• Nem Talált Eredményt

Conditions of managing sustainable change in Hungarian health care organisations

N/A
N/A
Protected

Academic year: 2024

Ossza meg "Conditions of managing sustainable change in Hungarian health care organisations"

Copied!
23
0
0

Teljes szövegt

(1)

PhD Theses

Dr. Miklós Szócska

Semmelweis University

Mental Health Sciences School of PhD Studies

Supervisor: Professor Mária Kopp

Opponents: Dr. Gyula Bakacsi

Dr. Ágnes Dósa Chair of thesis committee: Dr. Péter Sótonyi Members of thesis committee: Dr. Miklós Dobák

Dr. Imre Boncz Dr. Zoltán Nagy Dr. Gábor Pörzse

Budapest

2008.

(2)

TABLE OF CONTENT

1. INTRODUCTION – MOTIVATION FOR THE RESEARCH ... 3

2. OBJECTIVES, RESEACH QUESTIONS ... 4

3. LITERATURE REVIEW ... 5

4. RESEARCH METHODS ... 6

4.1. QUALITATIVE RESEARCH METHODS... 7

4.2. QUANTITATIVE RESEARCH METHODS... 8

5. RESULTS... 8

6. DISCUSSION, EVALUATION OF RESULTS ... 9

6.1. CLASSIFICATION OF MANAGERIAL CONSTRAINTS AND CAUSES FOR RESISTANCE... 10

6.2. MAJOR FINDINGS... 10

6.3. THE PERVERTED HEALTH POLICY CYCLE... 11

6.4. CONDITIONS OF MANAGING SUSTAINABLE CHANGE, CHANGE MANAGEMENT RECOMMENDATIONS... 12

6.4.1. first condition: Leaders of the change project know where they are going... 13

6.4.2. Second condition: the core of achieving change is Communicating, and establishing a Shared vision of the future state... 14

6.4.3. Third condition: Appropriate change infrastructure is available for implementation, or necessary developments are outlined if they are missing... 15

6.4.4. fourth condition: Incentives are well tailored towards the desired future state and/or a critical mass of people is involved, willing and capable to work towards change ... 15

6.4.5. fifth condition: There is consistency in implementation ... 15

6.4.6. sixth condition: The change manager has personal change management competencies, experience of implementing change and credibility among the employees, and this is maintained throughout the change process... 16

6.4.7. seventh condition: Resistance to change is managed by involvement and communication ... 17

6.4.8. the relation of Health policy and management of change... 17

6.4.9. summary ... 18

6.5. PRACTICAL UTILISATION OF FINDINGS, MAIN FURTHER RESEARCH TOPICS... 18

6.6. CLOSING REMARKS... 19

7. PUBLICATIONS RELATED TO THE PHD THESIS... 20

8. ACKNOWLEDGMENTS... 23

(3)

1. INTRODUCTION MOTIVATION FOR THE RESEARCH

Recent generations had exceptional historic experiences to live through the social changes of the last decades. Due to the frequent and deep changes in the environment, Hungarian health services organisations lived their life under constant adaptational challenges. Besides having difficulties in responding to those challenges, the members of organisations wanted to see the democratisation to happen not only in society in general, but in organisational life as well. These experiences motivated me and my colleagues to develop change management programmes and develop change management methodologies to support the sustainability of ongoing change efforts and the social reform process. We were convinced that to complete the social reforms we have to democratise organisational and management culture in public organisations as well. This conviction was supported by evidences from organisational studies, showing that taking the human dimensions of organisations into account can be a contribution to improved organisational efficiency.

We gained experiences with organisational change in our change management and management development programmes for hospital managers and hospitals. We could observe, follow and analyse numerous change projects carried out with the Beckhard- Harris change model. We had the opportunity to support and observe more than 500 change projects. We have achieved striking successes with building hospital teams, motivating people towards change, raising the commitment of clinical managers towards change and the decentralisation of managerial responsibilities during change.

On the other hand we faced the challenge of high failure rate of change projects and that raised my motivation to improve the efficiency of change projects. We have identified three major factors that contributed to change failures. Through the exploration and reduction of these factors we could raise the sustainability of change efforts:

1. On the first place we have to list the inexperience of managers.

2. The second is the managerial constraints (mistakes).

3. The third is the organisational resistance towards change.

These observations and experiences led me to the selection of my thesis topic. To explore these areas I set up the method and plan of my research. In the thesis I introduce the objectives of the research, the methodologies, the results and discuss the critical conditions of sustainable change that were defined on the analysis of managerial constraints and causes for organisational resistance.

