction
4
2. Methodology
5
2.1 Sampling and Data Collection
5
2.2 Data Analysis
6
3. Case Description
9
4. Results
10
4.1 Barriers to centre formation
10
4.2 Facilitators to centre formation
14
5. Discussion
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5.1 Confrontation with literature
22
6. Propositions
30
7. Conclusions
33
7.1 Limitations and Future Research
34
7.2 Acknowledgement
35
8. References
35
4
1. Introduction
The current business environment is continuously changing, and becoming increasingly complex. This consequently increases the difficulty to bring about change within organisations. Organisations for which this certainly holds are health care organisations, and in particular hospitals. Today, health care is increasingly complex, with a multiplicity of possible diagnostic and treatment approaches, all requiring extensive specialization, and with patients who are increasingly suffering from comorbidity and chronic conditions (Molleman et al., 2010). In order to deliver high quality care, collaboration is essential. In clinical settings, multidisciplinary medical teams dealing with patients with complex health problems, such as cancer, diabetes, or chronic respiratory diseases, have become part of everyday life (e.g., Grumbach & Bodenheimer, 2004; Haward et al., 2003; Lemieux-Charles & McGuire, 2006). Also transplantation related care can be considered as highly complex. As a response to the need for a different organization of care within hospitals, a recent trend is to form centres in which these multidisciplinary teams can operate efficiently. A possible description of the characteristics a centre possesses is provided by Van Harten en Rodenhuis (2012), as they described their oncology centre as “(part of) a hospital in which oncology patients are being treated multidisciplinary by medical specialists and other professionals who exclusively, or almost exclusively, deliver oncological care”. Similar descriptions hold for centres delivering other types of care. However, to date there is no uniform successful approach to the formation of centres within hospitals, causing many attempts either to partially succeed or fail entirely. Though, over the last decade, within the healthcare sector guiding coalitions are increasingly emphasized as a prerequisite for successful change (e.g. Narine and Persaud, 2003; Harris et al., 2006; Heineman, 2010). Smith (1998) and Lozon and MacGilchrist, (1999) defined a guiding coalition as a committed group of stakeholders drawn from every area and level of the organisation. In most successful cases, the coalition is always pretty powerful – in terms of titles, information and expertise, reputations, and relationships (Kotter, 1996). A rather practical definition is provided by Cunningham and Kempling (2009), stating that a guiding coalition is a committed leadership team, which purpose is to represent the informal organisation and should gather information, listen to people, do research and make adjustments during any change process (i.e. lead the change effort).
5 been conducted that focuses on the characteristics and roles of guiding coalitions in businesses (e.g. Kotter 1996; Rainey, 2006). However, no research has been conducted on how to develop centres within hospitals, the role that guiding coalitions have in this process, and on factors that act as barriers or facilitators to this process. This research therefore contributes to our understanding on change processes within the health care sector known as highly complex and uncertain. This knowledge might aid in increasing change success in future processes. The following research questions will guide this research: How are centres formed in hospitals, and how do guiding coalitions contribute to the success of this change process?
This paper is structured as follows: it first outlines the research design. Then, it provides a short case description in which main events from the past and the current situation will be discussed. Thereafter, results of the data analysis are provided and linked to existing literature. Next, findings are discussed with respect to the role of guiding coalitions in centre formation within the healthcare context. In the conclusion, limitations and suggestions for future research are outlined.
2. Methodology
Qualitative research methods facilitate exploration of a phenomenon within its contemporary context using a variety of data sources (Eisenhardt, 1989; Yin 1989, 1993, 1994; Baxter and Jack 2008). This method is recommended for exploratory research and is suited to uncover the meaning that people assign to their experiences (Hignett, 2003). In order to uncover the stakeholders’ understanding of their experiences with regard to the start-up of the Comprehensive Transplant Centre, the method used in this study involved a grounded theory analysis (Glaser and Strauss, 1967; Charmaz, 2006). Grounded theory is an inductive method of qualitative analysis designed to develop theory about a phenomenon (Locke 2002). This type of research is executed through direct contact with the social world studied, hence does not follow the a priori theorizing approach. It is informed by the theoretical perspective of symbolic interactionism (Blumer, 1973), which takes a process view of social reality. According to this view, human interaction with the world is mediated through processes of interpretation and sensemaking. As mentioned above, researchers therefore are concerned with understanding situated meanings and experiences. Thus, the focus of grounded theory is to unravel the elements of an experience. From the examination of the components of the experience and their relationships, a theory is developed that provides insights into the ‘nature and meaning of an experience for a particular group of people in a particular setting’ (Moustakas 1994).
2.1 Sampling and Data Collection
6 meetings and conducting short face to face interviews that were unstructured. Data were gathered around perceived key triggers that led to the creation of the Comprehensive Transplant Centre in a university hospital in The Netherlands, and what this new form of organisation brought them. This primary data also aided in choosing the right respondents for this study that represented the parties involved in the change process. Next, secondary data were collected. Following the grounded theory approach of theoretical sampling (Strauss, 1987; Corbin and Strauss, 2008), initial interviewees were selected along various dimensions, such as disciplines. rank, activity in the process and time of participation to find variation in the data. Creswell (2007) suggests that an investigator should ‘select a sample of individuals to study based on their contribution to the development of theory (p.240). Therefore, data arising from early interviews guided the choice of participants for later interviews. Four major groups of respondents can be identified, consisting of three managers/staff members, four medical managers (e.g. the head of department X), four medical specialists (e.g. surgeons and physicians) and three professionals from other disciplines (including physiotherapists, psychosocial care, etc.). They all either have participated in the development of the comprehensive transplant centre, or currently are participants in the project and represent the groups that are involved in this project. The (in total) 14 in-depth interviews lasted between 45 and 90 minutes, and were all conducted by the researcher. Moreover, all interviews, consisting of over 13h of data, were tape recorded for later full transcription. A semistructured interview protocol was developed in order to ensure coverage of all relevant topics, provide a consistent data collection approach across respondents, and to allow the interviewee to describe events and issues from their point of view (Bryman and Bell, 2003). The interview focused on respondents’ reflections on their initial
7 involvement with the comprehensive transplant centre, their current view on the project, the perceived support within their stakeholder group, the role of the guiding coalition, the perceived level of communication and success, and their expectations about the (near) future with regard to this project.
