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2007 39: 150Administration & SocietyCharo Rodríguez, Ann Langley, François Béland and Jean-Louis Denis

Interorganizational NetworkGovernance, Power, and Mandated Collaboration in an

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150

Governance, Power, andMandated Collaborationin an InterorganizationalNetworkCharo RodríguezMcGill University, Montréal, Québec, CanadaAnn LangleyHEC, Montréal, Québec, CanadaFrançois BélandJean-Louis DenisUniversité de Montréal, Québec, Canada

This article explores the challenges of mandated collaboration among publichealth care organizations. This in-depth longitudinal multiple case studyexamines the interests and values of various organizational actors in threecollaborative initiatives, focusing on the mobilization of power within thegovernance frameworks available to them. The authors elaborate on threealternate readings of the processes examined: The managerialist views poorinterorganizational collaboration as a failure to adequately manage theprocess; the symbolic focuses on the value of collaborative initiatives even inthe absence of instrumental results; and the third examines the systemic webof power relationships reproduced over time.

Keywords: mandated interorganizational collaboration; governance; power;values; interests

The topic of interorganizational collaboration has generated enormousresearch interest in recent years as the phenomenon has become more

widespread in both private and public sectors and as managers have strug-gled, sometimes succeeded, but sometimes failed to come to grips with itschallenges (Grandori & Soda, 1995; Griesinger, 1990; A. L. Oliver & Ebers,1998; C. Oliver, 1990; Park, 1996; Provan & Milward, 1995). Interorganizational

Administration & SocietyVolume 39 Number 2

April 2007 150-193© 2007 Sage Publications

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Authors’ Note: This work was supported financially by Health Canada through a NationalHealth Research and Development Program (NHRDP) research funding (#6605-4909-011).



collaboration is intriguing, in particular, because of its paradoxical nature,combining competition and cooperation, and autonomy and interdependence.

Interorganizational collaboration has been tackled from a wide variety ofempirical, theoretical, and methodological angles. For example, theoreticaldebates have raged concerning the relative weight of economic oppor-tunism and relational trust in explaining the initiation, success, and dura-bility of alliances among organizations (Carson, Madhok, Varman, & John,2003; Jones, Hesterly, & Borgatti, 1997; Ouchi, 1980; Ring & Van de Ven,1992; Vangen & Huxham, 2003; Williamson, 1975, 1979). Other theoreti-cal angles used to explain collaboration include knowledge-based theory(Grant & Baden-Fuller, 1995, 2004), agency theory (Milward & Provan,1998, 2000), social embeddedness (Gulati & Gargiulo, 1999; Gulati,Nohria, & Zaheer, 2000), institutional theory (Phillips, Lawrence, & Hardy,2000), and resource dependence or power-based theories of negotiation andcollaboration (Eden & Huxham, 2001; Hardy & Phillips, 1998; Pfeffer &Salancik, 1974). Empirical studies have examined the effects and perfor-mance of interorganizational relationships at organizational (Pfeffer &Salancik, 1974), dyadic (Van de Ven & Walker, 1984), and network (A. L.Oliver & Montgomery, 1996; Provan & Milward, 1995; Provan &Sebastian, 1998; Zollo, Reuer, & Singh, 2002) levels in a wide variety oforganizational contexts. Finally, methods used to study such relationshipshave included cross-sectional surveys (Aldrich, 1976; Zollo et al., 2002),network analyses (Knoke & Rogers, 1979), and in-depth case studies(Hardy, Phillips, & Lawrence, 2003; Provan & Milward, 1995). Some stud-ies have combined multiple methods in large-scale efforts to better under-stand collaboration (e.g., Agranoff & McGuire, 2003).

Collaborative arrangements have recently attracted particular interestamong scholars of public administration, as governmental organizationshave discovered the limitations of the traditional “command and control”models of public policy development and have increasingly participated inpolicy networks that traverse multiple sectors (public, private, and volun-tary) and organizations (see, e.g., Agranoff & McGuire, 2003; Kickert,Klijn, & Koppenjan, 1997; Mandell, 2001). The governance challengesassociated with network management—in which power and operations maybe diffused across multiple public and private partners—have beenaddressed in different ways by Milward and Provan (1998), Lowndes andSkelcher (1998), Kickert and Koppenjan (1997), Klijn (2001), McGuire(2002), and O’Toole and Meier (2004), among others.

Despite the huge development of the body of research on interorganiza-tional relationships and collaboration, very little attention has been paid to

Rodríguez et al. / Mandated Collaboration 151



the study of mandated collaborative relations (Halpert, 1982; Gray, cited inLaurie, 2002) in which collaboration is imposed on separate organizationsby a third party. This research aims to shed some light on this poorly exam-ined topic. In particular, our purpose in this article has been to explore theparticular governance challenges of newly mandated processes of collabo-ration among a complex set of public health care sector organizations overtime. We were interested, in particular, in how the choice of governmentmechanisms affected the success of the collaborative effort. The specificcase examined in this study is the implementation of new forms of interor-ganizational collaboration in an urban health region in Canada following amajor government reform of health service delivery. In particular, we com-pare the governance processes used to implement three different mandatedcollaboration initiatives and relate these processes to the relative success ofthe initiatives in achieving change.

Our point of departure is Gray’s (1989) definition of interorganizationalcollaboration as an emergent process between interdependent organizationalactors who negotiate the answers to shared concerns. More recently, criticalauthors such as Lawrence, Phillips, and Hardy (1999) have described col-laboration as “a cooperative, interorganizational relationship that relies onneither market nor hierarchical mechanisms of control” (p. 481; Hardy et al.,2003, p. 323; Phillips et al., 2000, p. 24; for a similar definition, see Agranoff& McGuire, 2003, p. 23). Drawing on these two definitions, we note thatinterorganizational processes of collaboration generally present two mainfeatures: (a) They are voluntary processes, a characteristic that implies theperception of interdependence between actors, and (b) the mode of regula-tion of exchanges between actors is the clan, a hybrid governance modebetween the hierarchy and the market (Ouchi, 1980), which calls for thedevelopment of shared meaning between actors.

However, the processes we study here differ from those that would beincluded in the definitions of collaboration noted above in that they weremandated (i.e., a third-party organization is attempting to impose collabo-ration on other organizations within its range of influence; Halpert, 1982).Because of its mandated nature, it appears unclear whether this particularinterorganizational cooperative relationship would or should rely on purelyclan-like mechanisms of regulation. Mandated relations can be seen as sim-ilar in many ways to the creation of horizontal linkages between businessunits within the same firm by a corporate parent. As Goold, Campbell, andAlexander (1994) suggest, however, such interventions are harder to pulloff successfully than one might assume, both because of their costs and becausethe partners may feel forced into relationships that appear suboptimal to

152 Administration & Society



them yet potentially beneficial to the firm as a whole. We thus decidedto undertake an in-depth examination of the governance challenges thatactors of a health region faced in implementing these mandated collabora-tive initiatives.

A central argument of the article (elaborated and illustrated below) isthat multiple types of governance mechanisms need to be mobilized foreffective collaboration in a mandated situation, each playing a different role(see also Bradach & Eccles, 1989; De Bruijn & Ten Heuvelhof, 1997;Lowndes & Skelcher, 1998). As we shall see, the data tend to confirm thisproposition and, in particular, the corollary that clan-based mechanismsalone are limited in their capacity to stimulate effective mandated collabo-ration in interorganizational networks where actors have little prior experi-ence of collaboration, different sources of power, and divergent values andinterests. This seemingly simple observation is of great importance becauseof the enormous amount of energy that can be invested in abortive collabo-rative initiatives both in the particular research situation described in thisarticle and elsewhere.

This begs the question: Why? Why, given these problems, do mandatingorganizations—and the organization studied, in particular—invest so heav-ily in developing purely clan-based initiatives while failing to mobilizecomplementary hierarchical and market-based sources of regulation? Asecond contribution of this article is to develop an understanding of howand why this might happen. To achieve this, after presenting empirical datathat illustrate our initial claim, we elaborate on three alternate readings orinterpretations of the processes observed. The first reading is managerial-ist in nature and views poor outcomes as a failure of management expertise:The events occurred because the people involved did not adequately man-age the process. The second reading digs beneath the surface to look at thesymbolic role of collaboration initiatives: In this reading, people are thoughtto have acted as they did at least in part because of the symbolic value ofthese processes rather than their instrumental value. Finally, the third read-ing views all organizations as caught up in a systemic web of power rela-tionships that tends to be reproduced over time: In this view, theserelationships were destined to block collaboration in one way or another,regardless of the mechanisms put in place. We conclude with a discussionof the three readings, attempting to reconcile them by taking a longer termand processual view of change. This trifocal perspective as well as its rec-onciliation could be helpful in understanding other processes of mandatedcollaboration and, more generally, other processes of mandated organiza-tional change.




The remainder of the article is organized as follows. First, we presentsome key theoretical elements that underlie our analysis, emphasizing thegovernance challenges of developing mandated collaboration within a net-work of organizations. Second, we describe the research context and meth-ods. We then present the processes and outcomes of the three collaborationinitiatives. This is followed by the three interpretive readings and a discus-sion of their implications.

Conceptual Background

The analysis in this article builds on the conceptual componentssketched below. In summary, mandated collaboration is viewed as an inher-ently political process that is seen to be regulated by multiple forms of gov-ernance that are linked dynamically over time.

Mandated Collaboration as a Political Process

We view the dynamics of mandated processes of collaboration as funda-mentally political in nature. Put differently, the structuring of interorgani-zational relationships depends on the power, values, and interests of thedifferent partners participating in the process (Pettigrew, 1973, 1979). Theprofessional bureaucratic nature of health care organizations (Mintzberg,1979) as well as the political essence of collaboration itself demand atten-tion to power dynamics (Agranoff & McGuire, 2001; Benson, 1975; Hardy& Phillips, 1998; Phillips et al., 2000).

Specifically, Benson’s (1975) classic work on interorganizational net-works as a political economy, as well as later contributions that developedthese ideas, had a major influence on this research (Hardy & Phillips,1998). This perspective begins from an identification of the main groups ofactors, their values and interests, and power (sources of influence) in theinterorganizational network.

Values and interests reflect the strategic purposes of organizationmembers (Hinings & Greenwood, 1988; Ranson, Hinings, & Greenwood,1980). Whereas values refers to ideological components of purpose, inter-ests refers to the more utilitarian component. For example, Benson (1975)suggests that in interorganizational relationships, agencies will tend todefend their own organization’s paradigm or technological-ideologicalcommitment (i.e., values) while also seeking to ensure a steady flow ofresources in terms of money and authority to enable the accomplishment of





the organization’s mission (related to interests). Drawing on Hardy andPhillips (1998) and Bourdieu (1998), it seems reasonable to assume thatinterests include not only material and political advantages but also sym-bolic ones, related to reputation, prestige, and legitimacy.

