# Introduction he conduct of the public organization, as Halachmi (1995) points out, was perceived as ideal because of its efficiency and rationality. However, it has been widely criticized for its rigorous dedication to procedures, which frequently resulted in rigidity and lack of reaction towards users (Wiesel and Modell, 2014). In T response to these criticisms, methods and techniques from the private sector have been implemented in the public sector to reflect more empowering performance (Moulton, 2009). But here again, the life cycle of these methods and techniques has not been convincing given the changes in the public sector (Bryson and al., 2013). These changes are partly reflected in public-private partnerships, with an emphasis on collaborative and digital approaches (Bryson and al., 2014;Dreveton, 2017). The notion of hybridity tends to find its place and characterize a large part of the approaches coming from the private sector. Among these, Eve and Sprimont (2016) highlight the quality approach as being governed by technical standards and leave the choice of strategy to the actors. The quality approach and renewed public management continue the commitment to the organization's values through learning and continuous improvement (Halachmi, 1995;Eve and Sprimont, 2016). To ensure that these two approaches are intertwined, Denis and al (2015) propose a hybrid organizational form, between the mechanistic foundations of public organization and the organic foundations specific to private organization. The hybridization between the quality approach and public management renewed by a procedural approach makes it possible to determine their internal consistency and external relevance. Process-based approaches to innovation (Bryson and al., 2013; Alford and Yates, 2014; De Vries and al., 2016) tend to consider experimental tools such as dashboards (Dreveton, 2017), cost calculations, performance measurement systems. However, public organizations in developing countries are confronted with the tools of this new public management without even having mastered traditional tools (Rolland, 2009;Okafor and al., 2014). In particular, Lozeau (1999) pointed out that the implementation of an innovation such as the quality approach meets institutional and cultural specificities. These specificities require an effort of adaptation as pointed out (Wiesel and Modell, 2014), in order to promote substantial rather than symbolic integration. The quality approach, focused on standardization and process control, contributes to strengthening the mechanical dimension of organizations, further altering the relationship with users (Leavengood and al., 2012). However, when the approach encourages actors to take the initiative, it requires skills to be rearranged according to the context of action (Fryer and al., 2007). This organic dimension allows, through the capacity of the actors, to develop unique and flexible coupling strategies. The traditional distinction between mechanistic and organic structure should show its potential through hybridization, through partial or total modification of the logic of each structure. Seeking to understand the concept of hybridity beyond the traditional approach to governance structures and to access broader literatures from organizational studies, Denis and al (2015) builds on the work of Battilana and Lee (2014) and Skelcher and Smith (2015), to propose the dimensions of structure (organizational design), agency (activities), institutional context (environment, culture) and identities (numbers) to characterize the theoretical challenges of hybridity in the public. Denis and al (2015) agree with Dreveton and Rocher (2014) that the dimensions of activities are even less studied and particularly in developing countries (Okafor and al., 2014). Hybridization is likely to occur in high activity contexts characterized by close coupling processes such as hospitals. In particular, one cardiology institute is meeting this challenge, with five quality certification renewals (2005,2008,2012,2015,2018). In exploring the perspective of hybridization, the question is to know which devices, understood as a set of means, to mobilize to succeed in this hybridization between mechanistic logic and organic logic? The objective of this article is to understand the progressive implementation of the interaction of quality management systems with the public organization. He wants to contribute to the literature on the hybridization of mechanistic and organic logic. After the presentation of the methodology, the article presents the mechanistic logic of setting up and then the mechanistic logic of maintaining the quality approach, continues with the structuring mechanisms before concluding how to make these quality mechanisms appear generic. # II. A Framework for Describing the Hybridization Experience As Collm and Schedler (2013) and Dreveton and Rocher (2014) point out, implementation experience studies require integration into the organization through prolonged immersion over time. The challenge in general is to clarify how reports and descriptions are produced in interaction, so that they achieve methodological status (Joannidès and al., 2013). To do this, it should meet three criteria: observation of the reality of a terrain, knowledge of the whole terrain in a practical way, and a description of the current meaning within a group that makes it possible to produce a rigorous knowledge because it is positioned in time and space (Piening, 2011). Access to the public organisation was possible from June 2012 to December 2016, ensuring immersion in the field for a sufficient period of time to acquire formal and informal language and reflexes. All this is coupled with participation in two internal and external customer satisfaction surveys (2013,2015), and teamwork by members of the