La prise de décision stratégique en contexte hospitalier pluraliste

The Lebanese health system is experiencing a chaotic evolution of its health sector, in a world of increasing competition. In addition, in the organization of this system, various groups of actors evolve and influence directly or indirectly the strategic decision-making of the Lebanese healthcare establishments. In a context in which evolves a plurality of actors who are interdependent and pursue divergent objectives, strategic decision-making seems a major challenge. Therefore, the present study aims to understand and analyze the dynamic processes of decisionmakers having an influence on strategic decision-making in a healthcare organization, in a pluralistic context, where various external and internal forces exert an influence on this strategic decision-making. To achieve this, strategic decision-making is analyzed from a power relation’s perspective, starting with the players in the health organization and the context in which they operate. This research proposes a conceptual model based on the general concepts of strategic analysis of Crozier and Friedberg (1977) combined with the garbage can model. The proposed elements of this conceptual framework are relevant for explaining the interaction between the freedom of actors and the power relations that emerge from it, the fortuitous presence of the currents leading to decision-making and the environment in which the actors are immersed which have a major influence on the development of strategic decision-making in a pluralistic healthcare establishment. To meet the objective of this research, we started with a literature review on strategic decisionmaking in a pluralistic context. Then, we used a qualitative approach based on semi-structured interviews and documentary analysis, within two Lebanese hospitals that are representative of the Lebanese hospital basin. This case study made it possible to trace 4 decisions from which the strategic behaviors mobilized by the actors were highlighted. To cite only a few listed strategies, we take the example of strategies of adapting to the environment, involving external actors as well as collaboration and negotiation that take into consideration the turbulent environment in which these establishments are surrounded. The results of this thesis show how the strategies developed by internal and external actors led to the formation of a broad constellation of leadership. This constellation is composed of multiple strategic actors who are in constant interaction, thus influencing the decision-making process through their power relations and strategic plays. Also, the results of this thesis highlight the 7 political decision-making process that takes place in a pluralistic health care organistion, leading to a better understanding of the strategic decision-making process in these establishments. In conclusion, concrete recommendations are made for decision-makers, to better manage health care organisations. In addition, the theoretical encounter developed for the first time in this thesis, makes an interesting contribution to the theories of organizations. Ultimately, the thesis opens the way to promising lines of reflection on strategic decision-making, in a pluralistic context.

Keyphrases: health care institutions, decision-making process, pluralism, strategic actors, power relations, Garbage Can Model, window of opportunity