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

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

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

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

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

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

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

8. External + Contexts Internal Inherited + InterventionsOutcomes Mediators Mediators influences influences Mediation Mediation People People Operational Operational system systemChangeIndicators Issues IssuesResponsesActionsReactionsOutcomes Moderators Intervening,Situational. Antecedents An Emergent Model of Internal Mediators and Moderators