quality committee, the communication department and the Executive Board. Deliverables are intermediate and final versions of reports, ensuring that actors acknowledge the facts as they are experienced (Joannidès and al., 2013). According to Denis and al (2015) and Battilana and Lee (2014), there are many theoretical perspectives on hybridity (structures and governance, institutional dynamics, agency practices, and roles and identities...). Each hybridization is a unique experience, because it is the unique translation of the adaptation of a productive model at a given time and in a given context. Attention in this context focuses on the roles played by the different actors in the hybridization process (Bédé and al., 2012;Perray-Redslob and Malaurent, 2015). With a view to understanding the structuring role of the quality approach, the perspective of agency practices, inspired by the basic ideas of the network actor, is mobilized (Callon, 1986;Justesen and Mouritsen, 2011). The basic concept is that of a complex network of actors composed of groups of human and non-human actors (actors), gathered in material semiotic networks. It is through these networks that hybridisation actions would develop (Moulton, 2009;De Vries and al., 2016). As these networks are fragile, diversified and changing, they are considered as a technology that brings together heterogeneous actors and allows for joint actions. Miller and al (2008) felt that, so far, too much attention has been paid to hybrid organizational forms rather than hybrid organizational processes and routines. They showed how accounting practices adapt to hybrid situations, highlighting the need to look beyond the structure and more towards processes. This logic is appropriate to the framework of the quality approach in a public context since it acts as a guide for action in general terms with a certain margin of manoeuvre (Bédé and al., 2012). It uses a mechanistic organizational logic, which is imposed on the existing system by the ISO 9001:2015 standard and has organic organizational elements in the form of quality circles or management reviews. While mechanistic organizational modes involve formal rules, hierarchy, routine and stability, organic mode involves informal coordination, discretion, improvisation and change. Presenting the hybridization approach, Pyun (2013, p. 34) first perceived it as static in order to encourage the introduction of the quality approach in the local context; then hybridization becomes dynamic in order to maintain performance and finally it adapts this time to the evolution of the environment. In contrast, mechanistic logic is translated by the organic state, the intensity of the additional effort that the Abidjan Heart Institute will have to make to move forward; the counterpart, the set of elements that contribute to its acceptance of the effort; and facilitation, which makes the effort lighter. # a) The organic state The organic state consists of the project opportunity study and the responsibility of the management to prepare the introduction. After ten years of operating difficulties related to technical, financial and organizational problems (1991-1999), its closure and 5 years of rehabilitation, the Abidjan Heart Institute reopened its doors in February 2005. The management, concerned with improving the quality of care and controlling the costs of services, has committed itself to the quality approach with a view to obtaining ISO 9001 version 2000 certification. According to the Director, "we have come a long way, I think we have to do the best we can with what we have available without waiting for help". As soon as he took up his duties, the General Manager chose the option of certification to lead the destiny of the new organization. Certification can appear as a way to differentiate oneself. The Management Committee (the Chief Executive Officer, the Chief Financial Officer, and the Medical and Scientific Director) in conjunction with an external board, studies the various options available. This committee is joined by a consultant and Master's student in quality research and a Doctor, quality auditor. Before launching its ISO 9001 quality approach, the Institute evaluates and wins the Quality Award at the national level in 2003 and 2004 and at the sub-regional level, the Quality Program Award of the Economic and Monetary Union of West Africa. With these results and compliance with the organisational decree, this management method could make it possible to ensure cardiovascular care and participate in preventive medicine, teaching and university research. Management responsibility refers, at a minimum, to what the management team must do to bring the Institute into compliance. To this end, the letter of commitment from the management of 01 March 2004 stipulates that "complete customer satisfaction is an essential objective for the Abidjan Heart Institute. By relying on our competence and technical expertise, we want to increase this satisfaction and meet the expectations of our customers and staff. The first step is to formalize a quality policy and objectives, and then to set up a quality structure. The quality policy was the first action management took to explain why and how it was committed to quality. This first official act states that: "the establishment of this quality system should strengthen and improve the organization and functioning of the establishment; it also aims to guarantee our competence and ensure a better quantitative and qualitative match between our service offer and the needs of the population in accordance with the general objective of the national health development plan". Based on this commitment, management then defined what it wants to improve and in which areas. Communications took the form of fairly frequent meetings and facilitation. All this is contained