L’incorporation de la responsabilité populationnelle dans la gestion des CSSS

En 2004, le gouvernement québécois s’est engagé dans une importante réorganisation de son système de santé en créant les Centres de santé et des services sociaux (CSSS). Conjugué à leur mandat de production de soins et services, les CSSS se sont vus attribuer un nouveau mandat de « responsabilité populationnelle ». Les gestionnaires se voient donc attribuer le mandat d’améliorer la santé et le bien-être d’une population définie géographiquement, en plus de répondre aux besoins des utilisateurs de soins et services. Cette double responsabilité demande aux gestionnaires d’articuler plus formellement au sein d’une gouverne locale, deux secteurs de prestations de services qui ont longtemps évolué avec peu d’interactions, « la santé publique » et « le système de soins ». Ainsi, l’incorporation de la responsabilité populationnelle amène à développer une plus grande synergie entre ces deux secteurs dans une organisation productrice de soins et services. Elle appelle des changements importants au niveau des domaines d’activités investis et demande des transformations dans certains rôles de gestion. L’objectif général de ce projet de recherche est de mieux comprendre comment le travail des gestionnaires des CSSS se transforme en situation de changement mandaté afin d’incorporer la responsabilité populationnelle dans leurs actions et leurs pratiques de gestion. Le devis de recherche s’appuie sur deux études de cas. Nous avons réalisé une étude de deux CSSS de la région de Montréal. Ces cas ont été choisis selon la variabilité des contextes socio-économiques et sanitaires ainsi que le nombre et la variété d’établissements sous la gouverne des CSSS. L’un des cas avait au sein de sa gouverne un Centre hospitalier de courte durée et l’autre non. La collecte de données se base sur trois sources principales; 1) l’analyse documentaire, 2) des entrevues semi-structurées (N=46) et 3) des observations non-participantes sur une période de près de deux ans (2005-2007). Nous avons adopté une démarche itérative, basée sur un raisonnement inductif. Pour analyser la transformation des CSSS, nous nous appuyons sur la théorie institutionnelle en théorie des organisations. Cette perspective est intéressante car elle permet de lier l’analyse du champ organisationnel, soit les différentes pressions issues des acteurs gravitant dans le système de santé québécois et le rôle des acteurs dans le processus de changement. Elle propose d’analyser à la fois les pressions environnementales qui expliquent les contraintes et les opportunités des acteurs gravitant dans le champ organisationnel de même que les pressions exercées par les CSSS et les stratégies d’actions locales que ceux-ci développent. Nous discutons de l’évolution des CSSS en présentant trois phases temporelles caractérisées par des dynamiques d’interaction entre les pressions exercées par les CSSS et celles exercées par les autres acteurs du champ organisationnel; la phase 1 porte sur l’appropriation des politiques dictées par l’État, la phase 2 réfère à l’adaptation aux orientations proposées par différents acteurs du champ organisationnel et la phase 3 correspond au développement de certains projets initiés localement. Nous montrons à travers le processus d’incorporation de la responsabilité populationnelle que les gestionnaires modifient certaines pratiques de gestion. Certains de ces rôles sont plus en lien avec la notion d’entrepreneur institutionnel, notamment, le rôle de leader, de négociateur et d’entrepreneur. À travers le processus de transformation de ces rôles, d’importants changements au niveau des actions entreprises par les CSSS se réalisent, notamment, l’organisation des services de première ligne, le développement d’interventions de prévention et de promotion de la santé de même qu’un rôle plus actif au sein de leur communauté. En conclusion, nous discutons des leçons tirées de l’incorporation de la responsabilité populationnelle au niveau d’une organisation productrice de soins et services. Nous échangeons sur les enjeux liés au développement d’une plus grande synergie entre la santé publique et le système de soins au sein d’une gouverne locale. Également, nous présentons un modèle synthèse d’un processus de mise en œuvre d’un changement mandaté dans un champ organisationnel fortement institutionnalisé en approfondissant les rôles des entrepreneurs institutionnels dans ce processus. Cette situation a été peu analysée dans la littérature jusqu’à maintenant.In 2004, the Quebec Government has engaged in a major reorganization of its health system, by creating the Health and Social Services Centers (Centre de santé et de services sociaux-CSSS). In addition to their mandate of delivering care and services, the CSSS gained a mandate of population-based responsibility. The managers of these organizations obtained the mandate to improve the health and well-being of the population living on a specific territory in addition to responding to the users of health care services. This dual responsibility brings managers to articulate more formally two fields of services delivery that have traditionally evolved with few interactions: “public health” and “healthcare”. Incorporating the population-based responsibility to the practice of managers creates a greater synergy between these two fields within an organization that produces health care services. The reform calls for major changes in different areas of activities and management roles. The main objective of our research is to have a better understanding of the change in the CSSS management practices in response to the required population-based responsibility. We conducted an in-depth longitudinal analysis of two CSSS cases. These cases were selected from the same region, Montréal. The two cases have been chosen according to the variability of their socio-economic context as well as the number and variability of institutions under the governance of CSSS. One case included an acute-care hospital while the other did not. Data collected include real-time observations of top management meetings at the regional and local levels during more than two years (2005-2007), 46 interviews with managers and key stakeholders as well as secondary data (planning documents, organizational charts, minutes of executive board meetings, etc.). We adopted an iterative process based on inductive thinking. We based our analysis on institutional theory in the theory of organization studies. This perspective is interesting because it allows us to link the organizational fields analyzed (pressures from different healthcare actors) to the roles of actors in the change process. This theory proposes to analyze both the environmental pressures which explain the constraints and opportunities of the actors in the organization field and the pressure created by the CSSS and the local strategic actions they develop. We discuss the evolution of CSSS by presenting three temporal stages characterized by dynamic interaction between the pressures created by the CSSS as well as those created by the other actors in the organizational field; stage 1 refers to compliance with policies put forward by the Government, stage 2 focuses on the adaptation to suggestions made by different actors in the organizational field and stage 3 corresponds to the development of projects at local level. We show through the process of incorporating population-based responsibility some change in management practices. Some management roles are closer to the entrepreneurship institutional theory being seen as leaders, negotiators and entrepreneurs. Through the process of transforming management roles, important changes happen regarding the actions put in place by CSSS such as the formal organization of primary care services, the development of health promotion and prevention activities and a more active implication in the community. In conclusion, we discuss findings from incorporating population-based responsibility into a delivery of health care services organization. We exchange on challenges associated with the development of a greater synergy between public health and healthcare into the same governance structure. Also, we present a synthetic model of the process of implementation of a mandated change into an organization field that is strongly institutionalized. We expand more specifically on the institutional entrepreneur role in that process of change. This situation has been rarely discussed in the literature so far

