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JHOM 29,1

Reforming primary healthcare: from public policy to organizational change

92 Received 24 February 2012 Revised 11 December 2012 18 July 2013 12 November 2013 13 November 2013 Accepted 17 November 2013

Frédéric Gilbert School of Management, University of Québec at Montréal, Montréal, Canada

Jean-Louis Denis Department of Public Health, National School of Public Administration, Montréal, Canada

Lise Lamothe Department of Administration Health, University of Montréal, Montréal, Canada

Marie-Dominique Beaulieu Department of Family and Emergency Medicine, University of Montréal, Montréal, Canada, and

Danielle D’amour and Johanne Goudreau Department of Nursing, University of Montréal, Montréal, Canada Abstract Purpose – Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec. Design/methodology/approach – An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis. Findings – The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of “intermediate change” and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery. Research limitations/implications – This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation. Practical implications – The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes. Journal of Health Organization and Management Vol. 29 No. 1, 2015 pp. 92-110 © Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-12-2012-0237

The authors would like to thank the referees for their most helpful comments. An earlier version of this manuscript was presented at the 2010 Academy of Management Annual Conference, Montreal, Canada and was part of the first author’s doctoral dissertation. The study presented in this paper was part of a research project funded mainly by the Canadian Health Services Research Foundation and the Fonds de la recherche en santé du Québec.

Originality/value – This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design. Keywords Change management, Policy, Public sector reform, Primary care, Change process Paper type Research paper

1. Introduction Disseminating best practices in primary care remains a worldwide challenge (Starfield, 2009). Since the 1970s, the perception of the primary care system has been that services offered are not accessible or efficient enough, and that attempts to change the system never reach their objectives (Lévesque et al., 2007). In this paper, we present the findings of a study that examined the implementation of a public policy that aims to reform primary care through the creation of family medicine groups (FMGs) in Quebec, Canada. The FMG policy aims to improve primary healthcare services by promoting the widespread adoption of organizational attributes identified as desirable, such as physician groups working with nurses, information systems, extended service hours, and patient registration, among others. In Quebec, primary healthcare services are mainly delivered through publicly funded private medical clinics. A full 77 per cent of family physicians work in such settings, compared to a mere 25 per cent of family physicians who work in public primary care organizations (Demers and Brunelle, 2000). Overall, 99 per cent of physicians are paid by the public health insurance plan, as per an agreement signed between the Ministry of Health and the general practitioners’ association. Primary healthcare is administered by a network of actors composed of the Ministry of Health, regional public health authorities, public and private professional organizations, and various professional associations. As in many other countries, Canadians’ “physicians were brought into Medicare on terms that included the continuation of fee-for-service remuneration, clinical autonomy, and control over the location and organization of their medical practice” (Hutchison et al., 2011, p. 257). Such a high level of professional autonomy in primary healthcare makes the implementation of planned large-scale change especially difficult. Previous research identified desirable characteristics of primary healthcare settings and their relation to patient health (Safran et al., 1994; Grumbach and Bodenheimer, 2004; Roland et al., 2012; Strumpf et al., 2012) as well as to professional autonomy and experience (McDonald et al., 2007). Such attributes often pertain to group practice, the involvement of non-physician health professionals, information systems, enhanced care coordination and access, limited co-payments, and patient registration (Shortt, 2004; Starfield, 2009; Hutchison et al., 2011). It is important to identify target organizational attributes to improve primary care, but little remains understood of the processes that will promote their adoption and spread into existing practices. To better understand primary care transformation, some have identified “change facilitators”. These include professionals’ readiness for change (Christl et al., 2010), adequate resources (Cohen et al., 2004), credible leadership (Chreim et al., 2012), positive interactions (Crabtree et al., 2011) and consistency among leading actors’ values (Vabø, 2009). Although these enabling mechanisms offer pertinent information on change implementation, they offer only a partial view of the complex change processes at play (Chreim et al., 2012). Studies focusing on the process of primary care transformation are less common. Their findings suggest that the adoption of organizational innovations is often a politicized process (Sheaff et al., 2009) and that transformations of general practices take form “through a series of subsystem micro-changes” (Chreim et al., 2012, p. 231).

