Disputats, Handelshögskolan, Stockholm, 2003.

Face aux pressions continues que subissent les systèmes de santé, de nombreuses réformes sont perpétuellement en cours pour améliorer le processus de soins et par conséquent, offrir des soins de qualité et accroître le niveau de santé des populations. Les réformes que connaissent actuellement les systèmes de santé visent à optimiser l’impact des services sur la santé de la population en introduisant le concept de la responsabilité populationnelle. Par ailleurs, il existe de plus en plus un consensus sur la nécessité d’établir une relation directe et durable entre les prestataires et la population des territoires desservies pour être en mesure de tenir compte des contextes personnels et sociaux des patients et de leurs familles et pour assurer la continuité des soins dans le temps et d’un service à l’autre. Cette thèse porte sur la Programmation régionale de services ambulatoires (PRSA) de Laval. Elle analyse cette programmation comme une solution innovatrice dans la mise en œuvre de la responsabilisation populationnelle des soins. La stratégie de recherche combine à la fois une revue intégrative de la littérature qui vise à analyser le bien-fondé de la PRSA; une étude quasi-expérimentale pour examiner ses effets; et enfin, une recherche synthétique de cas pour comprendre l’évolution de la PRSA et analyser l’institutionnalisation du changement dans les organisations de la santé. Dans le premier article, nous nous sommes employés à analyser le bien fondé c’est-à-dire la plausibilité des mécanismes causaux présumés. La PRSA est un modèle d’intégration régionale basée sur une approche populationnelle. La stratégie de réseaux intégrés de soins et de case management combinée avec une approche populationnelle telle que mise de l’avant par le PRSA sont trois éléments essentiels en faveur d’une responsabilité populationnelle des soins. À l’aide d’une revue intégrative de la littérature, nous avons démontré qu’il s’agit d’une programmation capable de consolider une intégration régionale en mettant de l’avant une approche populationnelle permettant de bien cibler les besoins des populations du territoire à desservir. Le deuxième article examine les effets populationnels de la PRSA en termes de réduction de la durée moyenne de séjour et de l’augmentation de la rétention régionale. Une approche quasi expérimentale a été utilisée. En ce qui concerne la durée moyenne de séjour, on n’observe aucune diminution pour l’asthme ni pour la démence. Par contre, il est plausible que l’implantation de la PRSA ait permis une diminution de la durée moyenne de séjour pour les maladies coronariennes, les MPOC, l’embolie pulmonaire et le cancer du sein. Pour la rétention régionale, aucun effet n’a été observé pour les MPOC, l’embolie pulmonaire et la démence. Une augmentation de la rétention régionale a été observée pour les maladies coronariennes, l’asthme et le cancer du sein. Cette augmentation pourrait être attribuée à la PRSA. Dans le troisième article, nous avons examiné les facteurs susceptibles d’expliquer l’évolution de la PRSA. En partant du point de vue des responsables de la programmation de la PRSA et les gestionnaires actuels de la programmation de services de la région de Laval, nous avons tenté de mieux cerner les facteurs qui ont provoqué la suspension du déploiement de la PRSA. Les résultats indiquent que les changements fréquents dans les structures dirigeantes du réseau de la santé ainsi que l’interférence de plusieurs autres réformes ont été un obstacle dans le maintien de la PRSA. Dans le contexte actuel des réformes en santé où l’approche de réseaux intégrés de soins et de responsabilité populationnelle sont mises de l’avant, les résultats de cette thèse apportent un éclairage certain sur l’opérationnalisation de ces orientations. / Due to the continuous pressures on the health systems, many reforms are perpetually implemented to improve care process and consequently the quality of care in order to increase public’s health level. The ultimate goal of this health system’s reform is to optimize the services impact on population’s health by introducing the populational responsibility concept; an approach based on the conviction that health is collective, therefore necessary to maintain and develop. In addition, there are more and more consensus on the necessity to establish a direct and durable relationship between care providers and communities. Thus, a way to be able to consider the patient’s personal and social contexts along with his family, and to ensure continuous care. This thesis, based on the Regional Programmation of ambulatory services (PRSA) of Laval, analyzes this program as an innovative solution concerning the introduction of populational approach in healthcare. The research strategy combines an integrated literature review, which analyses the pertinence of the PRSA; a quasi-experimental study, to examine its effects; and finally, a synthetic research that allows grasping the PRSA’s evolution and to analyze the institutionalization of change in healthcare organizations. In the first article, we analyse the pertinence of the PRSA’s model or, in other words, the plausibility of the causal relation that is presumed by this model. The PRSA is a regional model that combines integrated healthcare networks, case management and a populational approach to achieve populational responsibility. We showed, based on an integrated literature review, that this program has indeed the potential to secure a regional integration using a populational approach to well assess its population’s needs. The second article analyses the PRSA’s populational effects in terms of length of stay (LOS) and regional retention. A quasi-experimental design was used. For the length of stay, no decrease could be noted for asthma or dementia. On the other hand, the PRSA’s implementation may have contributed to decrease the LOS for heart disease, chronic obstructive pulmonary disease (COPD), pulmonary embolism and breast cancer. Concerning the regional retention of patients, no significant changes were seen for COPD, pulmonary embolism and dementia though effects were observed for heart disease, asthma and breast cancer. Finally, in the third article, we look at the reasons that lead PRSA’s suspension. Based on the PRSA’s manager and the current services programs managers in Laval, we tried to get a better understanding of the factors that delayed the PRSA’s implementation. The results indicate that the frequent healthcare system leading structures reorganizations and the interference of several other reforms in the past years were obstacles in the PRSA’s implementation. Considering the current context, in which health care system is going through several reforms and where the network approach and the populational responsibility are valued, the results of this thesis bring a valuable contribution to the comprehension and the implementation of these concepts.

