Subordinate Activation Tactics: Semi-professionals and Micro-level Institutional Change in Professional Organizations

this two-year ethnographic study of the primary care departments in two U.S. hospitals examines how managers can bring about micro-level institutional change in professional practice even when such change challenges professionals’ specialized expertise, autonomy, individual responsibility, and engagement in complex work, which previous research has shown to create difficulties. In this study, managers in both hospitals attempted to implement the same patient-centered medical home (PCMH) reforms among doctors, had the same external pressures for micro-level institutional change, worked under the same organizational and reimbursement structure, and had the same contextual facilitators of micro-level institutional change present within their organizations. But managers in one hospital successfully accomplished change in professional practice while those in the other did not. I demonstrate that managers can accomplish micro-level institutional change in professional organizations using “subordinate activation tactics”—first empowering and motivating subordinate semi-professionals to activate their favorable structural position vis-à-vis the targeted professionals on behalf of managers and next giving semi-professionals positional tools to use in their daily work to minimize the targeted professionals’ concerns about the threats associated with change. Keywords: micro-level institutional change, professions, occupations, professional organizations, semi-professionals, hospitals, healthcare management, PCMH implementatio

Making the Cut: Using Status-Based Countertactics to Block Social Movement Implementation and Microinstitutional Change in Surgery

Much of the change that social movements try to accomplish requires changing practices inside organizations, yet reform implementation is difficult to achieve. This comparative case study of two hospitals demonstrates that implementing reform inside organizations may require internal reformers not only to mobilize with one another but also to stand up to internal defenders' countertactics in everyday encounters. Because reformer alliances across identity lines often require reformers with different statuses to collaborate with one another, defenders can divide reformer coalitions by linking reform practices to a status characteristic associated with lower-status reformers, denigrating higher-status reformers by associating them with these practices, and reintegrating higher-status reformers into the defender group. When status threat inside an organization is high to begin with, higher-status reformers are likely to be concerned about loss of privilege in the face of defenders' status-based countertactics and, in response, distance themselves from reform practices and align themselves with defenders to protect their identity and its rewards. This can undermine the multi-identity reformer coalition and cause change to fail. These findings regarding status-based countertactics contribute to our understanding of social movement implementation and microinstitutional change

Challenging operations : changing interactions, identities, and institutions in a surgical teaching hospital

Thesis (Ph. D.)--Massachusetts Institute of Technology, Sloan School of Management, June 2005."May 2005."Includes bibliographical references (leaves 165-170).If institutions are comprised of cultural and positional prescriptions for action and interpretation, then institutional change must depend at some point on thinking the unthinkable, acting in "inappropriate" ways, and convincing powerful others to give up their privilege. How does this happen? How do people come to question taken-for-granted beliefs? How do they decide to attempt the unacceptable in their interactions with others? How do they persuade those who benefit from the status quo to change? And how do they extend new understandings created in particular interactions into future situations? In this dissertation, I tell the story of surgical residents at ACADEMIC hospital who accomplished both institutional stability and institutional change in their interactions with one another in the wake of nationwide changes occurring outside their hospital. Using findings from a 15 month ethnography of this surgical teaching hospital, I demonstrate that institutional stability and change occur only insofar as they are negotiated in interactions between particular workplace members with particular reasons for wanting either to maintain or to challenge the status quo.(cont.) I draw on these findings, in combination with identity theory and symbolic interactionism, to develop a relational, identity-based framework for understanding processes of institutional stability and change. Members negotiate institutional stability and change as they shape their actions in particular situations according to their sense of self in relation to the situation, their own personal narrative, and their judgment of the likely response of their interaction partner to their various actions. What looks like institutional stability or change in the abstract is, in fact, constituted through the culturally and politically-charged daily contests between organization members interacting with one another to either protect or change their way of life and the persona and authority associated with it. At first pass, these daily contests between one action or another in familiar situations may seem obvious, even unimportant. But it is in these simple contests around habitual issues that the institutional order is constructed. The institutionalized values, positions, and beliefs that shape the patterned action of large numbers of people across decades are built up and torn down in these daily contests between challengers and defenders of the status quo and the varied positions of privilege and senses of self that that this status quo provides.Katherine C. Kellogg.Ph.D