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Many have indeed suggested that gradual implementation (Denis and Langley, 2002; Oldham, 2009) and professional involvement are essential (Bååthe and Norbäck, 2013; Best et al., 2012). Such factors beget emergent change processes – as opposed to prescribed ones – at various levels of the transformation. From this viewpoint, primary care reform “cannot be a carefully engineered, stepwise process, but rather will need to be the result of emergent properties, processes, and structures” (Crabtree et al., 2011, p. S37). Several authors have recognized the presence and importance of emergent processes at various levels in the implementation of planned transformations (Innes and Booher, 2003; Lipsky, 2010) but little is known about the actual interaction between emergent and prescribed change processes. Indeed, some have called for further investigation of the “several driving forces [that combine] to give a process its unique trajectory” (Bidart et al., 2013, p. 6). It is precisely these driving forces that this paper aims to elucidate. Specifically, our central question was: How do prescribed and emergent mechanisms interact at various stakeholder levels, from the inception of a policy to the transformation of primary care organizations? 2. Relevant literature and analytical framework Public policy emergence and implementation are closely tied (Storey, 2011). As Friedman explained, “policy analysis must also be intertwined with organizational analysis” (Friedman, 2006, p. 493). Like other authors (Barzelay and Jacobsen, 2009; Bidart et al., 2013), we developed our methodology and conceptualization based on Pettigrew’s process-based research perspective (Pettigrew, 1985; Pettigrew, 2012). A “processual”, or process-based research perspective, is particularly important in pluralistic contexts such as primary healthcare, where implementing change is often more challenging than determining what needs to be done (Maioni, 2004). Pettigrew’s perspective allows one to overcome the limitations inherent in variance studies, which aim to explain change only by linking independent and dependant variables (Poole and Van de ven, 2004). We drew heavily from Pettigrew’s seminal work (Pettigrew, 1985) in the creation of a framework to guide our analysis of the nature of a transformation (change content) and its relationship with the change process in a pluralistic change context. Change content refers to “what” is changed, the actual transformation that occurs. To analyse change content, we examined both the end state on its own (post-change) and the differences between the initial and the end states. This difference refers to the scale of change and can vary from minor convergent transformations to major shifts in core activities (Greenwood and Hinings, 1996). Studies focusing on change content provide “knowledge of “what works” […]. However, when considered more carefully, it is clear that something important is missing, yet needed to make this kind of knowledge truly actionable” (Langley et al., 2013, p. 4). The missing part may come from studies looking at “how” change occurs – in other words, the change process (Poole et al., 2000). Change process is considered to be “a continuous, interdependent sequence of actions and events, that [can] explain the origins, continuance, and outcome of some phenomena” (Pettigrew, 1987a, p. 656). An analysis of process aims to uncover the “valid generative mechanisms that explain regular patterns in event sequences” (Sminia, 2009, p. 97). Two types of generative mechanisms can comprise change processes: prescribed (planned) and emergent. To analyse the coexistence of both types of generative mechanisms Pettigrew’s “contextualist” view on change processes has “strong affinities” with neo-institutional

theory (Caldwell, 2006). The two derive from structuration theorists and consider “both agency and structure, so a researcher can accommodate both purposeful managerial activity […] as well as the enabling and constraining effects of structural features […]” (Sminia, 2009, p. 111). Change context deals with “why” change occurs, which is answered by looking at the internal and external contexts. Internal context “refers to the structure, corporate culture and political context within” the organization and external context “refers to the economic, business, political and societal formations in which firms must operate” (Pettigrew, 1987b, p. 657). Many authors agree that the degree of pluralism in a given context profoundly affects the feasibility of effecting change, both at organizational (Denis and Langley, 2002; McNulty and Ferlie, 2004) and system (Klijn and Koppenjan, 2000) levels. Pluralistic contexts are characterized by the presence of multiple actors seeking different goals, by ambiguous power relationships, and by knowledge-based work (Denis et al., 2007). Primary care is considered to be highly pluralistic in Canada (Hutchison et al., 2011) and elsewhere (Crabtree et al., 2011). Many studies have observed a significant imperviousness to external pressure to change in healthcare (Coiera, 2011; Randall and Williams, 2009) and other pluralistic settings (Brock, 2008). In such systems, external control over professional practice is limited (Reynaud, 1988), owing to widespread professional autonomy and its inherent change agency at various levels (Chreim et al., 2010). That said, many authors have shown a decline in physicians’ dominance in favour of managerial authority (Gabe et al., 2013; Sheaff, 2009) and a weakening of physicians’ over-riding authority in decision making. Nonetheless, transformations in primary care services are more often characterized by politicized innovations (Sheaff et al., 2009) and ongoing negotiations to reach a required agreement (Chreim et al., 2012). In short, change refers to both “what” varies (change content) and “how” it occurs (change process). Change content and process are closely linked to change context which, in this study, is a highly pluralistic one.