In this article, we also adopt Hardy and Phillips’s (1998) conceptionof power dependencies in interorganizational relations as made up offormal authority, control over critical resources, and discursive legitimacy.Organizational power has been extensively explored from very differentperspectives (see, e.g., Bachrach & Baratz, 1962; Clegg, 1989; Dahl, 1957;Etzioni, 1961; Hardy, 1994; Hickson, Hinings, Lee, Schneck, & Pennings,1971; Lukes, 1974; Mintzberg, 1983; Parsons, 1968). Hardy and Phillips’sproposition appears particularly useful here for helping to understand thesocial construction of collaboration in an interorganizational space. Formalauthority refers to a recognized legitimate right to make decisions and isusually associated with hierarchical position. Critical or scarce resourcessuch as money, expertise, or information are a second source of power thatmay create dependencies among organizations. The degree to which con-trol over resources is centralized or dispersed will affect the types of rela-tionships likely to emerge. Finally, discursive legitimacy allows someorganizations and individuals to speak on behalf of issues because of theirability to mobilize support from groups beyond the immediate set of orga-nizations involved in the collaboration (Benson, 1975). In a public healthcare system, this form of power is omnipresent because of the importanceof this issue to the public. In this article, we assume that patterns of formalauthority, resources, and discursive legitimacy will interact with themotives, values, and interests of organizational and individual actors todetermine the forms of collaboration that will emerge.

Mandated Collaboration as Regulated byMultiple Modes of Governance

Scott, Ruef, Mendel, and Caronna (2000) have defined governancestructures as “all those arrangements by which field-level power andauthority are exercised involving, variously, formal and informal systems,public and private auspices, regulative and normative mechanisms“ (p. 173).Among these, the specific mode of governance, called the clan, is Ouchi’sseminal contribution to the hierarchy/market typology of governance ofexchanges proposed by Williamson (1975, 1979). The hierarchy/clan/market framework of governance is thus located in the rationalistic institu-tional economic tradition. Because, as noted previously, collaboration has



been conceptualized as an interorganizational relationship regulated byclan-like mechanisms (Hardy et al., 2003; Lawrence et al., 1999; Phillipset al., 2000), we have considered that this classic trichotomy—still widelyused in the literature—is a helpful starting point in the study of multiplestrategies available to conveners (or mandators) in a situation of mandatedcollaboration. However, we conceptualize hierarchy/clan/market modes ofgovernance not as fixed structures but as entities that are both the mediumand the outcomes of mandated processes of collaboration with which theyare linked through dynamics of power (Ezzamel & Willmott, 1993). As wesee below, Benson (1975) implicitly drew on similar concepts in his workon interorganizational relationships. Typologies used or developed by otherauthors often tend to represent variations or elaborations around this basictrichotomy (e.g., De Bruijn & Ten Heuvelhof, 1997; Lowndes & Skelcher,1998; Osborne, 1997; Powell, 1991). We now define more precisely eachof three governance modes as used in this article.

Bureaucratic or hierarchical mechanisms include management fiat, for-malized rules and regulations, and formal performance monitoring. In hisdiscussion of strategies for social change in interorganizational networks,Benson (1975) refers to these mechanisms as authoritative strategies. Henotes that they may include the creation of new entities within the network,the redesign of interorganizational boundaries, and the specification of for-malized rules for interaction. Only a few agencies in an organizational net-work can intervene in this way—usually those directly linked to a centralgovernmental authority. It is clear that, by definition, mandated collabora-tion involves some degree of use of these mechanisms, if only to conveneparticipants who did not of their own accord see the benefits of voluntaryexchange. In theory, a wide range of regulatory options may be available toa powerful convener. However, as Benson (1975) notes, in a complex net-work of agencies with varied sources of power, this strategy has limits: “Inan authoritative strategy, attention must be paid to the mobilization of polit-ical forces and the formation of an effective coalition” (p. 245). In otherwords, even a powerful agency with formal authority and control overresources (the first two sources of power described above) needs to con-sider whether its interventions will be seen as legitimate.

Whereas bureaucratic mechanisms tend to influence behavior by impos-ing constraints, in contrast, market-based mechanisms of governance relyon incentives that reorient what individuals and groups within an organiza-tion or network are likely to want (i.e., their interests). We take a broad per-spective on the market mechanism that allows for both external and internalprice or incentive mechanisms that reorient people’s behavior. In the context




of change in interorganizational networks, Benson (1975) implicitly refersto this mechanism in his discussion of manipulative strategies that play onagencies’ resource-seeking orientations. These mechanisms might provideone means of stimulating a perception of interdependence among agenciesin a network where this may not exist previously. For example, Gray andHay (1986) have noted that dominant actors in interorganizational networksmay tend to avoid participation in the process of collaboration because theydo not see a need for it, and by participating, they may risk their dominantposition. In a situation of mandated collaboration, however, such actorsmay be forced to participate or risk losing their legitimacy (Halpert, 1982).Because collaborative processes are imposed, they can take on a coopera-tive appearance that, in fact, disguises strategies of preservation of pri-vileged positions (Hardy & Phillips, 1998). The use of market-basedmechanisms in the form of incentives that foster the emergence of interde-pendency among participants could overcome this by changing the interestsof participants in collaboration.

Whereas market-based mechanisms work by manipulating interests,clan-based mechanisms contribute to the development of cooperativevalues. In fact, clan-based governance mechanisms lie at the heart of anycollaborative effort (Lawrence et al., 1999). Clan governance implies bydefinition the existence of shared values and beliefs to enhance coordina-tion. The key mechanisms associated with the development of sharedunderstanding across organizational boundaries involve interactions: face-to-face communication, information exchange, and socialization in commonactivities (Daft & Lengel, 1986; Ouchi, 1980). The creation of interorgani-zational task forces, committees, training sessions, and other joint activitiesshould contribute to the creation of this new interorganizational space(Gray & Hay, 1986). When successful, these mechanisms should allowmutual learning and the creation of a high degree of interorganizationaltrust and consensus on respective domains of activity and modes of inter-vention. This dynamic will favor the construction and management of a setof rules, procedures, values, and symbols that sets up shared meaning(Ouchi, 1980) and sense-making processes (Weick, 1995).

As noted above, we argue in this article that the three types of gover-nance mechanisms all play different but essential roles in stimulating effec-tive collaboration in a situation of mandated collaboration. Althoughbureaucratic mechanisms are necessary to bring partners to the table andestablish rules of engagement, incentives based on market-based mecha-nisms function by altering participants’ interests in collaboration. Finally,we propose that interactions among actors (clan-based mechanisms) can





favor mutual understanding and adjustment by stimulating the creation ofshared meaning and values that enable smooth coordination.

Mandated Collaboration as a Dynamic Process

When an agency initiates a process aimed at creating new interorganiza-tional relationships, the operation takes place over time. Simplifying some-what, we can break down this process into at least two phases or modes ofactivity: (a) a design mode, in which the mandating actor and other partnerscollaborate to design a form of organization that will allow enhanced coor-dination between them in the longer term, and (b) an operating or imple-mentation mode in which operational relationships between organizationsare managed on an ongoing basis. The distinction made here is related tothat suggested by Benson (1975) between the “superstructure” made up ofan equilibrium pattern of work coordination (the operating mode) and thestrategies used by actors within the network to challenge and change exist-ing forms of collaboration (in the design mode). In practice, design andoperations shade into one another: Changes in the second will emerge fromthe first. In addition, both design and operations are regulated by gover-nance mechanisms that may be bureaucratic, market-based, or clan-like.Thus, mandated collaboration is a dynamic path-dependent process inwhich the three governance mechanisms described earlier are both themedium and the potential outcome of collaboration (see also Bryson &Crosby, 1992). The use of rules, incentives, and interactions at the designstage may lead to the production of changes in rules, incentives, and inter-actions to be used in implementation and in the operating mode.

Drawing the above conceptual elements together, the analysis in thisarticle will examine how the political context and the governance mecha-nisms adopted affect the evolution of collaborative relationships over time.Specifically, we expect that the emergence of successful collaboration willbe associated (a) with a political context in which interests and values arealigned with proposed initiatives and (b) with the use of governance mech-anisms that combine elements of hierarchy, market, and clan-based mecha-nisms that are regenerated as the collaboration evolves from design tooperationalization.

Research Context

In 1995, the Regional Health Board studied in this research submitted aplan to the provincial Ministry of Health involving a major reorganization



of health service delivery in the region. This plan was associated with majorbudget reductions to the region and reflected evolving demographic, tech-nological, and economic pressures common to health care systems acrossthe developed world.

The Regional Board proposed a reform plan to achieve “a new balance”within the health care system through (a) the closing of several acute carehospitals, (b) an increase in services provided on an ambulatory care basis,(c) the coordination of all organizational partners around several specificclient groups, and (d) the development of a more significant role for pri-mary care providers, in particular, the neighborhood health and socialservice agencies, called CLSCs (centres locaux de services communau-taires). In other words, the Regional Board proposed moving the regionalhealth care system toward integrated delivery (Leggat & Leatt, 1997;Shortell, Gillies, Anderson, Erickson, & Mitchell, 1996), a form of organi-zation involving collaboration, coordination, and continuity of care acrossorganizational boundaries.

The purpose of this study was to understand the mandated process ofinterorganizational collaboration between CLSCs and their partners (acutecare hospitals and private physicians) to achieve integrated care for patients(e.g., through referrals from hospital to home care provided by the CLSCs).Specifically, we asked, (a) How will the partners initiate and develop col-laboration? (b) What is the form of emerging interorganizational relation-ships? and (c) What factors facilitate or hinder collaboration? In this article,we focus specifically on the role of governance mechanisms in achievingcollaboration, with a particular emphasis on the processes set in motion bythe mandating actor, the Regional Board.

Method

The research design adopted here is a comparative longitudinal casestudy with embedded units of analysis (Yin, 1994). This seems appropriateto develop a rich understanding of how and why collaboration emerges in amandated situation. The embedded units of analysis refer to different timeperiods, different subprocesses, and different relationships within the largernetwork. In this article, we focus on two main time periods and three dif-ferent subprocesses.

The two main time periods are (a) an initial period of design in whichthe Regional Board as mandating actor initiates collaborative processesamong CLSCs and partner organizations in the network, and (b) a second




time period of operationalization in which the network partners build on theresults of the development process to establish ongoing relationships. Threedifferent subprocesses or foci of collaboration were studied. These are(a) posthospitalization care, (b) single entry point program for the elderly,and (c) CLSC-medical clinic coordination. The way in which these initia-tives are constructed and evolve over time is examined across the two timeperiods. The design phase is very much centered on the mandating actor.For the operationalization period, the focus shifts somewhat to CLSCs andtheir partners.