2.2 Data analysis
Following grounded theory (Crobin and Strauss, 2008), constant comparative analysis was used to guide the analysis of the qualitative data. Constant comparative analysis is described as the process of taking information from data collection and comparing it to emerging categories (Hutchinson, 1993). Three stages of coding are used, including open coding, axial coding and selective coding. During the open coding process, the thoughts, ideas, and meanings of respondents are organized into categories, using Atlas.ti software (Muhr 2004, Charmaz 2006). Codes were collected either in vivo or in the participants’ own words (see figure 1). The second stage of coding,
8 axial coding, consisted of investigating categories within their conditional context. This allowed the researcher to look for connections and relations within the various categories that were initially identified, shown in figure 2. Brown and Stevens (2002) state that the focus of axial coding is “to create a model that details the specific conditions that give rise to a phenomenon’s occurrence”. Third, selective coding enables the researcher to integrate and refine categories around a central explanatory concept or category (Strauss and Corbin, 1998). To increase the trustworthiness of this article, during interviews, statements of the respondent were summarized to confirm the adequacy of the understanding. Audiotapes were transcribed following each interview, and afterwards the researcher read the transcript and listened to the corresponding tape simultaneously in order to identify the errors, if present. As a final stage of control, the transcripts were sent to all respondents for review in order to ascertain the quality and adequacy. This process increases the validity of this research (Van Aken et al., 2012). Lastly, as all interviews were in Dutch, data was translated to English by the author who is fluent in English.
3. Case description
The case being analysed for this research concerns the development of a Comprehensive Transplant Centre (CTC) in one of the University Medical Hospitals (UMC) in The Netherlands. Approximately two years ago, a symposium was organised at which trans-disciplinary, transplant related topics (e.g. dietetics and nutrition) were discussed. Professionals from different disciplines and levels were invited. At this symposium, people stood together and exchanged experience and ideas on transplant related care. They noticed that although they worked in the same organisation, they did not exactly know how other disciplines provided care to their patients. These people saw opportunities to improve the quality of care and become more efficient if disciplines increasingly collaborated. The idea to develop multidisciplinary cooperation in transplant related care was not new though. Over the past decade multiple initiatives were taken to increase collaboration but these initiatives never were successful. The most prominent given reasons for the unsuccessful attempts concerned power struggles and money. It seemed that project leaders pursued their personal interests (such as autonomy, power, and money) instead of trying to achieve the common goals. The general motives for cooperation though were similar in all initiatives, of which the following three were most evident: increase the quality of care for transplant patients, enhance efficiency of working practices, and promote the UMC as the hospital for transplant related care.
9 representatives were medical specialist known for their expertise in this area, not e.g. the heads of the relevant departments. The underlying idea was to primarily get the professionals on the same wavelength as, taking earlier attempts into consideration, this was deemed to be a necessary prerequisite for success. Other care professionals and managers would possibly be approached at a later stage. During this meeting, all parties present were convinced that the quality of transplant related care could be improved compared to the current level, and moreover identified areas of considerable potential such as research. A shared urgency for collaboration was created and a guiding coalition was born. This initial guiding coalition consisted of eight persons, a number that remained relatively stable over the year. During the first year, initial plans and ideas were developed and decisions were made with regard to the direction of this Comprehensive Transplant Centre. However, as within a hospital, no plan of this size and impact will be executed without support from the Board of Directors, this support was essential to obtain in order to proceed with this project. After one year, the urgency for approval was felt within the guiding coalition and the BoD was asked to give its consent, which it did. Since then, different working parties were installed and situated in one of three pillars: care, research or education. Professionals from all disciplines and all levels of the organisation jumped on the bandwagon to make their contribution to this effort. New ideas were brought to the table and some initial plans were executed in this second year. The size of the guiding coalition in two years had grown from 3 to 55 members.
4. Results
This section first presents six barriers towards the centre formation process that arose from the data. These factors could be identified by at least three out of four respondent groups, and were mentioned multiple times. Additional evidence with regard to these barriers is provided in table 1. After having discussed the barriers, five facilitators towards this process are presented and supported by additional evidence (see table 2).
4.1 Barriers to centre formation
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Barrier 1: Different interests/goals
A first important barrier involved the different interests and goals of people being involved. Across every respondent group it was evident that those who were (actively) involved had their interests they wanted to protect or goals they tried to pursue. Whenever someone did not see the added value nor had interest in the project, this caused inactivity. One inactive medial specialist summarised: “Undoubtedly they see a potential gain together, but for me personally it shows no signs of added value for my group of patients.” Contrasting interests and goals were particularly evident when comparing those of managers and CPs. As two managers reflected, “When I look three years ahead, I hope that this CTC has been developed and promoted externally.” A very different goal was mentioned by one of the CPs as she noted, “It is of great importance for patients to train better, but also more frequently.” This might cause difficulties as one respondent stated: “People always tend to protect their own interests first before looking at common goals.”
Barrier 2: Financial issues
The second barrier is related to financial issues resulting from the centre formation. All respondent groups stressed the important role finance plays in this process, and from which group resistance can be expected. As one medical manager noted, “Head of departments, who have a lot of power always opposed these initiatives concerning centres as this transcends their power. These initiatives threaten their revenues and cash flows.” A care professional echoed this statement: “They still have to keep the department up and running. If a large part of their revenues is lost from which they financed other activities, the heads will not be happy.” The managers/staff also noted that finance does play a role, particularly during the formalisation process (see table 1).
