UNRAVELING THE HELIX OF CHANGE An activity-theoretical study of health care change efforts and their consequences

The study examines change efforts and their consequences in health care in the public sector. The aim of this study is, by providing a new conceptual framework, to widen our understanding of organizational change efforts and their consequences and managerial challenges. Public sector health care is currently pressured with opposing demands such as objectives for fast service production and cost effective care in tandem with requirements for the provision of high quality care. Despite the multiple change efforts, the results of health care development projects have not been very promising, and many developmental needs and managerial challenges exist. The study challenges the predominant, well-framed health care change paradigm and calls for an expanded view to explore the underlying issues and multiplicities of change efforts and their consequences. The study asks what kind of expanded conceptual framework is needed to better understand organizational change as transcending currently dominant oppositions in management thinking, specifically in the field of health care. The study includes a series of explorative case studies of health care change efforts and their consequences. Theory and practice are tightly interconnected in this study. The methodology of the study integrates the ethnography of organizational change, a narrative approach and cultural-historical activity theory, which also provides theoretical tools for analyzing health care change efforts and their consequences. In grounding its conceptual framework, the study introduces the focal literature on organizational change, change management and studies, taking a multi-site, multi-level and multi-logic approach to organizations. From the stance of activity theory, historicity, contradictions, locality and employee participation play significant roles in developing organizations. The empirical data of the dissertation was collected in four public sector health care organizations during the years 2004–2010. By exploring the oppositions between distinct views on organizational change and the multi-site, multi-level and multi-logic of organizational change, the study develops an expanded, multidimensional activity-theoretical framework on organizational change and management thinking. The findings of this study contribute to activity theory and organization studies, and provide information for health care management and practitioners. The study illuminates that continuous development efforts bridged to one another and anchored to collectively created new activity models can lead to significant improvements and organizational learning in health care. Some of the studied change efforts were discontinuous or encapsulated, not benefiting the larger whole. The study shows that the stagnation and unexpected consequences of change efforts relate to the unconnectedness of the different organizational sites, levels and logics. If not dealt with, the unintended consequences such as obstacles, breaks and conflicts may stem promising change and learning processes. The ways of conducting change efforts in organizations play a critical role in the creation of collective new practices and tools and in establishing ownership over them. Breaking hierarchical boundaries, engaging previously distinct parties in designing and analyzing change, and diffusing and bridging successive results across projects, spaces and time are crucial learning challenges for health care organizations. Achieving system-level changes and learning requires the development of shared tools and managerial support. Nurturing the continuity and sustainability of promising new practices, tools and learning becomes a crucial management issue. Achieving profound change in the level of activity requires a long, collective learning process. Due to oppositions to and the complexity and multidimensionality of change, the development of health care practices is slow and demanding. The study shows that the consequences of change efforts often emerge in the long haul. Expansive organizational learning only emerges slowly, a process which may take years. In the development of health care, further connecting of different organizational sites, levels and logics with the aid of system-level interventions focusing on qualitative transformations is needed. This calls for a new expanded vision on health care change from health care practitioners, managers and political decision makers.