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3. Methodology Studying change processes calls for specific methodologies (Langley, 1999; Pettigrew, 2012; Eisenhardt, 2007). A multi-level longitudinal research strategy is more effective for revealing the change processes as well as the contexts “that produce and are produced by them” (Pettigrew, 1997, p. 340). For the purpose of this study, we utilized Yin’s multiple-case study design (Yin, 2009) to analyse five FMGs (cases). The five cases were selected to contrast contexts (urban, semi-urban) and organizational characteristics (private/public, number of sites) (see Table I). The groups were assigned a letter code to protect their anonymity.

Characteristics Region Number of public organizations Number of private organizations Total organizations Total number of sites Number of physicians – T1 Number of physicians – T2

A Urban

B Semi-urban

Cases C Urban

D Urban

E Semi-urban

1 0 1 1 23 22

1 2 3 3 7 10

1 0 1 1 19 15

1 0 1 3 17 18

1 2 3 3 8 11

Table I. Case characteristics

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Our unit of analysis was the transformation in the five cases studied. To capture the transformation, we analysed the content, process and context of change from the perspective of a local context (FMGs) embedded in a larger one (region and province). Analysis at the local level was deemed essential to: […] understand the nature of professional collaboration at the operational level, because it is here that fundamental boundaries are defined, and it is here that most concrete boundary-crossing initiatives must penetrate and take root if they are to be successful (Denis et al., 1999, p. 108).

We built the five cases using three types of data: interviews with key informants (health professionals and local and regional managers); a survey administered to health professionals; and documentary data (e.g. contracts, forms, letters, reports, and print media coverage). The first round of 47 interviews was conducted in 2003 (T1), in the months following the FMGs’ accreditation. It provided information on the historical and contextual backgrounds of each case, the process of their involvement with the policy, and the formation and initial functioning of the groups. Two years later, another 57 interviews were conducted (T2). All interviews were recorded, transcribed, and then coded according to our framework. Databases were created for each case by combining interview content with that of the surveys and documents. These databases integrated the sequence of events characterizing each case, the mechanisms driving each process (Poole and Van de ven, 2004), and the pre- and post-change comparative analyses. Data were analysed separately by three researchers. Differences in coding were discussed until a consensus was reached among researchers on the coding of change content, process and context. Group discussions on the preliminary results were held on two occasions with a number of participants from each of the five groups studied (approximately six months after each round of interviews). These discussions allowed us to fine-tune the analysis (Patton, 2002). The initial analyses also revealed the complexity of change-generating mechanisms, which called for additional clarification from participants (Eisenhardt, 2007; Langley, 1999) as to the multiple mechanisms at play and their interactions. 4. Results The results suggest that the transformation occurred in three stages. The first involved coming to a consensus at the system level over both the need to improve primary healthcare, and the FMG as the means to achieve this. In the second stage, the government launched the policy and the FMGs underwent an accreditation process. Once accredited, the FMGs proceeded with the actual change at the practice level. Table II presents a synthesis of these stages. Stage 1: pressure for change and consensus-building Widespread dissatisfaction regarding access to healthcare was the context that led the government forming a public commission. The public commission revealed primary care’s contribution to healthcare system performance as well as some promising innovations experienced by primary care organizations. These public discussions led to a consensus on the attributes sought in primary care organizations, which were reflected in the commission’s final report (CESSSS, 2000). The commission proposed to reorganize primary care by creating FMGs. This recommendation was in keeping with recommendations expressed by nurses to be allowed to play an “enhanced” role in primary care, as the provision of primary care by nurse practitioners is notably still the exception in Quebec. The proposed

Federal funding Public commission report well received

Variable local contexts Policy framework (characteristics)

2: Policy inception

3: Policy implementation

Policy adapted to diverse contexts Variations in change content due to variable local contexts All administrative components (except IT) implemented

Public policy on primary care reform through FMGs Transformation of traditional arrangements between physicians and government