(4)

The study offers the analysis of change from a behavioural approach and aims to improve the efficiency and sustainability of change efforts through the development of the practice of change management.

2. OBJECTIVES, RESEACH QUESTIONS

The selected managerial constraints and causes of organisational resistance during change can be interpreted as critical success factors in the management of change.

These two critical factors can be influenced primarily in order to improve the efficiency of change. There are popular models and sets of recommendations in the field of change management. However, it is striking how poor resources are available in the systemic analysis of managerial constraints and causes for organisational resistance.

The Hungarian literature resources of this topic were nonexistent. In respect of the managerial constraints and causes for organisational resistance we set up the following research questions:

1. In the field of managerial constraints during change: What managerial constraints during change can be identified in Hungarian health care organisations? How could we classify these managerial constraints according to the various phases of change? Which are the critical managerial constraints according to their importance and frequency of occurrence?

2. In the field of causes for organisational resistance during change: What causes for organisational resistance can be identified in Hungarian health care organisations?

How could we classify these causes for resistance according to the various phases of change? Which are the critical causes for resistance according to their importance and frequency of occurrence?

3. Based on these results what change management model could be elaborated, that is valid to public and health care organisations and what change management conditions or/and recommendations could be set up?

From the research questions it is obvious that the study intended to be an explorative research, thus we did not set up research hypotheses. On the other hand, the research questions outlined the research objectives. According the questions three major objectives were formulated one of which has been modified during the course of the study:

1. Identification of managerial constraints during change, valid in the Hungarian organisational milieu. Classification of the managerial constraints according to the various phases of change. Identification of the critical managerial constraints according to their importance in change failures and frequency of occurrence.

(5)

2. Identification of causes for organisational resistance during change, valid in the Hungarian organisational milieu. Classification of the causes for organisational resistance according to the various phases of change. Identification of the critical causes for organisational resistance according to their importance in change failures and frequency of occurrence.

3. Elaboration of a change management model valid to Hungarian health and public organisations in order to support efficient and sustainable change. This objective was modified along the study to the following: elaboration of change management criteria and sustainability recommendations to Hungarian health and public organisations in order to support efficient and sustainable change. These recommendations could form the basis of elaborating a more comprehensive change methodology in the future.

To be able to avoid change failures, it is imperative to set up the collected list of managerial constraints and causes for organisational resistance during change and valid to the Hungarian organisational milieu.

At the beginning the study targeted the elaboration of a change management model based on the Beckhard-Harris model. During the course of the study our approach was modified based on the experiences. These showed that it is better to avoid a prescriptive approach and favour a sustainability condition approach. Instead of prescribing steps and activities during change it is more appropriate to define recommendations and conditions based on managerial constraints and causes for organisational resistance that have to be met to improve the sustainability of change. These conditions, however, do not represent a comprehensive or exclusive system of conditions.

3. LITERATURE REVIEW

The theory and practice of change management is built on the achievements of management and organisational studies, and represents an integrated approach on a multidisciplinary field. My literature review was a targeted effort to explore the principles and various models of change management, and was carried out reviewing comprehensive studies. I carried out an empirical search in the field of managerial constraints and organisational resistance during change. During the literature review we:

• Studied and proved the current significance of the selection of the thesis topic.

The identification of managerial constraints and causes for organisational resistance (specific to the Hungarian organisational culture) is a critical factor to

(6)

the improvement of efficiency of change projects in the Hungarian health care.

This results the creation of knew knowledge;

• Identified existing change models and placed the used Beckhard-Harris model and our modifications on the methodological spectrum of change management studies;

• Studied already existing research on the fields of managerial constraints and causes for organisational resistance during change. This study contributed to the setup of our list of constraints and causes of resistance.

4. RESEARCH METHODS

The overview chart of research methods demonstrate the applied methodologies according to research objectives and expected results. According to the complex nature of the examined change processes we applied a broad spectrum of qualitative and quantitative methodologies.

The background of the research was provided by the various change management training programmes of the Health Services Management Training Centre: the hospital oriented change management programme and the open programmes for hospital teams and individual managers. As part of the complex process of these programmes we could examine the research questions. The change projects, that formed the basis for analysis, the list of managerial constraints and causes for organisational resistance were initiated, planned and implemented by the participants in the frame of these programmes.

(7)

Overview chart of research methods according to the research objectives of the study.