in a participatory managerial approach with an emphasis on recognizing the efforts of staff. The management had just created a full-time communication function for this purpose. In the 2005 initial audit report, it states: "The objectives are defined at the appropriate levels and functions to define the contribution of the organization's various stakeholders. Action plans are being followed. An organisation chart and function sheets make it possible to define roles and responsibilities for the exercise of authority". # b) The counterparties The elements that contribute to its acceptance of the effort are the sub-entities and the quality documentation of the organization. The first concerns the management structure, roles and responsibilities for quality, defined by management. The establishment of a quality committee in charge of managing the quality system, the representation within the quality function's organisation chart, and the implementation of function sheets, met the requirements of the standard. It also requires the appointment of a quality manager whose main role is, in relation to the quality committee, to ensure the implementation and development of the system. But the administrative vacuum of that time led the management to assume this role. It therefore provides a framework, at intervals scheduled for specific meetings to "review" the system with a view to improving it. In Memorandum No l75/MEMSP/ICA/DtionGle of 18 September 2003, a steering committee and a monitoring committee were set up to lead the implementation of the quality approach at the ICA, the External Consultations and Explorations services having been retained for the initial experimentation the Quality Coordinator and the Chairman of the Quality Committee. The Monitoring Committee is composed of the Quality Coordinator and the pilots for the consultation, five in number, and four for the external explorations. The role of these committees is to define the objectives and results to be achieved and to ensure that activities are properly carried out as part of the quality approach. The second forms the documentation that constitutes the main basis of a quality management system. Indeed, the quality culture is more, through its formalism, a culture of the written word than an oral culture. In a 2006 official speech, the Director noted that "oral communication is not prohibited... but it is better to set out the accepted rules in writing (and improve them) than to discuss them each time". The Director also insists on documentation as a fundamental requirement of a quality system and the practical advantages of using writing: "writing requires reflection, allows for the homogenization, memorization and verification of information, becomes a reference that can be easily disseminated, allows the classification and archiving of information (the right document in the right place)". The quality manual is at the highest level of the document pyramid. It defines all the processes on which the organization commits itself to its customers, within the framework of ISO 9001 certification. Its drafting was outsourced and then contextualized by the Management. In this way, by describing the processes, the Directorate ensured that the writing of medical procedures and its meanders constituted a "memory" and a common language for agents, thus contributing to describing and clarifying the value chain. Communication and training are crucial because they prove (to auditors, customers...) the effective implementation of the quality approach. They provide tangible evidence of what has been done, i.e., the activities that have been carried out or the results that have been achieved. All information, documents and records affecting product quality are mandatory. The administrative and medical departments are responsible for ensuring that they are consistent and up-to-date. # c) The facilitations The facilities concern resource management and mediatized activities. For the first part, management shows that there can be no obstacles to improving the organization's activities due to a lack or insufficiency of resources. It determines the skills required for staff performing work that affects service quality. It then shows that the institute is able to meet skills needs through training in these different forms (individual, group, distance learning, etc.) or through other actions (recruitment, outsourcing, use of consultants, etc. These two notes show that the Institute is strengthening the skills of its medical and nursing staff. But also, in order to ensure the reinforcement of skills, it sends collaborators on training or internships in partnership with Canadian and Korean structures, with the objective of acquiring the critical skills to come. This allows us to remain open to good sector practices and to capitalize on them in our operations. The mediatized activities for the second component, are to be carried out as well as the groups in charge of writing the documentary system, their facilitators are planned and executed. The following dates retrace the main points: This chronology shows that management's responsibility is reflected in a set of strengths. First, there is a demonstrated commitment on the part of the general management, driven by a shared vision and values, which are conducive to the change from an "administrative" institutional culture to an "organizational" culture focused on results and client satisfaction. Then a customer listening system based on a reception and information station provided by hostesses, customer appointment cards containing all relevant information, complaint and complaint forms, customer satisfaction surveys, customer information tables. ? IV. The Organic Logic of Maintaining Quality Approach Although mechanistic and organic logic is more or less present, coexistence will