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Strategize to Organize or Organize to Strategize? Structuration and

Sensemaking in Newly Formed Organizations1

Jean-Louis Denis2, jean-louis.denis@umontreal.ca,

Lise Lamothe1,

lise.lamothe@umontreal.ca

Ann Langley3, ann.langley@hec.ca

Mylaine Breton1,

Julie Gervais1, Louise-Hélène Trottier1,

Damien Contandriopoulos1, Carl-Ardy Dubois1

February 2008

1 The authors thank the Canadian Institute for Health Research and the Social Sciences and Humanities Research Council of Canada for their financial support of this research. An earlier version of the paper was presented at the European Group for Organization Studies Conference in Vienna, July 2007. 2 Groupe de recherche interdisciplaire en santé et Département d'administration de la santé, Université de Montréal, C.P. 6192 Succursale Centre-Ville, Montréal, Canada H3C 3J7 3HEC Montréal, 3000, chemin de la Côte Sainte-Catherine, Montréal, H3T 2A7

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Strategize to Organize or Organize to Strategize? Structuration and

Sensemaking in Newly Formed Organizations

Abstract Drawing on a longitudinal study of the first two years of implementation of health care networks

in Quebec, this paper describes how public sector managers deal with the complex challenges

faced when both organizational structures and organizational strategies are radically transformed

simultaneously. The new organizations studied had to completely reshuffle roles and

responsibilities of their management teams while making sense of their new mandate to produce

effective practice innovations – all the time maintaining day-to-day operations. The four health

care networks studied proceeded somewhat differently to meet these reciprocal challenges. The

study reveals the importance of balancing structuring initiatives with strategizing initiatives,

developing capacities for sensemaking through the creation of key “sense-maker/ sense-giver”

positions whose occupants are able to ensure that conceptual activities engage people working at

different levels across the organization, and mobilizing external constraints and influences as

opportunities and resources in sensemaking and restructuring.

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Organizational restructuring that radically redefines organizational boundaries and missions and

that creates new organizational entities out of older ones is a topic that has attracted considerable

attention in the study of private sector organizations (Volberda and Lewin 2003; Pettigrew,

Whittington et al. 2003; Child and McGrath 2001). Public organizations in various sectors such

as health and education (Denis, Lamothe, Langley, and Valette 1999; Wallace and Pocklington

2002) face similar pressures for radical restructuring. Such newly formed organizations are

particularly interesting as they engage managers simultaneously in intensive strategizing and

organizing activities whose complexity have often been underestimated. In this paper, we

examine the interplay between formal restructuring and sensemaking in the context of public

organizations, namely newly formed heath care networks in Canada. We explore how

strategizing activities contribute to organizing and inversely how organizing constrains or

enables the development of strategies. More specifically, we analyse how a mandated large-scale

change – the implementation of local health networks in the Quebec health care system – creates

cognitive disorder (Balogun and Johnson 2004) among managers and professionals and

stimulates various patterns of sensemaking and structuring activities.

Conceptual Background

Based on the work of Karl Weick and colleagues on sensemaking in organizations (1979, 1995,

2005), we suggest that attempts to radically transform organizations generate disruptions in

expectations and routines, producing situations of ambiguity among organization members.

Situations of ambiguity can be seen as the engine that drives the emergence of new forms of

organizing (Eisenberg 2006). The ambiguity associated with restructuring will tend to be greater

when change initiatives involve the bridging of various organizations or changes in

organizational boundaries as in a merger.

In a situation of organizational ambiguity, actors will develop various strategies to gain a better

understanding of other actors and organizations, of the nature of their current and future

relationships and of the context of restructuring. Interactions and communications are central to

the strategizing activities of organizational members and may culminate in more convergent

interpretations regarding proper courses of action. The interplay between strategizing activities to

make sense of new contingencies and formal structuring to adapt to new situations needs to be

explored. Recently, Vlaar and colleagues (2006) suggested that formalization may nourish and

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foster sensemaking activities (at least to a certain point) and may help in developing congruence

in strategy in the context of interorganizational relationships.

Our study examines various pathways used by organizations to orchestrate strategizing

(sensemaking) and organizing (structuring) in practice. While investments in sensemaking can

generate rich interpretations of issues and alternative courses of action, they may not always be

conducive to substantive changes. Conversely, investments in formal restructuring may provide

an impression of "being organized" and of achieving change but they may also create rigidity and

block further attempts to bring about changes in strategizing. In addition, rich sensemaking will

be insufficient on its own if sensegiving activities are not performed to spread understandings

beyond a small group (Maitlis and Lawrence 2007; Gioia and Chittipeddi 1993).

Two research questions will be explored in this paper: How do public sector organizations and

managers react and deal with major destabilization and ambiguity? How do they use

sensemaking and organizing activities to balance continuity and strategic innovation? This paper

is based on an analysis of the dynamics involved in the initiation of a process of strategic change

in the health care sector. After summarizing the methodology, we describe the nature of the

change pursued. We then present key aspects of the dynamics of sensemaking and organizing

observed in four case studies of the implementation of Health and Social Services Centres

(HSSCs) and their local networks. As described below, the HSSCs are a new organizational form

created through the merger of existing organizations operating in the same geographical territory.

Methodology

We conducted an in-depth longitudinal, retrospective and prospective case study of four

emerging local health networks in the Quebec health care system between 2004 and 2007. The

four cases were sampled from the entire population of 58 local networks to allow comparison of

different degrees of complexity. Specifically, two cases included an acute-care hospital within

their formal organization while two did not. A pair of cases (one with and one without a hospital)

was selected from two different health regions.

The data collected include real-time observation of top management meetings within each of the

new organizations, as well as a total of 58 interviews with managers, professionals and key

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stakeholders. Interviews were between one and two hours long and were taped and transcribed.

Secondary data (planning documents, organizational charts, minutes of executive board

meetings, etc.) were also collected. The focus at this stage of the study is on the roles of top

management teams and key organizational leaders in the process of restructuring these

organizations.

We report here on the progress accomplished from 2004 to 2007 in the creation and

implementation of the new organizations and their networks. The four cases are described,

focusing on key moments in sensemaking and organizing activities and examining their

evolution and orchestration through time.

The Nature of the Structural and Conceptual Change

Figure 1 (taken from a regional health agency document) illustrates the nature of the overall

structural change studied in this paper. The new "Health and Social Service Centres" (HSSCs) at

the centre of the figure were created through the merger of several organizations operating on the

same well-defined geographical territory – CLSCs (community clinics offering home care and

social services), CHSLDs (long-term care, nursing homes), and CHSGSs (community general

hospitals). These new HSSCs were in turn required to develop contractual agreements with other

health care providers inside or outside their territory providing services needed by the local

population (e.g., voluntary agencies, physicians and medical clinics, specialized care hospitals)

to create local health and social services networks.

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Figure 1: Schematic Representation of the Health and Social Services Centres (HSSCs)

Source: Regional Agency document

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Table 1: Changing Conceptualization of the Health Care System

Source: Regional Agency document

Table 1 illustrates the conceptual changes associated with these structural changes. As can be

seen, the proposal involves a move from what is labelled a "service-based" to a "population-

based" approach. The new HSSCs are being asked not only to provide services to those who

request them, but more broadly to become responsible for the health status and needs of the

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population in their geographical territory. This is a radical change in focus. Taken together,

Figure 1 and Table 1 indicate a change in "organizational archetype" – involving a shift in both

structure and corresponding interpretive scheme (Hinings and Greenwood 1988; Greenwood and

Hinings 1993).