Operating Room: Relational Spaces and Microinstitutional Change in Surgery

One of the great paradoxes of institutional change is that even when top managers in organizations provide support for change in response to new regulation, the employees whom new programs are designed to benefit often do not use them. This 15‐month ethnographic study of two hospitals responding to new regulation demonstrates that using these programs may require subordinate employees to challenge middle managers with opposing interests. The article argues that relational spaces—areas of isolation, interaction, and inclusion that allow middle‐manager reformers and subordinate employees to develop a cross‐position collective for change—are critical to the change process. These findings have implications for research on institutional change and social movements.Alfred P. Sloan Foundatio

An intraorganizational model for developing and spreading quality improvement innovations

BACKGROUND Recent policy reforms encourage quality improvement (QI) innovations in primary care, but practitioners lack clear guidance regarding spread inside organizations. PURPOSE We designed this study to identify how large organizations can facilitate intraorganizational spread of QI innovations. METHODOLOGY/APPROACH We conducted ethnographic observation and interviews in a large, multispecialty, community-based medical group that implemented three QI innovations across 10 primary care sites using a new method for intraorganizational process development and spread. We compared quantitative outcomes achieved through the group's traditional versus new method, created a process model describing the steps in the new method, and identified barriers and facilitators at each step. FINDINGS The medical group achieved substantial improvement using its new method of intraorganizational process development and spread of QI innovations: standard work for rooming and depression screening, vaccine error rates and order compliance, and Pap smear error rates. Our model details nine critical steps for successful intraorganizational process development (set priorities, assess the current state, develop the new process, and measure and refine) and spread (develop support, disseminate information, facilitate peer-to-peer training, reinforce, and learn and adapt). Our results highlight the importance of utilizing preexisting organizational structures such as established communication channels, standardized roles, common workflows, formal authority, and performance measurement and feedback systems when developing and spreading QI processes inside an organization. In particular, we detail how formal process advocate positions in each site for each role can facilitate the spread of new processes. PRACTICE IMPLICATIONS Successful intraorganizational spread is possible and sustainable. Developing and spreading new QI processes across sites inside an organization requires creating a shared understanding of the necessary process steps, considering the barriers that may arise at each step, and leveraging preexisting organizational structures to facilitate intraorganizational process development and spread.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially

Improvisation and Transformation: Yes to the Mess

The field of organizational change has chiefly been studied from a teleological perspective. Most models of change emphasize action that is rational and goal oriented. What often gets overlooked and under theorized is the continuous, iterative nature of organizational life, the unplanned and serendipitous actions by and between people that lead to new discoveries and innovation. Recent research on organizational improvisation seeks to explore this area. In this chapter we will address two questions – what is the experience of improvisation and what are the conditions that support improvisation to flourish in organizations? In the first part of this paper, we look at the phenomenology of improvisation, the actual lived experience of those who improvise in the face of the unknown or in the midst of chaotic conditions. We will explore the strategies that some professional improvisers employ to deliberately create the improvisatory moment. We will then look at the dynamics of organizational life and explore the cultural beliefs, organizational structures, and leadership practices that support improvisation. We will draw primarily upon the model from Barrett (2012) that focuses on the how the nature of jazz improvisation and the factors that support improvisation can be transferred to leadership activities. This falls in the tradition of others who draw upon arts-based metaphors, including jazz music and theatrical improvisation, to suggest insights for leadership and ways of organizing. Since this is a book devoted to individual transformation as well as organizational transformation, we will also touch on the topic of how improvisation is a developmental project and explore the potential for improvisation to lead to personal transformation. We will attempt to move back and forth between both themes – organizational and personal transformation. Ultimately the two topics are not separate. Any significant organizational transformation begins with an improvisation. And any meaningful improvisatory move by a person is potentially a moment of self-discovery and an identity-shaping event

Evaluation of a Peer Network-Based Sexual Risk Reduction Intervention for Men in Beer Halls in Zimbabwe: Results from a Randomized Controlled Trial

While much emphasis has been placed on involving men in AIDS prevention in sub-Saharan Africa, there remain few rigorously evaluated interventions in this area. A particularly appealing point of intervention is the sexual risk behavior associated with men’s alcohol consumption. This article reports the outcomes of The Sahwira HIV Prevention Program, a male-focused, peer-based intervention promoting the idea that men can assist their friends in avoiding high-risk sexual encounters associated with alcohol drinking. The intervention was evaluated in a randomized, controlled trial (RCT) implemented in 24 beer halls in Harare, Zimbabwe. A cadre of 413 male beer hall patrons (~20% of the patronage) was trained to assist their male peers within their friendship networks. Activities included one-on-one interactions, small group discussions, and educational events centering on the theme of men helping their male friends avoid risk. Venues were randomized into 12 control versus 12 intervention beer halls with little cross-contamination between study arms. The penetration and impact of the intervention were assessed by pre- and post-intervention cross-sectional surveys of the beer hall patronage. The intervention was implemented with a high degree of fidelity to the protocol, with exposure to the intervention activities significantly higher among intervention patrons compared to control. While we found generally declining levels of risk behavior in both study arms from baseline to post-intervention, we found no evidence of an impact of the intervention on our primary outcome measure: episodes of unprotected sex with non-wife partners in the preceding 6 months (median 5.4 episodes for men at intervention beer halls vs. 5.1 among controls, P = 0.98). There was also no evidence that the intervention reduced other risks for HIV. It remains an imperative to find ways to productively engage men in AIDS prevention, especially in those venues where male bonding, alcohol consumption, and sexual risk behavior are intertwined

An Analysis of Enzyme Kinetics Data for Mitochondrial DNA Strand Termination by Nucleoside Reverse Transcription Inhibitors

Nucleoside analogs used in antiretroviral treatment have been associated with mitochondrial toxicity. The polymerase-γ hypothesis states that this toxicity stems from the analogs' inhibition of the mitochondrial DNA polymerase (polymerase-γ) leading to mitochondrial DNA (mtDNA) depletion. We have constructed a computational model of the interaction of polymerase-γ with activated nucleoside and nucleotide analog drugs, based on experimentally measured reaction rates and base excision rates, together with the mtDNA genome size, the human mtDNA sequence, and mitochondrial dNTP concentrations. The model predicts an approximately 1000-fold difference in the activated drug concentration required for a 50% probability of mtDNA strand termination between the activated di-deoxy analogs d4T, ddC, and ddI (activated to ddA) and the activated forms of the analogs 3TC, TDF, AZT, FTC, and ABC. These predictions are supported by experimental and clinical data showing significantly greater mtDNA depletion in cell culture and patient samples caused by the di-deoxy analog drugs. For zidovudine (AZT) we calculated a very low mtDNA replication termination probability, in contrast to its reported mitochondrial toxicity in vitro and clinically. Therefore AZT mitochondrial toxicity is likely due to a mechanism that does not involve strand termination of mtDNA replication

A communal catalogue reveals Earth's multiscale microbial diversity

Our growing awareness of the microbial world's importance and diversity contrasts starkly with our limited understanding of its fundamental structure. Despite recent advances in DNA sequencing, a lack of standardized protocols and common analytical frameworks impedes comparisons among studies, hindering the development of global inferences about microbial life on Earth. Here we present a meta-analysis of microbial community samples collected by hundreds of researchers for the Earth Microbiome Project. Coordinated protocols and new analytical methods, particularly the use of exact sequences instead of clustered operational taxonomic units, enable bacterial and archaeal ribosomal RNA gene sequences to be followed across multiple studies and allow us to explore patterns of diversity at an unprecedented scale. The result is both a reference database giving global context to DNA sequence data and a framework for incorporating data from future studies, fostering increasingly complete characterization of Earth's microbial diversity.Peer reviewe