This thesis analyses the difficulties encountered in the promotion of usability, especially in relation to occupation health issues, when developing IT systems in a public authority. It examines what happens when User-Centred Systems Design (UCSD) approaches are introduced to organisations with in-house systems development for their employees. It studies how stakeholder values affect the outcomes in terms of usability, occupational health, and institutional acceptance. Moreover, new methods are examined and evaluated as potential tools for assisting the adoption of UCSD. These methods are for example Field studies for system developers, Usability coaching for stakeholders and Management views of usability. A stated aim is to influence systems development in practice. Hence an action research paradigm has been employed, carrying out research and change in real life settings, gathering and analysing data using qualitative techniques. This thesis is based on a constructivist perspective, where theories in the areas of learning and organisational change have been used in order to better understand the research questions. The research demonstrates that most people are enthusiastic to, and interested in, UCSD with a focus on the computerised work environment. Many of the stakeholder groups, such as managers, users, project managers and system developers, changed their construct of identity as well as practice when UCSD was introduced. However, this research shows that there are several values that affect systems development and hinder usability work. These include for example value of rationality and objectivity, and differing values and perspectives underpinning descriptions and discourse on work and systems development. Values such as automation, efficiency, and customer satisfaction shape the development of new technology, and ultimately the tasks, work practices integrated in IT systems. Moreover, the results demonstrate that even though many consider usability as important, few take active responsibility for it, as the title of this thesis suggests.

No description available.

New developments in information and communications technologies have rapidly made their way into the forefront of educational concerns. With exciting possibilities for global communication, access to vast amounts of information and new approaches to teaching and learning practices, a small number of schools have integrated the technology into the school environment. However, the majority of schools are just feeling their way and this is particularly so in small rural schools which are removed from the high technology communications networks of the capital cities. This study placed open learning technology into three rural schools where the teachers had control over its use. Using qualitative multi-site case study techniques, the effect of the technology on the planning and teaching strategies of the teachers, classroom organisation and management, changes in teacher-student interactions, student motivation, curriculum enhancement and/or extension, the role of the teacher, and professional development issues was investigated. It was found that the use of the technology had a positive effect on encouraging open learning and student-centred approaches to lesson delivery. The Internet and e-mail were accepted by the teachers and the wider school community and became part of normal classroom activities. Staff development opportunities figured largely in the outcomes of this study being revealed as a necessity for teacher adoption of the innovation. The leadership role of the principals emerged as an important theoretical construct influencing the implementation of the innovation. Finally, the introduction of the technology was found to contribute to breaking down the barriers of distance that are a characteristic of rural and isolated schools. By providing teachers in rural schools with access to open learning technology that can be readily integrated into teaching activities, it is likely that lasting change in attitude to the legitimacy of information gained through the technology, and a greater level of independent student classroom activity, will occur.

Contemporary organisations face a raft of challenges in coping with competing demands and rapidly changing environments. With these demands and changes comes the need for those within the organisation to be adequately skilled to meet these challenges both now and into the future. There is a growing concern that the rate of change is such that learning will not be sufficient and that individuals will need to be skilled in unlearning or letting go of past practice and behaviour. This research investigated individual unlearning as it applies in the workplace, and enabled the development of a process model of unlearning that provides specific indication of factors affecting unlearning during times of change. In particular, this thesis highlights the critical importance of elements of a more personal and affective nature; often referred to as "soft" issues. Six key factors at the level of the individual were identified as impacting unlearning; positive prior outlook, individual inertia, feelings and expectations, positive experience and informal support, understanding the need for change, and assessment of the new way. Two factors emerged from the organisational level that also impact unlearning; organisational support and training and history of organisational change. Many change efforts will fail because of lack of attention to individuals, how they unlearn and the level of feelings and expectations that accompany change. This research demonstrates that organisations must provide resources and education to provide both those in supervisory roles and those impacted by change with the necessary skills to unlearn and to embrace change at an individual level.

When the Labour Government won the election in 1997, one of the biggest challenges they faced was restructuring the public sector. This forced the new Government to move the public sector away from managerialism to become a more collaborative organisation, with greater employee engagement (Senior, 2008). This was when the work of developing new ways of partnership working was started in the NHS (Munro, 2002; Farnham et al., 2003).In order to assist the restructuring of the public sector, the Government introduced change in response to human capital needs, this included the implementation of the Agenda for Change Programme which was the biggest alteration to the pay structure of NHS staff in 50 years. Agenda for Change covered over one million NHS employed staff (with the exception of doctors, dentists and some senior management positions), and aimed to offer fairer pay based on new job evaluation, and to move towards harmonised conditions of service for NHS staff, to build links between career and pay progressions (DoH, 2004a). A partnership approach was seen as being a critical success factor in implementing this change. This thesis focuses on partnership working through the implementation of Agenda for Change in the NHS. It aimed to explore the perceptions of different levels of participants of Agenda for Change Implementation Teams in relation to organisational change and partnership working. Four research questions were considered to address the above aim: 1). What were the perceptions of the Organisational Change which occurred within the NHS? 2). What key aspects of Partnership Working were employed in the NHS to address Organisational Change prior to the implementation of Agenda for Change? 3). What were the key constituents of Partnership Working that facilitated Agenda for Change and how were they developed by its implementation? 4). What were the incentives and challenges in implementing Agenda for Change? As a phenomenological study, this research intended to interpret people's perceptions and experience of partnership working and Agenda for Change. Some 18 individual interviews were conducted with selected members of the implementation teams across three Health Boards in Scotland. Particular attention was given to the organisational change context, Agenda for Change, and partnership working in the Scottish context. This research confirms the perceived view that there has been a period of continuous planned change within the NHS and these changes have transformed the culture of the organisation to become more business focused. Agenda for Change, was perceived, in the main, through the whole organisation, as a positive one offering an easier and fairer pay system allowing workforce flexibility. However there were indications that partnership working does not go on at all levels and where it is present it places a great strain on staff and resources which in the main, is in decline. The Agenda for Change structure has distinguished characteristics of organisational development. Unions and employees had much influence through the change process since partnership working existed at three levels: strategic, functioning, and workplace. However, findings suggest that despite the well maintain partnership at the strategic and functioning level, a partnership arrangement cannot be fully supported at workplace level. Workplace manager's faced pressure from the Government's targets and deadlines, as well as financial budget cuts; which were some of the challenges of encouraging partnership working at workplace level.