Of course, these two diagrams as well as the documents from which they are drawn constitute in

themselves a form of "sensegiving" on the part of the regional agency responsible for overseeing

the implementation of the reform. The documents produced by the regional agency were widely

distributed and are still available on its website. Similar representations were produced by other

regional agencies. These figures are thus representative of the type of changes expected from the

newly created organizations.

The changes described in this paper clearly created a situation of significant cognitive and

structural ambiguity within the Health and Social Service Centres (HSSCs). A new structure had

to be developed to manage the newly created centres, necessarily involving the reshuffling of

management positions and the displacement of managers to new roles. At the same time, the

management teams had to make sense of their new mandate: what exactly did it mean to move

from a service-based to a population-based responsibility? How would they proceed to define

their organization's role, at a time when the people at the top were all groping to understand their

new roles as managers? How would they go about developing linkages with partners? Table 2

provides some quotations from each of the four CEOs in our sample HSSCs to illustrate how

some of the structural and conceptual challenges were perceived. The contexts of these four

organizations are different, but the quotations reveal similar preoccupations related to the

complexities of internal reorganizing and the ambiguities of the new populational mandate.

In summary, these new organizations were faced with a highly complex task: to simultaneously

realign their structures and their strategic roles while maintaining ongoing services. The

following sections of the paper will first describe the initial conditions that affected the

positioning of the four organizations with respect to this task, and will then elaborate on the key

themes emerging from our analysis of how they simultaneously and reciprocally strategized and

organized, placing emphasis on the similarities and differences between the practices adopted in

the four contexts.

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Table 2: Perceptions of Structural and Conceptual Challenges in the Four HSSCs Structural challenge: Merging and reorganizing

multiple organizational units Conceptual challenge: Integrating the population-

based mandate HSSC1 "And that's a challenge… a challenge because for a

CEO in an organization, it's very easy to get lost in the organization, the internal part.(…) But if we only do that, we may have a great internal organization but we won't fulfill the major part of our population-based responsibility (CEO, HSSC1).

"But the population responsibility… there's a lot of work to be done. What does that mean? How far do we go? I don't know. That remains to be defined." (CEO, HSSC1).

HSSC2 "The challenge we have is that it is two organizations that operated as silos. (…) But we have no slack resources. We are down to the bone. (…) There's no room to manoeuvre and the cultures are very different" (CEO, HSSC2).

"I see our main mission as bringing health services close to the population. But population health in general… that's pretty vague. (…) There's a lot to do. I could spend practically all my time on that. But I have to prioritize. I have difficulty prioritizing, because everything is a priority." (CEO, HSSC2)

HSSC3 "With the creation of the HSSCs, peoples' reference points disappeared. These reference points are often the boss – or the priorities they might have (…) Who will be my boss? Will I change programs? This remains a worry. That perception is there and it does not contribute to mobilization" .(CEO, HSSC3)

"On the "population responsibility" mandate, there are very very few people in the organization who will carry that. You cannot expect the nurse or social worker or the doctor to work with a population-based approach. It's impossible. At first, I thought that it could be done perhaps…" (CEO, HSSC3)

HSSC4 "Just putting the structure in place, that takes two years. (…) There's so much to do that all our energies are invested in that." (CEO, HSSC4).

"The particular challenge is that we all have to develop a population-based mindset, and we have our work cut out for us with that at every level " (CEO, HSSC4)

Case Histories

To obtain a clearer picture of the interactive dynamics between organizing and sensemaking, we

develop case histories of the four organizations according to the following major themes:

historical antecedents, the composition of the executive team at the creation of the HSSCs and

changes through time, the role of CEO in organizing and sensemaking, the designation and role

of what we call "sensemakers-in-chief", the role of consultants and external agencies in

sensemaking activities and finally the resulting dynamics between structuring/organizing and

strategizing/sensemaking and its influence on strategic innovation and stability. It is through

these dimensions that we will analyse how each organization invested in structuring and

strategizing in a context of ambiguity and major change.4

Historical antecedents

Each of the HSSCs had a different history and this clearly affected the complexity of the

structural and conceptual challenges it faced, and at the same time the resources it could draw on

in its organizing and strategizing efforts. Critical antecedents include the number and type of

organizations that were being combined to create the new organizations and how these

4 In some cases, the gender of protagonists has been disguised to preserve confidentiality.

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organizations had been previously configured. Table 3 shows a comparison of the four sites

according to levels of structural and external complexity. The table also provides quotations

illustrating how each organization's particular history affected the structuring and sensemaking

challenges faced.

Table 3: Internal and External Complexity of the Changes among the Four HSSCs Region 1 Region 2

Without hospital HSSC1 Moderate internal complexity - 3 former organizations, 7 sites - No hospital - ~2000 employees Moderate external complexity - Must negotiate linkages with teaching hospital - Previous successful experience with inter-

organizational collaboration - Previous involvement in research and teaching “I think that having a research and teaching mission gives us extraordinary tools, compared to other organizations. First, it gives us openness to what is being done elsewhere, a culture of curiosity and innovation."

HSSC2 Lowest internal complexity - 2 former organizations, 5 sites - No hospital - < 1000 employees High external complexity - Highly politicized environment - Need to negotiate with several hospitals - 20 different municipalities “We have the challenge of showing that the shape of our local network is a good thing. Because the ministry and regional authorities wanted us to merge with (name of territory) and not to be an autonomous network, we have to prove ourselves”.

With hospital HSSC4 High internal complexity - 6 former organizations, 11 sites - Includes a hospital - ~3500 employees Lower external complexity - More autonomous than other HSSCs - Strong prior linkages with community - Centre of gravity weighted towards acute care,

but prior linkages to community provide a base to build on. Some continuity possible.

“It's a big plus having a hospital because it makes us largely autonomous in terms of specialized care (…) In family medicine for example, 50% of our family doctors work in the community. The doctors know each other. It's a tight community and there are leaders.”

HSSC3 Highest internal complexity - 6 former organizations, 17 sites - Includes a hospital - ~4000 employees High external complexity - 1 regional university hospital nearby - Linkage with community strong in CLSCs, but

weak in hospital. For most services the future linkage with the community will have to include the regional university hospital.

“The hospital is a relatively closed environment, which means that it is a milieu that had a care philosophy where they did everything. Only the hospital could give good care to its patients… So it means a longer journey, there are few links with primary care.”

HSSC1 is located in a large metropolitan area. The population of its territory is multi ethnic.

However, there are many industries and schools in the territory that attract many non-residents

who consume care services in the HSSC. This is seen as a challenge for the definition of the

population for which the HSSC is responsible. The HSSC was created by merging 3

organizations on 7 sites including both CLSCs and nursing homes. The HSSC does not include a

hospital so it is internally less complex than some other HSSCs, but it needs to develop

contractual linkages with a nearby teaching hospital. One of the founding organizations had a

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university affiliation which is seen by many as helpful in leading innovations. Prior to the current

merger, the 2 primary care/nursing home organizations had collaboration agreements for both

clinical and administrative services and had participated in a research project experimenting a

new model of services for the frail elderly. This context was seen as relatively favourable and

supportive for the management of change

HSSC2 is situated in a large region that surrounds a major metropolitan area. It is the result of

the integration of two organizations: a CLSC and a multi-site nursing home. This HSSC is

embedded in a semi-rural environment composed of more than 20 municipalities. It was created

following pressures by the local community to resist the structural scenario proposed by the

regional board. The CLSC had the reputation of being very active in the community and

historically had strong links with local volunteer groups. HSSC2 is thus operating very much in a

context of strategic continuity. However, its legitimacy is highly dependent on its ability to

respond to expectations of the active stakeholders in its local environment. The newly formed

organization can be characterized as being of low internal complexity (small size, absence of

hospital). However, conversely, it needs to negotiate with a large number of other organizations

including hospitals in several different administrative regions to ensure that its population

receives adequate services.