FMGs proposed to improve primary care

Consensus among leading actors on need for change

Limited access to primary care Generalized dissatisfaction re. access to primary care Local innovations in primary care organizations

1a: Consensus-building on issues (Pressure for change)

1b: Consensus-building on desired primary care innovation

Change content

Initial context

Stages

Accreditation and formalization through contractual arrangements Operational transformations Specific initiatives to support changes in clinical practices

Government adopts public policy

Change process formed of individual initiatives Change content (consensus on need for change) emerges from individual initiatives Change process prescribed by public commission Change content emerges from consultations and dialogue Change process (unilateral policy adoption) prescribed by government Change content (policy content) prescribed by government (although informed by public commission’s consensual recommendations) Change process emergent via local initiatives for both the accreditation and the operational transformation Change content prescribed by policy content

Change process Observed change patterns

Increase pressure on government via individual initiatives Launch of public commission Consultations and dialogue among leading actors on problems and solutions

Actions

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Table II. Change analysis highlights by stages

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creation of FMGs was also in line with physicians’ recommendation to be provided additional resources in existing medical settings. Not surprisingly, these two important professional groups supported the proposed change (Sirois and Gagnon, 2001). Stage 2: policy inception and FMG accreditation In 2001, the Quebec government followed the commission’s primary recommendation and instituted a policy to improve primary care through the creation of FMGs. It should be noted that forming an FMG does not necessitate the creation of a new organization, but rather involves physicians consenting to a new contractual arrangement. The policy offers additional resources to groups of six to 12 physicians working out of one or more organizations, who collaborate to improve accessibility and continuity of care. As such, FMGs can take the form of an organized network of professionals (Fattore and Salvatore, 2010; Strumpf et al., 2012). The additional resources mentioned above include clerical and administrative support, financial compensation for extra staff, payment for registered patients over and above their usual remuneration, and the provision of information systems. FMGs must offer a minimum number of service hours and provide 24/7 on-call service for at-risk patients. Under this policy, physicians’ roles are altered somewhat, in that they collaborate with two nurses who take on more clinical responsibilities, such as following-up with chronically ill patients. After launching the policy, the Health Minister gave only a few weeks to submit project proposals. Having followed the public commission closely, the groups in this study had already begun reflecting on desired changes and were thus prepared to act quickly. The various groups held multiple meetings to discuss their respective proposals. The time spent at this stage varied across the groups according to the degree of initial consensus among professionals. Two main visions driving physicians to create FMGs coexisted in all groups: improving patient access to care, and improving working conditions (e.g. workload sharing, better recruitment, and additional resources). The predominant vision in groups A, C and D was for service improvement, although concerns for facilitating service delivery were also present. The high consensus within each of these groups could be partially explained by the fact that they consisted of physicians who had been working together for several years and had developed common views over time. In groups B and E, both of the above visions were present but with less consensus among individuals, some favouring patient care and others prioritizing the needs of professionals. All groups submitted a proposal and then underwent an accreditation process to determine whether they met policy requirements to form an FMG. At this stage, physicians formalized, through various multi-level agreements, the composition of their respective groups, the services they intended to offer (opening hours, on-call services, etc.), and the service delivery mode (location, modalities of on-call system, etc.). For the first time in Quebec, an agreement existed between government and the medical profession, whereby the provision of resources was contingent on specific modes of production (e.g. minimum requirement of front-line services), professional practices (e.g. involvement of nurses) and outputs (e.g. number of patients accessing services) (see Figure 1). Since the 1970s, the government had no authority over the organizational characteristics or level of services offered in traditional family medicine settings. By forming an FMG, physicians inherently accepted a partial reduction in the autonomy that had characterized their practice for decades.