This dissertation presents an intervention-based study that aimed to enable teachers to improve teaching and learning in one school in Ramallah, Palestine. The non-positional approach to teacher leadership was adopted as a means to mobilise all teachers in the drive towards bottom-up, participatory school change processes that increase teacher self-efficacy and collaboration, build professional capacity and social capital, and promote sustainability. The Teachers Leading the Way programme provided a contextually tailored strategy, and set of instruments and tools that through reflective exercises and dialogic activities aimed to support teachers to innovate practice, and impact organisational structures and professional culture. This is significant in the Palestine setting for facilitating the building of locally based and sourced knowledge to inform an authentic Palestinian vision and agenda for policy-making and education reconstruction, with implications for countries of the Middle East and North Africa region. In the process, a grassroots change movement is intended to shift historical and continued reliance on foreign intervention and international assistance, and lay the foundation for democratisation and social transformation. The intervention was investigated using a critical action-based, participatory methodology that emphasised context and researcher reflexivity in one school and amongst a cohort of 12 participants. Data were collected using a range of research-designed and programme-based methods and instruments, analysed deductively and inductively, and narrated critically to maintain coherence, and convey experiential and temporal dimensions. The study outcomes indicate that teachers in Palestine are capable of leading school improvement, and impacting school structures and professional culture for system-wide change, when the proper support is provided. Non-positional teacher leadership is the vehicle and can be developed through Teachers Leading the Way. At the individual level, this is enabled through a transformation in teachers’ perspective towards a self-empowered, agential mindset that leads to action on ways to improve practice. The transition process underscores the role of effective facilitation as an enabling condition for developing non-positional teacher leadership in Palestine and similar settings.

The focus of this study was to investigate the employment difficulties faced by individuals who had been retrenched from the insurance industry during the years 2000 to 2013 in order to develop an understanding of the continuity in the specialist type of work after their retrenchment. The study also aimed to investigate the actual and perceived barriers that need to be addressed in the South African small business environment and the specific soft skills and business skills of small business owners and non-small business owners. The research design of this exploratory study entailed a positivist research philosophy using a deductive research approach. This quantitative research was conducted by means of a survey questionnaire. A questionnaire was designed and used to determine the level of importance and the level of own skills for small business owners and non-small business owners respectively in terms of predetermined soft and business management skills. The answers provided on these questions were then analysed to determine whether there was a gap between the level of importance assigned to these skills and their own skill ratings. This research determined the barriers faced by small businesses in South Africa as well as the level of agreement regarding the predetermined actual and perceived barriers pertaining to the small business environment. Notable findings of this study include that there was a distinct lack of continuity in the specialist type of work by the small business owner respondents in the insurance industry. There was a marked difference between the level of portance and own skill ratings assigned to the predetermined soft skills and business management skills with non-small business owner respondents mostly rating themselves as better skilled than small business owners did. However, the fact that these non-small business owner respondents did not start their own small businesses points towards higher risk aversion. This study also found that small businesses in South Africa are facing pronounced barriers within the small business environment. / Business Management / M. Com. (Business Management)

Change in today’s business environment may be seen as inevitable however in the absence of a generic and endemic Change Framework for Managing and Leading Change; South African businesses face a difficult task of surviving into the future unless they are able to find an Organisational Change Management Approach that will assist them in navigating the Organisational Change Landscape for the 21st Century. This study provides an exploratory approach to understanding the nature of Organisational Change Management in South Africa, by exploring the following key concepts: (1) An understanding of the nature of Organisational Change Management in South Africa (2) The Critical Success Factors needed for Organisational Change Management to succeed in South Africa (3) The provision of a practical Organisational Change Management Framework and Scorecard for the measurement of Organisational Change Management processes and initiatives (4) Recommendations towards a Organisational Change Management Scorecard The study which is largely qualitative in nature makes use of a multiple case study design methodology for the collection of empirical evidence as well as quantitative research data from a survey questionnaire to support the underlying constructs and research questions posed within the study. The use of data and methodological triangulation, namely research interviews, survey data, company and archival documentation as well as focus group discussion points has provided the research study with the necessary validity and reliability to support research results, findings and recommendations.This information should be utilized by Change Practitioners practicing organisational change within a rapidly transforming environment, where Mergers and Acquisitions are major force for change as it would help to provide the necessary change framework and change scorecard for the management and measurement of organisational change interventions. This study also highlights the Critical Success Factors for change by focusing on the Emotional side (Low impact) and Change Imperatives / Prerequisites (High impact) for the management of organisational change. In addition, the study also provides a first view of some change performance measures in the form of a Change Scorecard, which can be used to assess the overall impact of the current change intervention being implemented. / Graduate School for Business Leadership / DBL