To document the operationalization period, we purposefully sampled fourCLSCs and partners for an in-depth study. First, we selected the two subre-gions slated for earliest implementation of the mandated collaboration effort(subregions 1 and 2). Second, based on our political model, we expected thatthe specific values and interests of CLSCs could have an effect on the way inwhich collaborative arrangements would develop. Therefore, we selectedspecific CLSCs from the available candidates so that they would have differ-ent initial service patterns related to different hypothesized value orientations.Thus, in each subregion, one CLSC was seen to be more community care–oriented, whereas the other was more health services–oriented (Poupart, Simard,& Ouellet, 1986), according to practices in 1995.1 This represents a most-similar/most-different design (Przeworski & Teune, 1970), whose advantageis that it maximizes the possibility of both types of theoretical replicationwithin a small sample (i.e., other things being equal, similar results should beobtained for similar sites, different results for different ones).

For each CLSC, we selected the two hospitals that accounted for thelargest proportion of admissions in their territory. Because the studyincluded two CLSCs from each subregion, this criterion led to overlap inpartners for each of the two CLSCs within the same subregion. Thus, fouracute care hospitals were included in the study as key partners of focalCLSCs. In each subregion, one was a community hospital and the other auniversity hospital (six sites in all because of hospital mergers in subregion2). A number of other partner organizations and individuals (e.g., voluntaryorganizations, private medical clinics) were also sampled by the snowballmethod to determine how their input affected practices.

Data Collection and Analysis

Data collection was carried out longitudinally between December 1995and October 1999. Sources were multiple and included in-depth interviews,observations, and documentary evidence. In total, 94 semistructured interviews




were carried out with managers and staff at the regional level and in theCLSCs and partner organizations. These interviews provided informationabout the characteristics of the organizations (values, interests, expertise,resources, other sources of influence), the strategies and changes imple-mented by them (governance mechanisms used), perceptions of collaborativeprocesses, and the degree of consensus and satisfaction with interorganiza-tional relations.2

Observations were used to obtain firsthand knowledge of the collabora-tion mechanisms in place, as well as to understand the strategies of differ-ent groups. Specifically, the first author was a nonparticipant observer in 44formal meetings between CLSCs, hospitals, and other partners at regionaland subregional levels, as well as a number of organizational meetings inCLSCs and hospitals. Documentary evidence such as minutes of meetings,service protocols, agreements, and reference documents were also con-sulted to provide information on processes, the regulatory framework, andformal linkages between organizations.

The qualitative data were first analyzed using the NUD*IST packageversion 4.0 (Richards & Richards, 1994). The data were coded according tokey themes including values, interests, power, and governance strategies.Seven descriptive case narratives were constructed, building on the the-matic analysis. The first three narratives described the first phase of collab-oration at the regional level, with one case for each of the three subprocessesexamined. The remaining four narratives described the process of collabo-ration surrounding each CLSC and its partners. A cross-case comparativeanalysis was then developed and will be presented here.

In the next two sections, we provide the empirical descriptions necessaryto develop our interpretations. First, following from the initial conceptualframe, we describe the political context surrounding the collaborative processesin terms of the values, interests, and sources of influence of key actors.Then, we examine the processes and, in particular, the governance mecha-nisms used to advance collaboration and their perceived results for each ofthe three subprocesses. This analysis is used to show how and why the gov-ernance mechanisms used contributed to different outcomes. Following thisfirst-level analysis, we explore in more depth the alternate interpretationsthat we briefly introduced at the beginning of the article.

Organizational Actors Involved in Collaboration

Before describing the processes of collaboration, we need to present theorganizational actors involved. In particular, it is important to understand




something of the political context present in the organizational network. Inthe description below, we draw on the categories indicated earlier (powerdependencies, values, and interests), simplifying somewhat the situation bygrouping actors into four categories: the Regional Board, acute care hospi-tals, CLSCs, and doctors.

Regional Board

The Regional Board is like an adolescent. They are learning their autonomy.They are not quite adult. They’ll be adult when they can give orders to thehospitals. (manager, CLSC)

The Regional Board was an agency newly created by the government tooversee health services in the region and, in particular, to allocate a globalbudget among institutions. It is the mandator of the collaborative processesdescribed here. In terms of power dependencies, the Board thus had newlyacquired formal authority, and control over critical resources, but fragilediscursive legitimacy associated with this newness (Stinchcombe, 1965), asillustrated in the quotation above. Also, as we shall see, its control overresources did not extend to the doctors working in the region, who werepaid by a separate government agency.

In terms of values and interests, it is clear that the Regional Board wasconcerned with delivering on the minister’s mandate for a budget cut and atransfer of resources to primary care. Not only was this a chance to demon-strate its competence, but managers also firmly believed that a reduction inacute care infrastructure was long overdue. Discursively, the members ofthe Board positioned themselves as neutral observers of the health carescene, the only group not contaminated by corporate interests and thus ableto speak on behalf of the public: “We are in a very good position to facili-tate that people sit down around the table and talk. We are well positionedto see the whole, as well as to see the different sets of problems of everynetwork” (manager, Regional Board). To consolidate this positioning,while attempting to maintain support among the health care organizationsinvolved, the Board undertook extensive public hearings on its restructur-ing plan. It was these hearings that led to the collaboration attemptsdescribed here.

Acute Care Hospitals

Hospitals are powerful organizations that have some well-connected peopleon their Boards. (manager, Regional Board)




The acute care hospitals had traditionally been the most powerful orga-nizations within the health care network, taking up a large share of thesystem’s financial resources as well as its professional and managementexpertise. Depending on their size and prestige, some had considerableinfluence with central government. The creation of the Regional Board andthe presence of a minister who favored decentralization altered this situa-tion to some extent. The smaller hospitals, in particular, became very vul-nerable and several were closed. With a reduced number of beds in thesystem, all hospitals came under pressure to increase efficiency and reducelengths of stay. One way to achieve this was by the early referral of patientsto home care, creating some dependence on the CLSCs: “It is a matter ofmoney again. Suddenly, they [the hospitals] have realized that they have torelease beds, and that this could pay” (manager, CLSC).

In terms of power dependencies, the acute care hospitals had no formalauthority over other organizations in the system and were dependent on theRegional Board for financial resources. However, they had large budgetsand extensive resources in terms of expertise and information. Because ofthis, the more prestigious institutions retained some discursive legitimacyin the sense that they were seen as able to speak competently about publicneeds (see the leading quote).

The analysis of values and interests at the organizational level is complex,as administrators and medical staff working in hospitals may have conflict-ing goals. For example, whereas administrators are accountable for meetingoperating budgets and therefore have incentives to limit volumes to levelsthat may be accommodated by current resources, physicians have a financialinterest in increasing or maintaining throughput to enhance fee-for-servicerevenues. With regard to issues of collaboration between hospitals andCLSCs, two broad patterns seemed to occur, depending on whether the hos-pital was a teaching institution or a community hospital. In the teaching hos-pitals, values of clinical excellence, combined with interests in treating ahigh volume of patients, tended to create a push toward discharging patientsto community care as soon as possible. In contrast, in the community hospi-tals with a less prestigious medical staff and less intense demand, values ofcontinuing care and interests in maintaining the current clientele created lesspressure (and even reluctance among physicians) for collaboration.

CLSCs (Community Clinics)

We had to combat the idea that CLSCs were worth nothing, that this was nogood, that patients would not be safe. That’s changing. (liaison nurse, hospital)




The region’s CLSCs had more limited financial and human resources thanthe hospitals. However, they all had elected boards of trustees, reflecting theirstatus as autonomous institutions. Each CLSC was responsible for commu-nity health care and social services within a specific geographical territory.

Overall, in terms of power dependencies, the CLSCs benefited from theincreased influx of resources promised in the Regional Board’s restructur-ing plan. Their monopoly over publicly funded home care for a specific ter-ritory created some bargaining power with the hospitals. However, becauseof their small size, they were strongly dependent on the Regional Board interms of formal authority and financial resources. Finally, they were weakin terms of discursive legitimacy (see the quotation above). Polls had shownthat these organizations were little known by the public and there was lim-ited confidence in their ability to take on increased responsibilities. Becauseof their large numbers, small size, and limited influence, the CLSCs oftenallowed their association (the Federation of CLSCs) to argue on theirbehalf.

In terms of values and interests, again, a mix of factors came into play.Generally, the CLSCs were interested in expanding their role and thus inenhancing their legitimacy. However, they were also protective of theirautonomy. Depending on their history and values (previous emphasis onhealth care vs. community services), individual CLSCs might be more orless responsive to demands for collaboration with medical clinics and hos-pitals. Over and above these value concerns, all CLSCs received historicallybased budgets independent of the volume of services offered in the shortterm. Thus, although interested in an expanded role, they were also con-cerned to avoid being overwhelmed by demands that they could not meet.“I had the impression that there was a mobilization—a force that reallywanted to move . . . but now, it seems the wheel has turned back—thingsmustn’t overflow too much” (manager, hospital). In sum, the CLSCs’approach to the Regional Board’s reforms was positive but cautious.

Physicians

Doctors are very very autonomous as an association and very autonomous indi-vidually. Nobody has control over the medical group. (manager, Regional Board)

Physicians control key expertise and access to care. The majority ofbasic medical care is offered in private practice clinics. Physicians are paidby a government agency on a fee-for-service basis. Fees are negotiated cen-trally between the physician associations and the government and must




cover expenses to run the practice, unless the professional activities takeplace in a public institution (e.g., a hospital).

In terms of power dependencies, most physicians, even those working inhospitals, see themselves as independent entrepreneurs rather than employ-ees. They are thus relatively free from formal authority. At the same time,they hold professional authority over other professional groups and are for-mally represented in the governance structures of the Regional Board andthe hospitals. In terms of resources, they are key holders of expertise andfinancially independent of the Regional Board and the hospitals. Finally,physicians are a high status professional group in whom the public tend tohave confidence concerning health care matters. They therefore also havehigh discursive legitimacy.

In terms of values and interests, physicians, like other groups, maydevelop a variety of perspectives. Generally, the care of patients is a keyconcern based both on training and on professional norms. The dominantfinancial incentive system partly supports this orientation, placing physi-cians in a situation where activities associated with direct patient care aremore remunerative than others. This also means that participation in activ-ities not directly compensated will require some commitment to noneco-nomic values, or a longer term perspective. Physicians generally also appreciateand are protective of their autonomy and have in the past strongly resistedattempts to reduce their role in governance structures.

In summary, this section has sketched some of the power dependencies,values, and interests in play as the newly created Regional Board attemptedto implement a new form of collaboration between hospitals, CLSCs, andphysician groups on a variety of issues. In terms of power dependencies, wesee that despite legitimate authority and control over extensive financialresources, the Regional Board as mandator was faced with a set of semiau-tonomous organizations with their own sources of power and legitimacy. Italso had to deal with a very powerful professional group whose involvementwas important for success but whose individual autonomy was such that theirparticipation could not easily be guaranteed. In terms of values and interests,we see a complex mix of goals driving the different groups. In the followingsections, we describe how these played out and interacted with the gover-nance mechanisms adopted for the three different subprocesses under study.