be made possible by an essentially organic form of adaptation. For Maclouf and de Fabregues (2015), such development occurs not only when the heritage and standards of different sectors merge. Miller and al (2008) point out that multiple actors create new organizational processes and implement new strategies based on hybridity and in response to stakeholder expectations. When coexistence is positive, as in this case, organic adaptation, then cultural and interactive, depends more on the ability to overcome incompatibilities and the trust network built (Eve and Sprimont, 2016). # a) The ability to overcome incompatibilities Addressing incompatibilities means addressing the challenges that the Heart Institute has as a public organization. The documentary research made it possible to meet the challenges of management commitment, the mobilization of own resources, incentives to be distributed, the satisfaction of staff needs, and the speed with which invoices were processed. The first element of organic adaptation is management's commitment to the client. Visible through its customer listening system. The Institute monitors client satisfaction using complaint and claim forms, satisfaction forms, process indicators and problem resolution request forms. The second element, resource management, simply reminds us that it is appropriate for the Management to provide the resources compatible with its ambitions. This is not a matter of course for public organizations. In the financial reports, it states that "the premium we paid is one of the highest in terms of care EPNs. Where nurses from other university hospitals received about 40,000 FCFA in annual premiums, the minimum amount of the 2016 premium is 237,000 FCA at the Institute. # Source: Administrative and Financial Department of the Heart Institute The third element is related to the provision of the public service. In this case, it is the public service that provides, if necessary, the personnel for all public organizations involving a significant number of employees and the consistent management of a large proportion of the active workforce. However the Institute must ensure that its staff members are aware of the importance of their activities and how they contribute to the achievement of quality objectives. To do so, it must have a choice of these human resources, placing them in a logic of merit and not career. Figure 3 shows that staff shortages have gradually been overcome, supported by the results achieved argument. To achieve this level of staff satisfaction, the Institute and the medical services inputs to avoid that the problems generated could lead to a final noncompliance of the service delivered to clients. It does so by committing to minimize the time between the issuance of purchase orders and the payment order between six days and two days with an average of three days (Figure 4). The CFO believes that there would be much to be gained by generalizing this approach because it would avoid a number of time-consuming audits. Here is his speech to the accounting officer: "Do your audit work quickly because behind me I have a supplier waiting for his invoice and an indicator of how long it takes to process invoices! ». # Source: Administrative and Finacial Department of the Heart Institute # Source: Administrative and Financial Department of the Heart Institute # b) The trusted network builds Trust, the second component of organic logic, makes it likely that hopes for reciprocity will be satisfied. Informal and disruptive mechanisms rely essentially on it to build the network that maintains organic logic (Moulton, 2009;Pyun, 2013). We observe that there is a contingency on the importance of the progress made by the quality approach. To illustrate these cases, the example of pharmacy, communication department, medicine, emergency, medical intensive care and surgical intensive care. Through open-ended interviews, the stories of trust network building seem to be in line with the three perspectives from Eve and Sprimont (2016). Greater visibility in traceability and thus anticipate problems that may not have been identified. # Global Journal of Management and Business Research Volume XIX Issue III Version I Year 2019 ( ) D 64 Certification has thus obliged the departments concerned to lay the foundations for internal control, which is essential for any deployment of the quality approach (rational perspective). ? Pharmacy: "On the distribution of the drug, we have been warning for years that we are not in the safety conditions provided for by law. Between medical prescription and distribution to the patient, there must be dispensing by the pharmacist: checking the compatibility of products, dosage, making alternative choices if drugs are not available,... and this for each patient. Normally, prescriptionsbecause the issue is the rupture of a heart and therefore of a life -should arrive at the pharmacy on time. However, everything happens at the stock level with all the possible errors and malfunctions! (Interview with a pharmacist). ? The communication department: "The difficulty of quality is not the objective, it is the means. For example, on the paddle paper, you are told "you have to do both sides", and then when you ask for copies from the reprography department, you are told that you are using too much. For example, in the protocol, it is noted that you have to use 1 package per month, but if you also have to make posters for the other services, then you use 2 or 3, but the protocol says you only need one. (...) So after the countdown, you have more at the end of the month so you ask for more, and you are told that you have already used too much. It's always like that. The economic service deliberately disconnects from the realities on the ground" (Interview with a communicator). Then a permanent vigilance made