Input

Traditional general practices

Output

Organizational characteristics

Output

Public financing Input

Family medicine groups

Organizational characteristics

Public financing

Administrative and clerical support front-line services

Nurses

Number of patients

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Service hours

FMG budget

FMG Policy

The structure of the groups was determined through the accreditation process and entailed varying degrees of change (content). In some groups (A, C and D), the new boundaries corresponded almost exactly to what was already in place in the organizations where physicians worked. Groups B and E, however, were made up of professionals that worked in different settings, where not everyone in these settings was a member of the group. In this respect, groups B and E can both be described as a network of organizations transcending various existing organizations. This process of FMG formalization was time-consuming for all groups. Since they were the first groups created under the policy, the rate of implementation was slowed by the many processes that had to be organized along the way. Some group-level negotiations continued among professionals during accreditation. The process was further drawn out for groups A and E, because their respective regional health authorities did not initially back the project, a prerequisite of FMG formation. Group A engaged in a series of discussions with the health authorities until consensus was reached. Group E mobilized its contacts at the ministry of health to urge approval. In Quebec, general practitioners are paid according to an agreement between their professional syndicate and the government. Adjustments to the agreement therefore needed to be negotiated at the provincial level between the government and the physicians’ professional association to clarify policy terms and financial incentives. These talks got off to a slow start (Sirois, 2002) but an agreement was finally reached a few months prior to the accreditation of the first groups. Although most groups maintained the composition they had originally submitted, group B lost 13 physicians in the accreditation process, making it a group of seven, in the end. Physicians cited the risk of loss of income and the lengthy accreditation process (21 months) as reasons for the attrition. Groups C and D originally submitted their proposals together but had to split their project in two to align with policy requirements. Once accredited, the groups could begin the actual practice transformations. Stage 3. implementation – operational transformations Our results indicated that specific processes were associated with various policy components, and that pluralism played an intervening role in implementation. As shown below, some of these policy components concerned the practice level and

Figure 1. Changes linked to FMG policy

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involved little intervention from external actors. Other changes exemplified the dependence of the groups on regional actors. Finally, the modification of professional practices through the involvement of nurses required multiple adjustments at the individual level. The addition of administrative and clerical staff and the modification in services was characterized by relatively low pluralism, minimal dependence on external players and little intra group variation. These changes required little time to implement because they had been discussed among physicians prior to group accreditation. The physicians’ authority over clerical and administrative staff was clearly defined from the beginning. The reorganization of front-line services was implemented quickly once groups reached a certain size. Patient registration was slow in most groups, and Ministry targets had not been reached by the end of the period studied. Some groups had smaller clienteles of patients with more complex clinical needs and therefore found it difficult to reach the clientele target imposed by the Ministry of Health. These groups developed strategies, such as offering registration by mail or by telephone to former patients. In this process, the influence of lead physicians over the size of their colleagues’ case load was limited, despite some variation from one group to another. For instance, in Group A, the lead physician put direct pressure on other physicians who had enroled fewer patients: I did put pressure on some players […]. If some currently see 1,100 patients […] while others see 200, 250 or 300 in the same working time, I start to ask questions […].

In Group E, which is a collective of physicians working out of several different clinics, the lead physician took a somewhat less authoritative stance: I still have two doctors here who intend to continue to vaccinate all their patients themselves. While I explained to them that this does not make sense, they are free to do as they please. I am not their boss, and they are not required to obey me.

The modification of opening hours and the 24/7 on-call service for at-risk patients directly affected the services offered. The nature of the transformation regarding service hours varied across groups, depending on the difference pre- and post-reform. Groups B and C saw an increase in their service hours. Group D maintained the same schedule, keeping the walk-in clinic open to the general public because of its downtown location and its population of unregistered at-risk patients. Group A is the only one that reduced services offered to the public during weekdays in order to maximize those offered to their registered clientele. Because of its limited size group E was, by the end of the study, still negotiating a partnership with a newly formed group to be able to offer the minimal services. The creation of on-call services for at-risk patients was a significant change for all groups, as they had to negotiate an agreement with the regional on-call service. The implementation of information systems revealed a strong dependency of groups on regional actors. None of the five groups had fully implemented systems by the end of the study. Information sharing on diagnoses and prescription drugs requires the use of systems that are compatible with the region’s hospitals and pharmacies, which was often not the case. Most professionals had initially perceived the information systems as an attractive feature of the policy but in actual fact observed limited impact aside from the new equipment provided. The integration of nurses within the general practitioners’ clinical activities also revealed a dependence on regional actors. Physicians are responsible for the clinical

aspects of their work, but nurses are legally employed by a public organization that contracts with the groups. Thus, FMGs had to collaborate with a public health centre to conduct the selection process. The groups took two to six months to fill the full-time nursing positions. Groups B and E needed additional time due to disagreements between group managers and the external public organization as well as with the nurses’ union. As a lead physician (Group E) explained:

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The first year was a nightmare that I never want to relive. Ever! The problems we had with the union here, it was like trying to negotiate with the mafia […].

