HYBRIDS NETWORKS &
ORGANIZATIONAL CHANGE:
facilitating change in complex
organizations
By
Professor Louise Fitzgerald,
Dept. of HRM; De Montfort University, Leicester.
RESEARCH TEAM

Professor Louise Fitzgerald, DMU

Professor Ewan Ferlie, Royal Holloway College,
London

Dr R. Addicott, Royal Holloway College, London;
Dr J. Baeza, Imperial College, London;
Professor D. Buchanan, Department of HRM, De Montfort
University;
C. Lilley, Department of HRM, De Montfort University;
Professor A. Rashid, Dept. of Primary Care, De Montfort
University.




OUTLINE METHODS &
APPROACH
Core research question:
 How do clinical directors and service managers
from non-clinical backgrounds interpret and enact
their roles and use them to implement service
change?
THIS RESEARCH IS SUPPORTED BY THE SDO R & D PROGAMME
OUTLINE METHODS & APPROACH
COMPARATIVE CASE STUDIES IN 11 SITES
ACROSS THE ACUTE & PRIMARY CARE
SECTORS;
AREAS OF CARE:
- CANCER CARE (PROSTATE CANCER)
- DIABETES CARE IN PRIMARY CARE
- MATERNITY CARE
METHODS
CASES CONSTRUCTED FROM:
 DATA ON CONTEXTS;
 INTERVIEWS WITH MANAGERS/STAFF;
 OBSERVATIONS OF MEETINGS.
ANALYSIS STAGED:
 WITHIN CASE, AGAINST QUESTION
THEMES;
 COMPARATIVE WITHIN CARE GROUP
 ACROSS ALL CASES
Overview of emerging findings
Presentation of findings clustered around five
topics:
 The way contexts influence events & rates of
change in particular,
 Dispersed leadership for change;
 Roles of hybrid managers; change
leadership;
 Networks of relationships
 Hybrids roles in networks
CONTEXTS




Complex contexts and unstable structures for
clinical work and for improvement initiatives.
eg. cancer networks and PCTs
Staff turnover : managerial levels of turnover;
variable levels of turnover in key clinical staff
groups eg. midwives.
Non-negotiable priorities and management
targets; (often policy driven).
Funding crisis or deficits in some organizations.
COMPARATIVE CHANGE CAPACITY
OF CONTEXTS