mandatory by certification, which makes it possible to report malfunctions and the need for steering tools. The quality approach here plays the role of revealing the need for control tools, which are therefore implemented more quickly (symbolic perspective). ? Surgical intensive care: "What scares us doctors is that when you do an operation that costs you more than expected because the patient stays in hospital two days longer than expected, we are finally told: "The quality is to do less time in hospital". Quality cannot be built on restrictive criteria. The standards scare me a little bit for that. They risk leading to restrictions on medical decisions and this, at the public hospital, is unacceptable" (Interview with a doctor). Finally, a faster integration of both tools and new staff due to the standardised framework it implies, as both the General Manager asserts: "Procedures are not fixed by certification, it makes it possible to go faster because the organisation is more efficient" and one of the deputy quality managers: "Certification allows us to save time, ensure transparency, replace someone quite easily because we are in a framework type" (legitimacy perspective). ? A steering committee: "Even now, when I talk about quality in a working group, I often see ironic smiles from doctors, even if they are selected. The notion of quality is still seen as something superficial, whereas it is the basic foundation of the terrain. Quality is not the smile of the hostess, it is time savings, dysfunctions that disappear. For example, the majority of physicians believe that their promotion to the rank has nothing to do with quality. They don't hang it on the word quality: quality is seen as a trick to please the General Manager" (Interview with a department head). ? Medical intensive care: "Financial problems are always present, but you can't save money on everything. If we want better quality of care for the patient, acts that respect protocols, a good welcome and time with the patient, we need more staff and equipment" (Interview with a nurse). V. The Mechanisms Structuring the Quality Approach After describing the different logics, the analysis of the role of the actors is carried out for certain critical tasks of the quality approach. The network actor theory makes it possible to reconstruct the chain of arguments to understand how actors define, associate and negotiate what constitutes their social world (Justesen and Mouritsen, 2011). According to this theory, hybridization can take place when different logics or rationalities are "translated" into each other's language to form a network. # a) A theorization based on translation moments The key concepts of network actor theory (Callon, 1986) in role analysis are primum movens, actants, translation, network, spokespersons and intermediaries. Hybridization becomes viable thanks to trial and error that furnishes either partial or total translation of the quality logic. # Global Journal of Management and Business Research Volume XIX Issue III Version I Year 2019 ( ) # D # First moment of translation The primum movens is the general manager. He is at the initiative of the quality approach and decides to create a pilot team in collaboration with the Management. As a sponsor, he analyses the context in which relationships between agents and processes take place. The reinterpretation of the symbols and rules in force is a moment before the problematization. The sponsor makes this reinterpretation using a constant system of ideas that link goals and missions and that must be preserved (Skelcher and Smith, 2015). It thus builds the informal rules for the interpretation of quality terms that allow communication in the public organization. As the level of professionalization has increased, so has the specificity of reinterpreting symbols and rules. The role of the sponsor and the pilot team is to spread communication flows characterized by a set of new symbols and rules. This means that this reinterpretation must be constantly adapted in order to be heard and understood in the organization. The unique and collective form of problematization becomes an obligatory point of passage (Perray-Redslob and Malaurent, 2015). The idea of the primum movens becomes a point of convergence of polarization, where other actors find their interests. # Second moment of translation The construction of legitimacy is based on the use of new symbols and rules as language and vocabulary to express oneself. It is also promoted by the fact that primum movens belongs to both the medical and administrative hierarchy. This position reinforces the implementation of the quality approach as an irreversible experience. primum movens establishes the anchoring of quality in the organization's codes, formalized strategies and regulations. These forms of concentrated and repeated decisions involve habits, rituals to think the same way over and over again (Lozeau, 1999;Eve and Sprimont, 2016). These rituals allow for greater effectiveness in organizational collaboration, as they make it unnecessary to revisit the specific form of collaboration in a situation. This translator role is initially assigned to the quality manager. When routine behaviour becomes an asset, it can develop into an institution (Bédé and al., 2012). Based on these rituals, it is necessary to imagine a collective interest of the (hospital) actors in terms of improvements in order to establish and stabilize the identity of the other actors that the entity has defined in its problematization. # Third moment of translation The management and the project team form a first network. Agents (administrative, medical and technical medical) form several networks, per department, with a clear distinction between the back office and the functions of the core business. The role of the primum movens was to