101

The actual involvement of nurses revealed numerous change processes at the individual level. The policy and contract reflect a collaborative vision of the nursephysician working relationship, describing nurses’ roles as “enhanced”, and regarding them as professionals with a specialized, valuable skill set. Many physicians shared this vision, but others held a rather “instrumental” perspective, wherein nurses were seen as a resource that supports the medical practice. Both views were present during implementation. From the beginning, the physicians in groups A, C and D had a predominantly collaborative vision. In each of these groups, physicians and nurses jointly defined their respective roles through formal processes (joint committee, inclusion of nurses in physicians’ meetings). In groups A and D, nurses’ attitudes positively influenced their involvement in the medical practice. Building on a long tradition of nurse-physician collaboration in these organizations, the nurses took the lead by preparing protocols and asserted their value to physicians, which was in turn supported by a cohesive medical leadership. In Group C, the process was slower because of inconsistent leadership of both physicians and nurses. Even though nurses were seen as partners from the beginning in groups A, C and D, in certain cases physicians needed more time to adjust their practices to bring them in line with their vision. Some professionals from Groups B and E shared and exercised this collaborative vision, but they were located in separate sites from the physicians with a more instrumental vision. A nurse working in Group B explained: “They have a vision: I’m the doctor and you’re the nurse, so I’m your boss”. The instrumental vision of some general practitioners evolved over time, but it slowed the implementation process, as explained by a physician working in Group E: We may have offered them tasks for which they were over-qualified. At that time, we lost four nurses. […] It led us to ask ourselves questions about how we use our nurses, […] and then give them tasks which made them feel appreciated and useful.

Emergent processes were observed in Groups B and E, but they were not as formalized or systematic (preparing protocols during vacation time, physician deciding to get involved in protocol preparation). Thus, in all groups, nurses’ involvement in service delivery was a function of the physicians’ vision of nursing and the development of their trust in nurses’ contribution. Their vision evolved to a collaborative approach through more or less formalized emergent processes that nurses participated in: When I first arrived here, they had no idea of what a nurse is qualified to do. So, we created our protocols and our teaching plans, and the response was: Oh my! You do all that […].

The interactions and the negotiations of numerous adjustments between nurses and physicians in each group led to the gradual establishment of their collaboration: […] before, it felt like [physicians] were just asking [nurses] to carry out their instructions, whereas now they have come to ask for our collaboration.

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As described above, some variation was seen in the extent to which different policy components were implemented and established; some components took root and stabilized quickly (e.g. modification of service hours), while others took form more gradually, often when the group depended on regional actors or when professional autonomy made for variations in practices (e.g. information systems). 5. Discussion We began this study with the goal of shedding light on how prescribed and emergent mechanisms interact at various stakeholder levels, from the inception of a policy to the transformation of primary care organizations. The results presented in the previous section provide a thorough description of the cases studied. We will now discuss the empirical and theoretical contributions of these results. Empirical contribution – change content To describe the transformations that took place, we compared the initial and end states of each group. Both variations and similarities in change were observed across groups. The variations were a reflection of differences in initial contexts, such as in pre-policy services offered, patterns of nurse-physician collaboration, and practice size; as well as in local initiatives, such as the provision of services strictly to registered patients. Differences in the organizational structures, such as FMGs based out of single vs multiple settings also accounted for variations in overall change. The analysis of change content revealed that similar end states concealed variations between groups in the scale of their respective changes. For example, Groups C and D were offering the same weekend services to their patients. However, prior to FMG creation, in contrast to Group D, Group C had offered very limited services of this kind. Furthermore, a less advanced end state was not necessarily indicative of the scale of change that had occurred. The integration of nurses in Groups B and E – both characterized by weaker initial physician consensus about nurses’ roles – was more problematic and had not fully stabilized by the end of the study. While a lesser degree of collaboration was achieved in their end state, Groups B and E had changed more with regard to the integration of nurses over the same time period than the other groups. These findings are in line with other studies’ conclusions that large-scale changes are formed of multiple heterogeneous subsystem changes (Chreim et al., 2012). The change content observed in this study does not qualify as “big bang” reform (Hutchison et al., 2011). Indeed, certain results suggest that the policy induced only minor convergent transformations. Physicians remained central actors in their role of overseeing nurses’ clinical roles and in retaining responsibility over patients’ treatments. The FMG reform did not impose new forms of direct supervision as other reforms have (McDonald, 2012; Sheaff et al., 2004). Physicians negotiated financial incentives while maintaining their regular fee-for-service remuneration, which is considered sub-optimal to foster integrated and team-based primary care (Margolius and Bodenheimer, 2010). Moreover, the policy did not impose change, as physicians were free to form FMGs or not. These results confirm the enduring nature of certain fundamental characteristics of healthcare systems, in which “the medical profession [possesses] a powerful veto” (Tuohy, 2010, p. 31), and therefore imposes the development of a policy that they will find acceptable (Marsh and Smith, 2000). The policy was nonetheless ground-breaking in that it altered the historical relationship between the medical profession and the Ministry of Health. The government