Barrier 3: Time
A third barrier involves the limited time that professionals have within hospitals; it was noted by all respondent groups except for the group of managers/staff. As one medical specialist explained, “I first wanted to put additional time and effort into this project, but eventually I didn’t. It costs me too much time which I do not have. Moreover, the activities linked to the CTC are not part of my performance evaluation.” A medical manager confirmed this statement: “People that were enthusiastic in the beginning drop out because of time constraints.” Also CPs argued that time perhaps would even be the major barrier to inhibit progress.
Barrier 4: Unknown consequences of change
11 not actively involved, because it is not concrete enough to see whether or not this will benefit our department; what will be the consequences for my activities and department?” For this medical specialist, the unknown consequences caused inactivity. On the other hand, the unknown consequences might be a source of activity as well, as has been stressed by one of the managers: “It is great to support an idea. Take e.g. a political party. You fully support their ideas, but when it becomes concrete and you have to start paying your membership fees or handing out folders in the streets, it gets a different dimension. On that moment it becomes tangible and it will go at the expense of something else. It is that moment that you will feel it.”
Barrier 5: Power/autonomy issues
Across informants, power and autonomy issues appeared to pose another important barrier. As one medical specialist noted, “Within our department transplantation is a large part of our activities. In the classic organizational structure a departmental manager will protect his nest, even though he might not even be interested in the egg ‘transplantation’. If anyone tells him the egg could better be transferred to another nest, he will not let this happen. This takes away part of his autonomy.” Also the other respondents groups mentioned power and autonomy as barriers to the development of a transplant centre (see table 1).
Barrier 6: Formalisation
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4.2 Facilitators to centre formation
The themes that informants consider to facilitate the centre formation include organic growth, support of Board of Directors, having a strong leader, common goal/problem, sense of urgency and visibility of results. Several of these facilitators directly addressed the barriers that are reported above, yet also other facilitators emerged. The respondents’ comments are presented in table 2.
Facilitator 1: Organic growth
One theme that was salient across almost all informants was that the organic development of the comprehensive transplant centre contributed to the success. A centre must be formed from the bottom up and not be implemented in a top down fashion. As one medical manager mentioned, “But it makes no sense to say: here we position a centre and you guys have to start working together. This simply does not work.” Care professionals echoed the importance of an organic process: “The approach is extremely important. Plans have been made in consultation and we noticed that people were enthusiastic and supported the idea. It is not a top down implementation, but initiated from where the expertise is situated.”
Facilitator 2: Support given by Board of Directors
The second facilitator involves the support pronounced by the Board of Directors, noted by almost all interviewees as being crucial for centre formation to succeed. Care professionals stated that “the main factor to success is the support given by the Board of Directors. They ratified their support at several formal meetings.” Also medical specialists recognized the support as being essential for success, though also argued that verbal support alone is not sufficient. As several specialists emphasized, “I think it is good publicity when the BoD pronounces their support. However, verbal support is not sufficient to make this process a great success.”
Facilitator 3: Strong leader
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Facilitator 4: Common goal/problem
Across informants, having a shared main problem or shared possibility for improvement appears to be another facilitator. The emphasis however sometimes differed between the respondent groups. The managers/staff stressed the important prerequisite of having either a common goal or shared problem, e.g. similar problems during the follow-up phase (see table 2). Medical managers echoed the importance of a common goal. As one MM noted, “People with different competences and fields of expertise sit at the same table, but should have a common goal in order to collaborate successfully.” Medical specialists stress the importance of collaboration in transdisciplinary areas as in those areas common problems can be found: “The CTC has added value in transdisciplinary areas. You should keep organ-specific ownership as it is. But again, there is considerable potential in transdisciplinary areas.” Also CPs reflected similar viewpoints towards a transdisciplinary focus; “From a care point of view we should collaborate and in particular create something transdisciplinary for all organ programs.”
Facilitator 5: Sense of urgency
A fifth important facilitator involves the presence of a sense of urgency. A large number of interviewees mentioned the importance of the presence of a sense of urgency. A manager e.g. noted, “With other centre formations we now work on our third attempt. In earlier attempts there was no shared sense of urgency, even though one knew analytically that it was necessary.” A medical manager who has been working for different hospitals throughout the country also stressed that: “Also in other hospitals I saw that a shared sense of urgency is essential for guiding coalitions to succeed.”
16 not see the importance for our department. I do see this in the long run. It could be that at a later stage, we will become actively involved if we see an opportunity to improve the quality of care for our patients.” One other MS, part of one of the largest transplant programs within the hospital, emphasized the urgency on different levels. He noted, “On national level, we have to make our mark as the top transplant centre to make sure everything is centralised here, not elsewhere. On the expertise level, we all have similar issues and we simply have to share this knowledge to increase the quality of care. At a European level research should be the focus of interest as we play a leading role in preservation research.”
Having presented both the barriers and facilitators objectively with regard to the centre formation process, the next section will interpret the results and link them to existing theories in order to develop sound propositions.
5. Discussion
The main objective for this discussion is to provide a strong foundation for developing sound propositions. In order to realise this desired state, first the results from the data analysis will be interpreted on a higher level of abstraction. This interpretation enabled the identification of two main stages in the centre formation process: 1) the creation of the guiding coalition and 2) the formalisation stage. Next, existing literature is reviewed and linked to both change stages in order to explain these findings and provide support for the propositions. Both the interpretation and confrontation with literature are structured by using the two stages.
As mentioned above, two main stages can be identified in the centre formation process in this case study. The term ‘stage’ is chosen deliberately. Whereas e.g. phases imply a sequential and planned change process, stages illustrate an evolving change process in which stages might overlap. As this overlap can be found in the stages of the centre formation process being analysed, this term best suited our analysis. The first stage concerns the creation of the guiding coalition up to the point of formalisation. The second stage includes the formalisation process. This formalisation process eventually might result in the centre being incorporated into the hierarchy. Moreover, tasks, rules and procedures might become embedded in the daily practices of the organisational members. Entering the second stage might lead to the abolishment of the guiding coalition, as one particular feature of the guiding coalition is its informal character and movement outside the normal hierarchy. Below the findings from our analysis are presented, structured in the two stages.
