L’incorporation de la responsabilité populationnelle dans la gestion des CSSS

En 2004, le gouvernement québécois s’est engagé dans une importante réorganisation de son système de santé en créant les Centres de santé et des services sociaux (CSSS). Conjugué à leur mandat de production de soins et services, les CSSS se sont vus attribuer un nouveau mandat de « responsabilité populationnelle ». Les gestionnaires se voient donc attribuer le mandat d’améliorer la santé et le bien-être d’une population définie géographiquement, en plus de répondre aux besoins des utilisateurs de soins et services. Cette double responsabilité demande aux gestionnaires d’articuler plus formellement au sein d’une gouverne locale, deux secteurs de prestations de services qui ont longtemps évolué avec peu d’interactions, « la santé publique » et « le système de soins ». Ainsi, l’incorporation de la responsabilité populationnelle amène à développer une plus grande synergie entre ces deux secteurs dans une organisation productrice de soins et services. Elle appelle des changements importants au niveau des domaines d’activités investis et demande des transformations dans certains rôles de gestion. L’objectif général de ce projet de recherche est de mieux comprendre comment le travail des gestionnaires des CSSS se transforme en situation de changement mandaté afin d’incorporer la responsabilité populationnelle dans leurs actions et leurs pratiques de gestion. Le devis de recherche s’appuie sur deux études de cas. Nous avons réalisé une étude de deux CSSS de la région de Montréal. Ces cas ont été choisis selon la variabilité des contextes socio-économiques et sanitaires ainsi que le nombre et la variété d’établissements sous la gouverne des CSSS. L’un des cas avait au sein de sa gouverne un Centre hospitalier de courte durée et l’autre non. La collecte de données se base sur trois sources principales; 1) l’analyse documentaire, 2) des entrevues semi-structurées (N=46) et 3) des observations non-participantes sur une période de près de deux ans (2005-2007). Nous avons adopté une démarche itérative, basée sur un raisonnement inductif. Pour analyser la transformation des CSSS, nous nous appuyons sur la théorie institutionnelle en théorie des organisations. Cette perspective est intéressante car elle permet de lier l’analyse du champ organisationnel, soit les différentes pressions issues des acteurs gravitant dans le système de santé québécois et le rôle des acteurs dans le processus de changement. Elle propose d’analyser à la fois les pressions environnementales qui expliquent les contraintes et les opportunités des acteurs gravitant dans le champ organisationnel de même que les pressions exercées par les CSSS et les stratégies d’actions locales que ceux-ci développent. Nous discutons de l’évolution des CSSS en présentant trois phases temporelles caractérisées par des dynamiques d’interaction entre les pressions exercées par les CSSS et celles exercées par les autres acteurs du champ organisationnel; la phase 1 porte sur l’appropriation des politiques dictées par l’État, la phase 2 réfère à l’adaptation aux orientations proposées par différents acteurs du champ organisationnel et la phase 3 correspond au développement de certains projets initiés localement. Nous montrons à travers le processus d’incorporation de la responsabilité populationnelle que les gestionnaires modifient certaines pratiques de gestion. Certains de ces rôles sont plus en lien avec la notion d’entrepreneur institutionnel, notamment, le rôle de leader, de négociateur et d’entrepreneur. À travers le processus de transformation de ces rôles, d’importants changements au niveau des actions entreprises par les CSSS se réalisent, notamment, l’organisation des services de première ligne, le développement d’interventions de prévention et de promotion de la santé de même qu’un rôle plus actif au sein de leur communauté. En conclusion, nous discutons des leçons tirées de l’incorporation de la responsabilité populationnelle au niveau d’une organisation productrice de soins et services. Nous échangeons sur les enjeux liés au développement d’une plus grande synergie entre la santé publique et le système de soins au sein d’une gouverne locale. Également, nous présentons un modèle synthèse d’un processus de mise en œuvre d’un changement mandaté dans un champ organisationnel fortement institutionnalisé en approfondissant les rôles des entrepreneurs institutionnels dans ce processus. Cette situation a été peu analysée dans la littérature jusqu’à maintenant.