Methods

Hospital change management programme Change management programmes

Brainstorming Change projects

Focus-group

Questionnaire

List of managerial constraints

List of causes for resistance

Major constraints Major causes

Critical change conditions

Results

4.1. Qualitative research methods

In the first explorative phase of the research we applied three qualitative research methods: document analysis of the change project documents elaborated in the various change management programmes; and group techniques brainstorming and focus groups.

The selection of the sample was targeted in all of the programmes for health care institutions, and the individual change management programme participants were delegated participants involved in change projects. The study was not carried out on a representative sample as my intention – from the start – was to carry our explorative- inductive method research. This way I wanted to reach so far unexplored areas that could clarify culturally specific conditions of efficient change and/or could clarify the cultural background of managerial constraints and causes for organisational resistance during change.

(8)

4.2. Quantitative research methods

In the second phase of the research we used questionnaires to gain insight in the frequency of occurrence and importance of managerial constraints and causes for organisational resistance during change. The elaboration of questionnaires was carried out through the synthetization of different methodologies.

The sample to answer the questionnaire was selected from experienced managers (5+

years in practice) who have already took part in a reasonable management education programme and either led or took part in change projects at least as middle managers in health care organisations.

The 100 member sample contained mid and top level managers, with different level of management education. On the other hand they were all well informed about the general knowledge of change management aspects. The filling of the questionnaires happen either by personal participation or through mail response. We have received 92 responses that were used for further analysis. In the results we analysed the basic frequency of occurrence and importance considerations.

5. RESULTS

According to the complex methodologies we have achieved results on various levels.

To interpret the results we have to separate the results based on qualitative and the following quantitative research phases. The list of managerial constraints and causes for organisational resistance are results themselves, and were developed through literature and document review and interaction with top and middle managers. The list itself can be used for change management and management development, managerial skills and personality development and self-learning purposes.

In the quantitative phase we received quantitative results on the importance and frequency of occurrence of the managerial constraints and causes for organisational resistance items on the lists. The quantitative results generally support the items on the list and in some cases as a negative or positive result they make the lists more accurate.

The positive and negative results offer interesting insights into the culturally specific aspects of managerial work during change.1

1 The lists of managerial constraints and causes for organisational resistance, the summary table of the results and the questionnaires used in the study are not quoted in this short thesis document due to volume limitations. In this short thesis document the discussion part refers to the major constraints or causes in respect of the critical change management conditions or recommendations.

(9)

1. The list of managerial constraints during change: The list, compiled during the qualitative phase of the study contains 48 managerial constraints.

2. The list of major managerial constraints: out of the 48 constraints of the original list 18 was identified as major by the respondents of the questionnaire phase. We considered a constraint major if at least 50% of the respondents rated the constraint as major according to their importance and/or frequency of occurrence. We also considered a constraint major, if they emerged from the average by their unimportance or rarity.

3. The list of causes for organisational resistance during change: The list, compiled during the qualitative phase of the study contains 29 causes for organisational resistance.

4. The list of major causes for organisational resistance: out of the 29 causes of the original list 8 was identified as major by the respondents of the questionnaire phase. We considered a cause major if at least 50% of the respondents rated the cause as major according to their importance and/or frequency of occurrence. We also considered a cause major, if they emerged from the average by their unimportance or rarity.

5. The description of the perverted policy cycle

I was able to describe the perverted policy cycle as a side product of the study on change projects.

6. DISCUSSION, EVALUATION OF RESULTS

The first two objectives of the research were to set up the list of managerial constraints and causes for organisational resistance during change. The list of constraints contains 48 while the list of causes contains 29 items. The study, in many respects, confirms earlier general results on constraints and resistance in the literature. On the other hand, as the study was directed towards change in health care organisations where there were no specific studies carried out on the major topics, the result generated new knowledge, especially in the newly identified causes or constraints and the culturally specific aspects of the management of change.

(10)

6.1. Classification of managerial constraints and causes for resistance

The managerial constraints and causes for organisational resistance outline some characteristic thematic focal points. The major constraints can be linked to the following thematic focal points:

1. Managerial duties in respect of the planning and initiating of change projects – organisational vision, problem definition, setting goals and the size of the change project, formulating strategy.

2. Personal characteristics of managers – setting personal examples, authenticity, education, commitment, consistency.

3. Interpersonal relations, division of work – communication, task performance strategies, delegation of responsibilities, shaping personal responsibilities.