CONSIDERABLE DIFFERENCES
BETWEEN CAPACITY WITHIN ACUTE
HOSPITALS & P.C.
STRUCTURAL FRAGMENTATION IS ONE
ELEMENT ONLY;
CHANGE CAPACITY AFFECTS THE
RECEPIVENESS OF CONTETXS FOR
CHANGE
Typology of change capacity
Next slide maps and compares the change
capacity of the eleven sites AND identifies
the key variables affecting change capacity
Limited change
Cancer 2
Resistance
Senior
management
attention
elsewhere;
Conflict (inc
between
clinicians);
New
clinicians,
resisting
improvement
roles.
Cancer 1
Proactive change
Diabetes 2 Maternity 1 Diabetes 1
Indifferenc
Conflict
Responsive Disinterest
e
Diabetes high
Diabetes low
Change due
priority;
Executive
Fragmented
focus on
leadership;
internal
Low clinical
structure;
involvement
No forum for
(PEC chair
exchange of
resigned);
improvement
Poor relations
ideas;
with acute
No designated
trust
improvement
roles.
to problems
outside of
control;
External
pressure for
change
Reactive
Frustration
Inactive
Struggle
Little or no
progress on
urological
cancer
Some ideas,
but no
executive
focus
Little or no
progress on
urological
cancer
2-1 star
rating
(03/4-04/5)
3-3 star
rating
(03/4-04/5)
Slow change
around DNSF; project
group lacked
financial
resources &
authority;
change
held back by
managerial
bureaucracy
2-2 star
rating
(02/3-03/4)
High
competency
change leader
in employed;
Diabetes 4 Maternity 2 Diabetes 5
Focused
1-2 star
rating
(03/4-04/5)
Focused
Diabetes high
Diabetes high
Internally
priority;
priority;
priority;
driven
Good &
Good
Cohesive &
change;
cohesive
leadership;
friendly
Towards
wider
Leadership;
High PEC
Leadership;
PFI project –
Clinical;
chair
High clinical
including
Involvement Involvement;
involvement
maternity
within PCTs
but other GPs
Good regionservices
but PCT
distanced;
wide
detached from
Good relations
external
GPs;
with acute
relations
Difficult
trust
relations
with acute
Active
Trust
Intermitte
nt
slow
Compromised Fragmentat
progress
on best
ion
course of
action
Supportive
Slow change
Fragmented
around DD-NSF
NSF,
change;
frustrated by
unfocused &
resignation of
diverse;
project
bottom-up
manager &
change driven
driven bottom
by individual
-up by GP
clinicians
PAG Chair
(often nurses)
(hybrid)
with acute
trust blocking
1-2 star
rating
(02/3–03/4)
1-1 star
rating
(02/3–03/4)
Key project
leads / key
players in
place;
All team
focused on
the same
outcome
2-3 star
rating
(03/4-04/5)
Slow
steady
progress
Timeconsuming
but effective
change
around D-NSF
involving all
stakeholders
across
primary &
acute care
1-2 star
rating
(02/3–03/4)
Cancer 3
Maternity 3
Motivated
Supportive
Key leaders
in strategic
roles;
Localised
support for
change;
Cohesive
view on
strategy
Impetus
provided by
service
reviews
Active
Sustained
focus on
urological
cancer
(despite
turnover of
key staff)
Gathering
Velocity
Diabetes low
priority;
Cohesive
Leadership;
High clinical
Involvement;
Conflict with
SHA
Active
Authority
delegated to
dynamic
leadership trio
at unit level
Small
changes
3-2 star
rating
(03/4-04/5)
Diabetes 3
3-3 star
rating
(03/4-04/5)
Proactive
Refocusing
D-NSF low
priority;
initially little
top-down
diabetes
leadership &
slow change,
retarded by
loss of project
leader; finally
driven bottomup quickly by
new project
manager
1-2 star
rating
(02/3–
Impact of Capacity of Context on
Change Processes
Proactive change
Limited change
Cancer 2
Resistance
Senior management
attention elsewhere;
Conflict (inc between
clinicians);
New clinicians,
resisting improvement
roles.
Inactive
Little or no progress
on urological cancer
Cancer 1
Diabetes 2
Diabetes 1
Indifference
Breakdown
Supportive
Struggle
Espoused
Active
Diabetes 3
Supportive
Cohesive view on
strategy
Analysis that translates
into posts and support
Proactive
Key managerial
appointments
High competency
Brings diabetes into
PCT control
Theme 1: Impact of Capacity of
Context on Change Processes

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Major “distractions” at each site that impede
service improvement;
Prioritisation of other care groups;
Turnover of staff at a senior (strategic level) –
“jerky change”;
Complex structures – ambiguous, blurred
roles, new organisational forms.
CONTEXT MATTERS
So…..
Context can be perceived as a part of the change
processes, not merely the backcloth;
Implementing service improvements is only
effective under certain conditions.
Effective change is not merely a matter of behaving
in a certain way, but of organizing & managing
the contextual influences.
The role of ‘distractions’ is evident e.g. deficits;
Foundation Hospital status
THEME 2 : HYBRIDS & DISPERSED
LEADERSHIP FOR CHANGE.
WHO IS MANAGING CHANGE?