HSSC3 is one of the largest HSSCs in the province. Like HSSC2, it is situated next to a major

metropolitan area. It is composed of a mid-size hospital dispensing specialized care and several

primary care organizations (CLSCs) and nursing homes. It operates on 17 different sites with a

total of around 4000 employees. The hospital has a strong tradition of autonomy and its

employees are proud of the quality of its services. The philosophy of care within the hospital has

been to take charge of the patient for as long as possible without much collaboration with other

health care resources. Before the merger, there was no explicit culture of quality improvement

and evaluation. The newly merged organization is thus characterized by high structural and

cultural complexity. Overall, the merger of these organizations represents a serious managerial

and clinical challenge because of the initial opposition and mistrust among the different

organizations regarding the merger, the variations in managerial cultures and their strong

attachment to respective identities and autonomy.

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HSSC4 is located in a large metropolitan area and in a poorer area in terms of standard of living

and economic development. As in the case of HSSC3, the inclusion of an acute care hospital

with very demanding operations (emergency room, operating room, etc.) draws the centre of

attention towards an acute-care focus and away from a population based or community- focused

structure and perspective. On the other hand, as several respondents noted, this particular

hospital had established a prior reputation for strong links with the community. Due to its size,

the HSSC presents relatively high structural complexity internally. However, the embedding of

these organizations within the local community and common dedication to serve the local

population reduces the cultural complexity of merging these organizations as compared with

HSSC3. Externally, the HSSC participates in four local community governance bodies and

serves a relatively captive population. Its autonomy with respect to other organizations is seen as

a strength. This context favours a careful and systematic approach to strategic change.

In summary, both HSSC1 and HSSC2 have a less complex internal organizational merger to

manage than the other two. These two organizations do not include a hospital and have fewer

employees. Of the HSSCs with hospitals, the internal complexity of HSSC3 is considerably

higher than HSSC4, since it involves more sites and a hospital more strongly focused on

specialized care. Other than these clear structural differences, each organization has its own

distinct history which suggests greater or lesser structural and conceptual compatibility with the

proposed reorganization. For example, it is interesting to note that for HSSC4, the inclusion of a

hospital is seen as strongly favourable to implementation of the changes because of a previous

history of collaboration and a relatively self-contained community. In contrast, for HSSC3, the

dominance of the hospital is seen as potentially problematic in implementing the changes.

Executive team composition

Due to the relative immunity of the professional core of these organizations to mandated

changes, the executive team will play (at least, this is the intention) a critical role in shaping the

implementation of the reform and in finding ways to make it penetrate the operational core of

these organizations. We will now examine for each of the four cases the influence of a first key

structural decision – the composition of the executive team – on subsequent structuring and

strategizing activities.

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While all four CEOs of the new organizations were recruited from outside (from other CLSCs in

the province), all four HSSCs (see Table 4) recruited a majority of their remaining executive

team members internally which means from the original organizations involved in the merger.

The reasons for this continuity in structure were in some cases related to financial constraints and

shortages of some type of managers, and in other cases to the desire to preserve expertise within

in the organization. A predominance of people with primary care experience (i.e., from CLSCs)

is observed for the two HSSCs that do not include a hospital (HSSC1 and HSSC2). It is clear

that in this context, the community health mission predominates over the long-term care mission

in the constitution of the executive team. When the HSSC includes a hospital in its structure

(HSSC3 and HSSC4), the hospital mission is well represented in the executive team, especially

for key positions regarding the organization of clinical production.

Table 4: Executive Team Composition: Continuity to Achieve Change? Region 1 Region 2

Without hospital HSSC1 - 14 out of 19 directors come from organizations involved in the merger. “The HSSC has chosen to retain all the managers and CEOs of the former organizations to compose its first macro structure. So we are 19 in the top management team. This was a transition strategy. We saw in this the advantage of keeping the knowledge of the former organizations.”

HSSC2 . 6 out of 8 directors come from organizations involved in the merger. “I will tell you frankly, I didn’t recruit outside the organization… I was limited in that’’

With hospital HSSC4 - 9 out of 15 directors come from organizations involved in the merger. “We have a structure that is not easy - where the players have to sometimes test their universe, where there are program directors who had positions in a more traditional structure, and they now have some difficulty letting go of certain pieces. That's a complicating factor that has to be sorted out to achieve change”

HSSC3 - 12 out of 15 directors come from organizations involved in the merger. “There are six people from the hospital, four from CLSC, two from nursing homes, most of the directors come from the hospital (…) I didn’t want all the directors with a similar background but continuity was important for me. I believed that most managers should come from the former organizations.”

Structurally, it appears that the composition of the executive team reflects key and powerful

missions involved in the HSSC. The executive teams of the HSSCs incorporate the various

missions in leadership positions, while according more weight to the hospital and community

health center (CLSC) missions. In the cases of HSSC3 and HSSC4, executive team composition

reflected the need to deal explicitly with the alignment of the hospital with the newly merged

organization. By recruiting mainly internally, the HSSCs also sent signals in favour of continuity

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and the preservation of the respective identities. This was most striking in HSSC1 where most of

the previous CEOs of the different organizations were retained in various roles creating a rather

large administrative structure initially. The sense of strategic continuity thus predominates in the

composition of the executive team. We will see now how this emerging organizational context

influences the implementation of mandated changes in each HSSC.

The role of CEO

Due to their key positions in the formal organizational structure and to their role of interface

between the organization and the environment, it is expected that CEOs will play a critical role

in structuring and strategizing. The CEOs played various roles in the four cases.

HSSC1: Seeking opportunities for innovation. Upon his arrival in HSSC1 (he had previously

been CEO of primary care organization), the CEO immediately focused on restructuring the

organization. He created programs in line with the main overall organizational activities (mental

health, frail elderly, etc.) He felt that this would help create a new sense of belonging to the new

organization and help harmonize operational practices between the merging organizations. The

selection of programs was also influenced by identified government priorities. In most of his

activities, the CEO tried to be in line with external pressures or opportunities. In addition to the

program restructuring, the CEO tried to project the image of his organization at the centre of a

network of services by designing an “external chart” which included all partners with whom

links needed to be created. These internal and external charts were highly publicized through

presentations made inside and outside the organization as a vision of where the organization was

going. In addition to a message of collaboration with partners, the external chart was presented

as a means to help integrate the population-based approach. Partners were also formally invited

to be part of committees and forums to participate in the discussions on the change.

This CEO has been constantly on the alert to take advantage of outside opportunities to acquire

additional resources, or participate in new projects (e.g., a new model of practice for primary

care physicians) which could help the organization progress in implementing the change

mandate. These opportunities mostly come from the regional agency with which he maintains

very friendly links. He is also involved with the association of healthcare organisations to

develop contacts and keep up with trends. This opportunism helps him sustain the image of an

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innovative organization. The university affiliation served as a stepping stone for the creation of a

change observatory and the use of a knowledge broker. His strategy can be summarized as

carefully leading the way with the help of outside stakeholders.

