Professions, Organizations, and the Challenges of Change: A Multi-Method Exploration in the Context of Healthcare Delivery

Organizations often struggle to implement change or to reconfigure their internal processes and practices to achieve desired performance outcomes. This can be particularly challenging with a professional workforce since many of the organization’s tools of influence may not work as intended due to the attributes of professionals and their work. As a result, the presence of professionals can complicate the change processes in ways that many of our current theories do not capture. My multi-method dissertation explores this by examining how organizations can change and innovate when their workforces are dominated by professionals. I study this in the context of healthcare service delivery. In the first study, I explore the efficacy of one of the organization’s main tools of influence: financial incentives. I develop a theory of situated professionalism to explore the conditions under which professionals change their activity patterns in response to changes in financial incentives. I find support for two conditions which dampen their incentive responses: when financially-motivated actions carry the potential to cause harm (and thus violate a central professional norm); and when work settings constrain autonomy. The analysis uses a matching methodology with difference-in-differences estimation on a large sample of physicians over nine years. In my second study, I use ethnographic data to explore how one hospital implemented a set of strategically important, centrally-designed tools and practices in five internal clinics. Although these changes did not affect the technical work of physicians (i.e., treating patients), teams struggled to engage physicians in the change. What emerged from the analyses was that physicians enacted their autonomy very broadly within the organization; it encompassed not only the technical work, but also the processes around the work. As such, these non-technical changes represented surprising infringements to physician autonomy. My analyses also highlight the importance of clinics’ adaptation processes in which they attempted to remove these infringements, while at the same time adapting the new practices to generate value. I conclude by integrating the two studies to elaborate on the studies’ common themes and to develop a set of policy considerations for organizations managing professionals, particularly in the healthcare context.Ph.D