build, through the 2004 and 2005 training sessions, the attributions of the persons who must be held responsible. The construction of the role of each actor through quality documentation, in particular process sheets and flowcharts, evokes the concept of "publicness" (Moulton, 2009). This attachment of the organization to public sector values has been the subject of investment in resources to interpenetrate the two logics. This allowed the management and project team to reduce the complexity of publicness by mobilizing allies. The emphasis on increasing profit-sharing bonuses and staff satisfaction as a means of transfer makes it possible to move from a mechanistic logic to an organic one. However, the objective of investing in resources, that of transferring the decision to agents in order to reduce this attachment, can create paradoxes (Bryson and al., 2013). Indeed, the quality approach may not appear to be justified and definitive and needs to be communicated. These mediatized activities strengthen the networks created. # Fourth moment of translation The creation of organizational memory is based on the use of symbols, rituals and intense communication, and thus the construction of recurrence, in order to restructure the future ecosystem. Recurrence and repetition in communication flows lead to reconfirmation of expectations regarding codes and concepts promoted by quality (Collm and Schedler, 2013). Blank audits, renewal and certification audits are new practices, based on common knowledge and attitudes between stakeholders (Piening, 2011). The creation of new legitimate concepts is based on these repeated audits, training and communication materials for human actors. Non-human actors, represented by the technical dimension of quality, are perceived in the tools in general (dashboards, complaint forms, problem solving sessions, etc.). This strategy creates pressure for the Institute to recognize the relevance of quality and include it in its daily decision-making processes such as process and leadership reviews. Thus, the quality approach opens a cultural and interactive gap at the opposite of the structural and formal by the redundancy of recognized communications. This shift from mechanistic to organic is based on the use of quality semantics, while maintaining practices and routines (Piening, 2011;Leavengood and al., 2012). # Fifth moment of translation Addressing certain incompatibilities such as above-average incentive and reduction in supplier processing times and the construction of a permanent method review network signals an organic adaptation. The entire quality documentation system highlights the opposition and alliance games followed by the actors to identify, contain and possibly divert the constraints that weigh on them. These include, for example, the management of drug stocks for the pharmacist and paddles for communication in a logic of efficiency. For those involved in decision-making, sociomaterial practices such as steering tools for medical services support identity and the construction of a sense of action. Enrolment will therefore aim to convince others, control their behaviour, gather sufficient resources in a given place has been a way of disseminating the statement in time and space (Wiesel and Modell, 2014). For those who were not involved in the decisions, such as the actors as a whole, mediatized activities and written forms of "quality" routines are tools for promotion and legitimization. They stabilize the continuous replication of quality practices and experience (Rolland, 2009). An organic adaptation is underway since the existing modalities now contain mechanisms similar to those of quality and these mechanisms already have an influence. # b) A synthesis of the quality approach mechanisms When the sponsor presents the project, the experience. This moment continues until the persuasion and the decision to launch the process. Thus, the organic state represents the opportunity study of the project (1. project) and the responsibility of the management (2. sponsor). The actors and the documentary system are led to form themselves for the creation of sub entities after a decision has been taken. They problematize the challenges and actions of translations into processes. Counterparties are transformations due to the creation of sub-entities (3. Processes) and quality documentation (5. ecosystem). Spokespersons carry out routineization by creating a micro-culture for feedback purposes. Facilitations are resource management (4. Feedback) and mediatized activities (6. Environment). The latter will involve suppliers and customers through feedback to achieve continuous improvement. The following figure illustrates their articulation. At first, it remains static to facilitate the introduction of the model into the local context. Once the quality approach has been introduced into the context, hybridization becomes dynamic to maintain or even improve the performance of the approach and to adapt it to the changing environment. Thus, at the beginning of hybridization, new quality practices appear and coexist with the old ones. In the long term, the hybridization observable through certifications goes beyond simple coexistence to innovation. # VI. Conclusion: A Hybridisation System on Consolidation The proposed hybridization scheme consists of six components: project, sponsor, process, feedback, ecosystem and environment. In the implementation of management systems, Fixsen and al (2012) developed a model with five components: source, destination, communication link, feedback and influence. Collm and Schedler (2013) provide routines, practices, roles, redundancy and semantics as an anchor point. These are elements that must be taken into account by managers when building strategies to ensure adequate 3. Processus 1. Project 2. Sponsor 4. Feedback 