Déclencher le changement institutionnel : une analyse de l’élaboration et de la mise en œuvre initiale des lignes directrices en allaitement maternel au Québec

L’allaitement maternel est reconnu comme la façon optimale de nourrir les nourrissons et les jeunes enfants. Néanmoins, le Québec présente des taux d’allaitement parmi les plus faibles au Canada. Dans un tel contexte, le gouvernement provincial plaça l’allaitement comme l’une de ses priorités de santé publique et il publia, en 2001, la politique L’allaitement maternel au Québec : Lignes directrices (LD). Cette étude a pour but de comprendre les processus d’émergence, d’élaboration et de mise en œuvre des LD. Il s’agit d’une étude de cas unique qualitative. Les données ont été recueillies par des entrevues et un groupe de discussion auprès de personnes engagées dans ce domaine et par la recension documentaire. Une analyse thématique déductive-inductive a été réalisée en utilisant la théorie institutionnelle. Les LD ont émergé à partir d’un mouvement professionnel qui a collaboré avec le ministère de la Santé et des Services sociaux pendant la phase d’élaboration et le début de la phase d’implantation de la politique. Au fil du temps, la prise de décisions a été centralisée, les mécanismes de concertation sont devenus désuets et les relations entre les acteurs concernés sont devenues moins coopératives. L’inconfort et le mécontentement avec cette nouvelle façon de gérer le dossier allaitement ont favorisé l’émergence d’un nouveau mouvement professionnel. L’étude conclut cependant que les acteurs concernés par l’allaitement au Québec visent l’atteinte du même but et que la collaboration est possible même dans un domaine très institutionnalisé comme celui de la santé, la preuve étant la formulation consensuelle des LD.

De consumidora a empreendedora institucional: um estudo de caso sobre o uso de estratégias discursivas na indústria de moda

A indústria criativa de moda está sendo impactada pela ação de consumidores que utilizam novos meios de comunicação como forma de interação, tais como blogs, Instagram e Twitter. Os consumidores que, nesse contexto, assumiram o papel de empreendedores, não estavam insatisfeitos com o mercado, apenas queriam compartilhar suas ideias e aquisições com outros usuários da rede. Com o decorrer do tempo, no entanto, essa ação, inicialmente despretensiosa, alcançou popularidade e captou a atenção de leitores e de empresas do setor, ganhando escala (DIAMANDIS & KOTLER, 2015) e visibilidade. Sendo assim, a pesquisa terá como objetivo identificar e analisar as estratégias discursivas que conduziram consumidores, que apenas desejavam se comunicar e trocar suas ideias em torno de um tema que lhes interessava, à categoria de empreendedores institucionais (ANSARI & PHILLIPS, 2011; DOLBEC & FISCHER, 2015). A pergunta de pesquisa respondida foi: Quais são as estratégias discursivas utilizadas por consumidores que se tornaram empreendedores institucionais? Para tal foi realizado um estudo exploratório, na forma de estudo de caso, com a blogger Camila Coutinho, do blog Garotas Estúpidas. Foram analisadas as estratégias discursivas da empreendedora, compiladas principalmente por meio de postagens do blog, materiais divulgados na mídia e entrevistas. Os dados foram analisados pelo método de análise de discurso (VAN DIJK, 1997; PHILLIPS & HARDY, 2002). Esta pesquisa contribui para a teoria de empreendedorismo institucional ao identificar e analisar as estratégias discursivas usadas por um empreendedor institucional. Além disso, contribui para a prática gerencial ao identificar as mudanças geradas por empreendedores no campo de mídia virtual.