Stage 1: creating the guiding coalition
17 described the characteristics of the guiding coalition as essential to this first stage. These characteristics included e.g. the informal structure, movement outside the hierarchy and the decentralised decision making (decision-making authority is based on expertise rather than hierarchy). Most respondents however did not refer to the term guiding coalition itself but instead used terms such as ‘centre’ or ‘project group’. Therefore, it seems that they viewed the guiding coalition already as an organisation in itself. Nevertheless, respondents stressed the importance of a guiding coalition by labelling its characteristics as ‘crucial’ for success.
The first stage is characterised by organic development, which is strongly linked to the evolution of a guiding coalition. Most respondents stressed the importance of organic growth in this stage and even identified organic growth as one of the key success factors. The concept of organic growth includes more aspects other than solely a bottom up approach. For example, in the very beginning there were no rules, procedures, structural meetings, organisational structure, or whatsoever. Moreover, every professional within the hospital that desired to participate in this guiding coalition and provided input related to their field of expertise was welcomed. This excessively open approach was a clean break with a history of failing attempts to form similar centres. As has been discussed in the case description, these failures particularly were caused by financial and power issues. A second major change compared to earlier attempts concerned the hierarchical level where the guiding coalition was created. Whereas previous guiding coalitions, besides physicians, surgeons and care professionals, also included heads of departments, the latter hierarchical level was not represented in the guiding coalition of this centre formation process. As discussions now took place at the work floor level, the focus of interest (e.g. during meetings) therefore shifted towards the expertise and care related topics, rather than issues related to finance and power. This shift can be explained by the obvious reason that financial and power issues play just a minor role on the work floor level compared to higher hierarchical levels. The majority of the respondents stressed the importance to focus on content first, and get the physicians, surgeons and care professionals on the same wavelength first. One respondent even argued that “if those groups do not walk in the same direction, the centre has no chance to be developed successfully”. All the above mentioned aspects therefore exhibit the importance of an open, evolving, and thus organic organisation during the first stage of centre formations.
18 is related to the interests issues described above, concerns the unknown consequences caused by the centre formation process. Especially members from ‘smaller’ disciplines (for which transplant care is not a core activity) showed inactivity caused by the unknown consequences. The reason for inactivity resulted from a (non-financial) cost-benefit analysis conducted by these members from smaller disciplines. The outcome of this analysis showed that they had to spend a relatively large amount of time, to achieve a potential small gain for their group of patients. The result was inactivity by those members. The same analysis however resulted in activity for the ‘larger’ disciplines (for which transplant care is a core activity). The importance for larger disciplines to be involved is evident as, next to the large potential gain for their group of patients, involvement enables them to steer the direction of the centre development and protect the interests of their disciplines. It seems therefore that the (in)activity could be explained by the potential impact this centre might have on the activities of a discipline. Whenever transplant care is a core activity, the centre might have a major impact on the activities of this discipline and therefore members from these discipline want to be actively involved to protect the interests of their discipline. On the other hand though, when transplant care is not a core activity, the impact the centre has on the discipline would be relatively small and therefore those members might want to invest less time and effort to protect their interests. However, as all disciplines have to participate in this centre, including the smaller disciplines as well, the interests also have to be aligned. The presence of a competent leader therefore is crucial. He or she has to keep every discipline ‘on board’ in order to develop this centre successfully.
Although organic growth and aligning interests are essential during the first stage, respondents stated that without the support of the board of directors, the centre formation process has no chance to succeed. Support was identified by respondents as a key success factor for centre formation. A major advantage for the guiding coalition is the gain of power. If the board of directors supports the idea, the power towards (medical) managers will increase as the centre has to be taken seriously and cannot be ignored anymore. The comprehensive transplant centre changes from an interesting idea to a serious project. However, this has consequences for the guiding coalition. Whenever the sign has changed from red to green, people expect plans to be executed. In order to do so efficiently, the organic organisation (guiding coalition) requires more structure. Important to mention is that the organisation still is informal and is situated outside the normal hierarchy. However, people have to get responsibilities for certain actions or tasks, and meetings have to be organised to discuss difficulties and share experiences. The leader of the guiding coalition has a major role and responsibility in this process. In order for people to execute these tasks properly, he or she has to describe the tasks and procedures needed. Moreover, the leader is responsible for arranging meetings, monitoring the progress, and motivating the members of the guiding coalition.
19 professionals started the guiding coalition, and made major first steps in the centre formation process. During this stage they adopted an active, hands-on approach in order to make progress. However, as the guiding coalition had increased in number, it was this group of members that formed (and still does) the steering committee. It seemed that the role of this core group of professionals shifted from a highly hands-on, towards a steering and governance role. The working groups now perform the tasks and the steering committee guards the direction and monitors the progress. They also seem to take final decisions.
Stage 2: the formalisation
Although the formalisation stage has not been finished during the research period, the results have provided sufficient information in order to include this stage in the analysis. The demand and need for formalisation that arises within the guiding coalition seems to be caused by an internal and external factor. The internal factor relates to the need for structure as the guiding coalition grows in size and scope. The external factor concerns the demand for power that arises as time goes by.
Over time, the guiding coalition grew in members as an increasing number of professionals wanted to become involved in the centre formation process. As an organisation grows in number, it becomes increasingly difficult to manage this group efficiently. However, not only had the size of the guiding coalition grown, but also the scope which increased the complexity even more. Meetings became inefficient and the need for structure arose. The leader of the guiding coalition therefore attempted to organise the ‘chaos’ as a steering committee and several working groups were installed during the first stage. These were the first steps towards formalisation. However, this demand for structure enhanced as the process of growth in size and scope continued. Moreover, as described in the previous section, the support given by the board of directors enabled members to execute plans. This induced rules, tasks, procedures to be formalised as well. Thus, the increasing internal complexity caused the demand and need for formalisation.
20 Although the formalisation may be desired by people within the guiding coalition, formalisation might also contain certain downsides. Two of the most important downsides will be discussed here, including the reduction of interpretational space, and the introduction of two important barriers of centre formation.