6. Environnement # Ecosystem project team learns about it through the sharing of hybridization. The starting point is a defined project, quality, the very source of the change that corresponds to the stimuli. Then a sponsor, the general manager and the project team, the communication link that aims to implement change through quality, it constitutes the internal pressure in the sense of Upping and Oliver (2011) These two components are united under the concept of stimulus by Luder (1992). Stimulus refers to events that occur in the first stage of the innovation process and that generate the need for users to improve the existing system. It is up to the sponsor and its show that translation is a chaotic process involving multiple times, the initial stages of problematization and profit-sharing. As a first approach, they correspond to temporary sedimentation, which is only of interest if it is continuously reactivated whenever the actors feel it necessary (Fryer and al., 2007). The focal point is the semantics of Collm and Schedler (2013). Then a process that structures the relationships between the recipients of the change leading to changes. Thus, instead of talking about recipients (practitioners or organizations) or obstacles, the concept of process would be appropriate. By communicating on processes, the sponsor avoids data duplication and reduces delays by limiting back and forth between departments (Alford and Yates, 2014). The feedback unanimously mentioned (Fixsen and al., 2012; Alford and Yates, 2014; Eve and Sprimont, 2016) makes it possible to adjust the flow and distribution of information in the public organization. It ensures the adjustment between the processes and the project, allowing information on the approach. We find the idea of redundancy of Collm and Schedler (2013) where the same thing is expressed several times in different forms. The unity constituted by the actors and the non-actors who establish multiple interactions between them through the quality approach builds an ecosystem, a place of mutual influences of the recipients. These are the routines of Collm and Schedler (2013) but with a dynamic orientation. Indeed, a public administration that introduces the quality approach invites its stakeholders to participate in a weakly structured process and thus to develop an innovation. Bryson and al (2013) describe this form of collaboration as open innovation. It is used to achieve agent acceptance of major changes and to improve service and customer orientation, hence the term "dynamic routines". The success of hybridization through procedures must be the continuous expression of a mixture of these conceptions to legitimize itself. This idea takes up the growing importance of customer requirements towards the quality assurance of the service provided by the implementation of a dedicated quality approach. To evoke this, Luder (1992) refers to structural variables that characterize the social context in the public sector. Upping and Oliver (2011) refer to external pressures. The pretext of the quality approach as a reference framework allows actors to engage in learning but it leads to circular reasoning (Maclouf and de Fabregues, 2015). ![. The steering committee is composed of the Directors (General, Medical and Scientific, Administrative and Financial); the Deputy Directors of Human Resources and Nursing; the Heads of the Consultations, External Explorations, Pharmacy, Biology, and the Autonomous Service for Control and Evaluation; Global Journal of Management and Business Research Volume XIX Issue III Version I Year 2019 ( ) D](image-2.png "") ![August 1, 2003: Launch of the quality approach by the ICA Director General; ? October 2003: Diagnostic audit of the Ivorian Quality Award; ? September 2003: Installation of the steering committee and monitoring of the quality approach; ? February 2004: Appointment of a quality manager; ? 3 March 2004: Training on service quality and customer service (UNIDO/UEMOA); ? June 11, 2004: Quality Management System Presentation Dinner at PEKIN; ? 11 March 2005: Launch of the certification project; ? 18 March 2005: Audit of the Ivorian Quality Award 2004 (level 2); ? 1 to 3 June 2005: Training of internal auditors by UNIDO/UEMOA (9/15); ? 20-21 September 2005: ISO 9001 version 2000 certification audit; ? 03-07 November 2008: Renewal audit 1 ISO 9001 version 2000; ? 26, 27, 30 and 31 January 2008: Renewal audit 2 ISO 9001 version 2008 ; ? April 13, 2015: ISO 9001 Certification Audit 2008 version; ? 06 August 2015: Presentation of the Ivorian Quality Award (Excellence Level) edition 2015; ? February 13, 2018: Renewal audit 2 ISO 9001 version 2015.](image-3.png "") 1![Figure 1: Own resources mobilized by the Heart 1 Institute](image-4.png "Figure 1 :") 2![Figure 2: Evolution of the gross amount of the incentive to be distributed](image-5.png "Figure 2 :") présence d'une logique mécanique fondée sur l'application des préceptes de la qualité. La logique organique, quant à elle, s'amorce par la capacité à combler les incompatibilités et la construction du réseau de confiance de la direction générale. L'hybridation se résume en un dispositif dynamisme liant le projet, le parrain, le processus, les rétroactions, l'écosystème et l'environnement. ? Group 1: Thursday, September 25, 2003, from 08 H30 min to 13 H 30 min and from 15 H to 17 H? Group 2: Friday 26 September 2003, from 08 H 30min to 13 H 30 min and from 15 H to 17 H? Group 3: Thursday, October 9, 2003, from 08:30 amto 1:30 pm and from 3 pm to 5 pm. ? Emergencies: "It's very practical what I'm going to tell you, but see, when you put in infusions for example, you don't follow the protocol, because you don't have the right equipment: you don't always change the infusion tubing, because you don't have the right equipment. 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