HSSC2: Focussing on access to care. At HSSC2, the CEO played a dual role. Internally, he was

the guardian of the integration of the two missions (community health and long term care) and of

organizational core values. For example, he began by working out a credo for the organization

with a consultant focusing on four key strategic areas associated with different keywords:

mobilizing, building the organization, building the network, and excelling. These keywords

served as a reference point through time. However, in more operational terms, the main focus of

the CEO was on the improvement of access in terms of quantity and quality of care through new

arrangements with university and key delivery organizations within the environment for the

population, a priority for major stakeholders within this local area. Thus, externally, he played a

significant role in the development of linkages with university hospital settings and in the

initiatives for the recruitment of physicians. He is also the main interface with the regional health

authority for negotiating budgets, obtaining authorization for new development and for support

in the management of the political environment that surround the HSSC. The CEO is mostly

oriented toward external actions to secure an appropriate supply of health care services (new

services agreements, affiliations with new clinical settings including private clinics…). His

strategy can be summarized as leading response to key stakeholders’ expectations in the

immediate environment.

HSSC3: Competing visions: From strategic to operational focus. The role of the CEO in HSSC3

is more complex to define partly due to the changing of the guard along the way. The founding

CEO came from a primary care organization external to the merger. He adopted a rational and

conceptual style, rather detached from day-to-day operations. He had a clear understanding of

the potential of the current reform and of the benefits that might be gained by trying to manage

health care services according to clinical priorities and performance and with a view to

improving the health of the population. He also had a clear view of how to redesign clinical

programs and services. His main preoccupation was with the conception of a new organizational

model based on a renewal of the strategy. Accordingly, the founding CEO hired a Special

Advisor to design the new organization. The CEO also created committees (pre-budgetary

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committees) to track patient flows within the HSSC, to optimize care paths and ultimately to

rationalize the use of resources. Despite these initiatives, a major budgetary rationalization was

imposed in Summer 2005 with the help of an external consultant. This contributed to

delegitimize the role of the CEO at that time, and specifically in relation to powerful hospital

constituents (especially doctors) and with the Chairman of the board. In fall 2005, the CEO

formed a planning committee to rethink the organizational chart. He also created an

organizational development group under the Special Advisor in charge of rethinking the culture

of the organization. To summarize, the founding CEO put in place a strategizing machine that

was perceived as somewhat distant from important constituents in the organization. This

machine was geared to implementing a population-based logic for the delivery of health care

services but was not strongly connected to operations. The adoption of a co-managed (medical

and administrative director) program design was well received but was not sufficient to preserve

CEO legitimacy and he eventually left the organization.

The associate CEO in charge of the program structure became interim CEO (spring 2006) and

refocused the leadership role on internal operations and structure. He undertook various internal

consultations to clearly define the various roles, responsibilities and linkages of the different

components of the organizational structure. A key piece of this action was to reinforce the

position and role of clinical leaders within the new program structures. The action of the interim

CEO seemed to reconnect strategizing activities with the operating core of the organization,

especially that of the hospital. However, the approach is much more conservative in the pursuit

of strategic change. At time of writing, the interim CEO has just been replaced by another new

CEO from outside the organization.

HSSC4: Moving incrementally and systematically. As described earlier, HSSC4 is a large

organizational structure with a strong sense of continuity and close linkages with its community.

HSSC4's CEO positioned himself somewhat distant from operations, delegating both operational

issues and sensemaking roles to others. His focus from the beginning was on organizational

design, administrative efficiency and external relations. His priority was clearly to ensure an

ordered and systematic transition towards a new model, beginning by putting in place what he

saw to be the required organizational structures. His management practices appeared formalized

and management meetings were short and to the point. Communications from the CEO appeared

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regularly in the internal house organ explaining the "redeployment" of the organization towards a

more horizontally organized structural form. As time advanced, the CEO began to talk more

about population responsibilities. However, the approach was always steady, systematic and

deliberate. While adopting such an incremental approach, the CEO kept up with regional agency

initiatives such as the creation of a new model for private clinics. The CEO conceived the current

reform as a way to finally integrate physicians within the broad functioning and objectives of the

health care system. While the CEO's role in HSSC4 can be interpreted as focusing on

consolidating the organizational structure as a basis for further strategizing efforts around the

mandate of population health, this approach does not impede the implementation of certain

innovations during this period, including the creation of family medicine groups and a new

centre for diabetic patients..

Table 5: CEO Roles and Priorities Region 1 Region 2

Without hospital HSSC1: Seeking opportunities for innovation “That is a challenge to mobilize the private medical community, primary medical care, specialized medicine. I think that we have to play our cards in a creative way -, we have to go further, that is not easy.”

HSSC2: Focussing on access to care “So I try to maximize the use of the hospital of (town close to their territory) and to develop links with them. But I have already contacted a hospital in (anther province) since a big part of my population goes there. We also have problems with ambulances, that is a big issue. (…) My goal is to develop care corridors with (another hospital) as soon as possible.”

With hospital HSSC4: Moving incrementally and systematically "I told myself, a merger like that will take 2 years (…) to establish the base, an important base. After that it's a question of fine-tuning policies and procedures and the rest. But just to put the structure in place, that is two years.(…)."

HSSC3: From strategy to operations The founding CEO : “The CEO is very intelligent. He sees very clearly. (…) He's conceptual The interim CEO “(…) For me, all the continuous improvement of quality process through all our activities, the customer approach (…) for me it is very important.”

Overall, we observed that the CEOs played an important role in shaping the evolution of the

newly created organizations. In a context of a mandated change and imposed mergers, three of

the four CEOs (all except HSSC3) chose to work mainly in continuity and to establish a working

structure before attempting to bring about major change. Having said this, the CEO of HSSC1

probably paid more attention initially to the need to implement or reinforce some structural

initiatives to harvest the innovative potential of the current reform (creation of a change

observatory, use of a knowledge broker , development of a dual organizational design: internal

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design and external design…). Table 5 provides some quotations from interviews that illustrate

the different styles.

Naming "sensemakers-in-chief"

We underlined previously that the HSSCs face three main challenges: (a) creating a new unified

organization based on the integration of various missions, (b) developing a new approach to

deliver care and services through local health networks, and (c) implementing a population-based

approach. The implementation of these changes is associated with a need for intense

sensemaking activities. One way all of our sample organizations dealt with the simultaneous

ambiguity surrounding the organization's strategy and structure was to develop a structure that

included positions specifically dedicated to "sensemaking" – i.e., concerned with defining the

organization's strategic direction. We have labelled these positions "sensemakers-in-chief"

although of course, the true titles were different and indeed quite varied. Our analysis suggests

that exactly who was assigned to play this role and how they chose to operationalize it could

have an impact on the nature of sensemaking within the management team, and the extent to

which sensemaking diffused both within the organization and outside it. Table 6 provides

illustrative quotations concerning these roles.

HSSC1: Grassroots sensemaking. In HSSC1, a person who plays a very active role in

sensemaking is the "Director of quality” This person has long-standing experience in one of the

merging organizations, in which he was interim general manager for 6 months. Since then, he

occupied influential staff positions in the organization. His life-long working experience gives

him operational knowledge of all the missions (primary care, long-term care, hospital, etc.). His

mandate give him the levers to be closely involved in all strategic and operational projects, and

numerous committees across the organization. His involvement within each of the programs adds

structure and coherence to the discourse used to make sense of changes. This individual is also

involved in all activities (committees and forums) where partners are invited to discuss or

negotiate with the management of the organization. He designs the content and processes of

these activities. He contributes actively to sensemaking and sensegiving by maintaining very

tight links with the CEO, with whom he shares common discourse, and by being involved in all

activities, both inside and outside the organization where the discourse may be constantly

19

repeated and discussed with managers and also professionals. In a sense, he is the guardian of the

vision as well as its operator.