Processes of Mandated Collaboration

The process of change in the health care system began immediately afterthe publication of a final reform plan in June 1995. While proceeding with





the closing of several acute care hospitals, the Regional Board put in placethree committees to study modes of collaboration between hospitals andprimary care agencies to ensure smooth patient referrals. The first commit-tee studied approaches to collaboration between hospitals and CLSCs foracute care patients (subprocess 1), the second discussed the implementationof a single entry point program for the frail elderly (subprocess 2), and thethird attempted to stimulate collaboration between private medical clinicsand CLSCs to improve access to basic medical care (subprocess 3). In eachcase, the committees were designed to be representative of the main stake-holders involved in the issue. In each case, these processes were launchedand pursued through the preparation and discussion of documents. In vari-ous ways, each process then proceeded with a broader consultation beforeterminating its work and “handing over” to other levels for operationaliza-tion. We now describe how each of these three subprocesses evolved, focus-ing specifically on the governance mechanisms put in place to manage theprocess and the results obtained. Table 1 summarizes the comparisonbetween the three subprocesses according to the conceptual categoriesintroduced earlier.

Subprocess 1: Acute Care

Of the three subprocesses examined, this is the only one that could bequalified as a moderate success (see Table 1). By the end of the study, thereferral process of acute care patients between hospitals and CLSCs wasseen to function relatively smoothly, although the extent of coordinationachieved was variable from one setting to another. This relative success canbe related partly to the governance strategies used. Unlike the otherprocesses considered, both clan-like and hierarchical governance mecha-nisms were mobilized here. Their use was assisted by the development of amodel for collaboration that appeared compatible with the interests of thevarious participants. We describe the process in two phases.

Phase 1: Design. The Regional Board initiated the process by setting upa committee of professionals from CLSCs and hospitals to develop a refer-ence document. The region’s hospitals, CLSCs, and the regional medicaladvisory council were then consulted in writing and gave their feedback onthe document. This was then revised and finalized. Thus, as indicated inTable 1, the governance mechanisms in play at this stage were largely clan-like, involving interactions among representatives of different groups witha view to arriving at some kind of consensus on the rules to be followed.

(text continues on p. 171)



Tabl

e 1

Pow

er D

epen

denc

ies,

Val

ues,

and

Inte

rest

in t

he N

etw

ork:

Som

e R

efle

ctio

ns

Reg

iona

l Boa

rdA

cute

Car

e H

ospi

tals

CL

SCs

Phys

icia

ns

“Too

man

y th

ings

go

on in

par

alle

l

betw

een

the

gove

rnm

ent a

nd th

e

med

ical

ass

ocia

tions

. Doc

tors

are

very

ver

y au

tono

mou

s as

an

asso

ciat

ion

and

very

aut

onom

ous

indi

vidu

ally

. Nob

ody

has

any

cont

rol o

ver

the

med

ical

file

.”

(Reg

iona

l Boa

rd m

anag

er)

“I u

sual

ly ta

lk to

phy

sici

ans,

and

they

hav

e th

e ch

ance

to h

ave

a

grea

t mob

ility

so

if it

doe

sn’t

wor

k he

re,t

hey

can

wor

k in

a

priv

ate

clin

ic,t

hey

can

go to

othe

r C

LSC

s,an

d th

is is

just

wha

t the

y do

.”(C

LSC

nur

se)

“I h

ave

to a

dmit

...L

ook,

whe

re I

was

bef

ore

[a C

LSC

],al

l the

hom

e ca

re n

urse

s (t

hey

are

mor

e

or le

ss a

s ol

d as

me)

,whe

n th

ey

knew

the

impl

emen

tatio

n of

the

ambu

lato

ry s

hift

,and

they

had

to h

ave

mor

e ac

ute

case

s,w

hich

wou

ld n

eed

a lo

t of

care

tech

-

niqu

es,t

hey

all l

eft (

hosp

ital

nurs

e)

“The

CL

SCs

are

not a

ble

to d

eliv

er

med

ical

car

e...

. Con

sequ

ently

,

whe

n w

e ta

lk to

the

CL

SCs

arou

nd a

pro

ject

that

incl

udes

med

ical

car

e,w

e kn

ock

agai

nst

a w

all.”

(hos

pita

l man

ager

)

“We

had

to c

omba

t the

idea

that

CL

SCs

wer

e w

orth

not

hing

,tha

t

this

was

no

good

,tha

t pat

ient

s

wou

ld n

ot b

e sa

fe. T

hat’s

chan

ging

.”(h

ospi

tal l

iais

on

nurs

e)

“Hos

pita

ls a

re p

ower

ful

orga

niza

tions

who

hav

e so

me

wel

l-co

nnec

ted

peop

le o

n th

eir

Boa

rds.

”(r

egio

nal m

anag

er)

“A h

ospi

tal w

as im

port

ant

acco

rdin

g to

the

num

ber

of it

s

beds

,but

now

it is

not

like

that

,the

num

ber

of b

eds

is

com

plet

ely

seco

ndar

y. Y

ou c

an

find

pre

-sur

gica

l clin

ics,

you

have

spe

cial

ized

clin

ics.

...

Thi

s ha

s ta

ken

a te

rrif

ic

size

....

”(h

ospi

tal m

anag

er)

“We

have

the

pow

er b

ut a

t the

sam

e tim

e w

e ha

ve p

artn

ers.

Peop

le in

the

fiel

d ha

ve a

rig

ht

to th

eir

say.

”(r

egio

nal

man

ager

)

“The

reg

ulat

ory

bodi

es

[Reg

iona

l Boa

rd]

are

very

impo

rtan

t bec

ause

if th

ey

don’

t set

an

orie

ntat

ion,

in

the

fiel

d—it’

s no

t exa

ctly

chao

s,bu

t it’s

a f

ree

for

all.”

(CL

SC m

anag

er)

“The

Reg

iona

l Boa

rd is

like

an

adol

esce

nt. T

hey

are

lear

ning

thei

r au

tono

my.

The

y ar

e no

t

quite

adu

lt. T

hey’

ll be

adu

lt

whe

n th

ey c

an g

ive

orde

rs to

the

hosp

itals

.”(C

LSC

man

ager

)

Pow

er d

epen

denc

ies

167

(con

tinu

ed)



“The

cur

rent

pro

blem

in th

e he

alth

care

sys

tem

is q

uite

less

the

ques

tion

of r

emun

erat

ion

than

wor

k co

nditi

ons,

for

phys

icia

ns

amon

g ot

hers

.”(h

ospi

tal

man

ager

)

“The

re is

no

phys

icia

n,no

one

of

our

phys

icia

ns a

ccep

t her

e to

wor

k on

wee

kend

s.”

(CL

SC

nurs

e)

“Hon

estly

,I h

ave

to te

ll yo

u th

at

I’ve

no

idea

abo

ut th

e si

ngle

entr

y po

int f

or e

lder

ly. W

e st

op

here

bec

ause

I a

m n

ot r

elat

ed to

this

.”(C

LSC

phy

sici

an)

“The

CL

SCs,

in g

ener

al,t

hey

reje

ct n

othi

ng w

hen

we

refe

r a

patie

nt. S

omet

imes

,som

e C

LSC

s

argu

e m

ore

...b

ut w

e

feel

...M

e,w

hen

I pa

rtic

ipat

e

in th

e co

mm

ittee

,I f

eel a

s th

ey

have

a g

uidi

ng,t

hey

reje

ct

noth

ing.

Nev

erth

eles

s,in

the

real

life

,...

som

etim

es th

e

proc

ess

is lo

ng.”

(hos

pita

l

man

ager

)

“The

re w

as a

nam

ed w

ill,b

ut w

as

ther

e a

real

will

? O

r ea

ch o

ne

was

ther

e to

inte

nd to

mai

ntai

n

as m

uch

as p

ossi

ble

its in

tere

sts.

”

(CL

SC m

anag

er)

“I h

ad th

e im

pres

sion

that

ther

e

was

a m

obili

zatio

n,a

forc

e th

at

real

ly w

ante

d to

mov

e..

.but

now

,it s

eem

s th

e w

heel

has

turn

ed b

ack.

Thi

ngs

mus

tn’t

over

flow

too

muc

h.”

(hos

pita

l

man

ager

)

“Aga

in,i

t’s a

que

stio

n of

mon

ey.

Sudd

enly

,the

y [h

ospi

tals

]

real

ized

that

they

had

to f

ree

up b

eds

and

that

this

wou

ld b

e

prof

itabl

e.”

(CL

SC n

urse

)

“I th

ink

that

tryi

ng to

lim

it th

e

leng

th o

f st

ay to

its

stri

ct

expr

essi

on is

a g

ood

idea

....

A h

ospi

tal e

piso

de

shou

ld b

e an

epi

phen

omen

on

in a

ny h

uman

bei

ng li

fesp

an.”

(hos

pita

l man

ager

)

“We

are

in a

ver

y go

od p

ositi

on to

faci

litat

e pe

ople

sit

dow

n ar

ound

the

tabl

e an

d ta

lk. W

e ar

e w

ell

posi

tione

d to

see

the

who

le,a

s

wel

l as

to s

ee

the

diff

eren

t set

s of

pro

blem

s

of e

very

net

wor

k.”

(Reg

iona

l

Boa

rd m

anag

er)

“The

idea

l pos

ition

that

we

have

n’t q

uite

obt

aine

d is

to b

e

perc

eive

d as

an

obje

ctiv

e

orga

nize

r w

orki

ng in

the

inte

rest

s of

the

popu

latio

n.”

(Reg

iona

l Boa

rd m

anag

er)

“We

put f

orw

ard

a pr

ojec

t tha

t is

flex

ible

,but

with

a u

nity

of

thou

ght.

We

did

not w

ant a

deba

te o

n st

ruct

ures

...w

e

wan

ted

the

proj

ect t

o pa

ss.”

(Reg

iona

l Boa

rd m

anag

er)

“It’s

not

true

that

we’

re c

reat

ing

a

syst

em b

y tr

ying

to s

et u

p

cons

ulta

tive

com

mitt

ees.

To

me,

the

who

le d

amne

d th

ing

is a

bloo

dy w

aste

of

time,

whe

n

ever

yone

,lef

t and

righ

t,is

tryi

ng

to lo

ok o

ut f

or h

is o

r he

r ow

n

inte

rest

s.”

(hos

pita

l man

ager

)

Val

ues

and

inte

rest

s

Not

e:C

LSC

s =

cent

res

loca

ux d

e se

rvic

es c

omm

unau

tair

es.