A typical consequence of formalisation is the reduction of interpretational space. Before formalisation, in the organic structure without rules, procedures, descriptions of tasks, etc., members of the guiding coalition were e.g. free to develop ideas or perform tasks the way they felt most comfortable with, or perhaps even served their interests. Moreover, professionals participating in the guiding coalition had the opportunity to interpret the centre in a way that served their interests. However, as tasks, procedures, structures, etc. become formalised, the interpretational space decreases. As the interpretational space decreases, members of the guiding coalition might lose the possibility to serve and protect their own interests, or the interests of their grassroots. Results have shown that whenever people cannot serve their interests anymore, people might become inactive. Formalisation therefore might result in ‘loosing’ members of the organisation.
A second downside concerns the introduction of two important barriers to centre formation; power and financial issues. Financial and power issues were both identified as barriers to centre formation processes. During the first stage, practically no financial or power dilemmas could be identified as the guiding coalition was created on the work floor, where these issues play a minor role. Therefore, as described above, discussions rather focused on the content and expertise with regard to the transplant centre. However, by formalising the organisational structure, the two problem areas are introduced to the centre formation process. Whenever an informal organisation becomes part of the formal organisation, one professional will become the ‘head’ of the organisation and receives the formal power. This largely differs from the distribution of power within the guiding coalition. The relative power of members of the guiding coalition therefore might decrease after formalisation. Also financial issues come into play, as the organisation will become responsible for its own revenues and costs. History reveals that these power and financial issues caused many attempts to fail.
21 of cooperation is not seen as harmful to the centre formation process, but the formalisation of structure is seen as a barrier. Power and financial issues seem to cause this difference.
The above analysis provided some initial insights in the results from the case study. The centre formation process seems to be divided in two main stages; creating the guiding coalition and the formalisation. During the first stage, in which respondents referred to the guiding coalition as ‘centre’, organic growth seems to be of great importance, partly resulting from the history of other attempts. Also the support by the board of directors and interests played a key role. The formalisation stage both showed benefits and difficulties, but in the end seems necessary to make the centre formation successful and embedded in the organisation. In the following section of this discussion, the above presented results will be linked to, and if possible explained by, existing literature in order to increase our understanding on the process of centre formation.
5.1 Confrontation with literature
The results arising from data analysis are linked to several existing theories in order to discuss and explain the centre formation process, and the role guiding coalitions play during this change process. As has been described above, two stages can be identified in the centre formation process.
Stage 1: ANT and guiding coalitions
In the first stage of centre formation, guiding coalitions seem to play a prominent and fundamental role. As has been mentioned, earlier attempts to form a Comprehensive Transplant Centre failed. Among others this was caused by a highly controlled, top down approach which was adopted by managers. Literature supports that in highly complex organisations and environments, a different type of management is required for successful change processes (e.g. Stacey, 1993; Hertog and Westerveld, 2009). For instance, Hertog and Westerveld argue that in complex environments, it is necessary to encourage informal structures with members from different business units, functions, levels, etc. This description is strongly related to the concept of guiding coalitions and therefore these coalitions seem highly appropriate for complex change processes, such as centre formations in hospitals.
22 organic organisations thrive in uncertain environments as they are able to respond to unstable demands. This is achieved through close interaction and communication across the organisation (horizontally, vertically, and diagonally). In order to respond to these unstable demands, the organic organisation also should adopt a matching organic structure to achieve this level of flexibility. Brown and Eisenhardt (1997) argued that organic structures have few, if any, rules, responsibilities, or procedures. The decision-making authority is not only decentralised, but resides with those who possess the expertise relevant to a particular task of problem, rather than from a position in hierarchy. This is consistent with what Galbraith & Lawler (1977,1993) referred to as lateral relations, which permits problems to be solved at the level where they occur, rather than being referred upward in the hierarchy. Organic structures therefore are effective in complex and uncertain environments as it distributes the demands for decision making to those who are most capable to make the decisions. This organic aspect is typical for the first phase in the centre formation process and one of the key facilitators of success mentioned by respondents.
In order to interpret the events that led to the contemporary stage (the stage up to the formalisation) in this centre formation process concepts from the actor-network theory (ANT) are used. Callon and Latour (1987), in one of the earliest works on ANT, outlined how actors (i.e. individuals) form alliances and enrol other actors, and use artefacts to strengthen such alliances. Thereby, they create heterogeneous networks consisting of humans and nonhuman artefacts. As these networks were found to act as if they were independent autonomous actors, they are referred to as 'actor-networks' (Sarkert et al., 2006). Actor-network theory is ostensibly a theory of innovation (emerging artefacts). It has developed out of a desire to trace the interrelations between human and nonhuman actors that facilitate the accomplishment of stability. Stability in this sense could be the temporary stability in centre formations, or the longer-term stability of 'society'. As this study focuses on an innovation (the centre itself) within the health care sector, ANT suits this research particularly well to interpret the events during this change process. An aspect that strengthens the argument for the use of ANT, is the link between organic growth and the ANT. This link has been found by Hanseth (2007). He described actor-networks as heterogeneous and organically evolving open systems. Moreover, he argues that “strength of network relations waxes and wanes, a fixed input to the system will not produce a fixed output”. Therefore, ANT seems a highly appropriate theory for analysing the first stage of the centre formation process.
23 with different interests. For example, in an organisational change process, any of the concerned parties –physicians, surgeons, care professionals, managers, etc.- may simultaneously initiate translation attempts to steer the outcome in their favour. Therefore a focal actor is key in this process, as this actor drives the process of enlisting the other actors’ support for the organisational change initiative (Sarker et al., 2006). It seems plausible that the leader of the guiding coalition acts as the focal actor in the first stage of the centre formation process. However, it is also possible that multiple actors can be identified as key actors, attempting to enrol support. Hence, in a broader sense all members of the guiding coalitions can be designated as key actors since they attempt to enrol support for this centre from their grassroots. When the four stages of translation are described, the leader of the guiding coalition will be regarded as focal actor.