HSSC2: Grassroots sensemaking. In HSSC2, a relatively small organization, a key position is the

post of Director of clinical programs. This is occupied by a person who had a long experience in

a similar role within the primary care organization that is part of the merger. This person

received the mandate of conceiving and planning the development of clinical programs within

the organization and with external partners. There is within this HSSC a kind of division of

labour with the CEO regarding sensemaking activities. The director of clinical programs used his

detailed knowledge of the environment to frame a perspective for the development of the clinical

programs. He also participates in external training programs to become an expert in evidence-

based decision-making in health care organizations. Through his actions, he promulgated the two

key orientations of focussing on the needs of the population and managing according to scientific

evidence. In HSSC2, the responsibilities for sensemaking activities are thus mainly delegated to

the director of clinical programs who through this position and through his experience can

connect easily with organizational members internally and with partners externally.

HSSC3: Disjointed sensemaking. The evolution of HSSC3 reveals a complex pattern of

sensemaking roles and activities. At the creation of the HSSC, the founding CEO hired, as

mentioned earlier, a Special Advisor in charge of creating the new strategy for the new

organization. The concentration of sensemaking activities within this key position did not make

the penetration of a new strategy across the organization possible. He tried to persuade other

directors of the importance of getting a university affiliation/ mission and to develop an

ambitious project to get the population more involved and responsible for their health. He

worked closely with the CEO but in a very affirmative and distant way from key constituents

within the organization. This director left the organization in Winter 2006. Meanwhile, to

compensate for his rational style of management, the CEO recruited an associate director of

clinical programs. known for his deep knowledge of hospital and program management and for a

management style more focused on human resources. After the departure of the CEO in spring

2006, the interim CEO (previously associate director of clinical programs,) had to take on a

critical role in sensemaking and to refocus internally around the harmonization of the different

20

missions and the coordination of operations across all operating sites. Strategic renewal was put

aside for a while.

Table 6: Sensemakers-in Chief Region 1 Region 2

Without hospital HSSC1: Grassroots sensemaking - Director of quality ‘All my assignments have a horizontal impact on the organization, so this impacts on every activity in the organization. I care about quality of services, quality of professional practices, about the performance of the organization (...) In addition to those responsibilities (...) there's the university mission, the management of teaching and research activities.”

HSSC2: Grassroots sensemaking - Director of clinical programs "He is another big piece since he has a clear vision of the clinical project […] and he had already developed significant links with stakeholders of all shapes and sizes through previous work… […] So I think because of his political abilities… I think that he is a very strong link in the clinical project."

With hospital HSSC4: Managed sensemaking - Director of program development "Perhaps the time has come for him to do a tour to inform people about the change – about the meaning of the change. People need to understand better. We have to do more… give concrete examples of change, why we're changing, exchange with people."

HSSC3: Disjointed sensemaking - Special advisor “I see problems, I see major mistakes. And obviously, all the hospital culture that is very refractory to strategies that are not hospital-focused has reacted negatively (…) It just worsened the relations between the CEO and physicians.”

HSSC4: Managed sensemaking: HSSC4 is also characterized by the propensity of the CEO to

formally delegate sensemaking activities to a member of the executive team. The director of

program development is seen as an integrative position with the mandate of conceiving and

planning new clinical programs while the rest of the organization is busy consolidating the new

structure. He was trained in community health and was assigned responsibility for producing the

statutorily required "clinical plans" that analyzed the needs of the client population and defined

how they would be met. He was also active in developing linkages with partners in collaboration

with program directors. The first version of the plan was initially carefully developed internally

and then submitted to a broad consultation with internal and external partners. This consultation

resulted in the re-writing of the plan in collaboration with partners. In contrast to the

"sensemakers-in-chief" from HSSC1 and HSSC2, he was initially less centrally involved in

mobilizing groups of employees and partners. The deputy CEO also plays a crucial role in this

process by working with the managers in charge of specific clinical programs to ensure that a

broad vision is developed and shared across the whole organization reaching beyond priorities

within existing missions (hospital, CLSC and long term care). Thus, two key persons have

played critical roles in sensemaking activities in this organization with one (director of program

development) playing a predominant conceptual role.

21

In the context of strategic change and ambiguity, the organizations devolved to key positions and

people a central role in sensemaking activities. While the CEOs are very busy keeping in touch

with external networks and in managing the interface with regional health authorities and the

Ministry of Health, key structural positions have been created with a mandate for defining a new

strategy for the emerging organization. We labelled this key staff (not line) position “sensemaker

in chief” to refer to their predominant role in shaping strategic renewal at least conceptually.

While the creation of such positions has its advantages, it also engenders a risk of being

disconnected from core operations or influential groups. There is a need to ensure that

sensemaking activities are at some point connected with key organizational processes to move to

a stage of implementation. Considerable energy has been placed on that in HSSC1, but the task is

very demanding and difficult. The relatively small size of HSSC2 may represent a favourable

context to ensure that strategizing will be connected along the way with structuring. In HSSC3,

we observed a period of detachment followed by an attempt to reconnect sensemaking with

organizing. In HSSC4 the connection between the sensemaker in chief and the deputy CEO (a

line role) is crucial to ensure that strategic renewal is connected with current restructuring.

Seeking sense from outside

Two main external inputs into sensemaking have been identified: the role of external agencies

(regional health authorities, ministry of health) and the role of experts and gurus (university

experts, consultants). Very often these two sources of sensemaking overlap, where consultants or

university professors participate in public events (ex.: colloquium) organized by the Ministry of

Health or Regional Agencies.

Seeking sense from above (regional health authority and ministry)

In the context of a highly regulated environment like the one found in a public health care

system, external agencies who have authority over the HSSCs play a critical role in shaping

strategizing. The Ministry of Health organized in January 2005 a full-day colloquium for the

executive teams of all the HSSCs of the province to present their perspective on the current

reform. University professors, managers of HSSCs and CEOs of regional health authorities

participated as speakers or panellists in this event. The colloquium was introduced by the

Ministry of Health. The ministry also sponsored and participated in an annual event aimed at

discussing key issues related to the implementation of the reform. This event attracted some 650

22

people. The ministry also organized a series of forums with CEOs of HSSCs around key

management issues under the responsibility of a very well known consultant who has also

intervened internally within the HSSCs (see below) on many occasions.

The HSSCs receive their resources and mandates from regional agencies who in both of the

regions studied took a particularly active role in orienting the HSSCs' structuring and

sensemaking activities. In turn, the regional agencies themselves were under pressure from

central government. For example, the delivery of so called “clinical plans” from each HSSC was

a central government-defined requirement with very short deadlines. In addition, each HSSC had

to sign a performance contract with the regional agency that included a long list of performance

indicators – most of these are essentially volumetric and not necessarily perfectly compatible

with the so-called population-based mandate.

The regional agencies also attempted to play a “helping” role by providing resources for the

HSSCs to assist them in their sensemaking activities. For example, region A developed a user-

friendly quantitative data base tool enabling the HSSCs to undertake in-depth analyses of the

populations of their territories. Region B developed a “knowledge platform” that included

updated literature as well as decision tools to assist the HSSCs in selecting their action targets for

a range of different service lines. This region organized an annual colloquium of 500 participants

from executive and clinical teams. Both regions organized regular meetings among the CEOs

and other managers at different levels in the HSSCs to discuss shared concerns. They also invited

consultants and organized training activities (including in the case of Region A visits to other

countries for the CEOs to see other forms of health care organization). Professional associations

such as the Association of health care organizations also intervened in shaping strategies. In the

very early days of the reform, the Association published a guide for the development of clinical

plans. They also organized an annual colloquium to discuss key issues associated with the

current changes.

