Stakeholders Identification Affecting the Scope and the Changes in the Health Care System

Changes taking place in healthcare require the involvement of everyone entities operating in the system...


Introduction
The necessity to introduce changes in health care, especially in the recent period, is not in doubt. However, this is not an easy or cheap task. For state and patient finances, for the health security of society, the situation of making changes requires constructive planning of the effects of change. Experts for several years show what changes would be beneficial, in which direction health care should be reformed, what solutions would bring the greatest benefits to all participants in the system. Observing changes in health care, it can be concluded that among many stakeholders operating in the system only some have a real impact on their introduction, type and course. The imbalance results from many factors related to the specificity of the system and its participants, the nature of changes and the political situation. The purpose of the work is to identify stakeholders who potentially have the greatest potential to influence the scope and course of changes in the healthcare system, and the sources of these possibilities.

Stakeholders
One of the difficulties of reforming the health sector is the large number of entities that operate under the health care system. We can call them health care stakeholders. Stakeholder theory was initiated by the Stanford Research Institute in 1963, it concerned organizations and proclaimed that stakeholders were groups without whose support the organization could not function. Now in 1984, Freeman decided that stakeholders were all individuals and groups in and around the organization that have an impact on the organization's goals or on which the organization could influence achieving its goals [1]. Therefore, it should be recognized that stakeholders will not be those units or groups that cannot influence the organization. Stakeholders can also be divided into internal and external. Internal is usually employees, management, shareholders and the supervisory board. Customers are external, competitors, suppliers, trade unions and state authorities [2]. It is believed [3] that the stakeholder theory can be applied to public organizations. The main difference is that public organizations operate in a highly politicized environment and the choice of specific strategic reasons is dictated not by their actual assessment, but by the bargaining power of the most influential stakeholders. If we consider the fact that stakeholders in public organizations have very unequal access to power, it may turn The introduction of fundamental changes in healthcare requires identifying one of the leading stakeholders and thinking about how they affect the introduction and course of changes in the system.

Changes in the Health Care System
In modern healthcare organizations, the changes have acquired a completely new character, ceased to be a specific event at a specific time, and have become a permanent process. The same situation occurs in Polish healthcare. For some time, all participants have been constantly experiencing new changes that involve very different aspects of the system's functioning. This is not one big change in the whole system, but a string of introducing new solutions and innovations. This is not an easy situation for all interested parties.
When making changes, the most important thing is to know what you want to change, plan the change, prepare people, make the change, and then control the adaptation. In practice, this is a very complicated process with many problems. Firstly, as a rule, there is no single idea for change, several variants of change methods are possible, and sometimes implementation in practice does not bring the planned effects. Secondly, changes always affect people, and this is the most unpredictable factor in the whole process. Changes disturb the existing order, raise fear of the unknown, threaten the economic situation and sense of security, and thus cause resistance from people to accept such solutions [4].
Most often the initiators of changes are individuals and small groups, and they concern large communities, sometimes entire societies. Health is the supreme value and is of great importance to people. S. Golinowska believes that the barriers that stand in the way of changes in health care are conscious and factual -real. In the sphere of consciousness there is: 1.
Lack of comprehensive approach to the healthcare system.

2.
Simplified diagnosis and numerous gaps in knowledge about the state of resources in the health care system and the quality of its management.

3.
Selective knowledge about the processes of changing the healthcare system in other countries, leading to unreliable use of international comparisons.

4.
Shaping the picture of the situation in health care mainly by the media, which uses selective information, with the dominance of sensational reports, often unreliable and often shaped by large interest groups.

5.
Phenomena in the sphere of consciousness affect the formation of real processes and, therefore, lead to a deepening crisis in the system, which manifests itself:

6.
Financial imbalance between funds flowing into the healthcare system and the costs of its functioning, leading to systematic indebtedness of health facilities.

7.
Imbalance of development between the basic parts of the health care system: public health, healthcare, rehabilitation and long-term care. Creating the basis for analyzing the quality of medical services,

3.
Creating information security about resources, services, patients,

4.
Introduction of principles of rational distribution of facilities and standards of their equipment [6].
When it comes to the financial sphere, the first and essential The co-payment system takes various forms -small fees that are charged when using benefits, indirect fees, i.e. subsidies for tobacco products or alcohol, up to an increase in the premium for some compulsory insurance, e.g. civil liability of vehicle users. However, the main core are additional health insurance. According to the author, there is also no need to change solutions that work and work well, such as organizational changes in a medical emergency.
However, there are also areas that require decisive changes, such as the functioning of hospitals (in the event of an epidemic), the valuation of services, management of health care facilities, computerization (knowledge of resources), quality and availability of health services.

Impact of Individual Stakeholders on the Introduction and Course of Changes in Health Care
All necessary changes in health care should have one main goal: improving the functioning of the system while not compromising its functioning, which will allow to meet the health needs of society. Stakeholders play a leading role in this process, as the type, direction and success of the changes depend on them.