Implanter des guichets d’accès aux clientèles sans médecin de famille à travers le Québec

En 2008, le gouvernement du Québec a mandaté les quatre-vingt-quatorze centres de santé et des services sociaux (CSSS) d’introduire un guichet d’accès aux « clientèles orphelines » (GACO; le terme de clientèle orpheline désigne les patients n’ayant pas accès à un médecin de famille) au sein de leur organisation. L’objectif des GACO est d’augmenter le nombre de patients avec un médecin de famille et de prioriser les patients vulnérables. La médiatisation de l’enjeu des patients orphelins et la Fédération des médecins omnipraticiens du Québec ont joué un rôle prépondérant dans la conceptualisation et l’introduction de cette réforme. Peu de balises ont encadré le développement de cette réforme laissant donc une grande flexibilité dans les stratégies de mises en œuvre à chacun des CSSS. Cette marge de manœuvre à l’échelle locale a entraîné une variation dans l’offre de services des GACO, conduisant à une inéquité de services pour la population. Depuis leur implantation, les incitatifs financiers mis en place pour favoriser la participation des médecins de famille ont été modifiés à deux reprises, particulièrement pour faciliter la prise en charge des clientèles plus vulnérables via les GACO. Une étude récente a montré que, malgré un différentiel important dans les incitatifs financiers donnés aux médecins pour des patients vulnérables, plus de 70% des patients inscrits à un médecin de famille via les GACO étaient des patients non vulnérables et provenaient majoritairement d’une au- toréférence par un médecin de famille. Le GACO répond, cependant, à une problématique importante en visant à réduire le nombre de personnes sans médecin de famille