4. Implementation issues – administrative capacities, policies.

5. Managing incentives and interest systems.

The major causes can be linked to the following thematic focal points:

1. Communication – lack of information or disturbance of communication on the future state of change and in respect of the actual change project. In close relation with:

2. involving employees and

3. Setting incentives – incentivising change with financial benefits and management of the interest system.

6.2. Major findings

Lack of information related to the future state of change as the major cause for triggering organisational resistance:

This finding represents the most important finding of the questionnaire and the whole study in general. According to the respondents’ perception this cause is the most significant resistance triggering factor, more important than the status quo defence mechanisms. This finding has a fundamental impact on the nature of managerial duties during change and our understanding of the dynamics of managing change. On one hand the finding proves that the natural status quo defence is not an ultimate objection

(11)

towards change. On the other hand it proves Lewin’s (experiential) recommendation to ensure psychological safety during change.

My finding suggests that the best way to ensure safety relies on our knowledge of the future state. Thus, change managers primary duty during change is not to maintain stability, but to plan and communicate future state to decrease uncertainty.

We have integrated these results in our Hungarian and international change management teaching programmes and participant feedback and observation of change projects also proves the validity of the finding.

Top management exercises increased direct involvement in implementing change projects:

The respondents classified as rarity the managerial constraint referring on top management’s missing direct involvement in implementation of change. The increased direct involvement of top management in implementation is a positive development in management and organisational culture.

Improved collaboration of professional groups, financial incentives:

Two negative findings of the causes for organisational resistance refer on recent positive developments. The cause referring on the refusal of non-doctor managers in health care organisations was rated unimportant by the respondents. This shows that acceptance of the various professionals and their cooperation in the health care has improved in recent years. We hope that further improvements of cross-professional cooperation will contribute to the further development of health services organisations and rule out the traditional and counter productive in-breeding.

Another negative finding shows the high importance of financial incentives in setting the change directions in health care organisations. With remembering the well known limitations of this tool, Hungarian change managers in health services organisations have to consider the importance of this material factor when planning and managing change projects.

6.3. The perverted health policy cycle

The starting point of perverted policy cycle is similar to the solution driven managerial constraint, when the managers of reforms (policy makers) force system level solutions under environmental pressure without problem based considerations. On one hand we could observe a cyclic dynamics in the policy environment of health care organisations.

(12)

On the other, we could also observe the impact of this cycle in the follow up of change management projects in health care organisations that were initiated as an adaptation response to the environmental changes. We could observe a similar cyclic pattern in institutions where the management was constantly changed according to changes of leaders on the national level. Since the 17 years from the system change Hungary had 11 ministers of health (and welfare) spending less than 1.5 years in office. This gave a fundamental change dynamics to a complex system. Through the steps of the policy cycle we could observe features similar to the managerial constraints and causes for organisational resistance during organisational change. The description of ideology based, solution driven reform methodology could be utilised for evaluating and forecasting the sustainability of reforms, and for health policy analysis in general. The correction of the perverted policy cycle can only be built on targeted managerial interventions, that are similar and built on the sustainable change criteria set up on the basis of managerial constraints and causes for organisational resistance.

6.4. Conditions of managing sustainable change, change management recommendations

The third objective of the thesis was to complement the Beckhard-Harris model with recommendations, sustainable change conditions valid to the Hungarian health care organisational milieu. The findings prove the relevance of the Beckhard-Harris model and our research identified typical change failures in the change management practice of Hungarian health care organisations.

In order to correct change management failures due to the lack of education and inexperience of managers I decided to set up critical change management criteria that could directly contribute to the improved sustainability of planning and managing change.

Primarily (but not exclusively) I deducted conditions to improve managerial work from the managerial constraints and primarily (but not exclusively) I deducted conditions to improve communication, teamwork from the causes for organisational resistance. With this complementation the Beckhard-Harris model is more relevant and can be more efficiently utilised in change projects and in supporting managers while planning and managing change.

Interpreting managerial constraints and causes for organisational resistance as “mini cases” allows us to utilise experiences creatively and build recommendations and improved managerial practice and methods on the actual situations.

(13)

6.4.1. FIRST CONDITION: LEADERS OF THE CHANGE PROJECT KNOW WHERE THEY ARE GOING

The H1, H2, H3, H4 and H10 major managerial constraints and E1 and E2 causes for organisational resistance have joint reference on the missing change objectives or the missing definition of the future state of changes. This can result in generating uncertainty or departing from realities. Managers have to exercise efforts to avoid these problems: leaders of change have to know where they are heading. The goals seem to be the most important elements, but some parameters of the goals are at least as important as having clear goals at all:

• Goals and future state of change have to be well defined.

• On the first place goals have to refer on the problem base. Reference on the problem base is critical in achieving an acceptance among followers that might lead to the emergence of a shared vision.

• Change has to have reasonable magnitude or structured to comprehensible components.

H 1. The leader/manager has no exact

organisational vision of the future state of changes.

H 2. The management (managerial board or top management) has no agreed strategy.

H 3. Without analysis the manager forces changes that ignore present realities, the decisions are made on an ad-hoc manner.

H 4. Facing obstacles emerging during the project the manager suddenly gives up his/her organisational vision.

H 10. The manager sets unrealistic goals and objectives, thus the half done project has to be stopped.

E 1. Lack of information related to the actual change project.

E 2. General uncertainty about the future state.

Who will do what and how?

(14)

6.4.2. SECOND CONDITION: THE CORE OF ACHIEVING CHANGE IS

COMMUNICATING, AND ESTABLISHING A SHARED VISION OF THE FUTURE STATE

The H2, H33, H45 and H46 major managerial constraints and E1, E2, E26 and E29 causes for organisational resistance have joint reference on the missing or defective communication of change goals and the future state of changes. Managers have to exercise efforts to avoid these problems: the backbone of change is communication and establishing a shared vision on the future of the organisation and the future state of change. This condition consist three elements:

• It is critically important that the leader or manager of change should properly

communicate the

organisational vision and its aspects should be well understood along the lines of organisational hierarchy.

• During change managers have to provide formal channels of communication and/or the organisation should have a natural holding environment for authentic forms of interpersonal communication.

• Communication should deal not only with the vision and objectives but refer on the change process and delegation as well.

• Communicating the vision and objectives through involvement change managers have to develop ownership of the project by those who are responsible for the implementation.

H 2. The management (managerial board or top management) has no agreed strategy.

H 33. The manager does not clarify and does make the change objectives understandable for employees. Disturbed and noisy communication.

H 45. The manager does not establish formal channels of communication in the organisation that could support the change project.

H 46. The manager does not take steps to clarify changing roles and responsibilities.

E 1. Lack of information related to the actual change project.

E 2. General uncertainty about the future state.

Who will do what and how?

E 26. Those expected to implement the changes are not involved in the decisions and the preparation of decisions.

E 29. A hectic, contradictory and disturbed top- down communication leads to repeated misunderstandings, thus management looses its credibility among employees.

(15)

6.4.3. THIRD CONDITION: APPROPRIATE CHANGE INFRASTRUCTURE IS AVAILABLE FOR IMPLEMENTATION, OR NECESSARY DEVELOPMENTS ARE OUTLINED IF THEY ARE MISSING

The H45, H47 and H48 major managerial constraints and the E29 cause for organisational resistance - have joint reference on missing administrative capacities necessary for implementing change.

Managers have to exercise efforts to avoid these problems: appropriate change infrastructure (personal, organisational, infrastructure) should be available or if not, the leader of change has determined concept to develop such infrastructure.

6.4.4. FOURTH CONDITION: INCENTIVES ARE WELL TAILORED TOWARDS THE DESIRED FUTURE STATE AND/OR A CRITICAL MASS OF PEOPLE IS INVOLVED, WILLING AND CAPABLE TO WORK TOWARDS CHANGE

The H12 and H22 major managerial constraints and the E13 and E20 cause for organisational resistance - have joint reference on contradictory or missing incentives or incentive systems necessary for the support of the implementation of change. These form the basis for the fourth condition or recommendation.

H 12. The manager does not take organisational resistance into consideration. Thus he/she repeatedly looses initiatives on resistance from employees or other stakeholders.

H 22. The manager is bounded by his/her personal interests and leaves the previous system’s authoritarian and hierarchical relationships unchanged.

E 13. The interest system in the organisation is mainly dominated by private and group interests that are antagonistic to the organisation’s and employees’.

E 20. Lack of financial incentives supporting the changes.

6.4.5. FIFTH CONDITION: THERE IS CONSISTENCY IN IMPLEMENTATION

The H4, H42 and H48 major managerial constraints and the E29 cause for organisational resistance - have joint reference on the missing commitment and consistency in implementation and communication. These formed the basis for the fifth condition or recommendation.

H 45. The manager does not establish formal channels of communication in the organisation that could support the change project.

H 47. The manager does not establish relevant administrative capacities (personnel, infrastructure etc.) to implement changes.

H 48. There are no plans and procedures prepared for the change so there is no systematic implementation of the project.

E 29. A hectic, contradictory and disturbed top- down communication leads to repeated misunderstandings, thus management looses its credibility among employees.

(16)

H 4. Facing obstacles emerging during the project the manager suddenly gives up his/her organisational vision.

H 42. There are no task performance strategies in the organisation. Tasks are performed on a casual way.

H 48. There are no plans and procedures prepared for the change so there is no systematic implementation of the project.

E 29. A hectic, contradictory and disturbed top-down communication leads to repeated misunderstandings, thus management looses its credibility among employees.

6.4.6. SIXTH CONDITION: THE CHANGE MANAGER HAS PERSONAL CHANGE MANAGEMENT COMPETENCIES, EXPERIENCE OF IMPLEMENTING CHANGE AND CREDIBILITY AMONG THE EMPLOYEES, AND THIS IS MAINTAINED THROUGHOUT THE CHANGE PROCESS

The H11, H 18, H31 and H45 major managerial constraints and the E29 cause for organisational resistance - have joint reference on missing change management competencies and skills. On the basis of these failures we set up the sixth critical success condition that is related to the personality and characteristic of the change manager: the change manager has to have change management competencies and experiences. He/She has to be an authentic person in the eyes of the followers and his credibility should be deliberately maintained throughout the change process.

H 11. The manager does not consider the risks during change and forgets to set up contingencies and alternative actions.

H 18. The manager has no training and attitude relevant to the needs of the change project and he/she does not have learning strategies.

H 31. The manager has no, or has not built up his/her personal credibility. His/her words have no weight for the employees.

H 42. There are no task performance strategies in the organisation. Tasks are performed on a casual way.

H 45. The manager does not establish formal channels of communication in the organisation that could support the change project.

E 29. A hectic, contradictory and disturbed top- down communication leads to repeated misunderstandings, thus management looses its credibility among employees.

(17)

6.4.7. SEVENTH CONDITION: RESISTANCE TO CHANGE IS MANAGED BY INVOLVEMENT AND COMMUNICATION

The seventh condition is deducted from major managerial constraint H12 and cause for organisational resistance E26. These have joint reference on the way organisational resistance is managed during

change. Experiences with reform and change failures show that to overcome resistance is a difficult, risky, expensive process, so the best strategy against is prevention.

Prevention also determines the magnitude of resistance. To define clear and engaging change goals, to involve people to develop ownership about the programme, the communication of future state in practical and down to earth way is the recipe for managing resistance. Resistance is as natural part of change as smoke of fire, sometimes even against the best possible preventive measures. It is impossible to deny, but necessary to perceive, diagnose its causes and implement interventions of communication and involvement.

6.4.8. THE RELATION OF HEALTH POLICY AND MANAGEMENT OF CHANGE The analysis of managerial constraints and causes for organisational resistance during change helps health policy or senior level decision makers to understand the complex sustainability conditions of policy reform or change interventions. On one hand it helps them to elaborate reform programmes responding to sustainability conditions. On the other hand, and given that reforms could only be realised through the organised actions of involved organisations the analysis helps them to understand the realities of organisational adaptation. This approach is critical to the sustainability of health reforms.

Given that health reforms generate a need for adaptational change efforts in organisations so the criteria should also be taken into account when determining the feasibility of the reforms. Though the basic natures of policy development and organisational management have obvious distinctive characters, the feasibility aspects of implementation of the reforms create a strong relationship between the two. The above criteria have to be addressed on both sides of the interventions. This requires policy makers to integrate these realities into their strategic thinking. They have to recognise organisational realities during implementation to increase the feasibility of their reforms. Just like organisational managers have to know that they need relevant administrative capacities to fulfil their objectives, policy makers have to be aware of the

H 12. The manager does not take organisational resistance into consideration. Thus he/she repeatedly looses initiatives on resistance from employees or other stakeholders.

E 26. Those expected to implement the changes are not involved in the decisions and the preparation of decisions.

(18)

existence or non-existence of these capacities on the macro level. The incorrect or missing perception of organisational realities can ruin even the most relevant reform efforts and can have damaging impact in the sector or even on national level as well.

The similarities between reform and organisational change failures demonstrate that policy makers should take into account the feasibility and sustainability considerations and process criteria of organisational change when planning and implementing reform programmes.

6.4.9. SUMMARY

Planning and running complex reform and change projects requires complex thinking in probabilities, contingencies and variability. The change management conditions, or recommendations cannot be considered as exclusive and comprehensive set of criteria or prescriptive model of change management. The recommendations help managers and policy makers to build their change efforts on critical sustainability criteria.