These activities clearly constrained, structured and nourished sensemaking in the HSSCs.

Managers from all the HSSCs chafed at the numerous demands that seemed to be placed on

them.

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Table 7: Role of Regional agencies and Ministry of Health in Sensemaking and Structuring Region 1 Region 2

Without hospital HSSC1: Proactively seeking opportunities “I am the first CEO who is adopting the X model, that is a model to care for vulnerable clients. The CLSC model didn’t work. That is the model of the past - the model of the future is one that takes care of vulnerable clientele with a multidisciplinary team. From this perspective, the HSSC is moving into secondary care (…) "So we are dependent on the pace of work in the region. Also, we have to be aware that our breathing room is narrow when we want to develop our services offerings. I won’t say that there is none, but it is quite restricted.”

HSSC2: Looking for concrete support “So there are additional costs that the organization has to assume at a time when we should be receiving financial support to help us to mobilize staff, for good change management (…) Sometimes we need external resources to do this (…) We don’t feel we have breathing room… We have to cut somewhere else sometimes (…) We always wish that ministry or the regional agency would tell us « we will support you a little more for the transition ».”

With hospital HSSC4: Seeking opportunities “First it is an idea from the Regional Agency CEO who believed that family medicine groups were poorly adapted to the context of (name of the region). So he proposed the implementation of network clinics which was a little bit less constraining for private doctors and obviously my CEO has spoken to me about that… We wanted to go fast in that sense, and frankly, we wanted to become the first HSSC to sign with the clinics.”

HSSC3: Searching for local coherence “The ministry has produced a document about the inputs to the clinical plan… I find it very interesting but I don’t have the appropriate mechanisms to diffuse this information. My director of clinical information or my director of prevention could assume part of this function, but presently those areas have temporary directors with temporary mandates… So this is very interesting but I don’t feel well organized for that. I have a puzzle with thousands of pieces and I see the image very clearly but there are some pieces that I cannot put together yet.”

As we noted, HSSC1 was very active in taking advantage in all opportunities offered by the

environment (e.g., creating a medical clinic). This organization wanted to be seen as a leader in

the implementation of change. HSSC2 interacted a good deal with the regional agency around

the fixing of budgetary issues and around authorization for some developments. It also got

involved in projects in primary care that became significant in the regional agenda. HSSC3 was

initially very active with the regional agency participating in panels and public events with

members of the executive team of the regional agency. However, with time, it was forced to

reorient towards a much more internal focus where the discourse about the conceptual

dimensions of the reform seemed less present. HSSC4 focused strongly on the consolidation of

its structure but was attentive to key initiatives of regional agencies and participated actively, in

the project of creating a new model for private medical clinics. Table 7 illustrates how each

HSSC reacted to regional and government initiatives.

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Relying on sense-gurus

All the HSSCs also relied on external consultants or what might be termed "sense-gurus" to help

them understand the new organizational role as well as to cope with its managerial challenges.

The creation of the HSSCs created a huge demand for expertise, filled partly by consulting firms,

partly by training firms and partly by academics. Consultants were drawn in to assist in a wide

variety of different ways. A very well known consultant with some international exposure had

been mobilized within both regions and all HSSCs to discuss models of organizing care such as

integrated delivery system, program design and strategies for aligning physicians with the

objectives and functioning of the system. Consultants on change management have also been

involved in all the HSSCs we studied (see Table 8).

Table 8: Sensemaking and Structuring Roles of Consultants Region 1 Region 2

Without hospital HSSC1: Demystifying language “I have tried to use a language that would demystify the clinical project, Several words used by the ministry such as population responsibility, care hierarchy, etc. After a discussion with people, it is clear that what we want is to better balance service offerings with the needs of the population.” (exchange in top management meeting)

HSSC2: Organizing values and priorities “We have hired someone from firm X. This is the third time we work with him. We will take all our issues and place them under each strategic thrust. These will define our priorities, a kind of action plan.”

With hospital HSSC4: Sharing interpretations "When he said that it’s a change in management culture, he is so right! That session did me so much good! He is so right, that's what is happening… to have that said… but that's why I absolutely must have him talk to the management team, because it will resonate and we can discuss this… but it's fundamental, it's a change in management culture as well as a change in clinical practices.”

HSSC3: Conflict resolution (structural role) "I suggested a mediator to my president, an external mediator. We hired Dr X who has been a CEO and has a solid reputation in the province (…) There is a good chance that he can resolve the situation.”

If we look more specifically at the use of consultants in each HSSC, a consultant was hired in

HSSC1 in order to clarify the different concepts associated with the change in care delivery

paradigm. Considerable semantic ambiguity had seemed to paralyze the development process of

the clinical project. His interventions allowed the top management team (especially the program

directors) to build a common understanding of the concepts, which was essential for them to be

able to structure their service offerings.

HSSC2 hired a consultant to help in the definition of core organization values and strategic

directions as an input to sensemaking. However, the other expertise used by this HSSC came

25

mostly from the regional health agency. For example, they received support for the development

of the clinical plan and to support the CEO in the development of an organizational design.

HSSC3 mainly used consultants for conflict resolution. In fact, they even hired an external

mediator in order to make sense “objectively” of the tensions between the CEO and physicians.

The CEO also hired a consultant to develop the hospital retrenchment plan, a strategy that

became ammunition for physicians who judged that the CEO did not have the competence

required to understand the workings of the hospital. The CEO used consultants mainly to resolve

dilemmas related to the integration of the hospital structure into the broader organization.

At HSSC4, the involvement of consultants seemed to be organized in a relatively ad hoc manner.

For example, early in the process, a well-known local health care consultant who had organized

colloquia on the reform was invited to present the implications of the population-based approach

to the top management team. The CEO had heard him speak at a colloquium and his

characterization of the transformation as a profound cultural change was seen as helpful in

getting the top management team to think differently. Another consultant was invited to join the

management team in developing a set of organizational values. Finally, more recently, as people

began experiencing difficulties in understanding their new management roles in a matrix

structure, another consultant was called in to organize an interactive training session on role

conflicts and ambiguities.

Overall, each HSSC is involved in sensemaking activities that transcend their own organizational

boundaries. Some of this involvement is more coercive in the sense that HSSCs have to

participate in regional agency and Ministry of Health activities. The roles of external agencies,

experts and consultants in regard to sensemaking can be qualified as one of creating a common

discourse around the population health approach and of helping HSSCs in some key areas for

strategizing and organizing as in the integration of various missions and the linkages between

HSSCs and private medical clinics. It is also clear that HSSCs were looking for external

resources to help them alleviate ambiguities concerning the management of change. The reliance

on external consultants or experts to help resolve concrete organizational problems may increase

in the next stage of implementation of the reform. Despite very active external resources for

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sensemaking, we observed that HSSCs proceeded in a variety of ways to articulate strategizing

and structuring.

Articulating strategy and structure

Over and above the question of choosing an executive team, identifying sensemakers-in-chief

and drawing on outside resources for sensemaking and structuring, perhaps one of the central

issues that these organizations had to wrestle with was exactly what to do first and how to

sequence and articulate the various elements. This dilemma underlies many of the other issues.

Should the HSSCs first design their strategy and then develop a structure to fit that, or should

they settle on a structure and rely on the new structure to generate a strategy? In this study, we

observed different attempted sequences of sensemaking and organizing activities as shown in

Table 9. One organization (HSSC4) deliberately focused initially on the development of a

functioning organizational structure, minimizing cognitive and human costs and then

progressively paying more attention to sensemaking activities and to more innovative programs

and actions.