24 structure the guiding coalition with all its tasks. The fourth stage of translation, mobilisation, involves getting actors to act on behalf of guiding coalition (Blackburn, 2002) which aids the change towards centre formation. It therefore concerns engaging others in fulfilling the roles, undertaking the practices and linking with others in the network (Sarker et al, 2006). Currently, everyone involved in the guiding coalition has a defined role and is part of either the steering committee or working groups. However, not everyone is engaged in fulfilling the roles. Besides the different interests people have, time constraints and unknown consequences of the change are barriers towards active involvement as well. This leads to a particular feature of actor-networks. This feature explains that networks can be convergent and divergent (Law and Callon, 1992). In convergent networks, the understanding of intermediaries among actors is shared, with the result that they have predictable translation effects (Alderman and Ivory, 2011). In these networks actors do not resist translation and therefore make these translations efficient. Convergent project networks typically have clear and agreed “obligatory points of passage” (Law & Callon, 1992, p. 31), as have been explained above. This is strongly linked to the facilitator ‘common problem/goal’ and ‘sense of urgency’. When there is a common goal, people will pass through the OPP as they perceive a sense of urgency to be part of this centre formation process. A prerequisite of course still is that individuals are able to serve their interests. On the other hand, actors in divergent networks do not share a common understanding, and therefore fail to recognize the legitimacy of the organisation or institution. This organisation or institution though is regarded by others as an OPP. In case of divergent networks, actors may resist the roles and begin to pursue their interests elsewhere, causing the network to be highly inefficient (Buchanan & Boddy, 1992). Therefore, the argument is that an efficient change process (centre formation), is one in which network translation result in actor convergence around stable goals. These are goals that are, from ANT’s perspective, held stable by the actor-network. As ‘different interests’ has been mentioned as one of the main barriers to centre formation the main challenge for the focal actor(s) is to align the interests of individuals. If these are not aligned, they will decrease the efficiency of the change process.
25 investigated in this paper, the comprehensive transplant centre. The interpretative flexibility of the role, use and purpose of the centre is relatively high in the first phase of the formation process. Without this interpretative flexibility, Berkhout (2006) argues that “it will be difficult for a vision to succeed in enrolling new adherents and advocates, because to be adopted by a new adherent, a vision would need to be matched to a new set of interests and a new (and in part private) image of the present”. Put differently, it will be difficult for a focal actor to enrol other actors in the network as their interests have to be matched with the interests of the network. The concept of interpretative flexibility therefore is particularly relevant for two stages of the translation process; interessement and enrolment. As mentioned above, when the centre develops, ideas are concretised and consequently the interpretative flexibility will decrease. This results in an increasing similarity in interpretation of what the transplant centre entails and focuses on. Whenever these plans do not cover the interests of particular actors, results show that these actors may become inactive or even withdraw from the guiding coalition. A similar result relates to what Caluwe and Vermaak (2006) refer to as the ‘pocket veto’ of actors. Hansen (1996) defined it as ‘the power exerted through inaction; in other words, people do not respond to requests or mandates for change’. Caluwe and Vermaak argue that employees have the possibility to make large parts of their activities invisible for their managers. The result is that managers perceive the employees to work according to their ideas, though employees act very differently. Actors show this behaviour when their manager asks or demands activities that they do not support. If employees (or actors) have developed an extensive pocket veto, this might be disastrous for the change process as two views of reality emerge: the reality of the change leader(s) and the reality of the professionals.
Since it is quite presumable that not all actors’ interests can be served, a major challenge arises for the focal actor during the phase before plans are executed and the interpretative flexibility decreases. This challenge includes aligning the interests of actors. If the focal actor is able to succeed in aligning the interests, most actors will experience that their interests are served and remain part of the guiding coalition. The question arises however how to optimally align the interests of actors with the network.
26 causes differences of understanding drawn into those networks. This results in further unanticipated translations and outcomes. According to Alderman and Ivory, networks therefore should be converged politically (i.e. aligning interests) and cognitively (i.e. through sensemaking) in order to be totally efficient. An efficient network in turn seems to be a prerequisite for successful centre formation processes.
As also has been discussed in the analysis above, the leader of the guiding coalition plays an important role in the process of creating the guiding coalition, and converging the network politically and cognitively. It seems that during these early stages, the leader needs transformational leadership capabilities. Burns (1978), who proposed transformational leadership, describes it as a process where leaders and followers engage in a mutual process of 'raising one another to higher levels of morality and motivation.’ Bass (1985) stated that this form of leadership contains four components: Charisma or Idealised Influence (followers trust in and emotionally identify with the leader), Inspirational Motivation (providing followers with challenges directed at goal achievement), Intellectual Stimulation (challenge followers to be innovative and question long-term assumptions) and Individualised Consideration (assignments are delegated to followers to provide learning opportunities). These components seem especially important during the first stage of the centre formation process in which the guiding coalition is formed. The role of the leader is to motivate, facilitate, develop a vision, set goals, stimulate, etc. These are all characteristics of transformational leader and particularly relevant during the first stage as the change process is initiated.
During the first stage of centre formation, as the guiding coalition grew in size and scope, more structure was needed to manage the guiding coalition. A steering committee and working groups were installed and provided with some possibilities, structural meetings were organised and some priorities were given. This is what Brown and Eisenhardt referred to as semistructures; neither everything is planned nor reacted upon chaotically. The movement from organic structures to semistructures leads the discussion to the second stage of centre formation: formalisation.
Stage 2: Formalisation
As has been mentioned in the analysis, the formalisation process has not been completed yet. Nevertheless the findings show interesting insights in the causes towards, and consequences of the formalisation process.
27 interplay of action and structure in social practice referred to as the duality of structure (Giddens, 1979;1984). Social phenomena, as Jones and Karsten (2008) argue, are a result of dialectic between structure and human action, rather than structure and human action existing simultaneously, yet independently of each other. The structural properties are both medium and outcome of the practices they recursively organize (see figure 3). Thus, as a result, structure is always both constraining and enabling of individual action. Structuration theory also argues that social systems, of which a centre is an example, are brought about by social practices. Within these systems, structural properties can be identified that guide action in terms of specific sets of rules and resources.