The criteria look very simple and for the first sight we can say we arrived to conclusions that are not revolutionary statements, already well known in the management literature for decades, even though their validity was not directly researched in Hungarian health and public organisations. Giving a more thorough consideration of the meaning of the criteria and their close reference on the policy cycle exercised by health policy makers we can set up statements of more fundamental consequences.

The importance of our approach lies in the close relationship between the experiences with the perverted policy cycle and the feasible change criteria. Though the nature of policy planning and implementation and organisational management is different, these criteria have to be addressed on both sides of the system. The sustainability criteria of reforms and organisational adaptation closely interlink the so far distinctly evaluated activities. We can improve the sustainability of organisational change and the correction of the perverted policy cycle can be achieved through leadership actions of similar nature.

6.5. Practical utilisation of findings, main further research topics

The findings serve various practical purposes. I received the first positive feed back on the practical utilisation of my work during the administration of the questionnaires when the respondants requested empty questionnaires for self study purposes. This experience demonstrated an important practical utilisation opportunity. The list of managerial constriants and causes for organisational resistanace during change could be

(19)

used as a personal management development tool. They can be used for personal and skill development purposes as well.

The recognition of organisational realities and the perverted policy cycle were important steps in improving the change management methodology of health reforms.

The conditions established on the basis of managerial constraints and causes for organisational resistance can be utilised the development of health policy and policy reforms, the evaluation and forecasting of sustainability of reforms either in the planning or implementation phase.

The thesis referred on the correct translation of the term change management to Hungarian. I suggest that instead of the passive “változásvezetés” we should use in professional terms the active form “változtatásvezetés”. This way the thesis will influence the terminology of Hungarian management professionals.

Main further research topics:

1. Identification of training needs. The lists of managerial constraints and causes for organisational resistance can directly be utilised for training need identification research and for the development of management training and development programmes.

2. The lists of managerial constraints and causes for organisational resistance can be utilised for diagnostic purposes as well. On one hand it can be used to diagnose the interdependent constraints, on the other hand it can be utilised to diagnose a personal change management constraint profile (that is possibly related to the type of personality involved).

3. Diagnosing and follow up of the environment of organisations and the adaptational capacities of organisations.

4. Evaluating feasibility, sustainability, efficiency of and the dynamics of performance during the change process.

5. Comparative change management research in Central and Eastern Europe.

6.6. Closing remarks

In my thesis I have identified and introduced the major causes of change failures in Hungarian health care organisations. Based on the change failures I set up change management conditions (recommendations), valid to the Hungarian organisational milieu, that contribute to the planning and management of sustainable change.

Though my work was concentrating on the correction of change failures, still, it is dealing with the management development issues from the negative perspective of

(20)

managerial mistakes and organisational resistance. The main explanation of this approach is of practical nature. I wanted to offer direct help to organisational managers who, many times, have to lead change without previous management or change experience and the radicalised culture hardly tolerates any mistake. Learning from change failures and the mistakes of their predecessors could offer them quick practical development opportunity.

Our problem based change conditions, built on the Beckhard-Harris model, represent a breakthrough opportunity for the improved sustainability and efficiency of change projects and the change process. My conviction is that we can only achieve these results through enlighted managerial culture and among democratic organisational conditions (civilised team culture, managerial assumptions focus on involvement, personal excellence, and responsible autonomy). These conditions are key to maintain and develop the self respect of the members of the organisation and not to torture them.

This is also a fundamental condition of renewing health care as public service in Hungary.

7. PUBLICATIONS RELATED TO THE PHD THESIS

In peer reviewed international scientific journals:

1. Gaal P., Belli P.C., McKee M., Szócska M. (2006): Informal payments for health care: Definitions, distinctions, and dilemmas. Journal of Health Politics, Policy and Law, 31 (2): 251-293.

2. Szócska M.K, Réthelyi, J.M, Normand, C. (2005): Managing healthcare reform in Hungary: Challenges and opportunities. British Medical Journal, 331 (7510):

231-233.

In international journals:

3. Miksovits E, Réthelyi J, Szócska M (2001): Coping with environmental change:

the hospital perspective in Hungary. Eurohealth, 7(3) :26-28.

In peer revied Hungarian journals:

4. Belicza É., Balogh Á., Szócska M. (2001): A kórházi ellátás minőségi indikátorai:

az akut myocardialis infarctus kezelésének értékelése. Orvosi Hetilap, 142(21):

1103-1109.