Two organizations (HSSC2 and HSSC3) attempted to focus initially more on sensemaking

activities and to delay restructuring until clear strategic directions were adopted. In the case of

HSSC2, pressures increased to formalize the structure due to insecurity among organizational

members. In another case (HSSC3) developing tensions between proposed strategic innovation

and one key structural component (the hospital) pushed for a refocusing of activities internally

around efficiency gains in the existing structure. In other words, both of these organizations

found themselves forced to switch their focus.

In HSSC1 organizing and sensemaking seemed to work more in synchrony with synergistic

investments on both side of the equation. This pattern of organizing and sensemaking is

consistent with the historical antecedents of one element of the newly formed organization (a

primary care organization that had been involved in the past in initiatives coherent with the

demand of the current reform).

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Table 9: Articulating Strategy and Structure Region 1 Region 2

Without hospital HSSC1: Strategy and structure in synchrony "It's a changing document because our organizational plan and our clinical plan will evolve as we develop (..) We have 225 people mobilized for the clinical plan. They are finalizing our current service offerings. But we still had to define our future service offerings. So we did it as best we could based on an analysis of the environment, and we created the beginnings of a business plan that will evolve continuously.. both in terms of the organizational chart as well as the clinical plan.”

HSSC2: Initially strategy before structure – but forced to adjust “In my mind, we had created a temporary organizational chart thinking that when the clinical plan had been defined, it would be easier to see the kind of structure that we needed, what type of managers would be needed (…) But in real life, what we are realizing is that to have a transitional organizational chart for a full year will be just too long […]. Because the temporary organization creates instability and it is not ideal in a period of change. (..) It's difficult, because we are doing everything at once...”

With hospital HSSC4: Structure before strategy “Just putting the structure in place – that takes two years. We'll have finished in the fall. There's so much to do that all our energies are taken up with that and it has to be done well. We have to have people who will pull in the same direction. Otherwise, it won't work. (…). We have to do it well to make sure that we have good leaders. (..). We're happy as it gives us a solid base to move on to other things. We've already started doing other things, by the way…(…) But the whole question of the populational approach, that's the real reform – not the merger…(…) We're now moving towards that starting several months ago, since the fall really.”

HSSC3: Initially strategy before structure, but forced to adjust “I had a strategy when I arrived that we would first define ourselves on the clinical side (…) And then the organizational chart would be defined once we had identified our clinical priorities, based on what had to be done in the organization (…) The problem with that was people were too insecure. I hadn't seen the impact of that… "yes but me, my job, what am I going to do?" So in the last few weeks, I reversed the order of priorities. I decided to work on the organizational plan to identify the leaders who will then work on the clinical plan after that.”

Overall, these observations tend to emphasize the central role of structure in reducing ambiguity.

Those organizations that appeared most preoccupied with allowing strategy to take precedence

over structure found themselves drawn, under the pressures created by ongoing ambiguity of

roles and positions, into using structure to stabilize their organizations, and perhaps in the

process, limiting the potential for strategic innovation. Only HSSC1 was in a position to maintain

a more synchronized process in which structure and strategy moved in tandem. In the next

section, we draw our observations together and relate them to the previous literature on

sensemaking and organizing.

Discussion: The Reciprocal Dynamics of Sensemaking and Organizing under Ambiguity

We initially asked two questions that are related to the management of strategic change in a

context of ambiguity. How do organizations and actors react and deal with major destabilization

and ambiguity? And how do they use sensemaking and organizing activities to balance

continuity and strategic innovations within major restructuring operations in public

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organizations? The problem we explore in this paper is similar to the one explored by Balogun

and Johnson (2005) in their study of the process of schemata transformation by middle managers

in a context of strategic change in a large company. In their study, the authors note that middle

managers “have the challenge of grasping a change they did not design and negotiating the

details with others equally removed from the strategic decision-making” (Balogun and Johnson

2005: 543). While our study focuses more on top management teams and professionals in

leadership situations, the HSSCs also had to make sense of and implement a mandated change

designed by external authorities. This change implies three specific challenges for HSSCs which

are the sources of major cognitive and structural disorder: 1) to merge previously distinct health

care organizations into a single and functional entity, 2) to develop local networks with partners

in their environment (medical clinics, community organizations…) and 3) to adopt and

implement an innovative perspective for intervention, namely the population health approach.

However, the specific content of these broad change issues and the process by which a

satisfactory implementation will be achieved are largely unspecified. HSSCs have to invest

locally in sensemaking and organizing activities to give meaning to and implement this strategic

change. Recently, Davenport and Leitch (2005) suggested that ambiguity can be an asset to

support the involvement of stakeholders in a change process and to stimulate progression of

change: “…we contend that strategic ambiguity can empower stakeholders by opening space for

the co-creation of meaning within organizational discourse” (Davenport and Leitch 2005: 1603).

A similar point has been made by Weick (1995) in relation to the role of ambiguity in

stimulating involvement and improvisation among concerned actors and organizations. Weick

(1995) and Vlaar et al. (2006) also suggested that an appropriate level of formalization may

support organizational members in their attempt to deal with situations of ambiguity. Our study

looks at the process by which organizations try to achieve restructuring in a context of ambiguity

and how they can develop strategic innovation in such an ambiguous context. We will discuss

three lessons that we learned from this study for the management of major strategic change in a

context of high ambiguity within public organizations.

29

Balancing investments in structure and investments in innovative ideas.

If we consider the initiation of the change process and the question of what to do first, the

dilemma between strategizing and structuring as described in the previous section (see also Table

9) can be summarized as follows. In abstract terms, investment in sensemaking before organizing

can be conducive to more innovative ideas. The chances that almost immediate restructuring will

reproduce deep patterns within the newly form organization is indeed rather high. However,

organizational members need to identify with their new work context and to find a way to relate

to imposed strategic change. Structure can become the privileged vector through which actors

will be able to position themselves and to progressively discover the roles they can adopt in the

transformation process. Actors at various levels of the organization can thus engage in practices

that will shape strategic change (Rouleau 2005).

Early establishment of structure favours a logic of continuity and marginal adjustments of pre-

existing practices at least in the short term. It can however be beneficial because it minimizes

destabilization and disruption within the newly formed organization. A logic of improvement

may thus dominate in the short term instead of a logic of innovation. On the other hand, all these

organizations remodelled their structures along program lines generating parallel lines of

authority in some cases. Restructuring thus initially produced greater security but also sent a

message of change.

While the early implementation of structural changes may be desirable to set direction, initial

structures can be hard to adjust significantly once established. Demands from external authorities

may simultaneously represent constraints and disruptions but also offer potential for innovative

strategic orientations. They can counter-balance these internal pressures for continuity in a

situation where the working out of a new structure in a majority of cases channels the agency of

executive team and organizational members toward more incremental change and innovation.

Despite a propensity to invest more in structuring, there is a need to rapidly catch up with rich

sensemaking and sensegiving activities to infuse these new emerging structures with new

meanings. Such investments in sensemaking and sensegiving may be the basis for strategic

innovation. However, it is not easy for these organizations to maintain coherence between

structure and conceptual frameworks.

30

Generating capacities for sensemaking and sensegiving in the midst of restructuring.