Figure 3. Structuration model of the intersection of coalition member’s actions and the transplant
centre (Groves et al., 2011 revised).
28 practice, as is shown in figure 3. Structure therefore constructs the system (e.g. transplant centre) with a clear and shared goal.
The sensemaking theory by Karl Weick (1979) also aids in explaining this process towards formalisation. If members within the guiding coalition interpret the comprehensive transplant centre, they do so using their own frame of reference. By doing this, they may even see their interests served and protected. As members perform actions, make decisions, and prioritise the goals of the centre, their interpretational space will decrease and their frames of reference will be adapted. As actions will be repeated, more structure is added which again leaves less room for interpretation. Over time, this frame of reference becomes stable within an organisation and leaves practically no room for interpretation. As has been mentioned, the decrease of interpretational space might lead to inactivity. The primary reason was that whenever members experience that their interests cannot be served anymore within the new frame of reference, they do not see the added value of being actively involved in the process. Ultimately this might result in withdrawal from the centre as they cannot protect their interests, or the interests of their grassroots.
Another important difference with the first stage is related to the role of the leader within the guiding coalition. As has been mentioned in the analysis, during the first stage, the leader has a major role in motivating members, setting goals, arranging meetings and monitoring the progress. The leadership linked to this stage was transformational leadership. As the second stage is characterised by different dimensions (see the above analysis), transformational leadership seems to be a less appropriate form to be adopted by the leader of the guiding coalition. During the formation stage, a leadership style is expected to be adopted that moves from a transformational, towards a rather transactional leadership style. A major difference is that whereas a transformation leader attempts to change the organisational culture by implementing new ideas, transactional leaders are active within an organisational culture. As during the formalisation stage the centre becomes structured and the interpretation of the centre is diminished, it seems that an organisational culture has been established and becomes rather stabilised. Another difference lies in the relationship between leaders and followers. According to Bass (1985), transactional leaders clarify for their followers what their responsibilities are, what is expected from them, their task descriptions, and the benefits to the self-interests of the followers for compliance. This differs from the transformational leaders who try to induce followers to transcend their self-interest for the sake of the organisation.
29 This confrontation resulted in linking the first stage to the actor network theory that focuses on the translation process (i.e. problematisation, interessement, enrolment and mobilisation). The second stage was linked to structuration theory explaining the duality of structure during and after formalisation process in which human action shapes, and is shaped by structure. Through the comprehensive explanation of events using both theories, the foundation has been provided for the development of ten sound propositions that are presented in the following section.
6. Propositions
The above conducted discussion of the results gave rise to an emerging understanding about how centres are formed in a complex health care environment, and the role guiding coalitions play in this process. In this section propositions are posited in order to make explicit our present understanding on centre formations. Propositions are statements that can be true or false, are tentative and lack rigorous testing. However, they provide researchers with a starting point to test concepts of how centres are formed in hospitals, and what the role is of guiding coalitions. These propositions are developed by using quotes and findings presented in the discussion.
By analysing the centre formation process on a higher abstract level, two stages can be identified. The first stage includes the creation of a guiding coalition, and the second stage the formalisation process. The term ‘stages’ is used as the process is not characterised by a sequence of phases, in which another phase is entered when the previous is completed, but is an on-going process in which stages overlap. As the majority of respondents viewed the formation process thus far as successful, the following proposition was developed.
Proposition 1: Successful centre formations in healthcare organisations are characterised by two stages: 1) the creation of a guiding coalition and 2) the formalisation.
One of the most prominent facilitators to centre formation success, as identified by respondents, concerned the organic growth during the first stage. One respondent stated: “The fact that it has developed from the work floor caused this success”. Another respondent stressed the importance of decentralising decision making authority: “Decisions should be made by those who possess the expertise, rather than having the formal decision making authority.” Therefore, this study supports the findings of previous research (e.g. Hertog and Westerveld, 2009 and Alderman and Ivory, 2011) that organic management is effective in complex and uncertain environments (such as centres within hospitals) as it e.g. distributes the demands for decision making to those who are most capable to make the decisions.
30 At the beginning of the first stage, a small group of professionals initiated the development of a comprehensive transplant centre. This group took the responsibility to make the first steps and therefore adopted a hands-on approach. However, as the guiding coalition grew in size and scope, the difficulty to manage this group efficiently increased. Working groups were installed as more professionals wanted to become actively involved in the process. The core group of professionals, who always executed the tasks themselves, from that moment, took a steering role within the newly installed steering committee. Their responsibilities shifted towards monitoring the progress and deciding on the direction of the comprehensive transplant centre. This leads to the next proposition.
Proposition 3: The role of the core group of professionals within the guiding coalitions will shift from a hands-on, tasks performing role, towards a steering role as the guiding coalition grows in size and scope.
During the first stage of the centre formation process, the leader of the guiding coalition plays a major and important role. One care professional characterised the leader as “main organiser and motor of the project”. In this first stage, the role of the leader is to motivate, facilitate, develop a vision, set goals, stimulate, etc. These are all characteristics of a transformational leader as found by Bass (1985). This leadership style was adopted by the leader of the guiding coalition and seems to facilitate the centre formation process. Therefore the next proposition is developed.
Proposition 4a: Transformational leadership by the leader of the guiding coalition is desired during the first stage of the centre formation process.