168

Tabl

e 1

(con

tinu

ed)

Reg

iona

l Boa

rdA

cute

Car

e H

ospi

tals

CL

SCs

Phys

icia

ns



Tabl

e 2

Gov

erna

nce

Mec

hani

sms,

Pow

er,a

nd M

anda

ted

Col

labo

rati

on

Subp

roce

ss 1

:Acu

te C

are

Subp

roce

ss 2

:Eld

erly

Car

eSu

bpro

cess

3:M

edic

al S

ervi

ces

Reg

iona

l Boa

rd (

man

dato

r)C

LSC

sPr

ivat

e do

ctor

s

Inco

mpa

tible

inte

rest

s:D

octo

rs n

ot in

tere

sted

in c

onst

rain

ing

thei

r m

odes

of

prac

tice

or ta

king

on

less

lucr

ativ

e re

spon

sibi

litie

s

Mos

t pow

erfu

l act

ors

are

not i

nter

este

d

Reg

iona

l Boa

rd (

man

dato

r)C

LSC

sA

cute

car

e ho

spita

lsL

ong-

term

-car

e ho

spita

lsD

ay c

are

cent

ers

Com

mun

ity o

rgan

izat

ions

Doc

tors

Com

plex

ity a

nd d

iver

genc

e of

inte

rest

san

d va

lues

:H

ospi

tals

’int

eres

t in

redu

cing

clie

ntel

e,bu

t wis

h to

con

trol

refe

rral

s to

long

-ter

m c

are

CL

SCs’

inte

rest

in r

ole

deve

lopm

ent,

but w

arin

ess

ofex

cess

ive

dem

and

and

unde

sire

dac

coun

tabi

litie

sR

esis

tanc

e of

long

-ter

m c

are

and

com

mun

ity g

roup

s to

dom

inan

tro

le o

f C

LSC

s D

octo

rs w

ishi

ng to

ret

ain

poss

ibili

tyof

dir

ect r

efer

rals

Dis

pers

ion

of p

ower

and

inte

rest

s

Reg

iona

l Boa

rd (

man

dato

r)A

cute

car

e ho

spita

ls

CL

SCs

Doc

tors

Rel

ativ

e fi

t with

inte

rest

s an

d va

lues

of

acto

rs:

Hos

pita

ls’i

nter

est i

n be

d re

duct

ions

and

low

er le

ngth

of

stay

C

LSC

s’in

tere

st in

rol

ede

velo

pmen

t,bu

t war

ines

s of

exce

ssiv

e de

man

ds

Doc

tors

’int

eres

t in

incr

easi

ngth

roug

hput

(es

peci

ally

inun

iver

sity

hos

pita

ls)

Mos

t int

eres

ted

acto

rs (

hosp

itals

) ar

epo

wer

ful

Mos

t pow

erfu

l act

ors

(doc

tors

) no

tne

cess

arily

dee

ply

invo

lved

Mai

n ac

tors

invo

lved

Patte

rn o

f in

tere

sts

and

valu

es

Pow

er d

epen

denc

ies

169

(con

tinu

ed)



Cla

n-ba

sed

inte

ract

ions

onl

yIn

tera

ctio

ns/c

lan

Doc

umen

tsTa

sk f

orce

Con

sulta

tions

ani

mat

ed f

acili

tate

d by

lo

cal p

eopl

eM

eetin

gsH

iera

rchy

Non

eIn

cent

ives

Non

eN

ot s

ucce

ssfu

l (0)

No

impl

emen

tatio

n

Cla

n-ba

sed

inte

ract

ions

and

unc

lear

rul

esIn

tera

ctio

ns/c

lan

Doc

umen

ts

Task

for

ce

Con

sulta

tions

Tra

inin

g pr

ogra

mH

iera

rchy

Del

egat

ion

base

d on

unc

lear

rul

esIn

cent

ives

Non

e

Lim

ited

succ

ess

(+)

Few

rea

l res

ults

Con

fuse

d im

plem

enta

tion

Cla

n-ba

sed

inte

ract

ions

and

cle

ar r

ules

Inte

ract

ions

/cla

nD

ocum

ents

Task

for

ceC

onsu

ltatio

nsH

iera

rchy

D

eleg

atio

n ba

sed

on c

lear

rul

esE

valu

atio

n of

out

com

esIn

cent

ives

L

engt

h of

sta

y ta

rget

s fo

r ho

spita

lsN

o ch

ange

in m

eans

of

fina

ncin

gM

oder

ate

succ

ess

(++)

Impl

emen

tatio

n of

ref

erra

lpr

otoc

ols

mos

t suc

cess

ful w

here

subn

etw

ork

Is c

entr

aliz

edN

o m

edic

al tr

ansf

ers

Gov

erna

nce

mec

hani

sms

used

to e

ncou

rage

colla

bora

tion

Res

ults

Not

e:C

LSC

s =

cent

res

loca

ux d

e se

rvic

es c

omm

unau

tair

es.

170

Tabl

e 2

(con

tinu

ed)

Subp

roce

ss 1

:Acu

te C

are

Subp

roce

ss 2

:Eld

erly

Car

eSu

bpro

cess

3:M

edic

al S

ervi

ces



The committee achieved agreement on a document that incorporated aseries of key provisions (called “objectives/expected results”) that becamethe core of the relationship between hospitals and CLSCs concerning acutecare patients. The most significant of these were the development of acommon referral form and procedure and the identification of a personresponsible for handling litigious cases in each organization. In this case,the clan-based process thus led to a hierarchically based set of rules thatwere largely followed in the implementation phase following a specificrequest from the Regional Board:

We realized that there were no relationships between hospitals and CLSCs,or they were very scarce. At that time, we decided to formulate a regionalpolicy blueprint named “Modes of Articulation Between Hospitals andCLSCs.” In 6 months, more or less, we carried out consultations and devel-oped content with an advisory board in order to clearly determine what werethe regional rules that the Regional Board would give to each hospital andeach CLSC. . . . In addition, we defined the performance goals to be respectedin transfers from hospitals to CLSCs. And we also defined transfer tools. Weorganized training sessions, involving people from the field and asking themto disseminate our regional frame. (manager, Regional Board)

Phase 2: Operationalization. Once the framework document had beendeveloped, the Regional Board delegated implementation to the organiza-tions involved. The referral form and procedures became the main tools inthis process. Thus, hierarchically based governance mechanisms were in clearevidence (see Table 1):

Regarding the acute-care clientele, expectations were very clear: the CLSCs’responsibility within 24 hours after discharge, information from the hospitalto the CLSC about discharge . . . well, it was very operational, a way wasopened and we made it work. (manager, CLSC)

Simultaneously, the staff of the Regional Board developed a series ofindicators and an evaluation process to determine the extent of implemen-tation of its plan, adding some incentives to the mix. However, the Boardalso encouraged the development of local coordinating committees in thesubregions to discuss joint issues and work out the details of referral proto-cols for specific categories of patients. Thus, clan-based interactions wereagain instituted at the more operational level. These interorganizational com-mittees involved hospitals and CLSCs in close geographic proximity to oneanother. We examined the processes developed in two different subregions.




Some clear differences were observed. Again, these can be related to theextent to which some form of common bureaucratic rules could be devel-oped to regulate exchanges between the different organizations in additionto clan-like interactions. The capacity to build common rules was in turnrelated to the structure of the two subnetworks.

Subregion 1 was geographically relatively self-contained at one end ofthe city. It was dominated by a single large teaching hospital surrounded byseveral CLSC territories. The large hospital took the lead in developing andnegotiating treatment protocols with the CLSCs. This organization was con-cerned, in particular, with achieving smooth referrals to the CLSCs so that itcould increase patient throughput and reduce lengths of stay. The CLSCsappreciated having clear rules to follow, although some found the hospital’sdemands difficult to meet. The two smaller community hospitals in the sub-region recognized the leadership of the teaching hospital and were only toohappy to accept the same protocols: “The hospital definitely led the wayconcerning clinical protocols. By contrast, it was agreed that whenever theyworked on a new protocol, a CLSC representative had to be there. But theyset the rhythm. Definitely!” (manager, CLSC). Thus, hierarchical mecha-nisms were observed in this subregion. Similar to Provan and Milward’s(1995) case of mental health services, the centralization of the region arounda key agency was a factor that assisted successful collaboration.

In contrast, subregion 2 had a highly fragmented interorganizationalstructure. The two main referring hospitals were both undergoing a processof merger, so the development of relationships with the CLSCs was com-plicated by internal integration difficulties. In addition, the two hospitalseach organized their own interorganizational committees with the CLSCs.Thus, the CLSCs in our study found themselves sending representatives totwo different subregional task forces, each operating in different ways. Thisresulted in more haphazard implementation:

It makes no sense—their personnel have to adapt to two or three protocolsthat all have their little particularities. I think that for the quality of care,for client follow-up, it’s terrible—but who should take the lead with that?(manager, hospital)

In summary, whereas subregion 1 developed new hierarchical andclan-based mechanisms to consolidate interorganizational relationships,subregion 2 relied on a thinner governance base. The bureaucratic rules inplace never extended beyond those established centrally, and the clan-basedgovernance structure was partial and fragmented. The result was that this





subregion did not attain the same level of coordination. Nevertheless, as wesee below, the development of collaboration for acute care was much moresuccessful than either of the other two processes set in motion by theRegional Board.

Subprocess 2: Elderly Care

The development of a single entry point program for the elderly wasanother of the key measures proposed by the Regional Board in its overallreorganization plan for the region. The idea was to improve coordination ofthe multiplicity of services available to the frail elderly by centralizingreferrals and case management within one agency: the CLSCs. The CLSCswere to take responsibility for identifying and following up with elderlypeople at risk in their territory. They were also to become responsible fordeveloping plans for care in the community and making referrals to nurs-ing homes, if necessary.

The process used to design and implement this program was similar inmany ways to that described above for acute care. However, it involved amuch wider range of agencies, including day care centers, rehabilitationcenters, and nursing homes as well as acute care hospitals, CLSCs, andphysicians. The process was not seen as successful (see Table 1). A greatdeal of energy was expended in committees, information sessions, andtraining programs. However, 6 months after the so-called “D-day” whenthe program was due to be implemented, a senior Regional Board officialdeclared it “dead.” We argue that this failure is related to the almost exclu-sive use of interactive clan-like mechanisms to develop modes of collab-oration in a context where interests and values were largely divergent andwhere there was no a priori shared conception of what single entry pointmeant. As above, we describe the processes set in motion in two phases.

Phase 1: Design. The Regional Board used a very similar process todevelop this program as it occurred for the acute care subprocess. Asbefore, discussions took place around a reference document prepared ini-tially by the permanent staff (see Table 1). The discussions revealed widedifferences between the participants concerning the role of the CLSCs, thedefinition of the “frail elderly,” and the need for and role of a case manager.Some agencies were uncomfortable with the idea that elderly people couldnot be referred directly to them for services but would have to go throughthe CLSCs. Rehabilitation centers were concerned that centralization ofreferrals to nursing homes in the CLSCs would delay the rapid referral



processes already in place. However, all the participants agreed on onething—that the Regional Board should more clearly define the elements ofthe program: the clients to be served, the roles of various agencies, the pro-cedures to be followed, the role of the case manager, and so on: “There’s afrustration that we all have because we each have a different perception ofwhat it is. And the frustration is—why doesn’t the regional board just tellus what it means? That’s all of us” (manager, hospital).

In other words, the committee members were demanding clear rules(i.e., hierarchical mechanisms), although there was no agreement aboutwhat those rules should be. The permanent staff of the Board was notwilling to impose such rules and continued to maintain that the detailscould be better worked out among the organizations directly involved; inother words, they delegated the creation of forms of complex collabora-tion largely to clan-like interactive mechanisms at a lower level: “If wecould agree with our partners on what the single entry point programwas, it might be interesting, but it’s still a pretty vague notion” (manager,hospital). Nevertheless, they announced an implementation date for thevaguely worded program and embarked on training programs for profes-sional staff in the CLSCs on the program and the case management role.We observed several training meetings. At each one, professionals raisedquestions about the same outstanding issues; at each one, they receivedthe same evasive answers—the details would have to be worked outlocally.

Phase 2: Operationalization. Although the staff in the organizations weobserved were familiar with the language of the single entry point program,their interpretations of what this meant were highly variable: “It would beinteresting if we and our partners could agree on what a single entry systemis, but this is still a somewhat nebulous concept” (manager, CLSC). In fact,the program was never really implemented and almost no collaborationtook place between the CLSCs and other organizations. Some members ofthe hospitals claimed that they had started referring elderly people to theCLSCs for the program but gave up when they found that this was neverfollowed up by the CLSCs. One of the CLSCs developed a program exclu-sively to manage care for the elderly in the community who were not serveddirectly by the CLSC. In other CLSCs, no effort was made to implementcase management and the pattern of referrals to community care and nurs-ing homes scarcely changed. Indeed, overall, the intensity of demand foracute care follow-up was so high that there was little time, attention, andfunds left for this responsibility:





The single entry point program was a very broad concept—very weak inoperational terms. So that generated a lot of pussyfooting around. It renderedeveryone insecure and generated different understandings of roles. (socialworker, CLSC)

In summary, although the Regional Board mandated the single entrypoint program and thus the process of interorganizational collaborationconcerning elderly care, the agencies that were delegated to implement itwere left very much to their own devices. Clan-like interaction mechanismswere the main mode of governance in a situation where there was nocommon understanding about the objectives and modalities of this programand limited incentives to collaborate to create them. Although the hospitalsmight have been interested in ensuring that elderly patients spent less timein the hospital, they had privileged access to the long-term-care system, andthe involvement of CLSCs would tend to delay things. For the CLSCs,under pressure to deliver increased acute care and chary of the discourse ofaccountability surrounding the case management role, this was additionalwork, responsibility, and internal reorganization that they did not necessar-ily relish. With no clear rules, and multiple other pressures to attend to, theorganizations involved simply continued much as before.

Subprocess 3: CLSC–Medical Clinic Coordination

The third subprocess was even less successful than the preceding one. Itinvolved a measure that the Regional Board had put forward to ensure thatprimary care medical services would be available 24 hours per day, 7 daysper week in all CLSC territories, either within the CLSC itself or in privatemedical clinics. The idea was to avoid unnecessary emergency room hospi-tal visits outside normal hours, given the pressure hospital closures werelikely to place on hospital services. Again, the Regional Board relied exclu-sively on clan-like mechanisms in a situation where the pattern of powerdependencies and interests played against collaboration (see Table 1).

Specifically, as for other processes, the Regional Board set up an advisorycommittee to develop a document describing the proposed arrangements.The committee mainly involved physicians, including representatives ofprivate practitioners and CLSCs. After two meetings, a newly hired doctorworking for the Regional Board submitted a draft to the group. The physi-cians present reacted negatively to the document because it appeared tosuggest that the Regional Board would be imposing modes of functioningon the private clinics (i.e. establishing hierarchical rules). They felt that this



approach would be very shocking to the private practice group and wouldlead them to strongly resist collaboration. They argued that the only way toobtain some kind of agreement would be to draw attention to the need tojointly solve problems (i.e., rely exclusively on clan mechanisms). The doc-ument was therefore toned down, losing clarity in the process.

Once the group was satisfied with the document, they decided to facili-tate a series of meetings with doctors in a sample of territories viewed aspromising locations to develop some form of collaboration. These meetingswere a great disappointment. They were poorly attended and participantsspent considerable time discussing why doctors might participate in theproposed scheme, given the nature of incentives, which did not favor homevisits or late hours. The Regional Board had little to offer on this front,although some facilitators argued that participating in this voluntaryprocess of collaboration might be a way of ensuring that more coerciveprocesses on the policy table could be avoided (an implicit threat). The dis-cussions produced no commitments to any form of future collaboration:

We never succeeded in getting collaboration. For all sorts of reasons, habits,or lack of experience, also questions of payment or modes of control. Doctorsdon’t trust the Regional Board. We’re seen as the bureaucrats who complicatesimple things. Yet, in this case, all we were trying to do was to improveservice for the population. (manager, Regional Board)

At a postmortem meeting, the Regional Board’s advisory committeeconcluded that the effort had failed. The senior administrator presentargued that what was needed was a clearer reference document that wouldspell out in more detail what kind of program would be implemented—animplicit return to the attempt to impose or agree on hierarchical rules thathad earlier been condemned. A new doctor working for the regional boardwas delegated to undertake this task. However, no document was produced.Moreover, 5 years later, the Regional Board is still struggling to find waysto achieve full-time coverage of basic medical services.

If we take the three subprocesses as a group, we see that the effortsinvested in creating collaborative networks among partners produced some-what disappointing results, and especially in the last two cases. Most striking,physicians even within the CLSCs remained indifferent and uninvolved.However, most hospitals and CLSCs did develop formal protocols thatallowed increased follow-up of acute care in the community. Subprocess 1was thus the most successful, subprocess 2 was limited in its effect, andsubprocess 3 clearly failed (see Table 2).




In the following sections of the article, we develop different interpreta-tions of these observations in three successively deeper “readings.”

Understanding Processes andOutcomes: Three Readings

First Reading: A ManagerialistPerspective—The Role of Governance Mechanisms

How can the outcomes of these three attempts at collaboration be under-stood? From the cases, we argue that the mix of governance mechanismsused, combined with the power, values, and interests of participating actors,provides a first explanation of the results of the three subprocesses as weexpected initially. In particular, we see that despite its formal authority andconsiderable power over resources, the Regional Board relied mainly oninteractive clan-based mechanisms of meetings, consultation, consensusbuilding, and documentation. Overall, its formal authority was used to con-vene participants to meetings and training sessions and to initiate solutions,but it hesitated to impose rules and modes of collaboration when there wasdisagreement. Its control over resources was used to reallocate money tothe CLSCs to enable them to increase services, to pay for training sessions,and for people to work on committees, but only very limited attempts weremade to change the incentives used to reward collaborative effort. In thecase of the acute care process, the Board came up with a set of minimalrules with which the participating organizations could agree. Thus, theyproduced a hierarchical mechanism of coordination that allowed some con-vergence. For the other two processes, however, no such clarity was forth-coming, with the result that much effort was expended with little result (seeTable 1). As one frustrated observer noted, “It is not true that we are creat-ing a system by trying to set up consultative committees. To me, the wholedamned thing is a bloody waste of time, when everyone, left and right, istrying to look out for his or her own interest.”

We argue that this result was theoretically predictable given the meansused. Although clan-based interactions might enable participants to learnabout each other and come to share ideas, they had little motivation to do soin the cases presented here. By its restraint in using formal authority, theRegional Board provided little basis around which collaborative efforts mightform, and by its restraint in the use of incentives, it did not stimulate interestin collaborating when this was not already present. In summary, the data tendto confirm the idea that clan-based mechanisms alone, although essential, are




insufficient to stimulate collaboration in a mandated situation. At first sight,this suggests that the Regional Board might have done more, and perhapsespecially so in the case of subprocess 2 where the power of the physicianswas not a major issue. The question then arises, why did they not do more?

The simplest explanation for this, and one that came rapidly to mind forseveral people we interviewed, was that as a new organization founded onthe basis of people who were previously employees of a purely advisorybody, the Regional Board lacked the expertise and the confidence requiredto do what needed to be done: “I often think that the Regional Board lacksexpertise on the ground.” Or as another manager noted, “They have becomean organization where you not only have to plan, you also have to opera-tionalize the plan. . . . Their planning was excellent, but success now dependson operationalization.” This interpretation also lies behind the earlier quo-tation describing the Board as “an adolescent” that needed to learn how totell hospitals what to do. Indeed, as the Regional Board’s managers them-selves noted, the shift to a more operational and directive role did notalways come easily: “Before we could only work with consensus. Sometimesthe consensus was significant, but often it was not. Now, we still try to getbuy-in from most people. But I believe we are developing an attitude ofdecision-makers.”

In summary, there is considerable evidence that the governance mecha-nisms put in place by the Regional Board were not perfectly adjusted to thetask at hand. A purely managerialist perspective leads to a rather criticalview of the Board’s management of these situations.

Second Reading: A SymbolicPerspective—The Intrinsic Value of Process?

An alternate interpretation of the events is that at least some of theprocesses set in motion were destined to fail, that the participants perhapssuspected that this was the case, but that they continued because theprocesses themselves had some intrinsic value in and of themselves to thepeople who participated in them. To elaborate on this possible explanation,we need to introduce a little more empirical analysis of the historical con-text in which these events occurred and, in particular, the origin of the col-laboration projects.

As noted above, the three processes were initially proposed in the con-text of a comprehensive plan for restructuring the health care network. Themost controversial aspect of this plan was the closure of several hospitals.This was a remarkable decision in a system where earlier initiatives to




convert acute care hospitals to long-term care had collapsed amid vociferouspublic opposition. In 1995, although fiscal pressures and new technologiesreducing the need for beds made hospital closures more plausible, the taskof convincing the public and providers that closing hospitals could lead toimproved health care was still a formidable one. That task fell to theRegional Board, mandated by the minister to produce an annual net savingsof an amount somewhat more than 5% on the regional budget.

To achieve its target, the Regional Board developed an initial planproposing hospital closures while transferring some resources to the com-munity. To develop the consensus needed to make the plan workable, theRegional Board held two sets of public hearings in which groups wereinvited to present their views on the plan. Between the two sets of hearings,the plan was adjusted to take into account the arguments put forward and toincorporate useful suggestions. In the second version of the plan, the Boardwas able to argue that there was a broad consensus against across-the-boardcuts and for the hospital closure solution. Most important for the argumentsto be developed here, it was also able to show that it had taken into accounta large number of the points made during the first hearings, including cer-tain proposals relating to interorganizational collaboration.

Thus, the initial proposal was elaborated to include some desirable mea-sures that the Board was now formally committed to implementing, andthat had helped legitimize the hospital closure plan. These included the sin-gle entry point program for the elderly and a commitment to provide 24hour/7 day per week medical services across the city. The potential benefitsof a single entry point program had been drawn to the Board’s attention ina memorandum from an academic expert in geriatric care during the firstset of hearings and were supported by a trend toward integrated healthservices in vogue at that time (Shortell et al., 1996).

All in all, the final version of the plan included about 40 distinct mea-sures that now had to be implemented. The Regional Board set up an imple-mentation committee and the evaluation department was mandated todesign an implementation plan. This included a PERT chart in which all theactivities required for implementation were specified, people were assignedresponsibilities, and deadlines were set. The three processes we havedescribed in this article were, of course, part of this project planning; it isclear that the Board had to act on them and had to be seen to act on them.And yet, several of these measures had been little studied (only 3 monthsseparated the two sets of hearings) and had been included in the plan atleast partly to legitimize a much more controversial but critical measure—the hospital closures themselves. From the beginning, then, several of these




measures (and notably that concerning the single entry point program) hadsomething of a symbolic (rather than tangible) quality.

This strongly recalls Brunsson’s (1993) arguments concerning the sepa-ration of talk and action in pluralistic organizational contexts, the phenom-enon that he provocatively calls the “organization of hypocrisy.” In manyways, for some of the measures described in this article, “talk” was perhapsmore important than “decision” or “action,” and talk about improving coor-dination in the health care system was particularly important to allow actionof a more coercive kind at another level (hospital closures).

This brings us to a second aspect of the situation surrounding these col-laboration initiatives. As we mentioned earlier, the Regional Board, in theory,had sufficient formal authority and control over resources to impose its posi-tion more strongly at least in the case of the acute care and elderly careprograms. However, one could also argue that it could not afford to deploy itscoercive power too strongly in this area if it wished to maintain the fragile(and fragmenting) support it maintained surrounding its other projects. Thus,its interest in depleting its store of political capital by antagonizing one groupor another was perhaps limited. It was easier to maintain a neutral stance,while making a virtue of its neutrality by arguing that the details of agree-ments were much better negotiated at local levels closer to the action.

Finally, not only the Regional Board but also other actors had someinterest in maintaining the talk while limiting action in certain areas. In thecase of the medical services committee (subprocess 3) as well as othergroups, the doctors ensured that their participation and contribution wasrecognized as important, while limiting their own commitments. Similarly,although all participants in the single entry point program committee wereconcerned with affirming their legitimate stake in the issue, none would beinterested in being blamed for a failure to deliver on promised serviceswhen the resource consequences of clarity in criteria and procedures couldnot be known with certainty. As Cohen and March (1986) have observed intheir discussion of “garbage can” processes in universities, a good deal ofdiscussion in committees seems more concerned with establishing rights toparticipate than with actually participating.

Overall, then, there is some evidence that part of the reason for some ofthe difficulties in implementation lies in the symbolic character of the initia-tives being pursued. This analysis suggests that when considering collabora-tion initiatives, the context in which they emerge is extremely important inunderstanding their eventual fate. In this particular case, the radical nature ofsurrounding changes (implemented successfully) explains both the existenceof the mandated collaboration initiatives and perhaps also why several of




them failed to penetrate to the level of action in the field. In this interpretation,the discussions, the meetings, the training programs, and other clan-like inter-action mechanisms were sufficient unto themselves. They were ineffectiveonly if one discounts their symbolic value in maintaining harmony and inallowing other desired changes to occur (see also Brown, 1994).

This second reading (especially when associated with the title ofBrunsson’s book) has, at first sight, a certain cynical quality about it. We donot intend to imply that individuals are always conscious of these symbolicprocesses or of the effects that they may be having on their own behavior.Indeed, we believe that the effectiveness of such processes starts to fail assoon as people become aware of them (see also Pfeffer, 1981). This bringsus to a third reading, which in some respects cumulates the insights of theprevious readings, but in which the unconscious aspects of power relationsalso take a central role.

Third Reading: An Extended PoliticalPerspective—The Four Dimensions of Power

Drawing on Clegg’s (1989) historical analysis of the literature, Hardy(1994) argues for the existence of four dimensions of power. The firstdimension, called decision-making power, implies the direct use of powersources such as resources and formal authority by some actors to obtain thecompliance of others. Our first reading presented above largely focused onan analysis of this type of power. Indeed, it was noted that the RegionalBoard failed to stimulate richer forms of mandated collaboration partlybecause it had insufficient power over the behavior of certain actors (e.g.,the doctors) but also largely because it failed to appropriately use the powertools that it did have to impose certain rules or to offer incentives.

The second type of power identified by Hardy (1994) and first pro-posed by Bachrach and Baratz (1962) is procedural or non-decision-making power, in which one group of actors has power over another groupbecause of its capacity to use organizational processes and procedures tocontrol the decision agenda. Thus, some actors may ensure that certainissues are or are not considered and that groups are or are not excludedfrom them. In our case, the Regional Board was able to initiate theregional agenda for discussion, giving it some control. However, it waslegally and morally obliged to hold many crucial meetings in public. Thevisibility of its processes and the legal autonomy of the organizations itwas attempting to regulate thus limited, to some extent, its non-decision-making power.




The third type of power is symbolic and implies the ability to “managemeaning” (Pettigrew, 1979), so that others take for granted the legitimacyof the options being proposed or the positions of another party. Our secondreading above emphasized the role of symbolic management in under-standing behavior. The way in which the Regional Board framed the hospi-tal closure decision was a classic case of impression management (Elsbach,1994), in which a central downsizing decision was legitimized in part byhighly acceptable (but hard to operationalize) proposals for stimulating col-laboration among participating groups and organizations.

Beyond this manifestation of symbolic power, the case also reveals anumber of occasions in which it is clear that actors interpreted certain situa-tions in terms that implicitly showed how other groups’ meanings had cometo dominate their thinking. This manifested itself in anticipatory concessionsthat avoided confrontation. The most remarkable case of this occurred in themedical services committee (subprocess 3), where the members insisted onwithdrawing references to the imposition of rules of collaboration because ofthe negative reaction that this would provoke among physicians. Rather thanallow the physicians to manifest their reaction overtly, the Regional Boardessentially “gave in” beforehand, smoothing over its language and presentingphysician groups with a proposal that demanded little—and could thereforereceive little in return (see earlier). A similar dynamic perhaps lay behind theBoard’s reluctance to challenge participating organizations more strongly forthe single entry point program (subprocess 2). The possibility existed that themore powerful organizations would simply refuse to collaborate. To draw ona metaphor, it may be more politic and ego-enhancing to order the sun to riseat 6:00 a.m. than at midnight (de Saint-Exupéry, 1995).

This brings us to the fourth type of power that Hardy (1994) labels sys-temic or Foucauldian. This type of power removes the focus from how oneorganization, group, or individual may acquire and use power over anotherto the way in which all organizations are embedded in a network of coun-tervailing powers, which mutually constrain all of them. Existing powerrelations become deeply rooted in supporting systems of ordered relations,incentives, values, and cultures that are mutually reinforcing and, thus, verydifficult to change. This type of analysis suggests that any form of actionwithin a complex network of influence will encounter the same lines ofresistance but in different ways. Thus, the Regional Board was perhapsrather timid in the way it conceded by anticipation to the power of physi-cians. However, had it acted more aggressively, that same power wouldhave ensured that its proposals would have been thrown out, and with per-haps more light and heat.




Similarly, all the other organizations and actors in the network were con-strained by existing power relations. The hospitals’ vision of interorganiza-tional collaboration with the CLSCs was one in which they took control.However, this was not viable in a system with established autonomous orga-nizations at a time when the support of the CLSCs was needed to achievehospital closures. The CLSCs saw themselves as the legitimate gateway tothe health care system but were unable either collectively or individually todo much more than simply counterbalance the entrenched position of doc-tors and hospitals. Meanwhile, whereas other actors attempted to obtaintheir voluntary collaboration, the doctors fought continually to maintaintheir autonomy. In sum, this reading takes a rather pessimistic view of thepotential for change.

The Three Readings Compared and Reconciled

The choice between the three interpretations can be seen at first sight asroughly equivalent to choosing between management inexperience, impres-sion management, or powerlessness as explanations for the RegionalBoard’s difficulties in implementing mandated collaboration. All of thesereadings seem partially plausible but incomplete.

The first reading draws attention to the predictability of failure based onthe limited range of governance mechanisms used but does not help us tounderstand why otherwise competent actors would set themselves up forsuch failure. The second reading interprets this by drawing attention to theimportant symbolic value of interactive clan-like mechanisms over andabove the concrete action they may eventually generate. Yet, by its insistenceon symbolic action, this reading tends to portray organization members asmore cynical and manipulative than observation would suggest is fair. Thethird reading recognizes the possibility of good faith but suggests that allactors are bound by the complex web of power relations and value commit-ments in which they are embedded. Thus, different types of actions to achievechange confront the same barriers, yet in different ways. Aggressive actionsthat challenge the barriers directly risk creating conflict and overt resis-tance. More subtle interventions tend to avoid the problem and concededefeat by anticipation. Although attractive and recognizable in much of thewriting on organizational change, this third reading of course overempha-sizes the forces for inertia. Experience has shown that organizations andsystems of organizations sometimes can and do change. Indeed, they did soto some extent in our case. Thus, this reading also needs to be nuanced. Amore long-term and dynamic perspective may enable the three readings to




be at least partly reconciled and may place a more positive spin on the util-ity of the huge investment made in clan-based interactions.

For example, building on the first reading, when looked at from adynamic perspective, the Regional Board’s collaboration initiatives are notsimply a reflection of management inexperience but an arena in whichRegional Board managers and other organizations were learning how tobetter manage such initiatives in the future. Building on the second reading,when looked at from a dynamic perspective, the interactions and negotia-tions that seemed rather symbolic nevertheless socialized participants to anew language (e.g., case management, integrated networks) that might bedrawn on more successfully in future discussions.

Finally, building on the third reading, one way to interpret the eventsdescribed is as a phase in an ongoing process of deinstitutionalization(C. Oliver, 1992) of the generally accepted patterns of power relations andvalues within an organizational field. These values and power relationsbased on organizational autonomy are being challenged by the emergenceof new institutional forms or archetypes founded, among other things, on agreater degree of horizontal integration (Hinings & Greenwood, 1988). Theexistence of the Regional Board itself is a first sign of this institutionalchange. The emergence of a popular discourse surrounding collaboration isanother. As one observer noted,

Integrated services, for me . . . it’s become a magic word. Continuum, it’s amagic word. When someone says that, you know he’s a good guy. The magicoperates. But between the magic and the reality, how do you succeed in get-ting real networks of articulation?