Finnish Institutional Innovation Support Policies from Russian Entrepreneurs' Perspective: Establishing Cross-Border Technology Oriented Start-Up Firm

The purpose of this thesis is to study how Russian entrepreneurs perceive Finnish institutional environment and innovation support policies provided in the country, as well as to present a practical example in form of a case study of one technology oriented start-up firm which was established in Finland by Russian entrepreneurs. The empirical research of the thesis is conducted qualitatively in two parts. First part is conducted through online questionnaire with open questions in order to review the perceptions of Russian entrepreneurs in general. Second part is based on personal interviews with case company’s founders with the focus on the process of establishing the company in Finland. In the first part of the empirical research, five Russian start-up firms were contacted, and four responses were received. All of these responses were qualified for further analysis. The findings of the first part of the research reveal that Russian entrepreneurs have rather positive attitudes towards Finnish institutional innovation support policies. However, most of the entrepreneurs stated that they are unlikely to create their presence in Finland. As an outcome of the second part of the research, the process of establishing a case company in Finland is illustrated. In order to be able to establish companies in Finland, Russian entrepreneurs who have a permanent residence outside European Economic Area (EEA) are required to apply for a permission to perform business operations in the country. In addition, the established company must engage in improving the economical stand of the country by creating new work places, raising tax revenues, develop technologies and generate innovations in the country.

The third transformation of Japan: An institutional narrative on agglomeration economies in abenomics

Objective of the study The aim of this study is to understand the institutional implications in Abenomics in a spatial context, the contemporary economic reform taking place in Japan, which is to finally end over two decades of economic malaise. For theoretical perspective of choice, this study explores a synthesis of institutionalism as the main approach, complemented by economies of agglomeration in spatial economics, or New Economic Geography (NEG). The outcomes include a narrative with implications for future research, as well as possible future implications for the economy of Japan, itself. The narrative seeks to depict the dialogue between public discourse and governmental communication in order to create a picture of how this phenomenon is being socially constructed. This is done by studying the official communications by the Cabinet along with public media commentary on respective topics. The reform is studied with reference to historical socio-cultural, economic evolution of Japan, which in turn, is explored through a literature review. This is to assess the unique institutional characteristics of Japan pertinent to reform. Research method This is a social and exploratory qualitative study – an institutional narrative case study. The methodological approach was kept practical: in addition to literature review, a narrative, thematic content analysis with structural emphasis was used to construct the contemporary narrative based on the Cabinet communication. This was combined with practical analytic tools borrowed from critical discourse analysis, which were utilized to assess the implicit intertextual agenda within sources. Findings What appears to characterize the discourse is status quo bias that comes in multiple forms. The bias is also coded in the institutions surrounding the reform, wherein stakeholders have vested interests in protecting the current state of affairs. This correlates with uncertainty avoidance characteristic to Japan. Japan heeds the international criticism to deregulate on a rhetorical level, but consistent with history, the Cabinet solutions appear increasingly bureaucratic. Hence, the imposed western information-age paradigm of liberal cluster agglomeration seems ill-suited to Japan which lacks risk takers and a felicitous entrepreneur culture. The Japanese, however, possess vast innovative potential ascribed to some institutional practices and traits, but restrained by others. The derived conclusion is to study the successful intrapreneur cases in Japanese institutional setting as a potential benchmark for Japan specific cluster agglomeration, and a solution to its structural problems impeding growth.

Matrix Support And Institutional Support: Analyzing Their Construction.

This is an analysis of the theoretical and practical construction of the methodology of Matrix Support by means of studies on Paideia Support (Institutional and Matrix Support), which is an inter-professional work of joint care in recent literature and official documents of the Unified Health System (SUS). An attempt was made to describe methodological concepts and strategies. A comparative analysis of Institutional Support and Matrix Support was also conducted using the epistemological framework of Field and Core Knowledge and Practices.