now provided supplementary resources in exchange for policy compliance and would thus oversee certain outputs, such as operating hours, patient registries, and services provided. This arrangement was a departure from the traditional autonomy of medical practice, and it shares similarities with the general movement toward “managerialization” (Sheaff, 2009; Freidson, 1984). The policy also induced a cultural shift for physicians in all groups by moving toward a more collective view of primary care, mainly through physicians’ shared responsibility for patient care and a closer professional collaboration with nurses.

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Theoretical contribution – change process This paper advances previous research on large-scale transformations in pluralistic contexts with two specific contributions: we revealed the interactions between change processes and content; and we showed the specific mechanisms that not only coexist but act sequentially at various levels to generate change at the clinical practice level. Change process and content. Our results demonstrate more precisely how change process and content work together. In organizational change analysis, change process and content are often viewed as a duo that interacts closely with context (Pettigrew, 2012). Change content is defined as the difference from “before to after”, and change process is the series of actions explaining how “before” evolved to become “after”. Our results show that some elements of change content do not result in a direct change in administrative or professional practices. Rather, an initial change leads to the implementation of a mechanism aimed at supporting future processes that will eventually lead to changes in services (see Figure 2). We observed such transformation chains at various levels. At the system level, for instance, the public commission launched by the government can be categorized as change content. The public commission was defined and launched following a series of actions taken by government. Once in place, however, it engaged actors in a process that fostered consensus-building among them. This newly formed consensus can be viewed as change content that emerged from this collective process. Similar chains were observed at the organizational level. Groups A, C and D held formal discussions (change process) which led to the establishment of nurse-physician committees in each group (change content) to support nurses’ integration. We found that these committees promoted greater interactions and “allowed members to develop familiarity and trust, and to cross professional barriers”, a pattern also observed by other researchers (Chreim et al., 2012, p. 231). As in many primary care reforms, nurses were integrated in FMGs to “take on much stronger roles – often providing services instead of the physician” (Reay et al., 2013, p. 9). The development of new professional attitudes toward other professions was essential to renegotiate “new boundaries with themselves and other disciplines” (Sibbald et al., 2006).

Change process (e.g. public commission launched in response to public dissatisfaction)

Change content (e.g. public commission established)

Change process (e.g. public commission’s work)

Change content (e.g. new consensus on problems and solutions)

Figure 2. Chain of change process and content

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In short, at both system and organizational levels these new “intermediate” change processes supported the negotiation of mutual adjustments, and allowed actors to progress from contemplation, to planning and, ultimately, to active change at the practice level (Prochaska et al., 2001). Mechanisms underlying change content and change processes. The second theoretical contribution offered by our findings was our uncovering of the sequence of mechanisms generating both change content and change processes. Previous studies have shown that several such mechanisms can coexist (Bidart et al., 2013; Poole and Van de ven, 2004) and that change is often the result of multiple sub-processes (Chreim et al., 2012). Our results go one step further by showing the sequence of emergent and prescribed change mechanisms (see Figure 3). Initially (Stage 1a), multiple independent initiatives expressing dissatisfaction with primary care caused a consensus to emerge on the need to improve them. Thus, both change process (independent initiatives) and content (consensus on need to change) were emergent. In response to this rising pressure, the government launched a public commission to analyse the situation and propose solutions (Stage 1b). The commission was an initiative prescribed by the government that described the process by which leading primary care actors would build consensus (emergent process) on the problems and potential solutions. In Stage 2, the government developed the policy to implement FMGs. This policy was informed by the commission’s recommendations. During this stage, the government prescribed both the process (policy formulation by the health ministry) and its content (policy terms) while the change content represented the consensus that emerged in Stage 1. It is this blending of processes that enabled prescribed change content to be perceived as acceptable by leading actors (Marsh and Smith, 2000, p. 6). During implementation (Stage 3), the policy provided the boundaries for most change content at the organizational level, but change processes were largely defined by local actors (emergent). The actors involved were required to implement policy terms and did so by organizing various processes (e.g. patient registration, information systems, nurse integration). These observations are similar to findings of other studies of healthcare settings, which showed that an absence of prescribed implementation plans nonetheless allowed for the emergence of various coherent changes (Buchanan et al., 2007). Prescribed