Minister of Health, Health Committee, Parliament
Politicians are the stakeholder group that has the greatest This situation raises many dangerous phenomena, e.g. a hospital pays to treat a patient who is in the ward for more than a certain number of days, or patients with specific diseases whose treatment is highly priced are admitted. By its activities, the payer of medical

Mid-Level Medical Staff Managed
Middle management has a special role to play in the process of change. These personnel are Growing uncertainty means that there must be changes in the area of activity of employees of "contractors". It should be noted that modern organizational concepts limit their activities to key areas.
This view may lead to the conclusion that middle management can be replaced by technology or computerization. Everything to "flatten" the organizational structure. This in turn may mean that the average level of management loses its function. The organizational structure is flattened, and control functions can be performed, e.g., by top management.
E.C. Shapiro believes that management theorists are constantly "coming up" with new organizational structures. All these proposals limit the importance of middle management. Are employees losing importance because the environment is complex? According to the authors, management theorists -probably yes, according to practitioners -no. The middle management position can be seen as a simple management process [7]. H. Willke notes that management concepts refer to planned changes and, as he writes, there is a "center" capable of observing the results of changes [7,8]. New strategic initiatives are emerging in planning changes, as W. Bonsiep and J. Klich notes, through interactive processes in the organization and up and down hierarchy levels. Therefore, the authors are in favor of including the average level in activities related to elections and reorganization activities [9]. They emphasize that the active inclusion of an average level of the organization in the change process contributes to: 1.
Increasing motivation to change,

2.
Obtaining and processing information necessary in the reorganization process,

3.
Average staff is the "link" explaining possible information disruptions,

4.
Enables effective management in large organizations.
The figure below shows the information processing cycle. It indicates that the amount of information processed at the top management level prevents the creation of detailed organizational change plans (Figure 2). This is due to the lack of chance to implement the given intention without consulting the middle management level.  There are other arguments in favor of recognizing the role of middle management as an important "actor" of the change process.
Z. Mikołajczyk presents the opinion that there are known cases of unsuccessful attempts to implement changes without obtaining mid-level management support [10]. In the opinion of W.D.Guth and I.C.Macmillan, "... mid-level managers can take over the role of intermediaries between top-level management and regular employees [11].
change. Middle management also participates in all phases of the management process. It should also be remembered that they are the basic source of innovation in the organization. Recognizing the significant role of middle management, it is important to include them in the reorganization process and, above all, provide them with information so that the planned change can be understood and accepted. Against this background, the question arises: how can they object to new solutions? There is no definite answer to this question. Perhaps it will be brought closer by a field of knowledge called partner management, whose guiding idea is that organizations be "closer" to the people who create them.

Patients
The change considered in the subjective area of the organization focuses primarily on the social aspect. Patients are at the center of the subjective interest of the change. They are a key factor in the success of this process. According to Carnall, the effectiveness of change in 40% depends on solving social problems [12]. People have to learn the change, take on a new task and then solve it.
Change in the social aspect is primarily its human orientation as the main focus of interest. Organizations change through people.
After all, people have to assimilate change and take on new tasks.
Therefore, the problem of change should be considered through the people involved in this process. A. Toffler wrote that "... the responsibility for change lies with ourselves. We must start with ourselves, learning not to shut our minds and hearts in advance of what is new, unexpected and seemingly radical [13]". In the literature devoted to the issues of change there is a great variety in presenting the problem of the patient's role in the process of change.
Some authors present the patient's needs in the process of change, others talk about the patient's attitude to change, while others deal with forms of showing resistance to changes in the healthcare system. However, it is undoubted that chances for success in the area of change should be sought in its social resources.
Liz Clarke writes that "a common mistake of many organizations is underestimating the impact of change on people [14]". Organization development is also based on people, because thanks to them the organization's resources are multiplied. Each organization through its social potential is able to efficiently assimilate changes and organize its activities in such a way as to improve itself. A modern organization cannot separate its other resources from people because it would lose its identity and values. Change, and especially its course, can be a derivative of the appropriate control of the centers of forces (power) that occur in the organization, as R. L.

Conclusions
Bearing the above in mind, the author comes to the following conclusions: 1.
There are many stakeholders in the healthcare system.
Their significance depends on many factors: power, economic resources, the roles they play, and the impact they have on the functioning of health care.

2.
All stakeholders have a very important goal to achieve -ensuring health security for the public. Regardless of whether their impact on change is large or not, it is important for everyone to make efforts to create an ever better functioning health care system, a system that everyone can afford.

3.
The changing health protection system must cultivate "social capital" in which man is the highest value. Based on the words of D. Cohen and L. Prusak, it can be added to the above statement that "management in the organization of health care is not only taking risks, but caring for human capital and social capital".

4.
Managers of healthcare organizations know that in order to make effective decisions about implementing changes, patients must be in the foreground. Patients constitute "capital" -an intangible asset of a healthcare organization. The position of man in the entire changing economic process of our millennium has been recognized. Assumptions of P.M.Senge in 'The Tifth Discipline.
Although the Art. And Practice of The Learning Organization refer to the concept of the so-called a learning organization, but in order to be able to fulfill its most ambitious aspirations and changes, the organization must implement, among others, the so-called thought models -based on discovering the real reality about the organization and the people creating them.