Finally, the perhaps rather halting attempts of the Regional Board to gobeyond simply closing hospitals to try to implement some of these ideas area third sign of movement in values. In this process, the Regional Board’s ini-tiatives, although only partly successful in the short term, shook some taken-for-granted assumptions and confronted power structures in place. Forexample, whereas the power of physicians was a major source of frustrationin attempting to implement 24-hour medical services (subprocess 3), the doc-tors’ indifference and lack of collaboration came at the cost of increasing crit-icism and the growing threat of more radical interventions that would curtailthis autonomy far more than what was being requested of them initially.

Thus, existing managerial competencies, symbolic languages, and theunderlying network of power relationships are slowly changing under thesepressures. As noted by one interviewee,




I think that we will see the outcome of all this in the next five years, but this hasbroken the balance. . . . The Regional Board’s slogan in its plan was “Toward aNew Balance.” It was a good thing. . . . There was an old balance, which could-n’t be continued. . . . The Regional Board’s plan did not obtain a new balance,but we have broken the old balance, and this will lead to something new. . . .What I think will remain is the feeling that—and this is not trivial—is that orga-nizations cannot work alone. (manager, Rehabilitation Center)

Conclusion

In this article, we investigated the process of mandated collaboration ina network of health care organizations. We noted that in contrast to volun-tary collaboration, mandated collaboration requires the mobilization ofmultiple governance mechanisms. However, our empirical data showed thatthe organizations involved relied principally on clan-based mechanismsalone, with disappointing results in two cases out of three. In particular, byproviding no clear formal rules, the mandating agency left the partner orga-nizations groping in ambiguity and unable to resolve differences. By itsrestraint in the use of incentives, it did not stimulate interest in collaborat-ing when this was not already present. We believe that this situation is acommon occurrence in organizational contexts and, in particular, amongpublic sector agencies. The most obvious implication is that the comple-mentary nature of the three types of governance mechanisms needs to beunderstood. From a managerial perspective, the chances for successful col-laboration seem higher if they are all mobilized in judicious ways. We alsobelieve, however, that the very frequency of this type of situation suggeststhat purely managerialist interpretations are missing part of the story. In thisarticle, we identify two additional explanations (symbolic and political)that can help explain why mandated collaboration initiatives often becomethe site of intensively participative but unproductive processes. Theseexplanations are worthy of consideration when organization members findthemselves in such situations. Is all this work being done mainly for sym-bolic reasons? Is it doomed to failure by the inability to confront systemicpower relations? Finally, regardless of their immediate effects, how are theprocesses in place altering the potential for change in the future by stimu-lating managerial learning, by altering the language used, or by questioningthe distribution of power over the longer term? An awareness of these pos-sibilities could be a first step toward developing a more reflexive andthoughtful style of management.





AppendixExample of an Interview Guide for a CLSC (centres

locaux de services communautaires) Manager

1. Introduction1.1. Please give me a brief overview of your career path to date.

2. Your OrganizationEveryone agrees that each CLSC has its own culture. The following ques-tions are aimed at better understanding your organization.2.1. Organizational Values

2.1.1. How would you describe the character of your organizationas compared with others in the network?

2.1.2. In this organization, what are the most important organiza-tional values in your opinion?

2.1.3. Please identify any main differences in the values of differentgroups in your organization (managers, professionals, etc.).

2.2. Expertise2.3.1. What are the main strengths of this organization?2.3.2. What are the main weaknesses?

3. The Transformation of the Network and Its ImpactThe next questions are aimed at better understanding the issues associatedwith the transformation for your organization.3.1. Interests

3.1.1. In concrete terms, what does this change mean for your orga-nization in terms of new roles? New responsibilities? Newvalues?

3.1.2. What are the positive aspects of this change for your organi-zation? What are the negative aspects?

3.1.3. What is your vision of the role CLSCs should play in thenetwork?

3.1.4. What are the incentives for working in partnership within thenetwork?

3.2. Structures of Reorganization3.2.1. What does this transformation mean for you in terms of new

modes of working? In terms of new modes of managingservices?

3.2.2. To undertake the change, what resources did you have? (Newbudget? New employees?)

3.2.3. What is the degree of matching between resources and needs?3.4.4. What does the term single entry point mean for you?




3.3. Consensus3.3.1. How do these changes affect the different professional groups

in your organization (doctors, nurses, others)?3.3.2. What are the points of disagreement among professionals

about this?

4. Your PartnersOur research aims to understand how new forms of collaboration have devel-oped between partners following the transformation. The following questionsare aimed at identifying these partners and their main characteristics.4.1 Partner Organizations

4.1.1. Can you specifically name your partners in order of impor-tance (hospitals, medical clinics, nursing homes, communityorganizations, other CLSCs, regional board, etc.)?

4.1.2. Did you have experience with these partners before the reform?Of what nature?

5. Development of Interorganizational Relationships5.1. Structures for CollaborationTo facilitate the creation of linkages between organizations, several differ-ent types of structures are possible: committees, task forces, consultingforums, training sessions, ad hoc meetings, etc. The following questions areaimed at understanding the different forums in which you have participatedand the roles these have played in the reform.

5.1.1. Can you identify the different forums in which your organi-zation has participated in order to implement different aspectsof the transformation?

5.1.2. Which are most important for you? Why?5.1.4. For each forum:

* Who convened it first? Why?* What were the objectives?* Who was involved?* What positions or roles did different participants adopt in

these meetings?* What has been your position/role?* What work has been done?* What agreements have been made?* What problems have been encountered? How were they solved?* What concrete results have been achieved?

5.2. Coordination MechanismsThese questions are aimed at understanding how collaboration has devel-oped between CLSCs and hospitals on a daily basis.For each of your main partners:

5.2.1. Can you explain the procedures you follow at present forreferred clients?

5.2.2. How did you come to develop this mode of functioning? Didyou develop agreements? Do you use formal protocols?




5.2.3. What problems have been encountered? Please giveexamples. How did you solve them?

5.3. Leadership5.3.1. Which partner organizations took the lead in developing

interorganizational relationships?5.3.2. Which partner organization is most active? Why?5.3.3. Have leadership patterns changed over time? How?

5.4. Consensus5.4.1. What have been the points of disagreement among partners

on modes of interaction, the roles of each partner, etc.?

6. Satisfaction With the Process of Development of Collaboration6.1. To what extent are you satisfied with the way the collaboration has

developed up to now?6.2. What were your expectations for your partners?6.3. What was missing in the process in your view?

7. ContextThese questions are aimed at understanding the role of regulatory organi-zations in this transformation.7.1. What role was played by the Ministry of Health in this process (e.g.,

in terms of resources, norms, control mechanisms, incentives, sup-port, etc.)?

7.2. What role was played by the Regional Health Board in the imple-mentation of the reforms (resources, norms, control mechanisms,incentives, support)?

7.3. Are you satisfied with this role? Why? What would you have pre-ferred as a mode of intervention?

7.4. Did you refer to the Regional Board to solve problems of disagree-ment between partner organizations?

8. General Comments Concerning the Success of the Reform and FuturePerspectives8.1. Do you believe that the reform proposed by the Regional Board will

attain its objectives of improving the continuity and quality of care?Why?

8.2. In your opinion, what are the factors that have facilitated the imple-mentation of effective collaboration mechanisms?

8.3. What are the factors that have inhibited the implementation of effec-tive collaboration mechanisms?

8.4. What could be done to improve the situation?8.5. What are your expectations for the future (short term, medium term,

long term)?

Note: Translated from the original French. In practice, questions were selected from thismaster list as needed; a somewhat different guide was used for respondents from differenttypes of organizations and from different professions.




Notes

1. Many of the early CLSCs (centres locaux de services communautaires) were created inthe 1970s with a strong community orientation. These organizations were preoccupied withsocial welfare issues more than health care issues. They tended to have a profile of servicesdominated by social work, community organization, and home help. In contrast, other CLSCssaw their role more as a provider of health care. They tended to have a service profile domi-nated by health services including walk-in clinics and home visits. The community and healthcare cultures were identified in a study by Poupart, Simard, and Ouellet (1986). In thisresearch, we used cluster analysis on profiles of employee categories to identify these types.

2. A typical interview guide (for a management participant) is provided in the Appendix.

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Charo Rodríguez is currently an assistant professor in the area of health services and policyresearch in the Department of Family Medicine at McGill University, Montréal, Quebec,Canada. She is also a member of the Interdisciplinary Research Group on Health (GRIS) at theUniversité de Montréal. She holds a license in medicine from the Universidad de Alicante(Spain) and obtained her PhD in public health (health care organization option) at the Universitéde Montréal in 2001. Her research interests include organizational power, interorganizationalcollaboration, organizational change and innovation, identity, and organizational discourse.This article is the second one drawn from her doctoral dissertation. The first one, entitled“Managing Across Boundaries in Health Care: The Forces for Change and Inertia in MandatedInterorganizational Collaboration,” was published in 2003 as a chapter of the book, ManagingBoundaries in Organizations: Multiple Perspectives, edited by Neil Paulsen and Tor Hernes.

Ann Langley is a professor of strategy at École des Hautes Études Commerciales (HEC-Montréal). Until 2000, she held a similar position at Université du Québec à Montréal. She isalso a member of the GRIS at the Université of Montréal. She received her PhD from HEC-Montréal in 1987. Her research interests include strategic change processes, decision making,innovation, and interorganizational relationships, with particular emphasis on health care orga-nizations. Her recent articles have been published in Management Learning, Health CareManagement Review, Public Administration, Human Relations, and the Academy of ManagementJournal.

François Béland is a professor in the Department of Health Care Administration at theUniversity of Montréal and a member of the GRIS. He is an adjunct professor in theDepartment of Geriatrics at McGill University. He obtained his PhD in sociology from LavalUniversity in 1978. His research interests include health services utilization and health servicesfor the elderly. His most recent publications concern integrated care for the elderly and contextual-level influences such as unemployement on the production of health in populations.

Jean-Louis Denis is a professor of health care administration and a member of the GRIS atthe Université de Montréal. He is the Canadian Institutes for Health Research/Canadian HealthServices Research Foundation Chair in the Transformation of Health Care Organizations. Hereceived a PhD in community health from the Université de Montréal in 1988. His researchdeals with leadership and change in health care organizations and with the role of evidence inthe adoption of clinical and organizational innovations in the health care sector. He hasrecently published in Management Learning, Health Care Management Review, PublicAdministration, Human Relations, and the Academy of Management Journal.




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