Canadian Institutes of Health Research (CIHR; 2005-2008)

Abstract Purpose -The aim of this paper is to illustrate and discuss how healthcare organisations can act as institutional entrepreneurs in a context of change. Design/methodology/approach -The authors conducted an in-depth longitudinal case study (2005)(2006)(2007)(2008)) of a healthcare organisation in the province of Quebec, Canada. Data collection consisted of real-time observations of senior managers (n ¼ 87), interviews (n ¼ 24) with decision-makers and secondary data analysis of documents. Findings -The paper reports on the extent to which entrepreneurial healthcare organisations can be a driving force in the creation of a new practice. The authors analyse the development of a diabetes reference centre by a healthcare organisation acting as an institutional entrepreneur that illustrates the conceptualisation of an innovation and the mobilisation of resources to implement it and to influence other actors in the field. The authors discuss the case in reference to three stages of change: emergence, implementation and diffusion. The results illustrate the different strategies used by managers to advance their proposed projects. Research limitations/implications -This study helps to better understand the dynamics of mandated change in a mature field such as healthcare and the roles played by organisations in this process. By adopting a proactive strategy, a healthcare organisation can play an active role and strongly influence the evolution of its field. Originality/value -This paper is one of only a few to analyse strategies used by healthcare organisations in the context of mandated change. Keywords Canada, Healthcare, Management strategy, Organisational theory, Leaders, Change process Paper type Research paper The current issue and full text archive of this journal is available at www. emeraldinsight.com/1477-7266.htm This article benefited from the insightful contributions and comments of Dr Raynald Pineault, Professor Emeritus, University of Montreal. Also, this paper was submitted at the 2011 annual meeting of Administrative Science Association of Canada. The authors thank two anonymous reviewers for their helpful comments. This study was part of the "Governing Change and Changing Governance in Health Care Systems and Organisations" project funded by the Canadian Institutes of Health Research (CIHR; Introduction Institutional theory is one of the most prominent approaches used for understanding organisational phenomena The objective of this paper is to illustrate and discuss how healthcare organisations can act as institutional entrepreneurs in a context of change. First, we present the institutional theory concepts on which our work is based, followed by our methodology and our research setting. We then present a summary of our longitudinal case study. We analyse the process of institutional change advanced by a healthcare organisation through the emergence, implementation and diffusion of an innovation in the organisational field. Based on this empirical case, we discuss how healthcare organisations can act as institutional entrepreneurs and become driving forces in de-institutionalising and re-institutionalising a field's practices. We conclude with a discussion of the implications of our findings for research and practice

Orthopedist involvement in the management of clinical activities : a case study

Background The rapid shift in hospital governance in the past few years suggests greater orthopedist involvement in management roles, would have wide-reaching benefits for the efficiency and effectiveness of healthcare delivery. This paper analyzes the dynamics of orthopedist involvement in the management of clinical activities for three orthopedic care pathways, by examining orthopedists’ level of involvement, describing the implications of such involvement, and indicating the main responses of other healthcare workers to such orthopedist involvement. Methods We selected four contrasting cases according to their level of governance in a Canadian university hospital center. We documented the institutional dynamics of orthopedist involvement in the management of clinical activities using semi-structured interviews until data saturation was reached at the 37th interview. Results Our findings show four levels (Inactive, Reactive, Contributory and Active) of orthopedist involvement in clinical activities. With the underlying nature of orthopedic surgeries, there are: (i) some activities for which decisions cannot be programmed in advance, and (ii) others for which decisions can be programmed. The management of unforeseen events requires a higher level of orthopedist involvement than the management of events that can be programmed. Conclusions Beyond simply identifying the underlying dynamics of orthopedists’ involvement in clinical activities, this study analyzed how such involvement impacts management activities and the quality-of-care results for patients

