Jean-Louis Denis

Towards systematic reviews that inform health care management and policy-making.

Objectives To identify ways to improve the usefulness of systematic reviews for health care managers and policy-makers that could then be evaluated prospectively. Methods We systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom (n=29), and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences (n=45). Results Our systematic review identified that factors such as interactions between researchers and health care policy-makers and timing/timeliness appear to increase the prospects for research use among policy-makers. Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them (e.g. contextual factors that affect a reviews local applicability and information about the benefits, harms/risks and costs of interventions) and having reviews presented in a way that allows for rapid scanning for relevance and then graded entry (such as one page of take-home messages, a three-page executive summary and a 25-page report). Managers and policy-makers have mixed views about the helpfulness of recommendations. Our analysis of websites found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used. Conclusions Researchers could help to ensure that the future flow of systematic reviews will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions. Research funders could help to ensure that the global stock of systematic reviews will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly ‘front ends’ for potentially relevant systematic reviews.

Strategizing in pluralistic contexts: Rethinking theoretical frames:

Pluralistic organizations characterized by multiple objectives, diffuse power and knowledge-based work processes present a complex challenge both for strategy theorists and for strategy practitioners because the very nature of strategy as usually understood (an explicit and unified direction for the organization) appears to contradict the natural dynamics of these organizations. Yet pluralism is to some extent always present in organizations and perhaps increasingly so. This article explores the usefulness of three alternate and complementary theoretical frames for understanding and influencing strategy practice in pluralistic contexts: Actor-Network Theory, Conventionalist Theory and the social practice perspective. Each of these frameworks has a predominant focus on one of the fundamental attributes of pluralism: power, values and knowledge. Together, they offer a multi-faceted understanding of the complex practice of strategizing in pluralistic contexts.

Explaining diffusion patterns for complex health care innovations.

Why are some less solidly supported health care innovations widely adopted while others with apparently stronger scientific support remain underused? Drawing on four case studies, the authors argue that the way in which the distribution of benefits and risks map onto the interests, values, and power distribution of the adopting system is critical to understanding how innovations diffuse.

Knowledge Exchange Processes in Organizations and Policy Arenas: A Narrative Systematic Review of the Literature

CONTEXT This article presents the main results from a large-scale analytical systematic review on knowledge exchange interventions at the organizational and policymaking levels. The review integrated two broad traditions, one roughly focused on the use of social science research results and the other focused on policymaking and lobbying processes. METHODS Data collection was done using systematic snowball sampling. First, we used prospective snowballing to identify all documents citing any of a set of thirty-three seminal papers. This process identified 4,102 documents, 102 of which were retained for in-depth analysis. The bibliographies of these 102 documents were merged and used to identify retrospectively all articles cited five times or more and all books cited seven times or more. All together, 205 documents were analyzed. To develop an integrated model, the data were synthesized using an analytical approach. FINDINGS This article developed integrated conceptualizations of the forms of collective knowledge exchange systems, the nature of the knowledge exchanged, and the definition of collective-level use. This literature synthesis is organized around three dimensions of context: level of polarization (politics), cost-sharing equilibrium (economics), and institutionalized structures of communication (social structuring). CONCLUSIONS The model developed here suggests that research is unlikely to provide context-independent evidence for the intrinsic efficacy of knowledge exchange strategies. To design a knowledge exchange intervention to maximize knowledge use, a detailed analysis of the context could use the kind of framework developed here.

Leadership and Strategic Change under Ambiguity

This paper draws on a case study of a large public hospital to examine the processes of leadership and strategic change in organizations where goals are unclear and authority is fluid and ambiguous. The case history describes the evolution of leadership roles during a period of radical change in which a general hospital acquires a university affiliation while moving towards a more integrated form of management. The study traces the tactics used by members of the leadership group to stimulate change, and the corresponding impact of these tactics on both the progress of change and on leadership roles themselves. It is suggested that strategic change in these organizations requires collaborat ive leadership involving constellations of actors playing distinct but tightly-knit roles. Yet, collaborative leadership is fragile and can easily disintegrate due to intemal conflict or to discreditation associated with more unpopular (although potentially effective) change tactics. Thus, under ambiguity, radical trans formations may tend to occur in a cyclical non-linear pattern with periods of substantive change alternating with periods of political realignment. The paper concludes with a series of five propositions concerning the collaborative, cyc lical, interpretative, and entropic nature of leadership and strategic change pro cesses under ambiguity.

Leadership in the Plural

This paper reviews the literature on forms of leadership that in one way or other imply plurality: that is, the combined influence of multiple leaders in specific organizational situations. We identify four streams of scholarship on plural leadership, each focusing on somewhat different phenomena and adopting different epistemological and methodological assumptions. Specifically, these streams focus on sharing leadership in teams, on pooling leadership at the top of organizations, on spreading leadership across boundaries over time, and on producing leadership through interaction. The streams of research vary according to their representations of plural leadership as structured or emergent and as mutual or coalitional. We note tensions between perspectives that advocate pluralizing leadership in settings of concentrated authority and those concerned with channeling the forms of plurality naturally found in diffuse power settings such as professional organizations or inter-organizational partnerships. It i...

Partnership experiences: involving decision-makers in the research process.

Objectives To describe researchers’ experiences with involving health system managers and public policy-makers (i.e. decision-makers) in the research process, and decision-makers’ experiences with the research process, including their assessments of the benefits and costs of the involvement, and their recommendations for facilitating it. Methods We conducted semi-structured interviews with principal investigators and research staff for the seven research programmes funded by the Canadian Health Services Research Foundation in the 1999 and 2000 competition years, and with the decision-makers they involved in the research programmes. Results We identify three models of decision-maker involvement - formal supporter, responsive audience, and integral partner - each of which yielded important contributions to the research process. Four factors - the stage of the research process, time commitment required, alignment between decision-maker expertise and programme needs, and an existing relationship between the researcher and decision-maker - influenced the role played by decision-makers. Conclusions While on balance a beneficial experience, the further promotion of decision-maker involvement in the research process should involve helping researchers and decision-makers identify strategic opportunities for decision-maker involvement and support the costs associated with the involvement. Consideration should also be given to undertaking and evaluating interactions between researchers and decision-makers outside of the research process.

The Corruption of Managerial Techniques by Organizations

Public sector organizations are under pressure to adopt private sector tools to sustain legitimacy despite uncertainty about the compatibility of the techniques with this context. We explore the consequences of the misfit between the theories underlying two widely adopted managerial techniques (strategic planning and quality management) and the pluralistic power structure and values of public hospitals. We identify four scenarios of adaptation and use qualitative data to examine their empirical prevalence. We suggest that when the compatibility gap is large, there is greater likelihood that formalized techniques will be captured by and integrated into existing organizational dynamics (corruption of the technique) than that the technique will change these dynamics in a way consistent with its objectives (transformation of the organization). We examine the implications of our observations for understanding the role of managerial techniques in organizational change.

Governance, Power, and Mandated Collaboration in an Interorganizational Network

This article explores the challenges of mandated collaboration among public health care organizations. This in-depth longitudinal multiple case study examines the interests and values of various organizational actors in three collaborative initiatives, focusing on the mobilization of power within the governance frameworks available to them. The authors elaborate on three alternate readings of the processes examined: The managerialist views poor interorganizational collaboration as a failure to adequately manage the process; the symbolic focuses on the value of collaborative initiatives even in the absence of instrumental results; and the third examines the systemic web of power relationships reproduced over time.

The Practice of Leadership in the Messy World of Organizations

This article examines the practice of leadership in organizations characterized by ambiguous authority relationships. Drawing on three empirical case studies illustrative of a long-term research program on change in health care organizations, we examine leadership as a practical activity focusing particularly on its dynamic, collective, situated, and dialectical nature. We invite researchers on leadership to look carefully at the embeddedness of leadership roles in context and at the type and consequences of practices that leaders develop in such contexts. Implications of these ideas for further research and for would-be leaders are discussed.