Brazilian foreign policy: Old and new paths as regards institutional aspects, multilateralism and foreign policy towards the South

This paper emphasizes the important changes in Brazilian foreign policy after Luiz Inacio Lula da Silva took tip the power in 2002. The paper defends the idea that it is not possible to argue that there were deep changes in comparison to Cardoso's administration. However, evidence shows that new things are happening as regards the design of a more active and clear foreign action line which led to institutional changes and to more incisive multilateral paths. This results both from the political profile of the direct operators of foreign policy and the aims of lite presidential diplomacy, The hypothesis dealt with on this paper consists on the fact that Lula's administration has not fully broken with the old administration practices, however the aims of global and regional integration are being plotted more clearly and with a higher degree of activism. This becomes clear in three aspects of the Brazilian foreign policy: the institutional framework, the practice of multilateralism and the foreign policy towards the South, the three topics analyzed in this paper.

A Computational Framework for Institutional Agency

This paper provides a computational framework, based on Defeasible Logic, to capture some aspects of institutional agency. Our background is Kanger-Lindahl-P\"orn account of organised interaction, which describes this interaction within a multi-modal logical setting. This work focuses in particular on the notions of counts-as link and on those of attempt and of personal and direct action to realise states of affairs. We show how standard Defeasible Logic can be extended to represent these concepts: the resulting system preserves some basic properties commonly attributed to them. In addition, the framework enjoys nice computational properties, as it turns out that the extension of any theory can be computed in time linear to the size of the theory itself.

INSTITUTIONAL DEVELOPMENT THROUGH POLICY-MAKING A Case Study of the Brazilian Central Bank

A number of contemporary studies rightly emphasize the notion that policy outcomes result from institutional determinants. But as a growing literature on institutional development notes, these institutions are themselves impermanent. Sometimes, in crisis moments, institutions are replaced wholesale. More frequently, institutions evolve gradually over time. Using the Brazilian Central Bank as a case study, this article illustrates that the policy-making process itself can be a central driver of gradual institutional development, with institutions evolving through the accumulation of policy choices made over many years and under different policymakers in response to contemporaneous events and unforeseeable economic and political challenges.

Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Multi-institutional Collaboration

Background: Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined. Objective: To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP. Design, setting, and participants: This is a retrospective, international, multi-institutional cohort analysis. There was amedian follow-up of 4.4 yr following SRP performed on 404 men with radiation-recurrent PCa from 1985 to 2009 in tertiary centers. Intervention: Open SRP. Measurements: BCR after SRP was defined as a serum prostate-specific antigen (PSA) >= 0.1 or >= 0.2 ng/ml (depending on the institution). Secondary end points included progression to metastasis and cancerspecific death. Results and limitations: Median age at SRP was 65 yr of age, and median pre-SRP PSA was 4.5 ng/ml. Following SRP, 195 patients experienced BCR, 64 developed metastases, and 40 died from PCa. At 10 yr after SRP, BCR-free survival, metastasis-free survival, and cancer-specific survival (CSS) probabilities were 37% (95% confidence interval [CI], 31-43), 77% (95% CI, 71-82), and 83% (95% CI, 76-88), respectively. On preoperative multivariable analysis, pre-SRP PSA and Gleason score at postradiation prostate biopsy predicted BCR (p = 0.022; global p < 0.001) and metastasis (p = 0.022; global p < 0.001). On postoperative multivariable analysis, pre-SRP PSA and pathologic Gleason score at SRP predicted BCR (p = 0.014; global p < 0.001) and metastasis (p < 0.001; global p < 0.001). Lymph node involvement (LNI) also predicted metastasis (p = 0.017). The main limitations of this study are its retrospective design and the follow-up period. Conclusions: In a select group of patients who underwent SRP for radiation-recurrent PCa, freedom from clinical metastasis was observed in > 75% of patients 10 yr after surgery. Patients with lower pre-SRP PSA levels and lower postradiation prostate biopsy Gleason score have the highest probability of cure from SRP. (C) 2011 European Association of Urology. Published by Elsevier B. V. All rights reserved.