Stage 3 Policy implementation in PC practices

Stage 2 Policy formulation

Stage 1a Pressure for change

Stage 1b Consensus on FMGs as solutions for PC

Change content

Figure 3. Generative mechanisms driving change content and change processes

Emergent

Change process

Prescribed

The observed interactions of change-generating mechanisms (Figure 3) are consistent with other studies’ findings that prescribed and emergent mechanisms explain change process (Van de ven and Poole, 2005) in pluralistic contexts (Buchanan et al., 2007; Chreim et al., 2010). Key insights for decision makers The above results shed light on the underlying aspects of large-scale organizational change in pluralistic contexts and offer key insights for decisions makers. Our analysis of the differences between initial and end states revealed important pre-post variations between groups, despite similarities in their post-policy services and practices. This suggests that policy evaluation that focuses only on the degree of group compliance with policies can miss the actual changes brought about by policy implementation. Such limitations can be avoided by a more detailed pre-post change analysis. Furthermore, we saw that change evolved more consistently when emergent processes were supported by specific formal mechanisms to structure actions. Indeed, the prescribed process scaffolded actors’ collaborative participation in moving toward implementation. As discussed, these “deliberately emergent” (Mintzberg, 2007) processes were observed at all levels. The public commission (system level) and the collective work of professionals on care protocols (practice level) illustrate that such processes acted as facilitators to redefine work boundaries by providing a time and place for “structured disagreement” and resolution (Reay et al., 2013, p. 9). Our results seem to be in line with Crabtree et al. (2011) who concluded the following from a 15-year research programme studying US primary care practice transformation: most practices are resistant to protecting time for reflection. They see it as an intrusion, thus, “forcing” time and space for reflection may be one of the more important components of a change management strategy.

6. Conclusion Our results offer unique contributions. They provide a better understanding of how planned large-scale change coexists with professional autonomy through an intertwining of change content and change processes. We also showed how change agency took the form of key initiatives at various levels in different contexts, and revealed the specific prescribed and emergent mechanisms driving change process and content. Our results suggest directions for future research on primary care transformations. We were able to observe the evolution of professionals’ visions with regards to the policy, as well as of their views toward greater involvement of nurses. A more in-depth study of the cycles of sensemaking (Weick et al., 2005) would therefore be pertinent. In such an investigation, an analysis of the behaviours of professionals and the administrative technicians provided to the FMGs could further add to our understanding and complement the findings of others, like Checkland et al. (2013) who showed that specific behaviours of middle-managers are closely linked with sense-making processes involved in the transformation of primary care practices, as well as Sylvain and Lamothe (2012) who described the crucial role of inter-professional dynamics in the construction of new meanings. This research has some limitations. It was conducted among early policy adopters (Rogers, 2003) and it investigated a limited number of primary care organizations.

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Little data were available to complement documentary analysis at the system level. Also, some might consider the period studied too short to analyse a public policy (Sabatier, 2005). However, given the international interest in primary care reform and other large-scale changes involving the medical profession, the results offer avenues for both policy development and implementation at the practice level.

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Further reading Mintzberg, H. and Waters, J.A. (1985), “Of strategies, deliberate and emergent”, Strategic Management Journal, Vol. 6 No. 3, pp. 257-272. Van de ven, A.H. and Poole, M.S. (1995), “Explaining development and change in organizations”, Academy of Management Review, Vol. 20 No. 9, pp. 510-540. Weick, K.E. and Quinn, R.E. (1999), “Organizational change and development”, Annual Review of Psychology, Vol. 50 No. 1, pp. 361-386.

Corresponding author Professor Frédéric Gilbert can be contacted at: [email protected]

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