The Interaction of Public Health and Primary Care: Functional Roles and Organizational Models that Bridge Individual and Population Perspectives

Introduction: Public health and primary care are often conceived as two entities providing complementary services within the health system. This scoping review aims to better understand how the two sectors interact by identifying their shared functions, and by identifying organizational models that could facilitate the interaction between the two domains. Methodology: We conducted a review of published literature using PubMed and CINAHL journal indices. Our search yielded 179 articles. We reviewed abstracts and retained 55 relevant articles. We developed an extraction grid, based on a conceptual framework of functions of public health and primary care, in order to evaluate the relevance of selected articles, classify the information according to their functional connection, and identify interactions between them. Results: Our search identified various activities through which public health can contribute to more effective primary care, and functions usually performed by primary care that seemed to support a population health approach. Most authors identified screening and immunization as actions that are carried out in primary care, but that can benefit from the support of public health. Health promotion and lifestyle modification are also shared responsibilities that can take the form of collective or individual intervention. The surveillance and protection function of public health, which actually takes place in primary care, consists of case identification for prevention or early treatment. Primary care is the setting where patients present, whereas public health has the role of investigation and of providing advice to clinical settings. Planning and evaluation are also emerging activities that concern both public health and primary care. Many authors recognized that public health provides tools that enhance the planning of primary care activities and are more aligned with the actual needs of populations. Others noted that public health is able to assess primary care in light of the changing health of populations, which may lead to better results for groups of patients. Conclusion: One of the routes to a better understanding of how public health and primary care organizations can better interact is to identify the different contexts in which they collaborate successfully. Our scoping review of the scientific and gray literature identified various ways by which public health and primary care either reinforce each other through their respective functions, or increasingly act in a collaborative manner to increase population health and improve health systems performance

Changing nursing practice within primary health care innovations: the case of advanced access model

Background: The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change. Methods: We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model 2014). Results: Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses’ practice change); facility and employment arrangements(supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledgeand capabilities; and 5) patient perceptions. Conclusions: Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses’ capacities within the team throughout AA implementation in order to reduce waiting times

Implementation of a new clinical and organisational practice to improve access to primary care services : a protocol for an effectiveness-implementation hybrid study

Introduction In Canada, as in most Organisation for Economic Co-operation and Development countries, healthcare systems face significant challenges in ensuring better access to primary care. A regional healthcare organisation in Quebec (Canada) serving a population of approximately 755 459 citizens has implemented a standardised access approach to primary care services for this population. The objective of this new clinical and organisational practice is to ensure that users benefit from the same referral process, regardless of the entry point, in order to be directed to the right services. This new practice integrates a shared decision-making process between the user and the professional, and a collaborative process between different health professionals within and between services. The objective of our research is to identify and characterise the conditions of implementation of this practice. Methods This effectiveness-implementation hybrid investigation will use an embedded single-case study, defined in this case as the process of implementing a clinical and organisational practice within a healthcare organisation. Further to an evaluation conducted during a preliminary phase of the project, this study consists of evaluating the implementation of this new practice in four medical clinics (family medicine groups). A qualitative analysis of the data and a quantitative preimplementation and postimplementation analysis based on performance indicators will be conducted. This study is ultimately situated within a participatory organisational approach that involves various stakeholders and users at each step of the implementation and evaluation process

Barriers to accessing primary health care: Comparing Australian experiences internationally

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain