L’incorporation de la responsabilité populationnelle dans la gestion des CSSS

In 2004, the Quebec Government has engaged in a major reorganization of its health system, by creating the Health and Social Services Centers (Centre de santé et de services sociaux-CSSS). In addition to their mandate of delivering care and services, the CSSS gained a mandate of population-based responsibility. The managers of these organizations obtained the mandate to improve the health and well-being of the population living on a specific territory in addition to responding to the users of health care services. This dual responsibility brings managers to articulate more formally two fields of services delivery that have traditionally evolved with few interactions: “public health” and “healthcare”. Incorporating the population-based responsibility to the practice of managers creates a greater synergy between these two fields within an organization that produces health care services. The reform calls for major changes in different areas of activities and management roles. The main objective of our research is to have a better understanding of the change in the CSSS management practices in response to the required population-based responsibility.      We conducted an in-depth longitudinal analysis of two CSSS cases. These cases were selected from the same region, Montréal. The two cases have been chosen according to the variability of their socio-economic context as well as the number and variability of institutions under the governance of CSSS. One case included an acute-care hospital while the other did not. Data collected include real-time observations of top management meetings at the regional and local levels during more than two years (2005-2007), 46 interviews with managers and key stakeholders as well as secondary data (planning documents, organizational charts, minutes of executive board meetings, etc.). We adopted an iterative process based on inductive thinking.    We based our analysis on institutional theory in the theory of organization studies. This perspective is interesting because it allows us to link the organizational fields analyzed (pressures from different healthcare actors) to the roles of actors in the change process. This theory proposes to analyze both the environmental pressures which explain the constraints and opportunities of the actors in the organization field and the pressure created by the CSSS and the local strategic actions they develop.  We discuss the evolution of CSSS by presenting three temporal stages characterized by dynamic interaction between the pressures created by the CSSS as well as those created by the other actors in the organizational field; stage 1 refers to compliance with policies put forward by the Government, stage 2 focuses on the adaptation to suggestions made by different actors in the organizational field and stage 3 corresponds to the development of projects at local level. We show through the process of incorporating population-based responsibility some change in management practices. Some management roles are closer to the entrepreneurship institutional theory being seen as leaders, negotiators and entrepreneurs. Through the process of transforming management roles, important changes happen regarding the actions put in place by CSSS such as the formal organization of primary care services, the development of health promotion and prevention activities and a more active implication in the community.  In conclusion, we discuss findings from incorporating population-based responsibility into a delivery of health care services organization.  We exchange on challenges associated with the development of a greater synergy between public health and healthcare into the same governance structure. Also, we present a synthetic model of the process of implementation of a mandated change into an organization field that is strongly institutionalized. We expand more specifically on the institutional entrepreneur role in that process of change. This situation has been rarely discussed in the literature so far.

Keyphrases: Institutional theory, Institutional entrepreneurship, Population-based responsibility, Public health, Healthcare