As during the formalisation stage the centre becomes increasingly structured and stable, an organisational culture seems to be developed. As one of the aims of a transformational leader is to change the organisational culture significantly, this leadership style seems less appropriate in the second stage of the centre formation process since the organisational culture, after a long process, finally has been developed. Therefore, during this formalisation process, the leadership style adopted by the leader of the guiding coalition shifts towards a rather transactional leadership style. According to Bass (1985), transactional leaders clarify for their followers what their responsibilities are, what is expected from them, their task descriptions, and the benefits to the self-interests of the followers for compliance. This leadership style therefore suits the formalisation stage better. This leads to the following proposition:
31 step in the development of the CTC is to receive the support of the board.” Another respondent argued that “The most important step in the development of the CTC is to receive the support of the board.” The logic behind these statements is fairly straightforward. As no support will be provided, there will not be any resources to develop such a centre. This leads to the next proposition.
Proposition 5: Without the support of the Board of Directors, centre formation will not be successful.
The above analysis discusses that, over time, more structure was given to the centre. Structure could result from prioritisation of goals, scope of the centre, etc. This increase in structure led to a decrease in interpretative flexibility (interpretational space) for members of the guiding coalition. This decrease in interpretational space meant that some members could not serve and protect their interest anymore within the centre, or only saw possibilities to do so in the future. These members seemed to be become inactive, while others that still could serve their interest stayed active. One respondent replied as follows after being asked what caused his decrease in involvement: “The aspects I prioritized are not dealt with at the moment.” Similar statements could be found by other respondents. This leads to the following proposition:
Proposition 6: A decrease of interpretative flexibility will lead to inactivity of members that, as a result of this decreasing interpretational space, are no longer able to serve their interests, or the interests of their grassroots.
Another reason for inactivity seems to be related to the degree of interests members have in the centre. Some disciplines have a high degree of interest in the centre (here: large disciplines), as transplant care is a core activity for them and a large part of total revenues. Other disciplines might have few interests in the centre (here: small disciplines), as transplant care is not a core activity and a small part of total revenues. During the first stage, relatively few consequences for the daily tasks members will perform within their own discipline are known. The result seems to be that members from large disciplines become very active and attempt to influence the direction to their advantage. Members from smaller disciplines on the other hand become less active. The reason is that they have to put relatively a lot of effort in the centre, for a potential small gain for their discipline. The next proposition therefore is stated as follows:
Proposition 7: Unknown consequences of change lead to active members from large disciplines and inactive members from smaller disciplines.
32 They argued that “professionals are hesitant to get involved due to the history the hospital has with regard to centre formation”. They see many difficulties on the road ahead and therefore might even resist this change process. This leads to the following proposition:
Proposition 8: Negative experiences from the past will negatively influence professionals’ view towards centre formation.
During the first stage, an increasing number of people become committed to the centre formation process. This means they become part of the network, as described in the discussion above. The role of the focal actor is to let them go through the Obligatory Passage Point. People will pass this point whenever they support the ideas that are formulated at this point. In case this point leaves much room for interpretation, more people will be willing to pass this point compared to a point leaving practically no room for interpretation. Therefore, in the early stages of the centre formation process, where the interpretative flexibility is high, it will be easier for people to pass this point than in later stages where the interpretative flexibility is lower. The following proposition therefore is stated as follows:
Proposition 9: The higher the interpretative flexibility, the easier people pass the Obligatory Passage Point.
The guiding coalition will grow over time both in size and scope. As the internal complexity increases, more structure is needed to keep the guiding coalition managed efficiently. The remedy might be to formalise tasks, procedures, meetings, etc. A second reason for the desire to formalise arises due to the lack of external voice. As the guiding coalition is an informal organisation, the centre will have no formal power to serve or protect its interests within the hierarchy. In order to increase the formal power (voice), the desire arises to become part of the formal hierarchy or that networks
become e.g. intertwined with the hierarchy. Therefore, the following proposition has been developed: Proposition 10: Desire to formalise is caused by both internal complexity and external voice.
7. Conclusions
33 interesting insights on the role of the leader of the guiding coalition (focal actor) with regard to the translation progress. The second stage was characterised by formalisation and consequently the increase of structure. To explain the events within this stage, structuration theory was used to analyse how structure developed and how members influence, and were influenced by this structure. This theory therefore aids in explaining the process and behaviour of members. The steps towards formalisation also influenced the role of the leader as her leadership style seemed to shift from a transformational style towards a transactional style. In addition to the stages, this study identified six barriers and five facilitators towards the centre formation process. They were salient across respondent groups and aid in understanding what factors constrain or accelerate the change process. Therefore, the findings of this study could aid in enhancing the success of other centre formations. Besides taking into consideration all barriers and facilitators, it seems that for both stages of the process, a different change approach is required. As the dimensions before and after formalisation differ significantly (an informal organisation vs. a formal organisation), a change manager should also adapt his change approach to each stage (Cawsey et al., 2012). Another practical implication is that different leadership styles seem appropriate during different stages of the centre formation process, as is mentioned before.
7.1 Limitations & future research
34 whether they hold in other centre formation processes or in other hospitals. Research is needed to further explore this.
Besides the initial insights on the centre formation process, this article might serve as a basis for future research to enhance our understanding of this change process in healthcare organisations, and the role guiding coalitions play. The researcher feels this issue is important given the high number, and rapid rate that centres are created and the difficulties that are encountered. As an initial starting point, future studies could first test the propositions in other centres to explore whether the propositions hold and findings can be generalised. Furthermore, the same research could be conducted in other centres within the same hospital, or centres within other hospitals to explore whether those findings are similar to this case study. Future research could also focus on the development of this comprehensive transplant centre to explore how the formalisation stage will completed (assuming this will happen). It might hold that for later periods of the formalisation stage, different dimensions will come into play and should be taken into consideration when forming a centre. Hence, future research could also look in more detail at one stage in particular as it appears that two different systems are present: a system before and after formalisation. This also would enhance our knowledge with regard to both stages.
7.2 Acknowledgement
The author is grateful to Dr. Cees Reezigt for expertly guiding him through the research process. The constructive feedback, conversations and counsel enabled him to write this article. Also, the author wants to offer a special thanks to Dr. Marion Siebelink and Dr. Gera Welker for providing the opportunity to conduct this research in the University Medical Centre, and the great cooperation. Naturally, the author wishes to thank the respondents as well for taking their time for the interviews.
