Stiofán deBúrca Ph.D . Health Service Executive, Ireland and University of Limerick

1. The Nature of Internal Mediator and Moderator Influences in a Health Care System in TransitionEHMA – Barcelona, June 2005 Stiofán deBúrca Ph.D. Health Service Executive, Ireland and University of Limerick

2. Background: • Embedded levels in a change context. • Inherited internal influences e.g., culture, style, strategy, structure, previous change/innovation. Literature: Policy, Systems, Theoretical Perspectives e.g., • Leadership approaches and change models. • Domains in tension, professional and managerial bureaucracies. Methodology/Methods: Case Study – Grounded Theory • Pluralist – methods, participants, settings. • Analytic Text – categories and paradigm analysis

3. Mediators and Moderators: Mediators • Inclusive concepts which encompass agents, agency, artifacts, ideas and social influence processes. (i) Influences: purpose, roles, leadership. (ii) People: relationships, ownership, capability, capacity. (iii) Operational System: structure, service management practices. • Define relationships which connect the organisation and people to the overall objective of activity. Moderators • Moderators, as intervening and situational variables, modify and affect mediators/mediation. • Moderators as systemic and/or substantive or intrinsic factors which affect mediator influence e.g., limitations, variations, substitutes and environments.

4. Potential and Experiential Change - Illustration Mediator Influence: • Purpose of Change: (i) Propensity: dependent on a shared purpose and enabling objectives (a) Population dimension – corporate. (b) Quality of care – managers and professionals. (ii) Actual: (a) Not tangible in Corporate roles (b) Explicit in roles of Managers – system, process. Professionals – practice.

5. Leadership: (i) Propensity : a shared objective linked to new ideology Managers - transparent, accountable organisation. Professionals - corporate exemplars and leadership skills. * Concept as: corporate accountability, clinical responsibility and professional influence on morale and practice. * Prototypes: Managers – leadership and change. Professionals – attractor/influencer. (ii) Actual: senior managers and change leadership Professional and domain leadership. • Style: (i) Propensity: Corporate level variety + (ii) Actual: Positive and empowering + Autocratic -

6. Mediating Change Through People • Relationships: (i) Propensity: Managers - wanted quality linkages and leaders with strong relational attributes. Professionals - wanted credible engaging leaders and relationships based on trust and mutual obligation. (ii) Actual: Managers - problems in linkages and mutual understanding! Professionals - relationship with management and inter/intra disciplinary tensions. Outcome: Positive indications through managers and professionals reciprocal engagement and, stakeholder participation and professional involvement. Positive relationships in smaller hospitals, MHS and Elderly Care.

7. Mediating Change Through the Operational System. • Structure: (i)Propensity: too hierarchical in acute or too loose in community care. MHS – flat and integrated with MDTs. Managers – separate strategic and operational. Professional – wanted clear lines of accountability for others. (ii) Actual: managers restructured the organisation with professionals’ input. Outcome: Managers – care group management and decentralised line and functional management. Professionals – good awareness, participation and integrated management.

8. An Emergent Model of Internal Mediators and Moderators Contexts Antecedents Interventions Outcomes Mediators influences Mediation People Operational system Issues Responses Actions Reactions Outcomes Change Indicators External + Internal Inherited + Moderators Intervening, Situational.