Extended classification of roles; especially ‘hybrid’
roles.
1.
4.
General manager
General manager, from clinical background
Clinical Director/clinical manager (Hybrid; dual roles)
Portfolio manager (Hybrid; multiple roles)

Implications of hybrid and portfolio roles
2.
3.
Change Leaders in Clinical Service
Improvement

Cancer
–
–

Clinical managers mainly view role as operational
Variability in willingness to accept strategic change
responsibilities
Maternity
- mixed picture; powerful hybrids; & paired roles effective

Diabetes
–
–
General managers hold specific service improvement
roles (with variable success); link to GPs critical?
Hybrid roles very fragile
Change Leaders in Clinical Service
Improvement

Where progress is being made, evidence of:
–
Dispersed change leaders across levels; professions;
clinical / managerial roles

–
Positive and negative examples
Supported by a designated service improvement role
DISPERSED LEADERSHIP FOR
CHANGE?
* The priority given to change management
- By senior managers
- By general managers
- By clinical hybrid managers
* Specialist change managers eg. service
improvement leads
THEME 3: ROLES OF HYBRIDS




HYBRIDS ROLES ARE ESSENTIALLY STRATEGIC IN
NATURE;
HYBRIDS CAN BE SEEN TO PERFORM ‘BRIDGING’
ROLES, WHICH ARE CRUCIAL TO EFFECTIVE
CHANGE;
THESE BRIDGES ARE BETWEEN PROFESSIONS;
AND BETWEEN SENIOR EXECUTIVES AND THE
OPERATIONAL SERVICE DELIVERY STAFF.
EFFECTIVENESS OF HYBRIDS



In P.C., hybrids are scarce in number and the
system is heavily dependent on a few
people;
Many hybrids are not trained in
management;
Some are not well supported by general
management.
Proposals / Ideas
Change leaders (in clinical service improvement)



Trusts have to help the CD/CM to understand
the role in broader “improvement oriented” terms
The most effective “leads” in service
improvement whether GMs or Hybrid CMs, work
as pairs or trios – “tag teams”;
Strategic competence in “lead” appointees
makes a difference.
THEME 4: RELATIONSHIPS :
networks of relationships



In most sites, clinical managers felt their
relationships with managers were sound, if
distant.
Relationships between GPs and PCT
managers were more remote.
Clinical managers felt they had lower
credibility with clinical colleagues and there
was evidence of distrust on some sites.
RELATIONSHIPS : organizational
networks

In all sites, there is evidence of a wider,
influential network of inter-organizational
relationships, eg. cancer networks; PCT and
GP practices.
We detect a growth in network forms of
organization in health care.
Theme 5 :Managing Change
Through Networks

What is the network?
–
–


Managed clinical networks for cancer
Diabetes: loose networks
Centrality of the site to the decision-making
or strategy making core; power dimensions
Limited engagement with network
DEPARTMENT
OF HEALTH
STRATEGIC HEALTH
AUTHORITY
NETWORK
MANAGEMENT TEAM
Primary
Care
PCT
COMMISSIONERS
User
Groups
Cancer
Centre
Cancer Units
Managing Change
Through Networks

Network Boards
–
–
–
–

Low level interaction with trust clinical staff
Do not make significant decisions
Low leverage / power to implement change at site level
Turnover of representation
Service Improvement Programmes
–
–
Not structured for managing change across boundaries
Complex roles and accountabilities
CHANGE PROCESSES IN
CONTEXT



Level of capacity to manage change varies
widely.
Radical variations between sites in the scale
and speed of change.
For example, in Case WMG there are
multiple initiatives and resources are
committed, whilst in case LH, there is a low
level of activity.
WHY DO CHANGE PROCESSES
DIFFER?





Priority given to the changes, against
competing targets/priorities
Local leadership competence
Structures may impede or facilitate
Deployment of senior staff onto other
activities; e.g. Foundation Trust status
Money may NOT be the critical factor, but
people resources are important.
SOME IMPLICATIONS OF
FINDINGS

CHANGE PROCESSES SHOW RADICAL
VARIATION IN SCALE AND PACE.
PRIMARILY BECAUSE ????
--CHARACTERISTICS OF CONTEXTS
--PRIORITIZATION OF CHANGE INITIATIVES
--COMPETENTCE OF CHANGE LEADERS
--INTER-GROUP RELATIONSHIPS
-- INTER-ORGANIZATIONAL NETWORKS
--PROCESSES ADOPTED