We initially suggested that sensemaking activities are critical to achieve change and innovation

in a context of high ambiguity. To respond to the challenges of implementing reorganizations in

such contexts, the HSSCs chose to formalize the function of sensemaking by designating a

position that we labelled "sensemaker-in-chief" within their structure. The identification of a

person in charge of shaping the sense of the current transformation appears to be a key structural

decision for the evolution of the change process. As we observed, the profile of these people

seems to influence the nature of the sense that is progressively constructed and the circulation of

this body of meanings across organizational levels and units. In two cases (HSSC1 and HSSC2),

the sensemakers-in-chief had an in-depth knowledge and experience of the organization and

could foster a sense of continuity by connecting the ambitions of the current transformation to

historical antecedents and experiences of the organization. They seemed to play important roles

in both sensemaking and sensegiving activities.

Our observations suggest, as proposed by Weick (1995) and Vlaar et al (2006) that formalization

can play a positive role in helping organizations dealing with ambiguous reality. However,

relatively little attention has been paid to the formalization of a role such as the one we have

described as “sensemaker-in-chief”. The formal attribution of a role may be an important

enabling condition for leaders or key actors to engage in sensemaking and sensegiving activities

(Maitlis and Lawrence 2007). The study of the role of sensemakers or sensegivers can improve

understanding of how people in their daily activities or micro-practices generate sensemaking

and sensegiving capabilities (Rouleau 2005; Maitlis and Lawrence 2007).

However, certain conditions need to be met to achieve the potential benefits of formalization.

Sensemakers-in-chief must develop processes that increase the connection between strategizing

and the history and daily life of the organization. A sensemaker may be very innovative and

ambitious in his or her proposals, but fail to connect with the rest of the organization. Meanings

need to be framed in a way that is anchored in organizational experiences and constraints and

processes need to be developed that will make possible the appropriation and adaptation of

strategic change by the operating core of the organization.

31

Despite the formalization of the role of sensemaker-in-chief, sensemaking can be conceived of as

a collective exercise (Denis, Lamothe, and Langley 2001) where sensemakers develop

cooperation with other organizational members to ensure the circulation of new meanings, the

generation of opportunities for sensemaking and sensegiving and the legitimacy of leaders in this

process (Maitlis and Lawrence 2007). In such a context, sensegiving appears as a necessary

complement to sensemaking activities. Sensemakers-in-chief can rely on various consultations,

committees and working groups to stimulate commitment and understanding of the nature of the

change. Because of the need to translate grand reformative schemata into operational initiatives,

we expect that the more sensemakers and sensegivers will try to penetrate the clinical sphere, the

more professionals in charge of operations will have to reconstruct meanings and redesign

programs of action. If actors from the operating core are not in a position to play a role in

sensemaking and sensegiving, the change process is at risk of creating further destabilization

rather than a new sense of coherence within the organization. The role of the executive team will

be to ensure that enough coherence is maintained around key strategic innovations emerging

from the bottom of the organization along the way. At time of writing, we are seeing that some

of the structural changes are generating their own waves of ambiguity at lower levels, as roles

are being renegotiated on the ground.

Where organizations face high levels of internal tensions or complexity, the tendency is to focus

inward and to assimilate sensemaking activities into core missions and the existing power

structure. While sensemaking activities can be formalized and delegated to a specific person

within the organization, this cannot be sustained in the medium term by ignoring dominant

interpretive schemes (e.g., the hospital's perspective in HSSC3) (Greenwood and Hinings 1996).

If sensemaking is too detached from dominant interpretive schemes and power structures,

sensegiving activities can be blocked and the transformative agenda may not reach the operating

core. The institutional and power bases of sensemaking activities need to be taken into account.

Generated meanings have differential legitimacy and represent varying potential for action

(Weick, Sutcliffe, and Obstfeld 2005).

32

Maintaining linkages with external demands and the environment.

We also observed that in the highly institutionalized environment of the public sector and in a

context of resource dependency, external authorities play critical roles in shaping transformation.

By imposing priorities and by using contracts and others forms of incentives to ensure the

involvement of organizations in various regional or national priorities and experiments, external

authorities create convergence among targeted organizations. Organizations in this context have

to work to construct their own strategic space. They do so by using external signals to gain

legitimacy and by getting involved where they can in innovative projects. They also try to

negotiate the pace by which desired changes will be implemented and to search for local

adaptation. While organizations seem to negotiate the implications of external demands, they

also use it to resist some internal pressures for less radical changes. The connection with the

external environments enrich sensemaking activities and may provide additional incentives for

organizations engaged in the restructuring process.

Pressures to implement certain types of changes for tight deadlines also stimulate the

mobilization by concerned organizations of experts and gurus. These experts appear early in the

process and have a role in helping the organizations making sense of mandated change and

consequently reducing ambiguity. They also intervene along the way to support the organization

in translating pressures from higher authorities into manageable initiatives locally. By playing

this role, they become key actors in sensegiving processes within the organization, and also in

transmitting learning and common conceptions across organizations within the field.

Finally, rich and complex processes such as those we observed do not necessarily produce

innovation. It is too early to assess the innovative potential of the pattern of strategizing and

structuring activities that were developed in reaction to an imposed but ambiguous change.

Processes were put in place in all organizations we studied and innovative structural designs

were adopted in an attempt to reorient the production of care and services. Explicit efforts to

construct new bodies of meanings and to diffuse them across organizational levels and units were

also realized. Among these structuring and strategizing activities, we observed four different

patterns. Overall, the observed patterns in this study of sensemaking (strategizing) and

organizing (structuring) can be summarized by the following labels that characterize each of our

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four cases: “synchronized evolution” characterized by concurrent evolution of sensemaking and

strategizing (HSSC1), “embedded externalization” where strategizing and organizing focuses

mainly on relations with key stakeholders and their expectations (HSSC2), “reactive

conservatism” (HSSC3) where innovative strategizing clashes with in-depth organizing forces

and “constructive consolidation” characterized by the search for an evolving fit between organizing

principles and strategizing (HSSC4). It is difficult to see which of these patterns is more

promising in the long run. Three of our organizations explicitly built on their historical heritage

and worked in continuity with their past, while the one that attempted to function differently was

forced back into a more conservative mode.

Nevertheless, continuity and innovation may not necessarily work in contradiction or opposition

in strategic renewal processes. The abilities of the top management team in shaping meaning, in

surfing on external pressures and opportunities, in identifying effective translators within their

own organization and in setting up opportunities to think about and experiment with change can

make a difference (Denis, Langley, and Rouleau 2007). Time will also play a crucial role.

Changes in the operations of these professionally-based organizations cannot be instantaneous in

situations where extensive sensemaking and sensegiving activities are needed.

Conclusions

What have we learned from this study of the management of strategic change in complex public

sector organizations? Our study deals with professional or knowledge-based organizations where

actors in the operating core have expertise and exert influence through complex networks that

reach beyond formal organizational boundaries. Such contexts are predominant in the

contemporary economy and the chances that ambitious restructurings will also be associated with

high ambiguity is rather high (Lowenthal and Revang 1998). In such contexts, ambiguity will

never be fully resolved at the top and consequently actors in charge of key operations have to

find in their immediate work environment resources and opportunities to accommodate

ambiguity and to engage in transformative practices. In addition, the equilibrium between

sensemaking and organizing activities cannot be achieved simply among the top management

team. Professionals or organizational members of the operating core play a role in the

synchronisation of innovations in organizational design such as program management with

innovative visions and perspectives that guide production. Our study suggests that the need to

34

balance continuity and innovation permeates the implementation of major strategic change, and

that workable accommodations along these two sides of the equation need to be regenerated

again and again at different levels of the organization.

35

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