5. Szócska M. (1999): Változásmenedzsment. Egészségügyi Gazdasági Szemle, 37(4): 414-420.

(21)

Major publications in non peer reviewed Hungarian periodicals:

6. Szócska M. (1999): Tájékoztatásról és meggyőzésről vezetőknek. Kórház, 6(5):

39-43.

7. Szócska M. (1999): Változtatás-menedzsment, mint az érdekek integrálásának eszköze. Kórház, 6(3): 26-29.

International teaching notes:

8. Szócska M. Hagovská A.: Základy manažmentu v zdravotníckych zariadeniach [The fundaments of health care management]. Bratislava, Budapest: Ministerstvo Zdravotníctva Slovenskej Republiky, 2006.

9. PhDr. A. Hagoska, Ing. Iveta Orbánova MUDr. Szócska M. Manazment zmety:

Princípy a Prax [The principals and practice of change management], Bratislava- Budapest: Ministerstvo Zdravotníctva Slovenskej Republiky 2006.

Textbook chapter in Hungarian:

10. Szócska M.: A menedzsment alapjai. in Kékes E. et al. (szerk.): Egészségügyi informatika. Budapest, Medicina, 2000.

Major international and Hungarian presentations in the topic of the PhD thesis:

On the Annual Conferences of the European Healthcare Management Association:

11. Szócska M.: „Is there future or just destiny” – summary of experiences with management development programmes in hospitals. 1996. Cascais, Portugal 12. Szócska M.: case study presentation: „From public to private – A case study of

the Hungarian National Health Insurance Fund” 1999. Parma, Italy 13. Szócska M.: „Skip mistakes and avoid resistance” 2001. Granada, Spain

14. Szócska M.: 2006. Budapest, keynote-speech: „Entrepreneurship in the Hungarian Health Services: Is it for our salvation or damnation?”

On the Annual Conferences of the Hungarian Hospital Association

15. Szócska M. presentation: „Változtatás-menedzsment mint az érdekek integrálásának eszköze” 1999.

16. Szócska M. presentation: „Társaságiforma-váltás és intézményi átalakulási tervek” 2002.

(22)

Other presentations:

17. Szócska M. Vevők és folyamatok a középpontban, előadás: „Szűkös források és pazarlás az egészségügyben”. 1999. XI. Budapesti Controlling Fórum

18. Szócska M. presentation: „Rajzold le a szervezeted – szervezetábrázolások ürügyén a magyar egészségügyi szervezetek néhány jellegzetes problémájáról”.

1999. VI. Magyarországi Egészségügyi Napok, Egészségügyi Gazdasági Vezetők Egyesülete,

19. Szócska M. invited speaker: "A Változtatás-menedzsment alkalmazásának lehetőségei a minőségügyi rendszerek fejlesztésében".2000. Minőségfejlesztés a Kórházakban, Minőségügyi rendszerkövetelmények országos konferencia

20. Szócska M. Szervezeti és Klinikai Kiválóság az Egészségügyben az EFQM kiválóság modell alkalmazása az egészségügyben, felkért előadó:

"Szervezetfejlesztési módszerek és az EFQM"2001.

21. Szócska M. analyzing presentation: „Az egészségügy, a fenntartható egészségpolitikai reformok és változtatások feltételeiről” 2002. Merre tovább egészségügy konferencia

22. Szócska M. „Management issues in changing health care institutions” 2004.

Kosovo, Pristina conference on reconstruction

(23)

8. ACKNOWLEDGMENTS

First of all I would like to express my gratitude to those health managers who let me learn from their cases, mistakes or successes. They were all committed to and worked to the benefit for their patients and public services. I hope that in exchange they have received valuable insights and advises from me. I also hope that their contribution to the development of new understandings of the management of change will help further generations of health managers in our future training programmes.

I would also thank my supervisor, Professor Mária Kopp, who ensured the greatest possible flexibility in my programme and supported me to complete my work.

To introduce change management or management development programmes is not a one-man enterprise. Thus I would like to thank my colleagues Dr. John Mitchell, Dr.

Vilmos Ivády and first the core team of our Centre and my present colleagues for their advices, their creative work on programme development and for their help. I owe special thanks to Dr. Péter Gaál, Dr. Katalin Husser, Dr. András Fogarasi, Dr. Tamás Mózes and Dr. János Réthelyi.

I would like to thank my close colleagues for the stimulating helping and working environment of our Centre. Also thank for making my inevitable study leaves possible.

Last but not least I owe sincere thanks for my family to support my work throughout the years and tolerated the burden of studiing the change failures. I share my achievements with them.

Hivatkozások

KAPCSOLÓDÓ DOKUMENTUMOK